Eating in the absence of hunger: Stability over time and associations with eating behaviours and body composition in children
Introduction
Increasing rates of obesity observed since the mid-20th century have been partially attributed to changes in the food environment, abundant in affordable, palatable and energy-dense foods, often served in large quantities, that promote greater energy intakes within and around meal times [25,33]. Responsiveness to environmental food cues like the sight or smell of foods can be reflected in physiological and behavioural responses. This includes increased salivation and endocrine changes, as well as increases in subjective appetite and selecting and consuming larger quantities of food [5,14,16,22,36,38]. Though the “obesogenic environment” is thought to promote overconsumption, there are individual differences in appetitive traits and responsiveness to environmental food cues, which emerge early in life and stabilise during development, and help to explain why not everybody overconsumes energy and develops obesity [32].
Eating despite being full when exposed to palatable foods is a behavioural expression of heightened food responsiveness that could put children at risk of overconsuming calories. This behaviour can be empirically measured by exposing children to freely available snacks immediately after consuming a meal to satiety, in what Fisher and Birch [19] conceptualised as the ‘Eating in the Absence of Hunger’ (EAH) paradigm. The EAH paradigm is primarily thought to test a child's responsiveness to external palatable food cues, however increased energy intake during this task might also reflect some aspects of satiety responsiveness [9], disinhibited eating [44,45] and emotional arousal [46]. Moreover, the propensity to eat without hunger has hereditary and genetic components [20,48] that are likely to be perpetuated by certain parental feeding practices, such as restriction of foods [12,18], indicating the potential for large individual differences in this behaviour.
EAH has been shown to be more prevalent among children with overweight/obesity, or at higher familial risk for overweight/obesity [15,23,24,27,35]. However, many of the studies examining the link between EAH and obesity in paediatric populations have been conducted only on girls, and those conducted on both boys and girls suggest that this relationship could be dependent on the child's sex and age (for full review see [31]). Studies conducted with girls show that EAH is stable over time [19] and is linked to higher adiposity and prospective weight gain [41]. Among studies which considered both sexes, some showed that EAH is linked to higher adiposity in girls, but not boys [12], while others demonstrated the links with adiposity among boys, but not girls [26]. Further research is needed to examine the stability of this behaviour among children from both sexes, and the potential links with body composition and weight gain over time.
Children who eat in the absence of hunger may be at risk for overconsuming calories and developing obesity, but it is unclear whether they also demonstrate other behaviours associated with higher energy intakes, such as selecting and consuming larger portions of food. Previous research demonstrated that among 4 year old children EAH was linked with increased intake of foods at lunch, particularly when children were presented with larger portions of food to consume [22]. Children, like adults, eat more when they are served larger portions of food [2,21,29,43] and it has been suggested that encouraging children to self-serve their food could be a strategy to promote self-regulation and reduce intake [4]. However, there are individual differences in self-served food portions and not all children eat less when given the opportunity to serve themselves at a meal [7,17,40]. It is possible that selecting larger portions of food could reflect a similar dimension of food cue responsiveness as that captured by the EAH paradigm, and highly food responsive children may select and consume larger portions of different foods, not just palatable snacks.
To better understand the link between EAH and weight status during childhood, the current study sought to test whether EAH is stable over time and is associated with larger portion selection, increased energy intake and adiposity in children. Specifically, we first examined whether EAH is a stable behaviour between 4.5 and 6 years of age (1). We then investigated the links between EAH and (2) energy consumed during an ad libitum lunchtime meal, (3) child selected ideal portion sizes across a range of foods (4) and child adiposity. We hypothesised that EAH would show stability from 4.5 to 6 years. We further predicted that children who ate in the absence of hunger would consume more energy at lunch, would have higher cumulative energy intakes across the two eating occasions and would select larger portions of foods on a computer based portion selection task. Finally, we predicted that EAH would be associated with higher BMI and higher adiposity at both time points, and children who ate in the absence of hunger at age 4.5 years would have higher BMI and greater increase in BMI between the ages 4.5 and 6 years.
Section snippets
Participants
The participants in this study were children from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort (N = 1247), who participated in eating behaviour measures (lunch selection and intake, and the EAH task) at 4.5 (± 2 months) and 6 (± 2 months) years of age. Eligibility criteria and recruitment methodology for the GUSTO cohort are described in detail elsewhere [42]. Pregnant women (18–50 years) were recruited from two major public hospitals in Singapore. Participants had to be
Statistical analysis
Children's energy intake during the EAH task was treated as a continuous variable, but was also converted into categorical variables to differentiate children who did not consume any food during the EAH task from those who consumed some energy, and who were further split to low vs high EAH intake using a median split adapted after [19]. All study aims were tested comparing children who did not show EAH and those who did (binary variable), and those with no EAH, low EAH and high EAH, to reduce
Sample characteristics
There sample consisted of 84 boys and 74 girls, who were of Chinese (n = 94), Malay (n = 32) or Indian (n = 32) ethnicity. The highest educational achievement reported by the mothers at recruitment was primary education (5.6%), secondary education (60.3%) or university education (31.6%, 2.5% unreported). The mean birth weight was 3137 g ± 450 and the majority of the sample had the gestational age above 37 weeks (94.4%).
Energy intake during lunch and the EAH task at both ages, presented for the
Discussion
The current study examined the stability of eating in the absence of hunger between 4.5 and 6 years, as well as the relationship between this behaviour and children's intake of energy, self-selected ideal portion sizes, and their body weight and composition. Children who showed EAH consumed cumulatively more energy over the two eating occasions (2), and tended to select larger ideal portions of foods (3). Importantly, children who showed EAH at 4.5 years were 3 times more likely to eat in the
Sources of support
This work is supported by the Translational Clinical Research (TCR) Flagship Program on Developmental Pathways to Metabolic Disease funded by the National Research Foundation (NRF) and administered by the National Medical Research Council (NMRC), Singapore-NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014. Additional funding is provided by the Singapore Institute for Clinical Sciences-Nestle Research Centre-Epigen Collaboration fund; (G00067; BMSI/15-300004-SICS), A*STAR and Nestec SA. KMG is
Authors' contributions
This study was conceived and designed by CGF, AF, KMC, MFFC and LRF. Analyses were performed and interpreted by AF, KMC and CGF. ATG, JYT and MJC were involved in data collection. AF, KMC and CGF prepared the draft manuscript with input from LRF, QPL and MFFC. YSC, KHT, FY, LPS, MJM, BFPB, YSL and KMG were responsible for conception and recruitment for the GUSTO cohort. All authors reviewed and approved the final draft.
Competing interests
K. M. G., Y. S. L., C.G.F. and Y.-S. C. have received reimbursement for speaking at conferences sponsored by companies selling nutritional products. They are part of an academic consortium that has received research funding from Abbott Nutrition, Nestec and Danone. L.R.F. is an employee of Nestec SA, working at the Nestlé Research Center. The other authors have no financial or personal conflict of interests.
Ethics approval and consent to participate
Informed written consent was obtained from participants, and the study was approved by the National Healthcare Group Domain Specific Review Board and SingHealth Centralized Institutional Review Board.
Acknowledgements
The GUSTO study group includes: Allan Sheppard, Amutha Chinnadurai, Anne Eng Neo Goh, Anne Rifkin-Graboi, Anqi Qiu, Arijit Biswas, Bee Wah Lee, Birit F.P. Broekman, Boon Long Quah, Borys Shuter, Chai Kiat Chng, Cheryl Ngo, Choon Looi Bong, Christiani Jeyakumar Henry, Claudia Chi, Cornelia Yin Ing Chee, Yam Thiam Daniel Goh, Doris Fok, E Shyong Tai, Elaine Tham, Elaine Quah Phaik Ling, Evelyn Chung Ning Law, Evelyn Xiu Ling Loo, Fabian Yap, Falk Mueller-Riemenschneider, George Seow Heong Yeo,
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