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Gender Analyses of Brazilian Parental Eating and Activity With Their Adolescents’ Eating Habits
ARTICLE IN PRESS Research Article Gender Analyses of Brazilian Parental Eating and Activity With Their Adolescents’ Eating Habits Diego G.D. Christofaro, PhD1; William R. Tebar, MSc1; Jorge Mota, PhD2; ^ mulo A. Fernandes, PhD1; Catarina C. Scarabottolo, MSc1; Ro Bruna T. Ciccotti Saraiva, MSc1; Leandro D. Delfino, MSc1; Selma M. de Andrade, PhD3 ABSTRACT Objective: To explore the associations between the eating habits of sons and daughters and the eating habits, sedentary behavior, and physical activity of their fathers and mothers. Design: A cross-sectional survey of adolescents. Setting: The 6 largest schools in Londrina, Brazil. Participants: A total of 842 adolescents, 842 mothers, and 842 fathers participated in this study. Main Outcomes Measures: Eating habits of adolescents and sedentary behavior, physical activity, and eating habits of their fathers and mothers, measured by questionnaire. Analysis: The associations were identified by binary logistic regression, adjusted by adolescent’s age, family’s socioeconomic status, parents’ educational level, and the other parental behavior. Results: Independent of educational level and socioeconomic condition, mothers’ eating behaviors seem to be more closely related to their adolescent children’s eating behavior (vegetables, fruits, fried foods, soft drinks, and sweets [P = .001]) than fathers’ behaviors (fried foods and sweets [P = .01], soft drinks [P = .001]). In addition, the behaviors of mothers were more associated to the behaviors of daughters than to the behaviors of sons (7 vs 5 associated behaviors), while behaviors of fathers were more associated with the behaviors of sons than to the behaviors of daughters (4 vs 2 associated behaviors). No associations were noted for sedentary and physical activity behavior and eating behaviors between adolescents and their parents. Conclusions And Implications: Many eating habits of adolescents were associated with eating habits of both fathers and mothers, emphasizing the importance of family-focused health promotion actions. Future research is needed incorporating into the analyses, among others, the nutritional statuses and the clustering of healthy and unhealthy behaviors of parents and their children. Key Words: eating habits, food intake, sedentary behavior, adolescent, parents (J Nutr Educ Behav. 2019;000:1−9.) Accepted September 24, 2019.
INTRODUCTION Unhealthy food behavior in adolescents, which is defined as higher consumption of snacks and fast foods, was associated with a 50% higher risk of becoming overweight,1 and the body mass index of children has been associated with their parent’s dietary
habits.2 High consumption of fried foods was associated with abdominal obesity in a large sample of adults,3 and similar findings have been reported in pediatric populations. In a longitudinal study with 1,189 children, Pan et al,4 reported that those who consumed large amounts of sugar-sweetened beverages were more
1
Department of Physical Education, School of Technology and Sciences, S~ao Paulo State University (UNESP), Presidente Prudente, Brazil 2 CIAFEL, Faculdade de Desporto, Universidade do Porto, Porto, Portugal 3 Department of Public Health, Londrina State University, Londrina, Parana, Brazil Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Diego G.D. Christofaro, PhD, S~ao Paulo State University (UNESP), School of Technology and Sciences, Roberto Roberto Simonsen, 305, CEP: 19060-900, Presidente Prudente, S~ao Paulo, Brazil; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.09.015
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likely to develop obesity. It is also emphasized that cardiovascular diseases developed in childhood and adolescence can continue in adult life.5 It is important to observe factors associated with the eating habits of adolescents because strategies to prevent obesity should be implemented early, and the family environment has been considered to play an important role.6 Parents’ eating habits seem to influence those of their children because parents serve as a model for their children’s behavior.7 One study reported an association between high consumption of energy-dense food by young women and their perceived consumption of energy-dense food by their mothers.8 Hansson et al9 observed a strong relationship between the consumption
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of pizza by Swedish mothers and their children aged 3−5 years. However, most articles have mainly analyzed the relationship between the eating habits of mothers and their children; few articles have analyzed the relationships between the eating habits of fathers and sons, fathers and daughters, mothers and sons, and mothers and daughters.10 Another aspect that needs to be better explored is whether other types of parental behavior might be related to the eating habits of children. Some studies have shown that among adolescents, sedentary behavior is associated with the consumption of fried foods, sweets, and soft drinks11,12 and that physical activity may be related to fruit and vegetable consumption.13 In an article of 1,435 families in 8 European countries, Bogl et al,14 reported higher correlations between healthy eating behaviors of parents and children than unhealthy behaviors; these correlations were stronger for younger children (2−10 years old) than older children (11−19 years old). However, there remains insufficient evidence to determine whether highly sedentary behavior by parents, as well as the practice of physical activity and eating habits, could be associated with these same behaviors in their children. In a systematic review and metaanalysis, Wang et al15 observed a weak to moderate relationship between the eating habits of parents and children. This analysis also demonstrated significant variations in the findings of the included articles. Furthermore, most of the articles had a small sample size and were carried out in the US, with limited data from developing countries. In Brazil, the correlations between food intake of parents and adolescents were high but dependent on socioeconomic status16 and food cost. For example, meat, milk, fruits, and vegetables tend to have a higher cost than ultraprocessed foods, which may compromise the frequency of consumption based on the income of the family.17 Therefore, it is essential to consider socioeconomic status as a possible confounding variable in these relationships. In an article focused on adolescents from different regions of
Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 Brazil, Barufaldi et al18 reported that the prevalence of adolescents who ate meals together with their parents was higher in the southern region of the country; nonetheless, these same adolescents had unhealthy eating behaviors, such as low breakfast consumption and low water intake. In light of these findings, it is necessary to examine the associations of parent-adolescent eating and other health-related behaviors to clarify the transmission of unhealthy behaviors in families. Therefore, the objective of the present study was to verify possible associations between the eating habits of adolescents and parents, with a specific focus on the gender of parents and children. In addition, this study analyzed possible associations between the sedentary behavior and physical activity of the parents and the eating habits of children. We hypothesized that parents’ healthy lifestyle habits (ie, healthy eating habits and physical activity) are associated with healthy eating habits in their adolescent children; whereas, unhealthy habits (ie, unhealthy eating habits and sedentary behavior) are associated with unhealthy eating habits in their adolescent children, and that these associations are differently affected by the gender of parents and their adolescent children.
METHODS Study Design This study with a quantitative crosssectional design was carried out using a convenience sample of adolescents and their parents from the 6 largest schools in the city of Londrina, Par State, southern Brazil. This projana ect was a part of a larger study aimed at analyzing the association of cardiovascular risk factors in adolescents and their parents. In calculating the sample size for the larger study with SPSS (version 15.0, SPSS Inc., Chicago, IL, 2006), a prevalence of 50% (equal chances of having or not having the outcome, a conservative approach to epidemiological studies with unknown prevalence of the outcome), a tolerable error of 4%, a significance level of .05 and a power of 80% were used. Because the study
used cluster sampling (schools and classrooms), a design effect of 1.5 was included, which resulted in the addition of 50% to the minimum sample size. Another 20% was added to account for possible losses. This process resulted in 1,044 adolescents as the minimum number of subjects to be evaluated. A total of 1,231 adolescents, 1,202 mothers, and 871 fathers were evaluated. However, there were responses from both parents for only 842 adolescents.
Participants The sample in the present study was composed of 842 adolescents (363 boys and 479 girls) and 1,684 adults (842 mothers and 842 fathers) from the city of Londrina, located in southern Brazil, which has a human development index (HDI) of 0.78, an HDI value slightly higher than that observed in Brazil (0.759). The HDI corresponds to an indicator of fundamental dimensions of human development: life expectancy, education and income per capita, and ranges from 0 (poor) to 1 (good). The HDI values observed for the city and the country put them in the high human development category, according to international data from the United Nations Development Programme, although inequality is not taken into account in this measure.19 This city, of approximately 550,000 inhabitants, was used because of the interest and the support of the State University and the Regional Center for Education of Londrina. The directors of each school were contacted, and a meeting was held with them. After their authorization, the researchers visited the classrooms, obtained the authorization of the teachers, and explained the objectives of the study to the adolescents. All classrooms in the 6 largest schools were visited. These schools were located in all regions of the city to obtain a heterogeneous sample. The adolescents who agreed to participate in the study took home questionnaires for parents and 3 consent forms. One consent form was for parents to authorize their children to participate in the study, and 2 consent forms were for parents to sign if they agreed to participate in the
ARTICLE IN PRESS Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 study. For parents who agreed to participate, the questionnaire on lifestyle issues was completed at home. The parents’ questionnaires were then delivered by the students to the researchers, together with the consent forms of the parents and their children. Only the students with the consent form signed by their parents and who agreed to participate were evaluated. The adolescents’ questionnaire was completed in the classroom in the presence of a researcher after signing a consent form. This study was approved by the Ethics and Research Committee of the Universidade Estadual de Londrina.
Eating Habits The types of dietary habits were evaluated by a food frequency questionnaire based on the studies by Block et al.20,21 The weekly frequency of ingestion of vegetables, fruits, fried foods, sweets, and soft drinks was evaluated for both adolescents and their parents. High consumption was defined as a frequency equal to or greater than 5 days per week, based on the World Health Organization’s definition,22 as adopted in epidemiological studies.11,23
Sedentary Behavior Sedentary behavior was assessed by self-report of time (weekly hours) spent on screen behaviors (watching television, using the computer, and playing video games). Parents were considered sedentary when the total time spent using these appliances was equal to or greater than 22 hours per week.24
Physical Activity Physical activity was evaluated using the questionnaire of Baecke et al.25 This instrument analyzes physical activity in different domains; it considers physical activity at work, leisure time, and occupational activities for adults. The sum of the time in the 3 domains provides a dimensionless score, based on which total physical activity is determined. This instrument was chosen because it has been validated for the Brazilian population26 and because it has been tested
against instruments considered the gold standards for the measurement of physical activity, such as doubly labeled water.27 The parents whose level of physical activity was located in the highest quartile were considered active.
Sociodemographic Variables Parents’ level of schooling was assessed by the number of years of study. The socioeconomic level was evaluated using the criteria for Brazilian Economic Classification28 from the Brazilian Association of Research Enterprises. This questionnaire considers household appliances (color televisions, VCRs or DVD players, radios, bathrooms, cars, washing machines, refrigerators, freezers), the number of rooms in the house, the presence of a housemaid and the education level of the head of household. Based on the total score, families were classified into different economic classes: A1, A2, B1, B2, C1, C2, D, and E. The adolescents classified as A1, A2, and B1 were considered as belonging to a high socioeconomic class; those classified as B2, C1 and C2 were considered as the average economic class; and those in the D and E classes were classified as being of a low economic class.
Reproducibility of Questionnaires Before the data collection, a pilot study was carried out with 30 students and their parents to test the reproducibility of the questionnaires on physical activity, sedentary behavior, and eating habits. The students and their parents answered the questionnaire twice with a 2-week interval. The agreement rate between answers ranged from 83% to 100%.
Statistical Analysis The characterization variables of the sample are presented as the mean and standard deviation. A matrix of correlations (Spearman) was performed to analyze the relationship between the frequency of food consumption of adolescents and the frequency of food consumption, sedentary behavior, and physical activity of fathers and mothers, as well as the correlations of
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mothers’ and fathers’ habits. The magnitude of the associations between mothers’ and fathers’ eating habits, sedentary behavior and physical activity and their children’s eating habits were analyzed by binary logistic regression adjusted by the age of the adolescents, the parents’ education level, the family’s socioeconomic condition, and the other parent’s corresponding habits (eg, when analyzing the relationships between a specific adolescent’s eating habit and their mother’s specific eating habit, the father’s specific eating habit was controlled for in the analyses). The threshold for statistical significance was 5%, and the confidence interval was 95%. The statistical package used was SPSS version 15.0 (SPSS Inc, Chicago, IL, 2007). Adjusted P values were calculated using the BenjaminiHochberg procedure and applying a false discovery rate of .05, to avoid type I error in multiple comparisons (ie, wrongly rejecting the null hypothesis).29
RESULTS The sample characteristics are presented in Table 1. Boys were heavier and taller, and they consumed sweets less frequently during the week but consumed fried foods and soft drinks more frequently than did girls. Comparing fathers and mothers, fathers had a higher average age, weight, and height. Fathers had a lower frequency of consumption of vegetables, fruits, and sweets and higher consumption of fried foods and soft drinks than did mothers. The matrix of correlations between the eating habits of adolescents and their fathers’ and mothers’ lifestyle variables are presented in the Supplementary Data. These data illustrated the significant associations in healthy and unhealthy behaviors of mother and father pairs and also revealed several significant parentchild associations. Table 2 shows the relationships between the eating habits of adolescents and their mothers’ habits. After adjusting the analyses for multiple comparisons, a reported high frequency of consumption of vegetables by mothers was associated with a reported high frequency of consumption of vegetables by their sons and
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Table 1. Characteristics of Brazilian Adolescents From 14−17 Years and Their Parents by Gender (n = 2,526)
Characteristics
Daughters (n = 479)
Sons (n = 363)
P
Mothers (n = 842)
Fathers (n = 842)
P
Age (years) Weight (kg) Height (cm) Vegetables (d/wk) Fruits (d/wk) Fried foods (d/wk) Sweets (d/wk) Soft drinks (d/wk)
15.6 (1.0) 58.9 (11.4) 162.5 (6.9) 4.3 (2.3) 3.7 (1.9) 4.6 (1.9) 3.9 (1.9) 3.0 (2.1)
15.3 (1.1) 64.2 (14.1) 172.3 (8.9) 4.0 (2.3) 3.7 (2.1) 4.4 (2.0) 3.3 (1.9) 3.4 (2.1)
<.001 <.001 <.001 .10 .73 .16 <.001 .004
42.9 (6.4) 68.0 (12.8) 161.5 (6.5) 5.4 (1.8) 4.2 (2.1) 4.2 (2.0) 2.7 (1.9) 2.3 (1.9)
45.6 (7.1) 82.4 (14.4) 173.2 (7.0) 4.9 (2.0) 3.6 (2.2) 4.6 (2.0) 2.4 (2.0) 2.8 (2.2)
<.001 <.001 <.001 <.001 <.001 <.001 .01 <.001
Notes: Data are shown as mean (SD). This analysis was performed using t test for independent samples. P < .05 considered significant. daughters. A reported high frequency of fruit consumption by mothers was associated with a reported high frequency of fruit and vegetable consumption by their sons and by their daughters. The high frequency of consumption of fried foods by mothers was related to their sons’ and daughters’ high frequency of consumption of fried foods, as well as their sons’ high frequency of consumption of soft drinks. A reported high frequency of consumption of sweets by mothers was associated with a reported high frequency of consumption of sweets and soft drinks by their daughters. The high consumption of soft drinks by mothers was associated with the high consumption of soft drinks by both their sons and daughters. The strongest associations of sons’ and daughters’ eating behaviors were with mothers’ high soft drink consumption, with odds ratios (ORs) as high as 5.17 and 9.07, respectively. In summary, maternal eating behaviors were associated slightly more frequently with their daughters’ eating behaviors (ie, 3 pairs of healthy-healthy and 4 pairs of unhealthy-unhealthy behaviors) than with their son’s behaviors (ie, 2 and 3 pairs, respectively). Compared with mothers, there were fewer associations observed between fathers’ eating habits and the habits of their sons and daughters (Table 3). Although several associations were observed in a pattern similar to that in mothers, controlling the analyses for multiple comparisons revealed significant associations between fathers’ high consumption of fried foods and both sons’ and daughters’ high consumption of
fried foods, as well as lower consumption of vegetables by sons. Fathers’ high consumption of sweets was associated only with the high consumption of sweets by their sons. High consumption of soft drinks by fathers was associated with both their sons’ and daughters’ high consumption soft drinks. Similar to the associations seen in mothers, the most significant associations were noted between fathers’ high consumption of soft drinks and both their sons’ and daughters’ high consumption of soft drinks, with 2 ORs exceeding 4.0. In summary, fathers’ unhealthy eating behaviors were associated with 4 and 2 unhealthy eating behaviors in their sons and daughters, respectively. None of the fathers’ healthy eating behaviors were associated with their children’s eating behavior. There was an association between mothers’ high sedentary behavior and high reported consumption of soft drinks by their sons (OR = 1.72; P = .03), as well as high reported consumption of fried foods by their daughters (OR = 1.60; P = .04). Mothers with high levels of physical activity were associated with high reported consumption of vegetables (OR = 1.48; P = .05) and fruits (OR = 1.44; P = .04) by their daughters. However, these associations were no longer statistically significant when adjusted for multiple comparisons. There were no significant associations between fathers’ sedentary behavior and adolescents’ eating habits.
DISCUSSION The present study showed that parental eating behaviors were associated
with eating behaviors of their adolescent children. However, the associations of parental sedentary and physical activity behaviors with eating behaviors of their adolescent children were much less common and did not reach statistical significance after controlling for multiple comparisons. Mothers’ eating behaviors seem to be more closely related to their adolescent children’s eating behavior than fathers’ behaviors. In addition, there were a greater number of associations between the behaviors of mothers and daughters than those of fathers and their daughters. Conversely, fathers’ eating behaviors were associated more frequently with their sons’ eating behaviors than with their daughters’ eating behaviors. These findings are consistent with an epidemiological study by Reinaerts et al30 that reported the consumption of fruits and vegetables by parents was related to the consumption of fruits and vegetables by their children. A 2-year longitudinal study by Person et al,31 also showed that fruit consumption by mothers was associated with fruit consumption by their children. In addition, the authors reported that over 2 years, these children could change their behavior in favor of higher fruit consumption based on the modeling of healthy food consumption by their mothers. Therefore, 1 possible reason for these relationships is that parents serve as models for their children.32 As such, parents with high consumption of fruits and vegetables would probably make these foods readily available at home for their children, and thus, encourage the consumption by all family members.33,34
Mothers’ Eating Habits (High Frequency) Eating Habits
Vegetables
P
Fruits
P
Fried Foods
P
Sweets
P
Soft Drinks
P
1.00 1.00 1.00 1.00 2.39 (1.40−4.07) .001* 1.42 (1.01−2.26) .05 1.31 (0.78−2.18) .17 0.87 (0.47−1.56) 1.00 1.00 1.00 1.00 0.95 (0.57−1.59) .98 2.10 (1.28−3.44) .001* 1.10 (0.87−1.40) .07 0.79 (0.43−1.45) 1.00 1.00 1.00 1.00 1.24 (0.76−2.04) .25 0.97 (0.61−1.53) .90 3.39 (1.97−5.83) .001* 1.93 (1.05−3.54) 1.00 1.00 1.00 1.00 0.80 (0.47−1.39) .70 0.60 (0.35−1.02) .10 0.97 (0.55−1.71) .89 2.16 (1.15−4.02) 1.00 1.00 1.00 1.00 1.27 (0.74−2.20) .39 0.75 (0.45−1.24) .20 2.72 (1.55−4.77) .001* 1.04 (0.55−1.97)
Daughters’ Eating Habits (n = 479) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
1.00 1.00 1.00 1.00 1.00 4.20 (2.48−7.11) .001* 1.71 (1.16−2.53) .007* 0.90 (0.58−1.37) .75 1.12 (0.70−1.78) .67 1.05 (0.61−1.81) .74 1.00 1.00 1.00 1.00 1.00 1.49 (0.90−2.49) .19 3.37 (2.20−5.15) .001* 0.82 (0.52−1.28) .38 1.07 (0.66−1.74) .53 0.69 (0.41−1.16) .31 1.00 1.00 1.00 1.00 1.00 1.14 (0.71−2.83) .83 0.89 (0.60−1.32) .79 5.00 (3.16−7.88) .001* 1.65 (1.02−2.68) .04 1.61 (1.01−2.85) .05 1.00 1.00 1.00 1.00 1.00 1.55 (0.94−2.56) .14 1.45 (0.97−2.19) .07 1.51 (1.01−2.40) .04 3.45 (2.14−5.58) .001* 1.77 (1.02−3.08) .04 1.00 1.00 1.00 1.00 1.00 0.79 (0.47−1.35) .41 0.76 (0.48−1.20) .17 1.17 (0.71−1.99) .58 1.99 (1.22−3.27) .006* 9.07 (4.91−16.75) .001*
.64 .48 .03 .01 .79
1.00 1.68 (0.87−3.27) .11 1.00 0.90 (0.45−1.76) .64 1.00 1.01 (0.53−1.96) .99 1.00 0.71 (0.33−1.52) .54 1.00 5.17 (5.61−10.65) .001*
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CI indicates confidence interval; OR, odds ratio. *P < .05; statistically significant when adjusted for multiple comparisons (Benjamini-Hochberg). Notes: Data are shown as OR (95% CI). Binary logistic regression analysis adjusted by the adolescent’s age, the family’s socioeconomic status, the educational level of the parents, and the eating habits of the fathers. High = food consumption on ≥5 days per week. Low = food consumption on <5 days per week.
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Sons’ Eating Habits (n = 363) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
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Table 2. Association Between the Eating Habits of Brazilian Adolescents Aged 14−17 Years and Those of Their Mothers
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Table 3. Association Between the Eating Habits of Brazilian Adolescents Aged 14−17 Years and Those of Their Fathers Fathers’ Eating Habits (High Frequency) Eating Habits
Vegetables 1.00 2.07 (1.30−3.32) 1.00 1.74 (1.07−2.84) 1.00 0.84 (0.54−1.33) 1.00 1.02 (0.62−1.71) 1.00 0.69 (0.42−1.12)
Daughters’ Eating Habits (n = 479) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
1.00 1.84 (1.19−2.84) 1.00 1.44 (0.99−2.25) 1.00 1.05 (0.70−1.60) 1.00 1.17 (0.75−1.81) 1.00 1.20 (0.73−1.97)
Fruits Fried foods Sweets Soft drinks
.03 .04 .42 .94 .19
.04 .11 .96 .67 .47
Fruits 1.00 1.37 (0.85−2.21) 1.00 2.47 (1.49−4.11) 1.00 1.24 (0.77−2.00) 1.00 0.61 (0.36−1.06) 1.00 0.80 (0.47−1.35) 1.00 1.26 (0.83−1.90) 1.00 2.13 (1.39−3.30) 1.00 0.81 (0.53−1.22) 1.00 1.07 (0.70−1.64) 1.00 0.96 (0.50−1.55)
P
.36 .03 .21 .10 .28
.34 .04 .25 .98 .98
Fried Foods 1.00 0.50 (0.30−0.85) 1.00 1.22 (0.78−1.92) 1.00 2.93 (1.74−4.92) 1.00 1.58 (0.90−2.76) 1.00 1.07 (0.61−1.88) 1.00 0.95 (0.62−1.45) 1.00 1.13 (0.72−1.77) 1.00 2.68 (1.70−4.20) 1.00 1.30 (0.83−2.05) 1.00 1.19 (0.72−1.95)
P
.01* .35 .01* .23 .31
.79 .17 .01* .06 .74
Sweets 1.00 1.26 (0.71−2.23) 1.00 1.52 (0.85−2.72) 1.00 1.42 (0.80−2.54) 1.00 3.55 (1.95−6.45) 1.00 1.86 (0.93−3.37) 1.00 0.97 (0.58−1.60) 1.00 1.00 (0.59−1.71) 1.00 1.59 (0.94−2.69) 1.00 1.85 (1.09−3.13) 1.00 1.37 (0.80−2.39)
P
.29 .08 .08 .001* .10
.74 .76 .12 .04 .25
Soft Drinks 1.00 1.49 (0.87−2.55) 1.00 1.03 (0.58−1.81) 1.00 1.99 (1.13−3.48) 1.00 1.58 (0.87−2.58) 1.00 4.09 (2.30−7.27) 1.00 0.79 (0.48−1.29) 1.00 1.47 (0.88−2.48) 1.00 1.29 (0.77−2.14) 1.00 1.79 (1.03−3.11) 1.00 4.30 (2.46−7.51)
P
.17 .81 .02 .24 .001*
.59 .16 .18 .02 .001*
CI indicates confidence interval; OR, odds ratio. *P < .05; statistically significant when adjusted for multiple comparisons (Benjamini-Hochberg). Notes: Data are shown as OR (95% CI). Binary logistic regression analysis adjusted by the adolescent’s age, the family’s socioeconomic status, the educational level of the parents, and the eating habits of the mothers. High = food consumption on ≥5 days per week. Low = food consumption on <5 days per week.
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Low High Low High Low High Low High Low High
P
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Sons’ Eating Habits (n = 363) Vegetables
ARTICLE IN PRESS Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 One of the findings of the present study was that these relationships between parents and children were significant regardless of gender. One hypothesis is connected to Brazilian culture, in which it is common to use salads as an accompaniment to lunch and dinner meals. Furthermore, fruits, such as oranges, mangos, and bananas, are a prevalent dessert option at lunch. Irrespective of the relationships between parents’ and their children’s healthy eating habits, which were independent of educational level and socioeconomic condition, it was not possible to answer the question of why some families more frequently select fruits and vegetables, whereas others do not, as this was beyond the scope of this study. Associations with the consumption of high energy-density foods, which, in this study, included fried food, sweets, and soft drinks, was observed between fathers and sons, fathers and daughters, mothers and sons, and mothers and daughters. Similar findings were reported by Bjelland et al,10 who demonstrated a significant association between the consumption of sugar-sweetened beverages in Norwegian parents and their children; although these relationships were dependent on the educational level of parents. In addition, Elfhag et al35 observed that the consumption of soft drinks by Swedish parents was related to higher consumption of these drinks by their children when controlled for parents’ educational level. The present study advances these findings by controlling for parents’ educational level and socioeconomic status. The present study also investigated whether the sedentary and physical activity behavior of parents could be related to their adolescent’s eating habits. Previous findings observed that spending more time engaged in sedentary behavior is related to higher consumption of unhealthy foods in adolescents11,12,36 and that the sedentary behavior of parents tends to be associated with the sedentary behavior of their children.37 It was also observed that women who engaged in a more advanced level of physical activity reported higher consumption of fruits and vegetables
than those who engaged in less physical activity.38 Physically active adolescents also exhibited higher consumption of fruits and vegetables compared with their insufficiently active counterparts.13 The present study initially observed that high levels of sedentary behavior by mothers were associated with unhealthy food consumption of sons and daughters, while high levels of physical activity of mothers were associated with healthy eating habits by their daughters. However, these associations were no longer statistically significant following adjustments for multiple comparisons. As such, it is possible that others key variables that were not assessed may confound the results, such as the frequency of family meals, eating habits of friends and siblings, and how often healthy and unhealthy foods are available at home, as well as the quantity of servings which are consumed by the parents and their children. Another explanation for this observation was that a broader approach to adolescent health and behavior was used in the present study, which compromised the multiple comparison analysis used to assess the relationship between parental behaviors and adolescent eating. Thus, more focused longitudinal studies are suggested to better elucidate the association of parental sedentary and physical activity behaviors with the eating habits of their adolescent children. In summary, the eating habits of parents, particularly of mothers, were related to the eating habits of their children, for both healthy and unhealthy foods. The consumption of soft drinks had the most significant association, which is concerning, as Pan et al4 observed that children who consume sugar-sweetened beverages have a higher risk of developing obesity compared with children who do not consume soft drinks. In Brazil, there is a high potential for parents to improve adolescents’ healthy eating, as more than two-thirds of adolescents often or always share their meals with their parents.18 In addition, the main pattern of Brazilian families’ diet is still traditional, that is, composed mainly of refined grains (eg, white rice) and
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beans, meat, eggs, milk, vegetables and fruits,39 although this pattern has been changing in recent decades to higher consumption of ultra-processed foods.40 In the present study, the influence of parental habits was observed regardless of the socioeconomic status and educational level. In addition, there may be different eating habits according to the family structure, as dual-headed families are more likely to have children with higher consumption of fruits, milk, and dairy foods than are those headed by a single parent.41 Berge et al42 observed that single-headed families reported the cost of meals as an important barrier for healthy eating habits, and the higher price of unprocessed or minimally processed foods in Brazil17 may be an obstacle for healthier choices, particularly in families with only 1 financial provider. A single-parent family may also lack time to prepare or plan healthy meals, as it is necessary to work, take care of the household’s necessities, and maintain the routine of the children. One of the limitations of this study is that eating habits, sedentary behavior, and physical activity were self-reported, which could contribute to the overestimation of healthy habits and the underestimation of habits not considered healthy (ie, more socially acceptable responses). Another point to be considered is the cross-sectional design of this study, which does not allow an analysis of the causality between the behaviors of parents and children. The criterion used to define sedentary activity of parents, that is, total time ≥22 hours per week in this behavior, was based on a cutoff point observed to be associated with overweight and obesity in adolescents.24 In addition, the current study did not collect information on other variables that could influence the observed relationships, such as how often adolescents share meals with their parents, the influence of friends’ and peers’ eating habits, the person in the household responsible for buying and preparing meals, and how many servings of each food were consumed per day, which could be used to better understand the eating habits of families
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and the role of each member in these healthy or unhealthy eating behaviors. Another limitation is that the present study collected information only on soft drinks consumption, which corresponds to just 1 type of sugar-sweetened beverages (SSB). It has previously been observed that soft drinks, among all types of SSB, were not the major contributor for the caloric intake in the Brazilian population,43 and the results of the present study are not comparable to studies that assessed SSB with an expanded definition. In addition, the sample size was calculated for the larger study, and the sample was reduced in the current study for combining mother−father and son− daughter pairs, consequently reducing the power of the study to detect statistically significant associations.
IMPLICATIONS FOR RESEARCH AND PRACTICE In the present study, healthy and unhealthy eating habits of adolescents were associated with healthy and unhealthy lifestyles of their parents, respectively. These results emphasize the importance of health promotion actions that are focused on the family. In addition, Brazil is a continent-sized country with huge economic disparities, demonstrated by its HDI adjusted by social inequality, which declined from 0.759 to 0.578.19 Therefore, future comparisons are needed to guarantee whether these relationships are similar among families from different regions or different countries. The consumption of soft drinks needs to be addressed in future intervention studies aiming to prevent or reduce this habit and the rising incidence of pediatric obesity. Some unanswered questions in this study could also be investigated in future research aiming to identify the relationships between parents’ and their children’s healthy and unhealthy behaviors, such as the role of friends and peers’ lifestyle and eating habits, the family structure, the nutritional statuses of parents and children on such associations, and how clustering of healthy and unhealthy behaviors of
Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 parents and children would relate to overweight and obesity and other health problems.
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ACKNOWLEDGMENTS The authors thank the Coordination for the Improvement of Higher Education Personnel for the doctoral scholarship provided to Diego G.D. Christofaro.
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SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi. org/10.1016/j.jneb.2019.09.015.
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REFERENCES 1. Borges CA, Marchioni DML, Levy RB, Slater B. Dietary patterns associated with overweight among Brazilian adolescents. Appetite. 2018;123:402– 409. 2. Liszewska N, Scholz U, Radtke T, Horodyska K, Luszczynska A. Bi-directional associations between parental feeding practices and children’s body mass in parent−child dyads. Appetite. 2018;129:192–197. 3. Guallar-Castill on P, Rodrıguez-Artalejo F, Fornes NS, et al. Intake of fried foods is associated with obesity in the cohort of Spanish adults from the European Prospective Investigation into Cancer and Nutrition. Am J Clin Nutr. 2007;86:198–205. 4. Pan L, Li R, Park S, Galuska DA, Sherry B, Freedman DS. A longitudinal analysis of sugar-sweetened beverage intake in infancy and obesity at 6 years. Pediatrics. 2014;134(suppl 1):S29–S35. 5. Hao G, Wang X, Treiber FA, Harshfield G, Kapuku G, Su S. Blood pressure trajectories from childhood to young adulthood associated with cardiovascular risk: results from the 23year longitudinal Georgia Stress and Heart Study. Hypertension. 2017;69: 435–442. 6. Bell LK, Perry RA, Prichard I. Exploring grandparents’ roles in young children’s lifestyle behaviors and the prevention of childhood obesity: an Australian perspective. J Nutr Educ Behav. 2018;50:516–521. 7. Draxten M, Fulkerson JA, Friend S, Flattum CF, Schow R. Parental role modeling of fruits and vegetables at meals and snacks is associated with
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ARTICLE IN PRESS Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 18. Barufaldi LA, Abreu Gde A, Oliveira JS, et al. ERICA: prevalence of healthy eating habits among Brazilian adolescents [in Portuguese]. Rev Saude Publica. 2016;50(suppl 1):6s. 19. United Nations Development Programme. Human Development Indices and Indicators: 2018 Statistical Update. Briefing note for countries on the 2018 Statistical Update: Brazil. New York, NY: United Nations Development Programme; 2018. http://hdr.undp. org/sites/all/themes/hdr_theme/country-notes/BRA.pdf. Accessed June 20, 2019. 20. Block G, Gillespie C, Rosenbaum EH, Jenson C. A rapid food screener to assess fat and fruit and vegetable intake. Am J Prev Med. 2000;18:284–288. 21. Block G, Clifford C, Naughton M, Henderson M, McAdams M. A brief dietary screen for high fat intake. J Nutr Educ. 1989;21:199–207. 22. World Health Organization. Diet, Nutrition and the Prevention of Chronic Diseases. Geneva: World Health Organization; 2002. 23. Costa Lda C, Vasconcelos Fde A, Corso AC. Risk factors associated with adequate fruit and vegetable intake by schoolchildren in Santa Catarina State, Brazil [in Portuguese]. Cad Saude Publica. 2012;28:1133–1142. 24. Thibault H, Contrand B, Saubusse E, Baine M, Maurice-Tison S. Risk factors for overweight and obesity in French adolescents: physical activity, sedentary behavior and parental characteristics. Nutrition. 2010;26:192–200. 25. Baecke JA, Burema J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr. 1982;36:936–942. 26. Florindo AA, Latorre Mdo R, Jaime PC, Tanaka T, Zerbini CA. Methodology to evaluation the habitual physical activity in men aged 50 years or more
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INTRODUCTION Unhealthy food behavior in adolescents, which is defined as higher consumption of snacks and fast foods, was associated with a 50% higher risk of becoming overweight,1 and the body mass index of children has been associated with their parent’s dietary
habits.2 High consumption of fried foods was associated with abdominal obesity in a large sample of adults,3 and similar findings have been reported in pediatric populations. In a longitudinal study with 1,189 children, Pan et al,4 reported that those who consumed large amounts of sugar-sweetened beverages were more
1
Department of Physical Education, School of Technology and Sciences, S~ao Paulo State University (UNESP), Presidente Prudente, Brazil 2 CIAFEL, Faculdade de Desporto, Universidade do Porto, Porto, Portugal 3 Department of Public Health, Londrina State University, Londrina, Parana, Brazil Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Diego G.D. Christofaro, PhD, S~ao Paulo State University (UNESP), School of Technology and Sciences, Roberto Roberto Simonsen, 305, CEP: 19060-900, Presidente Prudente, S~ao Paulo, Brazil; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.09.015
Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019
likely to develop obesity. It is also emphasized that cardiovascular diseases developed in childhood and adolescence can continue in adult life.5 It is important to observe factors associated with the eating habits of adolescents because strategies to prevent obesity should be implemented early, and the family environment has been considered to play an important role.6 Parents’ eating habits seem to influence those of their children because parents serve as a model for their children’s behavior.7 One study reported an association between high consumption of energy-dense food by young women and their perceived consumption of energy-dense food by their mothers.8 Hansson et al9 observed a strong relationship between the consumption
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of pizza by Swedish mothers and their children aged 3−5 years. However, most articles have mainly analyzed the relationship between the eating habits of mothers and their children; few articles have analyzed the relationships between the eating habits of fathers and sons, fathers and daughters, mothers and sons, and mothers and daughters.10 Another aspect that needs to be better explored is whether other types of parental behavior might be related to the eating habits of children. Some studies have shown that among adolescents, sedentary behavior is associated with the consumption of fried foods, sweets, and soft drinks11,12 and that physical activity may be related to fruit and vegetable consumption.13 In an article of 1,435 families in 8 European countries, Bogl et al,14 reported higher correlations between healthy eating behaviors of parents and children than unhealthy behaviors; these correlations were stronger for younger children (2−10 years old) than older children (11−19 years old). However, there remains insufficient evidence to determine whether highly sedentary behavior by parents, as well as the practice of physical activity and eating habits, could be associated with these same behaviors in their children. In a systematic review and metaanalysis, Wang et al15 observed a weak to moderate relationship between the eating habits of parents and children. This analysis also demonstrated significant variations in the findings of the included articles. Furthermore, most of the articles had a small sample size and were carried out in the US, with limited data from developing countries. In Brazil, the correlations between food intake of parents and adolescents were high but dependent on socioeconomic status16 and food cost. For example, meat, milk, fruits, and vegetables tend to have a higher cost than ultraprocessed foods, which may compromise the frequency of consumption based on the income of the family.17 Therefore, it is essential to consider socioeconomic status as a possible confounding variable in these relationships. In an article focused on adolescents from different regions of
Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 Brazil, Barufaldi et al18 reported that the prevalence of adolescents who ate meals together with their parents was higher in the southern region of the country; nonetheless, these same adolescents had unhealthy eating behaviors, such as low breakfast consumption and low water intake. In light of these findings, it is necessary to examine the associations of parent-adolescent eating and other health-related behaviors to clarify the transmission of unhealthy behaviors in families. Therefore, the objective of the present study was to verify possible associations between the eating habits of adolescents and parents, with a specific focus on the gender of parents and children. In addition, this study analyzed possible associations between the sedentary behavior and physical activity of the parents and the eating habits of children. We hypothesized that parents’ healthy lifestyle habits (ie, healthy eating habits and physical activity) are associated with healthy eating habits in their adolescent children; whereas, unhealthy habits (ie, unhealthy eating habits and sedentary behavior) are associated with unhealthy eating habits in their adolescent children, and that these associations are differently affected by the gender of parents and their adolescent children.
METHODS Study Design This study with a quantitative crosssectional design was carried out using a convenience sample of adolescents and their parents from the 6 largest schools in the city of Londrina, Par State, southern Brazil. This projana ect was a part of a larger study aimed at analyzing the association of cardiovascular risk factors in adolescents and their parents. In calculating the sample size for the larger study with SPSS (version 15.0, SPSS Inc., Chicago, IL, 2006), a prevalence of 50% (equal chances of having or not having the outcome, a conservative approach to epidemiological studies with unknown prevalence of the outcome), a tolerable error of 4%, a significance level of .05 and a power of 80% were used. Because the study
used cluster sampling (schools and classrooms), a design effect of 1.5 was included, which resulted in the addition of 50% to the minimum sample size. Another 20% was added to account for possible losses. This process resulted in 1,044 adolescents as the minimum number of subjects to be evaluated. A total of 1,231 adolescents, 1,202 mothers, and 871 fathers were evaluated. However, there were responses from both parents for only 842 adolescents.
Participants The sample in the present study was composed of 842 adolescents (363 boys and 479 girls) and 1,684 adults (842 mothers and 842 fathers) from the city of Londrina, located in southern Brazil, which has a human development index (HDI) of 0.78, an HDI value slightly higher than that observed in Brazil (0.759). The HDI corresponds to an indicator of fundamental dimensions of human development: life expectancy, education and income per capita, and ranges from 0 (poor) to 1 (good). The HDI values observed for the city and the country put them in the high human development category, according to international data from the United Nations Development Programme, although inequality is not taken into account in this measure.19 This city, of approximately 550,000 inhabitants, was used because of the interest and the support of the State University and the Regional Center for Education of Londrina. The directors of each school were contacted, and a meeting was held with them. After their authorization, the researchers visited the classrooms, obtained the authorization of the teachers, and explained the objectives of the study to the adolescents. All classrooms in the 6 largest schools were visited. These schools were located in all regions of the city to obtain a heterogeneous sample. The adolescents who agreed to participate in the study took home questionnaires for parents and 3 consent forms. One consent form was for parents to authorize their children to participate in the study, and 2 consent forms were for parents to sign if they agreed to participate in the
ARTICLE IN PRESS Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 study. For parents who agreed to participate, the questionnaire on lifestyle issues was completed at home. The parents’ questionnaires were then delivered by the students to the researchers, together with the consent forms of the parents and their children. Only the students with the consent form signed by their parents and who agreed to participate were evaluated. The adolescents’ questionnaire was completed in the classroom in the presence of a researcher after signing a consent form. This study was approved by the Ethics and Research Committee of the Universidade Estadual de Londrina.
Eating Habits The types of dietary habits were evaluated by a food frequency questionnaire based on the studies by Block et al.20,21 The weekly frequency of ingestion of vegetables, fruits, fried foods, sweets, and soft drinks was evaluated for both adolescents and their parents. High consumption was defined as a frequency equal to or greater than 5 days per week, based on the World Health Organization’s definition,22 as adopted in epidemiological studies.11,23
Sedentary Behavior Sedentary behavior was assessed by self-report of time (weekly hours) spent on screen behaviors (watching television, using the computer, and playing video games). Parents were considered sedentary when the total time spent using these appliances was equal to or greater than 22 hours per week.24
Physical Activity Physical activity was evaluated using the questionnaire of Baecke et al.25 This instrument analyzes physical activity in different domains; it considers physical activity at work, leisure time, and occupational activities for adults. The sum of the time in the 3 domains provides a dimensionless score, based on which total physical activity is determined. This instrument was chosen because it has been validated for the Brazilian population26 and because it has been tested
against instruments considered the gold standards for the measurement of physical activity, such as doubly labeled water.27 The parents whose level of physical activity was located in the highest quartile were considered active.
Sociodemographic Variables Parents’ level of schooling was assessed by the number of years of study. The socioeconomic level was evaluated using the criteria for Brazilian Economic Classification28 from the Brazilian Association of Research Enterprises. This questionnaire considers household appliances (color televisions, VCRs or DVD players, radios, bathrooms, cars, washing machines, refrigerators, freezers), the number of rooms in the house, the presence of a housemaid and the education level of the head of household. Based on the total score, families were classified into different economic classes: A1, A2, B1, B2, C1, C2, D, and E. The adolescents classified as A1, A2, and B1 were considered as belonging to a high socioeconomic class; those classified as B2, C1 and C2 were considered as the average economic class; and those in the D and E classes were classified as being of a low economic class.
Reproducibility of Questionnaires Before the data collection, a pilot study was carried out with 30 students and their parents to test the reproducibility of the questionnaires on physical activity, sedentary behavior, and eating habits. The students and their parents answered the questionnaire twice with a 2-week interval. The agreement rate between answers ranged from 83% to 100%.
Statistical Analysis The characterization variables of the sample are presented as the mean and standard deviation. A matrix of correlations (Spearman) was performed to analyze the relationship between the frequency of food consumption of adolescents and the frequency of food consumption, sedentary behavior, and physical activity of fathers and mothers, as well as the correlations of
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mothers’ and fathers’ habits. The magnitude of the associations between mothers’ and fathers’ eating habits, sedentary behavior and physical activity and their children’s eating habits were analyzed by binary logistic regression adjusted by the age of the adolescents, the parents’ education level, the family’s socioeconomic condition, and the other parent’s corresponding habits (eg, when analyzing the relationships between a specific adolescent’s eating habit and their mother’s specific eating habit, the father’s specific eating habit was controlled for in the analyses). The threshold for statistical significance was 5%, and the confidence interval was 95%. The statistical package used was SPSS version 15.0 (SPSS Inc, Chicago, IL, 2007). Adjusted P values were calculated using the BenjaminiHochberg procedure and applying a false discovery rate of .05, to avoid type I error in multiple comparisons (ie, wrongly rejecting the null hypothesis).29
RESULTS The sample characteristics are presented in Table 1. Boys were heavier and taller, and they consumed sweets less frequently during the week but consumed fried foods and soft drinks more frequently than did girls. Comparing fathers and mothers, fathers had a higher average age, weight, and height. Fathers had a lower frequency of consumption of vegetables, fruits, and sweets and higher consumption of fried foods and soft drinks than did mothers. The matrix of correlations between the eating habits of adolescents and their fathers’ and mothers’ lifestyle variables are presented in the Supplementary Data. These data illustrated the significant associations in healthy and unhealthy behaviors of mother and father pairs and also revealed several significant parentchild associations. Table 2 shows the relationships between the eating habits of adolescents and their mothers’ habits. After adjusting the analyses for multiple comparisons, a reported high frequency of consumption of vegetables by mothers was associated with a reported high frequency of consumption of vegetables by their sons and
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Table 1. Characteristics of Brazilian Adolescents From 14−17 Years and Their Parents by Gender (n = 2,526)
Characteristics
Daughters (n = 479)
Sons (n = 363)
P
Mothers (n = 842)
Fathers (n = 842)
P
Age (years) Weight (kg) Height (cm) Vegetables (d/wk) Fruits (d/wk) Fried foods (d/wk) Sweets (d/wk) Soft drinks (d/wk)
15.6 (1.0) 58.9 (11.4) 162.5 (6.9) 4.3 (2.3) 3.7 (1.9) 4.6 (1.9) 3.9 (1.9) 3.0 (2.1)
15.3 (1.1) 64.2 (14.1) 172.3 (8.9) 4.0 (2.3) 3.7 (2.1) 4.4 (2.0) 3.3 (1.9) 3.4 (2.1)
<.001 <.001 <.001 .10 .73 .16 <.001 .004
42.9 (6.4) 68.0 (12.8) 161.5 (6.5) 5.4 (1.8) 4.2 (2.1) 4.2 (2.0) 2.7 (1.9) 2.3 (1.9)
45.6 (7.1) 82.4 (14.4) 173.2 (7.0) 4.9 (2.0) 3.6 (2.2) 4.6 (2.0) 2.4 (2.0) 2.8 (2.2)
<.001 <.001 <.001 <.001 <.001 <.001 .01 <.001
Notes: Data are shown as mean (SD). This analysis was performed using t test for independent samples. P < .05 considered significant. daughters. A reported high frequency of fruit consumption by mothers was associated with a reported high frequency of fruit and vegetable consumption by their sons and by their daughters. The high frequency of consumption of fried foods by mothers was related to their sons’ and daughters’ high frequency of consumption of fried foods, as well as their sons’ high frequency of consumption of soft drinks. A reported high frequency of consumption of sweets by mothers was associated with a reported high frequency of consumption of sweets and soft drinks by their daughters. The high consumption of soft drinks by mothers was associated with the high consumption of soft drinks by both their sons and daughters. The strongest associations of sons’ and daughters’ eating behaviors were with mothers’ high soft drink consumption, with odds ratios (ORs) as high as 5.17 and 9.07, respectively. In summary, maternal eating behaviors were associated slightly more frequently with their daughters’ eating behaviors (ie, 3 pairs of healthy-healthy and 4 pairs of unhealthy-unhealthy behaviors) than with their son’s behaviors (ie, 2 and 3 pairs, respectively). Compared with mothers, there were fewer associations observed between fathers’ eating habits and the habits of their sons and daughters (Table 3). Although several associations were observed in a pattern similar to that in mothers, controlling the analyses for multiple comparisons revealed significant associations between fathers’ high consumption of fried foods and both sons’ and daughters’ high consumption of
fried foods, as well as lower consumption of vegetables by sons. Fathers’ high consumption of sweets was associated only with the high consumption of sweets by their sons. High consumption of soft drinks by fathers was associated with both their sons’ and daughters’ high consumption soft drinks. Similar to the associations seen in mothers, the most significant associations were noted between fathers’ high consumption of soft drinks and both their sons’ and daughters’ high consumption of soft drinks, with 2 ORs exceeding 4.0. In summary, fathers’ unhealthy eating behaviors were associated with 4 and 2 unhealthy eating behaviors in their sons and daughters, respectively. None of the fathers’ healthy eating behaviors were associated with their children’s eating behavior. There was an association between mothers’ high sedentary behavior and high reported consumption of soft drinks by their sons (OR = 1.72; P = .03), as well as high reported consumption of fried foods by their daughters (OR = 1.60; P = .04). Mothers with high levels of physical activity were associated with high reported consumption of vegetables (OR = 1.48; P = .05) and fruits (OR = 1.44; P = .04) by their daughters. However, these associations were no longer statistically significant when adjusted for multiple comparisons. There were no significant associations between fathers’ sedentary behavior and adolescents’ eating habits.
DISCUSSION The present study showed that parental eating behaviors were associated
with eating behaviors of their adolescent children. However, the associations of parental sedentary and physical activity behaviors with eating behaviors of their adolescent children were much less common and did not reach statistical significance after controlling for multiple comparisons. Mothers’ eating behaviors seem to be more closely related to their adolescent children’s eating behavior than fathers’ behaviors. In addition, there were a greater number of associations between the behaviors of mothers and daughters than those of fathers and their daughters. Conversely, fathers’ eating behaviors were associated more frequently with their sons’ eating behaviors than with their daughters’ eating behaviors. These findings are consistent with an epidemiological study by Reinaerts et al30 that reported the consumption of fruits and vegetables by parents was related to the consumption of fruits and vegetables by their children. A 2-year longitudinal study by Person et al,31 also showed that fruit consumption by mothers was associated with fruit consumption by their children. In addition, the authors reported that over 2 years, these children could change their behavior in favor of higher fruit consumption based on the modeling of healthy food consumption by their mothers. Therefore, 1 possible reason for these relationships is that parents serve as models for their children.32 As such, parents with high consumption of fruits and vegetables would probably make these foods readily available at home for their children, and thus, encourage the consumption by all family members.33,34
Mothers’ Eating Habits (High Frequency) Eating Habits
Vegetables
P
Fruits
P
Fried Foods
P
Sweets
P
Soft Drinks
P
1.00 1.00 1.00 1.00 2.39 (1.40−4.07) .001* 1.42 (1.01−2.26) .05 1.31 (0.78−2.18) .17 0.87 (0.47−1.56) 1.00 1.00 1.00 1.00 0.95 (0.57−1.59) .98 2.10 (1.28−3.44) .001* 1.10 (0.87−1.40) .07 0.79 (0.43−1.45) 1.00 1.00 1.00 1.00 1.24 (0.76−2.04) .25 0.97 (0.61−1.53) .90 3.39 (1.97−5.83) .001* 1.93 (1.05−3.54) 1.00 1.00 1.00 1.00 0.80 (0.47−1.39) .70 0.60 (0.35−1.02) .10 0.97 (0.55−1.71) .89 2.16 (1.15−4.02) 1.00 1.00 1.00 1.00 1.27 (0.74−2.20) .39 0.75 (0.45−1.24) .20 2.72 (1.55−4.77) .001* 1.04 (0.55−1.97)
Daughters’ Eating Habits (n = 479) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
1.00 1.00 1.00 1.00 1.00 4.20 (2.48−7.11) .001* 1.71 (1.16−2.53) .007* 0.90 (0.58−1.37) .75 1.12 (0.70−1.78) .67 1.05 (0.61−1.81) .74 1.00 1.00 1.00 1.00 1.00 1.49 (0.90−2.49) .19 3.37 (2.20−5.15) .001* 0.82 (0.52−1.28) .38 1.07 (0.66−1.74) .53 0.69 (0.41−1.16) .31 1.00 1.00 1.00 1.00 1.00 1.14 (0.71−2.83) .83 0.89 (0.60−1.32) .79 5.00 (3.16−7.88) .001* 1.65 (1.02−2.68) .04 1.61 (1.01−2.85) .05 1.00 1.00 1.00 1.00 1.00 1.55 (0.94−2.56) .14 1.45 (0.97−2.19) .07 1.51 (1.01−2.40) .04 3.45 (2.14−5.58) .001* 1.77 (1.02−3.08) .04 1.00 1.00 1.00 1.00 1.00 0.79 (0.47−1.35) .41 0.76 (0.48−1.20) .17 1.17 (0.71−1.99) .58 1.99 (1.22−3.27) .006* 9.07 (4.91−16.75) .001*
.64 .48 .03 .01 .79
1.00 1.68 (0.87−3.27) .11 1.00 0.90 (0.45−1.76) .64 1.00 1.01 (0.53−1.96) .99 1.00 0.71 (0.33−1.52) .54 1.00 5.17 (5.61−10.65) .001*
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CI indicates confidence interval; OR, odds ratio. *P < .05; statistically significant when adjusted for multiple comparisons (Benjamini-Hochberg). Notes: Data are shown as OR (95% CI). Binary logistic regression analysis adjusted by the adolescent’s age, the family’s socioeconomic status, the educational level of the parents, and the eating habits of the fathers. High = food consumption on ≥5 days per week. Low = food consumption on <5 days per week.
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Sons’ Eating Habits (n = 363) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
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Table 2. Association Between the Eating Habits of Brazilian Adolescents Aged 14−17 Years and Those of Their Mothers
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Table 3. Association Between the Eating Habits of Brazilian Adolescents Aged 14−17 Years and Those of Their Fathers Fathers’ Eating Habits (High Frequency) Eating Habits
Vegetables 1.00 2.07 (1.30−3.32) 1.00 1.74 (1.07−2.84) 1.00 0.84 (0.54−1.33) 1.00 1.02 (0.62−1.71) 1.00 0.69 (0.42−1.12)
Daughters’ Eating Habits (n = 479) Vegetables Low High Fruits Low High Fried foods Low High Sweets Low High Soft drinks Low High
1.00 1.84 (1.19−2.84) 1.00 1.44 (0.99−2.25) 1.00 1.05 (0.70−1.60) 1.00 1.17 (0.75−1.81) 1.00 1.20 (0.73−1.97)
Fruits Fried foods Sweets Soft drinks
.03 .04 .42 .94 .19
.04 .11 .96 .67 .47
Fruits 1.00 1.37 (0.85−2.21) 1.00 2.47 (1.49−4.11) 1.00 1.24 (0.77−2.00) 1.00 0.61 (0.36−1.06) 1.00 0.80 (0.47−1.35) 1.00 1.26 (0.83−1.90) 1.00 2.13 (1.39−3.30) 1.00 0.81 (0.53−1.22) 1.00 1.07 (0.70−1.64) 1.00 0.96 (0.50−1.55)
P
.36 .03 .21 .10 .28
.34 .04 .25 .98 .98
Fried Foods 1.00 0.50 (0.30−0.85) 1.00 1.22 (0.78−1.92) 1.00 2.93 (1.74−4.92) 1.00 1.58 (0.90−2.76) 1.00 1.07 (0.61−1.88) 1.00 0.95 (0.62−1.45) 1.00 1.13 (0.72−1.77) 1.00 2.68 (1.70−4.20) 1.00 1.30 (0.83−2.05) 1.00 1.19 (0.72−1.95)
P
.01* .35 .01* .23 .31
.79 .17 .01* .06 .74
Sweets 1.00 1.26 (0.71−2.23) 1.00 1.52 (0.85−2.72) 1.00 1.42 (0.80−2.54) 1.00 3.55 (1.95−6.45) 1.00 1.86 (0.93−3.37) 1.00 0.97 (0.58−1.60) 1.00 1.00 (0.59−1.71) 1.00 1.59 (0.94−2.69) 1.00 1.85 (1.09−3.13) 1.00 1.37 (0.80−2.39)
P
.29 .08 .08 .001* .10
.74 .76 .12 .04 .25
Soft Drinks 1.00 1.49 (0.87−2.55) 1.00 1.03 (0.58−1.81) 1.00 1.99 (1.13−3.48) 1.00 1.58 (0.87−2.58) 1.00 4.09 (2.30−7.27) 1.00 0.79 (0.48−1.29) 1.00 1.47 (0.88−2.48) 1.00 1.29 (0.77−2.14) 1.00 1.79 (1.03−3.11) 1.00 4.30 (2.46−7.51)
P
.17 .81 .02 .24 .001*
.59 .16 .18 .02 .001*
CI indicates confidence interval; OR, odds ratio. *P < .05; statistically significant when adjusted for multiple comparisons (Benjamini-Hochberg). Notes: Data are shown as OR (95% CI). Binary logistic regression analysis adjusted by the adolescent’s age, the family’s socioeconomic status, the educational level of the parents, and the eating habits of the mothers. High = food consumption on ≥5 days per week. Low = food consumption on <5 days per week.
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Low High Low High Low High Low High Low High
P
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Sons’ Eating Habits (n = 363) Vegetables
ARTICLE IN PRESS Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 One of the findings of the present study was that these relationships between parents and children were significant regardless of gender. One hypothesis is connected to Brazilian culture, in which it is common to use salads as an accompaniment to lunch and dinner meals. Furthermore, fruits, such as oranges, mangos, and bananas, are a prevalent dessert option at lunch. Irrespective of the relationships between parents’ and their children’s healthy eating habits, which were independent of educational level and socioeconomic condition, it was not possible to answer the question of why some families more frequently select fruits and vegetables, whereas others do not, as this was beyond the scope of this study. Associations with the consumption of high energy-density foods, which, in this study, included fried food, sweets, and soft drinks, was observed between fathers and sons, fathers and daughters, mothers and sons, and mothers and daughters. Similar findings were reported by Bjelland et al,10 who demonstrated a significant association between the consumption of sugar-sweetened beverages in Norwegian parents and their children; although these relationships were dependent on the educational level of parents. In addition, Elfhag et al35 observed that the consumption of soft drinks by Swedish parents was related to higher consumption of these drinks by their children when controlled for parents’ educational level. The present study advances these findings by controlling for parents’ educational level and socioeconomic status. The present study also investigated whether the sedentary and physical activity behavior of parents could be related to their adolescent’s eating habits. Previous findings observed that spending more time engaged in sedentary behavior is related to higher consumption of unhealthy foods in adolescents11,12,36 and that the sedentary behavior of parents tends to be associated with the sedentary behavior of their children.37 It was also observed that women who engaged in a more advanced level of physical activity reported higher consumption of fruits and vegetables
than those who engaged in less physical activity.38 Physically active adolescents also exhibited higher consumption of fruits and vegetables compared with their insufficiently active counterparts.13 The present study initially observed that high levels of sedentary behavior by mothers were associated with unhealthy food consumption of sons and daughters, while high levels of physical activity of mothers were associated with healthy eating habits by their daughters. However, these associations were no longer statistically significant following adjustments for multiple comparisons. As such, it is possible that others key variables that were not assessed may confound the results, such as the frequency of family meals, eating habits of friends and siblings, and how often healthy and unhealthy foods are available at home, as well as the quantity of servings which are consumed by the parents and their children. Another explanation for this observation was that a broader approach to adolescent health and behavior was used in the present study, which compromised the multiple comparison analysis used to assess the relationship between parental behaviors and adolescent eating. Thus, more focused longitudinal studies are suggested to better elucidate the association of parental sedentary and physical activity behaviors with the eating habits of their adolescent children. In summary, the eating habits of parents, particularly of mothers, were related to the eating habits of their children, for both healthy and unhealthy foods. The consumption of soft drinks had the most significant association, which is concerning, as Pan et al4 observed that children who consume sugar-sweetened beverages have a higher risk of developing obesity compared with children who do not consume soft drinks. In Brazil, there is a high potential for parents to improve adolescents’ healthy eating, as more than two-thirds of adolescents often or always share their meals with their parents.18 In addition, the main pattern of Brazilian families’ diet is still traditional, that is, composed mainly of refined grains (eg, white rice) and
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beans, meat, eggs, milk, vegetables and fruits,39 although this pattern has been changing in recent decades to higher consumption of ultra-processed foods.40 In the present study, the influence of parental habits was observed regardless of the socioeconomic status and educational level. In addition, there may be different eating habits according to the family structure, as dual-headed families are more likely to have children with higher consumption of fruits, milk, and dairy foods than are those headed by a single parent.41 Berge et al42 observed that single-headed families reported the cost of meals as an important barrier for healthy eating habits, and the higher price of unprocessed or minimally processed foods in Brazil17 may be an obstacle for healthier choices, particularly in families with only 1 financial provider. A single-parent family may also lack time to prepare or plan healthy meals, as it is necessary to work, take care of the household’s necessities, and maintain the routine of the children. One of the limitations of this study is that eating habits, sedentary behavior, and physical activity were self-reported, which could contribute to the overestimation of healthy habits and the underestimation of habits not considered healthy (ie, more socially acceptable responses). Another point to be considered is the cross-sectional design of this study, which does not allow an analysis of the causality between the behaviors of parents and children. The criterion used to define sedentary activity of parents, that is, total time ≥22 hours per week in this behavior, was based on a cutoff point observed to be associated with overweight and obesity in adolescents.24 In addition, the current study did not collect information on other variables that could influence the observed relationships, such as how often adolescents share meals with their parents, the influence of friends’ and peers’ eating habits, the person in the household responsible for buying and preparing meals, and how many servings of each food were consumed per day, which could be used to better understand the eating habits of families
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and the role of each member in these healthy or unhealthy eating behaviors. Another limitation is that the present study collected information only on soft drinks consumption, which corresponds to just 1 type of sugar-sweetened beverages (SSB). It has previously been observed that soft drinks, among all types of SSB, were not the major contributor for the caloric intake in the Brazilian population,43 and the results of the present study are not comparable to studies that assessed SSB with an expanded definition. In addition, the sample size was calculated for the larger study, and the sample was reduced in the current study for combining mother−father and son− daughter pairs, consequently reducing the power of the study to detect statistically significant associations.
IMPLICATIONS FOR RESEARCH AND PRACTICE In the present study, healthy and unhealthy eating habits of adolescents were associated with healthy and unhealthy lifestyles of their parents, respectively. These results emphasize the importance of health promotion actions that are focused on the family. In addition, Brazil is a continent-sized country with huge economic disparities, demonstrated by its HDI adjusted by social inequality, which declined from 0.759 to 0.578.19 Therefore, future comparisons are needed to guarantee whether these relationships are similar among families from different regions or different countries. The consumption of soft drinks needs to be addressed in future intervention studies aiming to prevent or reduce this habit and the rising incidence of pediatric obesity. Some unanswered questions in this study could also be investigated in future research aiming to identify the relationships between parents’ and their children’s healthy and unhealthy behaviors, such as the role of friends and peers’ lifestyle and eating habits, the family structure, the nutritional statuses of parents and children on such associations, and how clustering of healthy and unhealthy behaviors of
Journal of Nutrition Education and Behavior Volume 000, Number 000, 2019 parents and children would relate to overweight and obesity and other health problems.
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ACKNOWLEDGMENTS The authors thank the Coordination for the Improvement of Higher Education Personnel for the doctoral scholarship provided to Diego G.D. Christofaro.
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SUPPLEMENTARY DATA Supplementary data related to this article can be found at https://doi. org/10.1016/j.jneb.2019.09.015.
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