589733 research-article2015

HPPXXX10.1177/1524839915589733Health Promotion PracticeAmuta et al. / Influence Of The Home Food Environment

Food and Exercise in Rural Areas

Influence of the Home Food Environment on Children’s Fruit and Vegetable Consumption: A Study of Rural Low-Income Families Ann O. Amuta, MPH, CPH1 Wura Jacobs, MSc, PhD1 Ehikowoicho E. Idoko, BSc1 Adam E. Barry, PhD E. Lisako J. McKyer, PhD, MPH1

Background. This investigation sought to identify micro-level built and sociocultural characteristics of a home food environment that have been theoretically linked with fruit and vegetable (F&V) consumption. Method. We examined rural families (n = 298) from the southeastern United States. Hierarchical multiple regression analyses determined the association between the outcome variable (F&V consumption) and microlevel built and sociocultural characteristics of a home food environment. Results. Demographic characteristics were entered at Step 1, explaining 14% of variance in vegetable consumption and 9% in fruit consumption. After entry of sociocultural factors in the home food environment, such as parenting styles and so on, in Block 2, the total variance explained increased by 25% for vegetable consumption and 12% for fruit consumption. Micro-level built environmental factors such as the availability of F&V in the home was entered at Block 3, total variance explained by the model for vegetable consumption was 67%, F(17, 111) = 13.5, p < .001, and for fruit consumption was 57%, F(17, 160) = 12.5, p < .001. Conclusion. F&V availability was the most important variable influencing a child’s consumption of F&V. There are modifiable factors within the rural low-income home that could serve as priorities for intervention to improve F&V consumption. Keywords: child/adolescent health; nutrition; rural health; health promotion; minority health

Health Promotion Practice September 2015 Vol. 16, No. (5) 689­–698 DOI: 10.1177/1524839915589733 © 2015 Society for Public Health Education

Introduction >> Fruit and vegetable (F&V) consumption provides health benefits for children, such as reducing risk of cancer and cardiovascular disease (Bhupathiraju et al., 2013; Centers for Disease Control and Prevention, 2013). Although there is strong evidence supporting the need for children to consume at least five servings of F&V per day, national studies contend that many children fail to meet this recommendation (Guenther, Dodd, Reedy, & Krebs-Smith, 2006; Krebs-Smith, Guenther, Subar, Kirkpatrick, & Dodd, 2010; Prelip, Le Thai, Erausquin, & Slusser, 2011). For instance, the average daily intake of fruits among both male and female children aged 9 to 13 years is 1.2 servings per day and 2.4 servings of vegetables per day, compared to the recommended daily servings of 3 and 5, respectively. Moreover, only 19% of children aged 9 to 13 reported consuming five or more daily servings of F&V (Guenther et al., 2006). Inadequate F&V consumption places children at higher risk for multiple chronic diseases such as type 2 diabetes, cancer, heart disease, and stroke (U.S. Department of Health & Human Services, 2011). While these diseases mostly manifest in adulthood, personal beliefs surrounding food and general eating habits developed during childhood set the stage 1

Texas A&M University, College Station, TX, USA

Authors’ Note: The project was funded by Grant 1P20MD0002295 from the National Center on Minority Health and Health Disparities. Address correspondence to Ann O. Amuta, Graduate Teaching Assistant, Department of Health & Kinesiology, Texas A&M University, 316 Blocker, 4243 TAMU, College Station, TX 77843, USA; e-mail: [email protected].

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for behaviors that may persist as one ages (Grimm, Kim, Yaroch, & Scanlon, 2014; U.S. Department of Health & Human Services, 2011). Consequently, there is a clear need to promote more F&V consumption among children (Centers for Disease Control and Prevention, 2011).

Background >> To design effective F&V communication campaigns, educational programs, and/or interventions, there is a clear need to understand the various interpersonal (e.g., parental eating rules) and environmental (e.g., F&V availability) factors that influence children’s consumption (Wyse, Campbell, Nathan, & Wolfenden, 2011), as a child’s food choices are influenced by factors beyond simple individual preferences (Rasmussen et al., 2006). Specifically, food choice is influenced by the demographic, socioeconomic, and environmental characteristics of the families to which children belong (Dubois, Farmer, Girard, Burnier, & Porcherie, 2011; Pearson, Biddle, & Gorely, 2009; Rasmussen et al., 2006). Examples of such family influences include, but are not limited to, cultural practices that influence the types of food consumed at home, income of parents, and eating rules enforced at home (Rosenkranz & Dzewaltowski, 2008). Theoretical Framework The model of the home food environment put forward by Rosenkranz and Dzewaltowski (2008) contends that children’s dietary behaviors are shaped by overlapping interactive domains consisting of (1) built and natural environment, (2) sociocultural environment, and (3) political and economic environment. Under each of these domains are both macro-level influences such as poverty, rural living, and race/ethnicity, as well as micro-level influences such as family eating rules, parents’ providing behaviors, and availability and accessibility of F&V in the home. Overall, Rosenkranz and Dzewaltowski assert that these home food aspects “represent a substantial part of the full environmental context in which a child grows, develops, eats and behaves” (p. 123). This study adapted Rosenkranz’s model of the home food environment. The home food environment (i.e., availability and accessibility of foods rich in nutrients such as F&V and grains), measured as a latent variable in our investigation, has been reported to significantly affect various diet-related health indicators including childhood obesity rates, F&V intake, and consumption of reduced-fat dairy products (Boles, Scharf, Filigno, Saelens, & Stark,

2013; Rosenkranz & Dzewaltowski, 2008). In addition to availability and accessibility of healthy foods in the home, studies have also shown that the more time children spend watching TV or playing video games, the less fruits and vegetables they consume (BoyntonJarrett et al., 2003; Falbe et al., 2014). Other aspects of the home food environment, such as parental diet and parenting practices, have also been shown to influence children’s healthy food consumption (Campbell et al., 2013; Draxten, Fulkerson, Friend, Flattum, & Schow, 2014; Rasmussen et al., 2006). Thus, the built and natural environment (i.e., F&V accessibility and availability), as well as the sociocultural environment (i.e., eating practices in the home, parents’ F&V consumption, rules and practices enforced by parents) represent key indicators of one’s overall home food environment and were specifically selected as measures for this investigation. Current Investigation Although there is a plethora of evidence supporting the importance of the home food environment (Andaya, Arredondo, Alcaraz, Lindsay, & Elder, 2011; Boles et al., 2013; Campbell et al., 2013; Christian, Evans, Hancock, Nykjaer, & Cade, 2013; Dean & Sharkey, 2011; Wyse et al., 2011) as a strong predictor of children’s F&V consumption, to date, much of this literature has examined families residing in primarily urban areas (Andaya et al., 2011; Boles et al., 2013; Campbell et al., 2013; Christian et al., 2013; Wyse et al., 2011). This is of concerning given that families residing in rural settings often lack convenient access to F&V (Dean & Sharkey, 2011; Sharkey, 2009; Sharkey, Dean, Nalty, & Xu, 2013; Sharkey & Horel, 2008; Sharkey, Horel, & Dean, 2010; Sharkey, Johnson, & Dean, 2010). Moreover, in rural areas, variety of healthy foods is limited, quality and overall freshness of the food are lower, and food is generally more expensive compared to urban settings (Dean & Sharkey, 2011). What is unique about this particular sample is that it is composed of rural minority participants providing insights into the influence of rurality and poverty on dietary behaviors. Consequently, this study sought to determine whether the home food environment, specifically the sociocultural environment and micro-level built environment (see Figure 1), was associated with child intake of F&V in rural and predominantly low-income families. This research article aims to inform intervention efforts that focus on the promotion of F&V consumption among rural, minority, and low-income families.

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Socio-cultural environment factors: - Screen me, me on videogame - parent eat with/ child, parent (F&V) providing behavior - dinnerme rules, dinner prep rules, dinner consumpon rules

Home Food Environment

Children’s Fruits and Vegetables Intake

Micro-Level built environment factors: - Fruit availability - Veg availability

Figure 1 The Sociocultural and Micro-Level Built Environment Factors of the Home Food Environment Influencing Children’s Fruit and Vegetable (F&V) Consumption

Method >> Data for this investigation came from the Student Wellness Assessment and Advocacy Project, a National Institutes of Health–funded culturally appropriate, multilevel intervention designed to prevent and reduce childhood obesity in rural Texas communities. Data reported herein specifically examine paper-and-pencil survey responses of parents, aged 18 or older, who had elementary school (kindergarten-5th grade) children attending one of the participating school sites. Parents were recruited from seven schools from three different rural school districts across Texas. Invitation solicitations and consent forms were sent home through students. All materials (e.g., questionnaires, consent forms, letters) were made available in both English and Spanish. Parents who completed the questionnaire received a $25 Walmart gift card. Details on data sampling and collection are reported elsewhere (Lu et al., 2014).

existing questionnaires such as Active Where survey by Sallis (Kerr, Sallis, Rosenberg, Norman, et al., 2008) and Texas Food and Nutrition Questionnaire (McKyer et al., 2011). These assessments have been previously used to examine F&V consumption and built environment influences among low-income respondents (EttienneGittens et al., 2010; Ettienne-Gittens et al., 2013). For this study, we examined only questions related to the home food environment, nutrition behavior, and demographic characteristics of parents/families. Frequency of children’s F&V consumption (outcome measures) was assessed via the following items: “In the past 7 days, for how many evening meals did your child eat fruits?” and “In the past 7 days, for how many evening meals did your child eat vegetables?” Possible response options ranged from 0 days to 7 days. Sociocultural environment (independent measures) was assessed by several items. These items included the following:

Measures

••

The quantitative instrument used for the parent grant/program consisted of 197 items that focused on issues related to childhood obesity, such as physical activity, nutrition, and school policies. The instrument, guided by the social-ecological model (McLeroy, Bibeau, Steckler, & Glanz, 1988) was derived from

••

Eating together: “In the past 7 days, how many evening meals did you eat with your child?” Possible response options ranged from 0 days to 7 days. Typical screen time: “Please indicate how much time in a typical weekday/weekend your child watches television/videos/DVDs.” Possible response rates ranged from 0 hours to 4 hours or more. Parents

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••

••



provided response for typical weekday as well as typical weekend. These responses were added to form a typical screen time cumulative measure. Typical video game time: “Please indicate how much time in a typical weekday/weekend your child plays computer or video games (e.g., Nintendo, Xbox, etc.).” Possible response rates ranged from 0 hours to 4 hours or more. Parents provided response for typical weekday as well as typical weekend. These responses were added to form a typical screen time cumulative measure. Cronbach’s alpha for typical screen and video game time items = .74. Dinnertime rules item was assessed by asking parents how often they enforce the following rules: ○  “No second helpings at meals”: Response options included yes (coded 2), sometimes (coded 1), and no (coded 0). ○  “Limited portion sizes at meals”: Response options included yes (coded 2), sometimes (coded 1), and no (coded 0). ○ “Limited consumption of fast food”: Response options included yes (coded 2), sometimes (coded 1), and no (coded 0).

The responses from the items above (second helpings, portion size, and consumption) were added to form a typical dinnertime rules cumulative measure. ••

••

Dinner preparation rules was assessed by asking parents how often they enforce the following rule: “Child must help with meal preparation at home.” Response options included yes (coded 2), sometimes (coded 1), and no (coded 0). Dinner consumption rules was assessed by asking parents how often they enforce the following rule: “Child must eat dinner with family.” Response options included yes (coded 2), sometimes (coded 1), and no (coded 0). All items that measured rules enforced by parents were included into one construct with Cronbach’s α = .89.

Independent measures were assessed based on availability of F&V in the home. Specifically, we inquired “In the past 7 days, for how many meals were fruits available for your child to eat?” and “In the past 7 days, for how many meals were vegetables available for your child to eat?” Possible response options ranged from 0 days to 7 days. Analysis Hierarchical multiple regressions were used for all analyses guided by the theoretical model we

proposed. Assumptions of normality, linearity, and multicollinearity were examined to ensure that the results were without statistical violations; no assumptions were violated. Step 1 of the regression model consisted of demographic characteristics (biological sex, income, marital status, household occupancy, race, and education). Step 2 consisted of factors of the sociocultural environment (i.e., number of times parents eat with child, screen time in a typical week, amount of video game time in a typical week, dinner rules at home, dinner preparation rules, dinner consumption rules, and parents’ providing behavior). The last step included a micro-level built environment factor (i.e., F&V availability). The rationale for the order of entry was ultimately to test how much (if any) additional variance in F&V consumption could be explained by factors of the home food environment above that explained by demographic characteristics. Separate models were conducted for F&V.

Results >> A total of 767 questionnaires were distributed to parents; 298 surveys were returned and considered eligible for analysis (41% response rate). The majority of the students from the three independent school districts (ISDs; Royal ISD, 2010; Waller ISD, 2010; Hempstead ISD, 2010) consisting primarily of Hispanic/ Latino (63.2%, 41.7%, and 48.5%, respectively) and African American/Black (24.1%, 12.9%, and 31.2%, respectively) respondents. Participants were predominantly low-income families (81.3%, 60.1%, and 73.3%, respectively). Most households were jointly run by married guardians/parents (69%, n = 204). Sample demographic information is detailed in Table 1. Fruit Consumption Demographic characteristics were entered at Step 1, explaining 9% variability in children’s fruit consumption behavior. On adding sociocultural factors (typical screen time, typical video game time, dinner preparation rules, and dinnertime rules) to the model (Step 2), the total variance explained increased by 12%. At Step 3 (including built environment factors into the model), the variance explained increased an additional 36%. The total variance for fruit consumption explained by the model as a whole was 57%, F(17, 160) = 12.5, p < .001. In the final model, statistical significance was found in income, dinner preparation rules, fruit availability in the home, and being Hispanic. For income (β = −.157, p < .05), with every 1-unit increase in parents’

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Table 1 Sample Demographic Characteristics (n = 298) Characteristics Age (years)  54  Missing Gender   Male parents   Female parents   Male children   Female children Parental marital status  Single  Married  Separated  Divorced  Widowed Household income  Low  Medium  High Parental highest education level   1st-6th grade   7th-9th grade   10th-12th grade   High school graduate  GED   Some college   Associates degree or technical college   Bachelor’s degree or higher   Missing responses Household occupancy  10  Missing

N

%

19 1 135 109 21 3 10

6.3 0.3 45.3 36.6 6.9 0.9 3.4

38 257 142 155

13 86 47 52

38 204 16 27 7

13 69 5 9 2

120 112 39

40 38 13

29 26 34 59 21 48 32

10 9 11 20 7 16 11

28

9

21

7

133 160 2 3

44.6 53.7 0.6 1.0

income there is a 0.157 decrease in the number of days children eat fruits during dinner holding all other variables constant. For dinner preparation rules (β = −.124, p < .05), results indicated that there is a 0.124 increase

in fruit consumption for children who prepare meals with their parents compared to parents who do not, holding all other variables constant. The results also indicated that for every additional day fruits are available in the home, there is a 0.652 increase in the number of days a child eats fruits holding all other variables constant (β = .652, p < .01). Being Hispanic was also associated with fewer days in which fruits were consumed (β = −.159, p < .05). The final regression model for children’s fruit consumption is shown in Table 2 and R2 changes are shown in Table 3. Vegetable Consumption Demographic characteristics were entered at Step 1, explaining 14% of the total variance in vegetable consumption. After entry of sociocultural factors (typical screen time, typical video game time, dinner preparation rules, and dinnertime rules) at Step 2, the total variance explained increased by 24%. At Step 3 (availability of vegetables in the home), the variance explained increased by an additional 27%. The total variance for vegetable consumption explained by the model as a whole was 67%, F(17, 111) = 13.5, p < .001. In the final model, statistical significance was found in parents eating with their child (β = .129, p < .05); this means that that for every 1-day increase in the number of times parents ate with their children there is a 1.29 increase in the number of days children eat vegetables during dinner, holding all other variables constant. Results for screen time in a typical week (β = −.157, p < .05) showed that for every 1-hour increase in screen time there is a 0.157 decrease in the number of days a child eats vegetables holding all other variables constant. Dinner preparation rules results (β = .116, p < .05) show that there is a 0.116 increase in vegetable consumption for parents who prepare meals with their children compared to parents who do not, holding all other variables constant. The results also indicated that for vegetable availability in the home (β = .657, p < .01), every additional day vegetables are available in the home; there is a 0.657 increase in the number of days a child eats vegetables holding all other variables constant. The final regression model for children’s vegetable consumption is shown in Table 2 and R2 changes are shown in Table 3.

Discussion >> This study aimed to assess the influence of the home food environment on children’s F&V consumption in a sample of children from predominantly rural, lowincome families. These factors were specifically selected based on the theoretical framework of Rosenkranz and Dzewaltowski (2008). While the study identified some

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Table 2 Multiple Linear Regression Analyses Predicting Home Environment Factors Implicated in Children’s Fruit and Vegetable Consumption (n = 298) Variable

Β

SE Β

Children’s fruit consumption  Constant 2.731 1.131 Step1: Demographic characteristics  Gender −0.500 0.340   Contact age −0.011 0.013  Education 0.072 0.070   Marital status −0.001 0.001  Income −0.115 0.045 0.052 0.077  Occupancy  Hispanic/Latino −0.671 0.315   Race White −0.004 0.310   Race Black −0.053 0.459 Step 2: Sociocultural environment   Eat with child 0.057 0.070   TV screen time 0.000 0.001   Video game time 0.001 0.001   Dinnertime rules −0.001 0.001  Dinner 0.275 0.123 preparation rules  Dinner −0.011 0.206 consumption rules   Fruit providing −0.134 0.254 Step 3: Built environment   Fruit availability 0.655 0.057 R2   0.570 F   12.498* df   17 Children’s vegetable consumption  Constant 0.304 1.114 Step1: Demographic characteristics  Gender −0.140 0.323   Contact age −0.011 0.014  Education 0.080 0.067   Marital status 0.000 0.001  Income −0.071 0.041  Occupancy 0.108 0.080  Hispanic/Latino 0.161 0.325   Race White −0.511 0.346   Race Black 0.068 0.495

β

t

p

2.414 .017 −.079 −.044 .073 −.046 −.157* .036 −.159* −.001 −.009

−1.470 −0.795 1.027 −0.815 −2.555 0.676 −2.132 −0.013 −1.14

.144 .428 .306 .416 .012 .500 .034 .989 .909

.046 0.810 .419 −.038 −0.555 .580 .088 1.263 .208 −.052 −0.957 .340 .124* 2.242 .026

−.003

−0.051 .959

−.029

−0.528 .598

.652* 11.538 .000       0.273 .785 −.025 −.046 .086 .020 −.108 .079 .042 −.132 .013

−0.432 −0.796 1.189 0.353 −1.723 1.355 0.495 −1.479 0.138

.666 .428 .237 .724 .088 .178 .621 .142 .891

(continued)

Table 2 (continued) Variable

Β

SE Β

β

t

p

Step 2: Sociocultural environment   Eat with child 0.157 0.077 .129* 2.043 .043   TV screen time −0.002 0.001 −.157* −2.172 .032 0.409 .683   Video game time 0.000 0.001 .029   Dinnertime rules −0.001 0.001 −.051 −0.851 .397  Dinner 0.230 0.114 .116* 2.011 .047 preparation rules  Dinner −0.227 0.172 −.080 −1.317 .191 consumption rules  Vegetable 0.191 0.228 .051 0.837 .405 providing Step 3: Built environment  Vegetable 0.744 0.075 .657* 9.877 .000 availability R2 = .674, F =   13.513*, degrees of freedom = 17 *p < .05.

sociocultural factors that influence children’s F&V consumption, the most powerful factor identified was the micro-level built environment. Specifically, findings from the study showed that having F&V in the home (availability) was the most powerful factor positively influencing the frequency of F&V consumption of children in this sample. Availability of F&V in the home is a part of the home environment that provides opportunity or constraint for children’s access to F&V. Earlier research asserts that the built environment of the home influences what F&V are available in the home as well as how much is eaten (Couch, Glanz, Zhou, Sallis, & Saelens, 2014; Kegler, Swan, Alcantara, Feldman, & Glanz, 2014). Particularly for low-income families and ethnic minorities residing in rural areas, findings from this study show that to increase F&V consumption among children from these areas, interventions targeting the built home environment will prove very effective. With the prior but not-too-successful effort that has been directed toward increasing children’s F&V consumption and with the still-increasing obesity rates, our findings provide health program planners with useful insight into perhaps a more effective avenue to which their efforts are better directed, particularly for children residing in

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Table 3 Model Summary (n = 298) Model

R

Children’s fruit consumption   Model 1: Demographics .307   Model 2: Demographics .462 and sociocultural   Model 3: Demographics, .755 sociocultural, and built environmental Children’s vegetable consumption   Model 1: Demographics .373   Model 2: Demographics .623 and sociocultural   Model 3: Demographics, .821 sociocultural, and built environmental

R2

R2 Change

.046 .135

.094 .119

.525

.357

.139 .388

.139 .249

.674

.286

such areas. Nevertheless, it is important to note also that availability of F&V is dependent on ease of access and acquisition, which can be influenced by a number of factors, one of the most influential being F&V availability in the communities where respondents live (Aggarwal et al., 2014; Graham, Pelletier, NeumarkSztainer, Lust, & Laska, 2013; McLeroy et al., 1988; Sharkey, 2009; Sharkey & Horel, 2008; Sharkey, Horel, et al., 2010; Sharkey, Johnson, et al., 2010). This is also an important factor that could influence F&V consumption among children and serve as an additional pointer for intervention programs particularly for low-income families residing in rural areas. Overall findings from this study support earlier research that highlights the home food environment as a powerful factor shaping the F&V consumption of children (Di Noia & Byrd-Bredbenner, 2014; Kegler et al., 2014; Sharkey, Horel, et al., 2010; Sharkey, Johnson, et al., 2010). In essence, if children have F&V readily available to them in the home, they are more likely to consume more F&V (Baranowski, Diep, & Baranowski, 2013; Campbell et al., 2013; Cook, O’Reilly, DeRosa, Rohrbach, & Spruijt-Metz, 2015; Couch et al., 2014). This finding also supports earlier studies that have shown that more availability of obesity-protective foods such as F&V will reduce the risk for obesity among this population and increase the consumption rates of F&V (Boles et al., 2013; Bourke, Whittaker, & Verma, 2014; Grimm et al., 2014; Nackers & Appelhans, 2013).

In addition to the micro-level built environment, the sociocultural environment of the home is an important determinant of children’s F&V consumption. The findings seem to be consistent with other research studies that have shown sociocultural factors such as parenting styles, practices, and rules and family eating patterns as determinants implicated in children’s F&V consumption behavior. These findings support Rosenkranz’s model that hypothesizes that family eating patterns in the home sociocultural environment are associated with children’s F&V consumption (Rosenkranz & Dzewaltowski, 2008). There are several possible explanations for this association. One explanation is that the observed influence could be a result of parental role modeling during mealtimes. Role modeling, particularly for children at this age, influences the uptake and reinforcement of behaviors and habits such as F&V consumption (Christian et al., 2013; Draxten et al., 2014). Essentially, children will mirror their parents’ behavior. Since most study participants reported eating evening meals with their children daily, intervention strategies targeted at encouraging parents to eat with children and incorporate F&V into all evening meals might be effective at improving children F&V consumption. Thus, the findings from this study further support research evidence in favor of the home food environment as an important setting for children to develop healthy dietary habits carried on to adulthood (Pearson et al., 2009). Limitations Findings from this study should be viewed within the context of the study limitations. First, the sample size is relatively small (

Influence of the Home Food Environment on Children's Fruit and Vegetable Consumption: A Study of Rural Low-Income Families.

This investigation sought to identify micro-level built and sociocultural characteristics of a home food environment that have been theoretically link...
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