Parent-Focused Nutrition and Feeding Education on Maternal Picky Eating and Food Refusal

Introduction Nutrition refers to the intake of essential nutrients by the body and their use in metabolic processes to sustain an individual's growth and development (MerkielPawłowska et al., 2017). Human health is directly related to nutrition. Therefore, nutrition provides the foundation for a quality life (Karavelioğlu, 2024). In the early years of life, a period we refer to as infancy, nutrition is the primary determinant of growth. The eating habits acquired during early childhood form the foundation of an individual's eating behaviors in later years and can have lasting effects in the long term. Additionally, nutrition during early childhood is effective in preventing diseases that may arise in adulthood (Koyuncu Şahin et al., 2018).

The family structure, and especially the parents' eating habits and nutrition strategies, play a significant role in shaping the eating habits of preschool children (Karavelioğlu, 2024). Parents who serve as role models for their children should introduce them to healthy foods during this period, limit sugary and saturated fat-added beverages, pay attention to food diversity, be mindful of their attitudes toward feeding, and allow their children to make choices (Tedik, 2017; Corkins et al., 2016). Increasing food diversity supports healthy growth and development in children (Karavelioğlu, 2024). Indeed, nutritional deficiencies characterized by developmental delays and a lack of micronutrient intake are frequently observed in children (MerkielPawłowska et al., 2017). One of the nutritional problems observed in early childhood is children's food selectivity (Keleş Ertürk et al., 2019).

Food refusal, which reduces dietary diversity, is primarily divided into two categories: selective eating and food neophobia. Food refusal is common in the preschool period, which we refer to as ages 2-6 (Foinant et al., 2022). Food neophobia is the rejection of foods without tasting them. Neophobic children show a strong aversion to new foods and instead seek out familiar ones (Taquet et al., 2022). Children affected by this condition are generally reluctant to try new tastes, textures, or colors. Rejection can also occur toward foods that look different due to changes in preparation or presentation (Łoboś, P et al., 2019). Food selectivity, on the other hand, is characterized by reluctance toward new or known foods. This can lead to insufficient energy intake (Taquet et al., 2022). The underlying factors of food neophobia and selectivity are genetic and environmental (Foinant et al., 2022). Selective eating is the rejection of certain foods based on preference, while food neophobia is an innate reluctance or fear of novelty (Długoński et al., 2025). Parents, who play a central role in their children's nutrition, can weaken or strengthen food rejection in children through their feeding practices (Foinant et al., 2022). For example, forcing children to eat or using food as a reward can reduce food refusal in children, while introducing vegetables during the transition to complementary feeding has a positive effect (De Costa et al., 2017; Cooke et al., 2018).

The aim of this study is to evaluate food rejection in children and food rejection behaviors in children, to assess food selectivity in mothers and the nutritional practices of mothers. Additionally, it aims to evaluate the impact of selective eating training for mothers on their selective eating behavior and children's food rejection. This study may help reduce selectivity toward new foods and food rejection in children, and promote positive feeding practices and the development of healthy eating strategies for children.

The hypotheses of the study are provided below. Hypothesis 1 H0: The selective eating training given to mothers does not affect children's food rejection behaviors.

H1: The selective eating training given to mothers affects children's food rejection behaviors.

Hypothesis 2 H0: The selective eating training given to mothers does not affect the selective eating condition of the mothers. H2: The selective eating training given to mothers affects the selective eating condition of the mothers.

Hypothesis 3 H0: The selective eating training given to mothers does not affect their nutritional practices.

H3: The selective eating training given to mothers affects their nutritional practices.

Hypothesis 4 H0: The selective eating behavior in mothers is not related to the food refusal behavior in children.

H4: The selective eating behavior in mothers is related to the food rejection behavior in children.

Methods Location and Timing of the Research The research was conducted at Şehit İbrahim Yılmaz Kindergarten in the Zeytinburnu district of Istanbul between December 2025 and January 2026. The research was approved by the Non-Invasive Research Ethics Committee of Üsküdar University with the decision dated 31/10/2025 and numbered 61351342/020-1591 (Appendix 8). Following the approval of the Ethics Committee, research permission was obtained from the Istanbul Governorate, Istanbul Provincial Directorate of National Education with the application number MEB.TT.2025.039734. with application number .01 (Appendix 9), research permission has been obtained.

Population and Sample of the Study The sample of the study consists of children aged 3-6 and their mothers who attend this kindergarten. The study group of the research will consist of a total of 202 mothers with children aged 3-6. Participants will be determined using a purposive sampling method and will be randomly divided into two groups: an experimental group (n1=101) and a control group (n2=101).

Inclusion criteria for the study: • Being in the age range of 3-6 years for students • Being the parents of students enrolled in the relevant institution • Being literate for parents • Signing the informed voluntary consent form • Not having any psychiatric disorder diagnosis • Not having any eating disorder diagnosis Exclusion criteria for the study: • Not being in the age range of 3-6 years for students • Not signing the informed voluntary consent form • Having any psychiatric disorder diagnosis • Individuals using psychiatric medication • Having any eating disorder diagnosis This study was conducted using a quasi-experimental design consisting of pre-test and post-test measurements with experimental and control groups. In the study, it was aimed to examine the effect of the intervention applied to the experimental group on the scores of the Adult Selective Eating Scale and the Child Food Refusal Scale. Measurements were conducted in both groups before the intervention (pre-test) and after the intervention (post-test).

When the literature is examined, no similar experimental study has been found that addresses selective eating behavior in adults and food refusal behavior in children together and is conducted with a pre-test-post-test design with experimental and control groups.

In this context, the sample size calculation was based on the group × time interaction, which allows for the evaluation of whether the change over time differs between the experimental and control groups. Power analysis was conducted using the G*Power 3.1.9.4 software, and the "ANOVA: Repeated measures, between factors" method from the family of F tests was preferred. In the analysis, two groups (experimental and control) and two measurement times (pre-test and post-test) were considered.

Due to the absence of a similar experimental study in the literature, a medium effect size (Cohen's f = 0.25) assumption was used for the effect size. The significance level α = 0.05, and the statistical power was determined to be 95% (1-β = 0.95).

As a result of the power analysis conducted based on these parameters, the total sample size required to statistically detect the group × time interaction was calculated to be 158 individuals. With this sample size, the actual power of the study was found to be 0.95. Accordingly, approximately 79 participants should be included in each group.

Data Collection Tools Mother's Sociodemographic Information Form Demographic characteristics such as the mother's age, self-reported body weight and height, marital status, number of children, education level, occupation, and income level were inquired. Additionally, questions regarding disease and allergy status, smoking and alcohol habits, and medication use were included.

Information Form on Mother's Eating Habits This section includes questions about the mother's meal quantity, meal skipping status and reasons, appetite status, and foods she refuses to eat, which are all part of her eating habits.

Child's Sociodemographic Information Form In this section, the mother is asked questions about her child's age, gender, birth weight, current body weight and height, breastfeeding duration, month of starting complementary foods, illness and allergy status, and medication use.

Information Form on the Child's Eating Habits In this section, the mother is asked questions about her child's daily meal quantity, meal skipping status, if there is meal skipping, which meal is skipped, appetite status, foods rejected, whether there is gagging/vomiting behavior during feeding, whether there is fear of choking or swallowing during feeding, whether there is food left on the plate and the reasons for it, and the feeding methods applied to the child when they do not eat.

Child Food Refusal Scale The Child Food Refusal Scale (ÇFRS), developed by Rioux and colleagues (2017) as a tool to detect food neophobia and selective eating in children, was used. The scale consists of 11 items divided into 2 sub-dimensions, examining the tendency to reject food in children aged 2-7 through their parents. The neophobia sub-dimension consists of 6 items, and the selectivity sub-dimension consists of 5 items. Each item is rated on a 5-point Likert scale (Strongly disagree, Disagree, Neither agree nor disagree, Agree, Strongly agree), and the items of the scale are scored between 1 "Strongly disagree" and 5 "Strongly agree." For the neophobia subscale, scores can range from 6 to 30, for the selectivity subscale from 5 to 25, and for the total from 11 to 55. The Turkish validity study of the scale was conducted by Şengüzel and colleagues (2021). The Turkish version of the scale consists of 10 items and includes 2 sub-dimensions: the neophobia sub-dimension and the selective eating sub-dimension. A total score can be obtained between 10-50. The scale does not have a cutoff point. The average scale score for children's food refusal was found to be 30.45±6.41. An increase in the scale score indicates a high level of food refusal (Şengüzel et al., 2022).

Adult Selective Eating Scale (ASES) Developed by Ellis and colleagues (2017), the scale is designed to assess the selective eating behaviors of adult individuals. The scale consists of a five-point Likert type, 16 items, and 4 sub-dimensions. In the "Food Presentation" sub-dimension, items "M1, M2, M3, M4, M5, M6, M7" are included; in the "Food Variety" sub-dimension, items "M8, M9, M10, M11"; in the "Avoidance of Food" sub-dimension, items "M12, M13, M14"; and in the "Avoidance of Different Tastes" sub-dimension, items "M15, M16" are included. The items in the survey are scored between 1 "Never" and 5 "Always." The score obtained from the scale ranges from 16 to 80. The Turkish validity study of the scale was conducted by Hamurcu and colleagues (2023). The higher the score obtained, the higher the selective eating behavior is evaluated (Hamurcu et al., 2023).

Research Plan Participation is based on voluntariness, and interviews were conducted with the mothers of preschool students who met the inclusion criteria. Informed Consent Forms (Appendix-1) were obtained from those who agreed to participate in the study.

This research is a pre-test - post-test control group quasi-experimental study conducted to examine the effect of selective eating training on parents' selective eating attitudes and children's food rejection. The participants included in the study were divided into two groups: the training group (n1=101) and the control group (n2=101). Pre-tests were administered to both groups at the beginning of the study. After the pre-test was administered to the training group, education on food selectivity and food refusal was provided in the form of 4 sessions, each lasting 30-45 minutes, once a week for 4 weeks. In the training program, topics such as the definition and causes of selective eating behaviors, parental attitudes and their effects, coping strategies, sensory sensitivities, the importance of modeling behavior, organizing the eating environment, and healthy approaches to preventing food refusal were covered. No training or information was provided to the control group. The final test data were collected from the mothers. Similarly, the final test data collection tools were applied to the control group as well. While preparing the training presentations, literature on food selectivity and food refusal was reviewed, and information from the Turkey Nutrition Guide 2022 was included.

Nutrition Education Program

1. st Week: The Importance of Adequate and Balanced Nutrition in Preschool Children. It was the first week of the training, and the researcher met with the mothers.

   The profession of dietitian was introduced. Basic concepts such as food, nutrients, nutrition, adequate and balanced nutrition were discussed.

   The possible consequences of inadequate and unbalanced nutrition were discussed.

   In accordance with the Turkey-Specific Nutrition Guide-2022 recommendations, food groups, the foods within those groups, the recommended portion amounts based on age and gender, and nutritional deficiencies have been explained. The healthy meal plate model, known as the "Plate Model by Food Groups," was explained.

2. nd Week: What is Food Neophobia and Selective Eating? Food neophobia, food selectivity, and food rejection were defined. The distinctive aspects of the concepts of food neophobia and food selectivity were discussed. The underlying factors of food rejection were explained. The effects of food neophobia on children's health were discussed. . Fluctuations in appetite during the preschool period were discussed. Developmentally normal behaviors were described to reduce parents' anxiety. When is it normal and when does it require intervention, and information about the symptoms of extreme selectivity (ARFID risk) were conveyed to mothers through presentation slides.
3. rd Week: What is the Role of the Mother in Food Preference/Selection in Preschool Children? Mothers were informed about parenting styles (authoritarian, authoritative, permissive, neglectful) and which of these styles is more effective and healthier. The classification of parental feeding practices was discussed. The negative consequences of forced feeding, the reward-punishment relationship, the "one more spoon" pressure, restriction, and feeding with screens, which are the most common parental mistakes, were discussed. The impact of managing their own anxiety, family attitudes, and being a role model was conveyed to parents through presentation slides.
4. th Week: What Should Parents Pay Attention to in Children's Eating Behaviors? ? How to manage children with food neophobia was discussed. . Science-based nutrition strategies were conveyed Mothers were informed through presentation slides about new food introduction methods, the arrangement of the meal environment, the structuring of meal times, the practice of repeated exposure to rejected foods, and the importance of covert control over overt control.