Facilitators and barriers to preparing and offering whole grains to children diagnosed with prediabetes: qualitative interviews with low-income caregivers

There is a growing epidemic of prediabetes and diabetes among children and adolescents. Through examining data from the National Health and Nutrition Examination Survey (NHANES), May et al. [1] found that the prevalence of U.S. adolescents (12–19 years) with prediabetes/T2D significantly increased from 9 to 23% between 1999 and 2008. Similarly, findings from the SEARCH for Diabetes in Youth Study, a multi-site observational study of diabetic children and adolescents in the U.S., suggest that the incidence of T2D among youth increased significantly from 9 cases to 12.5 cases (per 100,000 youth) between 2002 and 2012 [2]. The study also reported that non-Hispanic black and Hispanic youth experienced a significant increase in the rate of new cases of T2D between 2002 and 2012, whereas non-Hispanic white youth did not. There is evidence suggesting that the prevalence of T2D may be higher in youth residing in low socioeconomic status (SES) households compared to those residing in higher-income households [3], but additional research is needed to elucidate the relationship between household SES and T2D risk amongst youth.

Dietary fiber (e.g., whole grains and vegetables) plays a significant role in the prevention and treatment of T2D. Especially important is the intake of whole grains, which have been shown to improve glucose control. In a systematic review and meta-analysis of 13 studies on whole grain intake and T2D risk, high intake of whole grains was inversely associated with T2D risk [4]. Results revealed that as whole grain intake increased (up to 50 g/day), T2D risk decreased by 25% [4]. For a 2000 cal diet, the 2015–2020 Dietary Guidelines for Americans recommends consuming 6-oz equivalents (oz. eq.) of grains/day with at least half of those grains being whole grains (i.e., 3-oz. eq./day; 1-oz. eq. = 1 slice of 100% whole wheat bread; USDHHS and USDA, 2015). An oz. eq. is approximately 16 g of whole grains [5]. In general, adolescents in the U.S. are not meeting dietary recommendations for whole grain intake, with recent data suggesting that adolescents consume 0.8-oz. eq. of whole grains on any given day (Tester, Leung, Leak, & Laraia, 2017). Furthermore, socioeconomic disparities in whole grain intake exist, such that adolescents residing in lower income households consume an average of 0.5-oz. eq. per day, while adolescents from a higher socioeconomic background consume an average of 1.0-oz. eq. per day [6].

There are many factors that influence youth intake of whole grains, with sensory-related characteristics (e.g., taste, appearance, and texture) being among the most cited factors and varying depending on the product [7‐10]. For example, some studies have shown that youth report favorable liking scores for pizza made with whole grain pizza crust [11, 12], whereas the findings are more mixed regarding the acceptability of whole grain tortillas [13, 14]. To address sensory-related barriers, several studies have examined the effectiveness of partially substituting refined grains with whole grains [11, 12, 14].

Caregivers also play a significant role in whether or not their children consume whole grains based on their own attitudes and beliefs about whole grains, willingness to role model whole grain intake, and whether they make whole grains available and accessible within the home [15, 16]. Several cross-sectional studies have shown that household availability of whole grains is positively associated with whole grain intake among children and adolescents [10, 17, 18]. However, limited neighborhood availability of whole grains continues to be a barrier [9], as it is challenging for caregivers to offer whole grains in the home if whole grains are not available for purchase in the neighborhood. Furthermore, studies have reported that low SES neighborhoods have limited access to healthier foods (e.g., whole grains) [19], and when healthier foods are available, they are more expensive in low SES neighborhoods compared to higher SES neighborhoods [20, 21].

The overall aim of this paper is to assess caregiver perceptions about facilitators and barriers to preparing and offering whole grains that they received as part of the 16-week Food Overcoming Our Diabetes Risk (FoodRx) pilot study. For the FoodRx pilot study, low SES households with a child with obesity and prediabetes received home deliveries of whole grains (bi-weekly) and vegetables (weekly). The FoodRx pilot study addressed the issue of limited neighborhood availability of whole grains, but what remained unclear were facilitators and barriers caregivers experienced when preparing and offering whole grains in the home.

Caregivers (n = 48) had a mean age of 43 years, were primarily female (n = 46), were predominantly Hispanic (71%), and approximately half (51%) were employed. On average, households consisted of 5.7 people (range: 2–15, median 5). Caregiver and household characteristics are described in more detail in Table 1.

When caregivers reflected on the feasibility of preparing and offering the whole grains that were included in their FoodRx deliveries, they described several facilitators and barriers. These are discussed in more detail in the following sections. In addition, a conceptual framework summarizing facilitators and barriers is depicted in Fig. 1, and additional supporting participant quotes can be found in Table 2.

Several interventions have attempted to improve fruit and vegetable consumption, but fewer interventions have aimed to improve whole grain intake, especially among vulnerable populations, such as children from low SES backgrounds diagnosed with prediabetes. The overall aim of the FoodRx pilot study was to increase fiber-rich food intake among obese children diagnosed with prediabetes that reside in low SES households by providing deliveries of whole grains and vegetables. Given that caregivers are often responsible for what foods are available and prepared in the home, it was important to conduct this current study in order to understand their perceptions about preparing and offering whole grains to their children.

Previous studies reveal that there is a general lack of knowledge about whole grains and the health benefits of them [7, 27]. For example, focus groups conducted with adults (almost half of whom were parents) demonstrated that participants knew what constitutes a whole grain, but only had a basic understanding of why consuming whole grains are an integral part of a healthy diet [27]. In another study, parents of elementary school-aged children reported that they recognized products if the phrase “whole grains” was written on the packaging and that whole grains were healthier than refined grains, but they were unable to articulate how [7].

Nutrition knowledge is positively associated with dietary intake [28], and thus intervention studies aimed at increasing whole grain intake have attempted to increase whole grain knowledge [16, 29]. For example, Burgess-Champoux et al. [16] engaged caregivers and children in an intervention to increase whole grain intake that included providing whole grains at school and nutrition education to both caregivers and children. At the end of the intervention, whole grain knowledge and intake significantly increased. Similarly, findings from the present FoodRx pilot study reveal that at study conclusion caregivers reported that they had a better understanding that whole grains are healthy, and some were even able to describe specific health benefits of whole grains. These findings may be a result of the study binder provided at the baseline clinic visit that included educational materials about whole grains. As such, this study and previous research highlight the importance of including whole grain education in interventions aimed at increasing whole grain intake.

After the completion of the FoodRx pilot study, many caregivers expressed that they lacked the skills and/or confidence to prepare whole grains that they were unfamiliar with. This is similar to perceptions from adult participants in an intervention by Kuznesof et al. [30], which aimed to increased whole grain intake by having participants substitute non-whole grain foods with whole grain equivalents that were provided. Despite being provided whole grains and instruction on how to substitute them in their diets, participants reported that they lacked the skills necessary to prepare certain whole grain foods and suggested that they had low self-efficacy when it came to preparing whole grains [30]. Other studies have examined what it is like for adults to prepare less familiar vegetables, and these studies report similar findings to whole grains, such that preparing novel vegetables is challenging for adults and it takes time to acquire skills and improve self-efficacy to prepare them [31, 32]. Thus, regardless if caregivers are preparing a novel vegetable or a novel whole grain, research suggests that lack of skills and confidence to prepare novel foods must be addressed. Other studies that have improved skills and self-efficacy for preparing and offering healthy foods have had participants engage in in-person culinary education, including demonstrations and hands-on food preparation [33, 34]. Therefore, it may be useful to incorporate several sessions of formal, in-depth culinary education into future interventions aimed at increasing whole grain intake.

Caregivers in the FoodRx pilot study described strategies they used to encourage whole grain consumption for children in the home, such as pairing whole grains with liked foods and providing verbal encouragement. Many of the strategies that FoodRx caregivers developed are similar to strategies that researchers have tested when attempting to increase child vegetable intake [35‐38]. In one study on increasing child whole grain intake, Burgess-Champoux et al. [7] asked parents for advice on how to introduce whole grain foods to children. Some of the suggestions included introducing whole grains gradually, allowing children to sample the whole grain foods, and possibly branding whole grain products with cartoon characters. As such, this current study provides additional information on strategies to increase whole grain intake among children. For example, caregivers in this current study paired whole grains with a liked food and mixed whole grains with refined grain foods. Therefore, it may be useful to describe these strategies in future whole grain intervention materials for caregivers in order to facilitate their offering of whole grains in the home.

This study is not without limitations. Using a convenience sample for the FoodRx pilot study limits the generalizability of these qualitative findings, since the sample may not be representative of all youth with obesity and prediabetes from low SES households. In addition, parental feeding behaviors are naturally different with younger children, and caregivers with children younger than the age included in this study (8–17 years) may have facilitators and barriers for whole grain intake not explored here. Furthermore, because these children had been identified to have prediabetes, caregivers may have had a higher level of concern and motivation than caregivers of peers with comparable sociodemographic backgrounds but lacking the identified risk for diabetes. Caregivers may have also been influenced to speak favorably about whole grains as a result of being in the FoodRx pilot study where whole grains were provided weekly and focused on. In addition, the authors did not concurrently conduct data collection and analysis due to study time constraints, which may have been beneficial in refining the interview guide. Furthermore, additional checks of data trustworthiness (checking transcriptions against recordings, 3rd coder, etc.) were not employed as the interviews were transcribed by a professional service and there were no coding discrepancies that were not easily reconciled. Lastly, due to the small sample size and qualitative exploration, it may be necessary to quantitatively (e.g., surveys) examine the feasibility of preparing and offering whole grains in the home among a larger sample.

Given the growing number of youth at risk for T2D, it is imperative to identify effective preventative strategies. Research shows that consuming adequate amounts of whole grains can be protective against T2D [4]. However, youth are not meeting dietary recommendations [6]. Caregivers are the gateway to the home food environment and thus play an essential role in whether or not whole grains are available and accessible for youth [15, 16]. However, to our knowledge, no study has examined caregiver perceptions of the feasibility of offering and preparing whole grains in low SES households with a child at risk for a chronic disease. As such, findings from the current study address a major gap in the literature. The qualitative interviews revealed that caregivers are receptive to offering whole grains to their children, but they may need additional support to address barriers to preparing novel whole grains. Future researchers should address these barriers when designing whole grain interventions for households with a child at risk for T2D.