Non-Responsive Feeding Practices, Unhealthy Eating Behaviors, and Risk of Child Overweight and Obesity in Southeast Asia: A Systematic Review

Childhood obesity is increasing dramatically in many Southeast Asian countries, and becoming a significant public health concern. This review summarizes the evidence on associations between parental feeding practices, child eating behaviors, and the risk of overweight and obesity in Southeast Asian children 2–12 years old. We systematically searched five electronic academic/research (PubMed, PsycINFO, ProQuest Nursing, Medline, and CINAHL) databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for peer-reviewed studies published in English between January 2000 and December 2016. Fourteen observational studies met the inclusion criteria and were reviewed. Reviewed studies were examined separately for preschool- and school-aged children and revealed that non-responsive parental feeding practices and unhealthy child eating behaviors were associated with a risk of child overweight and obesity in several Southeast Asian countries. Nonetheless, due to the small number of identified studies (n = 14) and because only about half of the Southeast Asian countries (Thailand, Vietnam, Singapore, the Philippines, and Malaysia) were represented (5/11) in the examined studies, additional research is needed to further understand the factors associated with childhood obesity among children in Southeast Asia to develop interventions that are tailored to the specific needs of Southeast Asian countries and designed to address practices and behaviors that may promote childhood obesity.


Records excluded (n = 533)
Full-text papers assessed for eligibility (n = 15) Full-text papers excluded (n = 6) Studies included in qualitative synthesis and review (n = 14) Additional records identified through other sources (manual search of full-text papers and reviews) (n = 5) Table S1. Quality assessment of included studies using adapted "Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)" statement. Items: #1. Is the study a longitudinal? #2. Does the paper describe the participants' eligibility criteria? #3. Were study participants randomly selected (or representative of the study population)? #4. Did the paper report information about the measures, including references used to assess parental feeding practices and/or children's eating behaviors? #5. Did the study include information on instrument or scale used to assess parental feeding practices and/or child eating behaviors have acceptable reliability? #6. Did the paper report how overweight and obesity was assessed in children participating in the study? #7. Did the study provide information power calculation to detect hypothesized relationships? #8. Did the study report the number of individuals who completed each of the different measures? #9. Did the participants/respondents complete at least 80% of measures? #10. Did analyses take into account confounding factors?   To assess the magnitude of overweight and obesity, and identify associated sociodemographic factors in a population of preschool-aged children in the kindergarten system of Vietnam's largest city Breast-feeding was defined as being breastfed at any time. Breastfeeding duration was measured in months using an interviewer-administered, pre-coded questionnaire.
Height and weight measured using standard methods and used to calculate child's BMI using age-and sex-specific BMI cut-off points proposed by International Obesity Task Force (IOTF) The odds of being obese significantly decreased by 5% for each additional month of breastfeeding. However, the association between breastfeeding duration was not significant after controlling for confounding factors.
Huynh et al. To identify risk factors associated with obesity at the community and family environment levels, and to identify individual parental and child characteristics associated with changes in adiposity indicators over a one-year period.
Height and weight measured using standard methods and used to calculate child's BMI using cut-off points for overweight in Asian populations (of >23 kg/m 2) Breast-feeding was associated with reduced risk of child obesity. The protective effect of breast-feeding appeared to be more obvious in boys than in girls (reduced BMI in boys by 0.05 units).

Author (Year) Country
Sample's characteristics and study design

Preschool-age Children
Thongbai et al. To compare and investigate the relationship between the nutritional status and eating practice.
Parental feeding practices questions were used to measure parental feeding practices.
Children dietary habit questions and the three days diet record were used to assess children's diet intake.
Height and weight measured using standard methods and used to calculate child's BMI, which was used to determine weight status using the WHO and CDC 2000 growth chart as a reference.
There were significant differences in nutrient intake between children in rural and urban areas. Children's BMI had a positive relationship with fast food intake (r = 0.274, p= < 0.05) and eating out (r = 0.207, p < 0.05) was used to assess parental attitudes, beliefs and practices related to feeding children. Children's diet question was used to assess children's level of food consumption including 1) amount of food and 2) fatty food, sweets and snacks consumption.

Author (Year) Country
Height and weight measured using standard methods and used to calculate child's BMI.
Child's BMI and the mother's perception of the child's weight was negatively associated with pressure to eat and positively associated with monitoring. Restriction was positively associated with mother's perception of the child's weight. High consumption of fatty food, sweets and snacks was associated with high restriction and monitoring in rural area and high restriction and pressure to eat but low monitoring in urban area. The amount of food consumed was negatively associated with pressure to eat in rural area, but positively associated with monitoring in urban area. Do et al. To estimate prevalence of overweight and obesity for preschool children in both urban and rural areas and to identify risk factors of overweight and obesity among children.
Structured questionnaires included amount of food, food consumption, fast eating, irregular snacks, outdoor physical activity, indoor physical activity, sedentary time, family economy, mother's education, household size, watching food advertisements, and snack availability. These questionnaires were used to assess child eating habits and lifestyle by interviewing parents or caregivers.
Height and weight measured using standard methods and used to calculate child's BMI. Overweight and obesity were defined using WHO standards.
In the urban area, overweight or obesity in children was significant associations with age, large amounts of food, fast eating and indoor activity. In rural area, overweight or obesity in children was significant associations with age, frequent consumption of fatty, and mothers watching food advertisements on TV.

School-age Children
Zaini et al. Height and weight was measured using standard methods and used to calculate child's BMI and the IOTF standard was used to classify weight status.
There was association between the proportion of students who were breastfed for more than six months and classified as overweight and obese and the proportion of students who were breastfed for less than six months and classified as overweight and obese ( To examine the influence of family characteristics and maternal feeding practices on eating behaviors, food consumption, and nutritional status of children.
Used an FFQ and 24-hour food recall to assess the food consumption patterns of the children for two days.
Height and weight measured using standard methods and used to classify child's nutritional status using weight-for-height Z score (WHZ). The Thai growth reference was used to classify weight status.
Maternal control over the consumption of high caloric food and large amounts of food consumed by the children was associated with childhood obesity. Compared to normal weight children, a higher proportion of obese children were not breastfed.

Author (Year) Country
Sample's characteristics and study design To evaluate the association between breastfeeding and overweight and obesity.
Parents completed an interviewer-administered survey that assessed whether the participating child was ever breast-fed, duration of breastfeeding and type of breast-feeding. Breast-feeding was dichotomized (yes/no). Breastfeeding duration was categorized into two groups (<3 months, >3 months). Type of breastfeeding was defined as exclusive (fed no food other than breast milk); mostly (breast milk and non-formula supplements such as water, sweetened water or juices); or partly (breast milk supplemented with formula milk or other complementary foods).
Height and weight measured using standard methods and used to calculate child's BMI using the IOTF cutoff points to determine weight status.
There were no significant associations between breastfeeding status (yes/no), duration of breastfeeding 3 months, >3 months) and type of breastfeeding and overweight and/or obesity for the cohort and by sex.
Serene et al. To explore the association between familial and socioenvironmental factors and childhood obesity.
The Child Feeding Questionnaire (CFQ) [51] was used to parental feeding strategies, and ideas (perceived parent weight, perceived child weight, perceived responsibility, concern about child's weight, and restriction and pressure to eat).
Height and weight measured using standard methods and used to calculate child's BMI, which was used to determine weight status using the WHO growth reference for children aged 5-19 years of age.
Pressure to eat showed a reverse association with child's risk of overweight and obesity. Dietary habits were assessed using a 3-day food record. Children were asked to record the type of foods, quantity, and portion size of all food consumed.

Author (Year) Country
Height and weight measured using standard methods and used to calculate child's BMI, which was used to determine weight status using the WHO BMI-forage Growth chart as a reference.
Children classified as obese skipped breakfast more frequently than those classified as having a normal weight group.
Wan et al. Height and weight measured using standard methods was used to calculate child's BMI using the BMI-for-age WHO Growth chart as standard reference.
Perception of child's weight, perceived parental weight, and food restriction factors were positively associated with child's BMI, whereas pressure to eat was negatively associated with child's BMI.
To assess the associations between snacking (e.g. time, frequency, amount, type of snacks) and risk of overweight and obesity.
Data about-midmorning, mid-afternoon (both at school during the week), and nighttime snack was collected using an intervieweradministered 24-hour food recall.
Height and weight measured using standard methods and used to calculate child's BMI using the (IOTF's genderand age-specific cutoff points was used to determine weight status. The odds of being overweight was associated with high total snack servings was 2.12. The odds of being obese (both males and females) were associated with calories obtained from snacking.

Author (Year) Country
Sample's characteristics and study design Study Aim (s)

Measures of feeding practices and eating behaviors
Measures of overweight and obesity

School-age Children
Tay et al. Height and weight measured using standard methods and used to calculate child's BMI using the WHO growth standards. WC was measured using standard methods. %BF was measured by bioelectrical impedance.
Food responsiveness was positively associated with body adiposity for both sexes. Desire to drink was positively associated with BMI and WC for girls. Satiety responsiveness was negatively associated with body adiposity in both sexes except for %BF of boys. Slowness in eating was negatively associated with WC in girls. Emotional under-eating was negatively associated with the body adiposity (BMI) of boys.