This paper is in the following e-collection/theme issue:

Prevention and Health Promotion (1015) Depression and Mood Disorders; Suicide Prevention (1392) Obesity and Nutrition as Public Health Problem (309)

Published on in Vol 3, No 2 (2017): Apr-Jun

Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Styles and Practices in Mothers of Young Children: A Systematic Review

Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Styles and Practices in Mothers of Young Children: A Systematic Review

Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Styles and Practices in Mothers of Young Children: A Systematic Review

Authors of this article:

Ana Cristina Lindsay1 Author Orcid Image ;   Tatiana Mesa1 Author Orcid Image ;   Mary L. Greaney2 Author Orcid Image ;   Sherrie F. Wallington3 Author Orcid Image ;   Julie A. Wright1 Author Orcid Image
Article Authors Cited by (10) Tweetations (3) Metrics

    Original Paper

    1Exercise and Health Sciences, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, United States

    2Department of Kinesiology, Kinesiology/Health Studies, University of Rhode Island, Kingston, RI, United States

    3Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Georgetown University, Washington, DC, United States

    *all authors contributed equally

    Corresponding Author:

    Ana Cristina Lindsay, DDS, MPH, DrPH

    Exercise and Health Sciences

    College of Nursing and Health Sciences

    University of Massachusetts Boston

    100 Morrissey Boulevard

    Boston, MA, 02125

    United States

    Phone: 1 617287579

    Fax:1 6172877500

    Email: Ana.Lindsay@umb.edu


    Background: Childhood obesity is a significant global public health problem due to increasing rates worldwide. Growing evidence suggests that nonresponsive parental feeding styles and practices are important influences on children’s eating behaviors and weight status, especially during early childhood. Therefore, understanding parental factors that may influence nonresponsive parental feeding styles and practices is significant for the development of interventions to prevent childhood obesity.

    Objective: The objectives of this systematic review were to (1) identify and review existing research examining the associations between maternal depressive symptoms and use of nonresponsive feeding styles and practices among mothers of young children (2-8 years of age), (2) highlight the limitations of reviewed studies, and (3) generate suggestions for future research.

    Methods: Using the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) guidelines, six electronic academic databases were searched for peer-reviewed, full-text papers published in English between January 2000 and June 2016. Only studies with mothers 18+ years old of normally developing children between 2 and 8 years of age were included. Of the 297 citations identified, 35 full-text papers were retrieved and 8 were reviewed.

    Results: The reviewed studies provided mixed evidence for associations between maternal depressive symptoms and nonresponsive feeding styles and practices. Two out of three studies reported positive associations with nonresponsive feeding styles, in that mothers with elevated depressive symptoms were more likely than mothers without those symptoms to exhibit uninvolved and permissive or indulgent feeding styles. Furthermore, results of reviewed studies provide good evidence for association between maternal depressive symptoms and instrumental feeding (3 of 3 reviewed studies) and nonresponsive family mealtime practices (3/3), but mixed evidence for pressuring children to eat (3/6) and emotional feeding (1/3). In addition, evidence for the association between maternal depressive symptoms and restricting child food intake was mixed: one study (1/6) found a positive association; two studies (2/6) found a negative association; whereas one study (1/6) found no association.

    Conclusions: This review indicates that the results of studies examining the associations between maternal depressive symptoms and parental feeding styles and practices are mixed. Limitations of studies included in this review should be noted: (1) the use of a diverse set of self-report questionnaires to assess parental feeding practices is problematic due to potential misclassification and makes it difficult to compare these outcomes across studies, thus caution must be taken in drawing conclusions; and (2) the majority of included studies (6/8) were cross-sectional. There is a need for additional longitudinal studies to disentangle the influence of depression on parental feeding styles and practices. Nevertheless, given that depressive symptoms and feeding styles and practices are potentially modifiable, it is important to understand their relationship to inform obesity prevention interventions and programs.

    JMIR Public Health Surveill 2017;3(2):e29

    doi:10.2196/publichealth.6492

    Keywords

    maternal depression; child; feeding behavior; practices; feeding styles; obesity 


    Childhood obesity is an important global public health issue due to existing prevalence and increasing rates worldwide [1,2]. The increasing prevalence of childhood obesity in young children is particularly concerning, given the evidence that children’s weight status is associated with weight status in adulthood, making early childhood a critical period for prevention of overweight and obesity [2-4]. Consequently, identifying modifiable factors associated with increased risk of early childhood obesity is a priority [1-4].

    Early childhood is an important period of growth and development that influences one’s health during childhood and beyond [3-7]. It is when the foundations for healthful eating habits that have long-lasting implications for weight status and related comorbidities are established [4,5,7-9]. Several parental characteristics are associated with children’s risk of overweight and obesity including parents’ weight status [1-4], sociodemographic and economic characteristics (eg, income, education) [1-4], and mental health status (eg, depression) [10-19]. Parents, especially mothers, influence their children’s development and maintenance of eating habits and food preferences [2,4-9,10]. Parental feeding styles and parental feeding practices have been identified as particularly important influences on children’s eating behaviors during early childhood [5,7,8,9-16,20-24].

    Parental feeding style, the overarching feeding strategy parents adopt during feeding situations [9,11,20,21], has been conceptualized as having two main dimensions: demandingness (also defined as control) and responsiveness (also defined as warmth). Within these two dimensions, there are four parental feeding styles typologies: (1) authoritative (high level of demandingness and high level of responsiveness), (2) authoritarian (high level of demandingness and low level of responsiveness), (3) indulgent or permissive (low demandingness and high responsiveness), and (4) uninvolved or neglectful (low demandingness and low responsiveness). Parental feeding practices are specific behaviors that parents use to influence the amount and/or type of food a child eats and include monitoring and controlling food intake, pressuring to eat, instrumental and emotional feeding, and so on [9,11,21-25].

    Family meals and family mealtime practices are key family routines relevant to obesity prevention [26]. Family mealtime practices encompass habits and processes that a family engages in around eating together [27]. Family mealtime may offer several benefits to children’s health and development such as helping children develop healthful eating patterns and weight status [27-29].

    Understanding factors that may be associated with parental feeding styles and practices, and family mealtime practices that are unintentionally detrimental to children’s development of healthful eating habits is of great importance to the development of interventions to prevent child obesity. Providing parents with guidance on healthful feeding styles and practices will help children develop healthful eating habits and, ultimately, maintain a healthy weight status [2-4,8,30,31].

    Research suggests that mental health status of the parents may influence the weight status of their child through parental feeding styles and practices [7,10-13]. Mental health conditions (eg, depression and depressive symptoms) among mothers of young children are increasingly recognized as an important public health concern [32-36]. According to the National Institute of Mental Health one in seven women of reproductive age are affected by depression, and 15% of women in the United States experience postpartum depression [32,36]. Depressive symptoms can affect mothers’ sensitivity and responsiveness to their children and can contribute to less engaged or responsive mother-child interactions as well as a higher use of disengaged (eg, uninvolved and permissive/indulgent) or controlling (eg, authoritarian) parenting behaviors [10-14]. In addition, elevated depressive symptoms such as low energy and diminished pleasure in activities may contribute to decreased maternal-child involvement [10-13], with mothers choosing strategies for coping that require less cognitive effort [11-13].

    Given the high prevalence (15%-38%) of depression and depressive symptoms among women of childbearing age [32-36] and increasing evidence linking maternal depressive symptoms to nonresponsive feeding styles and practices related to the risk of childhood obesity [11-14,30,37], the objectives of this systematic literature review were to (1) identify and review existing research examining the associations between maternal depressive symptoms and use of nonresponsive feeding styles and practices among mothers of young children (2–8 years of age), (2) highlight the limitations of reviewed studies, and (3) generate suggestions for future research.


    Study Design

    We conducted this review by following the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [38]. These guidelines include a four-phase flow diagram to guide the inclusion and exclusion of research papers [38]. In addition, the guidelines provide a 27-item checklist outlining standards per review section (eg, title, abstract, introduction, methods, results, discussions, funding) to ensure that reviews are systematically conducted and reported [38].

    Search Strategy

    We searched six electronic databases: Science Direct, PubMed, PsycINFO, PscyARTICLES, Medline, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between April and June 21, 2016. The search was limited to full-text, peer-reviewed articles published in English between January 2000 and June 2016. Key search terms included: (1) child* OR pediatric*; (2) maternal depress* OR maternal depress* symptoms OR maternal “depressive symptoms”; and (3) “feeding practices” OR “feeding behavior” OR feeding srateg* OR feeding style (see Figure 1). Two authors (ACL, TM) independently examined the titles and abstracts of all citations, and the citations were excluded when both authors determined that the study did not meet the inclusion criteria. The same two authors independently reviewed the retrieved articles and identified studies to be included in this systematic review. They also searched the reference lists [39-46] and other review studies focusing on infants and/or children older than 8 years of age [7,10-16,25,31,47-49].

    Study Selection

    This systematic review was limited to peer-reviewed studies that included mothers 18+ years old of normally developing children (ie, not born preterm, not diagnosed with physical or mental complications) between 2 and 8 years of ages (ie, early childhood). We identified studies that (1) examined the association between maternal depression and/or maternal depressive symptoms (independent variable) and parental feeding styles, parental feeding practices, and/or family mealtime practices (outcome variables), and (2) measured maternal depression or depressive symptoms with a validated questionnaire or scale at any period prior to or following childbirth. Studies that focused on special groups (eg, teen mothers, children born pre-term or low birth weight, or special needs such as cerebral palsy) or populations with health concerns (eg, mothers diagnosed with HIV) were excluded. Studies that used qualitative methods exclusively were also excluded to simplify comparison of findings across studies. Additionally, studies that focused exclusively on breastfeeding and/or complementary feeding practices were excluded as previous review papers have examined the association between maternal depressive symptoms and infant feeding practices [15,25,31,47,49].

    Data Extraction and Data Synthesis

    Using the search strategy illustrated in Figure 1 (PRISMA flow diagram), we identified eight observational studies meeting eligibility requirements [39-46]. Two authors (ACL, TM) independently read and completed an article extraction form for all articles. The data extraction form gathered the following information: (1) authors, (2) study setting, (3) sample size, (4) participant characteristics, (5) study design, (6) study aim(s), (7) measure (s) of maternal depressive symptoms, (8) measure(s) of parental feeding styles and practices and family mealtime practices, and (9) study results. The two authors who completed the data extraction forms compared their results and discussed discrepancies, which were resolved with feedback from a third author.

    This review extracted data on associations between maternal depressive symptoms (exposure) and parental feeding styles, parental feeding practices, and/or family mealtime practices (outcomes) and summarized the findings. Due to the range of study designs, assessment of exposure, and outcomes, conducting a meta-analysis of the data was not appropriate, and results of this review are presented as a narrative summary.

    Quality Assessment of Included Studies

    The first author (ACL) assessed the quality of reviewed studies using a modified version of the Strengthening in the Reporting of Observational Studies in Epidemiology (STROBE) statement [50], which were confirmed by two authors (MLG, JAW). STROBE is an international, collaborative initiative of epidemiologists, methodologists, statisticians, researchers and journal editors who have a common goal of strengthening reporting of observational studies in epidemiology. The combined STROBE checklist for cohort, case-control, and cross-sectional studies includes 22 items [50]. For this review, we included 11 of these items to (1) identify potential sources of bias, and (2) identify possible methodological areas that were insufficiently addressed (see Multimedia Appendix 1). Each question was designed to be answered either “yes” or “no,” with a score of 1 assigned to “yes” response, and a score of 0 to “no” response (range of scores 0-11). Total scores were then used to assign a rating of the study as strong (score> 8), moderate (score between 8-6), or weak (score between 5-0).

    ‎
    Figure 1. PRISMA Flow Diagram.
    View this figure

    Search Results

    We identified 297 unique citations and two authors (ACL, TM) independently examined the titles and abstracts of the identified citations. We excluded 272 citations that did not meet the eligibility criteria, and 35 full-text articles were selected for detailed review and assessed by two authors independently. Eight studies that met the eligibility criteria were included in this systematic review (see Figure 1). Studies included in this review fell into three categories, and this review is organized by the study’s purpose. The three purpose categories were to examine the associations between: (1) maternal depressive symptoms and nonresponsive parental feeding styles, (2) maternal depressive symptoms and nonresponsive parental feeding practices, and (3) maternal depressive symptoms and nonresponsive family mealtime practices.

    Study Characteristics

    Eligible studies examined maternal depressive symptoms [51-56] and parental feeding styles [57] and feeding practices [58-64] using a wide variety of tools. Of the 8 included studies, 3 focused on feeding styles [39,41,46], 6 on nonresponsive feeding practices [40,41,43-46] and 3 on nonresponsive family mealtime practices [41,42,44]. Summary characteristics of included studies are presented in Multimedia Appendix 2, whereas synthesized information on methodology and main findings are presented in Multimedia Appendix 3.

    Study Quality

    The quality of the reviewed studies varied (See Multimedia Appendix 1). Out of the 8 included studies, 6 were assigned a rating of > 8 (strong), and 2 were rated between 8-6 (moderate). Most of the reviewed studies presented methodological limitations: (1) nearly all (6/8) used cross-sectional study designs that prohibit determining causal inferences between maternal depressive symptoms and child-feeding practices and styles [39,41,42,44-46], (2) all studies (8/8) relied on self-reporting of maternal depressive symptoms [39-46], and (3) the majority (6/8) relied on self-reporting of parental feeding styles, parental feeding practices and family mealtime practices [39-42,44,46]. Furthermore, it was not always possible to determine whether analyses controlled for potential confounding factors and analyses were not stratified by child gender.

    Moreover, maternal depressive symptoms [51-56] and parental feeding practices [58-64] were assessed by an array of instruments, which made it difficult to compare results across studies. For example, across the 8 reviewed studies, 6 different instruments were used to measure maternal depressive symptoms [51-56], whereas 7 instruments were used to assess parental feeding practices [58-64], 2 instruments were used to assess family mealtime practices [59,61], and 1 to assess parental feeding styles [57].

    Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Styles

    Out of the 8 included studies [39-46], 3 studies [39,41,46] examined the association between maternal depressive symptoms and nonresponsive feeding styles. Two [39,41] of these studies used the validated Center for Epidemiological Study Depression (CES-D) instrument [51], whereas 1 used the Depression Anxiety Stress Scale 21-item (DASS-21) [53] to assess maternal depressive symptoms. All three studies were cross-sectional [39,41,46] and used the validated Caregiver’s Feeding Styles Questionnaire (CFSQ) [57] to assess parental feeding styles. The CFSQ is a 19-item valid, reliable measure developed for use with caregiver’s of preschool-age children [57].

    Of the 3 studies examining associations between maternal depressive symptoms and nonresponsive parental feeding styles in adjusted analysis, only 2 studies found positive associations [39,41], with mothers with elevated depressive symptoms being more likely to exhibit uninvolved [39,41] and permissive styles [41] than those without these symptoms.

    A cross-sectional study [41] conducted in the United States with a sample of low-income mothers of whom approximately 30% were Hispanics, found that mothers reporting elevated depressive symptoms reported using more demandingness (eg, encouragement or discouragement of child’s eating behaviors) and permissive feeding styles (eg, fewer authority narratives about feeding) than mothers without elevated depressive symptoms after adjusting for potential confounders. One cross-sectional study [39] conducted in the United States with a sample of low-income mothers, of whom approximately 55% were Hispanic and 45% were African-American, found that after adjusting for potential confounders, mothers employing an uninvolved feeding style (a permissive feeding style) reported less positive affect and more parenting stress than mothers who used authoritative, authoritarian, or indulgent/permissive feeding styles. In addition, mothers with elevated depressive symptoms were more likely to present low authority in child feeding [39].

    One cross-sectional study [46] conducted in Australia found that mothers who reported experiencing higher levels of depressive symptoms also reported using higher levels of the authoritarian feeding style. In adjusted analysis, however, none of the maternal psychosocial well-being variables independently contributed to the prediction of authoritarian parental feeding style.

    Associations Between Maternal Depressive Symptoms and Nonresponsive Feeding Practices

    Out of the 8 reviewed studies, 6 [40,41,43-46] examined the association between maternal depressive symptoms and nonresponsive feeding practices. Four studies [41,44-46] employed cross-sectional designs and two used longitudinal designs [40,43]. The 6 studies used five different instruments [51,53-56] to assess maternal depressive symptoms, with the Edinburgh Postnatal Depression Scale (EPDS) [53] being used in 2 [40,43] and the Depression Anxiety Stress Scales 21-item (DASS-21) [54] also being used in 2 studies [43,46]. The validated Child Feeding Questionnaire (CFQ) [58] was the instrument most used to assess parental feeding practices (5/6). In addition, five other validated instruments were used across the 6 studies [59-64]. All 6 reviewed studies [40,41,43-46] provided information on the reliability and validity of the instruments used to assess both maternal depressive symptoms and parental feeding practices (see Multimedia Appendix 3).

    In summary, 3 studies reported positive associations between maternal depressive symptoms and use of instrumental feeding (eg, using food as a reward) (3/3) [40,44,45], and pressure to eat (3/6) [40,41,45]. One study reported positive associations between maternal depressive symptoms and restriction of child’s food intake (1/6) [40], and emotional (eg, using food to manage child’s mood) feeding (1/3) [40]. In addition, 2 studies (2/6), one with a cross-sectional design [44] and one using a longitudinal design [43], reported negative associations between maternal depressive symptoms and restriction of child food intake. In contrast, a cross-sectional study (1/6) [45] found that elevated depressive symptoms were not associated with restriction of child food intake. Moreover, 1 study (1/4) reported that elevated depressive symptoms were negatively associated with monitoring of child food intake [43].

    Pressure to Eat

    Six of the reviewed studies examined the association between maternal depressive symptoms and mothers’ use of pressure to get their children to eat [40,41,43-46], and all found positive associations between elevated maternal depressive symptoms and pressure to eat in unadjusted analyses. However, only three studies (3/6), one using a longitudinal design [40] and two using cross-sectional designs [41,45], reported significant positive associations between maternal depressive symptoms and pressure to eat after adjusting for several key child (eg, age, gender, child body mass index) and maternal characteristics (eg, age, BMI, race, income, educational level). Results of these 3 studies [40,41,45] indicated that mothers reporting elevated depressive symptoms were more likely to report pressuring their children to eat than mothers without elevated depressive symptoms after adjusting for potential confounding factors.

    Restriction of Child’s Food Intake

    Six of the reviewed studies [40,41,43-46] examined associations between maternal depressive symptoms and restrictions in child food intake. Three of these studies [40,41,46] reported positive associations between maternal general depressive symptoms and restriction in feeding in unadjusted analyses. However, after adjusting for key maternal (age, education, BMI) and child covariates (age, gender, BMI at 4 months and feeding mode at 4 months), only one longitudinal study [40] found that maternal general depressive symptoms were associated with the restriction of children’s food intake. In contrast, a longitudinal study [43] found that high depressive symptoms predicted less maternal use of restriction. Likewise, a study [44] using a cross-sectional design found a negative association between maternal depressive symptoms and use of restriction of child’s food intake, with mothers reporting mild and moderate to severe symptoms were less likely to restrict their child’s intake than mothers not reporting depressive symptoms. Moreover, a cross-sectional study [45] determined that maternal depressive symptoms were not predictive of mothers’ restrictive feeding practices.

    Monitoring of Child Food Intake

    Four of the reviewed studies, two employing longitudinal study design [40,43] and two cross-sectional designs [41,44], examined associations between maternal depressive symptoms and monitoring of child food intake. Of the 4 studies, 1 longitudinal follow-up study found that maternal depressive symptoms partially negatively predicted monitoring of child food intake [43].

    Instrumental and Emotional Feeding Practices

    Three [40,44,45] studies examined the relationship between maternal depressive symptoms and instrumental feeding practices (eg, using food as a reward, increased use of incentives) and emotional feeding (eg, using food to manage child mood). All 3 studies found a positive association between maternal depressive symptoms and instrumental feeding [40,44,45], whereas one (1/3) found a positive association between maternal depressive symptoms and emotional feeding [40]. One longitudinal study found that mothers with elevated depressive symptoms were more likely to employ both instrumental and emotional feeding practices adjusting for maternal and child covariates [40] than mothers with low or without depressive symptoms. Additionally, 2 studies using cross-sectional designs [44,45], one conducted in the United States [44], and one in England [45], found positive associations between maternal depressive symptoms and the use of instrumental feeding practices (eg, use of food as reward, or use of incentive and conditions to get child to eat). In adjusted analysis, higher maternal depressive symptoms were significantly associated with use of food as a reward [44] and with greater use of incentives or conditions to eat [45].

    Associations Between Maternal Depressive Symptoms and Nonresponsive Family Mealtime Practices

    Out of the 8 reviewed studies [39-46] 3 [41,42,44], all of which employed cross-sectional designs and were conducted in the United States with low-income mothers, examined the association between maternal depressive symptoms and a number of nonresponsive family mealtime practices. Two [41,42] of these studies used the Center for Epidemiological Study Depression (CES-D) instrument [51], whereas one [44] used the Patient Health Questionnaire-9 (PHQ-9) [55] to assess maternal depressive symptoms. Two different instruments [59,61] were used to assess family mealtime practices by 2 [42,44] of the 3 studies, and 1 study [41] used both semistructured narrative interview and videotaped observations of mother-child feeding situations.

    All 3 studies determined that children in households with mothers with elevated depressive symptoms were more likely to be exposed to less optimal mealtime practices and routines than children in households with mothers with low or without any depressive symptoms [41,42,44]. Moreover, all 3 studies found that mothers reporting elevated depressive symptoms were more likely to report nonresponsive feeding practices which were associated with both uninvolved (eg, mother not being present during meals, child skipping breakfast, child eating while watching television) and permissive (eg, lower levels of maternal control over child eating routines, greater child choice over snacking) feeding styles.

    One study [41] found that in households of mothers with elevated depressive symptoms, children were less likely to eat at the kitchen or dining table, the television was more likely to be audible during meals, and children were less likely to eat with their mothers. Similarly, 1 study [42] found that maternal depression was significantly associated with lower maternal presence when the child ate, lower levels of maternal control over child eating routines, greater child choice over snacking, and fewer optimal mealtime practices than in homes of mothers without higher depression scores [42]. Likewise, 1 study [44] found in adjusted analyses that mothers reporting mild depressive symptoms were more likely to have children who consumed sweetened drinks daily, who did not eat breakfast regularly, and who ate out in restaurants 3 or more times per week than mothers without depressive symptoms.


    Principal Findings

    The aim of this systematic review was to identify and review existing research examining associations between maternal depressive symptoms and nonresponsive parental feeding styles and parental feeding practices in mothers of young children. The 8 reviewed studies provide mixed support for associations between maternal depressive symptoms and nonresponsive feeding styles, feeding practices, and family mealtime practices. Uninvolved and permissive feeding styles, and feeding practices use of instrumental feeding (eg, use of food as reward) and pressuring children to eat were the most consistently associated with depressive symptoms among studies included in this review. In addition, maternal depressive symptoms were associated with uninvolved and permissive family mealtime practices.

    Across the reviewed studies, elevated maternal depressive symptoms were most often associated with uninvolved and permissive parental feeding styles [39,41]. Two of the three studies examining associations between maternal depressive symptoms and nonresponsive feeding styles (uninvolved and permissive) found a positive association [39,41]. These findings concur with results of studies [11,12] and review papers [10,15,25,47,49,65] conducted among mothers with infants. Furthermore, available evidence from the extant literature on maternal mental health and parenting suggests that maternal mental health issues may impair mothers’ responsiveness to, and interactions with, their children. The reduced interaction may manifest in nonresponsive, more controlling, and less-sensitive parenting [10,29,37,47,49,60]. In addition, research suggest that elevated depressive symptoms may contribute to decreased maternal–child interactions [30,66], with mothers being less responsive to their children and choosing strategies for coping that require less cognitive effort [11-13].

    Evidence for associations between maternal depressive symptoms and nonresponsive maternal feeding practices was mixed across reviewed studies [40,41,43-46]. Instrumental feeding (eg, use of food as reward; 3/3) [40,44,45] and pressure to eat (3/6) [40,41,45] were the most consistently nonresponsive feeding practices associated with elevated depressive symptoms across the studies included in this review. Evidence from studies [11,12,16] and systematic reviews [25,47] with mothers of infants and toddlers suggests that mothers experiencing elevated depressive symptoms are more likely to use restrictive and controlling feeding practices than mothers without elevated depressive symptoms. Moreover, evidence suggest that mothers experiencing elevated depressive symptoms are less likely to be responsive to their children’s cues of hunger and satiety and less likely to respect their child’s ability to self-regulate food intake [10-13,66]. Previous studies indicate that nonresponsive feeding practices interfere with a child’s natural ability to self-regulate food intake based on hunger and satiety cues [14,19,30,67-69]. Furthermore, research suggests that both parental pressure to eat and feeding restrictions are associated with unrestrained eating and disinhibited eating in later life, excessive weight gain, and increased risk of child obesity in children [5,20,21,67-71].

    Studies included in this review provide consistent evidence for the association between maternal depressive symptoms and nonresponsive family mealtime practices [41,42,44]. Children in households with mothers having elevated depressive symptoms were more likely to be exposed to less optimal mealtime practices and routines than children in households with mothers having low or no depressive symptoms [41,42,44]. Elevated depressive symptoms such as low energy and diminished pleasure in activities may contribute to decreased maternal involvement with the child [5,21,67-69,30], resulting in mothers being less responsive to their children and choosing strategies for coping that require less cognitive effort [5]. Suboptimal family mealtime practices have been reported to be associated with children’s unhealthy eating habits [72-77], which in turn have been linked to risk of overweight and obesity [72-77].

    Limitations and Strengths

    Our evaluation of the methodologies of studies included in this systematic review suggests some limitations, and therefore caution in the interpretation of study findings. The majority (6/8) of studies used cross-sectional study designs precluding a causal assessment of associations between maternal depressive symptoms and feeding styles and practices [39,41,42,44-46]. Additional longitudinal studies are necessary to understand whether mothers’ depressive symptoms influence their feeding styles and practices. Furthermore, nearly all examined (6/8) studies used an array of self-reported questionnaires for assessments of maternal depressive symptoms and parental feeding practices (7/8), which is potentially problematic due to possible misclassification of depressive symptoms (exposure) and parental feeding practices (outcome). Finally, variability in the assessment of maternal depressive symptoms (eg, CES-D, DASS, BSI) and parental feeding practices (eg, Child Feeding Styles Questionnaire [CFSQ], CFQ, Family Mealtime Coding System [FMCS]) make it difficult to compare findings across studies and indicate that caution must be taken in drawing conclusive assertions.

    Strengths of this review include the use of systematic criteria (ie, PRISMA) to identify and select studies and a quality assessment tool for the critical appraisals of studies. Nonetheless, this review may be incomplete given limitation to studies published in English. Another possible limitation of this review is the variability in the studies’ location. Multiple countries (United States, Australia, and England) were represented, which may limit cross-study comparisons. Finally, publication bias should also be considered, as should the fact that this review is limited to full-text studies published in English and may have excluded studies published in other formats and/or languages.

    Future Directions

    Additional research is needed to further examine the relationships between maternal depressive symptoms and nonresponsive parental feeding styles and practices. Specifically, longitudinal studies and additional studies including low-income and racial/ethnic minority populations at increased risk of depressive symptoms are needed. Future studies should explore the associations between maternal depressive symptoms, food insecurity and maternal feeding styles and practices. This is required especially due to documented evidence of greater prevalence of obesity among racial/ethnic minority populations [78]. In 2 examined studies [39,42], authors suggest that food insecurity may interact with maternal depressive symptoms such as stress to increase the risk of unintentionally detrimental feeding practices such as pressuring child to eat and/or restricting child food intake. Therefore, studies that assess the potential interactions of food security status and maternal depressive symptoms on maternal feeding styles and practices are needed. Moreover, given the inconsistencies in results across studies included in this review, future research should also consider the potential influence of additional factors such as mother’s socioeconomic status, acculturation level, social support, as well as contextual factors such as work strain, access to healthful foods, and so on. Finally, future research may benefit from examining differentials of depressive symptoms and parental feeding styles and practices according to the gender of the parent and the child.

    Conclusions

    In summary, studies identified and synthesized in this review provided mixed evidence for associations between maternal depressive symptoms and nonresponsive maternal feeding styles and practices. Nevertheless, given the high prevalence of maternal depressive symptoms among women of reproductive age [32-35], the indication from some studies of associations between maternal depressive symptoms and nonresponsive feeding styles and practices, and the fact that both maternal depressive symptoms and that nonresponsive feeding styles and practices are potentially modifiable, further understanding of these associations are likely to provide important insights for the development of interventions to prevent and control childhood obesity.

    Acknowledgments

    The authors are grateful for library assistance provided by Ms Teresa Maceira, Reference Librarian at the University of Massachusetts, Boston.

    Conflicts of Interest

    None declared.

    ‎

    Multimedia Appendix 1

    Quality assessment of 8 included studies using an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

    PDF File (Adobe PDF File), 49KB
    ‎

    Multimedia Appendix 2

    Description of the 8 studies included in systematic review.

    PDF File (Adobe PDF File), 85KB
    ‎

    Multimedia Appendix 3

    Characteristics of 8 included studies included in systematic review.

    PDF File (Adobe PDF File), 56KB
    1. WHO. Report of the first meeting of the ad hoc working group on science and evidence for ending childhood obesity. Geneva: World Health Organization; 2014 Jun 18 Presented at: World Health Organization; June 18-20, 2014; Geneva, Switzerland p. 1-49   URL: http://www.who.int/end-childhood-obesity/echo-final-report-august-2014.pdf
    2. Institute OM. Examining a Developmental Approach to Childhood Obesity: The Fetal and Early Childhood Years: Workshop Summary (2015). Washington, DC: National Academies Press; 2015 Presented at: Institute of Medicine; Food and Nutrition Board; 2015; Washington, DC.
    3. Institute OM. Early childhood obesity prevention policies. Washington, DC: National Academies Press; 2011.
    4. Lumeng JC, Taveras EM, Birch L, Yanovski SZ. Prevention of obesity in infancy and early childhood: a National Institutes of Health workshop. JAMA Pediatr 2015 May;169(5):484-490. [CrossRef] [Medline]
    5. Anzman SL, Rollins BY, Birch LL. Parental influence on children's early eating environments and obesity risk: implications for prevention. Int J Obes Relat Metab Disord 2010 Mar 02;34(7):1116-1124. [CrossRef] [Medline]
    6. Lindsay AC, Sussner KM, Kim J, Gortmaker S. The role of parents in preventing childhood obesity. Future Child 2006;16(1):169-186. [Medline]
    7. Birch LL. Learning to eat: behavioral and psychological aspects. Nestle Nutr Inst Workshop Ser 2016;85:125-134. [CrossRef] [Medline]
    8. Patrick H, Hennessy E, McSpadden K, Oh A. Parenting styles and practices in children's obesogenic behaviors: scientific gaps and future research directions. Child Obes 2013 Aug;9 Suppl:S73-S86 [FREE Full text] [CrossRef] [Medline]
    9. Ventura AK, Birch LL. Does parenting affect children's eating and weight status? Int J Behav Nutr Phys Act 2008 Mar 17;5:15 [FREE Full text] [CrossRef] [Medline]
    10. El-Behadli AF, Sharp C, Hughes SO, Obasi EM, Nicklas TA. Maternal depression, stress and feeding styles: towards a framework for theory and research in child obesity. Br J Nutr 2015 Jan 15;113(S1):S55-S71. [CrossRef] [Medline]
    11. Hurley KM, Black MM, Papas MA, Caulfield LE, Caufield LE. Maternal symptoms of stress, depression, and anxiety are related to nonresponsive feeding styles in a statewide sample of WIC participants. J Nutr 2008 Apr;138(4):799-805 [FREE Full text] [Medline]
    12. Savage JS, Birch LL. WIC mothers' depressive symptoms are associated with greater use of feeding to soothe, regardless of perceived child negativity. Pediatr Obes 2016 Feb 29. [CrossRef] [Medline]
    13. Lovejoy M, Graczyk P, O'Hare E, Neuman G. Maternal depression and parenting behavior. Clin Psychol Rev 2000 Aug;20(5):561-592. [CrossRef] [Medline]
    14. Milgrom J, Skouteris H, Worotniuk T, Henwood A, Bruce L. The association between ante- and postnatal depressive symptoms and obesity in both mother and child: a systematic review of the literature. Women's Health Issues 2012 May;22(3):e319-e328. [CrossRef] [Medline]
    15. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child 2012 Dec;97(12):1019-1026 [FREE Full text] [CrossRef] [Medline]
    16. Barrett KJ, Thompson AL, Bentley ME. The influence of maternal psychosocial characteristics on infant feeding styles. Appetite 2016 Aug 1;103:396-402. [CrossRef] [Medline]
    17. Lampard AM, Franckle RL, Davison KK. Maternal depression and childhood obesity: a systematic review. Prev Med 2014 Feb;59:60-67 [FREE Full text] [CrossRef] [Medline]
    18. Tate EB, Wood W, Liao Y, Dunton GF. Do stressed mothers have heavier children? a meta-analysis on the relationship between maternal stress and child body mass index. Obes Rev 2015 May;16(5):351-361 [FREE Full text] [CrossRef] [Medline]
    19. Duarte CS, Shen S, Wu P, Must A. Maternal depression and child BMI: longitudinal findings from a US sample. Pediatr Obes 2012 Apr;7(2):124-133 [FREE Full text] [CrossRef] [Medline]
    20. Vollmer RL, Mobley AR. Parenting styles, feeding styles, and their influence on child obesogenic behaviors and body weight. a review. Appetite 2013 Dec;71:232-241. [CrossRef]
    21. Shloim N, Edelson LR, Martin N, Hetherington MM. Parenting styles, feeding styles, feeding practices, and weight status in 4-12 year-old children: a systematic review of the literature. Front Psychol 2015;14(6):1849. [CrossRef] [Medline]
    22. Hubbs-Tait L, Kennedy TS, Page MC, Topham GL, Harrist AW. Parental feeding practices predict authoritative, authoritarian, and permissive parenting styles. J Am Diet Assoc 2008 Jul;108(7):1154-61; discussion 1161. [CrossRef] [Medline]
    23. Kiefner-Burmeister A, Hoffmann D, Zbur S, Musher-Eizenman D. Implementation of parental feeding practices: does parenting style matter? Public Health Nutr 2016 Sep;19(13):2410-2414. [CrossRef] [Medline]
    24. Hurley KM, Cross MB, Hughes SO. A systematic review of responsive feeding and child obesity in high-income countries. J Nutr 2011 Mar;141(3):495-501 [FREE Full text] [CrossRef] [Medline]
    25. Dennis C, McQueen K. The relationship between infant-feeding outcomes and postpartum depression: a qualitative systematic review. Pediatrics 2009 Apr;123(4):e736-e751. [CrossRef] [Medline]
    26. Fiese BH, Hammons A, Grigsby-Toussaint D. Family mealtimes: a contextual approach to understanding childhood obesity. Econ Hum Biol 2012 Dec;10(4):365-374. [CrossRef] [Medline]
    27. Black M, Hurley K. Child-encyclopedia. 2007. Helping children develop health eating habits   URL: http:/​/www.​child-encyclopedia.com/​sites/​default/​files/​textes-experts/​en/​540/​helping-children-develop-healthy-eating-habits.​pdf [accessed 2017-05-15] [WebCite Cache]
    28. Fiese B, Foley K, Spagnola M. Routine and ritual elements in family mealtimes: contexts for child well-being and family identity. New Dir Child Adolesc Dev 2006;Spring(111):67-89. [Medline]
    29. Franko DL, Thompson D, Affenito SG, Barton BA, Striegel-Moore RH. What mediates the relationship between family meals and adolescent health issues. Health Psychol 2008;27(2, Suppl):S109-S117. [CrossRef]
    30. Barlow J, Coren E. Parent-training programmes for improving maternal psychosocial health. Cochrane Database Syst Rev 2004(1):CD002020. [CrossRef] [Medline]
    31. Hurley KM, Black MM. Introduction to a supplement on responsive feeding: promoting healthy growth and development for infants and toddlers. J Nutr 2011 Mar;141(3):489 [FREE Full text] [CrossRef] [Medline]
    32. Ertel KA, Rich-Edwards JW, Koenen KC. Maternal depression in the United States: nationally representative rates and risks. J Womens Health (Larchmt) 2011 Nov;20(11):1609-1617 [FREE Full text] [CrossRef] [Medline]
    33. Ko JY, Farr SL, Dietz PM, Robbins CL. Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009. J Womens Health (Larchmt) 2012 Aug;21(8):830-836 [FREE Full text] [CrossRef] [Medline]
    34. Farr S, Bitsko R, Hayes D, Dietz P. Mental health and access to services among US women of reproductive age. Am J Obstet Gynecol 2010 Dec;203(6):542.e1-542.e9. [CrossRef] [Medline]
    35. Le Strat SY, Dubertret C, Le FB. Prevalence and correlates of major depressive episode in pregnant and postpartum women in the United States. J Affect Disord 2011 Dec;135(1-3):128-138. [CrossRef] [Medline]
    36. National Institute of Mental Health. Depression: What You Need to Know. 2015.   URL: https:/​/www.​nimh.nih.gov/​health/​publications/​depression-what-you-need-to-know/​depression-what-you-need-to-know-pdf_151827.​pdf [accessed 2017-05-15] [WebCite Cache]
    37. Kendall-Tackett K. The new paradigm for depression in new mothers: current findings on maternal depression, breastfeeding and resiliency across the lifespan. Breastfeed Rev 2015 Mar;23(1):7-10. [Medline]
    38. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009 Jul 21;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]
    39. Hughes SO, Power TG, Liu Y, Sharp C, Nicklas TA. Parent emotional distress and feeding styles in low-income families. the role of parent depression and parenting stress. Appetite 2015 Sep;92:337-342. [CrossRef] [Medline]
    40. Mallan KM, Daniels LA, Wilson JL, Jansen E, Nicholson JM. Association between maternal depressive symptoms in the early post-natal period and responsiveness in feeding at child age 2 years. Matern Child Nutr 2015 Oct;11(4):926-935. [CrossRef] [Medline]
    41. Goulding AN, Rosenblum KL, Miller AL, Peterson KE, Chen Y, Kaciroti N, et al. Associations between maternal depressive symptoms and child feeding practices in a cross-sectional study of low-income mothers and their young children. Int J Behav Nutr Phys Act 2014;11:75 [FREE Full text] [CrossRef] [Medline]
    42. McCurdy K, Gorman KS, Kisler T, Metallinos-Katsaras E. Associations between family food behaviors, maternal depression, and child weight among low-income children. Appetite 2014 Aug;79:97-105 [FREE Full text] [CrossRef] [Medline]
    43. Gemmill AW, Worotniuk T, Holt CJ, Skouteris H, Milgrom J. Maternal psychological factors and controlled child feeding practices in relation to child body mass index. Child Obes 2013 Aug;9(4):326-337. [CrossRef] [Medline]
    44. Gross RS, Velazco NK, Briggs RD, Racine AD. Maternal depressive symptoms and child obesity in low-income urban families. Acad Pediatr 2013 Jul;13(4):356-363. [CrossRef] [Medline]
    45. Haycraft E, Farrow C, Blissett J. Maternal symptoms of depression are related to observations of controlling feeding practices in mothers of young children. J Fam Psychol 2013 Feb;27(1):159-164. [CrossRef] [Medline]
    46. Mitchell S, Brennan L, Hayes L, Miles CL. Maternal psychosocial predictors of controlling parental feeding styles and practices. Appetite 2009 Dec;53(3):384-389. [CrossRef] [Medline]
    47. DiSantis KI, Hodges EA, Johnson SL, Fisher JO. The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review. Int J Obes (Lond) 2011 Apr;35(4):480-492. [CrossRef] [Medline]
    48. Bascom EM, Napolitano MA. Breastfeeding duration and primary reasons for breastfeeding cessation among women with postpartum depressive symptoms. J Hum Lact 2016 May;32(2):282-291. [CrossRef] [Medline]
    49. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. The timing of maternal depressive symptoms and mothers' parenting practices with young children: implications for pediatric practice. Pediatrics 2006 Jul;118(1):e174-e182. [CrossRef] [Medline]
    50. von EE, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007 Oct 20;335(7624):806-808 [FREE Full text] [CrossRef] [Medline]
    51. Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977;1(3):385-401 [FREE Full text]
    52. Abidin R. Parenting stress index: professional manual. 3rd edition. Odessa, FL: Psychological Assessment Resources; 1995.
    53. Cox J, Holden J, Sagovsky R. Detection of postnatal depression. development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 1987 Jun 01;150(6):782-786. [CrossRef] [Medline]
    54. Antony M, Bieling P, Cox BJ, Enns M, Swinson R. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment 1998;10(2):176-181. [CrossRef]
    55. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001 Sep;16(9):606-613 [FREE Full text] [Medline]
    56. Zigmond A, Snaith R. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983 Jun;67(6):361-370. [Medline]
    57. Hughes SO, Power TG, Orlet FJ, Mueller S, Nicklas TA. Revisiting a neglected construct: parenting styles in a child-feeding context. Appetite 2005 Feb;44(1):83-92. [CrossRef] [Medline]
    58. Birch L, Fisher J, Grimm-Thomas K, Markey C, Sawyer R, Johnson S. Confirmatory factor analysis of the child feeding questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite 2001 Jun;36(3):201-210. [CrossRef] [Medline]
    59. McCurdy K, Gorman KS. Measuring family food environments in diverse families with young children. Appetite 2010 Jun;54(3):615-618. [CrossRef] [Medline]
    60. Musher-Eizenman D, Holub S. Comprehensive feeding practices questionnaire: validation of a new measure of parental feeding practices. J Pediatr Psychol 2007 Sep;32(8):960-972. [CrossRef] [Medline]
    61. Larios SE, Ayala GX, Arredondo EM, Baquero B, Elder JP. Development and validation of a scale to measure Latino parenting strategies related to children's obesigenic behaviors. the parenting strategies for eating and activity scale (PEAS). Appetite 2009 Feb;52(1):166-172 [FREE Full text] [CrossRef] [Medline]
    62. Wardle J, Sanderson S, Guthrie CA, Rapoport L, Plomin R. Parental feeding style and the inter-generational transmission of obesity risk. Obes Res 2002 Jun;10(6):453-462 [FREE Full text] [CrossRef] [Medline]
    63. Ogden J, Reynolds R, Smith A. Expanding the concept of parental control: a role for overt and covert control in children's snacking behaviour? Appetite 2006 Jul;47(1):100-106. [CrossRef] [Medline]
    64. Haycraft EL, Blissett JM. Maternal and paternal controlling feeding practices: reliability and relationships with BMI. Obesity (Silver Spring) 2008 Jul;16(7):1552-1558 [FREE Full text] [CrossRef] [Medline]
    65. Fildes A, van Jaarsveld CH, Llewellyn C, Wardle J, Fisher A. Parental control over feeding in infancy. influence of infant weight, appetite and feeding method. Appetite 2015 Aug;91:101-106. [CrossRef]
    66. Paulson JF, Dauber S, Leiferman JA. Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Pediatrics 2006 Aug;118(2):659-668. [CrossRef] [Medline]
    67. Tschann JM, Martinez SM, Penilla C, Gregorich SE, Pasch LA, de Groat CL, et al. Parental feeding practices and child weight status in Mexican American families: a longitudinal analysis. Int J Behav Nutr Phys Act 2015 May;12:66 [FREE Full text] [CrossRef] [Medline]
    68. Rodgers RF, Paxton SJ, Massey R, Campbell KJ, Wertheim EH, Skouteris H, et al. Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study. Int J Behav Nutr Phys Act 2013;10:24 [FREE Full text] [CrossRef] [Medline]
    69. Hennessy E, Hughes SO, Goldberg JP, Hyatt RR, Economos CD. Permissive parental feeding behavior is associated with an increase in intake of low-nutrient-dense foods among American children living in rural communities. J Acad Nutr Diet 2012 Jan;112(1):142-148. [CrossRef] [Medline]
    70. Gross RS, Fierman AH, Mendelsohn AL, Chiasson MA, Rosenberg TJ, Scheinmann R, et al. Maternal perceptions of infant hunger, satiety, and pressuring feeding styles in an urban Latina WIC population. Acad Pediatr 2010 Jan;10(1):29-35. [CrossRef] [Medline]
    71. Lumeng JC, Ozbeki TN, Appugliese DP, Kaciroti N, Corwyn RF, Bradley RH. Observed assertive and intrusive maternal feeding behaviors increase child adiposity. Am J Clin Nutr 2012 Jan 25;95(3):640-647. [CrossRef]
    72. Horodynski MA, Stommel M, Brophy-Herb HE, Weatherspoon L. Mealtime television viewing and dietary quality in low-income African American and Caucasian mother-toddler dyads. Matern Child Health J 2010 Jul;14(4):548-556. [CrossRef] [Medline]
    73. Domoff SE, Lumeng JC, Kaciroti N, Miller AL. Early childhood risk factors for mealtime TV exposure and engagement in low-income families. Acad Pediatr 2016 Dec 13;17(4):411-415. [CrossRef] [Medline]
    74. Trofholz AC, Tate AD, Draxten ML, Neumark-Sztainer D, Berge JM. Home food environment factors associated with the presence of fruit and vegetables at dinner: a direct observational study. Appetite 2016 Jan 01;96:526-532 [FREE Full text] [CrossRef] [Medline]
    75. Martin-Biggers J, Spaccarotella K, Berhaupt-Glickstein A, Hongu N, Worobey J, Byrd-Bredbenner C. Come and get it! a discussion of family mealtime literature and factors affecting obesity risk. Adv Nutr 2014 May;5(3):235-247 [FREE Full text] [CrossRef] [Medline]
    76. Wyse R, Campbell E, Nathan N, Wolfenden L. Associations between characteristics of the home food environment and fruit and vegetable intake in preschool children: a cross-sectional study. BMC Public Health 2011 Dec 16;11:938 [FREE Full text] [CrossRef] [Medline]
    77. Østbye T, Malhotra R, Stroo M, Lovelady C, Brouwer R, Zucker N, et al. The effect of the home environment on physical activity and dietary intake in preschool children. Int J Obes (Lond) 2013 Oct;37(10):1314-1321 [FREE Full text] [CrossRef] [Medline]
    78. Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA 2016 Jun 07;315(21):2292-2299. [CrossRef] [Medline]

    ‎
    BMI: body mass index
    BSI: Brief Symptom Inventory
    CES-D: Center for Epidemiologic Studies Depression Scale
    CFSQ: Child Feeding Styles Questionnaire
    CFQ: Child Feeding Questionnaire
    CINAHL: Cumulative Index to Nursing and Allied Health Literature
    DASS: Depression Anxiety Stress Scales
    EPDS: Edinburgh Postnatal Depression Scale
    FMCS: Family Mealtime Coding System
    HIV: human immunodeficiency virus
    PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis
    STROBE: Strengthening in the Reporting of Observational Studies in Epidemiology

    Edited by G Eysenbach; submitted 13.08.16; peer-reviewed by F Aboud, R Rodgers; comments to author 08.09.16; revised version received 16.12.16; accepted 25.03.17; published 26.05.17

    Copyright

    ©Ana Cristina Lindsay, Tatiana Mesa, Mary L. Greaney, Sherrie F. Wallington, Julie A. Wright. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 26.05.2017.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Public Health and Surveillance, is properly cited. The complete bibliographic information, a link to the original publication on http://publichealth.jmir.org, as well as this copyright and license information must be included.