Parents consistently endorse that a nutritious diet is crucial for their child’s medical, social, and educational development [1]. Despite this, 31.8% of American children and adolescents from 2009–2010 were either overweight or obese [5]. The first step in addressing the discrepancy is often to examine parental knowledge of nutrition and health. Children are unlikely to receive adequate nutrition when their parents act on knowledge that is incompatible with recommended dietary guidelines. These same children are also more likely to ingest an excess of energy compared to expenditure.

Parents have variable knowledge in both the areas of nutrition and health. On the one hand, parents feel that health information is relatively straightforward [13]. A high number of parents report they are interested in food labels so that they can compare their knowledge with the food they are considering for purchase [15]. When examining health claims on food packaging, parents consider certain foods to be either “good” or “bad” [15]. Foods that are “bad” include fat, salt, sugar, and energy (i.e., calories) [15]. Aspects of foods that parents also consider but do not necessarily disqualify the food from purchase include vitamins, minerals, cholesterol, carbohydrates, protein, fiber, saturated fats, and unsaturated fats [15].

On the other hand, parents demonstrate confusion about the specifics of nutritional knowledge [13]. We will address the source of some of the confusion in our final section regarding the overall state of nutritional research. When they have questions about diet or feeding, parents access information from the Internet, their friends and family, and their pediatricians [13]. Where parents look for information depends on the nature of their question. In one study, parents unanimously reported visiting Internet sites as their primary source of information [13]. While a preferred method, parents also report that the amount of information on the Internet feels overwhelming [13]. Parents also display concern for the authenticity of the information they find on the Internet [13]. In one study, parents reported an awareness that some level of critical thinking was required to determine accurate sources of information from inaccurate sources [13]. However, the propagation of false dietary information on social media implies that many parents are either unaware of the need for critical appraisal or require more assistance in accomplishing that task successfully.

Friends and family are sought out when parents think their social contacts have prior experience with the situation they currently face and can consequently offer insight [13]. In one study, parents reported that they asked their children’s doctors for answers to their dietary questions only as a last resort [13]. These parents explained that before speaking with their doctor, their question had to have risen to a level they felt was of clinical significance [13]. Thus, we can infer that patient-initiated discussions of diets mainly occur when parents have already identified the gap in their own knowledge.

Realistically, parents may not always know when a situation is out of their depth. One study of Australian parents revealed that among their sample, even parents who reported a strong investment in a nutritious diet were unable to name a heavily promoted government public health message as to the number of recommended daily servings of fruits and vegetables [1]. Parents in that study also reported that they were feeding their children more healthfully than their peers, thus reducing the likelihood of changing their feeding practices even when they fell below recommended dietary guidelines [1]. In the United States, data from the Third National Health and Nutrition Examination Survey uncovered that nearly one third of mothers with overweight children did not consider their children to be overweight [16]. Among low-income families, seventy to 80% of mothers of overweight children thought their children were a healthy weight or even underweight [17]. This gap in recognition may be partially explained by the perception of some parents that a heavy child is a healthy child [2]. These parents believe that a heavy child is a sign of good parenting [2]. Given that most parents report accessing information from the Internet, they may be further unaware of the influence of misinformation. Increasing amounts of non-clinical dietary recommendations (such as “clean eating”) have infiltrated the popular consciousness without needed checks on accuracy. Therefore, pediatricians should consider dietary discussions with parents without waiting for parents to raise the issue. Because habits established when children are young linger into adulthood, conversations held during the pre-school years are most likely to have a meaningful, lasting impact [2].

We make a distinction between parental knowledge of nutrition and knowledge of feeding practices. For example, one study showed that the children of parents with higher nutrition knowledge less likely to eat fat in the home [18]. Greater general nutrition knowledge was associated with higher consumption of fruits and vegetables [18]. The association between general nutrition knowledge and parenting style found that parents’ knowledge of nutrition alone neither predicted nor mediated outcomes in their children’s diets [18]. Only in cases where the parenting style was already optimal was increased nutrition knowledge observed to have a small impact on children’s consumption of non-core (i.e., not fruits or vegetables) foods [18]. While this study supports interventions designed to increase parental nutritional knowledge, clearly parental knowledge is a necessary but not sufficient component of a healthy diet for children [18]. Therefore, conversations with parents to increase their knowledge should not focus solely on nutritional content; they should also mention the research presented below on parenting styles, the overall state of nutrition research, and address any parents who may be following diets not currently established in the research base as effective.

A common parental complaint about their efforts to provide their children with a healthy diet is the nature of advertising [19]. Advertising in the media is a significant challenge, with children between the ages of 8–18 spending on average more time on media consumption daily than any activity other than sleeping [9]. In addition to advertisements, many products aimed at children’s palates use packaging featuring promotional characters; such characters are used predominantly to promote less-healthy foods [20]. A qualitative survey of 124 children in three schools in Australia (selected to include low-, medium-, and high-economic status school districts) found that both parents and children widely discussed advertisements [4]. Parents commented that the intensity of advertising was correlated with specific food properties, such that the most advertisements seen were for foods highest in fat, salt, and/or sugar [4]. Their observations were consistent with content analysis studies that have quantified the amount of advertising spent based on food type [21]. Nearly all of the advertisements aired during children’s television shows promote foods that are low in nutrients and high in fat, sodium, and added sugars [22]. It would be barely an exaggeration to state that if a child is viewing the ad, the product marketed is automatically low in nutritional value and high in energy.

The strategies employed by most advertisements follow principles of classical conditioning [23]. Commercials widely pair images of children who are happy, popular, loved, and/or having fun with the advertised product [4]. After repeated viewings, children begin to associate the food product with the desirable social and emotional characteristics of the children in the advertisements. This same strategy is used when marketing food to parents; however, the emotions and behaviors paired with the food differ markedly from the child versions. In one study, researchers coded food commercials that aired during children’s television programming based on intended audience: parent or child [24]. Parents were coded as the audience when the commercials sent messages of family bonding and love, contrasted with messages highlighting fun when children are the audience [24]. These content analysis findings were consistent with the reports of the Australian parents and their children who described similar themes in commercials [1].

After children receive these messages from advertisements, they are likely to bother their parents until they obtain the desired food [4]. Parents in one small focus group study stated that dealing with the effects advertising had on their children felt like a “battle” [13]. Their impressions are borne out in observational research. Both academic and consumer research reveals that young children who accompany their parents during grocery shopping indeed influence their parents’ food purchases [9]. While parents’ engagement with their children about these messages can mitigate the advertisements’ influence, the messages remain persistent enough to continue to exert influence over children’s preferences [25]. Given the sums food companies spend on advertising annually, we assume that directly marketing to children has an appreciable effect on sales.

Social learning theory proposes one mechanism by which commercials exert influence on children [26]. According to this theory, children learn by observing the social world around them and incorporating the behaviors and beliefs they observe into their operational framework [26]. Yet young children are thought not to understand that the social world displayed in commercials is influenced by a specific point of view, that is, with the aim of selling a product [26]. The distinction between objective and subjective information needed to parse out this motive is typically not appreciated until children are 9 years old [26]. By this age, children have already been exposed to countless advertisements, which have contributed to the formation of their thinking and behavior [26]. Thus, children are particularly susceptible to accepting marketers’ messages [26].

Many parents report awareness of the influence advertisements exert over their children, but it is not clear how parents understand their own perceptions of advertisements and front-of-packaging health claims. Current regulations permit food producers to post nutrition- or health-related (NH) claims on their packaging, provided the claim is not misleading [27]. To this end, the Food and Drug Administration regulates the types of NH claims products can make in accordance with the scientific evidence available [27]. Claims range from merely providing content (e.g., “Contains fiber”) to asserting health claims (e.g. “Reduces risk of heart disease”) [27]. Despite regulators’ careful attention to these distinctions, research shows that adults considering these claims largely do not distinguish between the types of claims [27]. In particular, a halo effect, in which people attribute many positive qualities to a product based on only one narrow claim, is consistently observed [27, 28]. The halo effect is an example of overgeneralization, which leads parents to assume the non-featured ingredients in the product are just as healthy or beneficial as the featured ones [27]. A strong example of overgeneralization is seen in the purchase of artificially low-fat or low-sugar products. Products low in fat often compensate for lack of flavor by increasing the amount of sugar, salt, or other ingredients [29]. Products marketed as low in sugar often use sugar substitutes that are sweeter than natural sugar, adjusting the taste preferences of the consumer to desire even more sugary substances [29]. Preliminary studies with humans suggest that a preference for sweet foods established in childhood may last well into adulthood [29]. So while one aspect of the food may appear healthy (e.g., low-fat or low-sugar) the product as a whole is not healthy.

While parents typically report negative opinions of giving their children foods with artificial sweeteners, parents often select these foods for purchase [29]. The discrepancy between belief and action implies parents may not understand the information they are presented with when purchasing food for their children [29]. As is true in all advertising, the marketer will present the information desirable to parents and withhold the information that would dissuade them from purchasing.

While parents remain the primary gatekeepers of young children’s food, once they start school (or daycare) other individuals play a prominent role in children’s lives. Peer impressions of foods begin to factor into children’s social worlds. In one study, when teachers enthusiastically ate a novel food, children were more likely to eat it [30]. However, if their classmates showed an aversion to the food the teacher was eating, children were more likely to reject it themselves [30].