- Email: [email protected]
Food hiding and weight control behaviors among ethnically diverse, overweight adolescents. Associations with parental food restriction, food monitoring, and dissatisfaction with adolescent body shape
Appetite 52 (2009) 266–272
Contents lists available at ScienceDirect
Appetite journal homepage: www.elsevier.com/locate/appet
Research report
Food hiding and weight control behaviors among ethnically diverse, overweight adolescents. Associations with parental food restriction, food monitoring, and dissatisfaction with adolescent body shape DenYelle Baete Kenyon a,*, Jayne A. Fulkerson b, Harsohena Kaur c a b c
Sanford Research/USD, Health Disparities Research Center, 900 W. Delaware St, Sioux Falls, SD 57104, USA University of Minnesota, School of Nursing, 5-160 Weaver-Densford Hall, 308 Harvard Street S.E., Minneapolis, MN 55455, USA University of Minnesota, General Pediatrics and Adolescent Health, Department of Pediatrics, 717 Delaware St SE, 3rd Floor (West), Minneapolis, MN 55414, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 May 2008 Received in revised form 9 October 2008 Accepted 19 October 2008
The present study aims to extend previous research conducted with children by examining associations between parental behaviors (food restriction, food monitoring) and parental perceptions (dissatisfaction with adolescent body shape) with adolescent behaviors (food hiding and weight control behaviors) among an ethnically diverse sample of overweight adolescents. Survey data were collected from overweight adolescents and their parents/guardians (n = 116 dyads) at an urban Midwest adolescent health clinic. Adjusting for parent and adolescent demographic characteristics, logistic regression analyses revealed a significant positive association between parental food restriction and adolescent food hiding. No significant associations were found between dissatisfaction with adolescent body shape or parental food monitoring and adolescent food hiding and adolescent weight control behaviors when controlling for demographic factors. Interventions with parents of overweight adolescents should focus on helping parents talk with their adolescents about weight concerns in a non-judgmental way and teaching parents strategies to both create a healthful home food environment and guide and support their adolescents to lose weight in a healthful manner. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Food hiding Weight control behaviors Food restriction Food monitoring Dissatisfaction with adolescent body shape Overweight Adolescents Parent food behaviors Parent feeding practices
Obesity is an escalating problem during adolescence. Recently, a nationwide survey in the United States revealed that over onethird of adolescents (aged 12–19) were overweight or at risk for overweight (Ogden et al., 2006). Increasingly, obesity in adolescence is becoming an international epidemic (James, Leach, Kalamara, & Shayeghi, 2001). Unfortunately, adolescents are a vulnerable population in terms of unfavorable nutritional intake (Schneider, 2000) and their susceptibility to dangerous weight control behaviors (Boutelle, Neumark-Sztainer, Story, & Resnick, 2002). This is a critical problem because adolescent overweight status bears a greater health burden in adulthood (James et al., 2001). Adolescent weight status is theorized to be influenced by many factors. Influences on adolescents’ weight status include individual (Story, Neumark-Sztainer, & French, 2002), physical environment (Davison & Birch, 2001), societal (Booth et al., 2001), and of most interest to the present study, social environment or interpersonal
* Corresponding author. E-mail address: [email protected] (D.B. Kenyon). 0195-6663/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2008.10.004
factors (Fulkerson, Strauss, Neumark-Sztainer, Story, & Boutelle, 2007). One important social influence to examine is the family environment. Although frequency of family meals decreases with age (Fulkerson, Neumark-Sztainer, & Story, 2006), and adolescents spend increasing amounts of time with their peers, parents still remain a strong influence in adolescents’ lives (Smetana, Campione-Barr, & Metzger, 2006). The family environment is important to examine because it is a proximal contextual factor, where experiences with food and eating patterns in the family can be directly intervened and modified (Birch & Fisher, 1998). Much of the research examining children’s eating behaviors and weight status in conjunction with the family environment has been conducted with young children under the age of 7 years (Birch & Fisher, 2000; Fisher & Birch, 2000; Stice, Agras, & Hammer, 1999). Although it is likely that younger children are more influenced by their parents than older youth, not much is known about parent–adolescent relationships regarding eating behaviors. This is true particularly for overweight adolescents, who are a critical population for intervention efforts because they are at a crucial juncture for establishing healthy eating and physical activity habits before the transition to adulthood.
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Associations between parental control and adolescent behaviors Previous research has examined several aspects of the parent– child relationship that may be associated with adolescent eating behaviors, including parental food control (e.g., parental modeling of eating behaviors and parent child-feeding practices) and beliefs (e.g., parent nutritional knowledge). In particular, positive parental verbal commentary has been shown to be associated with health behaviors among overweight youth. For example, parental encouragement of vegetable intake has been shown to be positively associated with higher vegetable consumption in overweight boys (Bourdeaudhuij et al., 2006). On the other hand, negative commentary has also been shown to have an effect. Overweight sons were more likely to engage in unhealthy weight control behaviors if their mothers encouraged them to diet (Fulkerson et al., 2007). Similarly, overweight adolescent females and males were found to have higher rates of unhealthy weight control behaviors if their fathers’ encouraged them to diet (Fulkerson et al., 2007). Further, negative maternal commentary has also been linked to more binge eating in a sample of boys who ranged in weight from underweight to obese (Fulkerson et al., 2002). In the same vein, family members’ weight-based teasing has shown to be damaging to adolescents’ emotional health (Eisenberg, Neumark-Sztainer, Haines, & Wall, 2006). Research examining parental control of child-feeding practices (monitoring, restriction, responsibility, and pressure to eat), mostly with preschool and school-age children, has been mixed. On the one hand, negative repercussions of parental food monitoring and food restriction have been found, with greater parental food restriction linked to more snacking in preschool girls (Birch & Fisher, 2000; Fisher & Birch, 1999). Likewise, parental control of children’s eating and exercise has been positively associated with children’s unhealthy eating (Arredondo et al., 2006). One hypothesis for how restriction of foods (usually energydense foods) may increase children’s risk of overweight is that these children are likely to overeat restricted foods when they have access (Davison & Birch, 2001). In fact, parental monitoring of specific food intake and restriction have been found to be especially detrimental to overweight children, who were more likely to show the greatest amount of overeating over time (Birch, Fisher, & Davison, 2003). On the other hand, additional research has failed to find an association between parental control and actual eating behaviors among children (Robinson, Kiernan, Matheson, & Haydel, 2001). As previously mentioned, none of the research in this area to date has included adolescents. Further, much of the research of parental influences on child eating behaviors has not separated the monitoring of food from general parental food restriction (Fisher & Birch, 1999). Thus, the present study aims to examine parental behaviors and eating behaviors among adolescent offspring, and separate parental food monitoring from food restriction in the assessment of these behaviors with adolescent food hiding and weight control behaviors. Associations between parental beliefs and adolescent behaviors Likewise, parental beliefs, not just parental behaviors, have been found to have a varied relationship with adolescents’ eating behaviors. For example, mothers’ perceptions of their daughters’ overweight risk have been found to be associated with their 5-yearold daughters’ lack of establishing self-control of food intake (Birch & Fisher, 2000). Mothers with a higher level of perceived risk of overweight in their child were more likely to have children with higher levels of overeating. Similarly, mothers’ dissatisfaction with their own body weight when their child was 1-month-old predicted
267
a greater likelihood of that child having unhealthy weight control behaviors at age 5 (Stice et al., 1999). Again, most of this work has been conducted with young children and their parents. One adolescent belief that has been found to be associated with adolescents’ eating and weight control behaviors is their own body dissatisfaction (Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002). Adolescents have been found to have higher levels of depression when they have a greater mismatch between how they want to look and how they actually perceive themselves to look (Sinton & Birch, 2006). However, there does not appear to be any research that has examined whether parents’ dissatisfaction of their adolescents’ body shape is associated with adolescent eating or weight control behaviors. Present study To date there is a dearth of research that examines the associations between adolescent eating or weight control behaviors and parental beliefs and behaviors. A majority of the research on parental restriction and monitoring has been performed with young, normal weight children in preschool (Birch & Fisher, 2000; Fisher & Birch, 2000). Therefore, it is not known how these associations may play out differently when examined among adolescents, particularly those who are overweight. By examining a sample that includes only overweight adolescents, we will help clarify the associations of parental control and beliefs among overweight adolescents. The aim of the present study is to examine how parental behaviors and beliefs are associated with adolescent food hiding and weight management behaviors. Based on the previous work of food restriction with young children and the literature of adolescent high risk eating behaviors, the present study posits the following hypotheses: (a) parental food restriction will be positively associated with adolescent food hiding and weight control behaviors, (b) parental food monitoring will be positively associated with adolescent food hiding and weight control behaviors, and (c) parental dissatisfaction with adolescent body shape will be positively associated with adolescent food hiding and weight control behaviors. The present study extends previous literature on parental foodrelated behaviors on adolescent eating/weight control behaviors by using (a) a sample of adolescents, rather than children, (b) a sample of adolescents with a BMI greater than the 85th percentile (which includes the CDC defined weight categories of ‘‘at risk for overweight’’ and ‘‘overweight’’), heretofore referred to as ‘‘overweight,’’ (c) participants who are ethnically diverse (mostly African American), and (d) data collected from parent and adolescent dyads rather than one reporter. Method Participants and procedure The present study utilized data collected from adolescents and their accompanying parents/guardians at an urban adolescent health clinic affiliated with a children’s hospital in the Midwest. Adolescents were seen for annual well-teen checkups, preparticipation sports physicals, reproductive health care, and common primary care problems such as acne, minor infections, school and behavior problems, mental health and social issues. The clinic volume was approximately 10,000 outpatient visits a year with about 60% of those being unique visits. Participants were approached when they checked in at the clinic. Exclusion criteria were an inability to understand English or having a cognitive disability that prevented participation. When more than one
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
268
adolescent from a family was at the clinic for a visit, the younger adolescent was selected to participate. Informed consent from the parent/guardian and assent from the adolescent were obtained. To maintain confidentiality, interviews were conducted in separate private interview rooms for parents and adolescents. Trained research staff administered the surveys, reading all the questions and responses aloud. Flip charts listing the responses were utilized to aid respondents in making choices. Adolescent weight and height were measured by the clinic staff, and were used to calculate body mass index (BMI) and BMI percentiles (BMI%) were generated using NCHS growth charts (Kuczmarski et al., 2002). No identifying information was recorded, and adolescent and parent surveys were linked using a unique study identification number. Adolescent and parent participants each received a $20 gift certificate for compensation. Over 4 months, 696 persons were approached and 49.3% agreed to participate, with 301 adolescents and 260 parents/guardians completing the survey. The present study sample included 116 dyads (see Table 1) of overweight adolescents (weight at or above 85th percentile) between the ages of 12 and 19.2 years (M = 15.1 years, S.D. = 1.7 years), and one of their parents/guardians (M = 40 years, S.D. = 7.5 years). Eighty percent of the parents were mothers and 11.2% were fathers. Although 9% of the parent sample was not a mother or father, the ‘‘other’’ category included grandparents (n = 3 grandmothers), other female relatives (n = 3), unrelated female guardians (n = 4), and all of them reported living with the adolescent at least some of the time. For simplicity, we will refer to all female guardians as ‘‘mothers’’. The study was reviewed and approved by the Human Subjects Committees at the Children’s Mercy Hospital in Kansas City and the University of Kansas Medical Center. Measures The present study focuses on data from the parent and adolescent surveys which took approximately 30 min to complete.
It was a comprehensive survey which included questions taken from other sources as described below to assess demographics, dietary practices, physical activity, smoking behaviors, availability of food in the home, perception of body shape, weight history, and attitudes towards eating. Dependent variables Food Hiding: Adolescents’ report of food hiding behavior was assessed with one item asking, ‘‘How often do you buy food and/or hide food so your parents won’t find out’’. Response options ranged from 1 = Usually to 5 = Never, and was reverse scored so that higher scores reflect higher frequency of food hiding behaviors. Food hiding frequency was skewed, thus the variable was dichotomized into 0 = Never and 1 = Rarely—usually for logistic regression analyses. Healthy and Unhealthy Weight control Behaviors: Adolescents reported weight control behaviors (healthy and unhealthy) using eight items based on the 2001 National Youth Risk Behavior Survey (Grunbaum et al., 2002). Consistent with previous research (Neumark-Sztainer et al., 2002), healthy weight control behavior items were ‘‘did you exercise to lose weight or maintain your current weight’’, and ‘‘did you eat less food, fewer calories, or foods low in fat to lose weight or maintain your current weight.’’ Unhealthy weight control behavior items were did you ‘‘go without eating for 24 h or more (also called fasting) to lose weight or maintain your current weight’’, ‘‘take any diet pills like Metabolife, powders or liquids without a doctor’s advice, to lose weight or maintain your current weight’’, ‘‘vomit to lose weight or maintain your current weight’’, ‘‘take laxatives to lose weight or maintain your current weight’’, ‘‘skip meals to lose weight or maintain your current weight’’, and ‘‘follow a diet program such as Weight Watchers, Jenny Craig, or Suzanne Sommers to lose weight or maintain your current weight’’. Adolescents marked 0 = No or 1 = Yes to indicate whether they had engaged in the behaviors in
Table 1 Demographic characteristics and dependent variables (n = 116). Parents (n = 116)
All adolescents (n = 116)
Adolescent females (n = 74)
Adolescent males (n = 42) n (%)
n (%)
n (%)
n (%)
Gender Female Male
104 (90.0) 12 (10.0)
74 (63.8) 42 (36.2)
74 (100)
Ethnicity Black White Other
69 (59.5) 34 (29.3) 12 (10.3)
71 (61.2) 30 (25.9) 15 (12.9)
45 (60.8) 24 (32.4) 5 (6.8)
26 (61.9) 6 (14.3) 10 (23.8)
Relationship to teen Mother Father Other
93 (80.2) 13 (11.2) 10 (8.6)
Parent education
20 (17.2) 39 (33.6) 57 (49.1)
Food hiding Never Rarely—usually
94 (81.0) 22 (19.0)
63 (85.1) 11 (14.9)
31 (73.8) 11 (26.2)
Healthy weight control behaviors None One or more
17 (15.0) 96 (85.0)
11 (15.3) 61 (84.7)
6 (14.6) 35 (85.4)
Unhealthy weight control behaviors None One or more
17 (34.0) 33 (66.0)
11 (33.3) 22 (66.7)
6 (35.3) 11 (64.7)
42 (100)
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
the last 30 days. Items were summed separately for the healthy and unhealthy subscales and then response options were collapsed into 0 = None and 1 = One or more categories for weight control behaviors analyses because of the low frequency of unhealthy weight control behaviors. Independent variables Parental Food Monitoring: Parents’ perceptions of tracking their children’s intake of sweets, snack foods, high fat foods, and sugared beverages were assessed using the four item Monitoring subscale from the Child Feeding Questionnaire (Birch et al., 2001). The CFQ has been validated in this sample of adolescents (Kaur et al., 2006). Example items include, ‘‘How often do you keep track of the high fat food that your teen eats’’ and ‘‘How often do you keep track of soda pop and drinks like Gatorade, Kool-aid, and Splash that your teen drinks’’. Items were rated on a five-point Likert scale ranging from 1 = Never to 5 = Always, and for each parent, the items were summed and a mean score was obtained. The scale was found to have high internal consistency in the present sample (a = .91). Parental Food Restriction: Parental behaviors to curb and regulate the intake of ‘‘junk’’ foods were assessed using the six items Restriction subscale from the Child Feeding Questionnaire, excluding the food reward items (Birch et al., 2001). The subscale has been validated in this sample of adolescents (Kaur et al., 2006). Parents’ degree of agreement was assessed on a five-point Likert scale ranging from 1 = Disagree to 5 = Agree. Example items include, ‘‘I have to watch out that my teen does not eat too many sweets like candy, ice cream, cake, or pastries’’ and ‘‘I intentionally keep some foods out of the house so my teen won’t eat them’’. Items were scored following the protocol established by Birch et al. (2001), and the scale was found to have adequate internal consistency in the present sample (a = .85). Parental Dissatisfaction with Adolescent Body Shape: Parents’ perception of dissatisfaction with their adolescent’s body shape was measured using the Gardner 13-figure schematic contour scale (Gardner, Stark, Jackson, & Friedman, 1999). The Gardner images were selected because the figures are intentionally free of details, such as hair and facial characteristics, therefore making it applicable to persons of a variety of ethnicities (Gardner et al., 1999). Images were created by generating 13 drawings distorted between 30% by increments of 5%, and were labeled A–M from left to right. Items were recoded with 1 = A and 13 = M, with higher scores indicating a higher perception of adolescent body size. Parents were presented with the gender appropriate version of the scale and asked to select their current assessment of their teen’s body shape, ‘‘Which figure do you think most closely resembles the way your daughter/son looks now?’’, and their ideal body shape for their teen, ‘‘Which figure most closely resembles how you would like your daughter/son to look?’’. Parents’ response to current body shape item was subtracted from their response to the ideal body shape item to obtain the final ‘‘parental dissatisfaction with adolescent body shape score’’. Scores ranged from 3 through 11. Higher scores represent higher parental dissatisfaction with adolescent body shape. Results Statistical analyses Descriptive statistics were conducted for the following variables: parental food monitoring, food restriction, and dissatisfaction with adolescent body shape; and adolescent food hiding and weight control behaviors for the whole adolescent sample and the
269
Table 2 Descriptive for all adolescents (n = 116), and by gender. Variables Total sample Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring Adolescent females Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring Adolescent males Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring
M
S.D.
Observed range
33.0 30.6 2.2
7.9 6.7 2.8
17.5–58.5 22.7–61.1 3–11
3.6 3.1
1.3 1.2
1–5 1–5
32.9 31.0 2.2
7.6 7.0 3.0
19.3–51.5 23.4–61.1 3–11
3.4 3.0
1.3 1.2
1–5 1–5
33.0 30.0 2.1
8.5 6.3 2.4
17.5–58.5 22.7–52.7 3–7
4.0 3.4
1.1 1.1
1.3–5 1.5–5
female and male subsamples (see Tables 1 and 2). Logistic regression analyses were performed with the dependent variables of adolescent food hiding, healthy weight control behaviors, and unhealthy weight control behaviors regressed onto parental monitoring, restriction, and dissatisfaction with adolescent body shape, in separate analyses by outcome. To determine whether demographic characteristics of parents and adolescents might significantly influence the relationships under investigation, correlations of study variables with demographic variables (i.e., adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, parent BMI parent gender, and parent ethnicity) were conducted. Because at least one of the correlational findings with adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, and parent BMI were significant, we chose to adjust for these demographic variables in one set of our analyses (see below) to see if associations between parental behaviors and beliefs and adolescent behaviors were affected by demographic characteristics. Furthermore, the logistic regression analyses were conducted in two ways: (1) ‘‘unadjusted’’ with only the parenting variables as predictors, and (2) ‘‘adjusted’’ with demographic variables of adolescent age, gender, ethnicity, BMI, and parent BMI as correlates, to determine if demographic characteristics change the association between the parenting variables and adolescent behaviors. Parental dissatisfaction with adolescent body shape and adolescent food-related behaviors As shown in Table 3, unadjusted logistic regression analyses regarding parental dissatisfaction with adolescent body shape and healthy adolescent weight control behaviors revealed a significant positive association. However the association was not significant after accounting for the demographic variables in the adjusted analysis. Similarly, unadjusted logistic regression analyses regarding parental dissatisfaction with adolescent body shape and unhealthy adolescent weight control behaviors revealed a significant positive association. However, after accounting for the demographic variables in the adjusted analysis, the association was no longer significant. Both unadjusted and adjusted logistic regression models demonstrated that the association between
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
270
Table 3 Logistic regression models of adolescent behaviors regressed onto parental behaviors and beliefsa (n = 116). Parental beliefs and behaviors
Adolescent health behaviors Food hiding Odds ratio
Unadjusted Parental dissatisfaction with adolescent body shape
Healthy weight control behaviors
Unhealthy weight control behaviors
95% confidence interval Odds ratio 95% confidence interval Odds ratio 95% confidence interval
1.00
.84–1.19
1.31*
1.02–1.68
1.41*
1.06–1.88
Adjusted Parental dissatisfaction with adolescent body shape .98 Adolescent age .99 b Adolescent gender 1.99 c Adolescent ethnicity .69 Parent BMI 1.02 Adolescent BMI 1.00
.79–1.22 .97–1.02 .73–5.40 .20–2.43 .96–1.09 .92–1.10
1.16 .99 1.13 1.05 1.00 1.12
.87–1.56 .96–1.02 .33–3.81 .27–4.02 .92–1.08 .94–1.34
1.21 .97y .35 .64 .99 1.23y
.84–1.74 .93–1.01 .06–1.87 .11–3.78 .91–1.07 .97–1.56
Unadjusted Parental food restriction
1.76*
1.09–2.84
1.45y
.98–2.13
1.65*
1.01–2.67
Adjusted Parental food restriction Adolescent age Adolescent genderb Adolescent ethnicityc Parent BMI Adolescent BMI
1.75* 1.01 1.56 1.02 1.01 .97
1.06–2.88 .98–1.03 .57–4.28 .32–3.27 .95–1.08 .89–1.06
1.30 .99 .98 1.12 1.00 1.15y
.85–1.98 .96–1.02 .28–3.43 .29–4.29 .92–1.08 .98–1.35
1.40 .97 .33 .65 .99 1.29*
.78–2.52 .94–1.01 .06–1.78 .11–3.87 .91–1.07 1.04–1.59
Unadjusted Parental food monitoring
1.55*
1.01–2.37
.89
.57–1.39
1.12
.66–1.91
Adjusted Parental food monitoring Adolescent age Adolescent genderb Adolescent ethnicityc Parent BMI Adolescent BMI
1.57y 1.01 1.81 1.05 1.01 .98
.98–2.50 .98–1.03 .67–4.89 .32–3.42 .95–1.08 .90–1.06
.72 .98 1.15 .89 1.00 1.19*
.79 .96y .32 .38 1.00 1.34*
.38–1.65 .92–1.00 .06–1.77 .06–2.56 .92–1.08 1.06–1.68
a b c y *
.44–1.20 .95–1.01 .35–3.80 .23–3.40 .93–1.09 1.01–1.40
Adjusted for adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, and parent BMI. Male is the reference group for gender. White is the reference group for ethnicity. p < .10. p < .05.
parental dissatisfaction with adolescent body shape and adolescent food hiding was not significant. Parental food restriction and adolescent food-related behaviors Logistic regression analyses regarding parental food restriction and adolescent food hiding revealed a significant positive association, even when controlling for the demographic variables (see Table 3). Unadjusted logistic regression analyses regarding parental food restriction and both healthy and unhealthy adolescent weight control behaviors revealed a significant positive association for unhealthy weight control behaviors, and a trend-level positive association for healthy weight control behaviors. However these associations were not significant after accounting for the demographic variables in the adjusted analyses. Parental food monitoring and adolescent food-related behaviors Unadjusted logistic regression analyses regarding parental food monitoring and adolescent food hiding revealed a significant positive association, which was reduced to trend-level when controlling for the demographic variables (see Table 3) The unadjusted and adjusted logistic regression models assessing the associations between parental food monitoring and adolescent food hiding, healthy and unhealthy weight control behaviors were not significant.
Discussion The main goals of the study were to examine the relationships between parents’ food-related control behaviors and beliefs about adolescent body shape and eating/weight control behaviors among a sample of overweight adolescents. The present study expanded previous research in this domain by examining these associations with an ethnically diverse sample of overweight adolescents rather than normal weight children. Although there did not appear to be a significant difference when controlling for ethnic group, testing our hypotheses with a largely African-American sample demonstrates the applicability of the results to diverse populations. The present study’s findings provided some support for our hypotheses by demonstrating significant associations between parental foodrelated behaviors and adolescent food hiding even after controlling for demographic characteristics. These findings suggest that there are some detrimental associations between parents’ and adolescents’ interactions surrounding topics of food and eating behaviors. The present study makes an important contribution to the literature by examining the unique variable of parental dissatisfaction with adolescent body shape with adolescent eating behaviors. Although we did not find significant associations when accounting for demographic factors, to our knowledge, there has not been any research examining parents’ views of the mismatch between how they believe their teen looks and how they want them to look, or of the associations of such a mismatch.
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Examination of the parental dissatisfaction with adolescent body shape variable frequencies demonstrated that even though this sample consisted solely of overweight adolescents, 7% of the parents reported that they wanted their child to have a larger body shape (gain weight), and 26% of the parents wanted their adolescents to remain the same shape. Parallel findings have been found that parents are often not the most accurate judges of their adolescents’ weight (Boutelle, Fulkerson, Neumark-Sztainer, & Story, 2004). Thus, parents appear to be somewhat inaccurate in assessing their adolescent’s weight status, yet parental dissatisfaction with their adolescents’ body shape is positively associated with teenagers’ weight control behaviors (e.g., eating less food, taking diet pills), until analyses are adjusted for demographic factors. It appears that adolescent age and BMI may influence this association (see Table 3). These findings suggest that although adolescent weight control behaviors may be associated with parents’ beliefs about their body shape, the adolescent’s weight or body size is likely to be more influential. Regardless, parents’ comments about adolescents’ body shape may backfire, and cause the adolescents to turn to extreme weight control behaviors, such as vomiting (Fulkerson et al., 2007; Stice et al., 1999). Our finding that adolescent food hiding behaviors were positively associated with parental food restriction builds upon previous research on younger children, where parental control was associated with children’s negative eating patterns and weight (e.g., Birch & Fisher, 2000; Birch et al., 2003). Although parents may believe they are helping their adolescents lose weight by trying to make sure they do not eat too many high fat foods or sweets, this food restriction may propel adolescents to hide unhealthy foods and engage in secretive eating behavior. On the other hand, given that our study was cross-sectional, another explanation is that parents may feel they need to restrict food when adolescents engage in food hiding. Regardless of the causal direction, our findings suggest a need for interventions to address overweight adolescents’ food hiding behaviors. These programs can help overweight adolescents identify the reasons why they are hiding food, and give them skills to help curb their desire to consume unhealthy foods in secret. Interventions can also help parents of overweight adolescents learn ways to be supportive of their adolescents’ attempts at healthy eating and help them refrain from negative comments or undue control of adolescents’ eating behaviors. Perhaps the easiest and least conflict ridden tactic would be for parents to make the home food environment healthier, making high-fat and high-sugar foods and beverages less accessible for the entire family, thus taking the focus off of the adolescent. This method would be less likely to target particular family members and promote better family health overall. Like some previous studies of associations between parental control and other child characteristics such as overweight status, increased child eating, and physical activity (Faith et al., 2004; Gable & Lutz, 2000; Robinson et al., 2001), our findings related to parental food restriction and food monitoring were not completely consistent across adolescent health behaviors, as food monitoring was not found to be associated with adolescent weight control behaviors. Although the present research adds to the literature in unique ways, the findings must be viewed in light of the study’s limitations. First, the sample size is somewhat small, and precludes the detection of smaller effect sizes, which may explain why some associations did not fully hold when controlling for demographic factors. Furthermore, the small sample size precluded having enough power to examine associations separately by gender or ethnic group membership. Second, since this is a cross-sectional study, analyses do not allow for causal sequencing. For example,
271
we cannot infer if parental restriction directly causes adolescents to engage in greater frequency of food hiding behaviors. In fact, this may be a reciprocal association, where adolescents who engage in secretive food hiding and unhealthy eating behaviors elicit greater regulation of food and eating behaviors from their mothers and fathers. Lastly, because all adolescents in the sample were obese, variability in the predictor and outcome variables may be limited. There are several important strengths of this study. First, we extended the literature by separating food monitoring behaviors from food restrictive behaviors, and studying a sample of adolescents, rather than children. Second, by studying only overweight adolescents, we were able to assess associations specifically among this high-risk group. Also, our study used data from both adolescents and parents rather than one informant. Lastly, our ethnically diverse population of adolescents and parents (mostly African-American) adds to the growing literature of non-white family patterns of eating and weight control behaviors. Future research with large ethnically diverse samples should assess the potential racial/ethnic differences in the relationship between parental food-related behaviors and adolescent outcomes. More research should continue to examine the construct of food hiding, to further understand the meaning of why overweight adolescents engage in food hiding and what parenting behaviors may lead to secretly hiding food. Acknowledgments Funding support was awarded to the first author from the Adolescent Health Protection Research Training Program (School of Nursing, University of Minnesota) grant number T01 DP000112 (PI: Bearinger) from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. References Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006). Is parenting style related to children’s healthy eating and physical activity in Latino families? Health Education Research, 21, 862–871. Birch, L. L., & Fisher, J. O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101, 539–549. Birch, L. L., & Fisher, J. O. (2000). Mothers’ child-feeding practices influence daughters’ eating and weight. American Journal of Clinical Nutrition, 71, 1054–1061. Birch, L. L., Fisher, J. O., & Davison, K. K. (2003). Learning to overeat: maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. American Journal of Clinical Nutrition, 78, 215–220. Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Sawyer, R., & Johnson, S. L. (2001). Confirmatory factor analysis of the child feeding questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36, 201–210. Booth, S. L., Sallis, J. F., Ritenbaugh, C., Hill, J. O., Birch, L. L., Frank, L. D., et al. (2001). Environmental and societal factors affect food choice and physical activity: rationale, influences, and leverage points. Nutrition Reviews, 59, S21–S39. Bourdeaudhuij, I. de. , Yngve, A., Velde, S. J. te. , Klepp, K. I., Rasmussen, M., Thorsdottir, I., et al. (2006). Personal, social and environmental correlates of vegetable intake in normal weight and overweight 9 to 13-year old boys. International Journal of Behavioral Nutrition & Physical Activity, 3, 37. Boutelle, K., Fulkerson, J. A., Neumark-Sztainer, D., & Story, M. (2004). Mothers’ perceptions of their adolescents’ weight status: are they accurate? Obesity Research, 12, 1754–1757. Boutelle, K., Neumark-Sztainer, D., Story, M., & Resnick, M. (2002). Weight control behaviors among obese, overweight, and nonoverweight adolescents. Journal of Pediatric Psychology, 27, 531–540. Davison, K. K., & Birch, L. L. (2001). Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews, 2, 159–171. Eisenberg, M. E., Neumark-Sztainer, D., Haines, J., & Wall, M. (2006). Weight-teasing and emotional well-being in adolescents: longitudinal findings from project EAT. Journal of Adolescent Health, 38, 675–683. Faith, M. S., Berkowitz, R. I., Stallings, V. A., Kerns, J., Storey, M., & Stunkard, A. J. (2004). Parental feeding attitudes and styles and child body mass index: prospective analysis of a gene-environment interaction. Pediatrics, 114, 429–436. Fisher, J. O., & Birch, L. L. (1999). Restricting access to foods and children’s eating. Appetite, 32, 405–419.
272
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Fisher, J. O., & Birch, L. L. (2000). Parents’ restrictive feeding practices are associated with young girls’ negative self-evaluation of eating. Journal of the American Dietetic Association, 100, 1341–1346. Fulkerson, J. A., McGuire, M. T., Neumark-Sztainer, D., Story, M., French, S. A., & Perry, C. L. (2002). Weight-related attitudes and behaviors of adolescent boys and girls who are encouraged to diet by their mothers. International Journal of Obesity & Related Metabolic Disorders: Journal of the International Association for the Study of Obesity, 26, 1579–1587. Fulkerson, J. A., Neumark-Sztainer, D., & Story, M. (2006). Adolescent and parent views of family meals. Journal of the American Dietetic Association, 106, 526– 532. Fulkerson, J. A., Strauss, J., Neumark-Sztainer, D., Story, M., & Boutelle, K. (2007). Correlates of psychosocial well-being among overweight adolescents: the role of the family. Journal of Consulting & Clinical Psychology, 75, 181–186. Gable, S., & Lutz, S. (2000). Household, parent, and child contributions to childhood obesity. Family Relations, 49, 293–300. Gardner, R. M., Stark, K., Jackson, N. A., & Friedman, B. N. (1999). Development and validation of two new scales for assessment of body-image. Perceptual & Motor Skills, 89, 981–993. Grunbaum, J. A., Kann, L., Kinchen, S. A., Williams, B., Ross, J. G., Lowry, R., et al. (2002). Youth risk behavior surveillance—United States, 2001. Journal of School Health, 72, 313–328. James, P. T., Leach, R., Kalamara, E., & Shayeghi, M. (2001). The worldwide obesity epidemic. Obesity Research, 9, 228S–233S. Kaur, H., Li, C., Nazir, N., Choi, W. S., Resnicow, K., Birch, L. L., et al. (2006). Confirmatory factor analysis of the child-feeding questionnaire among parents of adolescents. Appetite, 47, 36–45.
Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L. M., Flegal, K. M., Mei, Z., et al. (2002). 2000 CDC growth charts for the United States: methods and development. Vital & Health Statistics—Series 11: Data From the National Health Survey, 246, 1–190. Neumark-Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weightrelated concerns and behaviors among overweight and nonoverweight adolescents: implications for preventing weight-related disorders. Archives of Pediatrics & Adolescent Medicine, 156, 171–178. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 1999–2004. Journal of American Medical Association, 295, 1549–1555. Robinson, T. N., Kiernan, M., Matheson, D. M., & Haydel, K. F. (2001). Is parental control over children’s eating associated with childhood obesity? Results from a population-based sample of third graders. Obesity Research, 9, 306–312. Schneider, D. (2000). International trends in adolescent nutrition. Social Science & Medicine, 51, 955–967. Sinton, M. M., & Birch, L. L. (2006). Individual and sociocultural influences on preadolescent girls’ appearance schemas and body dissatisfaction. Journal of Youth and Adolescence, 35, 165–175. Smetana, J. G., Campione-Barr, N., & Metzger, A. (2006). Adolescent development in interpersonal and societal contexts. Annual Review of Psychology, 57, 255–284. Stice, E., Agras, W. S., & Hammer, L. D. (1999). Risk factors for the emergence of childhood eating disturbances: a five-year prospective study. International Journal of Eating Disorders, 25, 375–387. Story, M., Neumark-Sztainer, D., & French, S. (2002). Individual and environmental influences on adolescent eating behaviors. Journal of the American Dietetic Association, 102, 40–51.
Contents lists available at ScienceDirect
Appetite journal homepage: www.elsevier.com/locate/appet
Research report
Food hiding and weight control behaviors among ethnically diverse, overweight adolescents. Associations with parental food restriction, food monitoring, and dissatisfaction with adolescent body shape DenYelle Baete Kenyon a,*, Jayne A. Fulkerson b, Harsohena Kaur c a b c
Sanford Research/USD, Health Disparities Research Center, 900 W. Delaware St, Sioux Falls, SD 57104, USA University of Minnesota, School of Nursing, 5-160 Weaver-Densford Hall, 308 Harvard Street S.E., Minneapolis, MN 55455, USA University of Minnesota, General Pediatrics and Adolescent Health, Department of Pediatrics, 717 Delaware St SE, 3rd Floor (West), Minneapolis, MN 55414, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 May 2008 Received in revised form 9 October 2008 Accepted 19 October 2008
The present study aims to extend previous research conducted with children by examining associations between parental behaviors (food restriction, food monitoring) and parental perceptions (dissatisfaction with adolescent body shape) with adolescent behaviors (food hiding and weight control behaviors) among an ethnically diverse sample of overweight adolescents. Survey data were collected from overweight adolescents and their parents/guardians (n = 116 dyads) at an urban Midwest adolescent health clinic. Adjusting for parent and adolescent demographic characteristics, logistic regression analyses revealed a significant positive association between parental food restriction and adolescent food hiding. No significant associations were found between dissatisfaction with adolescent body shape or parental food monitoring and adolescent food hiding and adolescent weight control behaviors when controlling for demographic factors. Interventions with parents of overweight adolescents should focus on helping parents talk with their adolescents about weight concerns in a non-judgmental way and teaching parents strategies to both create a healthful home food environment and guide and support their adolescents to lose weight in a healthful manner. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Food hiding Weight control behaviors Food restriction Food monitoring Dissatisfaction with adolescent body shape Overweight Adolescents Parent food behaviors Parent feeding practices
Obesity is an escalating problem during adolescence. Recently, a nationwide survey in the United States revealed that over onethird of adolescents (aged 12–19) were overweight or at risk for overweight (Ogden et al., 2006). Increasingly, obesity in adolescence is becoming an international epidemic (James, Leach, Kalamara, & Shayeghi, 2001). Unfortunately, adolescents are a vulnerable population in terms of unfavorable nutritional intake (Schneider, 2000) and their susceptibility to dangerous weight control behaviors (Boutelle, Neumark-Sztainer, Story, & Resnick, 2002). This is a critical problem because adolescent overweight status bears a greater health burden in adulthood (James et al., 2001). Adolescent weight status is theorized to be influenced by many factors. Influences on adolescents’ weight status include individual (Story, Neumark-Sztainer, & French, 2002), physical environment (Davison & Birch, 2001), societal (Booth et al., 2001), and of most interest to the present study, social environment or interpersonal
* Corresponding author. E-mail address: [email protected] (D.B. Kenyon). 0195-6663/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2008.10.004
factors (Fulkerson, Strauss, Neumark-Sztainer, Story, & Boutelle, 2007). One important social influence to examine is the family environment. Although frequency of family meals decreases with age (Fulkerson, Neumark-Sztainer, & Story, 2006), and adolescents spend increasing amounts of time with their peers, parents still remain a strong influence in adolescents’ lives (Smetana, Campione-Barr, & Metzger, 2006). The family environment is important to examine because it is a proximal contextual factor, where experiences with food and eating patterns in the family can be directly intervened and modified (Birch & Fisher, 1998). Much of the research examining children’s eating behaviors and weight status in conjunction with the family environment has been conducted with young children under the age of 7 years (Birch & Fisher, 2000; Fisher & Birch, 2000; Stice, Agras, & Hammer, 1999). Although it is likely that younger children are more influenced by their parents than older youth, not much is known about parent–adolescent relationships regarding eating behaviors. This is true particularly for overweight adolescents, who are a critical population for intervention efforts because they are at a crucial juncture for establishing healthy eating and physical activity habits before the transition to adulthood.
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Associations between parental control and adolescent behaviors Previous research has examined several aspects of the parent– child relationship that may be associated with adolescent eating behaviors, including parental food control (e.g., parental modeling of eating behaviors and parent child-feeding practices) and beliefs (e.g., parent nutritional knowledge). In particular, positive parental verbal commentary has been shown to be associated with health behaviors among overweight youth. For example, parental encouragement of vegetable intake has been shown to be positively associated with higher vegetable consumption in overweight boys (Bourdeaudhuij et al., 2006). On the other hand, negative commentary has also been shown to have an effect. Overweight sons were more likely to engage in unhealthy weight control behaviors if their mothers encouraged them to diet (Fulkerson et al., 2007). Similarly, overweight adolescent females and males were found to have higher rates of unhealthy weight control behaviors if their fathers’ encouraged them to diet (Fulkerson et al., 2007). Further, negative maternal commentary has also been linked to more binge eating in a sample of boys who ranged in weight from underweight to obese (Fulkerson et al., 2002). In the same vein, family members’ weight-based teasing has shown to be damaging to adolescents’ emotional health (Eisenberg, Neumark-Sztainer, Haines, & Wall, 2006). Research examining parental control of child-feeding practices (monitoring, restriction, responsibility, and pressure to eat), mostly with preschool and school-age children, has been mixed. On the one hand, negative repercussions of parental food monitoring and food restriction have been found, with greater parental food restriction linked to more snacking in preschool girls (Birch & Fisher, 2000; Fisher & Birch, 1999). Likewise, parental control of children’s eating and exercise has been positively associated with children’s unhealthy eating (Arredondo et al., 2006). One hypothesis for how restriction of foods (usually energydense foods) may increase children’s risk of overweight is that these children are likely to overeat restricted foods when they have access (Davison & Birch, 2001). In fact, parental monitoring of specific food intake and restriction have been found to be especially detrimental to overweight children, who were more likely to show the greatest amount of overeating over time (Birch, Fisher, & Davison, 2003). On the other hand, additional research has failed to find an association between parental control and actual eating behaviors among children (Robinson, Kiernan, Matheson, & Haydel, 2001). As previously mentioned, none of the research in this area to date has included adolescents. Further, much of the research of parental influences on child eating behaviors has not separated the monitoring of food from general parental food restriction (Fisher & Birch, 1999). Thus, the present study aims to examine parental behaviors and eating behaviors among adolescent offspring, and separate parental food monitoring from food restriction in the assessment of these behaviors with adolescent food hiding and weight control behaviors. Associations between parental beliefs and adolescent behaviors Likewise, parental beliefs, not just parental behaviors, have been found to have a varied relationship with adolescents’ eating behaviors. For example, mothers’ perceptions of their daughters’ overweight risk have been found to be associated with their 5-yearold daughters’ lack of establishing self-control of food intake (Birch & Fisher, 2000). Mothers with a higher level of perceived risk of overweight in their child were more likely to have children with higher levels of overeating. Similarly, mothers’ dissatisfaction with their own body weight when their child was 1-month-old predicted
267
a greater likelihood of that child having unhealthy weight control behaviors at age 5 (Stice et al., 1999). Again, most of this work has been conducted with young children and their parents. One adolescent belief that has been found to be associated with adolescents’ eating and weight control behaviors is their own body dissatisfaction (Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002). Adolescents have been found to have higher levels of depression when they have a greater mismatch between how they want to look and how they actually perceive themselves to look (Sinton & Birch, 2006). However, there does not appear to be any research that has examined whether parents’ dissatisfaction of their adolescents’ body shape is associated with adolescent eating or weight control behaviors. Present study To date there is a dearth of research that examines the associations between adolescent eating or weight control behaviors and parental beliefs and behaviors. A majority of the research on parental restriction and monitoring has been performed with young, normal weight children in preschool (Birch & Fisher, 2000; Fisher & Birch, 2000). Therefore, it is not known how these associations may play out differently when examined among adolescents, particularly those who are overweight. By examining a sample that includes only overweight adolescents, we will help clarify the associations of parental control and beliefs among overweight adolescents. The aim of the present study is to examine how parental behaviors and beliefs are associated with adolescent food hiding and weight management behaviors. Based on the previous work of food restriction with young children and the literature of adolescent high risk eating behaviors, the present study posits the following hypotheses: (a) parental food restriction will be positively associated with adolescent food hiding and weight control behaviors, (b) parental food monitoring will be positively associated with adolescent food hiding and weight control behaviors, and (c) parental dissatisfaction with adolescent body shape will be positively associated with adolescent food hiding and weight control behaviors. The present study extends previous literature on parental foodrelated behaviors on adolescent eating/weight control behaviors by using (a) a sample of adolescents, rather than children, (b) a sample of adolescents with a BMI greater than the 85th percentile (which includes the CDC defined weight categories of ‘‘at risk for overweight’’ and ‘‘overweight’’), heretofore referred to as ‘‘overweight,’’ (c) participants who are ethnically diverse (mostly African American), and (d) data collected from parent and adolescent dyads rather than one reporter. Method Participants and procedure The present study utilized data collected from adolescents and their accompanying parents/guardians at an urban adolescent health clinic affiliated with a children’s hospital in the Midwest. Adolescents were seen for annual well-teen checkups, preparticipation sports physicals, reproductive health care, and common primary care problems such as acne, minor infections, school and behavior problems, mental health and social issues. The clinic volume was approximately 10,000 outpatient visits a year with about 60% of those being unique visits. Participants were approached when they checked in at the clinic. Exclusion criteria were an inability to understand English or having a cognitive disability that prevented participation. When more than one
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
268
adolescent from a family was at the clinic for a visit, the younger adolescent was selected to participate. Informed consent from the parent/guardian and assent from the adolescent were obtained. To maintain confidentiality, interviews were conducted in separate private interview rooms for parents and adolescents. Trained research staff administered the surveys, reading all the questions and responses aloud. Flip charts listing the responses were utilized to aid respondents in making choices. Adolescent weight and height were measured by the clinic staff, and were used to calculate body mass index (BMI) and BMI percentiles (BMI%) were generated using NCHS growth charts (Kuczmarski et al., 2002). No identifying information was recorded, and adolescent and parent surveys were linked using a unique study identification number. Adolescent and parent participants each received a $20 gift certificate for compensation. Over 4 months, 696 persons were approached and 49.3% agreed to participate, with 301 adolescents and 260 parents/guardians completing the survey. The present study sample included 116 dyads (see Table 1) of overweight adolescents (weight at or above 85th percentile) between the ages of 12 and 19.2 years (M = 15.1 years, S.D. = 1.7 years), and one of their parents/guardians (M = 40 years, S.D. = 7.5 years). Eighty percent of the parents were mothers and 11.2% were fathers. Although 9% of the parent sample was not a mother or father, the ‘‘other’’ category included grandparents (n = 3 grandmothers), other female relatives (n = 3), unrelated female guardians (n = 4), and all of them reported living with the adolescent at least some of the time. For simplicity, we will refer to all female guardians as ‘‘mothers’’. The study was reviewed and approved by the Human Subjects Committees at the Children’s Mercy Hospital in Kansas City and the University of Kansas Medical Center. Measures The present study focuses on data from the parent and adolescent surveys which took approximately 30 min to complete.
It was a comprehensive survey which included questions taken from other sources as described below to assess demographics, dietary practices, physical activity, smoking behaviors, availability of food in the home, perception of body shape, weight history, and attitudes towards eating. Dependent variables Food Hiding: Adolescents’ report of food hiding behavior was assessed with one item asking, ‘‘How often do you buy food and/or hide food so your parents won’t find out’’. Response options ranged from 1 = Usually to 5 = Never, and was reverse scored so that higher scores reflect higher frequency of food hiding behaviors. Food hiding frequency was skewed, thus the variable was dichotomized into 0 = Never and 1 = Rarely—usually for logistic regression analyses. Healthy and Unhealthy Weight control Behaviors: Adolescents reported weight control behaviors (healthy and unhealthy) using eight items based on the 2001 National Youth Risk Behavior Survey (Grunbaum et al., 2002). Consistent with previous research (Neumark-Sztainer et al., 2002), healthy weight control behavior items were ‘‘did you exercise to lose weight or maintain your current weight’’, and ‘‘did you eat less food, fewer calories, or foods low in fat to lose weight or maintain your current weight.’’ Unhealthy weight control behavior items were did you ‘‘go without eating for 24 h or more (also called fasting) to lose weight or maintain your current weight’’, ‘‘take any diet pills like Metabolife, powders or liquids without a doctor’s advice, to lose weight or maintain your current weight’’, ‘‘vomit to lose weight or maintain your current weight’’, ‘‘take laxatives to lose weight or maintain your current weight’’, ‘‘skip meals to lose weight or maintain your current weight’’, and ‘‘follow a diet program such as Weight Watchers, Jenny Craig, or Suzanne Sommers to lose weight or maintain your current weight’’. Adolescents marked 0 = No or 1 = Yes to indicate whether they had engaged in the behaviors in
Table 1 Demographic characteristics and dependent variables (n = 116). Parents (n = 116)
All adolescents (n = 116)
Adolescent females (n = 74)
Adolescent males (n = 42) n (%)
n (%)
n (%)
n (%)
Gender Female Male
104 (90.0) 12 (10.0)
74 (63.8) 42 (36.2)
74 (100)
Ethnicity Black White Other
69 (59.5) 34 (29.3) 12 (10.3)
71 (61.2) 30 (25.9) 15 (12.9)
45 (60.8) 24 (32.4) 5 (6.8)
26 (61.9) 6 (14.3) 10 (23.8)
Relationship to teen Mother Father Other
93 (80.2) 13 (11.2) 10 (8.6)
Parent education
20 (17.2) 39 (33.6) 57 (49.1)
Food hiding Never Rarely—usually
94 (81.0) 22 (19.0)
63 (85.1) 11 (14.9)
31 (73.8) 11 (26.2)
Healthy weight control behaviors None One or more
17 (15.0) 96 (85.0)
11 (15.3) 61 (84.7)
6 (14.6) 35 (85.4)
Unhealthy weight control behaviors None One or more
17 (34.0) 33 (66.0)
11 (33.3) 22 (66.7)
6 (35.3) 11 (64.7)
42 (100)
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
the last 30 days. Items were summed separately for the healthy and unhealthy subscales and then response options were collapsed into 0 = None and 1 = One or more categories for weight control behaviors analyses because of the low frequency of unhealthy weight control behaviors. Independent variables Parental Food Monitoring: Parents’ perceptions of tracking their children’s intake of sweets, snack foods, high fat foods, and sugared beverages were assessed using the four item Monitoring subscale from the Child Feeding Questionnaire (Birch et al., 2001). The CFQ has been validated in this sample of adolescents (Kaur et al., 2006). Example items include, ‘‘How often do you keep track of the high fat food that your teen eats’’ and ‘‘How often do you keep track of soda pop and drinks like Gatorade, Kool-aid, and Splash that your teen drinks’’. Items were rated on a five-point Likert scale ranging from 1 = Never to 5 = Always, and for each parent, the items were summed and a mean score was obtained. The scale was found to have high internal consistency in the present sample (a = .91). Parental Food Restriction: Parental behaviors to curb and regulate the intake of ‘‘junk’’ foods were assessed using the six items Restriction subscale from the Child Feeding Questionnaire, excluding the food reward items (Birch et al., 2001). The subscale has been validated in this sample of adolescents (Kaur et al., 2006). Parents’ degree of agreement was assessed on a five-point Likert scale ranging from 1 = Disagree to 5 = Agree. Example items include, ‘‘I have to watch out that my teen does not eat too many sweets like candy, ice cream, cake, or pastries’’ and ‘‘I intentionally keep some foods out of the house so my teen won’t eat them’’. Items were scored following the protocol established by Birch et al. (2001), and the scale was found to have adequate internal consistency in the present sample (a = .85). Parental Dissatisfaction with Adolescent Body Shape: Parents’ perception of dissatisfaction with their adolescent’s body shape was measured using the Gardner 13-figure schematic contour scale (Gardner, Stark, Jackson, & Friedman, 1999). The Gardner images were selected because the figures are intentionally free of details, such as hair and facial characteristics, therefore making it applicable to persons of a variety of ethnicities (Gardner et al., 1999). Images were created by generating 13 drawings distorted between 30% by increments of 5%, and were labeled A–M from left to right. Items were recoded with 1 = A and 13 = M, with higher scores indicating a higher perception of adolescent body size. Parents were presented with the gender appropriate version of the scale and asked to select their current assessment of their teen’s body shape, ‘‘Which figure do you think most closely resembles the way your daughter/son looks now?’’, and their ideal body shape for their teen, ‘‘Which figure most closely resembles how you would like your daughter/son to look?’’. Parents’ response to current body shape item was subtracted from their response to the ideal body shape item to obtain the final ‘‘parental dissatisfaction with adolescent body shape score’’. Scores ranged from 3 through 11. Higher scores represent higher parental dissatisfaction with adolescent body shape. Results Statistical analyses Descriptive statistics were conducted for the following variables: parental food monitoring, food restriction, and dissatisfaction with adolescent body shape; and adolescent food hiding and weight control behaviors for the whole adolescent sample and the
269
Table 2 Descriptive for all adolescents (n = 116), and by gender. Variables Total sample Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring Adolescent females Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring Adolescent males Parent BMI Adolescent BMI Parental dissatisfaction with adolescent body shape Parental food restriction Parental food monitoring
M
S.D.
Observed range
33.0 30.6 2.2
7.9 6.7 2.8
17.5–58.5 22.7–61.1 3–11
3.6 3.1
1.3 1.2
1–5 1–5
32.9 31.0 2.2
7.6 7.0 3.0
19.3–51.5 23.4–61.1 3–11
3.4 3.0
1.3 1.2
1–5 1–5
33.0 30.0 2.1
8.5 6.3 2.4
17.5–58.5 22.7–52.7 3–7
4.0 3.4
1.1 1.1
1.3–5 1.5–5
female and male subsamples (see Tables 1 and 2). Logistic regression analyses were performed with the dependent variables of adolescent food hiding, healthy weight control behaviors, and unhealthy weight control behaviors regressed onto parental monitoring, restriction, and dissatisfaction with adolescent body shape, in separate analyses by outcome. To determine whether demographic characteristics of parents and adolescents might significantly influence the relationships under investigation, correlations of study variables with demographic variables (i.e., adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, parent BMI parent gender, and parent ethnicity) were conducted. Because at least one of the correlational findings with adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, and parent BMI were significant, we chose to adjust for these demographic variables in one set of our analyses (see below) to see if associations between parental behaviors and beliefs and adolescent behaviors were affected by demographic characteristics. Furthermore, the logistic regression analyses were conducted in two ways: (1) ‘‘unadjusted’’ with only the parenting variables as predictors, and (2) ‘‘adjusted’’ with demographic variables of adolescent age, gender, ethnicity, BMI, and parent BMI as correlates, to determine if demographic characteristics change the association between the parenting variables and adolescent behaviors. Parental dissatisfaction with adolescent body shape and adolescent food-related behaviors As shown in Table 3, unadjusted logistic regression analyses regarding parental dissatisfaction with adolescent body shape and healthy adolescent weight control behaviors revealed a significant positive association. However the association was not significant after accounting for the demographic variables in the adjusted analysis. Similarly, unadjusted logistic regression analyses regarding parental dissatisfaction with adolescent body shape and unhealthy adolescent weight control behaviors revealed a significant positive association. However, after accounting for the demographic variables in the adjusted analysis, the association was no longer significant. Both unadjusted and adjusted logistic regression models demonstrated that the association between
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
270
Table 3 Logistic regression models of adolescent behaviors regressed onto parental behaviors and beliefsa (n = 116). Parental beliefs and behaviors
Adolescent health behaviors Food hiding Odds ratio
Unadjusted Parental dissatisfaction with adolescent body shape
Healthy weight control behaviors
Unhealthy weight control behaviors
95% confidence interval Odds ratio 95% confidence interval Odds ratio 95% confidence interval
1.00
.84–1.19
1.31*
1.02–1.68
1.41*
1.06–1.88
Adjusted Parental dissatisfaction with adolescent body shape .98 Adolescent age .99 b Adolescent gender 1.99 c Adolescent ethnicity .69 Parent BMI 1.02 Adolescent BMI 1.00
.79–1.22 .97–1.02 .73–5.40 .20–2.43 .96–1.09 .92–1.10
1.16 .99 1.13 1.05 1.00 1.12
.87–1.56 .96–1.02 .33–3.81 .27–4.02 .92–1.08 .94–1.34
1.21 .97y .35 .64 .99 1.23y
.84–1.74 .93–1.01 .06–1.87 .11–3.78 .91–1.07 .97–1.56
Unadjusted Parental food restriction
1.76*
1.09–2.84
1.45y
.98–2.13
1.65*
1.01–2.67
Adjusted Parental food restriction Adolescent age Adolescent genderb Adolescent ethnicityc Parent BMI Adolescent BMI
1.75* 1.01 1.56 1.02 1.01 .97
1.06–2.88 .98–1.03 .57–4.28 .32–3.27 .95–1.08 .89–1.06
1.30 .99 .98 1.12 1.00 1.15y
.85–1.98 .96–1.02 .28–3.43 .29–4.29 .92–1.08 .98–1.35
1.40 .97 .33 .65 .99 1.29*
.78–2.52 .94–1.01 .06–1.78 .11–3.87 .91–1.07 1.04–1.59
Unadjusted Parental food monitoring
1.55*
1.01–2.37
.89
.57–1.39
1.12
.66–1.91
Adjusted Parental food monitoring Adolescent age Adolescent genderb Adolescent ethnicityc Parent BMI Adolescent BMI
1.57y 1.01 1.81 1.05 1.01 .98
.98–2.50 .98–1.03 .67–4.89 .32–3.42 .95–1.08 .90–1.06
.72 .98 1.15 .89 1.00 1.19*
.79 .96y .32 .38 1.00 1.34*
.38–1.65 .92–1.00 .06–1.77 .06–2.56 .92–1.08 1.06–1.68
a b c y *
.44–1.20 .95–1.01 .35–3.80 .23–3.40 .93–1.09 1.01–1.40
Adjusted for adolescent age, adolescent gender, adolescent ethnicity, adolescent BMI, and parent BMI. Male is the reference group for gender. White is the reference group for ethnicity. p < .10. p < .05.
parental dissatisfaction with adolescent body shape and adolescent food hiding was not significant. Parental food restriction and adolescent food-related behaviors Logistic regression analyses regarding parental food restriction and adolescent food hiding revealed a significant positive association, even when controlling for the demographic variables (see Table 3). Unadjusted logistic regression analyses regarding parental food restriction and both healthy and unhealthy adolescent weight control behaviors revealed a significant positive association for unhealthy weight control behaviors, and a trend-level positive association for healthy weight control behaviors. However these associations were not significant after accounting for the demographic variables in the adjusted analyses. Parental food monitoring and adolescent food-related behaviors Unadjusted logistic regression analyses regarding parental food monitoring and adolescent food hiding revealed a significant positive association, which was reduced to trend-level when controlling for the demographic variables (see Table 3) The unadjusted and adjusted logistic regression models assessing the associations between parental food monitoring and adolescent food hiding, healthy and unhealthy weight control behaviors were not significant.
Discussion The main goals of the study were to examine the relationships between parents’ food-related control behaviors and beliefs about adolescent body shape and eating/weight control behaviors among a sample of overweight adolescents. The present study expanded previous research in this domain by examining these associations with an ethnically diverse sample of overweight adolescents rather than normal weight children. Although there did not appear to be a significant difference when controlling for ethnic group, testing our hypotheses with a largely African-American sample demonstrates the applicability of the results to diverse populations. The present study’s findings provided some support for our hypotheses by demonstrating significant associations between parental foodrelated behaviors and adolescent food hiding even after controlling for demographic characteristics. These findings suggest that there are some detrimental associations between parents’ and adolescents’ interactions surrounding topics of food and eating behaviors. The present study makes an important contribution to the literature by examining the unique variable of parental dissatisfaction with adolescent body shape with adolescent eating behaviors. Although we did not find significant associations when accounting for demographic factors, to our knowledge, there has not been any research examining parents’ views of the mismatch between how they believe their teen looks and how they want them to look, or of the associations of such a mismatch.
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Examination of the parental dissatisfaction with adolescent body shape variable frequencies demonstrated that even though this sample consisted solely of overweight adolescents, 7% of the parents reported that they wanted their child to have a larger body shape (gain weight), and 26% of the parents wanted their adolescents to remain the same shape. Parallel findings have been found that parents are often not the most accurate judges of their adolescents’ weight (Boutelle, Fulkerson, Neumark-Sztainer, & Story, 2004). Thus, parents appear to be somewhat inaccurate in assessing their adolescent’s weight status, yet parental dissatisfaction with their adolescents’ body shape is positively associated with teenagers’ weight control behaviors (e.g., eating less food, taking diet pills), until analyses are adjusted for demographic factors. It appears that adolescent age and BMI may influence this association (see Table 3). These findings suggest that although adolescent weight control behaviors may be associated with parents’ beliefs about their body shape, the adolescent’s weight or body size is likely to be more influential. Regardless, parents’ comments about adolescents’ body shape may backfire, and cause the adolescents to turn to extreme weight control behaviors, such as vomiting (Fulkerson et al., 2007; Stice et al., 1999). Our finding that adolescent food hiding behaviors were positively associated with parental food restriction builds upon previous research on younger children, where parental control was associated with children’s negative eating patterns and weight (e.g., Birch & Fisher, 2000; Birch et al., 2003). Although parents may believe they are helping their adolescents lose weight by trying to make sure they do not eat too many high fat foods or sweets, this food restriction may propel adolescents to hide unhealthy foods and engage in secretive eating behavior. On the other hand, given that our study was cross-sectional, another explanation is that parents may feel they need to restrict food when adolescents engage in food hiding. Regardless of the causal direction, our findings suggest a need for interventions to address overweight adolescents’ food hiding behaviors. These programs can help overweight adolescents identify the reasons why they are hiding food, and give them skills to help curb their desire to consume unhealthy foods in secret. Interventions can also help parents of overweight adolescents learn ways to be supportive of their adolescents’ attempts at healthy eating and help them refrain from negative comments or undue control of adolescents’ eating behaviors. Perhaps the easiest and least conflict ridden tactic would be for parents to make the home food environment healthier, making high-fat and high-sugar foods and beverages less accessible for the entire family, thus taking the focus off of the adolescent. This method would be less likely to target particular family members and promote better family health overall. Like some previous studies of associations between parental control and other child characteristics such as overweight status, increased child eating, and physical activity (Faith et al., 2004; Gable & Lutz, 2000; Robinson et al., 2001), our findings related to parental food restriction and food monitoring were not completely consistent across adolescent health behaviors, as food monitoring was not found to be associated with adolescent weight control behaviors. Although the present research adds to the literature in unique ways, the findings must be viewed in light of the study’s limitations. First, the sample size is somewhat small, and precludes the detection of smaller effect sizes, which may explain why some associations did not fully hold when controlling for demographic factors. Furthermore, the small sample size precluded having enough power to examine associations separately by gender or ethnic group membership. Second, since this is a cross-sectional study, analyses do not allow for causal sequencing. For example,
271
we cannot infer if parental restriction directly causes adolescents to engage in greater frequency of food hiding behaviors. In fact, this may be a reciprocal association, where adolescents who engage in secretive food hiding and unhealthy eating behaviors elicit greater regulation of food and eating behaviors from their mothers and fathers. Lastly, because all adolescents in the sample were obese, variability in the predictor and outcome variables may be limited. There are several important strengths of this study. First, we extended the literature by separating food monitoring behaviors from food restrictive behaviors, and studying a sample of adolescents, rather than children. Second, by studying only overweight adolescents, we were able to assess associations specifically among this high-risk group. Also, our study used data from both adolescents and parents rather than one informant. Lastly, our ethnically diverse population of adolescents and parents (mostly African-American) adds to the growing literature of non-white family patterns of eating and weight control behaviors. Future research with large ethnically diverse samples should assess the potential racial/ethnic differences in the relationship between parental food-related behaviors and adolescent outcomes. More research should continue to examine the construct of food hiding, to further understand the meaning of why overweight adolescents engage in food hiding and what parenting behaviors may lead to secretly hiding food. Acknowledgments Funding support was awarded to the first author from the Adolescent Health Protection Research Training Program (School of Nursing, University of Minnesota) grant number T01 DP000112 (PI: Bearinger) from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. References Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006). Is parenting style related to children’s healthy eating and physical activity in Latino families? Health Education Research, 21, 862–871. Birch, L. L., & Fisher, J. O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101, 539–549. Birch, L. L., & Fisher, J. O. (2000). Mothers’ child-feeding practices influence daughters’ eating and weight. American Journal of Clinical Nutrition, 71, 1054–1061. Birch, L. L., Fisher, J. O., & Davison, K. K. (2003). Learning to overeat: maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. American Journal of Clinical Nutrition, 78, 215–220. Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Sawyer, R., & Johnson, S. L. (2001). Confirmatory factor analysis of the child feeding questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36, 201–210. Booth, S. L., Sallis, J. F., Ritenbaugh, C., Hill, J. O., Birch, L. L., Frank, L. D., et al. (2001). Environmental and societal factors affect food choice and physical activity: rationale, influences, and leverage points. Nutrition Reviews, 59, S21–S39. Bourdeaudhuij, I. de. , Yngve, A., Velde, S. J. te. , Klepp, K. I., Rasmussen, M., Thorsdottir, I., et al. (2006). Personal, social and environmental correlates of vegetable intake in normal weight and overweight 9 to 13-year old boys. International Journal of Behavioral Nutrition & Physical Activity, 3, 37. Boutelle, K., Fulkerson, J. A., Neumark-Sztainer, D., & Story, M. (2004). Mothers’ perceptions of their adolescents’ weight status: are they accurate? Obesity Research, 12, 1754–1757. Boutelle, K., Neumark-Sztainer, D., Story, M., & Resnick, M. (2002). Weight control behaviors among obese, overweight, and nonoverweight adolescents. Journal of Pediatric Psychology, 27, 531–540. Davison, K. K., & Birch, L. L. (2001). Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews, 2, 159–171. Eisenberg, M. E., Neumark-Sztainer, D., Haines, J., & Wall, M. (2006). Weight-teasing and emotional well-being in adolescents: longitudinal findings from project EAT. Journal of Adolescent Health, 38, 675–683. Faith, M. S., Berkowitz, R. I., Stallings, V. A., Kerns, J., Storey, M., & Stunkard, A. J. (2004). Parental feeding attitudes and styles and child body mass index: prospective analysis of a gene-environment interaction. Pediatrics, 114, 429–436. Fisher, J. O., & Birch, L. L. (1999). Restricting access to foods and children’s eating. Appetite, 32, 405–419.
272
D. B. Kenyon et al. / Appetite 52 (2009) 266–272
Fisher, J. O., & Birch, L. L. (2000). Parents’ restrictive feeding practices are associated with young girls’ negative self-evaluation of eating. Journal of the American Dietetic Association, 100, 1341–1346. Fulkerson, J. A., McGuire, M. T., Neumark-Sztainer, D., Story, M., French, S. A., & Perry, C. L. (2002). Weight-related attitudes and behaviors of adolescent boys and girls who are encouraged to diet by their mothers. International Journal of Obesity & Related Metabolic Disorders: Journal of the International Association for the Study of Obesity, 26, 1579–1587. Fulkerson, J. A., Neumark-Sztainer, D., & Story, M. (2006). Adolescent and parent views of family meals. Journal of the American Dietetic Association, 106, 526– 532. Fulkerson, J. A., Strauss, J., Neumark-Sztainer, D., Story, M., & Boutelle, K. (2007). Correlates of psychosocial well-being among overweight adolescents: the role of the family. Journal of Consulting & Clinical Psychology, 75, 181–186. Gable, S., & Lutz, S. (2000). Household, parent, and child contributions to childhood obesity. Family Relations, 49, 293–300. Gardner, R. M., Stark, K., Jackson, N. A., & Friedman, B. N. (1999). Development and validation of two new scales for assessment of body-image. Perceptual & Motor Skills, 89, 981–993. Grunbaum, J. A., Kann, L., Kinchen, S. A., Williams, B., Ross, J. G., Lowry, R., et al. (2002). Youth risk behavior surveillance—United States, 2001. Journal of School Health, 72, 313–328. James, P. T., Leach, R., Kalamara, E., & Shayeghi, M. (2001). The worldwide obesity epidemic. Obesity Research, 9, 228S–233S. Kaur, H., Li, C., Nazir, N., Choi, W. S., Resnicow, K., Birch, L. L., et al. (2006). Confirmatory factor analysis of the child-feeding questionnaire among parents of adolescents. Appetite, 47, 36–45.
Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L. M., Flegal, K. M., Mei, Z., et al. (2002). 2000 CDC growth charts for the United States: methods and development. Vital & Health Statistics—Series 11: Data From the National Health Survey, 246, 1–190. Neumark-Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weightrelated concerns and behaviors among overweight and nonoverweight adolescents: implications for preventing weight-related disorders. Archives of Pediatrics & Adolescent Medicine, 156, 171–178. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 1999–2004. Journal of American Medical Association, 295, 1549–1555. Robinson, T. N., Kiernan, M., Matheson, D. M., & Haydel, K. F. (2001). Is parental control over children’s eating associated with childhood obesity? Results from a population-based sample of third graders. Obesity Research, 9, 306–312. Schneider, D. (2000). International trends in adolescent nutrition. Social Science & Medicine, 51, 955–967. Sinton, M. M., & Birch, L. L. (2006). Individual and sociocultural influences on preadolescent girls’ appearance schemas and body dissatisfaction. Journal of Youth and Adolescence, 35, 165–175. Smetana, J. G., Campione-Barr, N., & Metzger, A. (2006). Adolescent development in interpersonal and societal contexts. Annual Review of Psychology, 57, 255–284. Stice, E., Agras, W. S., & Hammer, L. D. (1999). Risk factors for the emergence of childhood eating disturbances: a five-year prospective study. International Journal of Eating Disorders, 25, 375–387. Story, M., Neumark-Sztainer, D., & French, S. (2002). Individual and environmental influences on adolescent eating behaviors. Journal of the American Dietetic Association, 102, 40–51.