Primary outcomes.

Child eating behaviors were assessed using Wardle et al.´s Child Eating Behavior Questionnaire (CEBQ). This is a 35-item instrument with eight subscales developed for children above two years of age [25]. The eight subscales are divided into two main dimensions; The Food approach dimension and the Food avoidance dimension. The CEBQ has good internal consistency, test-retest reliability and construct validity [26], and has previously been translated to Norwegian [27]. For the Child Eating Behavior Questionnaire subscales, Cronbach´s α varied between 0.7 and 0.9, indicating a moderate to good internal consistency.

To evaluate the child´s willingness to try new food, we used the 6-item Child Food Neophobia Scale (CFNS) modified by Wardle et al. [28]. The CFNS is a reliable and widely used questionnaire which has been validated against behavioral measures of food neophobia [29]. A Norwegian version of CFNS has previously been translated and published [30]. The range of possible scores varies between 6 and 24, with a high score indicating high levels of child food neophobia. For the Child Food Neophobia Scale, Cronbach´s α was 0.9, indicating a good internal consistency.

Child food intake was assessed by a food frequency questionnaire developed for this study, based on questionnaires from a Norwegian national survey [31] and the large population-based Norwegian Mother and Child Cohort Study (MoBa) [32, 33]. The MoBa-study has documented their rationale for use of the FFQ [33], and a Norwegian validation study of the national survey FFQ has been done for child age 24 months [34]. Frequency of intake was assessed without specifications of amounts consumed. Questions about drink and food intake were asked as follows: “How often does your child drink/eat the following beverages/food nowadays?” with answer-options from never/seldom to ≥5/day. These responses were recoded into a times-per-day score, e.g. 1–3 times/week was recoded into 0.3 times per day and 4–6 times/week was recoded into 0.7 times per day.

We made four different food category scores by summing the individual scores in each category: In the vegetable score we included the times-per-day scores for 15 different vegetables (potato, carrot, rutabaga, sweet potato, cauliflower, broccoli, green salad, spinach, cucumber, tomato, corn, peppers, peas/beans, frozen vegetable mix and salad of mixed raw vegetables) and in the fruit score we included times-per-day scores for 10 different fruits/berries (orange/clementine, banana, apple, pear, plum, grapes, kiwi, melon, mango, berries—all types). In the sweet/salty-snack score, we summed the times-per-week scores for five snacks (cakes/cookies or similar, dessert/ice cream, chocolate, sweets, potato chips) and in the soft-drink score we summed the times per week scores for sweetened beverages (lemonade, soda). All four food-category scores were then dichotomized at the median intake into a high or low score.

Questions about mealtime routines were based on questions used in the Australian NOURISH-study [35]. Parents were asked “How often do the following statements fit the child's meals today?", e.g. My child sits down when having meals. Response-options were almost always, often, sometimes, seldom, almost never. These were subsequently recoded into always/often and sometimes/seldom/never. We further asked how often the child were eating family meals nowadays, specifying “family” to be at least one adult eating the same meal. Response options were never/seldom, 1 time/week, 2 times/week, 3 times/week, 4 times/week, 5 times/week, every day. These were recoded into ≤ 3 times/week and ≥ 4 times/week.

The Child Feeding Questionnaire (CFQ) developed by Birch et.al. [36], is one of the most widely used questionnaires to assess parental feeding practices and examines parental attitudes and behaviors towards children´s diet. We included two subscales, Restriction and Pressure, to assess maternal controlling feeding practices in our sample. The CFQ has previously been translated to Norwegian and the same subscales were used in the Norwegian MoBa study [32]. Cronbach´s α for the Restriction and Pressure subscales of the Child Feeding Questionnaire was 0.66 and 0.63, respectively, indicating a moderate internal consistency for these subscales.

In addition, we used the Parental Feeding Style Questionnaire (PFSQ) designed by Wardle et al. [37], a tool for assessing four aspects of parental feeding styles; Instrumental feeding, Encouragement, Emotional feeding and Control over eating. PFSQ is a widely used questionnaire which shows good test-retest reliability and is validated in several cultures [38], and has also previously been used in Norway [27]. For the Parental Feeding Style Questionnaire subscales, Cronbach´s α varied between 0.7 and 0.8, indicating a moderate to good internal consistency.

Secondary outcomes.

Child weight and length at baseline (5 months), 12, and 24 months were measured at the child health clinics and reported by the mothers. If the child had not been to the clinic at these time-points, mothers had the opportunity to omit responding. Z-scores for weight-for-age and body mass index (BMI)-for-age were calculated using the software program WHO Anthro version 3.2.2. (Department of Nutrition, World Health Organization, Geneva, Switzerland) and macros.

Sub-group analysis.

At child age 12 months, we found no differences between mothers with lower and higher education for experiencing the intervention as feasible and easy to understand [24]. Since mothers with lower socioeconomic status constitutes a group of special interest in this field, we wanted to explore whether there were indications of any differences in the intervention’s suitability for this group compared to the entire study population. We performed a subgroup-analysis for the primary outcomes child dietary intake and mealtime routines including mothers who fulfilled at least one of the following criteria: 1) Lower education (not college/university degree); 2) Financial difficulties indicated by not being able to pay an unforeseen expense of 3000 NOK or having experienced difficulties paying their rent, food or transportation during the last six months; 3) Being a single mother (not married/cohabitant). The questions on financial difficulties were developed for the large population-based MoBa-study from the Norwegian Institute of Public Health to measure the family´s financial situation [33].

The participants´ compliance with the intervention.

In the intervention-group, 81% of the mothers reported to have watched all or most of the videos addressing infant feeding topics, while 9% reported to have watched two or less. For the cooking videos, 73% of the mothers reported to have viewed all or most of the films while 10% had viewed two or less. This is quite consistent with what we found at child age 12 months, where 85% of the mothers reported watching all or most of the feeding videos and 66% reported watching all or most of the cooking films. The respective percentages for viewing less than two of the videos were 8% and 20% [24].

Child eating behaviors.

Table 2 shows the means and differences in means for the Child eating behavior questionnaire (CEBQ) and for Child food neophobia (CFNS). At child age 24 months we found a between-group difference for the subscales Food responsiveness and Emotional over-eating, with higher scores for both subscales in the intervention group. For willingness to try new food assessed by the Child Food Neophobia Scale, we found no difference between the groups.

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Table 2. Child eating behavior, food neophobia and food-category intake at child age 24 months.

https://doi.org/10.1371/journal.pone.0220437.t002

Child dietary intake and mealtime routines.

At child age 24 months, there was no evidence of a retained effect of the intervention on the combined fruits/vegetables score (6.51 ± 2.36 vs. 6.30 ± 2.26 for intervention versus control group; p = 0.41; data not shown). Table 3 presents child dietary intake of all the food-categories and mealtime routines at child age 24 months. We found no between-group differences for intake of fruits, vegetables, sweet and salty snacks or soft drinks. We neither found between-group differences for child eating mostly homemade versus commercially prepared dinner, child mealtime habits or frequency of family meals.

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Table 3. Child dietary intake and mealtime routines at child age 24 months.

https://doi.org/10.1371/journal.pone.0220437.t003

Subgroup analysis limited to the group of mothers with lower socio-economic status

In our sample 45 out of 293 (15.4%) of the mothers had a lower socioeconomic status defined by having either lower education, financial difficulties or being a single mother. The mean maternal age was the same as for the whole sample. The primary outcomes child dietary intake and mealtime routines for this sub-group are presented by allocation in Table 4. We found no significant differences between the groups, but the between-group differences were in the same directions as for the whole sample regarding intake of fruits and vegetables as well as for eating breakfast together with family.

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Table 4. Child dietary intake and mealtime routines in the lower-SES group at child age 24 months.

https://doi.org/10.1371/journal.pone.0220437.t004

Maternal feeding practices/styles.

Table 5 presents maternal feeding practices assessed by the Child Feeding Questionnaire and the Parenting Feeding Style Questionnaire at child age 24 months. We found no evidence for the intervention having an impact on maternal feeding practices or maternal feeding styles.

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Table 5. Maternal feeding practices and feeding styles at child age 24 months.

https://doi.org/10.1371/journal.pone.0220437.t005

Child anthropometric data.

Table 6 shows the between-group differences in weight-for-age z-scores and BMI-for-age z-scores at child age 24 months. There was no difference between groups in weight-for-age z-score. For BMI-for-age z-score, we found a higher score in the intervention group. Descriptive growth-trajectories from birth to 24 months including all available data for the control and intervention group are presented in Supporting Information (S1 Fig).

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Table 6. Difference in weight-for-age z-score and BMI-for-age WHO z-score at 24 months between groups (intervention minus control).

https://doi.org/10.1371/journal.pone.0220437.t006

We used the expectation-maximization (EM) technique to estimate values for the missing child anthropometric values at age 24 months. When comparing the intervention and control group including imputed values, we found no significant between-group differences when adjusting for baseline values, neither for BMI-for-age z-score (mean difference 0.09 (-0.07 to 0.25); p = 0.29) nor weight-for-age z-score (mean difference -0.04 (-0.16 to 0.09); p = 0.55). However, these findings are only meant to be explorative and must be interpreted with caution.

Relationship between the Child Eating Behavior Questionnaire (CEBQ) subscales Food responsiveness and Emotional over-eating and child BMI.

Due to higher scores in the intervention group for the CEBQ-subscales Food responsiveness (FR) and Emotional over-eating (EOE), we explored the relationships between each of these scores and BMI-for-age z-score at child age 24 months by multiple regression, adjusting for group status and baseline BMI-for-age z-score. We further explored the same relationship for the CEBQ composite-score Food Approach Dimension. Neither the subscales Food responsiveness (β = 0.36, p = 0.16), Emotional over-eating (β = 0.15, p = 0.60) nor the Food approach dimension score (β = 0.40, p = 0.30) were significant independent predictors of BMI-for-age z-scores at child age 24 months. Group allocation was also no independent predictor for child BMI-for-age z-score in any of the three models (β = 0.38 to 0.44, p = 0.12 to 0.18). Baseline BMI-for-age z-score was a strong independent predictor for BMI-for-age z-score at child age 24 months in all three models (β = 0.48 to 0.53, p = 0.002 to 0.005).

We further examined whether higher scores on the Food approach dimension was associated with the child being overweight/obese in our sample using logistic regression without adjusting for baseline values or group allocation. We used the revised, age-specific international IOTF BMI-cutoffs for overweight and obesity in children aged 2–18 years; child BMI ≥ 18.4 for boys and BMI ≥18.09 for girls aged 2 years [39]. In this sample, 12% (14/117) met the criteria for overweight or obesity. We found the Food approach dimension to be a significant independent predictor for overweight/obesity at child age 2 years (OR = 4.73; 95% CI = 1.0 to 22.40; P = 0.05).

Child eating behavior, food-intake and mealtime routines.

The sub-scale scores for the Child Eating Behavior Questionnaire in our sample were similar to previous scores for the same age group [40]. For the subscales Food responsiveness (FR) and Emotional over-eating (EOE) we found higher scores in the intervention group. These two subscales are included in the CEBQ composite-score Food approach dimension, which has been associated with increased food intake and overweight in children [41, 42], also as early as by the age of 2 years [43]. A higher score on this dimension could therefore be interpreted as an adverse finding. Our results at child age 24 months were similar to what we found at child age 12 months, where the intervention group had higher scores on the subscale Food responsiveness and the Food approach dimension-score [24]. When exploring the relationship between the Food approach dimension-score and BMI-for-age z-score at 12 months, adjusting for group status and baseline value of BMI-for-age z-score, we found that the Food approach dimension score was an independent positive predictor for BMI-for-age z-score at 12 months while group affiliation had no significant influence. At child age 24 months, neither Food responsiveness, Emotional over-eating nor the Food approach dimension significantly predicted BMI-for-age z-score at child age 24 months when adjusting for baseline BMI-for-age z-score and group status. Group allocation did not independently predict child BMI-for-age z-score at 24 months, while baseline BMI-for-age z-score was a strong positive independent predictor in all three models. Hence, the study’s intervention did not seem to have an adverse effect on the children’s weight-development. Nevertheless, for the whole sample we found the Food approach dimension to be associated with overweight/obesity at child age 2 years when not adjusting for baseline BMI-for-age z-scores. Our findings thereby support previous research indicating that eating behaviors measured by the CEBQ can be used to identify appetite-traits associated with weight status as early as by 2 years of age.

We found no impact of the intervention on child food neophobia measured by the Child Food Neophobia Scale (CFNS) at child age 24 months. Neither our earlier reported results at child age 12 months showed any between-group difference [24]. However, for both the control and intervention group the mean CFNS-scores were increased by 2.5, indicating an increased level of food neophobia at child age 24 months compared to child age 12 months. This is consistent with a normal eating development and in line with previous research finding that refusal of unfamiliar food begins in infancy, but peaks between 2 and 6 years of age [44].

A recently published Cochrane review on interventions for increasing fruit and vegetable consumption in children ≤ 5 years, concluded that the evidence for effective interventions remains sparse. Child feeding interventions appeared to increase fruit and vegetable intake, but this conclusion was based on very low-quality evidence, the effect sizes were small, and long-term follow-up was required [45]. This is consistent with findings from a recent review including 22 home-based and community-based interventions aiming to increase vegetable intake in children between 2 and 12 years [46]. Based on the calculated percentage change in vegetable intake, the included interventions reported a mean increase in vegetable intake of 29%, which equates to an increase of a quarter to a half of a serving of vegetables. Only ten of the studies reported long-term follow-up, of which six studies were considered to be effective also in longer term.

This study contributes to the existing body of research by demonstrating the small effect-sizes, the necessity of continuing support and the need for larger samples and longer-term follow-up. At child age 24 months, and without further intervention, we found no longer evidence for an impact of the intervention on child dietary intake of fruit, vegetables, sweet and salty snacks, soft drinks nor mealtime routines. Yet, the differences between the control and intervention group were still in the same direction as in our earlier reported outcomes at child age 12 months for intake of fruits and vegetables as well as for eating breakfast together with family [24]. When exploring potential differences in child food-intake and mealtime routines within the subgroup of mothers with lower socioeconomic status, we found the same directions for between-group differences, except for intake of sweet and salty snacks. Finding similar between-group differences for the control- and intervention group within the group of mothers with lower socioeconomic status, may support that the intervention did not differ in suitability depending on educational level or socioeconomic background.

Maternal feeding practices.

Recognizing and responding appropriately to the infant’s cues of hunger and satiety is critical in supporting the infant’s innate capacity to self-regulate food-intake [47, 48]. Hence, the importance of a responsive feeding style was emphasized when designing the intervention. Despite this, we found no differences between the groups for maternal feeding practices or feeding styles neither at child age 12 nor 24 months. Whether the intervention’s web-based delivery mode is of importance remains unclear. Although previous studies using traditional intervention approaches have been able to show some impact on desirable parental feeding practices [15, 48, 49], the effects are small to modest and few long-term follow-up studies exist.

Child anthropometry.

We found no impact of the intervention on child anthropometry at child age 12 months [24]. At child age 24 months, there was no between-group difference for weight-for-age z-score, but the intervention-group children had a higher BMI-for-age z-score. The meaning of these findings is unclear and the interpretation tentative, particularly due to missing values for more than half of the child anthropometric data. The sensitivity test using multiple imputations for missing data revealed no significant between-group differences. With reservations, we therefore interpret our findings in the sense that there is no strong evidence for a difference between the groups for child anthropometric outcomes at child age 24 months. This is consistent with previous research showing that although interventions may improve parental feeding practices or children’s nutrition and activity status, it is more difficult to demonstrate an impact on child growth. A systematic review including trials aiming to reduce the risk of overweight and obesity in infancy and early childhood, found that interventions addressing infant diet and parental responsiveness to infant cues, showed promise in terms of self-reported behavioral change but not weight [50]. Another systematic review including childhood obesity interventions in the first 1000 days, concluded that obesity interventions may have the greatest preventive effect if begun early in life, but so far few effective interventions exist [51]. Further, a 2014 meta-analysis of interventions aimed at reducing obesity in early childhood involving parents, concluded that although interventions may be effective at short-term follow-up, results are not retained in the long run [52]. The current study contributes to existing research by reaffirming the early onset of childhood overweight and obesity. In this sample consisting mostly of mothers with higher education, 12% of the children met the criteria for overweight or obesity at child age 2 years. Further, we found that growth trajectories associated with childhood overweight and obesity were established during infancy, as BMI-for-age z-score at 5 months was a strong positive independent predictor for BMI-for-age z-score at child age 24 months.