Background
Although genetic contributors to childhood obesity and their interactions with the environment cannot be overlooked [
1], early environmental influences (during ages two-eight years) in child diet and physical activity have been linked to both current weight status and weight status later in life [
2]. Davison and Birch have suggested, based on their longitudinal study of girls, that families can be classified by their patterns of dietary and physical activity behavior, in combination with parent weight status, as obesogenic or non-obesogenic [
3]. Subsequent work has suggested that the relationships between child BMI and household environmental factors, such as parental control and feeding styles may be moderated by race/ethnicity, socio-economic status and child age [
4‐
6]. Although substantial evidence from primarily white populations supports the critical role of the family environment and highlights the association between parent weight status and household dietary and physical activity characteristics [
6‐
10], the relationship between household environments of young children and child weight status in racially and ethnically diverse populations has received less attention. In particular, it is unclear whether the relationships between household factors such as family meal frequency and rules and practices around food availability and access are the same across race-ethnic and socio-economic spectrums. Given the higher prevalence of overweight in young non-white and lower socio-economic status children, identification of modifiable household environmental factors is essential to the development of preventive interventions.
Eating dinner together as a family has been associated with fewer sedentary activities, such as TV watching [
11], and higher diet quality in children [
12]. Likewise, family meals have been positively associated with intakes of fruits, vegetables, dairy products, and several nutrients, and inversely associated with intakes of soft drinks [
12‐
14]. Taveras and colleagues found a lower prevalence of child (ages 9–14) overweight in families that reported family dinner “most days” or “everyday”, as opposed to “never” or “some days” [
15]. Some evidence suggests that these beneficial effects may be moderated by race/ethnicity in adolescents [
16]. The observation that the cross-sectional associations identified by Taveras et al. did not persist in subsequent
longitudinal analyses suggests that the relationship between family dinner and child weight status is complex and may be moderated by other factors [
15]. For example, it has been suggested that the household
environment in which meals are eaten, such as allowing the TV to be on or serving prepared foods, may attenuate some of the beneficial effects of family meals [
17‐
20]. Further, the relationship between family meals and obesity has been shown to be moderated by sex in Hispanic and non-Hispanic black children and some studies observe a
positive relationship between family meal frequency and risk of obesity in Hispanic boys (≤ 12 years) living in low-education households [
21]. In sum, further investigation of the associations among family dinner, TV, and child weight status in racially and ethnically diverse populations is warranted.
A considerable body of evidence links restrictive parental practices involving food, particularly snack food, with child overweight [
7,
22‐
25]. However, due largely to the cross-sectional nature of most investigations [
7,
9,
26‐
28] the degree to which parental restriction is a response to child overweight rather than a contributor is not clear. An increased desire for restricted snack foods, compared to unrestricted snack foods was demonstrated in boys and girls ages 3–6 years [
27]. Similarly, maternal restriction of foods was associated with decreased ability to self-regulate snack intake, greater snack food consumption and energy intake, and was predictive of child weight status in girls [
7]. When this relationship was explored cross-sectionally in a sample of boys and girls, the association was observed only in girls [
29]. Indeed, most studies of parental food restriction and child weight status have been limited to Caucasian girls of higher socio-economic status living in two-parent households [
28]. The few studies conducted in more diverse populations have found either no association, weak associations, or inverse associations between parental restriction and child overweight [
28,
30‐
32]. This represents a critical gap in the literature, inasmuch as the prevalence of overweight is higher in racial and ethnic minorities and in children from lower-socioeconomic status families [
31,
33].
Likewise, some evidence suggests that household norms surrounding food, child feeding practices and responses to child overweight are different across income levels and race/ethnicity. For example, focus group findings [
34] demonstrated a higher propensity to characterize overweight body type schematic images as normal weight among African-American mothers and middle-income white mothers, when compared to low-income white and Hispanic mothers. Likewise, Hispanic mothers reported being more concerned about their children’s health and their eating
enough than about their body weight, while African-American mothers believed that their children would outgrow overweight and that higher body weight in childhood was healthy [
34].
Other studies of household norms and behaviors have found that household food availability and parental consumption of particular foods influence children’s consumption [
35], and that child TV viewing is associated with increased risk of being overweight [
35‐
37]. Consumption of sugar-sweetened beverages has also been consistently associated with excess weight in children [
38,
39].
This paper describes the behaviors and demographic and household characteristics of a group of racially and ethnically diverse, urban-dwelling first through third grade children, and explores cross-sectional associations with weight status. The purpose of this investigation was to further elucidate the complex associations among household and family factors such as family dinner and food rules and practices surrounding food intake and weight status in a low socio-economic, racially/ethnically diverse population.
Results
The prevalence of child overweight (defined as BMI z-score above the 85th percentile for age) in the sample of 820 children was 38.0%. Prevalence was 35.3% for girls and 40.8% for boys. Table
1 displays demographic variables by child weight status (normal weight vs. overweight). Weight status differed by racial/ethnic group (χ
2 = 16.04, p = 0.014), with Hispanic children most likely (52.2%) to be in the overweight category. As expected, overweight parents were more likely to have overweight children than were normal weight parents (χ
2 = 21.37, p < 0.001).
Table 1
Distribution of child and family demographic characteristics by child weight status
a
in a sample of racially and ethnically diverse first through third grade children
Sex (%)
| 2.56 | 0.063 |
Female | 422 (51.7) | 273 (64.7) | 149 (35.3) | | |
Male | 395 (48.3) | 234 (59.2) | 161 (40.8) | | |
Race/ethnicity (%)
| 16.04 | 0.014 |
Caucasian | 422 (51.9) | 266 (63.0) | 156 (37.0) | | |
Black | 97 (11.9) | 63 (64.9) | 34 (35.1) | | |
Hispanic | 115 (14.1) | 55 (47.8) | 60 (52.2) | | |
Asian | 40 (4.9) | 27 (67.5) | 13 (32.5) | | |
Multi-Ethnic | 93 (11.4) | 61 (65.6) | 32 (34.4) | | |
Other | 46 (5.7) | 33 (71.7) | 13 (28.3) | | |
Maximum parent education (%)
| 2.71 | 0.439 |
< High School | 47 (5.9) | 27 (57.4) | 20 (42.6) | | |
High School/GED | 265 (33.2) | 160 (60.4) | 105 (39.6) | | |
Two Year College | 202 (25.3) | 122 (60.4) | 80 (39.6) | | |
College or beyond | 284 (35.6) | 187 (65.8) | 97 (34.2) | | |
Maximum parent weight category (%)
| 21.37 | < .001 |
Underweight | 5 (0.7) | 5 (100) | | | |
Normal | 144 (19.8) | 106 (73.6) | 38 (26.4) | | |
Overweight | 340 (46.8) | 223 (65.3) | 118 (34.7) | | |
Obese | 237 (32.6) | 125 (52.7) | 112 (47.3) | | |
Grade level (%)
| 1.12 | 0.571 |
First Grade | 319 (39.0) | 191 (59.9) | 128 (40.1) | | |
Second Grade | 248 (30.4) | 156 (62.9) | 92 (37.1) | | |
Third Grade | 250 (30.6) | 160 (64.0) | 90 (36.0) | | |
Health behaviors and household characteristics
Of the parent/guardian respondents, 88% were the child’s mother, 10% were the child’s father, and fewer than two percent were the child’s guardian.
Nearly half of the respondents reported that children ate one serving or fewer of vegetables and one serving or fewer of fruits per day. Mean daily intake was 1.55 (±0.92) servings for vegetables and 1.66 (±0.93) servings for fruits (Table
2). Additionally, 72% (489/677) reported that their child consumed more than two sugar-sweetened beverages per week. Total screen time, including TV, video games, DVD’s, and computers averaged 1404 (±642) minutes per week, or 3.3 hours per day. Nearly 50% of parents reported that their child had a TV in his or her bedroom and almost 40% reported that the child ate dinner with the TV on “a lot” or “sometimes”.
Table 2
Distribution of health behaviors by child weight status
a
in a sample of racially and ethnically diverse first through third grade children
Sweet beverages/week, n (%)*
| 4.51 | .212 |
0-2 | 188 (27.8) | 128 (68.1) | 60 (31.9) | | |
3-5 | 161 (23.8) | 101 (62.7) | 60 (37.3) | | |
6-8 | 157 (23.2) | 97 (61.8) | 60 (38.2) | | |
≥9 | 171 (25.3) | 98 (57.3) | 73 (42.7) | | |
Snack rule, n (%)**
| 591 (74.6) | 350 (71.0) | 241 (80.6) | 9.07 | .002 |
Kitchen access rule, n (%) **
| 570 (71.4) | 338 (68.0) | 232 (77.1) | 7.55 | .017 |
% Snack + Kitchen Rule, n (%)**
| 489 (62.0) | 285 (58.0) | 204 (68.5) | 8.53 | .002 |
Family dinner, n (%)*
| 18.97 | <.001 |
A lot | 597 (74.3) | 396 (79.5) | 201 (65.7) | | |
Sometimes/rarely/never | 207 (25.7) | 102 (20.5) | 105 (34.3) | | |
% TV in child’s bedroom** | 399 (49.8) | 244 (48.9) | 155 (51.3) | .443 | .277 |
% TV on during dinner, n (%)*
| 0.23 | .351 |
A lot/sometimes | 323 (39.8) | 204 (40.5) | 119 (38.8) | | |
Rarely/never | 488 (60.2) | 300 (59.5) | 188 (61.2) | | |
% Parent physically active w/ Child, n (%)*
| 1.65 | .120 |
A lot/sometimes | 700 (87.0) | 439 (88.2) | 261 (85.0) | | |
Rarely/never | 105 (13.0) | 59 (11.8) | 46 (15.0) | | |
% Children take vitamins, n (%)**
| 353 (43.6) | 242 (48.2) | 111 (36.0) | 11.50 | .001 |
Vegetable servings/day
+
**
| 1.55 (0.9) | 1.55 (0.9) | 1.54 (0.9) | | .835 |
Fruit servings/day
+
**
| 1.66 (0.9) | 1.67 (0.9) | 1.63 (0.9) | | .556 |
Dairy servings/day
+
**
| 2.67 (1.1) | 2.74 (1.1) | 2.57 (1.1) | | .026 |
Snack servings/day
+
**
| 1.80 (1.0) | 1.84 (1.0) | 1.71 (0.9) | | .082 |
Screen time
+
**
(Minutes/week)
| 1404 (642) | 1360 (636) | 1476 (646) | | .012 |
Sports
+
**
(Number/Year)
| 2.37 (2.4) | 2.41 (2.4) | 2.29 (2.3) | | .490 |
In unadjusted analyses, patterns for several health behaviors and household characteristics differed by weight status (Table
2). Households with children in the overweight category were more likely to have rules related to snacking (χ
2 = 9.07, p = 0.002) and about whether or not children were allowed to help themselves to food in the kitchen (χ
2 = 7.55, p = 0.017) than those with children in the normal weight category. Parents/guardians in households with overweight children reported lower frequency of having family dinner “a lot” than children in the normal category (χ
2 = 18.97, p < 0.001). There was no difference between the two weight categories in parent/guardian reports of frequency of being physically active with their children. Overweight children were less likely to take vitamin/mineral supplements than normal weight children (χ
2 = 11.5, p = 0.001). Overweight children had significantly (p = 0.012) more minutes of screen time per week (1476 ± 646) than children in the normal weight category (1360 ± 636 minutes). The number of daily servings of low-fat dairy was higher for normal weight than for overweight children (2.74 vs. 2.57, p = .026), whereas the number of fruits, vegetables, and snacks per day did not vary significantly between groups (Table
2).
Table
3 shows the results of the final logistic regression model predicting the presence of child overweight compared to normal weight. Controlling for the other variables in the model, the likelihood of overweight was higher in Hispanic than Caucasian children (OR = 2.36; CI 1.35 to 4.12). Children in households with one food rule were more likely to be overweight than those in households with no food rules (OR = 2.61; CI 1.33 to 5.09); having two food rules increased the odds ratio for overweight further (3.53; CI, 1.96 to 6.35). Having dinner as a family frequently (reported as “a lot”) and reported child use of vitamin/mineral supplements were associated with a lower likelihood of overweight (OR = 0.47; CI 0.31 to 0.71) and (OR = 0.54; CI, 0.37 to 0.78), respectively. Child sex, child age, number of sugar-sweetened beverages consumed per week, parent overweight and parent education were not significantly related to child overweight in this model.
Table 3
Odds of overweight in a sample of racially and ethnically diverse first through third grade children
Family dinner
|
“A lot” | -.763 | .211 | .466 | (0.31-0.71) |
Sometimes/rarely/never | -- | -- | 1.00 | Reference |
Number of food rules
|
0 Food rules | -- | -- | 1.00 | Reference |
1 Food rule | .958 | .342 | 2.61 | (1.33-5.09) |
2 Food rules | 1.26 | .300 | 3.53 | (1.96-6.35) |
Racial/ethnic group
|
Caucasian | -- | -- | 1.00 | Reference |
Black | .048 | .306 | 1.02 | (0.58-1.91) |
Hispanic | .857 | .285 | 2.36 | (1.35-4.12) |
Asian | -.103 | .433 | .902 | (0.39-2.11) |
Multi | .077 | .304 | 1.08 | (0.59-1.96) |
Other | -.350 | .482 | .705 | (0.28-1.81) |
Vitamin/mineral supplement use
| -.621 | -.192 | .538 | (0.37-0.78) |
No evidence for interactions between sex and racial/ethnic group, parent overweight and food rules, or family dinner and TV viewing during dinner was evident (p-values for all interaction terms exceeded 0.05). Inclusion of each set of interaction terms had negligible effects on the other covariates.
Discussion
This study is among the first to find that frequent family dinners are associated with lower risk of overweight and that household food rules are associated with higher risk in a socio-economically and racial/ethnically diverse early elementary school population. Specifically, the analyses highlight the cross-sectional relationships between the household practices of family dinners and food rule-setting in relation to child overweight in a multi-racial/ethnic, urban sample of early elementary school children. The influences were evident after adjusting for a wide variety of demographic and behavioral factors. These findings extend previously documented observations regarding the importance of children’s environments, particularly their household environments and parent/caregiver influences, in association with weight status in Caucasian families to racially and ethnically diverse families [
3,
13,
48].
The finding that children whose parents reported having dinner with them frequently were less likely to be overweight than those whose parents reported having dinner with them infrequently or never, is consistent with some, but not all, published research [
13‐
15]. Having the TV on during dinner was not associated with weight status in our sample and we saw no evidence that having the TV on during dinner influenced the association between family dinner and child overweight. Some evidence suggests that, at least for adolescents, the inverse association between family meals and overweight is restricted to non-Hispanic Caucasians [
16]. This cross-sectional study demonstrates that this association occurs in other racial/ethnic groups. It should be noted that we assessed only the relationship between TV watching during dinner and weight status. Previous studies have emphasized dietary
quality in relation to this practice. While family meals without the TV have consistently been associated with higher dietary quality, at least one study demonstrated that even with TV use, family meals provide a dietary quality advantage for children when compared to absence family meals [
49].
The finding of greater odds of overweight in children from households with at least one rule restricting food access, and still greater odds in the presence of two such rules was also consistent with previous findings [
7,
26,
27]. However, because temporality cannot be determined from cross-sectional data, we are not able to determine whether household food rules restricting snacking and kitchen access precipitated overweight or whether such rules were established by parents in response to their child’s weight status. Others have suggested that relationships between parental rule-setting about food intake and children’s weight status are complex and not unidirectional [
9,
29,
50]. Most studies of food rules and parental restriction have been limited to Caucasian and higher socioeconomic populations [
51,
52]. These findings document this association in a racially/ethnically diverse population.
Use of vitamin/mineral supplements was found to vary by weight category and thus was tested in the regression model. It may be that vitamin/mineral supplement use is a proxy for a consistent, organized household or healthy behaviors resulting from overall adaptive family functioning [
53]. The concept of household order has been associated with better outcomes in families for other pediatric conditions [
54‐
56], but has been less frequently explored in the context of childhood obesity [
57,
58]. Interestingly, Joyce and colleagues [
59] demonstrated that “parenting chaos”, or the degree of inconsistency and unpredictability in parenting routines in the context of eating [
60], may moderate the relationships among food restriction, disinhibited eating and child BMI. Specifically, the association between food restriction and disinhibited eating was stronger in households with higher levels of parent chaos [
59].
Having frequent family dinners may also be related to household order [
61]. It is also plausible that use of vitamin/mineral supplements and having frequent family dinners may correlate with socio-economic status (SES). That low SES may be associated with a poorer home environment overall and thereby an increased risk for obesity has been previously observed [
62,
63]. However, parental education, an SES indicator, was accounted for in this present study. Overall, these findings suggest the need for further investigation and, as Fiese and colleagues indicate the importance of investigating household and family routines in the broader context of social, economic and cultural factors [
64].
Indeed, differences in
context may explain discrepancies seen across studies in associations between childhood weight status and the household and family factors discussed above. For instance, child feeding practices have been shown to vary across both socioeconomic status and racial/ethnic groups [
65] and some have suggested that
cumulative effects of neighborhood and family level factors must be considered when explaining environmental risk factors for childhood obesity [
64]. Gaps remain in fully describing these associations.
This study had several strengths. This investigation lends to the knowledge base in this area as it was conducted in an ethnically diverse population, assessed a range of socio-demographic variables, and explored a wide variety of behavioral and household issues. All questionnaires and study materials were translated into parents’ native languages to support inclusion of a more diverse sample of respondents than has typically been included in similar studies. Finally, sample size was sufficient to build a model that supported analysis of a substantial number of variables simultaneously.
Several limitations are noteworthy. Most importantly, the cross-sectional design precludes determination of causality. Also, this study, like others [
15] used qualitative descriptors of characteristics that are poorly suited for direct quantitative interpretation. For example, physical activity was assessed via questions about involvement in
organized physical activity, such as team sports or swimming lessons. While this approach yields information about the type, frequency, and consistency with which children in the sample engaged in physical activity, it fails to capture non-organized physical activities, such as riding a bicycle or playing neighborhood basketball. This discrepancy may explain the lack of an observed effect of physical activity on weight status. Additionally, all information from parent questionnaires was self-reported and, as such, may be subject to both error and bias. Further, the dichotomous (yes/no) response choices for the household food rule questions do not fully capture nuances that are likely to exist in the area of household food restriction. For instance, food rules may be time or context-specific, permanent or temporary, and may represent a wide range in terms of degree of restrictiveness. Lastly, the response rate from parents of racial/ethnic minority children was significantly lower than for parents of Caucasian children. This may have influenced the internal validity and generalizability of results.
Competing interests
Sonya Irish Hauser: reports no competing interests.
Christina D. Economos: reports no competing interests.
Miriam Nelson: reports no competing interests.
Jeanne P. Goldberg: reports no competing interests.
Raymond Hyatt: reports no competing interests.
Elena N. Naumova: reports no competing interests.
Sarah E. Anderson: reports no competing interests.
Aviva Must: reports no competing interests.
We certify that this manuscript is original work and has not been published elsewhere. The authors do not have any conflicts of interest, financial or otherwise. All authors listed have read the manuscript, agree that the manuscript is ready for submission to a journal and are willing to accept responsibility for the manuscript’s contents.
Authors’ contributions
SIH performed data analysis and interpretation and drafted the manuscript. CDE was the principal investigator for the larger intervention from which data for this current analysis was drawn and assisted in drafting and editing the manuscript. MN participated in design of the larger intervention contributed to manuscript editing JPG participated in design of the larger intervention contributed to manuscript editing RH assisted in data analysis and manuscript editing ENN participated in design of the larger intervention contributed to manuscript editing. SEA assisted in data analysis, interpretation and manuscript editing AM participated in design of the larger intervention, interpretation of analyses, and contributed to manuscript conceptualization and writing. All authors read and approved the final manuscript.