How a cartoon bear revealed surprising gaps in toddler hunger awareness

Can a cartoon bear really tell us how hungry kids are? Researchers say yes, for most. A validated hunger-rating tool offers insights into preschoolers’ eating behavior, but may need tweaks for the youngest tots.

Study: Validation of the Teddy the Bear hunger and satiety rating scale in 3-5-year-old children. Image Credit: matka_Wariatka / Shutterstock

In a recent article published in the journal Appetite, researchers evaluated the validity of a satiety and hunger rating scale for preschool children aged 3 to 5 years, examining whether ratings differed between typical and avid eaters or across sex. They found that children’s hunger ratings fell after they ate a standardized meal, indicating that the scale successfully captured changes in hunger. While avid and typical eaters showed no significant difference, those who ate more and those who were more likely to be avid eaters did show greater changes in their hunger ratings. However, the authors note that the lack of statistically significant differences between eating profiles may be due to the relatively small number of children in the avid eating subgroup, which limited statistical power.

Background

Hunger and satiety are vital for regulating food intake, with hunger driving eating and satiety stopping it. While parent-reported questionnaires like the Children’s Eating Behaviour Questionnaire (CEBQ) are widely used to assess children’s general appetite traits, they cannot measure real-time hunger.

Pictorial rating scales have been developed for this purpose and can be more engaging for young children. However, few of these tools have been validated, particularly in preschool-aged children between three and five years old, who may struggle with understanding such scales.

Several pictorial tools exist, such as cartoon figures or dolls that indicate fullness, but research has rarely validated them against actual food intake or children’s eating behaviors. The Teddy the Bear Hunger and Satiety Rating Scale, developed by researchers Carmel Bennett and Jacqueline Blisset in 2014, is one such tool. It was validated in older children between the ages of five and nine, but not in preschoolers.

Moreover, children’s eating behavior – especially those with “avid” profiles characterized by high food responsiveness and low satiety – may affect their hunger perception.

About the Study

In this study, researchers assessed the validity of the Teddy the Bear scale for younger children and investigated whether hunger ratings differ by eating profile. Researchers expected that hunger ratings would decrease after eating and that avid eaters would report higher hunger before and after meals.

This study, which involved 132 preschoolers aged three to five, was part of the larger Appetite in Preschoolers: Producing Evidence for Tailoring Interventions Effectively (APPETItE) project.

Participants were recruited from the Birmingham area of the United Kingdom through various channels, including nurseries and online ads. Children with diet-related conditions such as food allergies, chronic illness, and autism were excluded. Ethical approval was obtained from relevant institutional bodies.

Before visiting the lab, parents filled out the CEBQ, which assessed traits like food and satiety responsiveness. Based on previous research, the latent profile analysis categorized children as having either an “avid” or “typical” eating profile.

Children were introduced to the scale at the lab through descriptions and a fictional story involving Teddy the Bear. The Teddy the Bear Hunger and Satiety Rating Scale featured five bear images with increasing food in their bellies, labeled from “very hungry” (1) to “very full” (5). Children rated both Teddy’s and their hunger levels before and after eating.

The children were served a standardized meal consisting of a sandwich, apple slices, cucumber, a cookie, and crackers. They ate until full. Hunger ratings were collected before and after eating to assess the scale’s sensitivity. Differences in hunger ratings were examined across eating profiles and by sex.

Findings

Data from 115 preschool children, aged three to five years, were analyzed. Most correctly identified Teddy’s pre-meal hunger (56.5%) and post-meal fullness (73.9%). Similarly, most children rated themselves as “very full” after eating (67%). While 14.9% of participants rated themselves as hungrier post-meal, their exclusion did not alter the findings.

Age was significantly associated with hunger ratings: older children provided more accurate ratings for Teddy and themselves, indicating that they consumed more energy from the meal. Sex did not influence hunger ratings or intake. Children rated both Teddy and themselves as significantly less hungry after eating.

Eating profile (typical compared to avid) did not significantly affect hunger ratings or energy intake. The authors caution that the absence of a significant difference may reflect the smaller-than-expected number of children with avid eating profiles, which limited the ability to detect group differences. Exploratory analyses revealed that greater appetite avidity, enjoyment of food, and higher energy intake were associated with greater changes in hunger ratings.

Conversely, slowness in eating was linked to smaller changes. Parent-reported satiety responsiveness did not correlate with children’s self-reported hunger, suggesting possible discrepancies between parent perceptions and children’s internal cues.

The article also notes that about one third of children—most of whom were three years old—showed no change in their hunger ratings before and after the meal, suggesting that some younger children may have had difficulty understanding or using the scale as intended. However, the majority of children could use the scale to rate their hunger, and children’s age was controlled for in the main analyses.

Conclusions

This study supports the validity of the Teddy the Bear Hunger and Satiety Rating Scale for use with preschool children between three and five years old. Most children exhibited expected changes in hunger ratings before and after meals, and the scale proved to be quick and practical for research use.

However, younger children, especially three-year-olds, had more difficulty using the scale accurately, possibly due to limited understanding or vocabulary. The authors suggest that further training or adaptation of the scale for younger children may improve its accuracy in this group. Although eating profiles did not show significant differences in hunger ratings, appetite traits such as enjoyment of food influenced children’s ability to perceive changes in hunger.

The lack of association between parent-reported traits and children’s hunger ratings indicates that children’s perceptions may offer unique insights. While the results are promising, future studies should refine the scale for younger children, explore effective training methods, and validate the findings in more diverse populations. Overall, this scale appears to be a valuable tool for assessing hunger in preschoolers at the group level.