Measuring hunger and satiety in primary school children. Validation of a new picture rating scale

doi:10.1016/j.appet.2014.03.011

Appetite

Volume 78, 1 July 2014, Pages 40-48

https://doi.org/10.1016/j.appet.2014.03.011 Get rights and content

Highlights

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The majority of children in the current sample appeared to be able to use the scale
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Children (5–9 years) were able to use the scale to rate estimated and real hunger
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Ratings were mainly unaffected by child age or gender
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he new scale has potential for assessing hunger/satiety in 5- to 9-year-olds

Abstract

Measuring hunger and satiety in children is essential to many studies of childhood eating behaviour. Few validated measures currently exist that allow children to make accurate and reliable ratings of hunger/satiety. Three studies aimed to validate the use of a new categorical rating scale in the context of estimated and real eating episodes. Forty-seven 6- to 8-year-olds participated in Study 1, which used a between-participant design. Results indicated that the majority of children were able to make estimated hunger/satiety ratings for a story character using the scale. No significant differences in the ratings of hunger/satiety of children measured before and after lunch were observed and likely causes are discussed. To account for inter-individual differences in hunger/satiety perceptions Study 2 employed a within-participant design. Fifty-four 5- to 7-year-olds participated and made estimated hunger/satiety ratings for a story character and real hunger/satiety ratings before and after lunch. The results indicated that the majority of children were able to use the scale to make estimated and real hunger and satiety ratings. Children were found to be significantly hungrier before compared to after lunch. As it was not possible to establish the types and quantities of food children ate for lunch a third study was carried out in a controlled laboratory environment. Thirty-six 6- to 9-year-olds participated in Study 3 and made hunger/satiety ratings before and after ingesting an ad libitum snack of known composition and quantity. Results indicated that children felt hungrier before than after the snack and that pre-snack hunger/satiety, and changes in hunger/satiety, were associated with snack intake. Overall, the studies indicate that the scale has potential for use with primary school children. Implications of the findings are discussed.

Introduction

Being able to accurately assess hunger and satiety in children is essential to many studies in the field of childhood eating behaviour. Studies measuring snack intake with the Eating in the Absence of Hunger (EAH) paradigm rely on children's self-reported hunger and satiety. Other studies rely on children being in a fasted or non-fasted state to later establish factors like children's abilities to compensate for different caloric preloads. Despite this, few validated measures exist that are known to accurately reflect children's own perceptions of their hunger and satiety.

Some studies into childhood eating behaviour have relied on visual analogue scales (VAS) commonly applied in research with adults and adolescents to establish hunger and satiety in children aged 8–12. Roemmich, Wright, and Epstein (2002) asked children to rate their hunger/satiety using a 100 mm VAS with the anchors “very hungry/very full.” Nevertheless, the paper did not present any indication of children's comprehension of this scale or of changes in hunger/satiety ratings prior to and after snack intake. Developmental research suggests that children need to be able to seriate their perceptions of hunger and satiety from hungry to full correctly before being able to use a VAS correctly and reliably (Shields, Palermo, Powers, Grewe, & Smith, 2003). Keller et al. (2006) found that the majority of children in their sample aged 4–5 years were able to use an age-appropriate VAS to reflect changes in estimated fullness, after having received a considerable amount of training. This suggests that abilities to seriate may be present from an earlier age, but that tasks relying on the application of seriation techniques may be dependent on training. It is therefore likely that ratings of hunger and satiety on an abstract VAS demand greater cognitive abilities than those commonly present in untrained children aged 7 years or younger (Shields et al., 2003). Research by Shields et al. indicated that child age and IQ, used as an indicator of cognitive ability, were the best predictors of kindergarteners’ abilities to correctly make ratings using a VAS. As more than 50% of children aged 5–7 years who participated in their study failed to use the VAS correctly, the authors suggest that alternative rating scales should be used when working with children aged 7 years or younger. In a further study carried out by Shields, Cohen, Harbeck-Weber, Powers, and Smith (2003) the ability of children aged 5–14 years to correctly mark a VAS and understand the concept of a VAS for pain experiences was tested. Shields et al. (2003) report that only one-third of the 106 children who participated in their study were able to correctly use and understand the VAS, with age being the best predictor of performance. Importantly, there were no differences in children's abilities to use and understand the VAS based on whether they received a basic or a more intensive amount of training to use it. Pilot work with three 7- to 8-year-olds in our own lab indicated that even children of this older age-range found abstract VAS difficult to use and that their ratings did not correspond with verbal explanations of their current hunger/satiety perceptions.

Previously developed hunger and satiety rating scales for use with children have generally consisted of figures with manipulated stomach regions as children have been found to reliably associate this body region with feelings of hunger and satiety (Faith, Kermanshah, & Kissileff, 2002). Fisher and Birch (1999) used cartoon figures with varying amounts of food in their stomachs to assess 3- to 6-year-old children's reported hunger and satiety in the context of an EAH paradigm. The authors only included the data of those children who reported being full after a meal and who had access to snacks afterwards, in their analyses. It remains unclear though how many children were excluded due to a failure to understand the scale.

Research by Faith et al. (2002) and Keller et al. (2006) has also focused on the development of measures assessing estimated hunger and satiety. Faith et al. developed a range of silhouettes to assess satiety in children aged 4–6 years. Silhouettes were gender specific and contained various amounts of food in the stomach regions, allowing children to make judgements of estimated fullness. Based on the research by Faith et al., Keller et al. developed an analogue scale (Freddy), which consisted of a cardboard cut-out doll, with an adjustable stomach, allowing children to dynamically regulate estimated hunger and satiety. This scale has shown good applicability to estimated hunger and satiety states in children aged 4–5 years and has also been used in the context of real eating episodes. Kissileff, Keller, Lofink, Torres, and Thornton (2008) evaluated the ability of 5- to 6-year-olds to use the scale to reflect increases in satiety in response to 15 individual 15 ml portions of a yoghurt shake and found that after two training/testing sessions the majority of the 11 children who participated in their study were able to indicate greater fullness in response to intake.

To address the lack of hunger/satiety rating scales that can be used in the context of estimated as well as real eating episodes, we developed a new picture rating scale, “Teddy the Bear,” consisting of five pictures of teddies which had varying amounts of food in their stomachs and which were accompanied by descriptive vignettes. The purpose of the scale was to allow children to make accurate ratings of their current feelings of hunger/satiety. Our studies therefore aimed to establish whether the Teddy scale could be used to measure hunger/satiety in primary school children aged 5–9 years. We assessed children's comprehension of the scale while examining possible effects of age and gender (Study 1) and also assessed the scale's ability to reflect changes in estimated hunger/satiety states (Study 1) and with respect to a real eating episode (Study 2). Additionally we established whether the scale was able to reflect changes in hunger/satiety in the context of the ingestion of an ad libitum snack in a controlled environment (Study 3).

Section snippets

Participants

Forty-seven children aged 6 to 8 years participated in this study. The sample consisted of 27 females and 20 males who were predominantly White British. Children were typically developing and attended years 3 and 4 of a primary school in Birmingham, UK. The Index of Multiple Deprivation (2010) for the school and the surrounding areas indicated that the sample of children participating in this study is likely to be drawn from the most deprived 50% of English communities (Index of Multiple

Study 2

The results from Study 1 indicated that children were able to use the scale to rate hunger/satiety. Study 1 also suggested that the scale is able to detect changes in estimated/imagined hunger/satiety in response to the story about Teddy the Bear. Nevertheless, it is unclear whether the scale is able to reflect changes in real hunger/satiety. To test this, Study 2 aimed to further assess the use of the picture rating scale to measure hunger/satiety in primary school children aged 5 to 7 years.

Study 3

The results of Study 1 and Study 2 indicated that children were able to use the Teddy picture rating scale to reflect large changes in hunger/satiety in the context of imagined and real eating episodes. Nevertheless, one major limitation of Study 2 was the absence of information regarding children's lunch foods. We were unable to establish how much and what types of food children ate during their lunch break. This caveat meant that we were unable to establish whether our scale is sensitive to

Overall discussion

The majority of primary school children are able to self-report feelings of hunger/satiety using a new picture rating scale. In Study 1 and Study 2, which included large samples of children, around 90% of children were able to make correct judgements of hunger and satiety for Teddy. Similar levels of accuracy in estimated hunger and satiety ratings have previously been reported by Faith et al. (2002), who measured children's abilities to rate hunger and satiety with gender specific silhouettes.

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Rating of fullness after ad libitum meals are not predicted from ratings of fullness during interrupted meals in pre-school children
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Citation Excerpt :
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^☆: Acknowledgement: We would like to thank the school and all the pupils for their participation.

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Research reportMeasuring hunger and satiety in primary school children. Validation of a new picture rating scale☆

Highlights

Abstract

Introduction

Section snippets

Participants

Study 2

Study 3

Overall discussion

Physiology & Behaviour

Appetite

Appetite

Appetite

Eating behaviour

Pain measurement tools for clinical practice and research

Journal of the American Association of Nurse Anesthetists

Research report
Measuring hunger and satiety in primary school children. Validation of a new picture rating scale☆