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Influences on adolescent eating patterns: the importance of family meals
JOURNAL OF ADOLESCENT HEALTH 2003;32:365–373
ORIGINAL ARTICLE
Influences on Adolescent Eating Patterns: The Importance of Family Meals TAMI M. VIDEON, Ph.D. AND CAROLYN K. MANNING, M.Ag., R.D.
Purpose: To provide national estimates of the frequency and determinants of adolescents’ consumption of fruits, vegetables, and dairy foods. Methods: Analyses were based on 18,177 adolescents in the first interview of the National Longitudinal Study of Adolescent Health. Multivariate logistic regressions provide estimates of the unique contribution of sociodemographic characteristics, body weight perception, and parental influences on adolescent food consumption. Results: Almost one in five adolescents reported skipping breakfast the previous day. A large percentage of adolescents reported eating less than the recommended amount of vegetables (71%), fruits (55%), and dairy foods (47%). Adolescents with better-educated parents had better consumption patterns than those with less-educated parents. Consumption patterns differed significantly by race. Adolescents who perceived themselves to be overweight were significantly more likely to have poor consumption patterns. Parental presence at the evening meal was associated with a lower risk of poor consumption of fruits, vegetables, and diary foods as well as the likelihood of skipping breakfast. Conclusion: Parental presence at the evening meal is positively associated with adolescents’ higher consumption of fruits, vegetables, and dairy foods. Nutrition and health professionals should educate parents about the role of family mealtimes for healthy adolescent nutrition. © Society for Adolescent Medicine, 2003
From the Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, New Brunswick, New Jersey (T.M.V.); and the Department of Nutrition and Dietetics, University of Delaware, Newark, Delaware (C.K.M.). Address correspondence to: Tami M. Videon, Ph.D., Institute for Health, Health Care Policy and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901-1293. E-mail: [email protected]. Manuscript accepted November 12, 2002. © Society for Adolescent Medicine, 2003 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
KEY WORDS:
Adolescent eating behavior Family meals Nutrition Racial differences
Adolescent eating patterns are established through a complex process involving internal and external factors such as food preferences and availability, body weight perception, and parental and peer influences [1–3]. Health professionals recognize that poor eating patterns may result in nutritional problems that can impair adolescent growth and development [4]. Furthermore, eating habits formed in adolescence continue into adulthood; consequently, poor dietary patterns among youth have important implications for health and well-being in adulthood [5,6]. Poor consumption of fruits and vegetables place individuals at risk for chronic diseases such as cancers, diabetes, hypertension, and cardiovascular disease [7,8], 4 of the 10 leading causes of death in the United States [9]. Inadequate intake of calcium is associated with increased risk of osteoporosis and low bone density [10]. An analysis of adolescents’ food intakes from 1965 to 1996 indicates that the nutritional and health status of adolescents may be compromised [7]. During this period the total fat intake of adolescents increased, but intake of raw fruit, nonpotato vegetable, and milk consumption decreased. Fiber intake was inadequate. This dietary pattern, along with the increasing prevalence of overweight adolescents [11], increases the risk for diabetes, hypertension, and cardiovascular disease in adulthood [7]. Other research findings reveal similarly low intakes of fruits and vegetables or nutrients from these foods 1054-139X/03/$–see front matter doi:10.1016/S1054-139X(02)00711-5
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and dairy foods [12–15]. According to the United States Department of Agriculture (USDA) Health Index Rating for 1994 to 1996, by adolescence 94% of children between ages 13 and 18 years show poorquality diets or diets in need of improvement [16]. Adolescence is a time of growing independence including increased opportunities to make decisions about what and when to eat [10]. Adolescents spend more time away from home as a result of social, school, and community activities and jobs; the amount of time an adolescent “has or wants to spend on food” is among the most important factors influencing adolescent food choices [17]. Skipping breakfast is a decision that adolescents frequently make [18 –21], and healthy eating is often a low priority or not practiced [17]. Working parents are often too busy to cook or eat as a family [14,17]. As children enter adolescence, the frequency of eating dinner with their families decreases [22]. Skipped meals and fewer family meals result in lower intakes of nutrients and food groups (fruits, vegetables, and dairy) [19,22–24]. In focus groups, adolescents associate eating healthful foods with eating family meals [25,26] and identify parents as important influences on their consumption patterns [17]. Eating patterns among adolescents show sociodemographic variations. Females skip breakfast more frequently than do males [18,20] and are more likely to consume lower-than-recommended intakes for calcium, especially as they get older [7,24]. In a national sample of adolescents, a large percentage, with girls in particular, were at risk for inadequate intakes of fruits and vegetables [27]. However, regionally specific samples provide inconsistent findings. For example, Minnesota adolescent males consumed fewer fruits and vegetables than females [23]. Black adolescents are at greater risk than Whites for poor vegetable [13], but not for poor fruit, consumption [23]. Native American adolescents are at highest risk for poor fruit consumption [23]. Asian and black adolescents and Hispanic females are more likely to report low intakes of dairy products [24]. The physical changes associated with adolescence bring about increased interest in body shape, size, and appearance. Adolescents’ physical self-image is significantly influenced by external factors such as peers and the media [1]. Adolescent dissatisfaction with weight increases the risk for inadequate consumption of fruits, vegetables, and dairy foods [23,24]. Understanding the broad range of factors that shape adolescents’ eating patterns is important for developing programs to address poor eating habits
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[2,3,17]. The present research examined the effects of parental influences, body weight perception and sociodemographic characteristics on adolescents’ consumption of fruits, vegetables, dairy foods, and breakfast. Specifically we were interested in seeing whether parental presence when adolescents leave for, and return from, school influences their consumption of various foods. Parents may be able to guide their children to snack on healthier foods if they are present when the child returns home from school. Moreover, we tested whether adolescents are less likely to choose to eat healthy foods when they have autonomy over their food choices. We examined the influence of family meals because past work suggests that at mealtimes parents provide healthy food choices and an example of good eating. Given the increasing incidence of childhood obesity and increased autonomy of adolescence, we were interested in knowing about food habits and parental influences for adolescents. Past research is largely based on convenience samples and/or community samples and indicates a need to examine these factors from a more representative sample of adolescents. We used data from the National Longitudinal study of Adolescent Health to investigate the effects of parental influences, body weight perception, and sociodemographic characteristics on adolescent consumption of fruits, vegetables, dairy foods, and breakfast.
Methods Research Design The National Longitudinal Study of Adolescent Health (Add Health) is a school-based study that utilized all high schools in the United States as its sampling frame. A detailed description of the Add Health study can be found elsewhere [28]. Briefly, schools were stratified by region, urbanicity, school type, ethnic mix, and size and selected with probability proportional to size. Rosters were obtained from each school, and a systematic sample was drawn after students were stratified by grade and gender. In addition, black adolescents from welleducated families, Chinese, Cuban, and Puerto Rican adolescents were oversampled. Weights control for the sampling procedures making results nationally representative of adolescents in grades 7 through 12 in the United States. The data for these analyses come from the Wave 1 interviews performed in the adolescent’s home between April and December 1995 (response rate ⫽ 79%).
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Measures Food consumption. Respondents were asked whether they “usually” ate specific categories of foods for breakfast on weekday mornings (i.e., milk, fruit, eggs, cereal). An “other” food category was provided for adolescents who usually consumed foods not specifically queried. A single measure was constructed to indicate whether respondents ate something or nothing for breakfast. Consumption of fruits, vegetables, and dairy foods were assessed by asking adolescents how frequently they ate foods in these categories the previous day. Although specific examples were not provided for fruit and vegetable consumption, dairy consumption was determined by asking the respondent how often they drank milk or ate yogurt or cheese the previous day. Response categories were: “ate twice or more,” “ate once,” and “did not eat.” Guidelines for older children and adults jointly developed by the USDA and Department of Health and Human Services recommend daily consumption of three to five servings of vegetables, two to four servings of fruit, and two to three servings of dairy foods [29]. In accordance with these guidelines, we created three dichotomous variables designating respondents who did not eat the recommended servings for each food category; poor consumption was defined as having eaten less than two servings of foods in each category the previous day (“1”). Parental influence. We constructed three measures of parental influence, the first of which examined the frequency of family meals. Adolescents were asked how many times at least one parent was present when they ate their evening meal in the past seven days. Respondents were divided into three groups: “seven or six meals,” “five or four meals,” and “three or fewer meals” with their parent(s). Respondents who ate three or fewer family meals constitute the reference group for all analyses. Adolescents were also asked how frequently a parent was at home when they left for school and how frequently a parent was home when they returned from school. Two broad measures of parental presence were constructed. These measures indicate whether a parent was “always,” “almost always,” or “sometimes” home when adolescents left for, and returned from, school or whether they were “never” or “almost never” home. The reference categories consist of respondents who “never” or “almost never” had a parent at home when they left for and arrived home from school. Finally, adolescents were asked
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whether their parents let them make their own decisions about the foods they eat. We used this dichotomous measure as an indication of adolescent autonomy (“1”) or parental control (“0”) over adolescents’ food choices. Body weight perception. Adolescents were asked how they think of themselves in terms of weight. We grouped adolescents who believed they were “very” or “slightly” underweight into an underweight category and those who responded they were “very” or “slightly” overweight into an overweight category. Respondents who reported their weight was “about right” are used as the reference category. Sociodemographic characteristics. Adolescents’ age was calculated using their birth month and year and the month and year of the interview. Respondent’s self-reported race and ethnicity are collapsed into five mutually exclusive categories. For respondents who indicated they were multiracial, we gave preference in coding in the following order: Hispanic, Black, Asian, Native American, and White. Parental education designates the highest level of education the most well-educated parent completed. Because the effects of education are not linear, four dummy variables were created: less than a high school education, high school graduate (or general equivalency diploma), schooling beyond high school, and college degree and beyond. High school graduate was used as the reference category. Analysis Strategy The interview was completed by 20,745 adolescents. A listwise deletion of cases without valid responses to study variables was performed (n ⫽ 18,379). Respondents with missing information on parental education remain in the analyses (n ⫽ 708) and an indicator variable was used to control for, and examine, potential biases of missing data. Slightly less than 1% (n ⫽ 173) of the remaining sample designated their racial/ethnic category as “other” or refused to answer questions on racial and ethnic origin. These cases were removed. Finally, because the research objective was to examine parental influences on adolescent eating patterns, the sample excluded 29 respondents who lived alone or in an institution, leaving a final sample size of 18,177 adolescents. Multivariate logistic regression analyses were used to examine the relation between adolescent food consumption and parental supervision, autonomy of food choice, and family meals while control-
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ling for body weight perception and sociodemographic characteristics. Because all outcome variables were coded “1” when adolescents had poor food intake, odds ratios greater than 1 designated increased risk and odds ratios less than 1 indicated protective factors. Because of the multistage sample design of the Add Health study, sampled adolescents were not selected independently. Schools were selected in the first stage, and then students within the school were selected. Analyses were performed in Survey Design Analysis Software (SUDAAN version 7.5.2) to control for the effects of the clustered sample design [30] and properly estimate the sampling variance associated with parameter coefficients. Variance and covariance estimates were produced by Taylor series approximations. Wald statistics provided tests of hypotheses concerning the model parameters. Analyses used sampling weights that make the results generalizable to all adolescents attending junior and senior high school in 1995.
Results Sample Characteristics Descriptive statistics of the sample are presented in Table 1. The sample was approximately half female, and the racial breakdown of the sample corresponded roughly with the racial breakdown of the population in the United States; slightly more than one-third (34.1%) of the sample was non-white. Adolescents in the sample ranged from age 11 to 21 years, with the average age being approximately 16 years. Nearly one-third of the sample perceived themselves to be overweight. A large majority reported a parent was at home at least “sometimes” when they leave for school (82.5%), and most adolescents indicated a parent was at home at least “sometimes” when they return from school (58.5%). Four of five adolescents reported their parent(s) let them make their own decisions about the foods they eat. Although almost half of the sample reported eating six or seven family meals, a substantial portion ate less than three family meals per week (30.9%). One in five adolescents responded they usually ate nothing for breakfast. Over 70% of the adolescents reported they did not eat at least two vegetables in the previous day; more than half (55%) did not eat at least two fruits, and almost half (47%) did not eat at least two servings of dairy foods in the previous day.
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Table 1. Weighteda Percentage of Adolescent Demographic Characteristics, Intake of Vegetable, Fruit, and Dairy Food Groups and Prevalence of Skipping Breakfast: 1994 National Longitudinal Study of Adolescent Health (n ⫽ 18,177) Variable Sociodemographic characteristics Gender Male Female Age Years (mean) Race/ethnicity White Black Hispanic Asian Native American Parental education Less than high school degree High school degree Some education after high school College degree Missing Parental influence Parental supervision/presence Parent(s) home at least some of the time when adolescent leaves for school Parent(s) home at least some of the time when adolescent returns from school Autonomy of food choices Adolescent decides Family meals Adolescent eats less than three per week Adolescent eats six or seven per week Adolescent eats four or five per week Body weight perception Thinks very/slightly underweight Thinks about the right weight Thinks very/slightly overweight Food consumption on previous day Ate nothing for breakfast Did not eat two or more vegetables Did not eat two or more fruits
%
51.0 49.0 15.9 65.9 16.1 12.1 3.9 2.0 12.1 31.0 20.7 32.2 3.9
82.8 58.5
80.7 30.9 48.3 20.8 16.6 51.6 31.8 20.0 71.3 55.0
a Weights compensate for unequal selection probabilities and provide nationally representative estimates.
Multivariate Analyses Table 2 presents the results of the logistic regression analyses. Girls and older adolescents were significantly more likely to report eating nothing for breakfast and poor consumption of dairy foods in the previous day than boys and younger adolescents. Parental education generally had a positive effect on adolescent consumption patterns. Higher levels of parental education were associated with lowered odds of poor vegetable, fruit, and dairy food consumption. Body weight perception was significantly
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Table 2. Relation of Race/Ethnicity, Family Influences, Body Weight Perception, and Sociodemographic Characteristics to Skipping Breakfast and Intake of Vegetable, Fruit, and Dairy Food Groups: 1994 National Longitudinal Study of Adolescent Health (n ⫽ 18,177) Skip Breakfast Variable Sociodemographic characteristics Gender Female Race/ethnicity Black Hispanic Asian Native American Age Age Parental education Less than high school degree Some education after high school College degree Body weight perception Underweight Overweight Parental influence Parental presence Leave for school Return from school Food decision-making Adolescent decides Family meals Adolescent eats six or seven family meals per week Adolescent eats four or five family meals per week
Not Eat 2⫹ Vegetables
OR
(95% CI) Sig.
OR
(95% CI) Sig.
1.38
(1.22–1.56)***
0.95
(0.86 –1.04)
0.65 0.74 1.25 1.25
(0.55– 0.76)*** (0.63– 0.88)*** (0.98 –1.59) (0.88 –1.77)
1.29 1.49 0.69 1.17
1.14
(1.10 –1.18)***
1.02
Not Eat 2⫹ Fruits OR
Not Eat 2⫹ Dairy
(95% CI) Sig.
OR
(95% CI) Sig.
0.94
(0.87–1.02)
1.57
(1.44 –1.72)***
(1.10 –1.50)** (1.22–1.82)*** (0.54 – 0.89)** (0.90 –1.52)
0.67 0.73 0.50 1.05
(0.58 – 0.77)*** (0.63– 0.83)*** (0.42– 0.61)*** (0.77–1.43)
1.68 1.34 2.05 1.03
(1.45–1.93)*** (1.15–1.56)*** (1.57–2.68)*** (0.77–1.39)
0.99
(0.95–1.02)
1.03*
(1.00 –1.06)
1.08
(1.05–1.12)***
(0.87–1.21)
1.10
(0.91–1.33)
1.08
(0.92–1.28)
1.11
(0.94 –1.30)
1.01
(0.88 –1.15)
0.80
(0.71– 0.90)***
0.83*
(0.71– 0.96)
0.84
(0.73– 0.96)*
0.83
(0.70 – 0.97)*
0.73
(0.65– 0.82)***
0.62
(0.56 – 0.70)***
0.71
(0.63– 0.80)***
0.92 1.94
(0.78 –1.09) (1.72–2.20)***
1.09 1.10
(0.96 –1.22) (1.01–1.20)*
1.07 1.14
(0.95–1.20) (1.04 –1.26)***
1.01 1.25
(0.90 –1.13) (1.12–1.38)***
1.07 1.17
(0.93–1.23) (1.04 –1.33)*
0.96 1.07
(0.86 –1.08) (0.98 –1.18)
0.91 1.01
(0.81–1.03) (0.93–1.10)
1.05 1.04
(0.94 –1.17) (0.96 –1.13)
1.25
(1.06 –1.46)**
0.96
(0.85–1.09)
0.94
(0.84 –1.05)
1.03
(0.93–1.14)
0.48
(0.42– 0.55)***
0.62
(0.55– 0.69)***
0.69
(0.61– 0.77)***
0.73
(0.66 – 0.81)***
0.61
(0.54 – 0.69)***
0.81
(0.70 – 0.93)**
0.78
(0.69 – 0.88)***
0.81
(0.72– 0.91)***
* p ⬍ .05; ** p ⬍ .01; *** p ⬍.001. Reference categories are: male, white, most educated parent has a high school degree, parent(s) are “almost never” or “never” home when child leaves for school, parent(s) are “almost never” or “never” home when child returns from school, eats three or fewer family meals, and believes they are “about the right weight.” All analyses include an indicator variable for missing parental education. The indicator was never significantly related to the outcomes and is not presented in the table. CI ⫽ confidence interval; Sig ⫽ significance.
associated with each of the consumption measures examined; adolescents who perceived themselves to be overweight were significantly more likely to report usually eating nothing for breakfast and significantly more likely to report poor consumption of vegetables, fruits, and dairy foods in the previous day. Significant patterns of food consumption emerged by race/ethnicity. Compared with their white peers, Blacks and Hispanics were less likely to skip breakfast and less likely to report poor fruit consumption in the previous day. However, Blacks and Hispanics were more likely to report poor consumption of vegetables and dairy foods. Asians were less likely than Whites to report poor vegetable and fruit con-
sumption, although they were significantly more likely to report poor consumption of dairy foods. Measures of parental influence had varying levels of importance for adolescent consumption patterns. The presence of a parent in the home when adolescents left for, and returned from, school was not significantly associated with the adolescent’s consumption of vegetables, fruits, and dairy foods. Similarly, adolescent autonomy, or parental control, of food choices was not significantly associated with adolescent food group intake. However, adolescents who were allowed to make their own decisions about the foods they ate were significantly more likely to skip breakfast than adolescents who reported their parents made decisions as to what they ate.
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More notably, the analyses revealed that the number of evening meals eaten with a parent present is significantly associated with adolescents’ eating patterns. Adolescents who ate more than three family meals a week were significantly less likely to skip breakfast and less likely to report poor consumption of fruits, vegetables, and dairy foods, compared with adolescents who ate three or fewer family meals. Compared with adolescents who ate three or fewer family meals, adolescents who ate four or five family meals were 19% less likely to report poor consumption of vegetables, 22% less likely to report poor consumption of fruits, and 19% less likely to report poor consumption of dairy foods. The beneficial effect of family meals increased as the number of meals increased; adolescents who consumed six or seven family meals had an even lowered odds of skipping breakfast and poor vegetable, fruit, and dairy foods consumption than those who consumed four or five family meals (as evidenced in the nonoverlap in odds ratios). Adolescents who ate six or seven family meals were 38% less likely to report poor consumption of vegetables, 31% less likely to report poor consumption of fruits, and 27% less likely to report poor consumption of dairy foods than adolescents who ate three or fewer family meals.
Discussion Parental Influences Our analyses, based on a nationally representative sample, showed the influence of specific parental activities on adolescent eating habits. The most significant parental influence was the family meal. The presence of at least one parent during the evening meal was associated with a lowered odds of poor consumption of fruits, vegetables, and dairy foods and a lowered odds of skipping breakfast among adolescents. The magnitude of the effect is quite large: Of adolescents who ate three or fewer family meals per week, three-fourths reported poor consumption of vegetables, compared with two-thirds of adolescents who ate six or seven family meals per week. Given that one of every three adolescents reported eating three or fewer meals with their parent(s), family meals constitute a prevalent risk factor for poor food intake. These findings are consistent with previous research using a younger sample (children aged 9 to 14 years), which demonstrated a positive parental influence on children’s eating patterns [22]. Moreover, our estimates of the
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frequency with which adolescents eat family meals are comparable with previous reports [31]. Parental presence in the home was not significantly related to adolescents’ consumption of fruits, vegetables, and dairy foods. And contrary to expectations, having a parent home in the morning before adolescents left for school did not significantly influence consumption of breakfast. Moreover, adolescents who had autonomy over the foods they ate were no more likely to have poor consumption patterns, indicating that given the choice, adolescents do not forgo healthy food choices. These findings suggest that the mere parental presence before and after school and parental control over the foods adolescents eat do not impact their food intake. However, family meals may be an opportunity for parents to provide healthful choices and be an example of healthy eating [17,26]. Past research indicates that when children do not eat family dinners, they are more likely to eat ready-made dinners that likely have lower nutritional quality [22]. A comparison of age groups within one study [22] showed drastic declines in the number of family meals for older adolescents and was likewise true in our data. Busy schedules of parents and teenagers interfere with more frequent family meals [17,25,31]. Therefore, when developing interventions to improve adolescent nutrition, particular attention should be paid to the challenges families with older children face in participating in regular mealtimes (i.e., schedules). Although adolescent autonomy was not a significant risk factor for poor consumption of fruits, vegetables, and dairy foods, it was a significant risk for skipping breakfast. Adolescents who made their own decisions of what they ate were 25% more likely to skip breakfast. Qualitative work indicates parental rules for eating breakfast are effective [25]. These findings suggest that providing some guidelines for adolescents in lieu of full adolescent autonomy may result in better consumption patterns. Omission of breakfast can result in inadequate nutrient intake [18] and jeopardize normal growth and development. The federally funded School Breakfast Program was established in recognition of the role of breakfast in ensuring adequate nutrient intake for children and adolescents [32]. The significance of family meals in influencing breakfast consumption indicates that there may be other factors involved in the association between family meals and adolescent consumption patterns. Parents may instruct children on the importance of nutritious foods during family mealtimes [33]. And parents who eat evening meals
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with children may be more likely to eat breakfast with their children. Encouraging parents of adolescents to emphasize the importance of breakfast and provide guidelines for their children represents a promising intervention for improving adolescent nutrition.
Sociodemographics and Body Weight Perception Our analyses revealed racial/ethnic and gender differences in eating patterns among adolescents. Replicating the findings of previous studies, we found Blacks and Hispanics, when compared with Whites, are at greater risk for poor consumption of vegetables and dairy foods [12,13,23]. Poorer dietary patterns among these minority groups may partly explain why these groups are at higher risk for various health problems such as cancers, diabetes, hypertension, and cardiovascular disease [34,35]. These findings indicate that interventions aimed at improving the dietary habits of minority youth may reduce racial health disparities later in life, a goal of Healthy People 2010 [36]. If such interventions are to achieve this long-term outcome, they need to take into account the racial/ethnic differences in food consumption revealed in these analyses and previous studies. Asian adolescents were significantly less likely than Whites to report poor consumption of fruits and vegetables. However, Asians were more than twice as likely as Whites to consume less than two dairy foods in the previous day. These findings are consistent with previous research showing lower calcium intakes for Asians [27,37] and are likely owing to the minor role of dairy foods in many Asian diets. Asian adolescents may be consuming soy foods in lieu of dairy foods and thus have lower calcium intakes. The amount of calcium in nonfermented soy foods, such as tofu and soy milk, varies greatly, depending on how the products are manufactured [38]. These soy foods provide less calcium than comparable dairy products unless the manufacturer adds calcium in some way during processing. Our analyses indicate that female adolescents are at greater risk for poor dietary habits than males. Girls are more likely than boys to skip breakfast and to have not eaten two or more dairy foods in the previous day. These findings are consistent with previous studies that indicate that when females skip breakfast, they have lower intakes of calcium [18]. Because calcium is particularly important for bone development in adolescence [10], these findings suggest that females, and possibly Asian Americans,
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may be at particular risk for osteoporosis in later life [39]. Perceived body weight had a significant impact on all four indicators of poor eating habits. Findings from the 1999 National Health and Nutrition Examination Survey indicate 14% of adolescents aged 12 to 19 years are overweight [11]. However, in our study population, more than double this percentage (31.8%) perceived themselves to be overweight. Part of this disparity may be owing to our combining adolescents who believe they are “very” overweight and those who think they are “slightly” overweight. Nonetheless, the large gap between the percentage of adolescents who are actually overweight and those who perceive themselves to be overweight underscores the need to educate adolescents about what is a healthy and desirable weight. Messages from the media and peers substantially influence the adolescent’s physical self-image [1]. Calling attention to nutrient dense foods (i.e., low-fat yogurt and skim milk) in health and nutrition courses and emphasizing the importance of fruits, vegetables, and certain dairy foods for healthy development may provide adolescents with information that facilitates healthy choices. Limitations These analyses involve some important limitations. First, we relied on self-reported consumption of various foods. Dietary questionnaires that ask how frequently categories of foods are eaten are known to underestimate intakes of nutrients [40]. And such broad questions lack information on the quality of food eaten. In particular, there is concern that adolescents in this study may be including fruit drinks in their fruit group consumption [7]. If this is true, findings that Blacks and Hispanics were less likely than Whites to have poor fruit consumption may not be accurate. Indeed, this may explain why our findings are contrary to other findings [13,23]. Better data on what foods are being consumed are needed to examine whether the racial/ethnic differences we report are accurate. The second wave of interviews in the Add Health data set provide the opportunity to explore this issue because more detailed questions of food consumption were asked. Our analyses of breakfast consumption explored the likelihood that adolescents would eat nothing for breakfast, rather than the consumption of various foods, and reflects the focus of this analysis on poor dietary patterns rather than nutrient intakes. Therefore, this broad measure will underestimate poor eating habits
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among adolescents; eating snack foods or drinking coffee for breakfast does not indicate healthy eating habits nor provide needed nutrients. Food intake is found to vary for most persons between weekdays and weekend, and therefore asking about food intake on the previous day may not accurately characterize the usual diet of an individual [40]. However, the usual diet of a group, as we are reporting, can be characterized using a short period of time, such as the previous day [40]. When we examined the data for weekday/weekend variation, we found that the inclusion of these measures did not significantly alter the findings we reported, indicating the robustness of our findings. A second limitation is that we were unable to determine whether adolescents are eating these various foods during the family meal. We interpreted our analyses to mean that parents are providing healthy choices at the evening meal. However, something associated with family meals (i.e., discussions about nutrition) may be responsible for the observed effect on fruit, vegetable, and dairy food intake. Future research should explore the specific foods eaten by adolescents during family meals. We also need to point out that our measure of family meals differs from measures used in other studies [22,25,31]. Our measure indicates whether a parent is present when the adolescent eats their evening meal but does not necessarily indicate whether the family eats their evening meal together. Notwithstanding different measures of family meals across studies, findings consistently indicate the importance of family meals for child and adolescent eating habits. Despite these limitations, a strength of the study is that it provides national estimates of consumption patterns among adolescents, including minority groups. Furthermore, Add Health provides several measures of parental influence on adolescent consumption. In summary, after controlling for sociodemographic characteristics and body weight perception, family meals were found to exert a substantial influence on consumption of fruits, vegetables, dairy foods, and breakfast. Although adolescence is thought of as a time of decreasing parental influence, our findings highlight the importance of the parent at the evening meal for food consumption.
References 1. Rees J, Pipes P. Nutrition for adolescents. In: Trahms C, Pipes P (eds). Nutrition in Infancy and Childhood, 6th edition. Hinsdale, IL: WCB/McGraw-Hill, 1997:305–30.
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2. Stockmyer C. Remember when Mom wanted you home for dinner? Nutr Rev 2001;59:57–60. 3. Story M, Neumark-Sztainer D, French S. Individual and environmental influences on adolescent eating behaviors. J Am Diet Assoc 2002;102(Suppl):S40 –51. 4. Society for Adolescent Medicine. Position Statement. Improving the nutritional health of adolescents. J Adolesc Health 1999;24:461–2. 5. Kemm J. Eating patterns in childhood and adult health. Nutr Health 1987;4:205–15. 6. Nicklas T, Farris R, Smoak C, et al. Dietary factors relate to cardiovascular risk factors in early life. Arteriosclerosis 1988; 8:193–9. 7. Cavadini C, Siega-Riz A, Popkin B. U.S. adolescent food intake trends from 1965 to 1996. Arch Dis Child 2000;83:18 –24. 8. Steinmetz K, Potter J. Vegetables, fruit, and cancer prevention: A review. J Am Diet Assoc 1996;96:1027–39. 9. Anderson R. Deaths: Leading causes for 1999. Natl Vital Stat Rep 2001;49:8. 10. Whitney E, Rolfes S. Life cycle nutrition: Infancy, childhood and adolescence. In: Understanding Nutrition, 9th edition. Belmont, CA: Wadsworth/Thomson Learning, 2002:560 –1. 11. National Center for Health Statistics. Health and stats. Prevalence of overweight among children and adolescents, United States 1999. Available at: http://www.cdc.gov/nchs/products/ pubs/pubd/hestats/overwght99.htm. Accessed October 9, 2001. 12. Krebs-Smith S, Cook A, Subar A, et al. Fruit and vegetable intakes of children and adolescents in the United States. Arch Pediatr Adolesc Med 1996;150:81–6. 13. Beech B, Rice R, Myers L, et al. Knowledge, attitudes and practices related to fruit and vegetable consumption of high school students. J Adolesc Health 1999;24:244 –50. 14. Neumark-Sztainer D, Story M, Resnick M, et al. Lessons learned about adolescent nutrition from the Minnesota Adolescent Health Survey. J Am Diet Assoc 1998;98:1449 –56. 15. Stang J, Story M, Harnack L, et al. Relationships between vitamin and mineral supplement use, dietary intake and dietary adequacy among adolescents. J Am Diet Assoc 2000; 100:905–10. 16. Lino M, Gerrior SA, Basiotis PP, et al. A report card on the diet quality of children. Washington, DC: USDA, Center for Nutrition Policy and Promotion, 1998:CNPP-Insight 9. 17. Neumark-Sztainer D, Story M, Perry C, et al. Factors influencing food choices of adolescents: Findings from focus-group discussions with adolescents. J Am Diet Assoc 1999;99:929 –34, 937. 18. Morgan K, Zabik M, Stampley G. Breakfast consumption patterns of U.S. children and adolescents. Nutr Res 1986;6: 635–46. 19. Siega-Riz A, Carson T, Popkin B. Three squares or mostly snacks—What do teens really eat? J Adolesc Health 1998;22: 29 –36. 20. Shaw M. Adolescent breakfast skipping: An Australian study. Adolescence 1998;33:851–61. 21. Dwyer J, Evans M, Stone EJ, et al. Adolescents’ eating patterns influence their nutrient intakes. J Am Diet Assoc 2001;101:798 – 801. 22. Gillman M, Rifas-Shiman S, Frazier A, et al. Family dinner and diet quality among older children and adolescents. Arch Family Med 2000;9:235–40. 23. Neumark-Sztainer D, Story M, Resnick M, et al. Correlates of inadequate fruit and vegetable consumption among adolescents. Prev Med 1996;25:497–505.
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24. Neumark-Sztainer D, Story M, Dixon L, et al. Correlates of inadequate consumption of dairy products among adolescents. J Nutr Educ 1997;29:12–20. 25. Neumark-Sztainer D, Story M, Ackard D, et al. The “Family Meal:” Views of adolescents. J Nutr Educ 2000;32:329 –34. 26. Kelsey K, Campbell M, Vanata D. Parent and adolescent girls’ preferences for parental involvement in adolescent health promotion programs. J Am Diet Assoc 1998;98:906 –7. 27. Pesa J, Turner L. Fruit and vegetable intake and weightcontrol behaviors among U.S. youth. Am J Health Behav 2001;25:3–9. 28. Bearman P, Jones J, Udry J. The National Longitudinal Study of Adolescent Health: Research Design. Available at: http:// www.cpc.unc.edu/addhealth/design.html. Accessed October 9, 2001. 29. United States Department of Agriculture and Department of Health and Human Services. The Food Guide Pyramid. Available at: http://www.pueblo.gsa.gov/cic_text/food/foodpyramid/main.htm. Accessed October 9, 2001. 30. Shah B, Barnwell B, Bieler G. SUDAAN User’s Manual, Release 7.0. Triangle Park, NC: Research Triangle Institute, 1996. 31. Neumark-Sztainer D, Story M, Ackard D, et al. Family meals among adolescents: Findings from a pilot study. J Nutr Educ 2000;32:335–40. 32. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J Am Diet Assoc 1996;96:913–17.
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33. Gillespie A, Achterberg C. Comparison of family interaction patterns related to food and nutrition. J Am Diet Assoc 1998;89:509 –12. 34. Ng-Mak D, Dohrenwend B, Abraido-Lanza A, et al. A further analysis of race differences in the National Longitudinal Mortality Study. Am J Public Health 1999;89:1748 –51. 35. Kington R, Smith J. Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. Am J Public Health 1997;87:805–10. 36. Healthy People 2010: Understanding and Improving Health. 2nd edition. Available at: http://www.health.gov/healthy people/Document/html/uih/uih_2.htm#goals. Accessed October 9, 2001. 37. Barr S. Associations of social and demographic variables with calcium intakes of high school students. J Am Diet Assoc 1994;94:260 –6, 269. 38. Liu K. Oriental Soy Foods. In: Ang C, Liu K, Huang Y-W (eds). Asian Foods. Lancaster, PA: Technomic Publishing Co., Inc, 1999:141–59. 39. Position of The American Dietetic Association and Dietitians of Canada: Women’s health and nutrition. J Am Diet Assoc. 1999,99:738 –51. 40. Hankin J. Dietary intake methodology. In: Monsen E (ed). Research: Successful Approaches. Chicago, IL: American Dietetic Association, 1992:173–94.
ORIGINAL ARTICLE
Influences on Adolescent Eating Patterns: The Importance of Family Meals TAMI M. VIDEON, Ph.D. AND CAROLYN K. MANNING, M.Ag., R.D.
Purpose: To provide national estimates of the frequency and determinants of adolescents’ consumption of fruits, vegetables, and dairy foods. Methods: Analyses were based on 18,177 adolescents in the first interview of the National Longitudinal Study of Adolescent Health. Multivariate logistic regressions provide estimates of the unique contribution of sociodemographic characteristics, body weight perception, and parental influences on adolescent food consumption. Results: Almost one in five adolescents reported skipping breakfast the previous day. A large percentage of adolescents reported eating less than the recommended amount of vegetables (71%), fruits (55%), and dairy foods (47%). Adolescents with better-educated parents had better consumption patterns than those with less-educated parents. Consumption patterns differed significantly by race. Adolescents who perceived themselves to be overweight were significantly more likely to have poor consumption patterns. Parental presence at the evening meal was associated with a lower risk of poor consumption of fruits, vegetables, and diary foods as well as the likelihood of skipping breakfast. Conclusion: Parental presence at the evening meal is positively associated with adolescents’ higher consumption of fruits, vegetables, and dairy foods. Nutrition and health professionals should educate parents about the role of family mealtimes for healthy adolescent nutrition. © Society for Adolescent Medicine, 2003
From the Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, New Brunswick, New Jersey (T.M.V.); and the Department of Nutrition and Dietetics, University of Delaware, Newark, Delaware (C.K.M.). Address correspondence to: Tami M. Videon, Ph.D., Institute for Health, Health Care Policy and Aging Research, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901-1293. E-mail: [email protected]. Manuscript accepted November 12, 2002. © Society for Adolescent Medicine, 2003 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
KEY WORDS:
Adolescent eating behavior Family meals Nutrition Racial differences
Adolescent eating patterns are established through a complex process involving internal and external factors such as food preferences and availability, body weight perception, and parental and peer influences [1–3]. Health professionals recognize that poor eating patterns may result in nutritional problems that can impair adolescent growth and development [4]. Furthermore, eating habits formed in adolescence continue into adulthood; consequently, poor dietary patterns among youth have important implications for health and well-being in adulthood [5,6]. Poor consumption of fruits and vegetables place individuals at risk for chronic diseases such as cancers, diabetes, hypertension, and cardiovascular disease [7,8], 4 of the 10 leading causes of death in the United States [9]. Inadequate intake of calcium is associated with increased risk of osteoporosis and low bone density [10]. An analysis of adolescents’ food intakes from 1965 to 1996 indicates that the nutritional and health status of adolescents may be compromised [7]. During this period the total fat intake of adolescents increased, but intake of raw fruit, nonpotato vegetable, and milk consumption decreased. Fiber intake was inadequate. This dietary pattern, along with the increasing prevalence of overweight adolescents [11], increases the risk for diabetes, hypertension, and cardiovascular disease in adulthood [7]. Other research findings reveal similarly low intakes of fruits and vegetables or nutrients from these foods 1054-139X/03/$–see front matter doi:10.1016/S1054-139X(02)00711-5
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and dairy foods [12–15]. According to the United States Department of Agriculture (USDA) Health Index Rating for 1994 to 1996, by adolescence 94% of children between ages 13 and 18 years show poorquality diets or diets in need of improvement [16]. Adolescence is a time of growing independence including increased opportunities to make decisions about what and when to eat [10]. Adolescents spend more time away from home as a result of social, school, and community activities and jobs; the amount of time an adolescent “has or wants to spend on food” is among the most important factors influencing adolescent food choices [17]. Skipping breakfast is a decision that adolescents frequently make [18 –21], and healthy eating is often a low priority or not practiced [17]. Working parents are often too busy to cook or eat as a family [14,17]. As children enter adolescence, the frequency of eating dinner with their families decreases [22]. Skipped meals and fewer family meals result in lower intakes of nutrients and food groups (fruits, vegetables, and dairy) [19,22–24]. In focus groups, adolescents associate eating healthful foods with eating family meals [25,26] and identify parents as important influences on their consumption patterns [17]. Eating patterns among adolescents show sociodemographic variations. Females skip breakfast more frequently than do males [18,20] and are more likely to consume lower-than-recommended intakes for calcium, especially as they get older [7,24]. In a national sample of adolescents, a large percentage, with girls in particular, were at risk for inadequate intakes of fruits and vegetables [27]. However, regionally specific samples provide inconsistent findings. For example, Minnesota adolescent males consumed fewer fruits and vegetables than females [23]. Black adolescents are at greater risk than Whites for poor vegetable [13], but not for poor fruit, consumption [23]. Native American adolescents are at highest risk for poor fruit consumption [23]. Asian and black adolescents and Hispanic females are more likely to report low intakes of dairy products [24]. The physical changes associated with adolescence bring about increased interest in body shape, size, and appearance. Adolescents’ physical self-image is significantly influenced by external factors such as peers and the media [1]. Adolescent dissatisfaction with weight increases the risk for inadequate consumption of fruits, vegetables, and dairy foods [23,24]. Understanding the broad range of factors that shape adolescents’ eating patterns is important for developing programs to address poor eating habits
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[2,3,17]. The present research examined the effects of parental influences, body weight perception and sociodemographic characteristics on adolescents’ consumption of fruits, vegetables, dairy foods, and breakfast. Specifically we were interested in seeing whether parental presence when adolescents leave for, and return from, school influences their consumption of various foods. Parents may be able to guide their children to snack on healthier foods if they are present when the child returns home from school. Moreover, we tested whether adolescents are less likely to choose to eat healthy foods when they have autonomy over their food choices. We examined the influence of family meals because past work suggests that at mealtimes parents provide healthy food choices and an example of good eating. Given the increasing incidence of childhood obesity and increased autonomy of adolescence, we were interested in knowing about food habits and parental influences for adolescents. Past research is largely based on convenience samples and/or community samples and indicates a need to examine these factors from a more representative sample of adolescents. We used data from the National Longitudinal study of Adolescent Health to investigate the effects of parental influences, body weight perception, and sociodemographic characteristics on adolescent consumption of fruits, vegetables, dairy foods, and breakfast.
Methods Research Design The National Longitudinal Study of Adolescent Health (Add Health) is a school-based study that utilized all high schools in the United States as its sampling frame. A detailed description of the Add Health study can be found elsewhere [28]. Briefly, schools were stratified by region, urbanicity, school type, ethnic mix, and size and selected with probability proportional to size. Rosters were obtained from each school, and a systematic sample was drawn after students were stratified by grade and gender. In addition, black adolescents from welleducated families, Chinese, Cuban, and Puerto Rican adolescents were oversampled. Weights control for the sampling procedures making results nationally representative of adolescents in grades 7 through 12 in the United States. The data for these analyses come from the Wave 1 interviews performed in the adolescent’s home between April and December 1995 (response rate ⫽ 79%).
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Measures Food consumption. Respondents were asked whether they “usually” ate specific categories of foods for breakfast on weekday mornings (i.e., milk, fruit, eggs, cereal). An “other” food category was provided for adolescents who usually consumed foods not specifically queried. A single measure was constructed to indicate whether respondents ate something or nothing for breakfast. Consumption of fruits, vegetables, and dairy foods were assessed by asking adolescents how frequently they ate foods in these categories the previous day. Although specific examples were not provided for fruit and vegetable consumption, dairy consumption was determined by asking the respondent how often they drank milk or ate yogurt or cheese the previous day. Response categories were: “ate twice or more,” “ate once,” and “did not eat.” Guidelines for older children and adults jointly developed by the USDA and Department of Health and Human Services recommend daily consumption of three to five servings of vegetables, two to four servings of fruit, and two to three servings of dairy foods [29]. In accordance with these guidelines, we created three dichotomous variables designating respondents who did not eat the recommended servings for each food category; poor consumption was defined as having eaten less than two servings of foods in each category the previous day (“1”). Parental influence. We constructed three measures of parental influence, the first of which examined the frequency of family meals. Adolescents were asked how many times at least one parent was present when they ate their evening meal in the past seven days. Respondents were divided into three groups: “seven or six meals,” “five or four meals,” and “three or fewer meals” with their parent(s). Respondents who ate three or fewer family meals constitute the reference group for all analyses. Adolescents were also asked how frequently a parent was at home when they left for school and how frequently a parent was home when they returned from school. Two broad measures of parental presence were constructed. These measures indicate whether a parent was “always,” “almost always,” or “sometimes” home when adolescents left for, and returned from, school or whether they were “never” or “almost never” home. The reference categories consist of respondents who “never” or “almost never” had a parent at home when they left for and arrived home from school. Finally, adolescents were asked
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whether their parents let them make their own decisions about the foods they eat. We used this dichotomous measure as an indication of adolescent autonomy (“1”) or parental control (“0”) over adolescents’ food choices. Body weight perception. Adolescents were asked how they think of themselves in terms of weight. We grouped adolescents who believed they were “very” or “slightly” underweight into an underweight category and those who responded they were “very” or “slightly” overweight into an overweight category. Respondents who reported their weight was “about right” are used as the reference category. Sociodemographic characteristics. Adolescents’ age was calculated using their birth month and year and the month and year of the interview. Respondent’s self-reported race and ethnicity are collapsed into five mutually exclusive categories. For respondents who indicated they were multiracial, we gave preference in coding in the following order: Hispanic, Black, Asian, Native American, and White. Parental education designates the highest level of education the most well-educated parent completed. Because the effects of education are not linear, four dummy variables were created: less than a high school education, high school graduate (or general equivalency diploma), schooling beyond high school, and college degree and beyond. High school graduate was used as the reference category. Analysis Strategy The interview was completed by 20,745 adolescents. A listwise deletion of cases without valid responses to study variables was performed (n ⫽ 18,379). Respondents with missing information on parental education remain in the analyses (n ⫽ 708) and an indicator variable was used to control for, and examine, potential biases of missing data. Slightly less than 1% (n ⫽ 173) of the remaining sample designated their racial/ethnic category as “other” or refused to answer questions on racial and ethnic origin. These cases were removed. Finally, because the research objective was to examine parental influences on adolescent eating patterns, the sample excluded 29 respondents who lived alone or in an institution, leaving a final sample size of 18,177 adolescents. Multivariate logistic regression analyses were used to examine the relation between adolescent food consumption and parental supervision, autonomy of food choice, and family meals while control-
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ling for body weight perception and sociodemographic characteristics. Because all outcome variables were coded “1” when adolescents had poor food intake, odds ratios greater than 1 designated increased risk and odds ratios less than 1 indicated protective factors. Because of the multistage sample design of the Add Health study, sampled adolescents were not selected independently. Schools were selected in the first stage, and then students within the school were selected. Analyses were performed in Survey Design Analysis Software (SUDAAN version 7.5.2) to control for the effects of the clustered sample design [30] and properly estimate the sampling variance associated with parameter coefficients. Variance and covariance estimates were produced by Taylor series approximations. Wald statistics provided tests of hypotheses concerning the model parameters. Analyses used sampling weights that make the results generalizable to all adolescents attending junior and senior high school in 1995.
Results Sample Characteristics Descriptive statistics of the sample are presented in Table 1. The sample was approximately half female, and the racial breakdown of the sample corresponded roughly with the racial breakdown of the population in the United States; slightly more than one-third (34.1%) of the sample was non-white. Adolescents in the sample ranged from age 11 to 21 years, with the average age being approximately 16 years. Nearly one-third of the sample perceived themselves to be overweight. A large majority reported a parent was at home at least “sometimes” when they leave for school (82.5%), and most adolescents indicated a parent was at home at least “sometimes” when they return from school (58.5%). Four of five adolescents reported their parent(s) let them make their own decisions about the foods they eat. Although almost half of the sample reported eating six or seven family meals, a substantial portion ate less than three family meals per week (30.9%). One in five adolescents responded they usually ate nothing for breakfast. Over 70% of the adolescents reported they did not eat at least two vegetables in the previous day; more than half (55%) did not eat at least two fruits, and almost half (47%) did not eat at least two servings of dairy foods in the previous day.
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Table 1. Weighteda Percentage of Adolescent Demographic Characteristics, Intake of Vegetable, Fruit, and Dairy Food Groups and Prevalence of Skipping Breakfast: 1994 National Longitudinal Study of Adolescent Health (n ⫽ 18,177) Variable Sociodemographic characteristics Gender Male Female Age Years (mean) Race/ethnicity White Black Hispanic Asian Native American Parental education Less than high school degree High school degree Some education after high school College degree Missing Parental influence Parental supervision/presence Parent(s) home at least some of the time when adolescent leaves for school Parent(s) home at least some of the time when adolescent returns from school Autonomy of food choices Adolescent decides Family meals Adolescent eats less than three per week Adolescent eats six or seven per week Adolescent eats four or five per week Body weight perception Thinks very/slightly underweight Thinks about the right weight Thinks very/slightly overweight Food consumption on previous day Ate nothing for breakfast Did not eat two or more vegetables Did not eat two or more fruits
%
51.0 49.0 15.9 65.9 16.1 12.1 3.9 2.0 12.1 31.0 20.7 32.2 3.9
82.8 58.5
80.7 30.9 48.3 20.8 16.6 51.6 31.8 20.0 71.3 55.0
a Weights compensate for unequal selection probabilities and provide nationally representative estimates.
Multivariate Analyses Table 2 presents the results of the logistic regression analyses. Girls and older adolescents were significantly more likely to report eating nothing for breakfast and poor consumption of dairy foods in the previous day than boys and younger adolescents. Parental education generally had a positive effect on adolescent consumption patterns. Higher levels of parental education were associated with lowered odds of poor vegetable, fruit, and dairy food consumption. Body weight perception was significantly
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Table 2. Relation of Race/Ethnicity, Family Influences, Body Weight Perception, and Sociodemographic Characteristics to Skipping Breakfast and Intake of Vegetable, Fruit, and Dairy Food Groups: 1994 National Longitudinal Study of Adolescent Health (n ⫽ 18,177) Skip Breakfast Variable Sociodemographic characteristics Gender Female Race/ethnicity Black Hispanic Asian Native American Age Age Parental education Less than high school degree Some education after high school College degree Body weight perception Underweight Overweight Parental influence Parental presence Leave for school Return from school Food decision-making Adolescent decides Family meals Adolescent eats six or seven family meals per week Adolescent eats four or five family meals per week
Not Eat 2⫹ Vegetables
OR
(95% CI) Sig.
OR
(95% CI) Sig.
1.38
(1.22–1.56)***
0.95
(0.86 –1.04)
0.65 0.74 1.25 1.25
(0.55– 0.76)*** (0.63– 0.88)*** (0.98 –1.59) (0.88 –1.77)
1.29 1.49 0.69 1.17
1.14
(1.10 –1.18)***
1.02
Not Eat 2⫹ Fruits OR
Not Eat 2⫹ Dairy
(95% CI) Sig.
OR
(95% CI) Sig.
0.94
(0.87–1.02)
1.57
(1.44 –1.72)***
(1.10 –1.50)** (1.22–1.82)*** (0.54 – 0.89)** (0.90 –1.52)
0.67 0.73 0.50 1.05
(0.58 – 0.77)*** (0.63– 0.83)*** (0.42– 0.61)*** (0.77–1.43)
1.68 1.34 2.05 1.03
(1.45–1.93)*** (1.15–1.56)*** (1.57–2.68)*** (0.77–1.39)
0.99
(0.95–1.02)
1.03*
(1.00 –1.06)
1.08
(1.05–1.12)***
(0.87–1.21)
1.10
(0.91–1.33)
1.08
(0.92–1.28)
1.11
(0.94 –1.30)
1.01
(0.88 –1.15)
0.80
(0.71– 0.90)***
0.83*
(0.71– 0.96)
0.84
(0.73– 0.96)*
0.83
(0.70 – 0.97)*
0.73
(0.65– 0.82)***
0.62
(0.56 – 0.70)***
0.71
(0.63– 0.80)***
0.92 1.94
(0.78 –1.09) (1.72–2.20)***
1.09 1.10
(0.96 –1.22) (1.01–1.20)*
1.07 1.14
(0.95–1.20) (1.04 –1.26)***
1.01 1.25
(0.90 –1.13) (1.12–1.38)***
1.07 1.17
(0.93–1.23) (1.04 –1.33)*
0.96 1.07
(0.86 –1.08) (0.98 –1.18)
0.91 1.01
(0.81–1.03) (0.93–1.10)
1.05 1.04
(0.94 –1.17) (0.96 –1.13)
1.25
(1.06 –1.46)**
0.96
(0.85–1.09)
0.94
(0.84 –1.05)
1.03
(0.93–1.14)
0.48
(0.42– 0.55)***
0.62
(0.55– 0.69)***
0.69
(0.61– 0.77)***
0.73
(0.66 – 0.81)***
0.61
(0.54 – 0.69)***
0.81
(0.70 – 0.93)**
0.78
(0.69 – 0.88)***
0.81
(0.72– 0.91)***
* p ⬍ .05; ** p ⬍ .01; *** p ⬍.001. Reference categories are: male, white, most educated parent has a high school degree, parent(s) are “almost never” or “never” home when child leaves for school, parent(s) are “almost never” or “never” home when child returns from school, eats three or fewer family meals, and believes they are “about the right weight.” All analyses include an indicator variable for missing parental education. The indicator was never significantly related to the outcomes and is not presented in the table. CI ⫽ confidence interval; Sig ⫽ significance.
associated with each of the consumption measures examined; adolescents who perceived themselves to be overweight were significantly more likely to report usually eating nothing for breakfast and significantly more likely to report poor consumption of vegetables, fruits, and dairy foods in the previous day. Significant patterns of food consumption emerged by race/ethnicity. Compared with their white peers, Blacks and Hispanics were less likely to skip breakfast and less likely to report poor fruit consumption in the previous day. However, Blacks and Hispanics were more likely to report poor consumption of vegetables and dairy foods. Asians were less likely than Whites to report poor vegetable and fruit con-
sumption, although they were significantly more likely to report poor consumption of dairy foods. Measures of parental influence had varying levels of importance for adolescent consumption patterns. The presence of a parent in the home when adolescents left for, and returned from, school was not significantly associated with the adolescent’s consumption of vegetables, fruits, and dairy foods. Similarly, adolescent autonomy, or parental control, of food choices was not significantly associated with adolescent food group intake. However, adolescents who were allowed to make their own decisions about the foods they ate were significantly more likely to skip breakfast than adolescents who reported their parents made decisions as to what they ate.
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More notably, the analyses revealed that the number of evening meals eaten with a parent present is significantly associated with adolescents’ eating patterns. Adolescents who ate more than three family meals a week were significantly less likely to skip breakfast and less likely to report poor consumption of fruits, vegetables, and dairy foods, compared with adolescents who ate three or fewer family meals. Compared with adolescents who ate three or fewer family meals, adolescents who ate four or five family meals were 19% less likely to report poor consumption of vegetables, 22% less likely to report poor consumption of fruits, and 19% less likely to report poor consumption of dairy foods. The beneficial effect of family meals increased as the number of meals increased; adolescents who consumed six or seven family meals had an even lowered odds of skipping breakfast and poor vegetable, fruit, and dairy foods consumption than those who consumed four or five family meals (as evidenced in the nonoverlap in odds ratios). Adolescents who ate six or seven family meals were 38% less likely to report poor consumption of vegetables, 31% less likely to report poor consumption of fruits, and 27% less likely to report poor consumption of dairy foods than adolescents who ate three or fewer family meals.
Discussion Parental Influences Our analyses, based on a nationally representative sample, showed the influence of specific parental activities on adolescent eating habits. The most significant parental influence was the family meal. The presence of at least one parent during the evening meal was associated with a lowered odds of poor consumption of fruits, vegetables, and dairy foods and a lowered odds of skipping breakfast among adolescents. The magnitude of the effect is quite large: Of adolescents who ate three or fewer family meals per week, three-fourths reported poor consumption of vegetables, compared with two-thirds of adolescents who ate six or seven family meals per week. Given that one of every three adolescents reported eating three or fewer meals with their parent(s), family meals constitute a prevalent risk factor for poor food intake. These findings are consistent with previous research using a younger sample (children aged 9 to 14 years), which demonstrated a positive parental influence on children’s eating patterns [22]. Moreover, our estimates of the
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frequency with which adolescents eat family meals are comparable with previous reports [31]. Parental presence in the home was not significantly related to adolescents’ consumption of fruits, vegetables, and dairy foods. And contrary to expectations, having a parent home in the morning before adolescents left for school did not significantly influence consumption of breakfast. Moreover, adolescents who had autonomy over the foods they ate were no more likely to have poor consumption patterns, indicating that given the choice, adolescents do not forgo healthy food choices. These findings suggest that the mere parental presence before and after school and parental control over the foods adolescents eat do not impact their food intake. However, family meals may be an opportunity for parents to provide healthful choices and be an example of healthy eating [17,26]. Past research indicates that when children do not eat family dinners, they are more likely to eat ready-made dinners that likely have lower nutritional quality [22]. A comparison of age groups within one study [22] showed drastic declines in the number of family meals for older adolescents and was likewise true in our data. Busy schedules of parents and teenagers interfere with more frequent family meals [17,25,31]. Therefore, when developing interventions to improve adolescent nutrition, particular attention should be paid to the challenges families with older children face in participating in regular mealtimes (i.e., schedules). Although adolescent autonomy was not a significant risk factor for poor consumption of fruits, vegetables, and dairy foods, it was a significant risk for skipping breakfast. Adolescents who made their own decisions of what they ate were 25% more likely to skip breakfast. Qualitative work indicates parental rules for eating breakfast are effective [25]. These findings suggest that providing some guidelines for adolescents in lieu of full adolescent autonomy may result in better consumption patterns. Omission of breakfast can result in inadequate nutrient intake [18] and jeopardize normal growth and development. The federally funded School Breakfast Program was established in recognition of the role of breakfast in ensuring adequate nutrient intake for children and adolescents [32]. The significance of family meals in influencing breakfast consumption indicates that there may be other factors involved in the association between family meals and adolescent consumption patterns. Parents may instruct children on the importance of nutritious foods during family mealtimes [33]. And parents who eat evening meals
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with children may be more likely to eat breakfast with their children. Encouraging parents of adolescents to emphasize the importance of breakfast and provide guidelines for their children represents a promising intervention for improving adolescent nutrition.
Sociodemographics and Body Weight Perception Our analyses revealed racial/ethnic and gender differences in eating patterns among adolescents. Replicating the findings of previous studies, we found Blacks and Hispanics, when compared with Whites, are at greater risk for poor consumption of vegetables and dairy foods [12,13,23]. Poorer dietary patterns among these minority groups may partly explain why these groups are at higher risk for various health problems such as cancers, diabetes, hypertension, and cardiovascular disease [34,35]. These findings indicate that interventions aimed at improving the dietary habits of minority youth may reduce racial health disparities later in life, a goal of Healthy People 2010 [36]. If such interventions are to achieve this long-term outcome, they need to take into account the racial/ethnic differences in food consumption revealed in these analyses and previous studies. Asian adolescents were significantly less likely than Whites to report poor consumption of fruits and vegetables. However, Asians were more than twice as likely as Whites to consume less than two dairy foods in the previous day. These findings are consistent with previous research showing lower calcium intakes for Asians [27,37] and are likely owing to the minor role of dairy foods in many Asian diets. Asian adolescents may be consuming soy foods in lieu of dairy foods and thus have lower calcium intakes. The amount of calcium in nonfermented soy foods, such as tofu and soy milk, varies greatly, depending on how the products are manufactured [38]. These soy foods provide less calcium than comparable dairy products unless the manufacturer adds calcium in some way during processing. Our analyses indicate that female adolescents are at greater risk for poor dietary habits than males. Girls are more likely than boys to skip breakfast and to have not eaten two or more dairy foods in the previous day. These findings are consistent with previous studies that indicate that when females skip breakfast, they have lower intakes of calcium [18]. Because calcium is particularly important for bone development in adolescence [10], these findings suggest that females, and possibly Asian Americans,
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may be at particular risk for osteoporosis in later life [39]. Perceived body weight had a significant impact on all four indicators of poor eating habits. Findings from the 1999 National Health and Nutrition Examination Survey indicate 14% of adolescents aged 12 to 19 years are overweight [11]. However, in our study population, more than double this percentage (31.8%) perceived themselves to be overweight. Part of this disparity may be owing to our combining adolescents who believe they are “very” overweight and those who think they are “slightly” overweight. Nonetheless, the large gap between the percentage of adolescents who are actually overweight and those who perceive themselves to be overweight underscores the need to educate adolescents about what is a healthy and desirable weight. Messages from the media and peers substantially influence the adolescent’s physical self-image [1]. Calling attention to nutrient dense foods (i.e., low-fat yogurt and skim milk) in health and nutrition courses and emphasizing the importance of fruits, vegetables, and certain dairy foods for healthy development may provide adolescents with information that facilitates healthy choices. Limitations These analyses involve some important limitations. First, we relied on self-reported consumption of various foods. Dietary questionnaires that ask how frequently categories of foods are eaten are known to underestimate intakes of nutrients [40]. And such broad questions lack information on the quality of food eaten. In particular, there is concern that adolescents in this study may be including fruit drinks in their fruit group consumption [7]. If this is true, findings that Blacks and Hispanics were less likely than Whites to have poor fruit consumption may not be accurate. Indeed, this may explain why our findings are contrary to other findings [13,23]. Better data on what foods are being consumed are needed to examine whether the racial/ethnic differences we report are accurate. The second wave of interviews in the Add Health data set provide the opportunity to explore this issue because more detailed questions of food consumption were asked. Our analyses of breakfast consumption explored the likelihood that adolescents would eat nothing for breakfast, rather than the consumption of various foods, and reflects the focus of this analysis on poor dietary patterns rather than nutrient intakes. Therefore, this broad measure will underestimate poor eating habits
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among adolescents; eating snack foods or drinking coffee for breakfast does not indicate healthy eating habits nor provide needed nutrients. Food intake is found to vary for most persons between weekdays and weekend, and therefore asking about food intake on the previous day may not accurately characterize the usual diet of an individual [40]. However, the usual diet of a group, as we are reporting, can be characterized using a short period of time, such as the previous day [40]. When we examined the data for weekday/weekend variation, we found that the inclusion of these measures did not significantly alter the findings we reported, indicating the robustness of our findings. A second limitation is that we were unable to determine whether adolescents are eating these various foods during the family meal. We interpreted our analyses to mean that parents are providing healthy choices at the evening meal. However, something associated with family meals (i.e., discussions about nutrition) may be responsible for the observed effect on fruit, vegetable, and dairy food intake. Future research should explore the specific foods eaten by adolescents during family meals. We also need to point out that our measure of family meals differs from measures used in other studies [22,25,31]. Our measure indicates whether a parent is present when the adolescent eats their evening meal but does not necessarily indicate whether the family eats their evening meal together. Notwithstanding different measures of family meals across studies, findings consistently indicate the importance of family meals for child and adolescent eating habits. Despite these limitations, a strength of the study is that it provides national estimates of consumption patterns among adolescents, including minority groups. Furthermore, Add Health provides several measures of parental influence on adolescent consumption. In summary, after controlling for sociodemographic characteristics and body weight perception, family meals were found to exert a substantial influence on consumption of fruits, vegetables, dairy foods, and breakfast. Although adolescence is thought of as a time of decreasing parental influence, our findings highlight the importance of the parent at the evening meal for food consumption.
References 1. Rees J, Pipes P. Nutrition for adolescents. In: Trahms C, Pipes P (eds). Nutrition in Infancy and Childhood, 6th edition. Hinsdale, IL: WCB/McGraw-Hill, 1997:305–30.
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2. Stockmyer C. Remember when Mom wanted you home for dinner? Nutr Rev 2001;59:57–60. 3. Story M, Neumark-Sztainer D, French S. Individual and environmental influences on adolescent eating behaviors. J Am Diet Assoc 2002;102(Suppl):S40 –51. 4. Society for Adolescent Medicine. Position Statement. Improving the nutritional health of adolescents. J Adolesc Health 1999;24:461–2. 5. Kemm J. Eating patterns in childhood and adult health. Nutr Health 1987;4:205–15. 6. Nicklas T, Farris R, Smoak C, et al. Dietary factors relate to cardiovascular risk factors in early life. Arteriosclerosis 1988; 8:193–9. 7. Cavadini C, Siega-Riz A, Popkin B. U.S. adolescent food intake trends from 1965 to 1996. Arch Dis Child 2000;83:18 –24. 8. Steinmetz K, Potter J. Vegetables, fruit, and cancer prevention: A review. J Am Diet Assoc 1996;96:1027–39. 9. Anderson R. Deaths: Leading causes for 1999. Natl Vital Stat Rep 2001;49:8. 10. Whitney E, Rolfes S. Life cycle nutrition: Infancy, childhood and adolescence. In: Understanding Nutrition, 9th edition. Belmont, CA: Wadsworth/Thomson Learning, 2002:560 –1. 11. National Center for Health Statistics. Health and stats. Prevalence of overweight among children and adolescents, United States 1999. Available at: http://www.cdc.gov/nchs/products/ pubs/pubd/hestats/overwght99.htm. Accessed October 9, 2001. 12. Krebs-Smith S, Cook A, Subar A, et al. Fruit and vegetable intakes of children and adolescents in the United States. Arch Pediatr Adolesc Med 1996;150:81–6. 13. Beech B, Rice R, Myers L, et al. Knowledge, attitudes and practices related to fruit and vegetable consumption of high school students. J Adolesc Health 1999;24:244 –50. 14. Neumark-Sztainer D, Story M, Resnick M, et al. Lessons learned about adolescent nutrition from the Minnesota Adolescent Health Survey. J Am Diet Assoc 1998;98:1449 –56. 15. Stang J, Story M, Harnack L, et al. Relationships between vitamin and mineral supplement use, dietary intake and dietary adequacy among adolescents. J Am Diet Assoc 2000; 100:905–10. 16. Lino M, Gerrior SA, Basiotis PP, et al. A report card on the diet quality of children. Washington, DC: USDA, Center for Nutrition Policy and Promotion, 1998:CNPP-Insight 9. 17. Neumark-Sztainer D, Story M, Perry C, et al. Factors influencing food choices of adolescents: Findings from focus-group discussions with adolescents. J Am Diet Assoc 1999;99:929 –34, 937. 18. Morgan K, Zabik M, Stampley G. Breakfast consumption patterns of U.S. children and adolescents. Nutr Res 1986;6: 635–46. 19. Siega-Riz A, Carson T, Popkin B. Three squares or mostly snacks—What do teens really eat? J Adolesc Health 1998;22: 29 –36. 20. Shaw M. Adolescent breakfast skipping: An Australian study. Adolescence 1998;33:851–61. 21. Dwyer J, Evans M, Stone EJ, et al. Adolescents’ eating patterns influence their nutrient intakes. J Am Diet Assoc 2001;101:798 – 801. 22. Gillman M, Rifas-Shiman S, Frazier A, et al. Family dinner and diet quality among older children and adolescents. Arch Family Med 2000;9:235–40. 23. Neumark-Sztainer D, Story M, Resnick M, et al. Correlates of inadequate fruit and vegetable consumption among adolescents. Prev Med 1996;25:497–505.
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24. Neumark-Sztainer D, Story M, Dixon L, et al. Correlates of inadequate consumption of dairy products among adolescents. J Nutr Educ 1997;29:12–20. 25. Neumark-Sztainer D, Story M, Ackard D, et al. The “Family Meal:” Views of adolescents. J Nutr Educ 2000;32:329 –34. 26. Kelsey K, Campbell M, Vanata D. Parent and adolescent girls’ preferences for parental involvement in adolescent health promotion programs. J Am Diet Assoc 1998;98:906 –7. 27. Pesa J, Turner L. Fruit and vegetable intake and weightcontrol behaviors among U.S. youth. Am J Health Behav 2001;25:3–9. 28. Bearman P, Jones J, Udry J. The National Longitudinal Study of Adolescent Health: Research Design. Available at: http:// www.cpc.unc.edu/addhealth/design.html. Accessed October 9, 2001. 29. United States Department of Agriculture and Department of Health and Human Services. The Food Guide Pyramid. Available at: http://www.pueblo.gsa.gov/cic_text/food/foodpyramid/main.htm. Accessed October 9, 2001. 30. Shah B, Barnwell B, Bieler G. SUDAAN User’s Manual, Release 7.0. Triangle Park, NC: Research Triangle Institute, 1996. 31. Neumark-Sztainer D, Story M, Ackard D, et al. Family meals among adolescents: Findings from a pilot study. J Nutr Educ 2000;32:335–40. 32. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J Am Diet Assoc 1996;96:913–17.
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373
33. Gillespie A, Achterberg C. Comparison of family interaction patterns related to food and nutrition. J Am Diet Assoc 1998;89:509 –12. 34. Ng-Mak D, Dohrenwend B, Abraido-Lanza A, et al. A further analysis of race differences in the National Longitudinal Mortality Study. Am J Public Health 1999;89:1748 –51. 35. Kington R, Smith J. Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. Am J Public Health 1997;87:805–10. 36. Healthy People 2010: Understanding and Improving Health. 2nd edition. Available at: http://www.health.gov/healthy people/Document/html/uih/uih_2.htm#goals. Accessed October 9, 2001. 37. Barr S. Associations of social and demographic variables with calcium intakes of high school students. J Am Diet Assoc 1994;94:260 –6, 269. 38. Liu K. Oriental Soy Foods. In: Ang C, Liu K, Huang Y-W (eds). Asian Foods. Lancaster, PA: Technomic Publishing Co., Inc, 1999:141–59. 39. Position of The American Dietetic Association and Dietitians of Canada: Women’s health and nutrition. J Am Diet Assoc. 1999,99:738 –51. 40. Hankin J. Dietary intake methodology. In: Monsen E (ed). Research: Successful Approaches. Chicago, IL: American Dietetic Association, 1992:173–94.