Friends and Family: How African-American Adolescents’ Perceptions of Dietary Beliefs and Behaviors of Others Relate to Diet Quality

RESEARCH

Original Research: Brief

Friends and Family: How African-American Adolescents’ Perceptions of Dietary Beliefs and Behaviors of Others Relate to Diet Quality Margaret M. Wrobleski, PhD, RDN, LDN; Elizabeth A. Parker, PhD, RD; Erin Hager, PhD; Kristen M. Hurley, PhD; Sarah Oberlander, PhD; Brian C. Merry, MPH; Maureen M. Black, PhD ARTICLE INFORMATION Article history: Submitted 17 January 2018 Accepted 27 July 2018

Keywords: Adolescent African-American Diet quality Parental monitoring of child feeding Social dietary influences 2212-2672/Copyright ª 2018 by the Academy of Nutrition and Dietetics. https://doi.org/10.1016/j.jand.2018.07.021

ABSTRACT Background Adolescents’ dietary intake often fails to meet national dietary guidelines, especially among low-income African-American youth. The dietary habits established in adolescence are likely to continue into adulthood, and a poor-quality diet increases the risk of developing obesity and chronic disease. Based on principles from ecological and social-cognitive behavior change health theories, perceptions of parental beliefs about healthy eating, perceptions of peer eating behaviors, and parental monitoring of what adolescents eat may positively influence adolescent diet quality. Objective The purposes of this study were to determine whether perceived parental beliefs about nutrition, perceived peer eating behaviors, and reported parental monitoring of the adolescent diet were related to African-American adolescent diet quality and whether these relationships were moderated by adolescent age or sex. Design This secondary cross-sectional study used baseline data (2002 to 2004) from an urban community sample of low-income adolescents participating in a health promotion trial. Participants/setting Participants were 216 African-American adolescent-caregiver dyads in Baltimore, MD. Main outcome measures The 2010 Healthy Eating Index was used to estimate adolescent diet quality. Statistical analyses performed Analyses included correlations, t tests, age- and sexby-perception regression interactions, and multivariate regressions adjusted for body mass indexefor-age percentile, caregiver weight status, and caregiver depressive symptoms. Results Higher diet quality scores were related to higher levels of perceived parental and peer support for healthy eating behaviors among adolescents (b¼.21; P<0.05; b¼.15; P<0.05, respectively) and to caregiver reports of parental monitoring of adolescent dietary behavior (b¼1.38, P<0.01). Findings were not moderated by age or sex. Conclusions Consistent with ecological and social-cognitive theories, adolescents look to their friends and family in making healthy food choices. The relationships uncovered by this study describe some of the contextual, interpersonal influences associated with diet quality among low-income, urban African-American adolescents and warrant further exploration in future intervention studies. J Acad Nutr Diet. 2018;-:---.

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HE DIETS OF MOST ADOLESCENTS ARE SUBOPTIMAL and fall short of national dietary guidelines,1 especially among African-American youth.2 Dietary habits established in adolescence are likely to continue into adulthood,3 and a poor-quality diet increases the risk of developing chronic disease and obesity as an adult.4 AfricanAmerican adolescents living in low-income families in blighted, urban environments have disproportionately poor diet quality,5,6 placing them at higher risk for nutritional inadequacies7,8 and obesity.9,10 Ecological and social-cognitive behavior change health theories describe how adolescent ª 2018 by the Academy of Nutrition and Dietetics.

dietary behaviors are impacted by multiple layers of sociocultural factors that surround and affect their lives.11,12 Improving African-American adolescents’ diet quality begins with a better understanding of the influences on their food choices, particularly how perceptions of social pressure from family and friends relate to adolescents’ nutritional intake.13 As primary caregivers throughout childhood, parents typically determine the food choices available to their children14 and are the normative influencers on adolescents’ consumption of healthy diets rich in fruits and vegetables.15 When adolescents perceived their parents’ style as highly JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH involved and relatively strict about their dietary behavior, there were stronger inverse associations with sugar sweetened beverage (SSB) intake than when adolescents believed their parents were less involved and not as strict about dietary practices.16 Restrictive parental snacking rules for adolescent children were related to a decrease in snack consumption, but only when parents modeled restriction of their own between-meal energy-dense snacking behavior.17 Concern for adolescent overweight predicted parental monitoring strategies among female caregivers, who also enforced dietary restriction with adolescents who were obese compared with those who were not overweight.18 Foodcontrolling parenting practices such as dietary restriction and pressure to eat are frequently used with adolescent children and are especially common among minority parents and those of low socioeconomic status.19 There is scant research published on parental monitoring of low-income, urban African-American adolescents’ diets. One study revealed that African-American adolescents reported healthier eating behaviors when family role models monitored their food consumption and implemented rules about food choices to encourage and enforce healthy eating.20 Low-income, African-American mothers and grandmothers have a positive effect on adolescents’ nutritional intake13 by encouraging them to eat fruits and vegetables.21 In neighborhoods characterized as urban food deserts, 64% of lowincome, African-American adolescents report that parents provide support for healthy food choices and create healthpromoting rules for their eating behavior.13 Among AfricanAmerican adolescents, parental encouragement for making healthy food choices was inversely related to SSB consumption.22 Adolescents may also adopt less desirable dietary habits from parents. In low-income, urban food desert communities, energy-dense, nutrient-poor food choices of African-American mothers were mirrored by their earlyadolescent daughters, revealing that girls from families in the lowest income levels were most at risk for poor diet quality and obesity.23 As adolescents mature, their autonomy in making food choices increases when they are eating at school, with friends, or at home alone24,25; and the social influencers on their dietary behavior shift as they age through puberty.26 Younger adolescents (12 to 14 years) have reported that parents pressure them to decrease SSB intake, whereas pressure to consume fewer SSBs among slightly older adolescents (15 to 17 years) was associated with peers.26 Peers can have both positive and negative influences on eating behavior.27 Consumption of energy-dense snack foods is more likely to occur when adolescents eat with their friends than when they eat at home.21,28,29 Adolescents attribute eating fast food30 and “unhealthy” foods to social pressures within peer groups13,31,32 and to friends who express negative attitudes toward consuming nutritious foods.21,33 Peers can also positively influence eating behaviors and attitudes,34-36 and adolescents are likely to consume more nutritious foods with peers who are eating healthy.37,38 Female adolescents consume more healthy snacks and fewer unhealthy foods when they are eating with girlfriends compared with when eating with their mothers, possibly as a strategy to make a favorable impression on their peers.34 Younger, urban African-American adolescents living in low-income families report that friends have little influence 2

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RESEARCH SNAPSHOT Research Question: Are perceived parental dietary beliefs, reported parental monitoring of adolescent diet, and perceived peer eating behaviors related to African-American adolescents’ diet quality, and are these factors moderated by participant age and sex? Key Findings: In this cross-sectional study of 216 lowincome, urban African-American adolescent-caregiver dyads, higher diet quality scores were related to higher levels of perceived parental dietary beliefs (b¼.21, P<0.05), perceived peer eating behaviors (b¼.15, P<0.05), and reported parental monitoring of the adolescent diet (b¼1.38, P<0.01). Adolescent age group or sex moderated none of the variables of interest. on their eating habits, whereas older adolescents admit friends do have some influence on their food choices, especially in instances when social conformity is important.13 For example, adolescents are more likely to purchase, share, and consume unhealthy snack foods with friends while “hanging out” by the neighborhood corner convenience store.13 To the authors’ knowledge, this study is unique in applying principles from ecological and social-cognitive behavior change health theories11,12 to simultaneously examine parental monitoring and perceived parental and peer social influences on African-American adolescent diet quality in an underserved and nutritionally at-risk population. The purposes of this research were to determine whether perceived parental dietary beliefs, caregiver-reported parental monitoring of the adolescent diet, and perceived peer eating behaviors are related to African-American adolescents’ diet quality and whether these factors vary by participants’ age and sex. The authors hypothesized that 1) reported parental monitoring of adolescent dietary intake, perceived parental dietary expectations, and perceived peer eating behaviors are related to diet quality; and reported parental monitoring of the adolescent diet and parental and peer social influences on diet quality are moderated by 2) adolescent age group and 3) sex. These hypotheses are based on research indicating that younger adolescents are more receptive to parental influences on dietary choices than older adolescents, who tend to be influenced by peer eating behaviors.19,26 Female adolescents can be socially influenced by girlfriends to make healthy food choices.34 In contrast, male adolescents are more likely to make poor-quality food choices, such as consuming high-calorie foods39 and engaging in snacking behavior when spending time with peers.30 In addition, boys are generally allowed more independence in adolescence, which affords greater autonomy in making food choices while socializing with friends outside the home.40,41

METHODS Study Design and Participants This is a cross-sectional secondary analysis of baseline data from a sample of low-income, urban African-American adolescents and their caregivers from the Challenge Study (n¼235), a longitudinal, randomized controlled trial (clinicaltrials.gov identifier NCT03103269) designed to evaluate the impact of promoting healthy dietary and physical --

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RESEARCH activity behaviors among middle school students.42 Adolescents, aged 11 to 16 years, were recruited from three local public schools and from a university medical center in Baltimore, MD. Eligibility requirements were age (11 to 16 years) and residence in a West Baltimore low-income community. Baseline measures were collected from July 2002 through May 2004. The institutional review board at the University of Maryland in Baltimore approved all study protocols. Signed informed consent or assent forms were obtained from participants (and parents of participants younger than 18 years). Baseline demographic, dietary, anthropometric, and income data were obtained from participants and their parents. All participants were compensated for study evaluation visits. Family income <185% of federal poverty level43 was defined as low income.

Anthropometrics Adolescents’ and caregivers’ body weight and height were measured using a digital Tanita scale (Tanita Company) to the nearest 100 g and a wall-mounted stadiometer, respectively. Each participant had the average of three height and weight measurements recorded. Adolescents’ body mass index (BMI; calculated as kg/m2) values were converted to percentiles and z scores, then categorized as underweight and normal weight (<85th percentile), overweight (85th percentile and <95th percentile), or obese (95th percentile), based on the 2000 Centers for Disease Control and Prevention age- and sex-specific tables and algorithms.44

Dietary Assessment Adolescent dietary intake over the prior 12 months was estimated using the Youth/Adolescent Questionnaire (YAQ), a validated food frequency questionnaire developed for older children and adolescents.45 The self-administered YAQ contains 131 items and reports estimated intake of energy and macronutrients, micronutrients, and average daily food servings consumed.

Measures The Perceived Parental Beliefs about Nutrition Scale used in this study is a 10-item survey adapted from the Role Model Scale in the Youth Health Survey.46 The Perceived Parental Beliefs about Nutrition Scale addresses nutrition-related behaviors that parents might expect of adolescents (eg, “My parents think I should eat no more than one salty or greasy snack most days [corn chips, potato chips, cheese curls].”). Response choices use a 4-point Likert scale with answers ranging from “1-strongly disagree” to “4-strongly agree.” Higher scores indicate stronger perceptions that parents want adolescents to eat nutritious food. Reliability testing conducted on this scale yielded an internal consistency score of 0.88 in this sample. The Perception of Peer Eating Behavior was measured using a 10-item questionnaire adapted from the Peers’ Health Behavior Scale found in the Youth Health Survey.46 The scale in the present study measures the adolescent’s perception of friends’ healthy eating habits with questions such as, “How many of your closest friends drink skim or 1% milk (instead of 2% or whole/vitamin D/red cap)?” A 4-point, numbered response set of answer choices includes the following options: 1¼none; 2¼some; 3¼most; 4¼all. Higher scores --

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indicate that the adolescent perceives more friends engaging in healthy nutrition behaviors. Internal consistency of this measure was 0.86 for this study sample. Parental Monitoring of Child Feeding is one of seven subscales used in the Child Feeding Questionnaire, an instrument widely used to evaluate a child’s proneness for obesity as a result of parental child feeding practices.47 The instrument was developed to measure parental attitudes, beliefs, and practices about feeding children with a focus on feeding restriction and pressuring children to eat and has been used successfully with adolescents.48-50 Data on this measure were collected from adolescents’ parents and caregivers. The parental monitoring subscale contains three items that assess the extent to which a parent tracks an adolescent’s food consumption (eg, “How much do you keep track of the sweets/snack foods/high-fat foods that your child eats?”). Responses to these items are on a 5-point Likert scale ranging from “1-never” to “5-always.” Higher scores indicate greater parental reported monitoring of an adolescent’s nutritional intake. The scale’s internal consistency was 0.89 for this sample. Parental depressive symptoms were assessed using the Beck Depression Inventory,51 one of the most widely used instruments for measuring the severity of depressive symptoms, which has been validated in a wide variety of healthy and psychiatric sample populations.52 It was used to control for parental depressive symptoms in evaluation of parental monitoring of adolescent diet because depressive symptoms have been associated with withdrawn, less reactive caregiving.53 Household food security was measured using the US Department of Agriculture’s Food Security Scale.54 The 18item survey was completed by adolescents’ parents and summarizes household food security in four categories: high, marginal, low, and very low food security. The high and marginal categories were collapsed as food secure, and the low and very low categories were combined as food insecure to create a dichotomous variable to preserve statistical power for this predominately low-income study sample. The internal reliability of the household food security measure was 0.87 for this sample.

Outcome Measure Diet quality was the outcome measure. It was assessed using the 2010 Healthy Eating Index (HEI-2010),55 which reflects alignment with key messages of the 2010 Dietary Guidelines for Americans56 and is calculated using a density approach. This density approach assesses intake in terms of the relative proportion of foods eaten rather than the total quantity of food consumed, regardless of an individual’s energy requirement, providing a common standard across sex and most age groups. The HEI-2010 consists of 12 food component scores summed for total diet quality score. The HEI-2010 consists of nine adequacy components (whole fruit, total fruit, total vegetables, greens and beans, dairy, whole grains, total protein foods, seafood and plant proteins, and fatty acids) and three moderation components (sodium, refined grains, and empty calories from solid fat, alcohol, and added sugars). Total HEI-2010 scores range from zero as the theoretical lowest score (but not practically possible) to a maximum score of 100, indicating that JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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Data Analysis Nineteen participants were excluded from this study. Six participants were missing a food frequency questionnaire; seven did not self-classify as African-American; and six reported an implausible daily energy intake (<500 or >8,000 kcal),57 resulting in a sample of 216 (92%) for analysis. Adolescents were classified as “younger” or “older” (11 to 13 years vs 14 to 16 years) based on the midpoint of the participant age range. Data from the YAQ were used to estimate dietary intake and calculate HEI-2010 scores. Publicly available SAS programming codes from the National Cancer Institute58 were used to convert food frequency data into HEI-2010 component and summary scores.55 A detailed description of scoring the HEI-2010 using YAQ data has been published elsewhere.59 Data were analyzed using IBM SPSS60 and SAS61 at a significance level of 0.05, with values reported as means with standard deviations. Missing data for the variables representing perceived peer eating behaviors and perceived parental beliefs were found to have less than 5% of data missing completely at random using Little’s Test in SPSS. Means testing on these key variables confirmed there was no difference between groups of respondents with and without missing data. Because this dataset was relatively small at 216 cases, the SPSS Missing Value Analysis module was used for data imputation to preserve all possible cases and maintain an adequate sample size for multivariate analyses. All analyses were conducted on both the original and imputed datasets to determine whether the data replacement led to a significant difference in findings, which it did not. Pearson correlations were used to examine bivariate relations among the three constructs of interest and adolescent diet quality. T tests and multiple regression interaction terms were used to determine whether the main study constructs and diet quality were moderated by adolescent age category or sex. Multiple linear regression analysis was used to determine whether perceived parental beliefs about nutrition, perceived peer eating behavior, and reported parental monitoring of the adolescent diet were related to adolescent diet quality (hypothesis 1). Some adolescents model parents in shaping their eating patterns and food choices.22 Parents consuming poor-quality diets and excess calories are likely to be overweight and may pass these dietary behaviors and food preferences on to their children,23 so parental weight status (normal BMI vs overweight/obese) was used in the model as a proxy for parents’ eating behavior. Covariates added to the regression model included adolescent sex, age category, adolescent BMI-forage percentile, parental weight status, and parental depressive symptoms. To test the second and third hypotheses, six interaction terms were created by sex and by age category with each of the three constructs of interest: perceived parental beliefs about nutrition, perceived peer eating behavior, and reported parental monitoring of the adolescent diet. Each interaction variable was entered into a regression model to test whether associations between each of the main constructs and diet 4

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quality were moderated by adolescent age category (hypothesis 2) or by sex (hypothesis 3).

RESULTS The study sample of 216 African-American adolescents was nearly evenly split between male (50.5%) and female participants with a mean age of 13.2 years at baseline. A majority of the sample consisted of younger adolescents aged 11 to 13 years (78%) compared with older adolescents aged 14 to 16 years. Mean BMI-for-age percentile was 68, ranging from 1.1 to 99.8, with 40% of adolescents above the 85th percentile. Twelve percent of adolescents were overweight and 28% were obese. Adolescent girls had higher age-adjusted BMI percentiles compared with adolescent boys (74 vs 63; P¼0.006). Although female participants had significantly higher BMI percentile scores, reported daily energy intake was similar for male and female participants (29181545 vs 29501451 kcal/day, respectively; P¼0.82). The mean age of caregivers was 40 years (range¼25 to 78 years), and 83% were the adolescent’s mother. A majority of caregivers were overweight or obese (77%), and caregiver BMI was correlated to adolescent BMI percentile (r¼0.23, P¼0.001). Fifty-seven percent of families lived at or below the federal poverty line, and most adolescents (61%) lived in female-led, single-parent households. A majority of participant households were food secure, with 30% reporting food insecurity. Parental monitoring of adolescent dietary intake was significantly higher among females and young adolescents, and perceived parental nutrition beliefs scores were higher among female adolescents (Table 1). Neither HEI-2010 total score nor perceived peer dietary behavior varied by age category or by sex. All three primary variables significantly predicted adolescent diet quality in multiple regression models before and after covariates were added to the model (Table 2). None of the interaction terms between main predictor variables and sex or age group were significantly related to diet quality, and there was no evidence of multicollinearity among the three constructs of interest.

DISCUSSION The two main findings are that diet quality scores among adolescents are positively associated with adolescents’ perceptions of parents’ beliefs regarding nutrition, healthy dietary choices among their peers, and caregivers’ reports of parental monitoring of adolescent dietary behavior. Consistent with predictions from ecological and social-cognitive theories, adolescents’ dietary behaviors reflect their perceptions of the social environment.12 These findings may be particularly salient among adolescents, who are transitioning from their families into the broader community and are highly influenced by their social context.13,26 As adolescents mature, they gain more autonomy in adopting new dietary behaviors, have greater independence in making their own food choices, and tend to eat fewer meals at home compared with younger adolescents.62 These findings suggest that further research is needed to explore how social norms about adolescent dietary behavior may be changed, perhaps through future interventions that target social environments. Additional research focusing on --

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RESEARCH Table 1. Total score summaries from the Challenge Study baseline data for HEI-2010a, reported parental monitoring of diet, perceived parental beliefs about nutrition, perceived peer eating behavior, and differences by age category and by sex (N¼216) Scores by Age Groupb

Total Scores

Scores by Sexb

Score

SDc

Score range

Maximum range

Young (11-13 y)

Old (14-16 y)

P valuec

Male

Female

P valued

55.9

8.16

33-77

0-100

56.2

54.9

0.376

55.3

56.5

0.309

3.2

1.12

1-5

1-5

3.3

2.8

0.003

3.1

3.4

0.049

Perceived parental beliefs about nutrition

26.6

6.90

1-40

1-40

26.6

26.6

0.981

25.3

27.9

0.005

Perceived peer eating behavior

12.9

7.98

1-38

1-40

13.1

12.0

0.441

12.5

13.3

0.446

Variable Diet quality measure HEI-2010 Dietary behavior measures Parental monitoring of diet

a

HEI-2020¼2010 Healthy Eating Index. t tests were used to assess differences in scores by age and sex. SD¼standard deviation. d Bolded P values indicate statistical significance and signify that greater levels of reported parental monitoring of adolescent diet were related to younger adolescents and female adolescents, and greater levels of perceived parental beliefs about nutrition (ie, that parents want adolescents to eat nutritiously) were related to female adolescents. b c

diet and modeling of desirable dietary behaviors are positively associated with adolescents’ increased fruit and vegetable consumption63 and with eating more healthful foods14,64,65 and negatively associated with adolescent SSB consumption.66 This study’s findings support previous research demonstrating that maternal influence on healthy eating behaviors in the home can improve nutritional

parental monitoring of adolescent eating behavior in lowincome African-American families is needed to develop new strategies to improve the diets of nutritionally at-risk youth. Perceived parental beliefs about nutrition were positively related to diet quality, and these findings are consistent with research that shows that parental attitudes about a healthy

Table 2. Simultaneous multiple regression analysis summaries from Challenge Study baseline data for perceived parental beliefs about nutrition, perceived peer eating behavior, reported parental monitoring of diet, and covariates predicting HEI-2010a score (N¼216) Model 1 Variable

b

Constant

b

SEM

c

d

b

Model 2 P value

b

e

b

SEMc

bd

P valuee

43.84

2.551

<0.0001

42.66

3.698

Perceived parental beliefs about nutrition

0.21

0.081

0.17

0.012

0.25

0.088

0.21

0.006

Perceived peer eating behavior

0.15

0.069

0.15

0.031

0.18

0.072

0.17

0.015

Reported parental monitoring of diet

1.38

0.488

0.19

0.005

1.24

0.517

0.17

0.017

Teen age category (11-13, 14-16 y)

0.36

1.373

0.02

0.794

Adolescent sex

0.80

1.160

0.05

0.493

0.02

0.021

0.07

0.363

0.18

1.326

0.01

0.890

0.05

0.117

-0.03

0.663

f

Adolescent BMI -for-age percentile Caregiver weight status Caregiver depression score Model adjusted R2

0.094

P value for overall test of model

<0.0001

<0.0001

0.102 <0.001

a

HEI-2010¼2010 Healthy Eating Index. b¼unstandardized coefficient. c SEM¼standard error of the mean. d b¼standardized estimate. e Bolded P values indicate statistical significance and signify that higher HEI-2010 scores were related to stronger perceptions that parents want adolescents to eat nutritiously; to adolescents perceiving more friends engaging in healthy eating behavior; and to greater levels of reported parental monitoring of the adolescent diet. f BMI¼body mass index. b

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RESEARCH intake.21 Contrary to earlier research indicating that mothers can have a positive influence on their daughters’ eating habits,40,67 parental dietary influence in this study was not moderated by adolescent sex. The results of this study support research that shows peers’ healthy eating behavior is positively related to adolescent diet quality.34-36 Although some adolescents look to parents as role models for eating habits, other adolescents rely on their social surroundings for behavioral cues. Peer influence becomes especially influential in middle adolescence as parents’ involvement in their children’s activities declines.68 Adolescents tend to choose friends who are similar to themselves, to the extent that adolescents’ BMIs correlate strongly with those of their friends’.69 Among adolescents, individual energy intake has been correlated to that of their best friends, with friends’ unhealthy eating behaviors being gradually adopted over time.31 Although sex differences in adolescent dietary behavior have been related to peer influence in previous research,30,34 the association between adolescent diet quality and perceived peer eating behaviors in this study did not vary by sex. Likewise, the absence of age differences in our findings may be partially explained by the relatively young age of the adolescents (mean of 13 years). This study confirms prior research indicating that positive parental monitoring of food consumption supports adolescents’ perceptions that parents want them to make healthy food choices.20 African-American parents who monitor their adolescents’ intake also tend to restrict junk food consumption and encourage adolescents to eat more nutritious foods.20 Comparatively, adolescents of parents practicing more permissive or less controlling feeding styles tend to make less healthy food choices.70 The results of this study are in alignment with the previous research finding that BMI of overweight and obese parents positively correlates with adolescent BMI.71 Children’s and adolescents’ diets tend to resemble those of their parents.40 Adopting undesirable dietary habits from parents who consume poor-quality diets containing excessive nutrientpoor calories29 can increase an adolescent’s obesity risk, especially among families of the lowest income levels who are most at risk for inadequate nutritional intake and obesity.23 This study revealed significant associations between perceived social influences and diet quality, but the effect sizes were small, suggesting there are additional factors affecting the adolescent diet. Family food insecurity can have a deleterious effect on adolescent diet quality.72 More than half of households in this sample lived at or below the federal poverty line, with almost a third of families reporting food insecurity. Low-income parents who face chronic, periodic food insecurity report concerns about their adolescent children not getting enough food.73 When food supplies are sufficient, parents will often encourage adolescents to overeat regardless of satiety and require them to finish all the food on their plates,73 putting adolescents in families receiving federal food assistance at a higher risk for obesity.74 A majority of adolescents in this study lived in single-parent households, which may have contributed to poor diet quality. Adolescents living in single-parent, low-income households relative to those living with two parents are more likely to have less parental monitoring of dietary behavior, eat fewer 6

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vegetables, consume more fast food, and engage in less healthy eating habits such as skipping breakfast and lunch.75 Nationally, the US food supply does not provide a balance of healthy foods that would enable everyone to meet the Dietary Guidelines for Americans recommendations,76 and this problem with upstream availability of healthful food has a trickle-down effect on vulnerable populations.77 Residents of disadvantaged neighborhoods living in lower-income households often have suboptimal dietary intakes compared with those living in more affluent areas,78 partly because of limited availability of nutritious food in poor, minority neighborhoods.79 In low-income, urban communities availability of affordable, healthful foods is limited in neighborhood convenience stores,80,81 creating social inequalities of quality food accessibility for poor, inner-city residents.82,83 Adolescents are less likely to consume a healthy diet when the availability of nutritious food is limited,84,85 and in low-income families enrolled in the federal Supplemental Nutrition Assistance Program, benefits may be insufficient to adequately meet the nutritional needs of rapidly growing male adolescents in the family.86 A strength of this study is that perceived parental and peer social influences and reported parental monitoring in relation to diet quality were examined simultaneously. Diet quality in this community sample was similar to national diet quality estimates of low-income, African- American adolescents,74 suggesting that study results may be informative for a broader sample of underserved African-American youth. This investigation was limited by its cross-sectional design and the use of self-reported adolescent dietary and parental monitoring data. Social desirability bias can be problematic when sensitive information about personal behavior, parenting practices, and nutritional intake is collected from study participants and caregivers.87-89 Data on parental dietary intake or eating behavior were not collected, so the extent of parents’ ability to be a positive social influence for their adolescent children in the study is unknown. The age distribution of adolescents in this study was skewed toward the younger age group, which may have contributed to the inability to detect whether parental and peer social influences on healthy eating in relation to adolescents’ diet quality were moderated by age. It is possible that the relatively small number of older adolescents in the sample may have been inadequate to detect a statistical difference between age categories in the regression model. The validity of the Perceived Parental Beliefs about Nutrition and the Perception of Peer Eating Behavior scales adapted for use in this study have not been previously evaluated in peerreviewed publications. Therefore the degree to which the scales assess nutrition-related behaviors that parents might expect of adolescents and adolescents’ perception of friends’ healthy eating habits, respectively, may be limited, as well as the generalizability of these data to other adolescent sample populations.

CONCLUSIONS These findings support the hypothesis that perceived social norms for healthy eating habits might positively influence adolescent eating behavior among friends and family. The overarching, valuable contribution of this study is that it --

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RESEARCH examined the relationship of reported parental monitoring and perceived social influences on adolescent diet quality within the context of living in a low-income, urban community. The results of this study suggest that adolescents look to their friends and family for support in making healthy food choices. The relationships uncovered by this study can shed light on some of the contextual, interpersonal influences that may enhance diet quality among low-income, urban African-American adolescents and inform future nutrition intervention studies.

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AUTHOR INFORMATION M. M. Wrobleski is a research consultant dietitian, E. Hager is an assistant professor, and B. C. Merry is a research associate, Department of Pediatrics, Growth and Nutrition Division, University of Maryland School of Medicine, Baltimore. E. A. Parker is an assistant professor, Department of Family and Community Medicine, Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore. K. M. Hurley is an assistant professor, Center for Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. S. Oberlander is a social science analyst, Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC. M. M. Black is a professor, Department of International Development, RTI International, Research Triangle Park, NC. Address correspondence to: Margaret M. Wrobleski, PhD, RDN, LDN, University of Maryland School of Medicine, Department of Pediatrics, Growth and Nutrition Division, 737 West Lombard St, Room 167, Baltimore, MD 21201. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT The research culminating in this manuscript was supported by grants R40MC00241, MCJ-240301, and R40MC04297 from the Maternal and Child Health Research Program, US Department of Health and Human Services; grant APRPA006000 from the Office of Population Affairs, US Department of Health and Human Services, the University of Maryland General Clinical Research Center; grant M01 RR16500 General Clinical Research Centers Program, National Center for Research Resources (NCRR), NIH, General Mills Champions for Healthy Kids. Disclaimer: The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the US Department of Health and Human Services.

AUTHOR CONTRIBUTIONS M. M. Black designed the research and edited and approved all drafts. K. M. Hurley, S. Oberlander, and B. C. Merry formatted, scored, and cleaned the data. E. Hager, M. M. Wrobleski, and E. A. Parker contributed to the analysis. M. M. Wrobleski wrote the manuscript with contributions from M. M. Black. All authors reviewed and commented on subsequent manuscript drafts.

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