ABSTRACT
Background
This systematic review was conducted by the 2025 Dietary Guidelines Advisory Committee as part of the process to develop the Dietary Guidelines for Americans, 2025-2030. The U.S. Departments of Health and Human Services (HHS) and Agriculture (USDA) appointed the 2025 Dietary Guidelines Advisory Committee (Committee) in January 2023 to review evidence on high priority scientific questions related to diet and health. Their review forms the basis of their independent, science-based advice and recommendations to HHS and USDA, which is considered as the Departments develop the next edition of the Dietary Guidelines. As part of that process, the Committee conducted a systematic review with support from USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the following question: What is the relationship between parental and caregiver feeding styles and practices during childhood and consuming a dietary pattern that is aligned with the Dietary Guidelines for Americans? This is a new systematic review.
Methods
The Committee conducted a systematic review using the methodology of the USDA NESR team. The Committee first developed a protocol. The intervention/exposure and comparators were parental or caregiver feeding styles or practices in children 2 to 6 years, and the outcomes were measures of diet quality as measured by the Healthy Eating Index (HEI) or dietary intakes of fruit and vegetables, whole grains, or sugar-sweetened beverages by children and adolescents 2 to 19 years. Additional inclusion criteria were established for the following study characteristics: a) use randomized or non-randomized controlled trial, prospective or retrospective cohort, or nested case-control/other study designs, b) be published in English in peer-reviewed journals, c) be studies from countries classified as high or very high on the Human Development Index, and d) enroll participants with a range of health statuses. The review excluded studies that exclusively enrolled caregivers with a disease or disorder that affects feeding or eating, and multicomponent interventions in which the isolated effects of the caregiver feeding styles and practices on dietary intake and dietary quality cannot be determined.
NESR librarians conducted a literature search in PubMed, Embase, CINAHL, and Cochrane to identify articles published between January 2000 and January 2024. Two NESR analysts independently screened all electronic results and the reference lists of included articles based on the pre-determined criteria. NESR analysts extracted data, from each included article, with a second analyst verifying accuracy of the extraction. Two NESR analysts independently conducted a formal risk of bias assessment, by study design, for each included article, then reconciled any differences in the assessment. The Committee qualitatively synthesized the evidence according to the synthesis plan, with attention given to the overarching themes or key concepts from the findings, similarities and differences between studies, and factors that may have affected the results. The Committee developed conclusion statements and graded the strength of evidence based on its consistency, precision, risk of bias, directness and generalizability.
Results
Structured feeding practices
Conclusion statement* and grade: Food parenting practices by caregivers of children ages 2 to 6 years that structure children’s physical and social eating environments (e.g. availability and accessibility of healthy foods, monitoring children’s eating, modeling of healthy eating behaviors, meal routines such as eating together as a family) are associated with higher intake of fruits and vegetables. This conclusion statement is based on evidence graded as moderate. (Grade: Moderate)
Summary of the evidence:
• Twenty-two articles examined structured feeding practices and dietary intakes aligned with the Dietary Guidelines for Americans. Ten were prospective cohort studies and 12 were randomized controlled studies.
• The direction of results and effect size were similar across studies.
• The size of the study groups was adequate for most studies. Variation around the effect estimates ranged from narrow to wide across studies.
• Few studies were designed and conducted well.
• The exposures and outcome measures that were examined directly represent those of interest in the review.
• The evidence may not apply to the U.S. population.
Controlling feeding practices
Conclusion statement* above and grade: A conclusion statement cannot be drawn about the relationship between controlling food parenting practices (e.g. pressure to eat, overt limits on consumption of certain foods) by caregivers of children ages 2 to 6 years and outcomes related to consuming a dietary pattern aligned with the Dietary Guidelines for Americans because there are substantial concerns with consistency in the body of evidence. (Grade: Grade Not Assignable)
Summary of the evidence:
• Six articles examined controlling feeding practices and dietary intakes aligned with the Dietary Guidelines for Americans. Five were prospective cohort studies and 1 was a randomized controlled trial.
• The 2025 Committee was not able to draw a conclusion due to critical limitations in the body of evidence.
Autonomy supportive feeding practices
Conclusion statement* and grade: A conclusion statement cannot be drawn about the relationship between food parenting practices by caregivers of children ages 2 to 6 years that provide developmentally appropriate support for children’s autonomy (e.g., responsive feeding, praise, child involvement in food and eating activities) and outcomes related to consuming a dietary pattern aligned with the Dietary Guidelines for Americans because there is not enough evidence available. (Grade: Grade Not Assignable)
Summary of the evidence:
• Four articles examined autonomy supportive feeding practices and dietary intakes aligned with the Dietary Guidelines for Americans. Two were prospective cohort studies and 2 were randomized controlled trials.
• The 2025 Committee was not able to draw a conclusion due to not enough evidence being available.
Feeding styles
Conclusion statement* and grade: A conclusion statement cannot be drawn about the relationship between feeding styles by caregivers of children ages 2 to 6 years and outcomes related to consuming a dietary pattern aligned with the Dietary Guidelines for Americans because there is not enough evidence available. (Grade: Grade Not Assignable)
Summary of the evidence:
• Two articles examined feeding styles and dietary intakes aligned with the Dietary Guidelines for Americans. Both were prospective cohort studies.
• The 2025 Committee was not able to draw a conclusion due to not enough evidence being available.
* A conclusion statement is carefully constructed, based on the evidence reviewed, to answer the systematic review question. A conclusion statement does not draw implications and should not be interpreted as dietary guidance.