Journal of the American College of Nutrition, Vol. 24, No. 2, 83-92 (2005)
Published by the American College of Nutrition
A Review of Family and Social Determinants of Children’s Eating Patterns and Diet Quality
Heather Patrick, PhD and
Theresa A. Nicklas, DrPH
Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
Address correspondence to: Heather Patrick, PhD, Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030. E-mail: hpatrick{at}bcm.tmc.edu
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ABSTRACT
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With the growing problem of childhood obesity, recent research has begun to focus on family and social influences on children’s eating patterns. Research has demonstrated that children’s eating patterns are strongly influenced by characteristics of both the physical and social environment. With regard to the physical environment, children are more likely to eat foods that are available and easily accessible, and they tend to eat greater quantities when larger portions are provided. Additionally, characteristics of the social environment, including various socioeconomic and sociocultural factors such as parents’ education, time constraints, and ethnicity influence the types of foods children eat. Mealtime structure is also an important factor related to children’s eating patterns. Mealtime structure includes social and physical characteristics of mealtimes including whether families eat together, TV-viewing during meals, and the source of foods (e.g., restaurants, schools). Parents also play a direct role in children’s eating patterns through their behaviors, attitudes, and feeding styles. Interventions aimed at improving children’s nutrition need to address the variety of social and physical factors that influence children’s eating patterns.
Key words: children’s eating patterns, children’s dietary quality, determinants of children’s eating patterns, review
Key teaching points:
• Importance of the physical and social environment in children’s eating patterns.
• Physical environment includes food availability, accessibility, and portion size.
• Social environment includes socioeconomic and sociocultural factors and mealtime structure.
• Parents’ behaviors, attitudes, and feeding styles also contribute to the social environment.
• Nutrition interventions should address a variety of characteristics that influence children’s eating.
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INTRODUCTION
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"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health." Hippocrates 460–377 BC.
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INTRODUCTION AND BACKGROUND
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Childhood obesity has become a serious public health problem. According to 2003 data, one in four children under the age of 18 are at risk for overweight, and 15% are overweight [1]. The prevalence of overweight among 4- and 5-year olds increased from 5% to 10.4% from 1976 to 2000 [2]. Obese children tend to become obese adults, putting them at greater risk for heart disease, hypertension, diabetes, and cancer [3]. Thus, researchers have begun to examine factors that influence eating behaviors and dietary quality, particularly in young children. By the time children are 3 or 4 years old, eating is no longer deprivation-driven but is influenced by their responsiveness to environmental cues about food intake. Thus, a variety of family and social factors influence children’s eating behaviors. Eating behavior has been conceptualized as a function of the social and physical environment [4]. The development of eating behaviors is affected by factors such as availability of and preference for particular foods, portion size, cultural values regarding food types and preparation, parents’ beliefs and practices, mealtime structure, and feeding styles. Research has shown that the family strongly influences childhood eating practices, including children’s attitudes toward food [5] and children’s assessment of satiety [6], factors which may later influence children’s weight. Clearly the family and other social factors influence children’s eating patterns which may subsequently influence the onset of obesity. The purpose of this paper is to highlight some of the family and social factors that influence children’s eating patterns and diet quality. Eating patterns have been defined in a number of ways, and definitions typically reflect characteristics of meals and/or food combinations. Diet quality typically reflects how one’s diet conforms to nutrient and food-based guidelines and recommendations. Family and social factors to be discussed include: food availability, preferences, accessibility, and portion size; modeling; mealtime structure; parent attitudes and behaviors regarding food; feeding styles; and socioeconomic and cultural factors. Research referenced includes samples of various ages (i.e., children, adolescents), ethnicities, income and education backgrounds. The review concludes with a call to researchers to develop interventions that address a variety of these family and social factors when attempting to improve or promote healthier eating patterns and diet quality among children.
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DESCRIPTION OF SUBJECT
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Preferences, Food Availability and Accessibility
Children’s Preferences.
Children do not eat foods they do not like [7]. Food acceptance patterns develop early in life, and childhood is a time of particular sensitivity for developing food preferences [8–10]. Indeed, food preferences developed during infancy remain relatively stable and are reflected in food choices made later in life [11–15]. The development of food preferences can be explained in part by Rozin’s [16] concept of food neophobia. Research has demonstrated that food neophobia is an important predictor of fruit and vegetable intake. Children who are reluctant to try new foods generally have lower intakes of fruit and vegetables [17]. However, research has demonstrated that exposure to foods is key to developing preferences [18–22] and that repeated exposure can overcome dislike of foods [23]. In one study with elementary school-aged children, 10 daily exposures to an unfamiliar vegetable was associated with a significant increase in children’s liking and consumption of that vegetable [24].
Food Availability and Accessibility.
In general, children choose to eat the foods that they are served most often, and they tend to prefer to eat foods that are readily available in the home [22]. For example, when fruit and vegetables are available, children are more likely to eat fruit and vegetables [25–29]. Thus, the foods to which children are routinely exposed shape preferences and consumption [18–19,21]. Adolescents also report that one of the most influential factors in their food choices is food availability [30]. Because parents are responsible for making foods available to children and adolescents, they can have a profound impact on preferences and, hence, consumption.
Other research has demonstrated the importance of not only availability but also accessibility of healthier foods [29]. That is, when foods are easily accessible and ready to be eaten, children are more likely to eat them. For example, Baranowski and colleagues [29] found that, among school children, fruit and vegetable intake is higher when these foods are not only available but also provided in accessible locations (i.e., easy for the child to reach) and in accessible sizes (e.g., apple wedges, carrot sticks). Thus, although children are not especially likely to get a carrot from a bag of full-sized carrots, they are more likely to eat carrots that have been cleaned and cut to age-appropriate sizes.
Parents’ Preferences, Beliefs and Attitudes.
Related to children’s preferences and food availability are parents’ preferences. Indeed, children’s food-related knowledge, preferences, and consumption are related to parents’ preferences, beliefs, and attitudes toward food [7,31–33]. Research has demonstrated that in children as young as two years old, food preferences were associated with their mothers’ food preferences [34]. This may be due, in part, to the fact that parents tend to have foods in the home that they like and eat [7]. Parents’ beliefs about which foods were healthy and their own food experiences were also related to children’s intake. For example, Dennison, Erb, and Jenkins [35] found that parents who believed that whole milk had more calcium and vitamins than reduced fat milk, that whole milk was healthier for children, and who had never tried reduced fat milk themselves were more likely to serve their children whole milk.
Modeling
Parents.
Children learn about eating not only through their own experiences but also by watching others [36]. A growing body of research demonstrates similarities between parents’ and children’s food acceptance and preferences, intake, and willingness to try new foods. Mothers and children show similar patterns of food acceptance and food preferences [37–38]. Children’s intake of fruit and vegetables was positively related to parents’ intake of fruit and vegetables [39–40], and parents’ modeling of healthful dietary behaviors was associated with low-fat eating patterns and lower dietary fat intake [41]. Rozin and colleagues demonstrated that, in Mexican families, children became more accepting of spicy foods when older members of the family modeled eating spicy foods [42]. Children are more likely to sample unfamiliar foods after they have seen an adult eating the food, and they are more likely to eat when they see their mother eating rather than a stranger [43]. Other research has shown that children model dieting behaviors as well. For example, dieting daughters were more likely to have dieting mothers [44], and parents who reported dietary inhibition or problems controlling their own intake were likely to have daughters who showed similar patterns [45]. Thus, parents’ behaviors with regard to dietary characteristics, food preferences, and intake regulation (e.g., dietary inhibition) are related to these same behaviors in children.
Peers.
Although parents provide the strongest influence on children’s health beliefs and behaviors [46], they are not the only people to model eating behaviors. Children and adolescents alike are also influenced by what their peers eat. In a study of preschool children, Birch [47] found that when children saw other children choosing and eating vegetables the observing children did not like, preferences for and intake of disliked vegetables increased. Peers are considered to be particularly influential in adolescent eating behavior [46,48–52]. In a study of adolescents, Feunekes and colleagues [53] found that, on food frequencies, 19% of foods consumed by adolescents were similar to those consumed by their friends. More specifically, associations with peer intake were found for type of milk used in coffee, alcoholic drinks, and several snack foods including French fries [53]. In a study of Costa Rican adolescents, peer influence was shown to significantly influence intake of foods rich in saturated fats [54]. Another study on adolescent girls’ eating behaviors found that peer pressure was a strong predictor of eating behavior, even after controlling for other interpersonal variables [54].
Mealtime Structure
The Family: The Social Context of Meals.
Whether a family eats together can have important effects on children’s food consumption patterns. A growing body of research demonstrates that children who eat meals with other family members consume more healthy foods and nutrients. Overall, children who have companionship at mealtimes tend to eat more servings of the basic food groups [55]. Neumark-Sztainer, Hannan, Story, Croll, and Perry [56] found that frequency of eating meals as a family was positively associated with intake of fruit, vegetables, grains, and calcium-rich foods, and with intake of protein, calcium, iron, folate, fiber, and vitamins A, C, E, and B-6. Frequency of eating meals as a family was negatively associated with soft drink consumption. In adolescents, the presence of the family at the dinner meal has been positively associated with consumption of fruit, vegetables, and dairy foods, and lower likelihood of skipping breakfast [57].
TV-Viewing.
By age 17, the average U.S. child has spent 15,000 to 18,000 hours watching television compared to 12,000 hours in school [58]. TV-viewing has been linked to children’s food consumption patterns. Research has demonstrated that, relative to those who do not watch TV during meals, children who are part of families in which TV-viewing is a normal part of the eating experience tend to consume fewer fruit and vegetables and more pizza, snack foods, and sodas [59]. Some researchers have speculated that these difference in food consumption patterns as a function of TV-viewing may be the result of advertising. Food is the most heavily advertised product during children’s television programming, and many of these products are fast foods or high in sugar [60]. One study showed that, during 12 hours of Saturday morning children’s television, a total of 225 commercials were broadcast; 71% of these commercials were for food products and 80% were ads for foods of low nutritional value [61]. Ads for cookies, candy, gum, popcorn, and snacks make up more than 1/3 of all food ads [62–63]. Food products that are most intensely advertised tend to be over-consumed, whereas food products that are less intensely advertised or not advertised at all (e.g., fruit, vegetables) are under-consumed [64]. Indeed, research has documented that children’s TV-viewing is positively associated with requests for and consumption of advertised foods, and parents’ willingness to purchase foods children request [65–71]. Further research has shown that TV-viewing during meals is associated with greater risk for nutritional deficiencies in people ranging in age from 2–24 years [72].
Eating Out.
In 1970, only 34% of a family’s food budget was accounted for by foods consumed outside the home [73], but by the late 1990s this had risen to more than 47% [74]. Eating out has been associated with higher intake of dietary fat and energy compared to eating at home [75–77], and as frequency of eating at fast-food restaurants has increased, consumption of fruit, vegetables, and dairy has decreased [78].
Portion Size.
In a trend that has been termed "the supersizing of America" it is clear that everything in America is getting bigger. On average, adults are 25% heavier than they were in 1990, and children are 30% heavier than they were in 1980 [79–80]. At restaurants, patrons eat nearly 350 calories per meal more than they did 15 years ago [81]. Fast food restaurants have introduced "big kids meals" which include adult-sized portions. Pizza franchises such as Domino’s and Pizza Hut no longer offer a "small" pizza [82–83]. In a survey of foods sold for immediate consumption in popular take-out restaurants published in 2002, all food portions except sliced white bread exceeded USDA and FDA standard portions, and these portions represented a substantial increase from those offered in the past [84]. For example, current sizes of common fast food items such as French fries, hamburgers, and soft drinks were two to five times larger than when the items were originally marketed [84]. Between 1977 and 1998, energy intake for soft drinks increased by 49 kcal, for hamburgers by 97 kcal, and for French fries by 68 kcal [85]. Data from the Bogalusa Heart Study showed that the average gram amount of foods consumed outside the home for lunch and dinner increased substantially from 1973 to 1993 [86]. Thus, larger portions not only contain more energy but also encourage people to eat more [87–89].
In children aged four to six years, Rolls, Engell and Birch [89] found a positive linear relationship between larger portion sizes (e.g., small, medium, and large) and intake. Additionally, Orlet Fisher, Rolls and Birch [90] found that doubling an age-appropriate portion of an entrée increased intake by 25% and that children who were served larger portions tended to take larger bites of the entrée. Together, the findings from these studies suggest that larger portions influence children’s eating by promoting intake.
School Meals.
School-based breakfast and lunch programs aim to promote healthy eating among children and adolescents, and have been largely successful [91–92]. However, the availability of competitive foods from vending machines and a la carte programs challenges the nutritious selections available in school meals. Nearly 25% of middle schools, 23% of high schools, and 9% of elementary schools serve name brand fast foods [93]. Most secondary schools (78%) have student-accessible vending machines, while 15% of middle schools and 34% of high schools permit students to use vending machines at any time [94]. Foods available from these a la carte programs and vending machines are typically higher in fat and lower in overall nutritive value than those foods served through the school lunch program. Some research estimates that only 36% of foods in a la carte programs and 35% of foods in vending machines meet the lower-fat criterion of 5.5 grams of fat per serving or less [95]. Additionally, research has now demonstrated that the presence of these alternatives has adverse effects on the quality of foods school children and adolescents consume. For example, Kubik, Lytle, Hannan, Perry, and Story [96] found that a la carte availability was inversely associated with fruit and vegetable consumption and positively associated with total and saturated fat intake. As vending machine availability increased, fruit consumption decreased. Thus, the types of foods available to children at school can also impact the types and quality of foods consumed.
Feeding Styles
Dietary guidelines convey the importance of consuming certain types of foods (e.g., fruit and vegetables) and limiting other types of foods (e.g., salty or sweet snack foods) [7,97]. Thus, parents may attempt to restrict children’s intake of "bad" foods and encourage their intake of "good" foods. Feeding styles represent the caregiver’s approach to maintain or modify children’s behaviors with respect to eating. Birch and Fisher [98] identified three child-feeding patterns that map on to Baumrind’s [99] taxonomy of parenting styles: authoritarian, permissive, and authoritative. Authoritarian feeding includes behaviors such as restricting the child from eating certain foods (e.g., desserts) and forcing the child to eat other foods (e.g., vegetables). Thus, authoritarian feeding is characterized by attempts to control the child’s eating with little regard for the child’s choices and preferences. Permissive feeding is characterized by what might be termed "nutritional neglect," whereby the child is allowed to eat whatever he or she wants in whatever quantities he or she wants. With permissive feeding, little or no structure is provided, and choices are limited only by what is available. Finally, authoritative feeding represents a balance between authoritarian and permissive feeding such that the child is encouraged to eat healthy foods but is also given some choices about eating options. With authoritative feeding, adults determine which foods are offered, and children determine which foods are eaten.
Feeding styles have been associated with both dietary intake and weight status. With regard to dietary intake, authoritarian feeding has been associated with lower intake of fruit, juices, and vegetables [100]. Children who were told to "clean their plates" were less sensitive to physiological cues of satiety [101], and when parents restricted their child’s consumption of foods high in fat and sugar, children were more likely to fixate on these items and consume the "forbidden foods" even when they were full [102]. Permissive feeding has been associated with drinking less milk and lower consumption of all nutrients except fat [103–104]. Authoritative feeding has been associated with greater fruit and vegetable availability, higher intake of fruit and vegetables, and lower intake of junk food [105]. Among adolescents, authoritative feeding was associated with more positive cognitions about fruit and more consumption of fruit [106], whereas permissive feeding has been associated with greater intake of fat and sweet foods, more snacks, and fewer healthy food choices [107–109]. In terms of the association between feeding styles and weight status, authoritarian practices such as restricting and monitoring the child’s intake have been associated with higher body mass, as indicated by both body mass index [102,110] and total fat mass [111].
Parents’ attempts to restrict some foods and encourage others have also been related to children’s preferences and intake. For example, feeding strategies that involve encouraging children to eat a particular food was associated with increased dislike for that food [112–114], and Hertzler [115] noted that the more parents encouraged children to eat vegetables, the lower children’s preferences for vegetables were. Parents may also try to limit children’s consumption of "bad" foods like salty and sweet snacks. In fact, in a 1989 study, 40% of parents believed that restricting or forbidding consumption of certain foods was effective for decreasing children’s preferences for these foods [116]. However, research does not support this belief. For example, Birch and colleagues [33] found that limiting the availability of foods high in fat, sugar, and energy that had been used previously as a reward was associated with increased liking for the limited foods. Fisher and Birch [98] found that restricting children’s access to certain foods may actually promote overconsumption of these "forbidden" foods.
Socioeconomic and Cultural Factors
Time Constraints, Education, and Income.
Today’s parents have longer work hours, and many families consist of only one parent or of two parents who are both working outside the home. Thus, parents increasingly rely on convenience foods [117]. In a nationally-representative survey, the NPD Group reported that time spent preparing meals declined more than 10% from 1994 to 1999, while home meal replacement such as restaurants and pre-packaged foods have become increasingly popular [118]. In addition to time constraints, various other sociodemographic factors influence the dietary quality of children and adolescents including parents’ education level and family income.
Higher parental education has been associated with health consciousness in food choices [119]. Adolescents whose parents were relatively more educated had higher intakes of carbohydrates, protein, fiber, folate, vitamin A, and calcium; higher consumption of vegetables; and greater likelihood of consuming the recommended servings of dairy products [120]. Mothers’ education level was inversely related to preschool children’s added sugar intake [121] and adolescent’s percentage of energy from fat [122]. Exclusive use of whole milk was highest in families in which parents had less than a high school education, and use of reduced-fat milk was highest among children who had college-educated parents [123].
Income is also an important predictor of eating patterns. The diets of individuals in relatively lower socioeconomic groups tend to be characterized by higher intake of foods such as meat products, full cream milk, fats, sugars, preserves, potatoes, and cereals, and relatively low intake of vegetables, fruit, and whole wheat bread [124]. Children and adolescents in relatively higher-income families had greater intake of polyunsaturated fats, protein, folate, calcium, and iron, and were more likely to meet the recommended number of daily servings for dairy products [120]. Other research has reported that as many as 40% of lower income adolescents do not meet recommended daily consumption of fruit and vegetables [125]. Among rural African-American children in single parent families, relatively higher income was associated with greater likelihood of the child taking vitamin supplements and eating patterns more consistent with recommendations for total dietary intake (i.e., nutrients and food) [126]. Children in low-income families in Mexico were less likely to meet recommendations for total dietary intake, and calcium intake was low [127]. British children in lower socioeconomic groups had significantly lower daily intakes of many micronutrients, a higher percentage of energy from fat, and a tendency to consume more full fat milk and receive a greater proportion of energy and nutrients from snacks than children in higher socioeconomic groups [128].
Ethnicity and Culture.
Ethnic groups have also been shown to differ in dietary quality and nutrient intake. This may be due to sociodemographic differences or cultural differences in the types of foods served and methods of preparation. Data from the Bogalusa Heart Study have shown that African-American children and adolescents had higher total energy intake and greater consumption of cholesterol, fat, and carbohydrates compared to Euro-Americans [129]. African-Americans also had higher percentage of energy from fat compared to Euro-Americans [129]. A recent study found that fat intake was lowest in Asian-Americans and highest in African-Americans, that Asian-Americans had significantly lower intakes of dairy products compared to African-Americans, Hispanics, and non-Hispanic Whites, and that of these ethnic groups Hispanics had lower intakes of vegetables [120]. In contrast, other research has shown that American Indians are at greater risk for inadequate fruit consumption and that African-Americans are at greater risk for inadequate vegetable consumption when compared to other racial/ethnic groups in the United States [125].
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CONCLUSION
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The research presented in this review speaks to the growing body of evidence supporting the notion that family and social environments play an important role in the development of children’s eating patterns and diet quality. Busy families rely on convenient foods which often come from fast food establishments, other restaurants, and the frozen and pre-packaged food sections of the grocery store. Hurried families no longer have time to sit down to eat meals together, even though eating together has been associated with greater intake of foods from the basic food groups in both children and adults. There have also been substantial changes with regard to portion sizes. What was once a single serving is now "super-sized," and what was once moderation is now an all you can eat buffet. Research has consistently demonstrated that people eat more when more food is placed in front of them. Thus, changing portion sizes may have contributed to today’s obesity levels. Other characteristics of the family influence children’s eating patterns as well. Family income often presents a barrier to healthy eating, with children in lower socioeconomic groups eating fewer fruit and vegetables and having higher intake of fat compared to children in relatively higher socioeconomic groups. Families who do not eat meals together or who have TV on during meals tend to have children who eat fewer fruit and vegetables and more snack foods.
Promoting healthier eating patterns among children requires a multi-faceted approach targeting children, parents, families, and schools. Much of the research summarized in this review highlights the ways in which characteristics of the social and physical environments contribute to less than optimal eating patterns. And some of these characteristics are more easily addressed through interventions than are others. For example, in the research on feeding styles, well-intentioned parents who are attempting to control their child’s eating by restricting intake of "bad" foods and encouraging the intake of "good" foods may actually foster the eating patterns they are trying to prevent. Satter [130,131] has suggested that one way to address this issue might be to develop a division of labor between parents and children: parents provide a healthful array of foods (i.e., availability) and the context that is conducive to children eating these foods (i.e., accessibility, modeling), and children decide when and how much to eat. Additionally, parent education classes that focus on developing more authoritative approaches to feeding (e.g., providing reasons and rationales for why children should eat more fruit and vegetables) could be beneficial.
Other research cited in this review points to the importance of early food experiences, particularly in terms of exposure to new foods and foods that they otherwise would not like (e.g., vegetables). Thus, interventions geared toward young children are particularly important. These interventions could be targeted at parents, including providing information about how children’s food preferences are formed, and providing concrete examples of how to make foods like vegetables both available and accessible (e.g., cutting up celery stalks into smaller pieces and putting them in single-serving containers or bags).
Other interventions could target day care centers and schools. Increasingly, schools and day care centers play an important role in the development of children’s eating, as children are spending more of their time and consuming more of their calories in these settings [132–139]. These interventions could focus on issues such as providing age-appropriate portion sizes, making healthful food choices like fruit and vegetables not only available and accessible but also appealing, and providing lower fat, lower sugar items in vending machines.
Because children’s eating patterns are influenced by such a range of characteristics of the social and physical environment, it is important to develop interventions that target the different levels at which these influences occur. At the level of the individual child, interventions that focus on increasing preferences for healthy foods like fruit and vegetables could be developed. At the level of the family, interventions that address issues such as feeding styles and mealtime structure could have a positive impact on children’s diet quality. Finally, at the level of the community, interventions that target schools and school meal programs are important for fostering healthy eating patterns among children when they are not at home. Clearly, this area is fertile ground, not only for individual researchers but also for multidisciplinary research teams to address multiple influences on children’s eating patterns.
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ACKNOWLEDGMENTS
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The authors wish to thank the Behavioral Nutrition Group at the Children’s Nutrition Research Center for their assistance in the preparation of this manuscript. Debby Demory-Luce, Sheryl Hughes, Sandra Jaramillo, Nilda Micheli, Miriam Morales, and Rajeshwari Ranganathan provided helpful comments on previous versions of the manuscript. Pamelia Harris provided valuable assistance in collecting references. Partial support for this project was received from the National Dairy Council.
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FOOTNOTES
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This work is a publication of the United States Department of Agriculture (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. Government. Partial support was received from the National Dairy Council.
Received February 16, 2004.
Accepted November 23, 2004.
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ABSTRACT
INTRODUCTION
