Family mealtimes: A contextual approach to understanding childhood obesity
Highlights
► We observed 200 families with a child with asthma during mealtimes. ► Healthy weight was associated with positive communication during meals. ► Obesity was best predicted with multiple risk including neighborhood poverty. ► Family mealtime social interactions may be affected by broader economic context.
Introduction
There is increasing evidence that frequency of shared family mealtimes is associated with positive health outcomes for children and youth including reduced risks for eating disorders (Neumark-Sztainer et al., 2008), increased consumption of fruits and vegetables (Neumark-Sztainer et al., 2004), less consumption of calorie dense foods (Videon and Manning, 2003) and risk for childhood obesity (Gable et al., 2007). In a recent meta-analysis pooling across 17 studies including 182,836 children and adolescents, frequency of shared meals was significantly related to nutritional health and weight status. For families who shared meals together three or more times per week, the odds of their children being overweight were reduced by 12%, the odds of eating unhealthy foods was reduced by 20% and there was an increased odds of eating healthy foods by 24% (Hammons and Fiese, 2011).
However, a focus on the number of times that a family gathers together to share a meal may be but a marker of the myriad of factors that go into organizing, sustaining, and managing this highly complex family event (Fiese et al., 2006). Mealtimes are part of the family's routine life that includes elements of planning, predictability, regulating emotion, and effective strategies for communication. Organizational features of family routines have been found to be related to a variety of health outcomes including adherence to medical regimens (Fiese et al., 2005, Greening et al., 2007), reduced risk of depression (Dickstein, 2002), alcoholism (Haugland, 2005), and obesity (Andersen and Whitaker, 2010).
In this paper, we provide an overview of the organizational features of shared family mealtimes that may account for the effects of this routine in preventing childhood obesity. Further, we recognize that the practice of mealtimes is embedded in a socio-economic context influenced by resources available to the family. Therefore, we present the study of family routines as part of an ecological framework to account for the multiple influences on childhood obesity (Harrison et al., 2011). We then provide evidence from an observational study of 200 family mealtimes demonstrating the complex interplay between family mealtime behaviors, socio-economic factors and child obesity status. We draw from a sample of families who have a child with persistent asthma. Children with persistent asthma are at increased risk for being overweight and obese (Luder et al., 1998, Shore, 2006). Although our sampling frame is selective in that focuses on families with a child with a chronic health condition, the co-morbidity of asthma and obesity is national public health problem that often co-occurs with other risk factors such as poverty and minority status (Stingone et al., 2011). Further, childhood obesity has far reaching consequences on child health and development (Cawley and Spiess, 2008). We conclude with recommendations for future research and policies to promote healthy living for families living in diverse economic circumstances.
Family mealtimes are one of the routines of family life. Routines provide structure and organization to family activities such that individual members know who will carry out particular functions, what to expect from others, and when and where family events will occur. There are two health promoting features of family routines- the organizational or planning component and the emotional connections made during the routine over time (Fiese, 2006). The organizational features of routines can be directly observed and reported and includes such features as planning ahead, assignment of roles, expectations for attendance, and stability and regularity of the routine over time (Fiese et al., 2002, Weisner et al., 2005)
Family theorists have long recognized that the mere practice of a routine does not tell the whole story behind what makes for successful and sustainable routine (Fiese and Spagnola, 2006, Patterson and Garwick, 1994, Reiss, 1989). How important the routine is to family life and the emotional investment made in carrying out the routine has been found to distinguish positive and negative outcomes including relationship satisfaction (Fiese et al., 1993), health symptomatology (Patterson and Garwick, 1994), and well-being (Fulkerson et al., 2007). The emotional connections made during the practice of routines over time are evident in the patterns of communication displayed by family members and report of the felt experience and importance ascribed to carrying out the routine into the future (Fiese and Spagnola, 2006, Patterson and Garwick, 1994, Reiss, 1989).
There is considerable variation in how families carry out their daily routines such that some families regularly plan ahead, openly communicate their feelings and emotions during regular events, and feel strongly that daily events such as mealtime should be carried on into the future. Other families, however, may conduct routines in a more haphazard way with little planning, an unevenness in communication such that there are bouts of conflict interspersed with moments of silence, and little regard for what happens in the future. These variations in planning, communicating, and organizing daily routines have been found to be related to important health outcomes for children including health quality of life (Everhart et al., 2008), disease severity (Fiese et al., 2005), behavior problems for children with a chronic illness (Greening et al., 2007), and substance abuse (Coley et al., 2008).
Mealtimes are one type of family routine whose quality has been associated with better overall child mental and physical health (Dickstein et al., 1999, Flores et al., 2005, Munoz et al., 2007). The direct observation of family mealtimes affords the opportunity to examine variations in how routines are carried out in the natural environment, how patterns of communication may be related to health outcomes, and if there are significant variations in practices of mealtime routines by socio-economic background.
To date, there has been some emerging evidence to suggest that the quality of shared family mealtimes is associated with risks for childhood obesity. In an earlier report we found that a global rating of mealtime observations in terms of how easily the task of the meal was accomplished and displaying positive interest and emotional connections during the meal distinguished families with children of healthy weight from those who were either overweight or obese (Jacobs and Fiese, 2007). Other researchers have found that making mealtimes a priority and self-report of positive mealtime climate reduces risks associated with childhood obesity such as depression and unhealthy weight control behaviors (Fulkerson et al., 2007). Families with children who met Centers for Disease Control (CDC, 2007) criteria for obesity and were enrolled in a weight management program reported more mealtime challenges and poorer mealtime quality than a comparison group of age matched peers (Zeller et al., 2007).
The research examining the link between quality of family mealtimes and risk for childhood obesity has been limited in two regards. First, a relatively wide net has been cast to capture the quality of family mealtimes thought to be associated with risk for obesity. We propose that the key elements to consider for healthy mealtimes are planning ahead, positive communication, and the relative importance placed on this family routine. This organizational framework is consistent with previous research documenting links between family routines and health outcomes (Fulkerson et al., 2007, Schreier and Chen, 2010). Second, scant attention has been paid to the socio-economic context of the quality of family mealtimes and links to childhood obesity. Because risks for obesity are embedded in a socio-economic context it is important to consider not only the proximal influences of family interaction but also the more distal influences of socio-economic and cultural resources (Harrison et al., 2011).
Children's health is embedded in a complex set of overlapping ecologies including the home, neighborhood, and cultural institutions. Child health disparities are commonly noted, with children from lower income families more likely to experience poorer health overall (Larson and Halfon, 2010) and obesity in particular (Bethell et al., 2010). Although it is plausible to assume that shared family mealtimes are a private event with their own unique characteristics, there are also social factors that affect the likelihood that meals are accomplished in a healthy manner. One factor that affects the type of foods placed on the table is access to healthy foods. Families that live in low income neighborhoods in large urban and small communities must travel further to purchase fresh fruits and vegetables (Walker et al., 2010). Families in low income neighborhoods are more likely to purchase foods at convenience stories or fast food outlets (Yoo et al., 2006). Thus, the opportunities for low income families to select healthy food choices for their children may be restricted.
There are inconsistencies in the literature as to whether there are significant variations in the practice of mealtime routines according to socio-economic background. Some researchers report a lower frequency overall of mealtime routines in lower income and families with lower parental education (Bradley et al., 2001, Flores et al., 2005) whereas others do not (Moore et al., 2009). Yet to be determined is whether socio-demographic variations significantly influence mealtime quality in relation to childhood obesity status. Because we consider childhood obesity embedded in a family climate and socio-economic context we propose that a cumulative risk approach may be a reasonable strategy for examining the s multiple ecologies related to childhood obesity.
A glaring omission in the mealtime literature is an integration of the more distal socio-economic context with the more proximal family mealtime practices in relation to children's health. This may be due, in part, to the sampling frame used by some of the mealtime studies. In some cases, the mealtime studies have either focused solely on low income families to identify risk factors associated with feeding practices (Hughes et al., 2006). In other cases, socio-economic factors are used as statistical controls thus masking potential contextual effects (Eisenberg et al., 2008). Because childhood obesity is over-represented in low income and racial minority families (Centers for Disease Control, 2007), it is important to consider both potential disparities and protective factors for childhood obesity. To do so, it is important to incorporate a theoretical and methodological approach that allows for a consideration of multiple contexts related to children's health.
One approach to understanding the intersection between socio-economic factors and the home environment in relation to risk for poor health is from a cumulative risk perspective. Simply put, cumulative risk models propose that adverse outcomes are rarely the result of a single risk factor but rather poor health results as an accumulation of multiple risk factors over time. These models are proposed to more accurately reflect an individual's simultaneous exposure to environmental risk than those that focus on single markers of risk exposure. Cumulative risk models have been successfully applied to the prediction of IQ in children raised in low income neighborhoods (Seifer et al., 1996), allostatic load in children raised in rural poverty (Evans, 2003), and quality of life of caregivers of children with a chronic health condition (Everhart et al., 2008). The advantage of taking a cumulative risk approach to predicting health outcomes is that it allows for the simultaneous consideration of socio-economic factors such as poverty, neighborhood resources and household factors such as routine organization and family climate. Thus, it is possible to simultaneously take a more contextual view of the intersection between family practices and socio-economic context in relation to childhood obesity.
To examine our questions, we draw from a select sample of families who have a child with persistent asthma. Pediatric asthma is the leading chronic illness among children and youth in the United States (NEPR-3, 2007). Children with persistent asthma are at increased risk for being overweight and obese (Luder et al., 1998, Shore, 2006). The exact mechanism is not clear. For example, prospective studies of physical activity and obesity in children with asthma do not show a direct link between lower levels of physical activity causing obesity in children with asthma (Nystad, 1997). Previous research comparing family social interaction patterns during meals between healthy and chronically ill children note that economic circumstances are often more distinguishing characteristics than the disease status itself (Piazza-Waggoner et al., 2008). Indeed, pediatric researchers have found mealtimes an important setting to study family social interaction in relation to health outcomes as it presents an opportunity to examine problem solving, communication, and affect regulation (Patton et al., 2006). Although this sampling frame results in a select sample, asthma and obesity are often considered more broadly as markers of children's health in large scale national studies (Bzostek and Beck, 2011).
We had two primary goals in this study. First, we wanted to ascertain, on a descriptive level, whether families who had a child who met criteria as set by the CDC for unhealthy weight (overweight or obese) would evidence different patterns of mealtime interactions and planning for mealtimes. Because most of the literature to date has focused primarily on frequency of shared family mealtimes or feeding behaviors with younger children we considered this an exploratory part of our study. In this report, we focus on the ABC's of family mealtimes to examine the potential relation between mealtime quality and childhood obesity. The ABC's of family mealtimes is a micro-analytic approach to coding mealtime interaction that includes the amount of time the family spends in Activities, Behavior Control, and Communication (Fiese et al., 2011). Because we are also interested in the potential role that planning plays in maintaining healthy routines we collected self -report information on planning and importance of mealtime routines.
Our second goal was to consider whether the cumulative effects of socio-economic risk and family mealtime practices would be associated with the child overweight or obese beyond any single risk factor. We consider socio-economic factors that have been shown to be associated with risk for adverse outcomes (Adler and Rehkopf, 2008, Burchinal et al., 2000, Chen et al., 2002, Evans and English, 2002) including single parent head of household and neighborhood poverty rates.
Section snippets
Participants
Data were drawn from a larger study of family life and asthma. Families were recruited through an ambulatory clinic at a teaching hospital, a pediatric pulmonary clinic, or area group pediatric practices in a mid-size city. A child was enrolled in the study if, at the time of recruitment, he or she: (1) was between the ages of five and twelve, (2) had an asthma diagnosis (of at least one year) as indicated by physician notes in medical records and by a spirometric test conducted by a licensed
Descriptive analyses
We first examined the group differences on the mealtime variables to determine whether there were significant differences in mealtime interactions between families with a child of healthy weight status and those who were overweight or obese. In terms of the directly observed family mealtimes we found that families with an overweight or obese child spent less time, on average, engaged in the meal than those with a healthy weight child. We also found that families with an overweight or obese
Discussion
We set out in this study to examine the relation between family level factors (mealtime practices) that are proximal to the child's daily experiences and broader socio-economic factors (concentrated neighborhood disadvantage) that are more distal to the child's daily life to consider how different ecological contexts may be related to risks for childhood obesity. We found some evidence supporting family and socio-economic context in relation to childhood obesity status, as well as the
Acknowledgements
Preparation of this manuscript was supported, in part, by grants from the National Institute of Mental Health (R01 MH51771) and the USDA National Institute of Food and Agriculture, Hatch Project number 793 328.
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