Deconstructing the Family Meal: Are Characteristics of the Mealtime Environment Associated with the Healthfulness of Meals Served?

RESEARCH

Original Research

Deconstructing the Family Meal: Are Characteristics of the Mealtime Environment Associated with the Healthfulness of Meals Served? Nicole Kasper, PhD; Sarah C. Ball, MPH, RD; Kristina Halverson, MPH, RD; Alison L. Miller, PhD; Danielle Appugliese, MPH; Julie C. Lumeng, MD; Karen E. Peterson, ScD ARTICLE INFORMATION Article history: Submitted 29 November 2017 Accepted 9 January 2019

Keywords: Family meals Diet quality Meal observation Television Family-style 2212-2672/Copyright ª 2019 by the Academy of Nutrition and Dietetics. https://doi.org/10.1016/j.jand.2019.01.009

ABSTRACT Background Multiple studies and guidelines emphasize the benefits associated with family meals. However, family meals are not well defined and little research has been conducted to determine whether mealtime characteristics are associated with the healthfulness of foods served. Objective The objective of this study was to define and measure specific mealtime characteristics and examine whether these characteristics are associated with the healthfulness of meals served to young children from low-income families, as measured by the Healthy Meal Index (HMI). Participants/setting Study participants included 272 young children from low-income families residing in southeast Michigan during 2011 to 2013. Design For this cross-sectional study, parents videorecorded 757 mealtimes that were coded for four mealtime variables and meal healthfulness using the HMI. Mealtime characteristics included Eating at a Table (vs not), Served Family-Style (vs not), TV Off (vs not), and Parent Partakes (sits and eats or drinks with child) (vs not). A Family Meal was defined as a meal that had all four measured mealtime characteristics. Main outcome measures All meals were scored using the HMI, which has two components: the HMI Adequacy score (based on the presence of foods that are recommended for a healthy diet) and the HMI Moderation score (based on the absence of foods recommended to be consumed in moderation). The scores are summed to obtain the HMI Total score. Statistical analyses performed Generalized estimating equations tested the associations of mealtime characteristics with HMI scores, controlling for child sex and age, and parent education and race/ethnicity. Results In adjusted models, Family Meals were positively associated with HMI Adequacy (P¼0.02) and Total (P¼0.05) scores. Eating at a Table was positively associated with HMI Moderation (P¼0.01) and HMI Total (P¼0.01) scores. Served Family-Style was positively associated with HMI Adequacy scores (P¼0.04). TV Off was associated with higher HMI Total scores (P¼0.05). Parent Partakes was not associated with HMI scores. Conclusions Family Meals were associated with greater healthfulness of the foods served. Characteristics of mealtime that are commonly utilized to define Family Meal were differentially associated with meal healthfulness. J Acad Nutr Diet. 2019;-:---.

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IVEN THE PERSISTENTLY HIGH PREVALENCE OF overweight and obesity in children,1 child feeding and dietary guidelines increasingly recommend shared family meals, without the television on and served family style, as a strategy for improving children’s diet quality and reducing the risk of obesity.2-6 Multiple studies have found positive health effects associated with family meals, such as lower risk of excessive weight gain,7-9 more healthy eating habits,8,10 and greater diet quality overall.11-14

ª 2019 by the Academy of Nutrition and Dietetics.

Studies also suggest that the presence of television and other forms of media during mealtimes are associated with lower overall diet quality and greater body mass index among children.15-19 Family-style service, allowing children to serve themselves from larger serving dishes, is believed to improve a child’s ability to eat in response to internal satiety cues by allowing children to decide what and how much to consume; however, different studies have found both positive and negative associations with food intake in preschoolers.20-23

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RESEARCH Family meals are hypothesized to improve overall dietary quality and weight status because parents serve food items that are healthier and more consistent with dietary guidelines.14,24,25 Although parents who report placing high value on family meals also self-report serving healthier foods at family dinners, few studies have actually assessed the healthfulness of the foods served during family meals.26 Others have examined total energy consumption or the overall dietary quality of children’s food consumption in relationship to family meals,10-14,27,28 yet only one other study has examined the association between television viewing and the healthfulness of meals served.19 Furthermore, there is no common criterion for defining a family meal.29 Different studies define and measure family meals in a variety of ways, which may lead to important factors within the mealtime environment being overlooked.27 For example, some studies characterize a “family meal” by the presence of different family members living in the household, ranging from one parent to all members.7,9,10,12,13,27,30-32 A family meal may be also characterized by preparation style; that is, prepared at home,11 or by eating location; that is, eaten within the dining room or kitchen,33 on a table,34 or simply at home.35 Finally, family meal research has focused primarily on assessing adolescents,13,16,27,28,34,36,37 with few studies assessing the meals of preschool-aged and school-aged children38-40 who have yet to fully establish eating patterns and habits.41,42 Young children from low-income families are of particular interest due to increased barriers to family meals,43 lower access to healthy foods,44,45 and greater risk of food insecurity.46 In summary, there are three major gaps within family mealtime research: the lack of studies that measure the healthfulness of meals served within the family mealtime, the limited understanding of the importance of different characteristics used to define the family meal, and the lack of research on young children from low-income families. To address the gaps in the literature, this study’s objective was to define and measure specific mealtime characteristics and examine whether these characteristics are associated with the healthfulness of meals served to young children from low-income families, as measured by the Healthy Meal Index (HMI).47 The hypothesis of our study was that certain mealtime characteristics (Eating at a Table, Served Family-Style, TV Off, and Parent Partakes) will be associated with higher meal healthfulness. A Family Meal variable (defined as meals in which all the previously mentioned mealtime characteristics are present) was hypothesized to be positively associated with HMI meal scores.

MATERIALS AND METHODS Participants and Recruitment Participants in this cross-sectional study included 301 parentechild dyads who were originally recruited between 2009 and 2011 to participate in a study investigating stress and eating behavior in children.48 The parent study included children aged 3 to 4 years from low-income families recruited from Head Start preschool programs in southeastern Michigan. Between 2009 and 2011, all children attending Head Start through several agencies in communities within 1 hour driving distance of the University of Michigan received flyers 2

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RESEARCH SNAPSHOT Research Question: Are characteristics of the mealtime environment associated with the healthfulness of foods served during the meal in a population of young children from low-income families? Key Findings: In this cross-sectional, observational study of 272 children who were videotaped in the home during three typical mealtimes, the following variables were positively associated with meal healthfulness scores: Family Meal, Eating at a Table, Served Family-Style, and TV Off. in their backpacks inviting the family to participate in a study of eating behavior. Two to 4 years later (2011-2013), primary caregivers were invited to participate in the current followup study seeking to understand how mothers feed their children.47 Families were contacted for this follow-up study by postcard or telephone. Those meeting the following criteria were eligible for inclusion: caregiver has less than a 4-year college degree; caregiver is fluent in English; child born at 35 weeks’ gestation or more and without significant perinatal or neonatal complications; child without history of food allergies, serious medical problems, or any form of disordered eating; and child not in foster care. Child participants were originally recruited from Head Start programs; therefore, at the time of recruitment into the original study, they were aged 3 to 4 years and living in families with limited income. Child sex, date of birth, and parent education and race/ethnicity were collected at enrollment in the original parent study. The University of Michigan Institutional Review Board approved the study protocol and all participants provided written informed consent and child assent.

Measures Home Mealtime Observation. As described elsewhere, caregivers were provided a video camera and asked to describe and videorecord three typical dinnertime meals for their child on a weekday.47 Requirements for the videotaped meal included the primary caregiving parent was at home and awake, meal must occur at home, and the primary caregiving parent must prepare the meal (even when preparation is defined as picking up take-out meals). Following the meal, on the same night, parents received a follow-up telephone call from a trained research assistant asking them to list all foods available to the child during the meal. Participants were compensated $10 for each mealtime recording they attempted.

HMI. As described elsewhere,47 the list of foods reported by the parent to the research assistant was coded into predetermined food group categories by trained coders. Food categories were determined by the 2010 US Dietary Guidelines for Americans, and included fruits, type of vegetable, type of grain, type of protein, type of dairy, sweets and desserts, type of beverage, and high saturated/trans fat foods.4 The presence or absence of each main food group, sweets and desserts, and beverages were recorded, including details about the type of food item. Condiments and preparation methods, except whether a potato or meat was deep fried, --

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RESEARCH and macaroni and cheese) were classified as such unless otherwise specified. HMI Adequacy, HMI Moderation, and HMI Total scores were calculated for each meal report individually and used as the outcome variables of interest in this study. The development and validation of the HMI system, as well as the coding and scoring details, is presented elsewhere.47

were not coded because this information was not uniformly available in the meal reports. A validation study in a subset of the sample demonstrated that the reported meals were highly consistent with the foods seen on the videotapes.47 All meals were then scored using the HMI. The HMI is a validated tool for measuring the healthfulness of foods served to children in a single meal and has two components: the HMI Adequacy score (based on the presence of foods that are recommended for a healthy diet) and the HMI Moderation score (based on the absence of foods recommended to be consumed in moderation), which are then summed to obtain the HMI Total score (Figure 1). For each score, higher values indicate healthier meals. The HMI Adequacy score has a range of 0 to 65, the HMI Moderation score has a range of 0 to 40, and the HMI Total score has a range of 0 to 105. Each individual food could fall into multiple points categories, depending on its characteristics. For example, chicken tenders would receive positive points for protein yet lead to zero points in the added and saturated fats and convenience foods categories. Foods fell into the healthy fats category in the case that they were fish, avocado, or nuts, because fat content was not directly measured. In addition, convenience foods were categorized based on information provided about whether the meal was prepared at home by scratch or prepackaged, take-out, frozen, or canned. Foods found to be nearly exclusively falling into the convenience foods category in the study population (such as pizza, chicken nuggets,

Mealtime Characteristics. Four mealtime characteristics were coded from the videotaped mealtime events: Eating at a Table, Served Family-Style, TV Off, and Parent Partakes (Figure 2). Coders trained to an initial reliability criterion of Cohen’s k>0.70 (k¼1.0 indicates exact agreement corrected for chance); 12% of videos were randomly selected and double-coded by two raters and inter-rater reliability by Cohen’s k exceeded 0.70 for all codes. A Family Meal was defined as one in which all of the following conditions were met: Eating at a Table, Served Family-Style, TV Off, and Parent Partakes.

Data Analysis Unadjusted bivariate associations were conducted to compare the dyads that did and did not provide videos. Unadjusted bivariate associations were also conducted on demographic characteristics—child sex, child age, parent race/ ethnicity, and parental education—as well as each of the four mealtime characteristics and the Family Meal variable with

Awarded Scorea HMI component

0

5

10

Definition

Adequacy score Fruit

N

Y

Fruit, excluding juice

Vegetables

N

Y

Vegetables, excluding fried potatoes

Vegetable quality

N

Y

Dark green/red/orange vegetables and legumes

Vegetable variety

N

Y

2 types of vegetables

Grains

N

Y

Any whole or refined grain, excludes fried/salty snacks

Whole grains

N

Y

Any whole grain, excludes fried/salty snacks

Dairy

N

Y

Dairy or dairy substitutes

Protein

N

Y

Meat, nuts, legumes, eggs, meat substitutes

Healthy fats

N

Y

Fish, nuts, avocados

Moderation score Convenience foods

Y

N

Take-out, fast food, prepackaged, and processed

Sugar-sweetened beverages or diet drinks

Y

N

Drinks with added sugar, diet drinks, flavored milk

Added and saturated fats

Y

N

Fried foods, beef, pork

Desserts and sweets

Y

N

Foods with high added sugar

a

Y indicates the score awarded in the case that the food was available at the meal and N indicates the score awarded in the case that the food was unavailable. Reprinted from Kasper and colleagues47 with permission from Elsevier. Figure 1. Scoring criteria for Healthy Meal Index (HMI). --

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RESEARCH Variable

Coding description

Eating at a Table (vs not)

Index child is eating at a kitchen or dining room table (ie, child is sitting on a chair at a distinct table, child is not sitting on a couch, sofa, or floor)

Served Family-Style (vs not)

Food is served in bulk on serving dishes or in containers (ie, casserole dish, pizza box, and Chinese food boxes) and placed on a dining room or kitchen table from which the parent serves others and/or index child serves self

TV Off (vs not)

Television is not audible during the meal (even in the case that the television is not visible)

Parent Partakes (vs not)

Throughout the meal, the index parent sits down and eats or drinks anything (including visual or audible evidence of her/him eating or drinking nearby during the meal, even in the case that the parent is cut off from the frame)

Family Meal (vs not)

Meets all of the following criteria: Eating at a Table, Served Family Style, TV Off, and Parent Partakes

Figure 2. Description of videotaped mealtime characteristic variables. HMI Adequacy, HMI Moderation, and HMI Total scores, utilizing generalized linear models that accounted for repeated measures within subjects. Generalized estimating equations estimated the association of mealtime characteristics with HMI Adequacy, HMI Moderation, and HMI Total scores. Generalized estimating equations account for the repeated mealtime measures within families. For each of the three HMI score outcomes, two models were constructed: one that included all four mealtime characteristics simultaneously (to reduce potential confounding) and the other that tested the Family Meal variable as a main effect, controlling for the demographic variables. Selection of potential confounders was based on the probable relationship between the confounder with the mealtime characteristics and meal healthfulness. For all models, the level of significance was a.05 and all statistical tests were two-tailed. All analyses were conducted in SAS version 9.3.49

RESULTS Of 301 caregivers who agreed to videorecord dinners and provide meal reports by telephone, all provided complete demographic information; however, 29 did not complete at least one videorecorded meal and meal report. Participating families did not differ from nonparticipants (ie, those who did not provide at least one videotaped meal) when compared on child sex and age, parent race/ethnicity, or education. The analytic sample for this study included 272 parentechild dyads with 757 mealtime observations and associated meal reports. Table 1 presents descriptive characteristics of the sample. The sample had approximately equal numbers of boys and girls with a mean child age just younger than 6 years. A majority of parents were nonHispanic white women (only two primary care-giving parents in this sample were fathers). There was equal representation between those with and without some education beyond a high school diploma. Mealtime characteristics are described in Table 2. A majority of meals (86.0%) were consumed at a table. Dinner was served family style in just more than one-fifth of all meals. The television was turned off in 52.6% of meals. The parent 4

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partook in 72.8% of meals. According to the unadjusted bivariate analysis (Table 2), HMI Total scores were higher for all mealtime characteristic variables in the anticipated direction (P0.05). HMI Adequacy scores were higher for Family Meals and each of the family meal components, except for Parent Partakes. HMI Moderation scores were higher for meals eaten at a table and meals in which the parent partook but not for meals served family style, meals with the television off, or Family Meals. Adjusting for all demographic variables in models, including all mealtime characteristic variables, only Served

Table 1. Demographic characteristics of 272 parentechild dyads from southeast Michigan Head Start families from a cohort investigating stress and eating behavior in children in 2011-2013 Characteristic

Result

Child sex

n (%)

Female

134 (49.3)

Male

138 (50.7)

Parent race/ethnicity White, non-Hispanic

187 (68.8)

Black, non-Hispanic

43 (15.8)

Hispanic

22 (8.1)

Biracial, non-Hispanic

18 (6.6)

Native American or Pacific Islander

2 (0.7)

Parent education High school diploma or equivalent or less

128 (47.1)

More than high school

144 (52.9)

Child age (mo)

70.98.4

meanstandard deviation

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RESEARCH Table 2. Bivariate associationsa of mealtime characteristics with Healthy Meal Index (HMI) Adequacy, Moderation, and Total scores during 757 observed family meals in 272 southeast Michigan parentechild dyads in 2011-2013 HMI Score Adequacy b

c

Mealtime characteristic

N (%)

mean–SE

Total sample

757 (100)

35.00.39

Yesd

651 (86.0)

35.50.5

No

106 (14.0)

31.81.1

Eating at Table

mean–SE

P value

mean–SE

P value

—

22.40.33

—

57.40.52

— <0.001

0.004 22.90.4

58.40.72

19.90.9

51.81.4

0.002

d

Total

P value

0.002

Served Family-Style Yes

Moderation

0.82

0.03

159 (21.0)

37.61.0

22.30.8

59.81.3

598 (79.0)

34.30.5

22.50.4

56.90.7

Yesd

398 (52.6)

36.20.6

No

359 (47.4)

33.70.6

No TV Off

0.003

Parent Partakes Yes

0.19 22.90.5 22.00.5

55.70.8

0.13

d

0.002 59.10.8

0.04

0.02

551 (72.8)

35.40.5

23.00.4

58.30.7

206 (27.2)

33.90.8

21.20.8

55.21.4

Yesd

114 (15.1)

37.61.2

22.90.8

60.41.4

No

643 (84.9)

34.50.5

22.40.4

57.00.6

No Family Meal

0.01

0.58

0.02

a

Generalized liner models, accounting for repeated measures within participants. Number of meals included in models. c SE=standard error. d Reference group for models. b

Family-Style and Family Meals were associated with HMI Adequacy scores (P¼0.04 and P¼0.02, respectively) (Table 3). Eating at a Table (bstandard error [SE]¼ 2.71.1; P¼0.01) was the only mealtime characteristic variable associated with

HMI Moderation scores. Eating at a Table (bSE¼4.61.7; P¼0.01), TV Off (bSE¼2.11.1; P¼0.05), and Family Meals (bSE¼3.01.5; P¼0.05) were associated with HMI Total scores.

Table 3. Multiple linear regression models of association of mealtime characteristics with Healthy Meal Index Adequacy, Moderation, and Total scores in 757 observed meals across 272 southeast Michigan parentechild dyads in 2011-2013 Adequacy

Moderation

b–SEb

P value

Model 1c Eating at Table

1.91.3

0.14

2.71.1

Served Family-Style

2.31.1

0.04

e1.20.9

0.18

11.4

0.49

TV Off

1.60.8

0.06

.50.7

0.46

2.11.1

0.05

.31

0.79

1.40.9

0.11

1.61.3

0.23

2.71.2

0.02

.40.9

0.66

3.01.5

0.05

Parent Partakes Model 2d Family Meal

b–SE

Total

Covariatea

P value

b–SE

P value

0.01

4.61.7

0.01

a

A positive response (yes) to each covariate is the reference category and is compared with the alternative (no). SE¼standard error. Model 1 includes all four mealtime characteristic variables, controlled for child sex (male as reference), child age (6 to 8 years as reference), parent education (greater than high school/ general equivalency as reference), parent race/ethnicity (non-Hispanic white as reference). d Model 2 includes the Family Meal variable, controlled for child sex, child age, parent education, and parent race/ethnicity. b c

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RESEARCH DISCUSSION This study assessed mealtime characteristics and their association with the healthfulness of meals served in a population of young children from low-income families. In unadjusted models, all mealtime characteristics were independently associated with HMI Total scores, and all but Parent Partakes were associated with HMI Adequacy scores, whereas only Eating at a Table and Parent Partakes were associated with higher HMI Moderation scores. In adjusted models that included all mealtime characteristics, Eating at a Table was positively associated with HMI Moderation and HMI Total scores. Served Family-Style was positively associated with HMI Adequacy scores. Meals served with TV Off had higher HMI Total scores. Family Meals, which were defined as meals that met all of the recommendations; that is, Eating at a Table, Served Family-Style, TV Off, and Parent Partakes were positively associated with HMI Adequacy and Total scores. Although Eating at a Table was associated with higher HMI Moderation and Total scores in this study and has been included as a component of a family meal in previous studies,34 there is not comparable literature that examines whether Eating at a Table, as a standalone variable, influences meal or dietary quality. One might speculate that meals eaten at a table, rather than elsewhere, could be more planned or thought-out and thus healthier. Alternatively, some families may not own a table or have room for a table, and these families might differ from other families by socioeconomic status or in the importance they place on meals. Meals Served Family-Style was associated with higher HMI Adequacy scores. One possible reason that a meal might have higher HMI Adequacy scores, but not HMI Moderation scores could be that the meal has greater overall variety of foods served. The greater number of healthy foods would lead to a higher HMI Adequacy score, whereas the greater number of unhealthy foods would lead to a lower HMI Moderation score. The finding that having the television off during the meal was associated with higher HMI scores is consistent with other studies. In a recent study that utilized direct meal observation, Trofholz and colleagues19 found that having the television on during the meal was associated with lower healthfulness of foods served during the meal, using an index similar to the HMI. In a study of preschool children, FitzPatrick and colleagues38 found that each night the television was on during dinner was associated with lower frequency of serving fruits or vegetables. The findings regarding television are also consistent with literature on the negative associations between television viewing and overall diet quality.15-17 Parent Partaking was not associated with HMI scores. Because family participation is a key component of the current definition of a family meal in the literature, these findings differ from the current understanding of the mechanisms through which family meals affect diet quality. For example, Burgess-Champoux and colleagues10 found that eating regular family meals, defined as meals in which “all or most of the family” ate together, was positively associated with dietary intake of vegetables, calcium-rich foods, fiber, and several vitamins and minerals in a longitudinal study of adolescents; however, the healthfulness of meals served was not assessed. Fink and colleagues11 found that children

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consuming five family meals per week, defined as meals that were shared by members of the household and prepared at home, had lower overall intakes of sugar-sweetened beverages and greater fruit and vegetable intake. These findings may suggest that the association of family presence at meals with overall diet quality works through a different pathway than healthfulness of the meals served, such as greater family functioning and parental support, which influence a child’s ability to make healthful decisions in choosing which food to consume.32,50 The finding that Family Meals were associated with HMI scores is consistent with previous literature examining the association between family meal frequency and overall diet quality.11-14 However, this study adds to the literature by elucidating some of the potential mechanisms driving those previously observed associations. In particular, there are two novel components to this investigation that expand our understanding of the family meal. First, in this study, individual components that are commonly used to define a family meal were assessed. Second, the association between family meals and meal healthfulness, one hypothesized pathway between family meals and diet quality, can be examined. When a family meal is broken down into its defining components, the underlying factors of a family meal that may be driving the observed associations can be identified. This allows researchers to identify which components of a family meal may be important to promote. It also shines light on a major flaw in the assumption that increasing the frequency of family meals can improve child nutrition just because the two are associated. Although this study examined only a piece of that puzzle, here one can see more easily that there is not a true logical pathway that leads from the variables used to define a family meal and meal healthfulness. Sitting at a table, eating without television viewing, serving meals family style, or the presence of a parent cannot directly change the healthfulness of foods served at the meal. There is more likely an underlying factor at play within a parent’s behavior, knowledge, and beliefs that leads to both the meal environment and the healthfulness of foods served at a meal. For example, parents who are more invested in their children’s health may be more likely to serve healthier meals and also to follow recommended feeding practices, such as eating at a table, serving family style, having the television off, and partaking in the meal. Socioeconomic status may also affect parents’ ability to access, purchase, and prepare healthful meals, as well as their ability to be present at meals, sit at a table, or serve meals family style. Although most studies, including this one, do attempt to control for socioeconomic factors, these variables cannot fully capture the extent of variability in socioeconomic status within a population. The second major aspect of this study that furthers the family meal literature is that the outcome was the food served at an individual meal, whereas the other studies have examined overall dietary intake as the outcome.11-14 Because many previous studies have demonstrated an association between family meals and dietary intake,11-14 it is now important for the field to gain a better understanding of the mechanisms that drive that association. This study demonstrates that one piece of that pathway may involve the association between family meals and meal healthfulness. However, a multitude of other potential pathways need to be

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RESEARCH investigated further. Some future questions to be addressed include, Do children choose more healthful foods to consume during family meals, and if so, why? and, Do children who regularly participate in family meals choose more healthful foods outside of family meals and if so, why? Understanding these pathways is crucial to designing effective interventions. It is important to note that the HMI scores, calculated based on the presence or absence of foods served to children at a meal, do not account for quantities served or consumed. Current feeding guidelines recommend that children are presented with a variety of healthful foods and allowed to decide how much to eat.5,50-53 The goal of such advice is to increase acceptance of a variety of foods by increasing exposure to different types of healthy foods and to increase the child’s reliance on using their internal hunger and satiety cues to dictate how much food to consume. The HMI allowed for better assessment of whether parents were following feeding recommendations than a measure of dietary intake, which would be confounded by an individual child’s preferences. There is evidence that the healthfulness of foods served during the meal is highly correlated with consumption during the meal. Trofholz and colleagues37 recently found that meal healthfulness was associated with overall diet quality and also that the presence of individual food groups during a meal was associated with greater dietary consumption of those foods.37 However, some aspects of parents’ feeding practices that have been shown to affect the quantity of food that a child consumes, such as responsive feeding (ie, whether a parent responds to hunger cues vs employing pressure, restriction, or indulgent feeding practices) were not included in this study.5,54 The present study has several strengths. First, the use of direct observation from videotaped dinners at home provides a more detailed examination of characteristics within the family mealtime environment in a naturalistic setting that may not be apparent within a laboratory setting, using inperson observation, or using self-reported measures from parents.55 The natural setting within the home also allows for greater variability of characteristics, because the meals are not staged. In addition, use of a validated instrument—the HMI—allowed for the measurement of the healthfulness of meals served. This study included young children during a critical time for the development of eating habits and adds findings on a different study population to family mealtime literature.42 Results from the present study must be interpreted with caution, in light of limitations. Cause and effect cannot be determined from a cross-sectional study and unmeasured confounding variables may have influenced the results. Participants may have modified their behavior and meal content due to awareness of being videotaped, which would have led to an upward bias of the estimates. Recall bias during telephone interviews after meals could have also occurred. Furthermore, the portion size of the foods assessed using the HMI was not recorded and the HMI did not measure preparation method or the presence of condiments. Another difference between this study and other previous studies that examined the association of eating together as a family is that, in this study, only whether the enrolled parent was present, sitting and eating or drinking at the table was examined and not whether other family members were present.7,9,10,12,13,27,30-32 It is possible that the presence of --

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other family members or guests may have been associated with the healthfulness of food served. In addition, preparation style of the meal (such as whether the meal was cooked from scratch in the home), which has been used in another study as a defining characteristic of a family meal,11 could not be assessed. Although the sample was restricted to lowincome families, as a result of the recruitment strategy from Head Start agencies additional income data were not available. Finally, this study was cross-sectional, prohibiting establishment of temporality, and may not be generalizable to children outside the ages 4 to 8 years, to other race/ethnicities or cultures, or to families of higher income.

CONCLUSIONS This study furthers the family meal literature by examining specific meal characteristics that are associated with meal healthfulness. Through a more nuanced examination of these structural characteristics, one can better understand the pathways through which family meals are associated with overall diet quality. Future intervention studies should investigate whether changes in the meal environment (such as eating at a table with the television off and serving meals family style) can positively influence the healthfulness of foods served in the meal. In addition, the associations between the healthfulness of meals served with overall dietary quality and risk of obesity should be studied, to allow for a better understanding of how changes in meal healthfulness can influence overall health.

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RESEARCH AUTHOR INFORMATION N. Kasper is a postdoctoral fellow, Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor; at the time of the study, she was a graduate student, Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor. S. C. Ball is a senior research area specialist, Department of Nutritional Sciences, School of Public Health, and the Michigan Nutrition Obesity Research Center, University of Michigan, Ann Arbor. K. Halverson is a regulatory affairs specialist, The Wonderful Company, Los Angeles; at the time of the study, she was a nutrition specialist and graduate student, Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor. A. L. Miller is associate professor of health behavior & health education, and a research associate professor, Center for Human Growth and Development, University of Michigan, Ann Arbor. D. Appugliese is the chief executive officer, Appugliese Professional Advisors LLC, Easton, MA. J. C. Lumeng is professor of nutritional sciences, School of Public Health; research professor, Center for Human Growth and Development; and professor of pediatrics and communicable diseases, Medical School, University of Michigan, Ann Arbor. K. E. Peterson is professor of nutritional sciences and chair, Department of Nutritional Sciences, and professor of global public health, School of Public Health, University of Michigan, Ann Arbor. Address correspondence to: Karen E. Peterson, ScD, Department of Nutritional Sciences, University of Michigan, 1415 Washington Heights, SPHI 1867, Ann Arbor, MI 48109-2029. E-mail: [email protected]

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

FUNDING/SUPPORT This research was supported by grant 5R01HD061356 from the National Institutes of Health. S. C. Ball, K. Halverson, and N. Kasper and were supported in part by the University of Michigan Momentum Center.

AUTHOR CONTRIBUTIONS N. Kasper conceived of the study question, statistical methods, and wrote the manuscript; S. C. Ball and K. Halverson conducted the literature review and assisted in writing the manuscript; A. L. Miller, J. C. Lumeng, and K. E. Peterson designed the study and oversaw data collection and analyses; and D. Appugliese conducted all data analysis and provided statistical expertise. All authors reviewed and commented on subsequent drafts of the manuscript.

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