Integration Services

Literature Review
by Denise Hardingham

Despite our increased awareness and understanding of nutrition many children continue to have diets lacking in essential nutrients(Falciglia, Couch, Gribble, Pabsta, & Frank, 2000). In particular the quality and variety of the modern western diet has become the focus of concern with fruit and vegetable consumption continuing to fail to meet recommended intake(Gregory, et al., 2000). This is thought to have major implications for the management of many chronic illnesses, including obesity related illnesses(World Health Organisation, 1990). Food preference is thought to be one of the strongest predictors of food intake(Cooke L., 2007). In an effort to improve dietary intake it is therefore important to understand food preferences and how they develop.
Food preference in adults and older children has been shown to have a strong relationship with food preference and aversion in early childhood. Nicklaus, Bogglio, Chabanet and Issanchou(2005) conducted a longitudinal study over 20 years and established that children’s food variety seeking at age two to three years was positively correlated with food variety seeking at ages 4 -7 years, 8 -12 years, 13- 16 years and 17 – 22 years of age. This study indicates that food choice and behaviours established prior to the age of four years are predictive of eating behaviours into early adulthood contributing to the evidence from other studies indicating similarly that dietary habits acquired in early childhood persist through to adulthood (Kelder, Perry, Klepp, & Lytle, 1994; Nicklas, 1995; Steptoe, Pollard, & Wardle, 1995). For this reason it is important to understand how food preferences and behaviours develop in early childhood. One of the factors that may contribute to this is food neophobia. Food neophobia is literally a fear, or avoidance of, new foods(Dovey, Staples, Gibson, & Halford, 2008). In recent research it is most commonly measured using Pliner and Hobden’s(1992) Food Neophobia Scale or versions of it, such as the Child Food Neophobia Scale(Pliner, 1994). This scale provides a score across a spectrum from lower to higher levels of food neophobia. Though research often implies a clinical cut off alluding dichotomously to having or not having food neophobia this is an inaccurate reflection of the capabilities of current measures. This review aims to focus on the factors contributing to food neophobia and consider their implications for intervention and improvements to the quality of dietary variety in western society.
Food neophobia
Some have argued that the development of food preferences may be subject to a sensitive or critical period in early childhood which is concurrent with a peak in food neophobia(Cashdan, 1994). Whilst in some individuals this persists throughout their lifetime it has been shown to have an increased prevalence in children between the ages of two and six years of age (Addessi, Galloway, Visalberghi, & Birch, 2005;Cashdan, 1994; Cooke, Wardle, & Gibson, 2003). Food neophobia increases gradually over the period from the introduction of solids between four and six months of age reaching a peak between two years and six years of age (Dovey et al., 2008; Addessi et al., 2005; Cashdan, 1994; Cooke, Wardle, & Gibson, 2003)before gradually reducing into adulthood for most individuals (Koivisto-Hursti & Sjöden, 1997). Research also indicates that there may be another increase in food neophobia in old age(Otis, 1984; Tuorila, Lahteenmaki, Pohjalainen, & Lotti, 2001). As suggested by Dovey et al., (2010) this may be due to a genuine increase in food neophobia perhaps precipitated by increasingly frail health or may simply be reflective of an issue in cross-sectional research, and in fact this is related to generational effects. Older people may have been exposed to less variety in their diets, particularly in the form of exposure to ethnic foods, throughout their lifespan than younger people. A better understanding of this apparent phenomenon may also contribute to our understanding of the peak in food neophobia observed in early childhood.
Food neophobia in early childhood is widely held to be an evolutionary adaption to protect young children from potential poisoning as they become independently mobile(Birch, Gunder, Grimm-Thomas, & Laing, 1998; Cashdan, 1998; Wright, 1991).Gerrish&Menella(2001) demonstrated a greater acceptance of novel foods in 4 and 6 month old children receiving three food items over a 10 day period than those who had exposure to only a single food. This supported earlier correlational studies reporting that eating behaviour in older children could be predicted by their exposure and experience of a variety of foods in infancy(Pelchat & Pliner, 1986; Skinner, Carruth, Bounds, Zeigler, & Riedy, 2002). Such research suggests that infancy, prior to the peak of food neophobia, is a key period for the introduction of dietary variety. Infants may however continue to have diets which are somewhat restricted or may vary from an adult diet for a number of reasons including the physical capacity to take food in adult form. Whilst capitalising on this very early period to introduce a variety of foods, it remains advantageous to be able to build on this experience in the toddler and pre-school years. This is an age when children are arguably developing critical foundations for food preference(Cashdan, 1994). Children with high levels of food neophobia have been reported to have diets that are nutritionally deficient(Falciglia, Couch, Gribble, Pabsta, & Frank, 2000) with notably poorer vegetable intake (Jacobi, Agras, Bryson, & Hammer, 2003; Galloway et al. 2003).
Eertman, Baeyens and van den Bergh (2001) suggested a model of food selection and intake which expanded on Rozin’s(1990)taxonomy of food rejection. In this model there are internal and external factors that impact on liking, anticipated consequences and ideational factors which directly influence eating behaviour, food choice and food intake. Research in the area of the attenuation of food neophobia may be most constructively focused on external factors that can be manipulated for successful intervention.

Food neophobia and picky/ fussy eating
A related though qualitatively distinct issue that at times confounds research in the area of food neophobia is picky/fussy eating. Food neophobia may be present in picky/fussy eaters but is not necessary. Picky/ fussy eating is defined by highly selective and restrictive eating behaviours. Such children may or may not have difficulties with trying new foods but will have issues related to many aspects of their ongoing diet including reduced dietary variety through rejection of familiar foods. The literature on picky/fussy eating as an independent construct is limited as this has been a fairly recent focus. On the other hand the literature on food neophobia has a much more extensive history; however the failure to separate these constructs at times makes interpretation of the literature difficult. Both the etiology and impact of food neophobia and pick/ fussy eating are likely to involve distinct and unique factors as well as some potentially shared factors. Food neophobia affects both children with and without picky/ fussy eating and may exacerbate the maintenance of picky/ fussy eating and detrimentally effect long term dietary variety through limited food preference, as children with food neophobia have limited opportunity to experience new foods and expand dietary repertoire.
Factors influencing food neophobia
Food neophobia has been shown to have both genetic and non-genetic contributions. Knaapila et al. (2007) conducted a study with 468 pairs of British twin girls and reported that genetic contributions account for an estimated two-thirds of the variance in the expression of food neophobia. Despite the heritable nature of food neophobia similar results have not been found for food preference (Greene, Desor, & Maller, 1975; Rozin & Millman, 1987). This may be in part due to methodological issues related to operationalisation and measures. It may also be reflective of the capacity for non-genetic factors to attenuate the expression, duration and intensity of food neophobia which can influence the development of food preferences.
It has been well established that the expression of food neophobia can be shaped through exposure in older children. The role of exposure has been explored in a number of ways from procedures involving “mere exposure” (Sullivan & Birch, 1990; 1994) to sensory food intervention studies (Mustonen & Tourila, 2010). The procedure for “mere exposure” studies involves simply presenting children with a novel food repeatedly over time (Cooke L. , 2007). These studies have demonstrated that between 8 and 15 exposures are required to increase food preference (Birch, Zimmerman, & Hind, 1980; Loewen & Pliner, 1999; Skinner, Carruth, Bounds, Zeigler, & Riedy, 2002; Sullivan & Birch, 1990). Most children in this age range are likely to receive far fewer presentations of food in a naturalistic setting (Carruth & Skinner, 2000; Skinner et al., 2002; Carruth et al. 2004).
Sensory food interventions are based on the premise that familiarity with foods increases with exposure and learning about food via preparation and cooking. These programmes, exemplified by the French Classes de Groût(Puisais & Pierre, 1987), tend to be undertaken with school-aged children and whilst increases in consumption of desired foods has been shown immediately subsequent to intervention there is some contention as to whether this has any long term impact on dietary choices (Mustonen & Tourila, Sensory education decreases food neophobia score and encourages trying unfamiliar foods in 8-12-year-old children, 2010). Food preferences established in a younger age group may have greater impact long term.
Despite the limited research regarding long term effectiveness sensory education programmes have had widespread appeal. Mustonen, Rantanen & Tourila (2009)studied children participating in a sensory education programme across a two year span with Finnish middle school children. Children’s sensory awareness of food in terms of taste and odour was measured before the study, after a first wave of education, before a second wave of education and finally after a second wave of education. As theoretically sensory education and exposure to a variety of foods is thought to lead to reduced reluctance to try new foods (lower neophobic behaviours) a measure of preparedness to try unfamiliar foods was also taken at each of the four stages mentioned. The researchers were not able to demonstrate an impact of such programs on children’s propensity to try new foods also highlighting results were not stable over time. This is consistent with the findings of Reverdy, Chesnel, Schlich, Köster, and Lange (2006)who reported that the initial decrease in declarative food neophobia of a group of 8 to 10 year olds engaged in a sensory food education programmes disappeared after 10 months. This study did however show an increase in chemosensory awareness in the younger age group that appeared to be more stable and concluded that sensory education programmes may be best applied to younger age groups. Such studies highlight that understanding the developmental path of our relationship with food is of key importance in considering the appropriateness of education programmes for bringing about behavioural change in eating.
Children when compared with adults place different values on the properties of foods with children being more concerned with sensory qualities and adults reporting greater concern with health and nutrition (Nicklaus et al., 2005), suggesting that the factors that impact upon our food choices change in relation to age. As children also place a greater value on the social context, and experiences related to eating this may in turn have an impact on the development of food associations and thus preferences. In a study of eating behaviours of Welsh school children, Warren, Parry, Lynch & Murphy (2008)found that both third grade and fifth grade children valued being given a choice about what they ate. The nature of this choice varied however, with younger children considering the limited choice afforded to them in the form of school dinners more attractive than packed lunches which they felt were provided with little consultation. By fifth grade the children no longer considered the limited selection on the school dinner menu to be representative of choice. Importantly younger children were also more concerned with the social context around eating than the food or level of choice indicating that the opportunity to eat with others negated their concern regarding the menu.
Social facilitation has been shown to have an important role in the attenuation of food neophobia in young children(Addessi, Galloway, Visalberghi, & Birch, 2005). As defined by Clayton (1978)social facilitation is the increased frequency of a pattern of behaviour in the presence of others displaying that behaviour. In the case of eating behaviour, social facilitation leads to increased consumption relative to the number of people present
(de Castro, 1997;2001; 2002; de Castro & Brewer, 1992)
In young children information about food acceptability and palatability is more readily conveyed through modeling than provision of information(Birch, 1980; Duncker, 1938; Marinho, 1940). Many studies have shown that children are more likely to try food in the presence of a model that is eating the same food (Birch, 1980; Addessi, Galloway, Visalberghi, & Birch, 2005). The influence of cognition in the area of learned behaviour associated with food and eating has had minimal attention. Pliner(1994) asked children who had reported rejection of certain foods, why they had done so. The researchers found their answers to be related either to appearance or to expectations about taste. This indicates that children are engaging established knowledge systems or cognitive schema about food developed at an earlier stage to assist them to make decisions about the acceptance or rejection of novel foods. Birch et al. (Birch et al., 1998) reported that children’s decisions to try or reject a novel food were related to their experiences with food that looked similar. Pliner(2008)suggests that cognitive schemas are a useful heuristic through which to understand the complex relationship humans rapidly develop with food in early childhood.
Food neophobia is widely reported to include a negative evaluative process in advance of having tried a novel food (Pliner, 2008). Food neophobic behaviour may be understood in terms of bias toward avoidance of false negatives. A false positive in terms of food ingestion would be that we presume a food to be nutritious and it is in fact not. Conversely a false negative would be when we presume a nutritious food to be dangerous and it is not, thereby missing out on its relative nutritional value. Should we miss judge the cost is far higher if we lean toward the false positive and ingest something that is not only devoid of nutrition but dangerous. Thus it is suggested that we are biased toward false negatives (Pliner, 2008).
One way to challenge schemata is to introduce an item that contradicts previous assumptions related to the given category. A new food that is both tasty and nutritious would represent such a stimuli in terms of schema related to novel foods. It has been shown that preparedness to try new foods increases significantly when positive taste information is made available (Pelchat & Pliner, 1995). Another method is to suggest that an item does not belong in the unfamiliar category. This is done using the flavour principle whereby condiments or seasonings familiar to the individual, usually culturally relevant, are added in order to encourage trying (Pliner, 2008). The new food is then disguised as a familiar food and ultimately is no longer an unfamiliar food. This second method is problematic as it involves the addition of potentially large quantities of nutrients such as salts common to many condiments, and as such may have limited utility with children. A further confound in such research as applied to food neophobia is that it relies on taste perception which implies that trying has taken place. Visual aspects of food have been shown to be an important factor in encouraging this initial trying, and thus temporarily overcoming food neophobia, in young children (Birch et al., 1998). Interventions such as those discussed above, which require tasting to occur, may be more pertinent to picky/ fussy eating.
Role of parental feeding styleThe parental role in the development of food preferences is significant and may start as early as the breast feeding phase. Infants have shown preferences for foods consumed by their mothers during breastfeeding (Mennella & Beauchamp, 1999; Sullivan & Birch, 1994). Cooke et al., (2003)were able to show this effect in fruit but not vegetable consumption indicating that there is yet more work to be undertaken in this area to fully appreciate the mechanisms behind this effect. Later parental food preferences and levels of neophobia influence children’s eating through the foods which are available and served in the household (Koivisto-Hursti & Sjöden, 1997). Given the genetic contribution to food neophobia it is likely that children with high food neophobia have at least one parent also displaying this trait thus further limiting the likelihood of diversity in family meals and opportunity for modeling.
The emerging complexities involved with learning processes in regard to the development of eating behaviours have led researchers to consider parental feeding styles more generally. In response to developing a better understanding of the mechanisms that contribute to parental feeding styles Birch et al. (2001)developed a parental self-report measure, the Child Feeding Questionnaire (CFQ), designed to assess parental attitudes, beliefs and feeding practices in relation to children’s obesity proneness. In this instrument control has been conceptualised as monitoring, pressure and restriction. Research in this area has thus tended to centre on these mechanisms of control.
Restriction relates to practices that involve the withholding of foods. Utilising food as a reward is included in restriction. Research looking at restriction has found that children whose access to particular foods is restricted tend to over eat in the absence of parental control (Birch, Fisher, & Davidson, 2003). A further complication of the effect of external cues such as parental reward, restriction, and pressure to eat is that our natural capacities to attend to internal cues such as bodily sensations signaling satiation appear to become diminished. Birch et. al. (1980) demonstrated that children who were encouraged to rely on external cues to eat, such as time, and to cease eating, such as “when you finish everything on your plate” had poorer response to the energy density of foods and meal size than children who had been encouraged to rely on internal cues to tell them when and how much to eat.
It has been demonstrated that pressure to eat is associated with lower fruit and vegetable consumption (Galloway, Fiorito, Lee, & Birch, 2005) though the directionality of such effects has been less clear. In an experimental design Galloway, Fiorito, Francis & Birch (2006)found that children ate less and expressed greater negative affect for foods under a pressured eating condition in a laboratory setting. Pressured eating conditions have also been reported to have long term negative consequences. Batsell, Brown, Ansfeild, &Paschall’s(2002)retrospective study of forced consumption found that such episodes had a lasting impact on an individual’s dislike for the food associated with that experience. Included in the forced consumption reports were feelings of helplessness and lack of control. On the other hand devolving decision making around food choices entirely to children has been related to drinking less milk and a lower intake of all nutrients with the exception of fats (Eppright, Fox, Fryer, & et al, 1970). Seagren& Terry (1991)reported that parents of obese pre-school children exercised less control over their child’s food.
This may be analogous to general theories of parenting styles in which subtle variations in level and type of control (discipline/ setting boundaries) results in the development of specific and differing traits in children (Baumrind, 1966). In terms of eating behaviours high levels of control are demonstrated by an attempt to control children’s food intake and eating behaviour via external coercion, reward and punishment. This would be analogous to an authoritarian parenting style. Permissive parenting styles exercise little control at all which seems to have equally undesirable consequences. Authoritative parenting may be analogous to forms of boundary setting and instruction which are consultative yet offer clear direction about appropriate food preferences and the reasons for this. As in the general literature on parenting styles, authoritative parenting has been suggested to be more effective in the development of adaptive eating behaviours and food preferences (Nicklas et al. 2001).
Just as the literature on general parenting styles has developed and been shown to be multi-dimensional so too the literature concerning parental feeding styles has further explored the complexities of parental control on children’s eating behaviour. In an attempt to better understand the nature of parental feeding styles in relation to control Ogden, Reynolds & Smith (2006)explored overt and covert styles of control. Covert controls are defined as forms of control which the child is not consciously aware such as avoiding certain food outlets or simply not bringing certain foods into the house. The researchers describe overt controls as forms of control which the child is aware of such as the types of restriction and pressure to eat that have been mentioned previously. The researchers reported that in their new measure of parental feeding style overt and covert control were highly correlated with the existing measures of pressure, monitoring and restriction, as measured by the CFQ, though no more so than each of the existing measures correlated with each other and that each construct contributed a significant unique proportion of the variance. The researchers concluded that covert and overt control were independent factors contributing to our understanding of the role of control in parental feeding styles.
Ogden, Reynolds & Smith (2006) also explored the role of overt and covert control on children’s snacking behaviour reporting that parents with lower body mass index and children perceived as heavier tended to use covert strategies to control their children’s food intake and parents of higher social class were more likely to use overt control. The researchers reported that children subject to covert control ate fewer unhealthy snacks whilst children subject to overt control ate more healthy snacks. Overt and covert control as measured by a 10 item scale devised by Ogden et. al. (2006) was reported to be measuring unique and additional elements of control in parental feeding style when compared to the three subscales (monitoring, restriction and pressure) of the CFQ(De Bourdeaudhuij, Te Velde, Maes, Perez-Rodrigo, de Almeida, & Brug, 2009) (Birch et. al., 2001).
Whilst it has been established that the Child Food Neophobia Scale (CFNS) as filled in by parents is a reliable measure of children’s food neophobia (Cooke et. al., 2006) very little research has focused on behavioural measures of food intake or eating behaviour. To date most studies investigating the relationship between children’s food neophobia and the role of control have either focused on the relationship between neophobia and parental feeding style or have relied on further parental report to assess children’s actual food intake.
An exception is Galloway et al’s (2003) study in which they looked at children’s intake of soup under pressure and unpressured eating conditions over time. Each condition in this experiment, pressure and no pressure, involved the presentation of a specific soup without the child having any choice of which soup they would be served. It is arguable that the laboratory setting and the condition of having a specific soup presented without choice introduces a form of control and pressure as this is an unnatural environment for young children. Young children in natural environments are generally presented with foods with little choice regarding what appears on their plate. There has as yet been no research investigating whether the level of control a child has over what is on their plate improves their preparedness to try new foods or whether the element of choice has specific impact on children with high food neophobia in a naturalistic setting.
The effects of control are particularly problematic in relation to food neophobia. The research and literature in this area has been muddied by the failure to distinguish adequately between neophobia and picky/ fussy behaviours (Dovey et. al., 2010). Many exposure studies include reference to the need for “trying” as an important variable in improving acceptance (Nicklas et al., 2001). This is then a step beyond neophobic behaviour as once trying has occurred neophobia has in theory been overcome, at least on that occasion. This is then the domain of a further set of factors contributing to the development and maintenance of picky/ fussy eating.
Summation and future directions
Food neophobia has been shown to have a significant role in the development of eating behaviours and food preferences in early childhood. Food preferences in early childhood have been linked to food preferences and eating behaviours that are persistent through adulthood. Though genetic influences account for a large proportion of the variability in food neophobia other factors such as social facilitation, exposure and parental feeding style have all been shown to be effective in the attenuation of the expression and duration of neophobic behaviours. Understanding the complexities of these factors and how they interact will assist in the development of interventions and education for parents and carers about how best to increase dietary variety in early childhood.
The literature on the influence of parental feeding styles on children’s fruit and vegetable consumption remains divided. Many studies have reported that parental pressure has a negative impact on children’s immediate and long term food intake and preferences (Batsell et al., 2002; Galloway et al., 2006). Restriction has been shown to be associated with greater uncontrolled consumption in absence of parental control and the consequences of using reinforcements in the modification of children’s eating behaviours may be successful in the short term but can have unintended and at times detrimental consequences. Other studies have found social factors such as parental modeling to have greater impact on children’s consumption than parental feeding styles(De Bourdeaudhuij, Te Velde, Maes, Perez-Rodrigo, de Almeida, & Brug, 2009; Vereecken, Legiest, De Bourdeaudhuij, & Maes, 2009; Vereecken, Rovner, & Maes, 2010; Wardle, Carnell, & Cooke, 2005). Boucier, Bowen, Meischke, & Moinpour ( 2003)found no relationship between the two factors
Several methodological issues arise when attempting to demystify the contradictions in these studies. Firstly there is little consensus regarding definitions of constructs (e.g. distinction between food neophobia and picky/ fussy eating) or instruments used to measure these. Secondly directionality remains ambiguous in studies that have found a relationship between parental feeding practices and children’s fruit and vegetable consumption. One study (Wardle, et al., 2005) found a significant negative correlation between parental control and children’s fruit and vegetable consumption. When the researchers further investigated this significance was lost once children’s level of food neophobia was taken into account. This leads to the question directionality. That is do the parent’s of neophobic children tend to use control strategies out of concern for their children’s lack of adequate dietary intake or are controlling parental feeding styles contributing to the expression of neophobic eating behaviours?
The literature on social facilitation and modeling makes a clear case for the importance of creating positive social feeding contexts for young children. Literature on effective parental feeding styles however is less clear though to some degree social facilitation and model may be related to this. Parental feeding style may contribute to affective associations formed around feeding contexts. The use of pressure and coercive methods to encourage children with high levels of food neophobia to eat may seem counter-productive in light of the research. Wardle et al., (2005) however found that the significant relationship between reduced fruit and vegetable consumption and controlling parenting style disappeared when level of neophobia was taken into account. It may be that the effects of controlling parental feeding styles are differentially related to highly neophobic children as opposed to their less neophobic peers. A level of control around feeding contexts may actually provide food neophobic children with an amount of security which lowers anxieties around trying new foods. The most appropriate intervention for neophobic eating behaviours may differ from those used with less neophobic or neophiliac children. Further research is certainly warranted in this area to establish group differences in relation to parental feeding style and to continue to try to establish issues of directionality with relation to whether parental feeding styles are impacting negatively on children’s eating behavior in relation to neophobia or whether more neophobic children encourage more controlling feeding styles in their parents. If children with higher levels of food neophobia actually benefit differentially to other children from more controlling parental feeding styles perhaps this is actually adaptive.

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