A healthful home food environment: Is it possible amidst household chaos and parental stress?

Appetite 142 (2019) 104391

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A healthful home food environment: Is it possible amidst household chaos and parental stress?

T

Jayne A. Fulkersona,∗, Susan Telkeb, Nicole Larsonb, Jerica Bergec, Nancy E. Sherwoodb, Dianne Neumark-Sztainerb a

School of Nursing, University of Minnesota, 5-160 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN, 55454, USA Division of Epidemiology and Community Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN, 55454, USA c Department of Family Medicine and Community Health, Medical School, University of Minnesota, 717 Delaware St. SE, Room 425, Minneapolis, MN, 55454, USA b

ABSTRACT

Purpose: This study examines how household chaos and unmanaged parental stress are associated with and contribute to variance in markers of the home food environment (family meal frequency, perceived barriers to cooking, healthful home food availability). Obtaining a better understanding of these relationships could guide more effective family-based interventions to promote healthful home food environments. Methods: The analytic sample included 819 households with children in the population-based Project EAT-IV cohort with survey data from 2015 to 2016. Multiple linear regression was used to generate means and 95% confidence intervals of home food environment variables, and estimates for the contribution of household chaos (defined by frenetic activity, loud noises and disorder), and quartiles of unmanaged parental stress (ratio of perceived stress and ability to manage stress). Model fit was also examined. Results/findings: Both household chaos and quartiles of unmanaged parental stress were independently and inversely associated with family meal frequency (p's < 0.001) and positively associated with perceived mealtime preparation barriers (p's < 0.001). Unmanaged parental stress was also inversely associated with healthful home food availability (p = 0.004). Models including demographic characteristics, household chaos scores, and quartiles of unmanaged parental stress index showed significantly improved model fit for all outcomes compared to less comprehensive models. Among families with high chaos, those having 7 + family meals/week were significantly more likely to have lower mealtime preparation barrier scores, younger children and higher healthful home food availability scores than families eating together less often. Conclusions: Interventions to assist with parental management of stress and chaos within the home environment (e.g., establishing routines) may increase family meal frequency and the quality of children's home food environments.

1. Introduction Frequent and healthier family meals have been found to benefit the nutritional health of family members (Berge et al., 2012; Fulkerson et al., 2017; Horning, Fulkerson, Friend, & Neumark-Sztainer, 2016; Woodruff & Hanning, 2008); benefits on weight-related health have been mixed with some studies indicating positive benefits (Berge et al., 2015; Fulkerson et al., 2015; Horning et al., 2016) and others with null findings (Berge et al., 2012; Valdes, Rodriguez-Artalejo, Aguilar, JaenCasquero, & Royo-Bordonada, 2013). Research has identified several barriers to frequent and healthier family meals, including scheduling challenges (Dwyer, Oh, Patrick, & Hennessy, 2015; Fulkerson et al., 2011; Neumark-Sztainer, Hannan, Story, Croll, & Perry, 2003), the cost of healthy foods, differences in food preferences (Dwyer et al., 2015; Fries, Martin, & van der Horst, 2017; Kauer, Pelchat, Rozin, & Zickgraf, 2015), and the lack of meal preparation skills and confidence to make

healthier family meals (Beshara, Hutchinson, & Wilson, 2010; Horning, Fulkerson, Friend, & Story, 2017). A limited number of programs that address these barriers and aim to increase family-level cooking skills to promote healthier eating have been developed and tested (Fulkerson et al., 2015, 2017; Miller et al., 2016; Reicks, Trofholz, Stang, & Laska, 2014). Although this work is promising, little is known about the factors within the household context such as disorganization, chaos and unmanaged parental stress that may set the tone of the family milieu and be critical issues to address when implementing intervention programs to promote the frequency and healthfulness of family meals. The home environment influences adults and children alike, but is particularly important for children as they develop physically and emotionally. Home environments can be viewed as microsystems of children's ecological environments and this context may be important for child health through daily processes and interactions (Fiese, Rhodes, & Beardslee, 2013; Kamp Dush, Schmeer, & Taylor, 2013). Moreover,

Corresponding author. E-mail addresses: [email protected] (J.A. Fulkerson), [email protected] (S. Telke), [email protected] (N. Larson), [email protected] (J. Berge), [email protected] (N.E. Sherwood), [email protected] (D. Neumark-Sztainer). ∗

https://doi.org/10.1016/j.appet.2019.104391 Received 31 January 2019; Received in revised form 22 July 2019; Accepted 30 July 2019 Available online 01 August 2019 0195-6663/ © 2019 Elsevier Ltd. All rights reserved.

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family-level factors such as chaos and stability within the home environment contribute to child and adolescent functioning (Brieant, Holmes, Deater-Deckard, King-Casas, & Kim-Spoon, 2017) and, although shown to be generally stable over time (Matheny, 1995; Whitesell, Teti, Crosby, & Kim, 2015), are amenable to intervention (Fiese et al., 2013). Within the home environment, chaos can be described as a setting with frenetic activity that is crowded, noisy, disorganized, and unpredictable (Evans, Eckenrode & Marcynyszyn, 2010) and, not surprisingly, the number of individuals in a household is positively associated with chaos (Whitesell et al., 2015). In a large study of predominantly low-income women and their partners, household chaos was significantly associated with poorer child health even after controlling for economic status, family structure, and maternal health status (Kamp Dush et al., 2013). In studies of preschoolers, household chaos has been shown to be inversely associated with positive child behaviors and learning. For example, children with a lack of routine scored lower on delayed gratification (Martin, Razza, & Brooks-Gunn, 2012). Similarly, in a study of adolescents and their parents, lower parent executive functioning longitudinally predicted lower adolescent executive functioning but only in households with high chaos (Brieant et al., 2017) and higher household chaos and lower socioeconomic status longitudinally predicted poorer self-control in youth (Holmes, Brieant, Kahn, Deater-Deckard, & Kim-Spoon, 2019). Related to dietary health, nurturing home environments (low family conflict, high family cohesion, and low household chaos) have been linked to higher child intake of healthier foods such as fruit and vegetables (Martin-Biggers, Quick, Zhang, Jin, & Byrd-Bredbenner, 2017), and Horning et al., 2017b found that more dinner time routines of structure and planning along with more frequent family meals were associated with lower standardized body mass index (BMI) scores among children. MacRae and colleagues (MacRae, Darlington, Haines, & Ma, 2017) have also shown associations between household chaos and fat intake among adults. Therefore, there is evidence that the family milieu, and in particular, low chaos or more structure, are related to healthier child development and may contribute to the healthier home food environment and dietary and weight-related health of both children and adults. A greater understanding of this phenomenon may inform what is needed to improve the mealtime milieu and promote health. Parental stress is another area within the family milieu that has not been examined extensively in relation to the healthy home food environments and frequent and healthy family meals. Devine and colleagues (Devine et al., 2006, 2009) have shown that parents will cope with daily stress by making trade-offs between healthier food and other family priorities by reducing expectations for food and eating. In research focused on the families of school-age children, parental stress earlier in the day predicted fewer homemade foods served at meals the same night (Berge et al., 2018). Thus, perceptions of stress may interfere with having home-prepared food, which tends to be healthier than convenience food. Research has shown parents’ emotional well-being, regardless of their work hours, can affect family meal frequency (Offer, 2013, 2014). Generally, stress can influence family eating styles and food intake (Birch & Davison, 2001; MacRae et al., 2017). Yet, demands seen as manageable versus limiting may have different associations with food choice strategies (Devine, Connors, Sobal, & Bisogni, 2003). Moreover, perceptions of stress and its management may or may not be associated with chaotic environments as thresholds for chaos may vary considerably across individuals (Tsai, Eccles, & Jaeggi, 2018). The objectives of the present study are to examine how household chaos and unmanaged parental stress are associated with and contribute to variance in markers of the home food environment (family meal frequency, perceived barriers to cooking, healthful home food availability) among families with young children, and describe characteristics of families with high chaos who manage to have frequent family meals. It is hypothesized that household chaos and unmanaged parental stress will be inversely associated with family meal frequency

and healthful home food availability while positively associated with perceived barriers to cooking. Previous research has separately examined how household chaos is related to dietary intake (Horning, Fulkerson, et al., 2017a; Martin-Biggers et al., 2017) and whether parental stress may influence the priority given to healthier foods (Devine et al., 2006, 2009), serving healthier foods (Berge et al., 2018), and meal frequency (Offer, 2013, 2014). However, a greater understanding of how household chaos and unmanaged parental stress are associated with the home food environment, and whether they contribute independently to the variance in these outcomes, will provide useful information for the development and refinement of intervention programs aiming to increase family meal frequency and promote serving healthier foods at meals. If household chaos and parental stress are found to be strongly linked to family meals and other aspects of the home food environment, it will be important to design interventions that either directly address chaos and stress and/or aim to improve the home food environment in ways that take into consideration high levels of chaos and parental stress within the home. Furthermore, understanding the characteristics of families who manage to have frequent family meals despite high chaos may also inform future interventions. 2. Materials and methods 2.1. Sample and study design Data for this cross-sectional analysis were drawn from Project EATIV (Eating and Activity in Teens and Young Adults), a population-based study of young adults. At the original assessment (1998–1999), a total of 4746 middle school and high school students at 31 public schools in the Minneapolis-St. Paul metropolitan area of Minnesota completed surveys and anthropometric measures (Neumark-Sztainer, Croll, et al., 2002a; Neumark-Sztainer, Story, Hannan, & Croll, 2002b). In 2015–2016, original participants who had responded to at least one of two previous follow-up surveys were mailed letters inviting them to complete the Project EAT-IV survey and a food frequency questionnaire with the offer of 50 dollars for survey completion. Complete follow-up survey data were collected online, by mail, or by phone from 66.1% of those for whom correct contact information was available (N = 1830 of 2770) and, for the present analysis, all participants who reported at least one child living with them at least 50% of the time were retained (n = 819). The unweighted analytic sample includes 304 men and 515 women with a mean age of 31.4 (SD = 1.6 years). A description of the study sample is provided in Table 1. The ethnic/racial composition of the sample was 68.6% white, 14.7% Asian American, 7.9% African American, 3.5% Hispanic, and 5.3% mixed or other. The majority of participants were living with a significant other (95.4%) with an average of 2.0 (SD = 1.1) children living in the home at least 50% of the time, and the average age of the oldest child was 6 years (SD = 4.5 years). All study protocols were approved by the University of Minnesota's Institutional Review Board Human Subjects Committee. 2.2. Survey development Modifications to the original Project EAT survey (Neumark-Sztainer, Croll, et al., 2002a; Neumark-Sztainer et al., 2003) were informed by input provided by 39 young adult parents in their late twenties and early thirties as part of formative focus groups. The selection of survey items for Project EAT-IV was further guided by social cognitive theory and a life course perspective (Fine & Kotelchuck, 2010; McAlister, Perry, & Parcel, 2008). Items such as the chaos scale and stress were added to assess important factors for the aging cohort (e.g., parenthood, work demands). Prior to fielding the EAT-IV survey, it was also pretested by 35 young adults in focus groups. Scale psychometric properties were examined in the full EAT-IV survey sample and estimates of 2

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create an Unmanaged Parental Stress Index (test-retest r = 0.78); quotient scores of less than one were interpreted as well-managed parental stress, and scores greater than one were interpreted as unmanaged parental stress. The Unmanaged Parental Stress Index is used for analyses.

Table 1 Demographics characteristics of the study sample (N = 819): A subset of young adults from EAT wave 4 (N = 1830) who have at least one child living with them at least 50% of the time. Study Sample (N = 819) Gender Female Male Age; mean(s) BMI (non-pregnancy) Underweight Normal Overweight Obese Race White Black Hispanic/Latino Asian American Hawaiian/Pacific Islander Native American Other/mixed Public Assistance No Yes I don't know Has a Significant Other Yes No Living with Significant Other Yes No

N

%

512 305 31.36 (1.5)

62.7 37.3

8 268 254 228

1.1 35.4 33.5 30.1

555 64 28 119 3 20 20

68.6 7.9 3.4 14.7 0.4 2.5 2.5

681 129 6

83.5 15.8 0.7

762 57

93.0 7.0

726 35

95.4 4.6

2.3.3. Home food environment Family meal frequency was assessed with the following question: “During the past seven days, how many times did all, or most, of the people living in your household eat a meal together?” For analysis, the midpoint of the response options was used (Never = 0; 1–2 times = 1.5; 3–4 times = 3.5; 5–6 times = 5.5; 7 times = 7; More than 7 times = 10). This variable has been used extensively in previous research (e.g. (Fulkerson, Neumark-Sztainer, Hannan, & Story, 2008; Larson, Neumark-Sztainer, Hannan, & Story, 2007; Neumark-Sztainer, Wall, Story, & Fulkerson, 2004),). Mealtime preparation barriers were assessed with five items: “How often are the following statements true? 1) I do not have enough time or energy to cook meals for my children; 2) I find time to cook meals for my children even when I am busy or tired; 3) I do not have enough time or energy to feed my children ‘right’; 4) I plan meals for my children at least 1 day in advance; and 5) I do not have enough time or energy to plan meals for my children.” The response options never, rarely, sometimes, often and always were respectively assigned values of one to five for analysis; items 2 and 4 were reverse coded. Assigned response values were summed to derive the Mealtime Preparation Barrier Scale score (α = 0.74, test-retest r = 0.73). Higher scores represent perceptions of greater meal preparation barriers. Healthful home food availability was assessed with the following five items: “How often are the following true? (by ‘home’ we mean where you lived for the majority of the time for the past year; 1) Fruits and vegetables are available in my home; 2) Vegetables are served at dinner in my home; 3) Whole wheat bread is available in my home; 4) Fruit is served at meals at my home; 5) Milk is served at meals at my home.” The response options never, sometimes, usually, and always were respectively assigned values of one to four for analysis. The summative score had the following properties: α = 0.68, test-retest r = 0.83. Higher scores represent more healthful home food availability.

item test-retest reliability, reported below, were determined in a subgroup of 103 participants who completed the EAT-IV survey twice within a period of one to four weeks. 2.3. Measures 2.3.1. Household chaos Household chaos was measured using four items from the Matheny, W, Ludwig, and Phillips (1995) Confusion, Hubbub and Order Scale (CHAOS) scale. The four items were chosen to represent the multiple dimensions of chaos based on findings from the original scale development study that showed evidence of a reasonably strong correlation with the item-total score. The household chaos score for the current analysis was based on strength of agreement (Strongly disagree, Somewhat disagree, Somewhat agree, Strongly agree) with the following statements about one's current home: 1) We almost always seem to be rushed; 2) It's a real zoo in our home; 3) No matter what our family plans, it usually doesn't seem to work out; and 4) You can't hear yourself think in our home. The score was found to have strong internal consistency (Cronbach's alpha = 0.79) among the EAT-IV sample and test-retest reliability among the survey development sample was high (r = 0.82). Imputation for missing values was not performed as very few cases had missing data.

2.3.4. Parent body mass index and demographic characteristics Self-reported height and weight were used to calculate parent body mass index (BMI in kg/m2). Self-report of height and weight (Test-retest r = 0.95 for height and r = 0.98 wt) were previously validated against objective measurements in an EAT-III subsample (n = 125). Results showed high correlations between self-reported and measured BMI in males (r = 0.95) and females (r = 0.98) (Quick, Wall, Larson, Haines, & Neumark-Sztainer, 2013; Sirard, Hannan, Cutler, & Neumark-Sztainer, 2013). The EAT-IV survey was also used to assess sex, age, eligibility for public assistance, parental situation, and household composition. Eligibility for public assistance was assessed with the question: “Do you receive public assistance (like food support/stamps, WIC, TANF, SSI or MFIP)?” (Test-retest к = 98%). Participants reported the age and living situation of each of their children. Variables were created to represent how many children lived in the participant's household and the age of the oldest child. Participants were also asked to report on household composition by indicating with whom they lived for the majority of the time in the past year (Test-retest agreement = 100%); responses were used to create an indicator variable to represent whether or not they lived with a significant other. Ethnicity/race was based on self-report on the original school-based survey (Test-retest к = 0.70–0.83).

2.3.2. Unmanaged parental stress index Participants self-reported their level of overall stress and their ability to manage their stress using items and a scoring index from previous research (Errisuriz, Pasch, & Perry, 2016; Nelson, Lust, Story, & Ehlinger, 2008). Perceived stress was assessed with the question “On a scale from one to ten, with one being not stressed at all and ten being very stressed, how would you rate your average level of stress in the past 30 days”. Management of stress was assessed with the question “On a scale of one to ten, with one being ineffective and ten being effective, how would you rate your ability to manage stress in the past 30 days?” Perceived stress scores were divided by management of stress scores to

2.4. Analytic approach Descriptive analyses were performed to describe the sample and evaluate modeling assumptions. Multiple linear regression was used to estimate means and 95% confidence intervals of continuous outcomes 3

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of family meal frequency, mealtime preparation barriers and healthful home food availability with marginal mean estimates for the contribution of household chaos scores (M = 8.4, SD = 2.5) and quartile of unmanaged parental stress index (Q1: n = 215, range = 0.1–0.5; Q2: n = 206, range = 0.6–0.9, Q3: n = 214, range = 1–1.3, Q4: n = 167, range = 1.4–10.0) Quartiles were used for the unmanaged parental stress index to protect against influential points and skewed distributions. Huber-White sandwich estimator of robust standard errors account for potential misspecification of the variance family. Post-hoc pairwise comparisons use Dunn-Sidak multiplicity correction. Four models are presented to assess the contribution of demographic variables only (model 1), demographic variables and household chaos (model 2), demographic variables and quartiles of unmanaged parental stress index (model 3); demographic variables, household chaos and quartiles of unmanaged parental stress index (model 4). All models are adjusted for parent gender, parent age, parent BMI, parent race/ethnicity, eligibility for public assistance, living with a significant other, number of children in the household, and age of oldest child. These adjustments allow us to assess associations between the main variables of interest while accounting for demographic variables know to be associated with the outcomes. Contributions of household chaos and quartiles of unmanaged parental stress index on model fit for predicting outcomes of family meal frequency, mealtime preparation barriers and healthful home food availability were examined with adjusted R-square and Likelihood Ratio Statistics. Chi-square tests of independence and ttests were used to better understand what factors are independently associated with frequent family meals (7 or more family meals per week) compared to less frequent family meals among families with highly reported household chaos. All analyses were performed in Stata 15.SE (College Station, TX).

unmanaged stress) with median value 0.9 (IQR = 0.5, 1.3) and M = 1.07 (SD = 0.9, range = 0.1–10.0). 3.2. Associations between measures of household chaos and the home food environment Table 2 shows adjusted mean family meal frequency, mealtime preparation barrier scores and healthful home food availability scores with household chaos scores. When controlling for demographic variables, a five-unit increase in family household chaos score was associated with a mean decrease of one meal per week (p < 0.001), an increase of 2.5 in meal preparation barrier score (p < 0.001) and a decrease of one-half point in healthful home food availability score (p = 0.02). 3.3. Associations between unmanaged parental stress and the home food environment Table 2 shows adjusted mean family meal frequency, mealtime preparation barriers and healthful home food availability associations with quartiles of unmanaged parental stress index. Families in the 1st quartile (lowest level of stress) of unmanaged stress index score (N = 215, M = 0.3, SD = 0.1) had a predicted mean meal frequency of almost 8 meals per week, significantly more family meals per week than families in the other quartiles, while adjusting for covariates (p < 0.01). Similarly, families in the 1st quartile of unmanaged parental stress index score had an adjusted estimated mean mealtime preparation barrier score of 9.5, which was significantly lower than families in the other quartiles (p < 0.01). Finally, families in the 1st quartile of unmanaged parental stress index score had an adjusted estimated mean healthful home food availability score of 16.2; a value that was significantly higher than families in the 4th quartile of unmanaged parental stress index score (p < 0.01) but not significantly different from the other groups.

3. Results 3.1. Descriptive findings: household chaos, unmanaged parental stress and the home food environment

3.4. Explained variance of household chaos and unmanaged parental stress index on the home food environment

The study sample reported eating family meals together an average of 6.8 times per week (SD = 3.13, range: 0–10). The average mealtime preparation barrier score was 11.0 (SD = 3.36, range: 5–23 with higher scores indicating more barriers), and the average healthful home food availability score was 15.7 (SD = 2.80, range: 7–20 with higher scores indicating more availability). The household chaos scale score was normally distributed (M = 8.36, SD = 2.5, range: 4–16). The unmanaged parental stress index was skewed toward higher values (more

Table 3 shows the contributions of household chaos scores and quartiles of unmanaged parental stress index on model fit for predicting family meal frequency, mealtime preparation barriers, and healthful home food availability to demonstrate whether these variables of interest contribute more variance than what would be predicted by demographic variables alone. The demographics only model (model 1)

Table 2 Adjusted mean family meal frequency, mealtime preparation barriers and healthful home food availability associations with household chaos scores and quartile of unmanaged parental stress index. Family Meal Frequency (times/week) Mean

95% CI

Household Chaos Score −0.20 (-0.28 to −0.11) Quartiles of Unmanaged Parental Stress Index (Low)1 7.70 a (7.3, 8.1) 2 6.71 b (6.3, 7.1) b (6.1, 6.9) 3 6.51 b (High) 4 6.15 (5.6, 6.7)

Mealtime Preparation Barrier Score

Healthful Home Food Availability Score

P-value

Mean

95% CI

P-value

Mean

95% CI

P-value

< 0.001 < 0.001

0.49

(0.38–0.61)

−0.10

(-0.18 to −0.02)

9.54 a 11.07 b 11.54 b 11.99 b

(9.0, 10.1) (10.5, 11.6) (10.9, 12.2) (11.2, 12.8)

< 0.001 < 0.001

16.22 a 15.84 ab 15.62 ab 15.07 b

(15.8, (15.5, (15.3, (14.6,

0.02 0.004

16.6) 16.2) 16.0) 15.6)

Models are adjusted for parent gender, age, BMI (non-pregnancy), race/ethnicity, public assistance, living with a significant other, number of children and age of oldest child. Huber-White sandwich estimator of robust standard errors account for the potential misspecification of the variance family. Quartiles are used for unmanaged parental stress index to account for skewed distribution towards higher values with high valued outliers. Classified unmanaged parental stress index scores by quartiles based on 25%, 50%, 75% and 100%. Margins sharing a letter in the group label are not significantly different at the 5% level using Dunn-Sidak. Huber-White sandwich estimator of robust standard errors account for the potential misspecification of the variance family. Table 2 Interpretation example: A five-unit increase household chaos score is associated with a mean decrease of one meal per week when controlling for demographic variables. 4

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Table 3 Contributions of household chaos and quartiles of unmanaged parental stress index on model fit for predicting family meal frequency, mealtime preparation barriers and healthful home food availability. Model

1 2 3 4

Demographics Only Model 1 + household chaos score Model 1 + quartiles of unmanaged parental stress index Model 1 + household chaos + quartiles of unmanaged parental stress index

Family Meal Frequency (times/week)

Mealtime Preparation Barrier Score

Healthful Home Food Availability Score

AdjR2

LRT P-value

AdjR2

AdjR2

0.07 0.10 0.10 0.12

< 0.0011 < 0.0011 < 0.0011; 0.0082; 0.0033

0.03 0.14 0.09 0.16

LRT P-value < 0.0011 < 0.0011 < 0.0011; 0.0032; < 0.0013

0.11 0.12 0.13 0.12

LRT P-value 0.21 0.0021 0.0021; 0.022; 0.23

Demographics include parent gender, age, BMI (non-pregnancy), race/ethnicity, public assistance, living with a significant other, number of children and age of oldest child. Classified unmanaged parental stress index by quartiles based on 25%, 50%, 75% and 100%. LRT = Likelihood Ratio Test. AdjR2 = Adjusted R-square. 1. P value for model comparison is from LRT of each model compared to model 1 (Demographics only). 2. P value for model comparison is from LRT of each model compared to model 2. 3. P value for model comparison is from LRT of each model compared to model 3. Table 3 Interpretation example: The demographics only model (Model 1) explained 7% of the variance in family meal frequency, 3% of the variance in mealtime preparation barrier score and 11% of the variance in healthful home food availability score. Models predicting family meal frequency and mealtime preparation barrier score were improved with the addition of household chaos score and quartile of unmanaged parental stress index score (Model 4) to the base demographics model (Model 4 compared to Model 1; LRT P-value < 0.001).

4. Discussion

explained 7% of the variance in family meal frequency, 3% of the variance in mealtime preparation barrier scores and 11% of the variance in healthful home food availability scores. Models predicting family meal frequency and mealtime preparation barrier scores were significantly improved with the addition of household chaos score (model 2) to the base demographics model (model 2 compared to model 1; LRT P-value < 0.001). Model 2 explained 10% of the variance in family meal frequency and 14% of the variance in mealtime preparation barrier score. Models predicting all outcomes were significantly improved with the addition of quartile of unmanaged parental stress index (model 3) to the base demographics model (model 3 compared to model 1; LRT P-value < 0.01). Model 3 explained 10% of the variance in family meal frequency, 9% of the variance in mealtime preparation barrier scores and 13% of variance in healthful home food availability scores. Model 4 (demographics + household chaos score + quartiles of unmanaged parental stress index) explained 12% of the variance for family meal frequency, 16% of the variance for mealtime preparation barrier scores and 12% of variance in healthful home food availability scores. Model 4 showed a significantly improved model fit for family meal frequency and mealtime preparation barrier scores for all comparisons (model 4 to all: model 1, model 2 and model 3; p < 0.01). Model 4 was also a significant improvement over models 1 and 2, but not model 3 for predicting healthful home food availability scores (p = 0.002, p = 0.02, p = 0.2; respectively), meaning that household chaos did not explain significant variance in healthful home food availability beyond demographic variables and quartiles of unmanaged parental stress index.

The present study examined the contributions of household chaos and unmanaged parental stress to measures of the home food environment in families with young children. Both household chaos and unmanaged parental stress were independently and inversely associated with family meal frequency and positively associated with perceptions of mealtime preparation barriers. Additionally, unmanaged parental stress was inversely associated with healthful home food availability. Models with both household chaos and unmanaged parental stress scores contributed significantly to the variance associated with family meal frequency and mealtime preparation barrier score outcomes above and beyond variance associated with demographic characteristics. Thus, providing families with strategies to manage household chaos in general, but particularly at mealtimes, may reduce their unmanaged stress, increase family meal frequency while reducing perceptions of mealtime preparation barriers. The present study findings indicate that not addressing underlying household chaos and parental perceptions of stress management in affected families may undermine intervention efforts to improve dietary and weight-related health. Furthermore, our study findings indicate that even in the presence of high chaos, families with few perceived mealtime preparation barriers and more healthful home food availability, particularly those with relatively young children, managed to have frequent family meals. These findings suggest that intervention programs to increase the healthfulness of foods made available in the home and reduce mealtime preparation barriers through development of routines around meal planning, shopping strategies and cooking skills may benefit families even in the presence of high chaos. Previous research has demonstrated the potential longitudinal effects of household chaos on child and adolescent functioning, particularly related to self-control (Brieant et al., 2017; Peviani et al., 2019) which may be very relevant for dietary and weight-related health. Support for managing chaos, stress and self-control could come in many forms. Research has demonstrated that practicing rituals to increase perceptions of self-discipline helped individuals increase their selfcontrol regarding eating (Tian et al., 2018) and perhaps a similar practice could be applied to improve self-efficacy of healthier grocery shopping, meal planning and meal preparation. These approaches may be especially useful given the findings of lower executive functioning among adolescents in households with high chaos (Brieant et al., 2017). Research also suggests that family routines can improve parenting competence, child adjustment and marital satisfaction (Fiese et al., 2002). Thus, meeting families where they are at by supporting the

3.5. Factors independently associated with frequent family meals among families with highly reported household chaos Table 4 shows the factors independently associated with seven or more family meals per week (N = 67. M = 9.3, SD = 1.3) compared to fewer than seven family meals per week (N = 94, M = 3.7, SD = 1.7) among households reporting high chaos (top quartile: N = 161, M = 12.1, SD = 1.2). Among high chaos households, families with frequent family meals had significantly lower average mealtime preparation barrier scores (p < 0.001), higher average healthful home food availability scores (p < 0.01), and the average age of their oldest child was younger compared to families with less frequent family meals; differences between groups were not significant for quartiles of unmanaged parental stress index, parent gender, parent race/ethnicity, parental age, receipt of public assistance, living with a significant other and parent BMI. 5

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Table 4 Factors independently associated with frequent family meals (≥7/week) compared to those with less frequent family meals (< 7/week) among families with high household chaos (top quartile: N = 161, M = 12.1, SD = 1.2). Frequent Family Meals (≥7/week) N = 67

Less Frequent Family Meals (< 7/week) N = 94

Factors N (%) N (%) Quartiles of Unmanaged Parental Stress Index (Low)1 4 (6.2) 2 13 (20.0) 3 24 (37.0) (High) 4 24 (36.9) Parent Gender Male 24 (35.8) Female 43 (64.2) Parent Race/Ethnicity White 52 (77.6) Black 1 (1.5) Hispanic 4 (6.0) Asian 8 (11.9) Other 2 (3.0) Public Assistance No 51 (77.3) Yes 15 (22.7) Living with a Significant Other No 0 (0.0) Yes 63 (100.0)

5 (5.5) 11 (12.1) 33 (36.3) 42 (46.2) 29 (30.0) 65 (69.2) 58 (62.4) 5 (5.4) 4 (4.3) 18 (19.4) 8 (8.6) 74 (78.7) 20 (21.3) 5 (5.8) 81 (94.2)

P-value 0.5

0.6 0.2

Frequent Family Meals (≥7/week) N = 67

Less Frequent Family Meals (< 7/week) N = 94

Mean (SD) 11.4 (3.0)

Mean (SD) 13.7 (3.5)

P-value < 0.001

16.1 (2.4)

14.7 (2.9)

0.001

Parent Age in Years

31.5 (1.3)

31.4 (1.6)

0.4

Parent Body Mass Index

30.1 (6.1)

28.3 (6.9)

0.1

Number of Children (range: 1 to 9)

2.3 (1.0)

2.4 (1.3)

0.7

Age in Years of Oldest Child (range: 0–18)

5.9 (3.6)

7.8 (4.4)

0.005

Factors Mealtime Preparation Barrier Score Healthful Home Food Availability Score

0.8 0.07a

Quartiles are used for unmanaged parental stress index to account for skewed distribution towards higher values with high valued outliers. Classified unmanaged parental stress index scores by quartiles based on 25%, 50%, 75% and 100%. Chi-square tests of independence for categorial factors and t-tests for continuous factors. Table 4 Interpretation example: The oldest child of families with frequent family meals are younger by almost 2 years compared to families with less frequent family meals among high chaos families (p = 0.005). a Fisher's exact test.

initiation, maintenance or increase of family routines could be a part of intervention programming to improve family health. Literature indicates that regular routines around mealtimes promote mealtime frequency (Fiese, Hammons, & Grigsby-Toussaint, 2012) and weight-related health benefits for children (Horning, Schow, et al., 2017b). One routine to promote could be related to mobility during meals. Meals can seem more chaotic when people are moving around; the literature suggests positive weight-related benefits when parents sit and eat with their children (Horning et al., 2016) and this could also reduce chaos and feelings of stress. Additionally, parental support to engage children in specific roles at mealtime such as setting the table, doing easy food preparation, and assisting with clean up may initially be more work, but in the long-term could reduce overall parental effort and stress and instill healthy life lessons in their children. Although very young children may be limited in their ability to help with mealtime tasks, parents could start with easy steps and build children's repertoire over time. Step-by-step guidance on how to incrementally increase mealtime routines in ways that are developmentally appropriate for children could be an important addition to intervention programs. Guiding families to plan meals in advance and prepare meals they feel comfortable making with the resources (time, skills, equipment, food budget) available to them could increase family meal frequency (McIntosh et al., 2010), but resources vary considerably among adults. Thus, understanding where families are at in terms of levels of chaos and stress, in addition to meal planning (e.g., never have a plan, make plans but get sidetracked by busy days), and working with them to make small but important changes over time could build confidence. Existing programmatic information may be useful (Flattum et al., 2015; Gurajada, Reed, & Taylor, 2017; Tessaro et al., 2006) as well as websites, particularly governmental (e.g., USDA) that provide healthy, easy recipes; many websites have built-in shopping lists available as well. Alternatively, perhaps providing simple strategies to increase getting families together for meals may decrease stress and chaos in households. Intervention success will be most likely when there is a true

understanding of each family's needs with programming to meet those needs in small steps over time. It is noteworthy that in spite of chaos and stress, some families managed to have frequent family meals. Our study findings indicate that even families with high levels of household chaos managed to have frequent family meals if their children were generally younger, they had healthier foods available in the home and they reported fewer mealtime preparation barriers. Thus, to facilitate the adoption of healthy eating behaviors at a young age, future interventions with families of young children may be particularly beneficial if they include efforts to create healthful home food environments and provide strategies to reduce mealtime preparation barriers. Decreasing household chaos and feelings of unmanaged stress in the promotion of healthier home food environments could be accomplished with the use of techniques and activities taught in skills training such as Problem-Solving Skills Training (PSST). PSST was developed to teach skills for effective problem-solving to assist families with health conditions (Law et al., 2017; Sahler et al., 2005, 2013), but skill development could be generalized to promote parenting strategies for dietary and weight-related health. For example, effective problem solving to build parental skills during challenging mealtime situations such as developmental differences between children in a household, health conditions that interfere with eating or sitting together at the table, and food rejection are likely to improve the milieu of mealtimes. Improvement of the mealtime milieu could enhance the home environment and improve child health beyond the short-term. Healthy family changes such as expectations for frequent family meals are more likely to be continued over time (Berge et al., 2015) and passed on to future generations (Friend et al., 2015; Watts, Berge, Loth, Larson, & NeumarkSztainer, 2018), which could promote health over the lifespan. Just as evidence suggests family meals have the potential to improve family relationships (while also recognizing that family relationships probably influence family meals), it is highly likely that family meals done in an easy and relaxed atmosphere have the potential 6

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to reduce chaos in the home and stressors. Yet, this change is easier said than done. It would be naïve not to recognize that pulling a family meal together can impose additional stress, but by building simple meals into a family's routine, it may help to develop a pattern of structure and ritual that may reduce chaos and stress. Furthermore, self-efficacy for meal preparation, routines, stress and chaos likely have reciprocal relationships where more regular routines and self-efficacy for meal preparation may decrease stress and chaos which may in turn allow for a greater ability to prepare meals and maintain routines. Further research is needed to explore these speculations. The present study has several strengths and limitations. The wealth of information on a relatively large group of diverse families in the Project EAT study is a significant strength of the present analysis and increases the generalizability of findings. In addition, the inclusion of strong measures of both chaos and parental stress together in the same models is a strength of the current study and has not been done in other studies examining the connection between stress and family meal frequency. It is important to note that the total amount of variance accounted for by these measures is modest, indicating that families manage to have family meals despite chaos and stress in their lives. The use of an abbreviated self-report measure of household chaos rather than the full CHAOS scale developed by Matheny (Matheny, 1995) is a study limitation. Although the present study did not assess the perceived causes of stress parents were reporting, the research literature suggests that time demands can interfere with family meals and food choices, particularly among adults with children at home (Devine, Stoddard, Barbeau, Naishadham, & Sorensen, 2007). The type and timing of stress may also be important as research has shown transient stressors related to interpersonal conflicts and finances have stronger effects on unhealthful food-related parenting practices than chronic stressors (Berge et al., 2018). Additionally, the study is limited to a onetime measurement of stress. Repeated measures of stress over time in a longitudinal study may help to understand the intersection of patterns of stress with meal frequency, perceived preparation barriers and healthful food availability. Another limitation may be response bias as families who returned surveys may have lower levels of stress and chaos.

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5. Conclusions Providing families with strategies to manage household chaos at mealtimes and to reduce their unmanaged stress may increase family meal frequency and the presence of healthier foods kept in the home while reducing perceptions of mealtime barriers. Potential strategies include promoting mealtime routines, structure and meal preparation roles, and building parental confidence through effective skill building in small steps over time. Not addressing underlying household chaos and unmanaged parental stress may undermine intervention efforts to improve dietary and weight-related health. However, unless broader societal issues such as expectations for sport programming for children, poverty, job demands and inflexibility of work settings change to promote family time, it may be difficult for many families to make family mealtimes a priority. Acknowledgements This study was supported by Grant Number R01HL116892 from the National Heart, Lung, and Blood Institute (PI: Dianne NeumarkSztainer). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.” Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.appet.2019.104391. 7

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