Family Mealtimes, Dietary Quality, and Body Mass Index in Children

Transcription

1 Uiversity of Teessee, Koxville Trace: Teessee Research ad Creative Exchage Masters Theses Graduate School Family Mealtimes, Dietary Quality, ad Body Mass Idex i Childre Claudia Christie Favre cfavre@utk.edu Recommeded Citatio Favre, Claudia Christie, "Family Mealtimes, Dietary Quality, ad Body Mass Idex i Childre. " Master's Thesis, Uiversity of Teessee, This Thesis is brought to you for free ad ope access by the Graduate School at Trace: Teessee Research ad Creative Exchage. It has bee accepted for iclusio i Masters Theses by a authorized admiistrator of Trace: Teessee Research ad Creative Exchage. For more iformatio, please cotact trace@utk.edu.

2 To the Graduate Coucil: I am submittig herewith a thesis writte by Claudia Christie Favre etitled "Family Mealtimes, Dietary Quality, ad Body Mass Idex i Childre." I have examied the fial electroic copy of this thesis for form ad cotet ad recommed that it be accepted i partial fulfillmet of the requiremets for the degree of Master of Sciece, with a major i Nutritio. We have read this thesis ad recommed its acceptace: Marsha Spece, Hillary N. Fouts (Origial sigatures are o file with official studet records.) Hollie A. Rayor, Major Professor Accepted for the Coucil: Dixie L. Thompso Vice Provost ad Dea of the Graduate School

3 To the Graduate Coucil: I am submittig herewith a thesis writte by Claudia Christie Favre etitled Family Mealtimes, Dietary Quality, ad Body Mass Idex i Childre. I have examied the fial electroic copy of this thesis for form ad cotet ad recommed that it be accepted i partial fulfillmet of the requiremets for the degree of Master of Sciece, with a major i Nutritio. Hollie A. Rayor, Major Professor We have read this thesis ad recommed its acceptace: Marsha Spece Hillary Fouts Accepted for the Coucil: Caroly R. Hodges Vice Provost ad Dea of the Graduate School (Origial sigatures are o file with official studet records.)

4 Family Mealtimes, Dietary Quality, ad Body Mass Idex i Childre A Thesis Preseted for the Master of Sciece Degree The Uiversity of Teessee, Koxville Claudia Christie Favre August 2010

5 Ackowledgemets First, I would like to thak Dr. Hollie Rayor for her uedig dedicatio to utritio research, icludig studet research. She is a outstadig educator, researcher, ad dietitia. Next, I would like to thak my committee members, Dr. Marsha Spece ad Dr. Hillary Fouts, for their feedback ad expertise. Thak you for your wisdom. My udergraduate research assistats, Chelsi Cardoso ad Rachel Zemel, were very helpful durig the data collectio process. They spet coutless hours eterig data ito Excelthak you! Additioally, I would like to ackowledge Kare Wetherall for her positive attitude ad costat affirmatio. O a persoal level, I would like to thak Christ Chapel for beig a woderful support system. Their thoughts ad prayers have helped me succeed. I would ot have bee able to meet my goals without my fellow classmates: Lizzy Miller, Lisa Fuller, Tega Medico, Beth Rohlig, Whitey Merola, Briaa Presper, Laura Dotso, Maasi Barot, Derek Grabert, ad all of the dietetic iters of Also, Shao Looey, Ashlee Schoch, ad Lusi Marti have bee great metors through the thesis process. I would like to give appreciatio to my ecouragig family for their cotiuous loyalty. Every day I am remided of how much they love me ad believe i my potetial. Lastly, I would like to thak my sympathetic fiacé, Adrew Carberry, for sustaiig me ad givig me the love that I eed. ii

6 Abstract Frequecy of family mealtimes has bee positively liked to dietary quality ad weight status i childre; however, there is a lack of research idetifyig what compoets of family mealtimes are associated with this positive effect. This study ivestigated family mealtime compoets that may impact dietary itake ad weight status i childre aged 5-11 years. Participats were paret/child pairs (child: age = 7.3 ± 2.0 years, female = 44%, stadardized body mass idex (zbmi) = 0.55 ± 1.0, overweight/obese = 26.0%; paret: age = 36.8 ± 8.7 years, female = 76%, BMI = 29.0 ± 6.6 kg/m 2, overweight/obese = 74.0%) recruited at local doctors offices, churches, ad a daycare for this cross-sectioal study. Childre were weighed ad measured while parets completed questioaires o child dietary quality ad family mealtimes. The family mealtime questioaire assessed six mealtime compoets: which meal, who was preset, what type of food was served ad eate, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Barriers to family mealtimes were also assessed. Parets reported that childre s daily servigs cosumed were: fruit = 2.1 ± 0.9; vegetables = 2.3 ± 1.1; low-fat dairy = 2.1 ± 1.3; sweeteed driks = 1.5 ± 1.6; ad 100% fruit juice = 1.8 ± 1.3. Hierarchical regressios, with child ad paret demographics cotrolled, foud that greater frequecy of dier cosumed at a restaurat/fast food establishmet ad limitig the child from eatig too much were sigificatly (p < 0.001) related to greater sweeteed drik itake. Not aswerig the phoe or textig durig the family meal was sigificatly (p < 0.05) iii

7 related to lower fast food frequecy. Limitig the child from eatig too much was sigificatly (p < 0.01) related to greater child zbmi. This suggests that family mealtimes eate withi the home, free of distractios, ad with set rules may impact o child dietary itake ad weight status. Experimetal studies are eeded to uderstad the potetial cause ad effect relatioships betwee these variables. iv

8 Table of Cotets CHAPTER I: LITERATURE REVIEW... 1 Childhood Overweight ad Obesity Epidemic... 2 Dietary Quality i Childre ad Adolescets... 2 Family Mealtimes Related to Childhood Nutriet Itake... 3 Family Mealtimes Related to Childhood Overweight ad Obesity... 5 Theorized Mechaisms of the Positive Ifluece of Family Mealtimes o Diet Quality ad Weight Status durig Childhood... 8 Paretig Styles 8 Paretig Behaviors Paretal Modelig Food Availability ad Locatio of Mealtime Child Developmet i Middle Childhood Challeges i Research about Family Mealtimes Which meal Who What Where How Atmosphere Recommedatios for Family Mealtimes Future Research CHAPTER II: MANUSCRIPT Itroductio Methodology Study Desig Recruitmet Eligibility Procedures v

9 Measures Demographics Athropometrics Family Mealtimes Diet Quality Statistical Aalyses Results Descriptive Fidigs The Relatioship betwee Family Mealtime Compoets ad Dietary Quality ad Weight Status i Childre Hierarchical Regressio Aalyses for Family Mealtime Compoets ad Child Dietary Itake Discussio REFERENCES APPENDICES APPENDIX A: Forms, Fliers, ad Questioaires IRB Approval Church Bulleti Recruitmet Flier Demographic Questioaires. 76 Family Mealtime Questioaire Dietary Itake Questioaire APPENDIX B: Limitatios APPENDIX C: Results Tables VITA vi

10 List of Tables Table 1. Paret, child, ad household demographics 95 Table 2. Dietary itake of childre...97 Table 3. Frequecy of sack food cosumptio per week 98 Table 4. Frequecy of family mealtimes..99 Table 5. Distributio of resposes for questios related to the types of food prepared/served..100 Table 6. Distributio of resposes for questios related to how the child is fed 102 Table 7. Distributio of resposes for questios related to the atmosphere of family mealtimes.103 Table 8. Distributio of resposes for questios related to adult satisfactio of family mealtimes.104 Table 9. Distributio of resposes for questios related to paret characteristics.105 Table 10. Distributio of resposes for questios related to potetial barriers to family mealtimes.106 Table 11. The relatioship betwee family mealtime frequecy ad child dietary itake ad athropometrics 107 Table 12. The relatioship betwee types of food prepared/served ad child dietary itake ad athropometrics 108 Table 13. Types of foods eate i a typical week compared to daily eatig habits of child participats ad athropometrics..109 Table 14. The relatioship betwee how the child is fed ad child dietary itake ad athropometrics 110 vii

11 Table 15. The relatioship betwee family mealtime atmosphere ad child dietary itake ad athropometrics 111 Table 16. The relatioship betwee adult satisfactio ad importace of family mealtimes ad child dietary itake ad athropometrics.112 Table 17. The relatioship betwee paret characteristics to family mealtimes ad child dietary itake ad athropometrics..113 Table 18. The relatioship betwee the barriers to family mealtimes ad child dietary itake ad athropometrics..114 Table 19. Hierarchical regressios of family mealtime compoets related to child itake ad athropometrics viii

12 CHAPTER I: Literature Review

13 Childhood Overweight ad Obesity Epidemic Childhood obesity is a growig epidemic ad thus is a public health cocer i the Uited States (US) (1). Rates of childhood obesity have icreased by 2.3 to 3.3 fold i a spa of approximately 25 years (1). Short-term effects of childhood obesity cosist of health complicatios, such as sleep apea, asthma, hypertesio, dyslipidemia, chroic iflammatio, icreased blood clottig, edothelial dysfuctio, hypertesio, ad psychological sequela, icludig social disturbaces ad struggles with acceptace amog peers (1). Moreover, obese childre are at icreased risk for developig cardiovascular disease ad type 2 diabetes i adulthood (1). Due to these outcomes associated with childhood obesity, reducig the prevalece of childhood obesity i the US is a priority objective i Healthy People 2010 (2). Dietary Quality i Childre ad Adolescets Very few elemetary school-aged childre or adolescets cosume the recommeded amouts per day of the stadard food groups (3). Failure to meet recommedatios for fruits, vegetables, dairy, ad whole grais icreases the risk of iadequate itake of calcium, vitami E, folate, iro, magesium, potassium, ad fiber (4). Despite the udercosumptio of several food groups, childre ted to cosume a diet high i fat, which may lead to a overcosumptio of eergy itake (4). Choosig foods high i fat ad eglectig target food groups idicates the overall quality of food choices amog childre is poor or eeds improvemet (1, 5). The Uited States Departmet of Agriculture (USDA) computes the average diet quality of childre aged 2 to 9 years usig the Healthy Eatig Idex (HEI) (6). This system uses a idex of te dietary itake compoets icludig grais, vegetables, fruits, milk, meat, saturated fat, cholesterol, ad 2

14 sodium i compariso to the USDA recommedatios, with each compoet valued at te poits (6). A diet that meets all recommedatios i all te compoets receives a score of 100 ad would be cosidered very high i diet quality (6). O average, childre aged 2-9 years score 70 poits o the HEI, which suggests that the quality of youg childre s diets ca be improved (6). Compoets of the HEI i which childre geerally score low i iclude fruit ad sodium (6). Additioally, grais, vegetables, ad meat scores declie as childre age (6). Although there is o sigle defiitio of healthy foods, geerally speakig, fruits, vegetables, whole grais, low-fat dairy, ad lea meat are cosidered healthy, while foods high i sodium; total, saturated, ad tras fat; as well as cholesterol are cosidered uhealthy. Family Mealtimes Related to Childhood Nutriet Itake As childre cosume the vast majority of their eergy itake durig meals (7), ivestigatig the relatioship betwee mealtimes ad dietary itake may be importat i uderstadig factors that may ifluece the quality of childre s diets. Iterestigly, there is a paucity of research coducted about the relatioship betwee family mealtimes ad dietary itake (7). Gillma ad colleagues (7) coducted what is cosidered to be a ladmark study regardig family meals ad dietary itake i childre from participats who were part of the Nurses Health Study II. This ivestigatio icluded 16,202 childre, aged 9 to 14 years, who were predomiatly white. Childre i this study completed several questioaires, icludig questioaires about family meals. Frequecy of family mealtimes were assessed by askig the questio, How ofte do you sit dow with other members of your family to eat dier or supper? The participats completed a validated semi-quatitative food frequecy questioaire to assess dietary itake. Results idicated that childre who ate family meals cosumed a diet 3

15 higher i utriet quality. Childre who more frequetly ate family meals reported cosiderably higher itakes of dietary fiber, calcium, folate, vitamis B12 ad B6, vitami E, ad iro (7). Total itake of tras ad saturated fat, as well as glycemic loads, were lower i childre who frequetly cosumed meals with their parets (7). Childre who ate meals with their families were more likely to use a multivitami (7). Eatig fried foods outside of the home ad drikig soda were decreased amogst childre who regularly cosumed family meals (7). A major limitatio of this study is that the cohort cosisted of childre of registered urses, thus are from families that may be more health aware (7, 8). Aother ivestigatio of family meals ad dietary itake examied data collected from 18,177 adolescets who participated i the Natioal Logitudial Study of Adolescet Health (8). Frequecy of family meals was self-reported by adolescets whe asked how may times at least oe paret was preset whe they ate their eveig meal i the past seve days (8). Dietary itake was measured usig a food frequecy iterview i which adolescets were asked a series of questios that correspoded to three dichotomous variables to determie whether or ot he/she ate the recommeded servigs of fruits, vegetables, ad dairy as well as a dichotomous variable to assess breakfast itake (8). The results of this study foud that paretal presece durig the eveig meal was positively associated with adolescet cosumptio of fruits, vegetables, dairy foods, ad the cosumptio of breakfast (8). Neumark-Sztaier ad colleagues (9) examied family meal patters ad their relatioship with sociodemographic family characteristics ad dietary itake amog adolescets. They studied 4,746 ethically diverse adolescets from Project Eatig Amog Tees (EAT). Dietary itake was assessed by the Youth ad Adolescet Food Frequecy Questioaire. Family mealtimes were assessed by askig, Durig the past seve days, how may times did all, 4

16 or most, of your family livig i your house eat a meal together? I this study, 14% of participats reported ever eatig family meals (9). I regards to the relatioship betwee family meals ad sociodemographic characteristics, frequecy of family mealtimes was associated with geder, school level, race, mother s employmet status, ad socioecoomic status (9). Boys, middle school studets, Asia Americas, childre of uemployed mothers, ad childre of high socioecoomic status were all associated with a higher frequecy of family meals (9). For the relatioship betwee family meals ad dietary itake, cosumptio of fruits, vegetables, grais, ad calcium-rich foods icreased as the frequecy of family meals icreased (9). As cosumptio of these food groups icreased, cosumptio of fiber ad several microutriets, such as calcium, folate, iro, vitamis B6, B12, C, ad E also icreased. Frequecy of cosumptio of family meals was egatively associated with soft drik cosumptio ad saturated fat itake (9). Fially, this study foud that the majority of adolescets reported that they ejoyed eatig with their families, ad they believed that their diets were healthier whe they ate with their family (9). Family Mealtimes Related to Childhood Overweight ad Obesity If family mealtimes are related to dietary itake, such that with less frequet occurrece of family meals childhood dietary quality dimiishes, it could be hypothesized that frequecy of cosumptio of family meals may also be related to childhood weight status. Usig the Natioal Logitudial Questioaire of Youth 1997, researchers explored the associatio betwee family mealtime frequecy ad overweight status ad examied this relatioship by race ad ethicity i 5,014 adolescets betwee 12 ad 15 years of age (4). Family mealtime frequecy was 5

17 assessed by askig the adolescets how may days their family ate dier together i a typical week i the past year (4). Body mass idex (BMI) was calculated usig self-reported athropometrics to assess weight status (4). Cross-sectioal aalyses foud that a greater frequecy of family mealtimes decreased the odds of beig overweight i white adolescets (4). I overweight white adolescets, greater frequecies of family meals icreased the chace of ceasig to be overweight (either by growth or weight loss) ad reduced the risk of becomig overweight i the ext three years, as assessed by a supplemetary logitudial aalysis (4). These associatios were ot true for black or Hispaic adolescets (4). A study coducted by Gable ad colleagues (10) examied the frequecy of family meals i relatio to childhood weight status i the Childhood Logitudial Study-Kidergarte Cohort i a sample of 8,000 elemetary school-aged childre. I this study athropometric measures were take by researchers ad computer-assisted telephoe iterviews were coducted at kidergarte fall ad sprig, first-grade sprig, ad third-grade sprig (10). Durig the iterviews, parets self-reported how may times per week their family ate the eveig meal together ad how may times at least someoe i the family ate breakfast together (10). Additioal iformatio was gathered regardig child televisio hours, child aerobic exercise, child opportuities for activity, ad parets perceptios of eighborhood safety (10). Three categories of overweight were created by researchers: ever overweight, overweight oset (those that became overweight betwee kidergarte ad third grade), ad persistet overweight (10). A associatio betwee family meal frequecy ad weight status i childre was reported, such that childre who ate fewer meals with their families were more likely to be persistetly overweight ad to have the oset of overweight before the third grade (10). This is the oly 6

18 study that has examied both family diers ad family breakfasts to obtai a broader, more accurate perceptio of family mealtimes. Taveras ad colleagues (11) used both cross-sectioal ad a oe-year logitudial aalyses to assess frequecy of family mealtimes ad overweight status, measured as a BMI greater tha the 85th percetile, i 16,882 childre aged 9-14 years. BMI was calculated from self-reported height ad weight measures ad frequecy of cosumptio of family diers was determied by askig the questio, How ofte do you sit dow with other members of your family to eat dier or supper? Results demostrated that there was a sigificat, positive associatio betwee frequecy of family mealtimes ad healthy weight status. However, whe aalyzed logitudially, this associatio did ot remai statistically sigificat, thus frequecy of cosumptio of family meals did ot predict weight status (11). Fulkerso ad colleagues (12) coducted a similar research study to Taveras ad colleagues (11) usig cross-sectioal ad logitudial aalyses over a five-year period. Participats were members of the Project EAT-II cohort, a five-year follow-up cohort of the Project EAT (12). This study examied the relatioship betwee family meal frequecy ad weight status i 2,516 adolescets. BMI was calculated usig self-reported height ad weight data (12). Family meal frequecy was assessed by askig the questio, Durig the past seve days, how may times did all or most of your family livig i your house eat a meal together? (12). Resposes were grouped ito a tricotomy of o, ifrequet, or frequet family meals (12). The oly statistically sigificat associatio foud was i white, female adolescets, who reported a low frequecy of family meals or o family meals. I these white, female adolescets, ifrequet cosumptio of family meals was associated with overweight status i the cross-sectioal aalysis. However, as with the study by Taveras ad colleagues (11), the 7

19 logitudial aalysis foud o relatioship betwee frequecy of meal cosumptio ad weight status i adolescets (12). Theorized Mechaisms of the Positive Ifluece of Family Mealtimes o Diet Quality ad Weight Status durig Childhood There are several mechaisms by which family mealtimes may positively ifluece dietary quality ad weight status i childre. These mechaisms focus o paretig ad feedig styles, paretig behaviors, ad paretal modelig. Additioally, the food eviromet that has bee established i the family home, which icludes food availability ad accessibility, ad locatio of the meal, may impact o dietary quality ad weight status i childre. Paretig Styles Paretig style is defied as a costellatio of attitudes toward the child that are commuicated to the child ad that, take together, create a emotioal climate i which the paret s behaviors are expressed (pg. 488) (13). Paretig style is composed of the emotioal paret-child relatioship, paretig behaviors, ad the parets belief systems. Researchers believe that paretig styles are stable ad do ot fluctuate over time as a child ages (14, 15), but little is kow about whether it is cosistet across childre for families that have more tha oe child (13). This stability i paretig style could be because paretig style is believed to be a characteristic of the paret (16, 17). Several paretig styles have bee idetified ad iclude authoritative, authoritaria, permissive, ad eglectful styles (16). Whe Baumrid ad colleagues (16) first described ad defied paretig styles, it was thought that authoritative paretig produced the most competet childre (13). However, this has bee critiqued ad may 8

20 ot be true for miorities, i which authoritaria paretig may be most effective (18, 19). Styles may co-vary with socioecoomic status, race, ad ethicity (18, 19). Authoritative paretig is a style that allows childre to develop a strog sese of idividuality ad allows their eeds to be met through sesitive paretig (13). At the same time, authoritative paretig holds cotrol over childre s behaviors through disciplie ad high expectatios of their maturity (13). Maccoby ad Marti (20) later coied these two traits as resposiveess (sesitivity to child) ad demadigess (expectatios of child). Four paretig styles (authoritative, authoritaria, permissive, ad eglectful) are ow geerally defied i terms of their level of resposiveess ad demadigess (13, 20). Thus, authoritative paretig is high i resposiveess ad demadigess. Authoritaria paretig is high i demadigess ad low i resposiveess, ad ofte coceptualized as a strict discipliaria. Permissive paretig places low demads o the child but is highly resposive to the child. The fourth style of paretig, eglectful, places low demads o the child ad is low i resposiveess. This type of paretig is also described as uivolved. Parets accomplish degrees of resposiveess ad demadigess i differet ways, such as expectatios of child maturity ad paretal cotrol, warmth ad urturace, commuicatio styles, ad discipliary strategies (13). For example, both authoritative ad authoritaria parets have high expectatios of child maturity ad paretal cotrol over the child but the differece betwee these two paretig styles lies i the warmth ad urturace that a authoritative paret uses to reach the child. Additioally, positive back-ad-forth commuicatio is characteristic of authoritative paretig (13). Parets with authoritative styles commuicate the reasos behid their policies or decisios ad allow childre a chace to state opiios ad commuicate special iterests (13). I cotrast, authoritaria parets ted to talk to their childre without listeig for 9

21 feedback. Discipliary strategies vary betwee paretig styles as well. For example, a permissive paret avoids disciplie altogether ad geerally allows the child to decide what is appropriate for himself/herself, whereas a authoritaria paret may disciplie frequetly whe the child does ot follow orders (13). While the relatioship betwee paretig style ad family mealtimes has ot previously bee ivestigated, the relatioship betwee materal paretig style ad weight status has bee examied i a study coducted o 872 first grade studets i the US (14). This study used data from the Natioal Istitute of Child Health ad Huma Developmet Study of Early Child Care ad Youth Developmet. The results of this study foud that childre with a authoritaria mother were five times more likely to be overweight i compariso to childre with a authoritative mother (14). Childre with permissive or eglectful mothers were two times more likely to be overweight tha those i the authoritative group (14). However, the associatio betwee materal paretig style ad weight status i childre is ot cosistet (21, 22). I oe study of Australia preschool childre, materal paretig styles were ot associated with a icreased risk of child overweight (21). However, for fathers, beig permissive or eglectful was associated with greater risk of child overweight (21). I aother study, o sigificat relatioship betwee materal paretig style ad risk of childhood obesity was foud i Australia childre aged 6-13 years (22). There is some evidece that geeral paretig style may ifluece dietary quality, at least amogst adolescets (23). Six-hudred ad forty-three adolescets participated i a crosssectioal study usig surveys that asked questios regardig their parets styles ad behaviors, as well as their persoal fruit cosumptio ad persoal beliefs ad attitudes toward fruit (23). Those that described their parets as authoritative had higher self-reported fruit cosumptio ad 10

22 more positive beliefs ad attitudes toward fruit compared to those with authoritaria or eglectful parets (23). Potetially, a paret s geeral paretig style may ifluece his/her feedig style. There are three mai types of feedig styles: authoritative, authoritaria, ad permissive (24). As with paretig style, authoritative feedig is believed to be the healthiest paretal feedig style for childre (24, 25). With this feedig style, the paret or adult chooses which types of foods to serve, givig several healthy optios. The child chooses which foods to eat ad how much to eat. This allows the child to liste to satiatio cues ad develops the child s self-efficacy for choosig healthy food items (25). Permissive ad authoritaria feedig styles are o opposite eds of the spectrum. A permissive feedig style is whe a paret has give up cotrol over a child s eatig ad the child has total cotrol over which foods are eate, i what quatity they are eate, ad whe they are eate (24). With this style the paret has lost cotrol of the food eviromet. Cotrary to this, a authoritaria feedig style is oe i which the paret is forceful about which foods must be eate ad which foods must be avoided (24). Geerally, a authoritaria feedig practice also dictates whe ad how much a child eats. A authoritaria feedig style is very cotrollig ad does ot allow child iput. A authoritative feedig style has bee kow to positively ifluece a child s dietary quality. Oe study looked specifically at Africa-America ad Hispaic pre-school-aged childre (24). I this cross-sectioal study, 231 parets or caretakers completed the Caregiver Feedig Styles Questioaire regardig two paretig styles: authoritaria ad authoritative. Feedig style was examied i relatioship to frequecy of servig, persuasio, ad cosumptio of dairy, fruit, ad vegetable food items. Authoritative feedig style was positively related to dairy, fruit, ad vegetable itake while a authoritaria feedig style was egatively related to dairy, fruit, ad vegetable itake (24). 11

23 Oe aspect of paret feedig style that has received cosiderable attetio i regards to impactig child dietary itake ad weight status is paretal food restrictio. Paretal food restrictio is defied as a attempt to cotrol child food cosumptio by restrictig certai food choices (26). Whe paretal food restrictio was first examied, studies were cross-sectioal i desig, thus whe the positive associatio was foud betwee weight status ad food restrictio, it was uclear which came first. For example, i a early study by Birch ad colleagues (27), materal food restrictio was measured by askig the same 9 questios for 10 sack foods regardig access, moitorig, ad limitig the specific food item ad foud that food restrictio was positively associated with child weight status (27). Iitially it was believed that greater food restrictio was producig icreased weight status i childre as it was theorized that restrictig foods may icrease the desirability of the food item ad therefore cause over cosumptio whe the food became available (26-28). Additioally, it was hypothesized that childre may lose the ability to self-regulate huger ad satiety cues whe exposed to restrictive paretal feedig (26-29). However, with the limitatios of the ability to ifer a cause ad effect relatioship betwee two variables i a cross-sectioal desig, it was uclear whether the practice of paretal food restrictio cotributed to childhood obesity or if the weight status of the child ecouraged paretal food restrictio (15). I a more recet prospective study, paretal food restrictio was defied as the extet to which parets attempt to restrict their child s eatig durig meals (pg. e430) (15). Restrictio was measured usig a Child Feedig Questioaire (CFQ) that evaluated attitudes ad feedig styles such as: perceived child weight, child weight cocer, perceived resposibility, restrictio, pressure to eat, ad moitorig (15). Athropometric data was collected at three time poits for childre (aged 3, 5, 7 years) ad obesity risk was determied by calculatig materal ad pateral BMIs (15). This study suggested a gee-eviromet 12

24 iteractio; childre with a geetic predispositio for obesity, ad thus greater risk for developig obesity, had parets who practiced more restrictive feedig practices (15). The results of this study are i cotrast to previous beliefs that restrictive feedig practices led to childhood obesity. Further research is eeded to cofirm the directio of the iteractio betwee childre with a geetic predispositio for obesity ad restrictive feedig practices, as well as to address the limitatios of the study. Limitatios of the study icluded the homogeeity of the cohort (white), a uderpowered sample size, ad lack of dietary itake measures (15). Paretig Behaviors Paretig behaviors (also kow as paret practices or paretal duties) guide resposes i childre (13). Paretig behaviors are believed to be actios parets egage i to ifluece a child s attitudes, beliefs, actios ad opiios (13). I the area of dietary itake, paretig behaviors could ifluece how a child develops table maers, listes to iteral cues of satiatio, makes choices about which foods to cosume, ad how food ca be used for reasos other tha to reduce huger (i.e., usig food as a reward) (14). Iterestigly, parets ted to report usig the same paretig behaviors that their parets used whe they were childre (30). Oe paretig behavior that iflueces child behavior is positive reiforcemet. A family meal provides a opportuity for a paret to positively reiforce healthy food choices i childre. Whe the child produces a observed behavior, such as eatig vegetables durig dier, this gives the paret a opportuity to provide positive reiforcemet for vegetable cosumptio to the child. The use of positive reiforcemet (i.e., praise) followig healthy food choices that a child might be makig icreases the likelihood that the behavior will occur agai, shapig the child s dietary itake (31). 13

25 Family mealtimes provide a opportuity for parets to develop the utritio beliefs ad attitudes of their childre (28). Childre look to their parets as a source of utritio iformatio ad almost always fid the iformatio useful (1). The utritio iformatio is retaied, as childre had greater overall utritio kowledge whe their parets discussed the utritioal values of foods at dier (30). Dier may be a ideal time for parets to educate their childre o healthy eatig practices ot oly by example but i coversatio as well (31-33). Oe study used taped iteractios of family mealtime coversatio to assess how utritioal advice is embedded i coversatio (34). Family mealtime coversatio may be the key to chagig attitudes towards healthy foods ad puttig utritioal advice ito practice (34). Researchers believed that by studyig spotaeous food talk they might be able to fid a way to desig utritio messages more applicable to idividuals ad their actual eatig routies (34). Paretal Modelig Childre may cosume healthier diets with more frequet family meals as a result of parets modelig healthy eatig (5). For istace, if parets are cosumig fruits, vegetables, whole grais, ad dairy durig a family meal, childre are more likely to also egage i this behavior to emulate the behavior of their parets. Appropriate modelig may be practiced more i homes where parets feel a greater resposibility for their child s eatig (35) ad/or chroic disease prevetio (26). It is believed that paretal modelig is especially importat whe childre are developig, such as i middle childhood, as compared to adolescets (25, 36). Parets ad childre ted to have similar dietary patters, icludig prefereces ad willigess to try ew foods (33, 37-39). This may be due to the selected food items that parets brig ito the home, which items they choose to itroduce to the child, ad which items the childre see 14

26 their parets cosumig (33, 37, 40). I theory, paretal modelig may work i four ways (41). First, childre are observatioal learers, meaig they will lear by watchig their parets (41). I this way, childre may lear which foods to eat ad which foods to avoid, based o their parets prefereces. Secod, childre observe the egative or positive cosequeces of a actio which will either discourage or ecourage their ow behaviors (41). With food, the cosequeces may be verbalized by the adult. For example, This piece of cake is goig to make me fat. Third, paretal modelig may cue the child to do the same behavior, i this case, eatig healthy food (41). Lastly, childre will use the same stadards that the parets have set for themselves. Therefore, if parets expect themselves to eat healthy, childre may assume the same resposibility to eat healthy (41). Food Availability ad Locatio of Mealtime Food availability at meals may help explai why family meals lead to a icrease i cosumptio of healthy foods ad a decrease i itake i those foods cosidered less healthy (26). For example, a cross-sectioal study coducted by Haso ad colleagues (32) looked at household food availability i 902 adolescets ad paret or guardia pairs (32). Household food availability was self-reported by parets usig a questioaire with questios such as, How ofte would you say fruits ad vegetables are available i your home (1) always; (2) usually; (3) sometimes; (4) ever? (32). Amog food served at meals, approximately 87.0% served vegetables but oly 66.6% served milk (32). Availability of healthy foods ad the absece of uhealthful foods at meals ca ifluece childre to make the healthiest food choices (32). The ability of food availability to ifluece cosumptio is uderstood withi the cotext of the behavioral theory i which atecedets (or cues) i the eviromet trigger behavioral 15

27 cosequeces (42, 43). For example, if cookies are bought ad the left o the couter, simply walkig ito the kitche may trigger the desire to eat the cookies (43). How food is preseted ad served at a family meal, or family mealtime style, may also ifluece cosumptio. Family mealtime styles iclude buffet style, family style, ad preportioed meals. With buffet style, the paret prepares the foods ad each member of the family prepares his/her ow plate of food from food stored away from the table, thus each family member decides which ad how much of each food to take. Buffet style provides a lot of cotrol to childre over their food choices ad portio sizes. Childre may ot be aware of appropriate servig sizes or the best choices of food whe allowed buffet style of family mealtimes. Oe beefit of buffet style is that geerally the food is left o the stove-top ad therefore is out of eye sight, which may make secod helpigs less temptig. Similar to buffet style, family style allows the child to prepare his/her ow plate, decidig which ad how much of each food to take. Family style is differet tha buffet style because the food is placed i the ceter of the table ad left there durig the meal, which may make secod helpigs more temptig. Leavig the food i eye sight cues family members, icludig childre, to eat more food. This promptig may be difficult to resist ad ecourage overeatig. The last type of family mealtime style is preportioed meals that are prepared ad portioed by the paret with varyig degrees of child iput, i which foods, or how much, is put o his/her plate. With pre-portioed meals, the food available to the child is limited based o what the provider desires the child to cosume, despite possible huger or satiety, thus the child has little cotrol over his/her food choices ad portio sizes. This family mealtime style may be cosidered restrictive. To date, there are o evidecebased recommedatios regardig which family mealtime style is the best for childre. 16

28 Family meals ca be cosumed i the home eviromet, or away from home. As a geeral tred, meals eate i the home ted to be less eergy dese tha meals eate i restaurats (1, 10). Restaurat foods, particularly fast food, are prepared with a lot of fat which sigificatly alters the eergy desity of the foods served (1, 10). Thus, where food is prepared for meals ad/or where the meal takes place may be a importat factor i ifluecig child dietary itake ad weight status. Additioally, there seems to be a iverse relatioship betwee fast food itake ad cosumptio of fruits, vegetables, ad dairy products (5). It is importat to ote that eatig a meal at home does ot mea that the meal is ot composed of food that was prepared outside of the home, ad ideed a meal eate at home ca be composed of fast food. Thus, meals eate i the home are ot automatically less eergy dese ad higher i dietary quality. Family meals composed of carry-out, take-out, ad delivery foods may be more similar to restaurat ad fast food tha foods prepared at home. Child Developmet i Middle Childhood Middle childhood is believed to be especially crucial i the developmet of obesity due to the rapid growth ad developmet that takes place durig middle childhood (15). Middle childhood ecompasses elemetary school-aged childre ad marks a age that is particularly impressioable, especially by paretig styles ad behaviors (15, 44). Whe compared to adolescets, childre youger tha 12 years of age may be more greatly iflueced by their parets paretig ad feedig styles, paretig behaviors, ad paretal modelig (44). To illustrate, a adolescet geerally has more autoomy tha a youger child ad thus may be less iflueced by home food availability due to havig the optio of obtaiig food at school or by havig other meas (i.e., a car or fiaces through a after school 17

29 job) to obtai foods ot available at home. Additioally, adolescets may ot be as motivated i makig healthy food choices as a youger child by paretal praise (i.e., Great job eatig vegetables! ) ad/or by paretal modelig tha would a elemetary school-aged child. Thus, middle childhood is a prime time for parets to practice effective paretig styles ad behaviors because the child may be more receptive to the messages that parets are sedig. Challeges i Research about Family Mealtimes Oe of the largest challeges i assessig the impact of family meals o the quality of the diet i childre, ad its potetial ifluece o weight status, is that there is o established defiitio of a family meal. The defiitio of a family meal is elusive ad geerally selfiterpreted by respodets. Without a established defiitio, it is difficult to compare betwee research studies ad to uderstad what compoets of a family meal may be ifluecig the quality of childre s dietary itake ad their weight status. For example, a commo way to assess occurrece of family meals is to ask, How ofte do you sit dow with other members of your family to eat dier or supper? (11). However, there are may drawbacks to this questio, as may aspects of what costitutes a family meal are uclear. For istace, the phrase other family members does ot desigate if a adult who lives i the household is preset at the meal. The settig of the meal is ot established, therefore, it does ot distiguish whether or ot the meal was eate at home or i a restaurat. The types of food beig served ad how the food is beig served are uclear also. Fially, what is the atmosphere of the family mealtime (i.e., how are family iteractios, are there other distractios occurrig, etc)? 18

30 May characteristics about family mealtimes may be importat i impactig the dietary quality ad weight status of elemetary school-aged childre. I defiig what makes a meal a family meal, six aspects should be cosidered, although may others may be importat. These six compoets iclude: 1) Which meal is eate? Breakfast, luch, or dier? 2) Who is preset at the meal? 3) What type of food is served ad eate? 4) Where is the food i the meal prepared ad/or eate at home or i a restaurat? 5) How is food served? 6) What is the atmosphere of the meal? Which meal It is importat to determie which meal is beig evaluated by the questioaire. Vague questios leave the family mealtime ope to iterpretatio by the respodet. Previous studies ivestigatig family meals have defied a specific meal whe family meals are assessed, predomiatly askig about eveig mealtimes, rather tha breakfast or luch (5, 31, 45). This leads oe to questio if there are potetial beefits of assessig other mealtimes whe tryig to idetify the aspects of a family meal that may cotribute to overall diet quality ad healthy weight status i childre. Who Determiig who is preset at the meal may be challegig due to the wide rage of family structures foud i the Uited States (46). However, it is importat i establishig the defiitio of a family meal, as may of the proposed mechaisms of the effect of family meals 19

31 ivolve a paret, or at least a adult family member, beig preset at the meal. Presumably, a mother or father would be the most likely to be egaged i paretig behaviors, such as modelig, positive reiforcemet, or restrictio, that may ifluece a child s eatig behaviors. I cotrast, if the adult family member is a older siblig or a aut/ucle, he/she may be less likely to impact the child s eatig through the aforemetioed paretig behaviors. What What kid of food is beig served ad cosumed is ecessary to establish compoets of family mealtimes that icrease the utriet quality of childre s diets. It is ecessary to evaluate whether or ot the kid of food served ad amout of food cosumed is i accordace to the Dietary Guidelies for Americas (47). Where From a utritio stadpoit, it is importat to kow where the food served at a family meal is beig prepared ad/or where the family meal is geerally takig place. Is the family preparig food at home ad eatig it there or are they gatherig outside of the home i a restaurat? Foods served at meals may also be delivered from restaurats or purchased from coveiece sectios i grocery stores. Potetially, food may be purchased from fast food establishmets ad take home to eat for a meal. As fast food is geerally high i saturated ad tras fat, high eergy-desity, high glycemic idex, ad packaged i large portio sizes, determiig if family meals regularly cotai fast food is importat (1). Similarly, sit-dow restaurats geerally serve food i large portios that are high i calories, fat, ad sodium with some meu items eve exceedig a full day s worth of fat ad saturated fat (48). 20

32 How How the meal is served may impact the type ad amout of food cosumed by the child. A few meal styles iclude buffet style, family style, ad pre-portioed meals. Buffet style is whe childre serve themselves from the stove-top ad have cotrol over their ow food choices ad servig sizes. With family style, childre serve themselves from dishes passed aroud the table. This style allows childre to cotrol food choices ad servig sizes. Pre-portioed meals are prepared by the paret, who also chooses to proportio ad serve plates to the childre accordig to her/his ow judgmet. Pre-portioed meals may have varyig degrees of child iput i makig food choices ad decidig portio sizes. Additioally, meal preparatio may be just as importat as the meal itself. Leavig a elemetary school-aged child out of the food selectio ad/or meal preparatio may egatively impact the family mealtime, whereas choosig to iclude him/her may positively impact the family mealtime (3). Atmosphere The atmosphere of the family meal may impact overall cosumptio ad food choices childre make (3). There are a variety of aspects that impact the atmosphere of a family mealtime ad thus ifluece dietary itake, icludig both family iteractios ad evirometal distractios. Family Iteractios Family iteractios iclude: adult satisfactio of mealtimes, paretig styles, paret feedig styles, paretig behaviors, positive reiforcemet, beliefs ad attitudes related to food, ad paretal modelig, ad may ifluece the atmosphere of a family mealtime. Additioally, 21

33 havig serious debates ad/or discussig disciplie at family mealtimes may create a egative atmosphere (3). Evirometal Distractios Leavig the televisio or radio o are examples of evirometal distractios at family mealtimes. Other distractig behaviors iclude aswerig or talkig o a telephoe, cell phoe, or textig. Aythig that takes the attetio off of the family mealtime coversatio ad iteractios at the table could be cosidered a evirometal distractio. Additioally, distractios i the eviromet may divert the child s attetio away from his/her huger cues (3). Recommedatios for Family Mealtimes I 2006, the America Dietetic Associatio (ADA) produced a brief review article titled Family Mealtimes: More tha Just Eatig Together (3). Upo reviewig research ivestigatig the impact of family meals o childre s dietary itake, ADA cocluded that family meals have a sigificat, positive impact o childre s diets (3). As a goal, ADA ecourages families to eat together at least four meals per week (3). It is recommeded for families to pla meals i advace, maitai a positive eviromet by avoidig serious debates or disciplie, be free of distractios, ad allow childre to be ivolved i the meal preparatio process (3). ADA cocludes that family meals are importat i the delivery of utritious meals, developig family uity, ad emphasizig healthful behaviors i youth (3). 22

34 Future Research Several studies cite a positive coectio betwee frequecy of family meals ad the utritioal cotet of the childre s diets (3-5, 7-12, 45, 47). Additioally, researchers believe that there may be a relatioship betwee the frequecy of family meals ad the child s weight status (3, 10, 12, 31, 47). However, the defiitio of a family meal ad the compoets that may promote a healthy diet ad weight status have yet to be established. Thus, to provide recommedatios to families o how to implemet a evidece-based family meal guidelie which has the best chace to positively impact child dietary itake ad weight status, more research is eeded o establishig the essetial compoets of family meals. Additioally, prior research o family mealtimes has more predomiatly focused o adolescets. This may be due i part to the Project EAT study coducted i public middle ad high schools (5, 9, 32). This cohort has bee used for several of the studies aforemetioed ad does ot iclude data o elemetary school-aged childre. Therefore, more research is eeded o family meals i elemetary school-aged childre (i.e., 5-11 years of age). Thus, the aim of this study was to determie compoets of family mealtimes that are related to a higher diet quality ad healthy weight status i elemetary school-aged childre. The compoets of family mealtimes that were assessed i this ivestigatio icluded the followig: which meal was eate, who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. This study collected iformatio about these compoets of a family meal ad diet quality i 62 elemetary school-aged childre from three questioaires that were completed by a paret or guardia of a 23

35 elemetary school-aged child. Height ad weight measures were collected by researchers. BMI was calculated from these measures ad coverted to stadardized BMI (zbmi). It was hypothesized that frequecy of family mealtimes would be positively associated with diet quality ad a healthy weight status. It was aticipated that dietary quality, defied by a dietary itake higher i fruits, vegetables, low-fat dairy, ad lower i sweeteed driks, ad sweet ad salty sack foods, would be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. Additioally, it was aticipated that a healthy weight status would be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. The followig aims were assessed i this ivestigatio: 1. Determie compoets of family mealtimes that were related to a higher dietary quality i elemetary school-aged childre. The compoets of family mealtimes ivestigated icluded: which meal was eate, who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. It was aticipated that dietary quality, defied by a dietary itake higher i fruits, vegetables, ad low-fat dairy, ad lower i sweeteed beverages, ad sweet ad salty sack foods, would be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. 24

36 2. Determie compoets of family mealtimes that were related to a healthy weight status i elemetary school-aged childre. The compoets of family mealtimes ivestigated icluded: which meal was eate, who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. It was aticipated that a healthy weight status would be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. 25

37 CHAPTER II: MANUSCRIPT 26

38 Itroductio Childhood obesity is a growig epidemic ad thus is a public health cocer i the Uited States (US) (1). Rates of childhood obesity have icreased by 2.3 to 3.3 fold i a spa of approximately 25 years (1). Short-term effects of childhood obesity cosist of health complicatios, such as sleep apea, asthma, hypertesio, dyslipidemia, chroic iflammatio, icreased blood clottig, edothelial dysfuctio, hypertesio, ad psychological sequela, icludig social disturbaces ad struggles with acceptace amog peers (1). Moreover, obese childre are at icreased risk for becomig obese adults ad developig cardiovascular disease ad type 2 diabetes i adulthood (1). Due to these outcomes associated with childhood obesity, reducig the prevalece of childhood obesity i the US is a priority objective i Healthy People 2010 (2). As childre cosume the vast majority of their eergy itake durig meals (3), ivestigatig the relatioship betwee mealtimes ad dietary itake may be importat i uderstadig factors that may ifluece the quality of childre s diets ad thus obesity. Ideed, previous research has foud sigificat relatioships betwee family meals ad child dietary itake ad weight status. Cross-sectioal studies have idicated a positive relatioship betwee the frequecy of family mealtimes ad childre s diets beig cosiderably higher i dietary fiber, calcium, folate, vitamis B12 ad B6, vitami E, ad iro (4, 5). Also, Video ad colleagues foud that paretal presece durig the eveig meal was positively associated with adolescet cosumptio of fruits, vegetables, dairy foods, ad the cosumptio of breakfast (6). Fially, Neumark-Sztaier ad colleagues reported a egative relatioship betwee family meals ad soft drik cosumptio ad saturated fat itake (7). Most importatly, cross-sectioal studies have 27

39 show that a greater frequecy of family mealtimes may decrease the odds of beig overweight for childre (4, 8, 9). However, this associatio has ot held true whe aalyzed logitudially i both a oe-year study (9) ad a five-year study (5). Oly oe logitudial study (4) has show a positive relatioship betwee the frequecy of family diers ad weight status i white adolescets over a three-year period. The cotradictory results idicate a eed for further research. Oe potetial reaso for the coflictig outcomes betwee family mealtimes ad weight status i childre is the lack of a established defiitio of a family meal. The defiitio of a family meal is elusive ad geerally self-iterpreted by respodets. Without a established defiitio of a family meal, assessig family meals is challegig, ad makes it difficult to compare outcomes betwee research studies. Fially, the lack of a defiitio for family meals makes uderstadig compoets of family meals that may be ifluecig the quality of childre s dietary itake ad their weight status early impossible. Eve with the eed for additioal research ad a lack of a established defiitio of a family meal, i 2006 the America Dietetic Associatio (ADA) produced a brief review article titled Family Mealtimes: More tha Just Eatig Together (10). Upo reviewig research ivestigatig the impact of family meals o childre s dietary itake, ADA cocluded that family meals have a sigificat, positive impact o childre s diets (10). As a goal, ADA ecourages families to eat together at least four meals per week (10). As part of ADA s goal, it is recommeded for families to pla meals i advace, maitai a positive eviromet by avoidig serious debates or disciplie durig mealtimes, cosume the meal free of distractios, ad allow childre to be ivolved i the meal preparatio process (10). ADA cocludes that 28

40 family meals are importat i the delivery of utritious meals, developig family uity, ad emphasizig healthful behaviors i youth (10). However, it is ucertai what characteristics about the family meal impact the quality of the diet i childre, ad potetially ifluece weight status. Theoretically, family mealtimes may positively ifluece childre s diet quality ad weight status through several mechaisms. These mechaisms focus o the behaviors that parets may be exhibitig durig the meal, as well as the food eviromet that has bee established i the family home. For istace, paretal modelig of cosumptio of fruits, vegetables, whole grais, ad dairy durig a family meal may ecourage childre to emulate the behavior of their parets (11-14). A family meal provides a opportuity for a paret to positively reiforce healthy food choices i childre. The use of positive reiforcemet (i.e., praise) followig healthy food choices that a child might be makig icreases the likelihood that the behavior will occur agai, shapig the child s dietary itake (15). Family mealtimes also provide a opportuity for parets to develop the utritio beliefs ad attitudes of their childre. Additioally, dier may be a ideal time for parets to educate their childre o healthy eatig practices ot oly by example, but also i coversatio (15, 16). Paretig styles, such as authoritative, authoritaria, permissive, or eglectful, may also ifluece family mealtimes ad may traslate ito paret feedig styles at mealtimes (14, 19, 21-23). Authoritative paretig ad feedig styles have high levels of resposiveess ad demadigess which may positively ifluece a child s dietary quality ad possibly promote a healthy weight status amogst childre (14, 19, 21-23). 29

41 Additioally, qualities of the food eviromet may be mechaisms by which family mealtimes may positively ifluece diet quality ad weight status i childre. Availability of healthy foods ad the absece of uhealthful foods at meals ca ifluece childre to make the healthiest food choices (16). Lastly, meals eate i the home ted to be less eergy dese tha meals eate i restaurats (1, 8). Restaurat foods, particularly fast food, are prepared with a lot of fat which sigificatly alters the eergy desity of the foods served (1, 8). Thus, where food is prepared for meals ad/or where the meal takes place may be a importat factor i ifluecig child dietary itake ad weight status. Therefore, there is reaso to believe that family mealtimes may ifluece diet quality ad weight status i elemetary school-aged childre. However, i order to provide recommedatios to families o how to implemet a evidece-based family mealtime guidelie which has the best chace to positively impact child dietary itake ad weight status, more research is eeded to establish the essetial compoets of family meals that are related to child dietary itake ad weight status. Thus, the purpose of this study was to determie compoets of family mealtimes that are related to a higher diet quality ad healthy weight status i elemetary school-aged childre. The compoets of the family meals that were assessed i this ivestigatio i relatio to child dietary itake ad weight status icluded the followig: which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. This study collected iformatio about these compoets of a family meal, ad diet quality i 62 elemetary school-aged childre from 30

42 three questioaires that were completed by a paret or guardia of a elemetary school-aged child. Height ad weight measures were collected by researchers. It was hypothesized that frequecy of family mealtimes would be positively associated with diet quality ad a healthy weight status. It was aticipated that diet quality ad a healthy weight status would both be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. Methodology Study Desig I this study, to determie the compoets of family mealtimes that may promote icreased diet quality ad a healthy body mass idex (BMI) i childre, a cross-sectioal desig study was used. A questioaire assessig compoets of family mealtimes hypothesized to be importat for ifluecig child diet quality ad weight status was collected. The compoets of the family meals that were assessed i this ivestigatio i relatio to child dietary itake ad weight status icluded the followig: which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. I additio, a questioaire was used to determie diet quality (i.e., itake of fruit, vegetable, low-fat dairy, sweeteed driks, etc.) of each child. BMI ad zbmi were calculated usig athropometric data collected by researchers. The idepedet variables i this ivestigatio were the compoets of family mealtimes, ad the depedet variables were child diet quality ad weight status. This study desig, as well as all 31

43 materials used, was approved by the Istitutioal Review Board (IRB) at the Uiversity of Teessee. See Appedix A for IRB approval. Recruitmet Participats were recruited from a variety of locatios from September 2009 through February 2010 usig several methods of recruitmet. Participats were recruited from two local doctors offices, icludig Cherokee Health Systems ad Koxville Pediatric Associates, P.C., both i Koxville, Teessee. Participats were recruited from two local churches, Mill Sprigs Baptist Church i Jefferso City ad Christ Chapel i Koxville, Teessee. I additio, the Early Learig Ceter (ELC), located o the campus of the Uiversity of Teessee, was used to recruit participats. Participats from all locatios were child ad paret/guardia pairs i which the child was aged 5-11 years. I the doctors offices, families who appeared to have a child that met the mai eligibility criteria of age were first idetified i the waitig area. I the waitig area, families were approached about their potetial iterest i participatig i the study usig a recruitmet script. Those that were iterested ad eligible completed the study as described below. I the churches, families were approached usig a aoucemet i the bulleti oe week before the data collectio. The aoucemet ca be foud i Appedix A. Iterested parets were istructed to go to a particular room followig the Suday church service o the date i which data collectio occurred. Oce iterested parets were together, the researcher used the recruitmet script to verify idividual iterest. 32

44 The ELC was give packets from the researchers to sed home with all eligible childre, usig the mai eligibility criteria of child age. A flier explaiig the study was set via the olie list serve at ELC to target eligible childre that do ot atted ELC (i.e., a older siblig of a studet). The flier ca be foud i Appedix A. Potetial participats respodig to fliers ad ayoe that heard of the study through word-of-mouth were istructed to call the Healthy Eatig ad Activities Lab (HEAL) to schedule a appoitmet with a researcher. Eligibility Family eligibility was based o the followig criteria: 1. Child was aged 5-11 years. 2. Child was feelig i good health. 3. Paret was willig to complete three questioaires. 4. Participats were excluded if: a. Paret was uwillig to complete the questioaires. b. Paret could ot read ad write i Eglish. c. Child was waitig for the physicia due to a illess or who were feelig ill. d. Child had ay coditios requirig diet restrictios prescribed by a doctor, icludig, but ot limited to: diabetes, celiac disease, croh s disease, ad pheylketouria (PKU). A total of sixty-two families were recruited for this study. Several other families were approached ad were either a) ot eligible, or b) did ot wat to participate. For Cherokee 33

45 Health Systems, forty-eight families were approached to participate i the study. Of those families approached to participate, five did ot wat to participate, four had childre that were too youg, two families had parets who did ot read/write i Eglish, ad oe family had a child that was sick. Thus, thirty-six families from Cherokee participated i the study. For Koxville Pediatric Associates, te families were approached, with oly oe family beig ieligible due to child age, totalig ie participatig families. For churches, fourtee families were approached ad oly oe family did ot participate due to lack of child asset, totalig thirtee participatig families. All church families that wished to participate were eligible. Of the ELC childre, fourtee packets were set home with eligible childre ad oly three were completed ad retured to researchers. Thus, eleve families chose ot to participate for reasos ukow. Oe additioal family from ELC was recruited through the olie flier. Procedures After recruitmet, iterested parets at each of the locatios were asked to sig a coset form that met the approval of the IRB from the Uiversity of Teessee (ad for Cherokee Health Systems, the Cherokee IRB). After coset ad child verbal asset were obtaied, procedures for all churches ad doctors offices were the same. The ELC locatio used slightly differet methods described below. For all churches, doctors offices, ad word-of-mouth participats at HEAL, parets completed three questioaires, takig approximately 20 miutes. Parets were istructed to complete the family mealtime ad diet quality questioaire thikig about the eligible child. While the paret/caretaker completed the questioaires, athropometric iformatio was collected by weighig ad measurig the child i a private area. Upo completio of all 34

46 measures, paret/child pairs were compesated for their time with a $10 gift card to atioal retail chai give to parets. At ELC, parets were istructed to retur their completed coset form ad surveys i a sealed evelope. After surveys were retured ad collected by researchers, childre were matched to their paret by the birthday provided o the demographic survey. Upo child asset, the child s athropometric iformatio was collected by weighig ad measurig the child at the ELC. After completio, childre were set home with a $10 gift card to a atioal retail chai to give to their parets as compesatio. Measures Demographics Child demographic iformatio icludig date of birth, geder, ad race/ethicity was collected from the child sectio of the Caretaker Demographic Questioaire. The Caretaker Demographic Questioaire was used to determie age, sex, relatioship to child, educatio, marital status, race, ethicity, self-reported height ad weight, ad icome of the paret or caretaker, as well as household size. Household size was broke dow ito adults ad childre. See demographic questioaires i Appedix A. Athropometrics Athropometric data was collected by researchers usig a electroic scale (Healthometer Professioal, Subeam Product Ic., Rato, FL) ad a portable stadiometer (SECA, ITIN Scale Compay, Brookly, NY). Childre were istructed to remove their shoes ad jackets for athropometric data collectio. For height, childre were asked to stad up 35

47 straight with heels agaist the stadiometer ad height was measured i iches ad rouded to the earest 1/8 of a ich. For weight, childre were asked to step oto the electroic scale without shoes ad to stad still with hads dow to their sides. Weight was measured i pouds ad rouded to the earest 0.1 poud. Height ad weight were used to determie the child s BMI, which was calculated by takig the child s weight i kilograms divided by height i meters squared. BMI was coverted to BMI percetile usig the Ceters for Disease Cotrol (CDC) BMI percetile charts (17). I childhood, the goal percetile rage for ormal weight is 5 th percetile ad <85 th percetile. Greater tha or equal to the 85 th percetile is cosidered overweight ad greater tha or equal to the 95 th percetile is cosidered obese (17). As BMI icreases as childre age, to be able to compare BMI iformatio amogst all childre i the sample, BMI was coverted to zbmi. Childre s zbmi was calculated by stadardizig the BMI value i relatio to the populatio mea ad stadard deviatio for childre s age ad geder (18). Family Mealtimes To establish face validity, the family mealtime survey was set to family mealtime researchers via . Feedback was provided from Jaye Fulkerso, PhD, RD, Mary Story, PhD, RD, ad Diae Neumark-Stzaier, PhD, RD. Slight chages were made to the questioaire based upo feedback obtaied. The followig paragraphs are orgaized by family mealtime compoet, whereas o the questioaire the questios are ot purposely grouped by compoet. Parets respoded to 63 questios regardig the frequecy of family mealtimes ad compoets of family mealtimes to ascertai the six idetified areas to assess i family meals: 36

48 which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. Questios were take ad adapted from related research ad brought together ito oe istrumet for this study (13, 15, 19). Additioally, origial questios were created. For all family mealtime questios, participats were asked to respod based upo a typical week. See the family mealtime questioaire i Appedix A. To address the areas of which meal, who is preset, ad where the meal is cosumed, parets were asked about the frequecy of family meals, where these meals geerally occur, ad adult family members geerally preset at these meals. Thus, parets reported family mealtime frequecy by umber of times per week for breakfast, luch, ad dier for a typical week (respose choices: 0-7). For each meal listed, frequecies of family mealtimes both at home ad i restaurats or fast food establishmets were asked. To determie who was geerally preset at family meals, parets wrote i which adult family members were typically eatig with the child at each particular meal (breakfast at home, breakfast i a restaurat or fast food establishmet, luch at home, luch i a restaurat or fast food establishmet, dier at home, dier i a restaurat or fast food establishmet). A total of 19 questios were asked pertaiig to the types of foods prepared ad served at family mealtimes. Seve of those questios assessed the frequecy of specific types of foods served ad eate at family meals durig a average week i the home ad, separately, the same seve questios were asked about family meals i restaurats ad fast food establishmets (respose choices: always, usually, sometimes, rarely, ever). Three questios pertaied to the types of foods that the paret cooks or buys. These 17 questios were derived from 37

49 questioaires by Fulkerso ad colleagues (13), Boutelle ad colleagues (19), ad Campbell ad colleagues (15). I additio, two origial questios were asked: I heat froze etrees (i.e., TV diers, froze lasagas, pot pies, hot pockets) for meals; I buy hot, pre-prepared food from the deli or grocery store (i.e., fried chicke, rotisserie chicke) ad serve it to my family i my home for a meal (respose choices: always, usually, sometimes, rarely, ever). Nie questios were asked about how the child is usually fed. Five of the questios were used to provide iformatio about the paret s ad/or child s role i the mealtime which provided iformatio about how food is served i family meals (respose choices: always, usually, sometimes, rarely, ever). Three of the five came from a questioaire coducted by Campbell ad colleagues (15) that looked at the restrictio of childre s eatig. Two related questios were created for this questioaire: My child is free to decide whe he/she is fiished eatig; I give my child small tasks to iclude him/her i the food preparatio process (respose choices: always, usually, sometimes, rarely, ever). Four origial questios helped determie how the paret served food at meals (i.e., I serve food family style by placig all food items o the table, passig them aroud, ad allowig childre to serve themselves.). This area of family meals has ever bee part of a family mealtime questioaire i previous research (respose choices: always, usually, sometimes, rarely, ever). Twelve questios were asked regardig the atmosphere compoet of family mealtimes. Three questios pertaied to the ejoymet of family mealtimes (respose choices: strogly agree, agree, either agree or disagree, disagree, strogly disagree). Two questios pertaied to family mealtime discussios ad four other questios related to other aspects of family mealtime atmosphere (respose choices: always, usually, sometimes, rarely, ever). These ie questios were derived from questioaires by Fulkerso ad colleagues (13) ad Boutelle ad colleagues 38

50 (19). I additio, three origial questios were asked about the atmosphere of family mealtimes, icludig: My family talks about food ad utritio durig mealtimes; I praise my child whe he/she makes healthy food choices; My family sits at a table durig mealtimes (respose choices: always, usually, sometimes, rarely, ever). To assess the adult satisfactio of family mealtimes, which may be related to the overall atmosphere of family mealtimes, six questios were asked. Three questios were asked regardig the adult perceptio of satisfactio ad importace of family mealtimes (respose choices: strogly agree, agree, either agree or disagree, disagree, strogly disagree). Three additioal questios regardig adult perceptio of satisfactio were asked (respose choices: always, usually, sometimes, rarely, ad ever). All of these questios were derived from questioaires by Fulkerso ad colleagues (13), Boutelle ad colleagues (19), ad Campbell ad colleagues (15). Seve questios were aimed at determiig paretig characteristics, aother area of the overall atmosphere of family mealtimes. Five of the questios were related to paretig behaviors that may affect how the child eats i specific locatios (i.e., I have to be sure that my child does ot eat too may high-fat foods at home durig meals.) ad oe questio was about paretig behaviors i geeral: I pre-pla meals before I prepare them (respose choices: always, usually, sometimes, rarely, ever). These questios were derived from questioaires by Fulkerso ad colleagues (13), Boutelle ad colleagues (19), ad Campbell ad colleagues (15). Additioally, oe origial questio was asked: I use a shoppig list at the grocery store (respose choices: always, usually, sometimes, rarely, ever). As previous research has show that may families do ot cosume family meals regularly (13), it was aticipated that some participats i this ivestigatio would fall ito this 39

51 category. Thus, three questios were asked about the frequecy of barriers i fidig time for a family meal i a average week (respose choices: always, usually, sometimes, rarely, ever). Questios about barriers were derived from questioaires by Fulkerso ad colleagues (13), Boutelle ad colleagues (19), ad Campbell ad colleagues (15). Diet Quality A separate questioaire was used to assess quality of the diet cosumed by the child. Parets respoded to several questios regardig their child s daily eatig habits. This questioaire was created ad used by Rayor ad colleagues (20) to assess eatig ad leisuretime behaviors i preschool-aged ad school-aged childre. For this study, oly eatig behaviors were assessed. See eatig questioaire i Appedix A. Parets were asked six questios regardig their child s daily eatig habits (respose choices: 0 to 5 or more) for the followig foods: fruit, ot icludig fruit juice; vegetables, ot icludig potatoes or Frech fries; low-fat dairy; soda, o-diet; sweeteed beverages; ad 100% juice. Parets were asked three questios regardig their child s weekly itake of certai types of foods, icludig the followig: fast-food itake (respose choices: ever, 1-2, 3-4, 5 or more); cosumptio of salty sack products such as tortilla chips, uts, popcor, etc. (respose choices: more tha oce a day, daily, 5-6 days/week, 3-4 days/week, 1-2 days/week, <1 day/week, ever); ad cosumptio of sweet sack products such as cady, cookies, pies, cakes, ice cream, etc. (respose choices: more tha oce a day, daily, 5-6 days/week, 3-4 days/week, 1-2 days/week, <1 day/week, ever). 40

52 Statistical Aalyses All data aalyses were coducted usig SPSS versio 18.0 (21). The sample used i the ivestigatio, icludig both childre ad adults, were described usig descriptive statistics (i.e., meas, percetages). Simple pearso-product correlatios were coducted to determie the relatioship betwee frequecy of meals ad dietary itake for variables assessed for daily itake, as well as zbmi, as all of these variables are iterval data (22). Spearma s Rho was used to determie the relatioship betwee frequecy of meals ad dietary variables for variables assessed with ordial outcomes (22). As all other family meal questios were assessed usig a ordial scale, the relatioship betwee each family meal questio ad dietary itake ad zbmi were also coducted usig Spearma s Rho, which is the most commo correlatio used to assess the relatioship betwee two ordial variables or oe ordial ad oe iterval variable (22). To determie which of the family meal questios iflueced diet quality ad zbmi i childre, a series of hierarchical multiple regressio aalyses were coducted. Each regressio tested a dietary outcome or zbmi as the depedet variable. I these regressios, child demographic variables were etered ito the first block. Paret demographic variables were etered ito the secod block. The third block cotaied those family meal questios that were sigificat i the simple correlatios. Correlatioal aalyses were coducted for those family meal items that were to be etered ito each regressio equatio to prevet issues of multicolliearity (r > 0.70) (23). Family meal items were etered i a forward step-wise fashio ito the regressio model. Variables ad regressio models were cosidered to be sigificat at the 0.05 level. 41

53 Results Questioaires ad athropometric data were collected for 62 families. However, due to missig demographic data, families were used for data aalysis. As this is a ew questioaire, there were limitatios to the tool. Limitatios are described i Appedix B. Descriptive Fidigs Participat Characteristics Demographic characteristics about the paret, child, ad household are show i Table 1, Appedix C. O average, childre were 7.3 ± 2.0 years old, with 26.0% overweight or obese, 44.0% female, 84.0% White, ad 94.0% o-hispaic/latio. The parets were approximately 36.8 ± 8.7 years of age, with 74.0% overweight or obese, 76.0% female, 88.0% White, ad 98.0% o-hispaic/latio. Most respodets reported beig married (72.0%) ad 44.0% of respodets had at least some college educatio. O average, 4.7 ± 1.6 people were reported to live i each household; with those family members icludig approximately two adults ad three childre. Household icomes raged from <$10,000 per year to $100,000 per year with 28.0%, the greatest percetage, reportig a icome bracket of $20,000-39,999 per year. Diet Quality Descriptios of the childre s daily dietary itake ad sack food cosumptio are show i Tables 2 ad 3, Appedix C. O average, it was reported by parets that childre cosumed 2.1 ± 0.9 daily servigs of fruit, ot icludig fruit juice, which is i lie with the MyPyramid recommedatio of 1.5 servigs of fruit for childre aged eight years (24). Parets reported that childre cosumed a average daily vegetable itake of 2.3 ± 1.1 servigs of vegetables, ot 42

54 icludig potatoes or Frech fries, which is i accordace with the recommeded two servigs of vegetables per day (24). However, parets reported that childre cosumed a average of 2.1 ± 1.3 daily servigs of low-fat yogurt, low-fat milk (skim or 1%), or low-fat cottage cheese, which is oe servig below the recommedatio (24). Eight ouce servigs of sweeteed beverages, icludig 8-ouce servigs of regular soda (o-diet), Kool-aid, fruit puch, o 100% fruit juice, ad sweeteed ice tea were cosumed 1.5 ± 1.6 per day for childre, as reported by parets. As recommedatios are to limit itake of sweeteed beverages, this itake is above recommedatios (24-27). Also, it is recommeded that childre cosume a maximum of 4-6 ouces of fruit juice per day (24, 25). I this sample, childre cosumed 1.8 ± 1.3, 8-ouce servigs per day of 100% fruit juice, ot icludig Kool-aid or fruit puch, which is 2-4 times the recommedatio for fruit juice. Additioally, 40.0% of parets reported that their childre eat salty sack products 1-2 days per week ad.0% of parets reported that their childre eat sweet sack products 1-2 days per week. Sweet ad salty sack products would be cosidered discretioary calories ad should ot make up more tha calories per day (childre aged 5-12 years) (24). Therefore, reported child salty ad sweet sack product itake was i lie with the recommedatios. Family Mealtimes Parets report the most frequet meal eate with a adult family member was dier at home (5.9 ± 1.5 times per week), followed by breakfast at home (3.9 ± 2.4 times per week). The least reported meals with a adult family member were breakfast ad luch at restaurats or fast food establishmets (1.0 ± 1.5 times per week ad 1.0 ± 1.2 times per week, respectively). Meals at home that were eate with a adult family member were reported more frequetly tha 43

55 meals i restaurats ad fast food establishmets with a adult family member. I total, family meals were eate together 15.3 ± 5.2 times per week while family meals at home were eate 12.1 ± 3.8 times per week. See Table 4, Appedix C. Table 5, Appedix C shows the distributio of paret resposes to the 19 questios pertaiig to the types of food prepared ad served i the home. Parets reported that they rarely (56.0%) or ever (4.0%) buy food from restaurats to serve to their families for a meal at home, ad parets reported sometimes (28.0%) or rarely (42.0%) buyig hot, pre-prepared food from the deli or grocery store to brig home. Parets claimed to cook a wide rage of foods from scratch usually (34.0%) or sometimes (30.0%), ad cooked ew dishes ad tried ew recipes sometimes (.0%) or usually (36.0%). Additioally, parets reported sometimes (44.0%) or rarely (32.0%) heatig froze etrees for meals. Parets reported that their child always or usually eats may differet foods (74.0%), vegetables (72.0%), fruits (66.0%), ad low-fat dairy (56.0%) at home durig meals. Parets reported that their child rarely (28.0%) or ever (14.0%) driks sweeteed driks at home durig meals. Also, 44.0% of parets reported that childre sometimes eat sweet sack products, ad parets reported that sometimes (38.0%) or rarely (44.0%) the child eats salty sack products at home durig meals. Whe asked about family mealtimes i restaurats ad fast food establishmets, parets reported that childre sometimes (38.0%) or rarely (36.0%) eat may differet foods. Parets reported that childre rarely or ever eat may vegetables (40.0%), fruits (40.0%), ad low-fat dairy (40.0%) i restaurats or fast food establishmets durig meals. Most parets reported that the child always (18.0%) or usually (42.0%) cosumes sweeteed driks i restaurats ad fast food establishmets durig meals, ad that the child sometimes (40.0%) eats sweet sack 44

56 products i restaurats ad fast food establishmets durig meals. Parets reported that childre eat salty sack products such as chips, Frech fries, pretzels or popcor sometimes (48.0%) or usually (22.0%) i restaurats/fast food establishmets durig meals. See Table 5, Appedix C. Table 6, Appedix C shows the distributio of adult resposes to the ie family mealtime questios regardig how the child is fed at mealtimes. The majority of parets reported always (40.0%) or usually (44.0%) servig their childre the same foods as they eat. Of the family mealtime servig styles, family style, buffet style, or pre-portioed meals, 78.0% of parets reported servig foods pre-portioed by preparig a plate of food for the child (28.0%- always,.0%-usually). Childre were always (12.0%) or usually (.0%) able to decide whe he/she is fiished eatig but were sometimes ecouraged to cotiue eatig (48.0%). Parets reported that they sometimes (40.0%) have to guide or regulate their child s eatig of his/her favorite foods, but parets report they rarely (36.0%) or ever (34.0%) have to limit their child from eatig too much. Parets reported usually (38.0%) or sometimes (54.0%) givig their child small tasks to iclude him/her i the food preparatio process. Table 7, Appedix C shows the distributio of adult resposes to the 12 family mealtime atmosphere questios. The majority of parets, 96.0%, agreed that family meals brought people together i a ejoyable way. Eighty-six percet of parets respoded i agreemet that mealtimes were pleasat for the whole family, ad 88.0% agreed that the family talks durig the meal. Parets respoded that the TV was always (18.0%) or usually (38.0%) off durig mealtimes ad that o oe aswers the phoe or texts durig the family meal either always (20.0%) or usually (36.0%). The majority of parets stated that their child is expected to always (52.0%) or usually (36.0%) behave a certai way at mealtimes, icludig always (56.0%) or 45

57 usually (38.0%) usig maers. Parets reported always (28.0%) or usually (42.0%) sittig at a table durig mealtimes ad the majority (64.0%) of parets reported that they sometimes talk about food ad utritio durig mealtimes. Parets reported that they always (34.0%) or usually (46.0%) praise their child whe he/she makes healthy food choices. Parets stated that they rarely (48.0%) or ever (28.0%) discussed puishmet ad rarely (38.0%) or ever (42.0%) discussed moey durig family mealtimes. Table 8, Appedix C shows the distributio of paret resposes to the six questios about their ow satisfactio of family mealtimes. Niety-four percet of parets agreed that it is importat that their family eats meals together. Similarly, the majority of parets (96.0%) agreed that eatig with their child was importat to them. Most parets (56.0%) disagreed that they were dissatisfied with how ofte their family eats together, implyig that they were satisfied with family mealtime frequecy. Parets reported that they always (36.0%) or usually (.0%) ejoy cookig for the family. Most parets are always (12.0%) or usually (58.0%) satisfied with their child s eatig habits at home, while i restaurats ad fast food establishmets parets are always (6.0%) or usually (.0%) satisfied with their child s eatig habits. Table 9, Appedix C shows the distributio of paret resposes to the seve questios about paret characteristics. Parets reported that they always (14.0%) or usually (56.0%) prepla meals before preparig them ad the majority reported that they always (28.0%) or usually (36.0%) use a shoppig list at the grocery store. Parets reported that they rarely (38.0%) or ever (14.0%) had to make sure that their child was ot eatig too may high-fat foods at home ad rarely (30.0%) or ever (4.0%) had to guide or regulate the child s eatig to prevet him/her from eatig too may juk foods at home durig meals. Parets reported rarely (26.0%) or ever 46

58 (24.0%) keepig certai foods out of the child s reach at home durig meals. Thirty-six percet of parets respoded that they sometimes had to be sure that the child did ot eat too may highfat foods i restaurats or fast food establishmets. Parets reported regulatig the child s eatig i restaurats ad fast food establishmets always (10.0%), usually (30.0%), or sometimes (18.0%). Table 10, Appedix C describes the distributio of adult resposes to the three family mealtime questios about barriers to family mealtimes. Parets stated that it is difficult to fid time for a family meal sometimes (40.0%), rarely (30.0%), or ever (22.0%). Childre s activities were rarely (44.0%) or ever (16.0%) a barrier ad adult work schedules were rarely (42.0%) or ever (16.0%) a barrier, accordig to parets. The Relatioship betwee Family Mealtime Compoets ad Dietary Quality ad Weight Status i Childre See Table 11, Appedix C for the relatioships betwee family meal frequecy ad child diet quality ad weight status. Sigificat, positive relatioships were foud betwee frequecy of breakfast i a restaurat or fast food establishmet ad vegetable itake (r = 0.340, p < 0.05), sweeteed drik itake (r = 0.723, p < 0.001), ad 100% juice itake (r = 0.296, p < 0.05). A sigificat, egative relatioship was foud betwee frequecy of breakfast i a restaurat or fast food establishmet ad fruit itake (r = , p < 0.05). Frequecy of luch at home was egatively related to low-fat dairy itake (r = , p < 0.05) ad egatively related to child zbmi (r = , p < 0.05). Frequecy of luch at a restaurat or fast food establishmet was positively related to sweeteed drik itake (r = 0.461, p < 0.01) ad weekly fast food frequecy (r = 0.344, p < 0.05). Frequecy of dier at home was egatively related to low-fat dairy itake 47

59 (r = , p < 0.05) ad child zbmi (r = , p < 0.05). Frequecy of dier i a restaurat or fast food establishmet was positively related to vegetable itake (r = 0.352, p < 0.05), sweeteed drik itake (r = 0.585, p < 0.001), ad weekly fast food frequecy (r = 0.385, p < 0.01). Next, frequecies of all meals as a family were combied, icludig both family meals at home ad i restaurats or fast food establishmets. Frequecy of all family meals was positively related to vegetable itake (r = 0.335, p < 0.05), sweeteed drik itake (r = 0.3, p < 0.05), ad juice itake (r = 0.312, p < 0.05). Lastly, family mealtime frequecies of breakfast, luch, ad dier at home were combied ad was sigificatly, egatively related to child zbmi (r = , p < 0.05). The types of foods served at family mealtimes were sigificatly related to several dietary itake variables ad athropometrics. See Table 12, Appedix C for types of foods prepared ad served i the home ad Table 13, Appedix C for types of foods eate i a typical week i both the home ad i restaurats ad fast food establishmets. Buyig food from a restaurat to brig home to serve the family was positively related to fast food itake (r = 0.290, p < 0.05). Heatig froze etrees was positively related to both sweeteed drik cosumptio (r = 0.465, p < 0.001) ad fast food itake (r = 0.310, p < 0.05). The child eatig may differet foods at home was egatively related to fast food itake (r = , p < 0.01), whereas the child eatig may differet foods at a restaurat or fast food establishmet was positively related to sweeteed drik itake (r = 0.348, p < 0.05) ad child zbmi (r = 0.355, p < 0.05). Whe the paret reported that the child eats may differet vegetables at home it was positively related to weekly vegetable itake (r = 0.366, p < 0.01). The same was true for fruit itake (r = 0.396, p < 0.01). Fruit cosumptio i restaurats or fast food establishmets was additioally egatively related to sweet sack product cosumptio (r = , p < 0.05). Low-fat dairy at 48

60 home or i a restaurat or fast food establishmet was positively related to weekly low-fat dairy cosumptio (r = 0.607, p < ad r = 0.307, p < 0.05, respectively) ad egatively related to 100% juice itake whe drak at home (r = , p < 0.05). Low-fat dairy i restaurats ad fast food establishmets was egatively related to both salty (r = , p < 0.05) ad sweet (r = , p < 0.05) sack product itake. Drikig sweeteed driks at home was positively related to weekly sweeteed drik cosumptio (r = 0.656, p < 0.001), 100% juice (r = 0.510, p < 0.01), fast food (r = 0.355, p < 0.05), ad salty sack products (r = 0.355, p < 0.05). Sweeteed driks cosumed at restaurats or fast food establishmets were egatively related to fruit itake (r = , p < 0.05) ad positively related to weekly sweeteed drik itake (r = 0.324, p < 0.05). Eatig sweets such as cookies, pie, cake, ad ice cream at home was positively related to weekly itake of sweet sack products (r = 0.362, p < 0.01) ad cosumptio of the same types of sweet sack products at restaurats or fast food establishmet was positively related to child zbmi (r = 0.288, p < 0.05). Lastly, eatig salty sack products such as chips, Frech fries, pretzels, or popcor at home was positively related to sweeteed driks (r = 0.331, p < 0.05), weekly salty sack products (r = 0.413, p < 0.01) ad weekly sweet sack products (r = 0.402, p < 0.01). Cosumptio of the same types of salty sack products i a restaurat or fast food establishmet was positively related to sweet sack product itake (r = 0.367, p < 0.01). How the child is fed was sigificatly related to several dietary itake ad weight status variables. See Table 14, Appedix C. First, servig the child the same foods as the paret was positively related to vegetable itake (r = 0.307, p < 0.05). The questio, My child is free to decide whe he/she is fiished eatig, was positively related to both salty (r = 0.404, p < 0.01) ad sweet (r = 0.280, p < 0.05) sack product cosumptio. Ecouragig the child to cotiue

61 eatig was positively related to fruit itake (r = 0.291, p < 0.05). Limitig the child from eatig too much was positively related to sweeteed drik itake (r= 0.579, p < 0.001) ad child zbmi (r = 0.417, p < 0.01). See Table 15, Appedix C for the relatioships betwee the atmosphere of family mealtimes ad child dietary quality ad weight status. Eatig family meals brigs people together i a ejoyable way, was egatively related to both salty (r = , p < 0.01) ad sweet (r = , p < 0.05) sack product itake. Talkig durig the family meal was also egatively related to sweet sack product itake (r = , p < 0.01). Havig the TV off durig mealtimes was egatively related to sweeteed drik itake (r = , p < 0.01), 100% juice itake (r = , p < 0.05), ad fast food itake (r = -0.3, p < 0.05). No oe aswerig the phoe or textig durig the family mealtime was also egatively related to sweeteed drik itake (r = , p < 0.05) ad fast food itake (r = , p < 0.001). Two variables, child expectatios durig mealtimes ad maers durig mealtimes, were both egatively related to salty (r = , p < 0.05 ad r = , p < 0.05, respectively) ad sweet (r = , p < 0.05 ad r = , p < 0.001, respectively) sack product itake. Sittig at a table durig mealtimes was egatively related to sweeteed drik itake (r = , p < 0.05), as was talkig about utritio durig mealtimes (r = , p < 0.01). Praisig the child for healthy food choices was egatively related to sweet sack product itake (r = , p < 0.01). Lastly, discussig puishmets durig family mealtimes was positively associated with fruit itake (r = 0.289, p < 0.05). Adult satisfactio ad importace of mealtimes was sigificatly related to several dietary itake variables. See Table 16, Appedix C. The perceived importace of family mealtimes was egatively related to both salty (r = , p < 0.01) ad sweet

62 (r = , p < 0.05) sack product itake. The statemet, Eatig meals with my child is very importat to me, was positively associated with fruit (r = 0.280, p < 0.05), vegetable (r = 0.292, p < 0.05), ad low-fat dairy (r = 0.290, p < 0.05) itake ad egatively associated with sweet sack product cosumptio (r = , p < 0.05). Lastly, dissatisfactio of mealtime frequecy was egatively associated with fruit (r = , p < 0.05) ad vegetable (r = , p < 0.05) itake. Two paret characteristics were sigificatly related to several dietary itake variables. See Table 17, Appedix C. The statemet, I have to be sure that my child does ot eat too may high-fat foods at home durig meals, was egatively related to low-fat diary (r = , p < 0.05) ad positively related to sweeteed drik cosumptio (r = 0.4, p < 0.01). Additioally, the statemet, If I did ot guide or regulate my child s eatig, he/she would eat too may juk foods at home durig meals, was positively related to sweeteed driks (r = 0.556, p < 0.001), 100% juice (r = 0.412, p < 0.01), ad fast food (r = 0.433, p < 0.01) ad egatively related to low-fat dairy itake (r = , p < 0.001). Barriers to family mealtimes were sigificatly, egatively related to oe dietary itake variable, vegetable itake. Both childre s activities ad adult work schedules were egatively related to vegetable itake (r = , p < 0.05 ad r = , p < 0.01, respectively). See Table 18, Appedix C. Hierarchical Regressio Aalyses for Family Mealtime Compoets ad Child Dietary Itake ad Athropometrics The overall models for fruit, vegetables, low-fat dairy, 100% juice, salty sack products, ad sweet sack products were ot sigificat ad thus are ot preseted. Sigificat models are preseted below ad show i Table 19, Appedix C. 51

63 Child Sweeteed Drik Itake After cotrollig for child ad paret demographics, two family mealtime compoet variables remaied i the fial regressio model for child sweeteed drik cosumptio ad these variables sigificatly icreased the proportio of accouted variace (R 2 = 0.082, p < 0.001) of child sweeteed beverage cosumptio. These variables were frequecy of dier i a restaurat/fast food establishmet (β = 0.380, p < 0.001) ad limitig the child from eatig too much (β = 0.367, p < 0.001). Iterestigly, i the paret demographic block, paret educatio was sigificatly related to child sweeteed drik itake (β = , p < 0.001). The overall model accouted for 84.5% of the variace for child sweeteed beverage cosumptio, which was sigificat (F(14, 30 ) = 11.7, p < 0.001). Child Fast Food Frequecy After cotrollig for child ad paret demographics, oe variable remaied i the fial regressio model for frequecy of child fast food itake ad this variable sigificatly icreased the proportio of accouted variace (R 2 = 0.108, p < 0.05) of frequecy of child fast food itake. The sigificat variable was, No oe aswers the telephoe, cell phoe, or text messages durig the family meal (β = , p < 0.05). The overall model accouted for 48.8% of the variace for frequecy of child fast food itake, which was sigificat (F(13, 33 ) = 2.4, p < 0.05). Child zbmi After cotrollig for child ad paret demographics, oe variable remaied i the fial regressio model for child zbmi, ad this variable sigificatly icreased the proportio of 52

64 accouted variace (R 2 = 0.141, p < 0.01) of child zbmi. The sigificat variable was stated as, I typically have to limit my child from eatig too much (β = 0.474, p < 0.01). The overall model accouted for 41.6% of the variace for child zbmi, which was also sigificat (F(12, 37 ) = 2.2, p < 0.05). Discussio The purpose of this study was to determie compoets of family mealtimes that were related to a higher diet quality ad healthy weight status i elemetary school-aged childre. The compoets of the family meals that were assessed i this ivestigatio i relatio to child dietary itake ad weight status icluded the followig: which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. It was hypothesized that frequecy of family mealtimes would be positively associated with diet quality ad a healthy weight status. It was aticipated that diet quality ad a healthy weight status would both be positively associated with: frequecy of family diers with a adult preset, healthy foods served ad eate at meals, meals prepared withi the home, servigs cosumed at meals determied by a adult, ad meals free of distractio. Results of this ivestigatio showed that several compoets of family meals were related to child cosumptio of sweeteed beverages, frequecy of cosumptio of fast food for childre, ad child zbmi. For sweeteed beverages, sigificat, positive relatioships were foud with frequecy of dier i a restaurat or fast food establishmet, ad limitig the child from eatig too much. This suggests that more frequet diers i a restaurat or fast food 53

65 establishmet was associated with higher overall sweeteed drik cosumptio. Also, a paretig feedig style that focuses o limitig the quatity of how much a child cosumes was associated with higher overall sweeteed drik cosumptio. For frequecy of cosumptio of fast food, limitig the frequecy of family members aswerig the phoe or textig durig the family mealtime was egatively related to this outcome. Lastly, a paretig feedig style that limits the child from eatig too much was sigificatly, positively related to child zbmi. Thus, results from this ivestigatio idicate that of the six hypothesized family meal compoets that would be related to child dietary itake ad weight status, a item from two compoets, where the meal was prepared ad atmosphere of the family mealtime, were show to be related to diet quality ad weight status i this study. Additioally, paretig behaviors, oe of the theorized mechaisms of the beefit of family mealtimes, was show to be related to sweeteed drik cosumptio ad child zbmi. Items related to which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, ad how food was served were ot sigificatly related to dietary itake or weight status variables i this study. Barriers to family mealtimes were also isigificat i this study. Iterestigly, fast food frequecy was egatively related to a lower frequecy of o oe aswerig the phoe or textig durig the family mealtime. As greater cosumptio of fast food geerally reduces the overall diet quality i childre (1, 8) ad is related to overweight/obesity i childre (1, 8), uderstadig factors that are related to fast food itake is importat. The relatioship betwee these variables could be explaied i several ways. First, the reduced frequecy of this behavior may be a marker of parets settig rules, i geeral, for the family to follow at mealtimes. Rule settig ca be characteristic of authoritative or authoritaria paretig (28, 29), but this study did ot collect iformatio about resposiveess i parets to further 54

66 defie which paretig style this characteristic might represet. This may be cosidered a limitatio of the study, as paretig styles may play a key role i family mealtimes, dietary itake, ad weight status i childre. Secod, the reduced frequecy of talkig o the phoe or textig durig a family meal could mea that the family members are less preoccupied at mealtimes, allowig meals to occur free of distractios. While there have bee o previous studies examiig telephoe, cell phoe, ad textig specifically, greater frequecy of other forms of distractios, such as televisio ad listeig to music, have bee related to a icreased fat itake ad cosumptio of eergy dese foods, whether it be from fast food or foods foud withi the home (30). The ADA recommeds eatig meals free of distractios (10) because distractios may mask feeligs of huger ad satiety (30). Previous research has reported that where a meal is prepared ad cosumed was related to sweeteed drik itake, such that meals prepared ad cosumed i restaurats ad fast food establishmets were positively related to sweeteed drik itake amogst childre ad adolescets (26, 27). Sweeteed driks are high i calories ad lack utritioal value, ad have bee liked to childhood obesity (1, 32-35), thus high itake of sweeteed driks is a public health cocer (1, 32-35). Idetifyig factors that are related to cosumptio of sweeteed beverages is importat i order to fid ways to reduce sweeteed drik itake amogst youth. Aother variable that was related to icreased sweeteed drik cosumptio was parets more frequetly limitig how much a child cosumes. This characteristic of a paret s feedig style is commoly referred to as food restrictio (35), ad has bee previously show to have uiteded egative cosequeces o child dietary itake (36). Geerally, parets restrict food items from a child s diet that are high i eergy desity or low i dietary quality (37). Parets egage i food restrictio because they may believe that restrictig a food item would lesse a child s preferece 55

67 for the food item ad reduce itake of the item that is restricted (35, 38). However, several studies have demostrated that ot oly do childre still have a preferece for the restricted food (36, 39), but also, they are more iclied to over-eat the restricted food item whe the paret is ot preset (36-38). Lastly, future research ivestigatig the associatio betwee paret educatio ad sweeteed drik itake may be importat, as this study foud a sigificat relatioship betwee these variables. Fially, greater frequecy of limitig a child from eatig too much, or food restrictio, was positively related to child zbmi i this study. Food restrictio has bee positively liked to child BMI i other cross-sectioal studies (40-42). For example, i a early study by Birch ad colleagues (42), materal food restrictio was measured by askig the same 9 questios for 10 sack foods regardig access, moitorig, ad limitig the specific food item ad foud that food restrictio was positively associated with child weight status (42). There are may theories regardig the relatioship betwee weight status ad paretal food restrictio. Primarily, researchers believe that a paretig feedig style that uses food restrictio may hamper the lack of maiteace of iteral self-regulatio mechaisms that pre-school-aged childre demostrate (35-37, 39). The lack of eergy self-regulatio capabilities could lead to overeatig, ad thus, weight gai (11, 37). Other factors that may explai the relatioship betwee these variables may be that childre of restrictive parets have bee show to cosume a greater percetage of calories from fat (11) ad to eat without huger (38). For example, Fisher ad colleagues (38) foud that materal food restrictio at age five predicted eatig i the absece of huger at age seve. Girls eatig i the absece of huger at age 5 ad age 7 were at greater risk of beig overweight (38). Iroically, Fracis ad colleagues (37) determied that mothers were more likely to use restrictive feedig whe they were cocered about their daughter s weight, whe 56

68 their daughter was heavier or perceived as heavier, ad whe they were ivested i weight ad eatig issues (37). Whe the relatioship betwee food restrictio ad weight status i childre was first examied, it was iitially believed that greater food restrictio was producig icreased weight status i childre (11, 35, 42). However, with the limitatios of the ability to ifer a cause ad effect relatioship betwee two variables i a cross-sectioal desig, it was uclear whether the practice of paretal food restrictio cotributed to childhood obesity or if the weight status of the child ecouraged paretal food restrictio (43). A more recet prospective study cocluded that there may be a gee-eviromet iteractio i which childre with a geetic predispositio for obesity, ad thus greater risk for developig obesity, had parets who practiced more restrictive feedig practices, which is i cotrast to the origial belief that food restrictio led to obesity (43). Experimetal research is eeded to cofirm the directio of the iteractio betwee weight status ad paretal food restrictio. Iterestigly, this study did ot fid a sigificat relatioship betwee frequecy of family meals ad dietary itake i childre (p > 0.05), whe this has bee the relatioship that has bee most frequetly reported previously betwee family meals ad dietary quality (3-10, 13, 19, 34). Gillma ad colleagues (3) coducted what is cosidered to be a ladmark study regardig family meals ad dietary itake i childre aged 9-14 years from participats who were part of the Nurses Health Study II. They foud that dietary itake was improved amogst childre with a greater frequecy of family mealtimes. Aother ivestigatio of family meals ad dietary itake examied data collected from 18,177 adolescets who participated i the Natioal Logitudial Study of Adolescet Health (6). The results of that study foud that paretal presece durig the eveig meal was positively associated with adolescet 57

69 cosumptio of fruits, vegetables, dairy foods, ad the cosumptio of breakfast (6). A third study examied family meal patters ad their relatioship with sociodemographic family characteristics ad dietary itake amog adolescets (7). Cosumptio of fruits, vegetables, grais, ad calcium-rich foods icreased as the frequecy of family meals icreased ad there was a sigificat decrease i sweeteed drik cosumptio (7). Furthermore, this study did ot fid a sigificat relatioship betwee frequecy of family meals ad weight status i childre (p > 0.05), whe several other cross-sectioal studies have foud this relatioship (4, 5, 8, 9). For example, oe study foud that i overweight white adolescets, greater frequecies of family meals decreased their odds of beig overweight, icreased the chace of ceasig to be overweight (either by growth or weight loss), ad reduced the risk of becomig overweight i the ext three years, as assessed by a supplemetary logitudial aalysis (4). Aother logitudial study examied the frequecy of family mealtimes i relatio to childhood weight status ad foud a associatio betwee family meal frequecy ad weight status i childre (8). Childre who ate fewer meals with their families were more likely to be persistetly overweight ad to have the oset of overweight before the third grade (8). Other studies have looked at family mealtimes i relatio to weight status i adolescets usig both cross-sectioal ad logitudial study desigs (5, 9). Results showed sigificat fidigs i which frequecy of family mealtimes was related to weight status whe aalyzed as cross-sectioal data but with the same variables had o-sigificat (p > 0.05) logitudial results after oe year (9) ad five years (5). Results of this study should be cosidered i light of its limitatios. A cross-sectioal study desig was used; therefore, o causal relatioships ca be established from this data. Additioally, the questioaires were purely self-reported, thus, the data may ot be as accurate 58

70 as other types of data. The sample size was small (=) ad fairly homogeeous, with 88% of parets ad 84% of childre beig white. Hece, the results of this study have limited geeralizability. As well, the variability of resposes by parets was limited. For example, parets reported a average of 5.9 ± 1.5 diers at home per week. A restricted rage i at least oe of the variables ca reduce the correlatio coefficiet ad obscure the relatioship that may be occurrig betwee the variables. Additioally, future research could iclude a objective way to measure compoets of family mealtimes. Recetly, the Family Mealtime Q-Sort was created as a reliable way to quatify frequecy ad cotext of family mealtimes through observatioal methods (44). I summary, several compoets of family mealtimes were assessed i relatio to child dietary itake ad weight status, icludig: which meal (i.e., breakfast, luch, ad/or dier), who was preset at the meal, what type of food was served ad eate at the meal, where the food i the meal was prepared ad/or eate, how food was served, ad the atmosphere of the meal. Also, barriers to family mealtimes were assessed. Results showed a positive relatioship betwee frequecy of dier i restaurats or fast food establishmets ad child food restrictio ad sweeteed drik cosumptio. Not aswerig the phoe or textig durig the family meal was egatively related to fast food frequecy. Also, a icreased child zbmi was liked to greater food restrictio. Logitudial ad experimetal research is eeded to cofirm these relatioships ad to determie the directio betwee variables. It is clear that family mealtimes have applicatios for families to ecourage healthy eatig. Family mealtimes eate withi the home, free of distractios, ad with set rules may have the greatest impact o child dietary itake ad weight status. Parets should be discouraged from food restrictio ad ecouraged to offer healthy food choices withi the home for the child 59

71 to choose from. The results of this study may be useful to practitioers as recommedig family meals may be a simple way to improve dietary itake ad possibly weight status amogst childre. 60

72 REFERENCES 61

73 Chapter I Refereces 1. Ebbelig CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, commo sese cure. Lacet. 2002;360: Healthy People [cited 2009 April 20]; Available from: 3. Carso KL. Family mealtimes: More tha just eatig together. J Am Diet Assoc. 2006;106(4): Se B. Frequecy of family dier ad adolescet body weight status: evidece from the atioal logitudial questioaire of youth. Obesity. 1997;14(12): Fulkerso JA, Neumark-Sztaier D, Story M. Adolescet ad paret views of family meals. J Am Diet Assoc. 2006;106(4): Carlso A, Lio M, Gerrior S, Basiotis P. Report card o the diet quality of childre ages 2 to 9. Nutritio Isights. 2001: Gillma MW, Rifas-Shima SL, Frazier AL, et al. Family dier ad diet quality amog older childre ad adolescets. Arch Fam Med. 2000;9: Video TM, Maig CK. Iflueces o adolecet eatig patters: the importace of family meals. J Adolescet Health. 2003;32: Neumark-Sztaier D, Haa PJ, Story M, Croll J, Perry C. Family meal patters: associatios with sociodemographic characteristics ad improved dietary itake amog adolescets. J Am Diet Assoc. 2003;103: Gable S, Chag Y, Krull JL. Televisio watchig ad frequecy of family meals are predictive of overweight oset ad persistece i a atioal sample of elemetary schoolaged childre. J Am Diet Assoc. 2007;107(1): Taveras EM, Rifas-Shima SL, Berkey CS, et al. Family dier ad adolecet overweight. Obes Res. 2005;13(5): Fulkerso JA, Neumark-Sztaier D, Haa PJ, Story M. Family meal frequecy ad weight status amog adolescets: cross-sectioal ad 5- year logitudial assocatios. Obesity. 2008;16: Darlig N, Steiberg L. Paretig style as cotext: a itegrative model. Psychological Bulleti. 1993;113(3): Rhee KE, Lumeg JC, Appugliese DP, Kaciroti N, Bradley RH. Paretig styles ad overweight status i first grade. Pediatrics. 2006;117(6): Faith MS, Berkowitz RI, Stalligs VA, Kers J, Story M, Stukard AJ. Paretal feedig attitudes ad styles ad child body mass idex: prospective aalysis of a geeeviromet iteractio. Pediatrics. 2004;114(4):e429-e Baumrid D. Child care practices atecedig three patters of preschool behavior. Geetic Psychology Moographs. 1967;75: Baumrid D. Curret patters of paretal authority. Developmetal Psychology Moograph. 1971;4(1): Walker SC, Maxso C, Newcomb MN. Paretig as a moderator of miority, adolescet victimizatio ad violet behavior i high-risk eighborhoods. Violece ad Victims. 2007;22:

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75 38. Musher-Eizema D, Holub S. Comprehesive feedig practices questioaire: validatio of a ew measure of paretal feedig practices. J of Ped Psych. 2007;32(8): Fracis L, Lee Y, Birch L. Paretal weight status ad girls' televisio viewig, sackig, ad body mass idexes. Obes Res. 2003;11: Lidsay AC, Susser KM, Kim J, Gortmaker S. The role of parets i prevetig childhood obesity. The Future of Childre. 2006;16(1): Tibbs T, Haire-Joshu D, Schechtma KB, et al. The relatioship betwee paretal modelig, eatig patters, ad dietary itake amog Africa-America parets. J Am Diet Assoc. 2001;101: Foster G, Makris A, Bailer B. Behavioral treatmet of obesity. Am J CLi Nutr. 2005;82(suppl):230S-5S. 43. Wadde T, Crerad C, Brock J. Behavioral treatmet of obesity. Psychiatr Cli N Am. 2005;28: Middle Childhood (9-11 years old). Ceters for Disease Cotrol ad Prevetio 2005 [cited 2010 Jauary 18]; Available from: Boutelle KN, Birbaum AS, Lytle LA, Murray DM, Story M. Associatios betwee perceived family meal eviromet ad paret itake of fruit, vegetables, ad fat. J Nutr Educ Behav. 2003;35: Hill MS, Yeug WJ, Duca GJ. Childhood family structure ad youg adult behaviors. J Popul Eco. 2001;14: Barlow S. Expert committee recommedatios regardig the prevetio, assessmet, ad treatmet of child ad adolecet overweight ad obesity: summary report. Pediatrics. 2007;120(4):S164-S Burto S, Creyer EH, Kees J, Huggis K. Attackig the obesity epidemic: the potetial health beefits of providig utritio iformatio i restaurats. Am J Public Health. 2006;96(9):

76 Chapter II Refereces 1. Ebbelig CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, commo sese cure. Lacet. 2002;360: Healthy People [cited 2009 April 20]; Available from: 3. Gillma MW, Rifas-Shima SL, Frazier AL, et al. Family dier ad diet quality amog older childre ad adolescets. Arch Fam Med. 2000;9: Se B. Frequecy of family dier ad adolescet body weight status: evidece from the atioal logitudial questioaire of youth. Obesity. 1997;14(12): Fulkerso JA, Neumark-Sztaier D, Haa PJ, Story M. Family meal frequecy ad weight status amog adolescets: cross-sectioal ad 5- year logitudial assocatios. Obesity. 2008;16: Video TM, Maig CK. Iflueces o adolecet eatig patters: the importace of family meals. J Adolescet Health. 2003;32: Neumark-Sztaier D, Haa PJ, Story M, Croll J, Perry C. Family meal patters: associatios with sociodemographic characteristics ad improved dietary itake amog adolescets. J Am Diet Assoc. 2003;103: Gable S, Chag Y, Krull JL. Televisio watchig ad frequecy of family meals are predictive of overweight oset ad persistece i a atioal sample of elemetary schoolaged childre. J Am Diet Assoc. 2007;107(1): Taveras EM, Rifas-Shima SL, Berkey CS, et al. Family dier ad adolecet overweight. Obes Res. 2005;13(5): Caso KL. Family mealtimes: More tha just eatig together. J Am Diet Assoc. 2006;106(4): Daviso KK, Birch LL. Childhood overweight: a cotextual model ad recommedatios for future research. Obesity Reviews. 2001;2: Tibbs T, Haire-Joshu D, Schechtma KB, et al. The relatioship betwee paretal modelig, eatig patters, ad dietary itake amog Africa-America parets. J Am Diet Assoc. 2001;101: Fulkerso JA, Neumark-Sztaier D, Story M. Adolescet ad paret views of family meals. J Am Diet Assoc. 2006;106(4): Lauzo-Guillai BD, Musher-Eizema D, Leporc E, Holub S, Charles MA. Paretal feedig practices i the Uited States ad i Frace: relatioships with child's characteristics ad paret's eatig behavior. J Am Diet Assoc. 2009;109: Campbell KJ, Crawford DA, Ball K. Family food eviromet ad dietary behaviors likely to promote fatess i 5-6 year-old childre. It J Obes. 2006;30: Haso N, Neumark-Sztaier D, Eiseberg ME, Story M, Wall M. Associatios betwee paretal report of the home food eviromet ad adolescet itakes of fruits, vegetables ad dairy foods. Public Health Nutr. 2004;8(1): Overweight ad Obesity. Ceters for Disease Cotrol ad Prevetio 2009 [cited 2009 February 8]; Available from: Kuczmarski R, Ogde C, Grummer-Straw L. CDC growth charts: Uited States. Hyattsville, MD;

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78 37. Fracis L, Hofer SM, Birch LL. Predictors of materal child-feedig style: materal ad child characteristics. Appetite. 2001;37: Fisher JO, Birch LL. Eatig i the absece of huger ad overweight i girls from 5 to 7 y of age. Am J Cli Nutr. 2002;76: Culle K, Baraowski T, Ritteberry L, et al. Socioevirometal iflueces o childre's fruit, juice, ad vegetable cosumptio as reported by parets: reliability ad validity of measures. Public Health Nutr. 2000;3(3): Birch LL, Fisher JO. Developmet of eatig behaviors amog childre ad adolecets. Pediatrics. 1998;Supplemet: Johso SL, Birch LL. Parets' ad childre's adiposity ad eatig style. Pediatrics. 1994;94: Birch L, Fisher J. Restrictig access to foods ad childre's eatig. Appetite. 1999;32: Faith MS, Berkowitz RI, Stalligs VA, Kers J, Story M, Stukard AJ. Paretal feedig attitudes ad styles ad child body mass idex: prospective aalysis of a geeeviromet iteractio. Pediatrics. 2004;114(4):e429-e Kiser LJ, Medoff D, Black MM, Nurse W, Fiese BH. Family mealtime Q-Sort: A measure of mealtime practices. Joural of Family Psychology 2010;24(1):

79 APPENDICES 68

80 APPENDIX A: Forms, Fliers, ad Questioaires 69

81 70

82 71

83 72

84 73