505904
research-article2013
CPJXXX10.1177/0009922813505904Clinical PediatricsSwindle et al
Brief Report
Pediatric Nutrition: Parenting Impacts Beyond Financial Resources
Clinical Pediatrics 2014, Vol. 53(8) 797–799 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813505904 cpj.sagepub.com
Taren M. Swindle, PhD1, Wendy L. Ward, PhD1, Leanne Whiteside-Mansell, EdD1, Jasmine Brathwaite, MD1, Patti Bokony, PhD1, Nicola Conners-Burrow, PhD1, and Lorraine McKelvey, PhD1 Introduction Intake of fruits and vegetables (FV) is associated with lower rates of obesity and diabetes for children.1,2 However, 50% of children 2 to 5 years old are not meeting the daily recommendations for fruit intake, and 78% are not meeting daily recommendations for vegetable intake.3 The proportion of children not meeting recommendations is even higher among low-income families. This is concerning as food habits and preferences are established in childhood and are maintained over time.4 In an attempt to improve the health and well-being of the US population, a goal of Healthy People 2020 is to increase FV intake, particularly among young, at-risk children.5 By understanding the predictors of intake in children, practitioners can be equipped to influence families effectively in the area of nutrition. The consumption of FV by children is affected by multiple factors. Families’ basic resources (affordability and access to FV) have well-documented impacts on FV intake for children.6,7 The impact of other family characteristics on dietary patterns have not been studied to the same extent. Although income is largely an inflexible risk factor, practitioners may be able to address other salient family characteristics that are related to a poor diet for low-income families. We explore the importance of parenting characteristics in predicting child fruit and vegetable consumption in light of financial barriers to provide a clearer understanding of the factors that contribute to a low-quality diet. Specifically, we hypothesize that parenting behaviors will uniquely predict FV intake above and beyond finances in a low-income sample. Addressing factors that are related to a poor quality diet may help practitioners to reduce health disparities that are related to dietary intake.
Methods
All families met enrollment criteria of 200% of poverty or less. The biological mother was the responding caregiver in most instances (89.5%). Respondents were mostly African American (74.4%). Many (52.7%) indicated at least some college education and current employment (73.9%). More than half indicated having a spouse or partner (55.4%).
Instrument The Family Map is a semistructured interview, composed of 12 sections that assess key areas of the family and home environment that are important for healthy development in children.8 The Family Map is composed of both survey (N = 91) and observational questions (N = 21) organized by area. Each section assesses risks and targets a specific aspect of the family that is impactful for the child. The Family Map demonstrates validity in estimating risk rates compared with national estimates and shows strong correlations to direct observations of conditions in the home as well as to independent assessments of risk by standard instruments in the field.8 Four constructs were considered in terms of the impact on FV intake: Financial Need, Parent Interaction With Child, Parent School Readiness Promotion, and Parental Provision of Experiences. These parent constructs are key components in promoting optimal outcomes for the child in both the short and long term and serve as markers for overall quality parenting. Fruit and Vegetable Consumption. Parents answered 2 questions about FV consumption in the home. Responses were given on a 1 to 5 scale where 1 = none and 5 = more than 1 per day.
1
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Sample Families (N = 446) in a state-funded, urban preschool program were interviewed by their child’s teacher during their parent–teacher conference in the fall semester.
Corresponding Author: Taren M. Swindle, Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, 530, Little Rock, AR 72205-7199, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
798
Clinical Pediatrics 53(8)
Table 1. Frequency of Fruit and Vegetable Consumption in the Home.a About how often does your child eat a food from each of the following groups, excluding foods eaten at the center: “Dark green or orange/yellow vegetables such as greens, carrots, broccoli, squash, sweet potatoes—but not French fries.” “Fruits like apples, oranges, bananas, grapes, peaches, applesauce—but not juice.”
None
Once a Week
2-6 Per Week
Once a Day
More Than 1 Per Day
5.2
8.1
29.6
29.1
28.0
4.0
3.8
19.3
35.2
41.3
a
All figures are percentages.
Financial Need. Parents may have difficulty paying for monthly bills, transportation, and other expenses. Four questions addressed the families’ capacity to provide payment for basic services over the past year (utilities, rent, transportation, and health care; 0 = never; 2 = 2+ times). Parent Interaction With Child. Playing with a parent promotes learning and secure attachment for children. Quality parent–child interactions are critical for healthy child development. Four questions asked about the frequency (0 = none; 4 = 6+ times) of parent engagement in various activities (toys/games, counting/singing, arts/ crafts, and talking) with the child over the past week. Parent School Readiness Promotion. Parents act as the first teacher for their child and play an important role in teaching basic concepts to their children to promote school readiness. Questions measured parents’ efforts to teach their child by asking about the frequency (0 = none; 4 = 6+ times) of purposeful interactions to work on 4 foundational areas (numbers, alphabet, colors, shapes/sizes) over the past week. Parent Provision of Experiences. Family activities in the community have many benefits for children. Parents receive social support, children are exposed to a broader range or settings and people, and the family bond grows stronger. Community-sponsored, free events are equally beneficial to activities associated with a cost. Six questions asked if parents had taken their child to places or events (library, movie theatre, sporting event, play/concert/show, zoo/aquarium, museum/gallery/historical site, and community event) over the past month and year (0 = no; 1 = yes).
Data Analysis Composite scale scores were created for each construct by summing across item responses. All scales were scored such that higher values indicated greater levels of
the construct. A regression analysis was conducted to determine the explanatory power of parenting on FV consumption beyond Financial Need. Available cases with all information (92% of full sample) were included and analyzed using SPSS Version 19. A follow-up analysis using full information maximum likelihood confirmed that missing data patterns did not affect results.
Results Table 1 details the parents’ report of child FV intake in the home. A hierarchical regression model predicting FV intake was evaluated whereby Financial Need was entered into in a first block followed by Parent Interaction, Parent School Readiness Promotion, and Parent Provision of Experiences in a second block. Financial Need was a significant predictor of FV consumption, R2 = .02, β = −.11, p < .05. However, the addition of the 3 Parenting variables in block 2 produced a model with significantly greater predictive power (R2change = .07, P < .01). Parent School Readiness Promotion (β = .16, P < .01) and Parent Provision of Experiences (β = .15, P < .01) each exhibited a unique influence on FV Intake in the presence of the other variables. Financial Need was not a significant predictor of FV intake in the presence of the Parenting variables. As seen in Table 2, the full model accounts for a significant portion of variance in child FV intake, F(4, 405) = 9.98, R2 = .09, P < .01.
Discussion Findings support previous studies showing that FV consumption is below recommended levels among lowincome children. For this low-income sample, parenting behaviors were more predictive of child FV intake than indicators of financial need. These findings are also consistent with previous research that interventions providing free/subsidized FV are not effective at altering dietary behaviors.9 Linking families with needed financial
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
799
Swindle et al Declaration of Conflicting Interests
Table 2. Hierarchical Regression Predicting Fruit and Vegetable Consumption.a Predictor Step 1 Financial need Step 2 Financial need Parent stimulation Parent school readiness promotion Parent provision of experiences
2
b (Standard Error)
β
−.19 (.07)*
−.11*
−.13 (.07) .03 (.04) .09 (.03)**
−.09 .05 .16**
.02*
.14 (.05)**
.15**
.07**
ΔR
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded in part by Agriculture and Food Research Initiative Competitive Grant No. 2011-68001-30014 titled “Interventions for Obesity Prevention Targeting Young Children in At-Risk Environments: An Integrated Approach” from the US Department of Agriculture, National Institute of Food and Agriculture.
a
Final model: F(4, 405) = 9.98; R2 = .09. *P < .05. **P < .01.
References
support (eg, WIC [Women, Infants and Children], SNAP [Supplemental Nutrition Assistance Program]) is an important, but insufficient, step for practitioners to partner with families in improving nutrition for children. This study illustrates that pediatric nutrition takes place in a broader parenting context. Parents struggling in the area of nutrition are likely struggling in other parenting domains. The American Academy of Pediatrics recommends anticipatory guidance during well-child visits to counsel with parents about behavior changes that will decrease the risk of adverse outcomes for the child.10(pp159-190) Of the 5 priority areas, 2 are related to obesity risk and reduction. FV intake is specifically targeted as a topic for “prevention counseling at well visits and at any other patient-physician encounters.”10(p187) Results of this study suggest that education and counseling of parenting behaviors more broadly during well visits are critical for FV intake. In some situations, health professionals should consider referrals to parenting intervention or training programs for parents of children presenting with a lowquality diet or overweight. Addressing the broader parenting context is a novel extension of the American Academy of Pediatrics’ anticipatory guidelines for care management, one that is likely to have positive impacts on medical and developmental issues aside from FV intake. Further study is needed on addressing parenting in clinical settings. Future research should study communication with parents during well visits and clinical visits to support parenting behaviors. Evaluation of the impact of clinical interventions targeting parenting behaviors on children’s FV intake is warranted to support the conclusions of this study.
1. Miller P, Moore RH, Kral T. Children’s daily fruit and vegetable intake: Associations with maternal intake and child weight status. J Nutr Educ Behav. 2009;43:396-400. 2. Rovner AJ, Nansel TR. Are children with type 1 diabetes consuming a healthful diet? A review of the current evidence and strategies for dietary change. Diabetes Educ. 2009;35:97-107. 3. Lorson BA, Melgar-Quinonez HR, Taylor CA. Correlates of fruit and vegetable intake in US children. J Am Diet Assoc. 2009;109:474-478. 4. Lytle LA, Seifer S, Greenstein J, McGovern P. How do children’s eating patterns and food choices change over time? Results from a cohort study. Am J Health Promot. 2000;14:222-228. 5. Healthy People 2020: nutrition and weight status. http:// healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=296. Accessed May 15, 2013. 6. Rasmussen M, Krølner R, Klepp KI, et al. Determinants of fruit and vegetable among children and adolescents: A review of the literature. Part I: Quantitative studies. Int J Behav Nutr Phys Act. 2006;3:22. 7. Ward-Begnoche WL, Thompson J. Economic considerations in treating overweight youth. J Ark Med Soc. 2008;105:43-45. 8. Whiteside-Mansell L, Bradley RH, Conners NA, Bokony PA. The Family Map: Structured interview to identify risks and strengths in head start families. NHSA Dialog. 2007;10:189-209. 9. Delgado-Noguera M, Tort S, Martinez-Zapata MJ, Bonfill X. Primary school interventions to promote fruit and vegetable consumption: a systematic review and meta-analysis. Prev Med. 2011;53:3-9. 10. Tanski S, Garfunkel LC, Duncan PM, Weitzman M, eds. Performing Preventive Services: A Bright Futures Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
research-article2013
CPJXXX10.1177/0009922813505904Clinical PediatricsSwindle et al
Brief Report
Pediatric Nutrition: Parenting Impacts Beyond Financial Resources
Clinical Pediatrics 2014, Vol. 53(8) 797–799 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813505904 cpj.sagepub.com
Taren M. Swindle, PhD1, Wendy L. Ward, PhD1, Leanne Whiteside-Mansell, EdD1, Jasmine Brathwaite, MD1, Patti Bokony, PhD1, Nicola Conners-Burrow, PhD1, and Lorraine McKelvey, PhD1 Introduction Intake of fruits and vegetables (FV) is associated with lower rates of obesity and diabetes for children.1,2 However, 50% of children 2 to 5 years old are not meeting the daily recommendations for fruit intake, and 78% are not meeting daily recommendations for vegetable intake.3 The proportion of children not meeting recommendations is even higher among low-income families. This is concerning as food habits and preferences are established in childhood and are maintained over time.4 In an attempt to improve the health and well-being of the US population, a goal of Healthy People 2020 is to increase FV intake, particularly among young, at-risk children.5 By understanding the predictors of intake in children, practitioners can be equipped to influence families effectively in the area of nutrition. The consumption of FV by children is affected by multiple factors. Families’ basic resources (affordability and access to FV) have well-documented impacts on FV intake for children.6,7 The impact of other family characteristics on dietary patterns have not been studied to the same extent. Although income is largely an inflexible risk factor, practitioners may be able to address other salient family characteristics that are related to a poor diet for low-income families. We explore the importance of parenting characteristics in predicting child fruit and vegetable consumption in light of financial barriers to provide a clearer understanding of the factors that contribute to a low-quality diet. Specifically, we hypothesize that parenting behaviors will uniquely predict FV intake above and beyond finances in a low-income sample. Addressing factors that are related to a poor quality diet may help practitioners to reduce health disparities that are related to dietary intake.
Methods
All families met enrollment criteria of 200% of poverty or less. The biological mother was the responding caregiver in most instances (89.5%). Respondents were mostly African American (74.4%). Many (52.7%) indicated at least some college education and current employment (73.9%). More than half indicated having a spouse or partner (55.4%).
Instrument The Family Map is a semistructured interview, composed of 12 sections that assess key areas of the family and home environment that are important for healthy development in children.8 The Family Map is composed of both survey (N = 91) and observational questions (N = 21) organized by area. Each section assesses risks and targets a specific aspect of the family that is impactful for the child. The Family Map demonstrates validity in estimating risk rates compared with national estimates and shows strong correlations to direct observations of conditions in the home as well as to independent assessments of risk by standard instruments in the field.8 Four constructs were considered in terms of the impact on FV intake: Financial Need, Parent Interaction With Child, Parent School Readiness Promotion, and Parental Provision of Experiences. These parent constructs are key components in promoting optimal outcomes for the child in both the short and long term and serve as markers for overall quality parenting. Fruit and Vegetable Consumption. Parents answered 2 questions about FV consumption in the home. Responses were given on a 1 to 5 scale where 1 = none and 5 = more than 1 per day.
1
University of Arkansas for Medical Sciences, Little Rock, AR, USA
Sample Families (N = 446) in a state-funded, urban preschool program were interviewed by their child’s teacher during their parent–teacher conference in the fall semester.
Corresponding Author: Taren M. Swindle, Department of Family and Preventive Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, 530, Little Rock, AR 72205-7199, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
798
Clinical Pediatrics 53(8)
Table 1. Frequency of Fruit and Vegetable Consumption in the Home.a About how often does your child eat a food from each of the following groups, excluding foods eaten at the center: “Dark green or orange/yellow vegetables such as greens, carrots, broccoli, squash, sweet potatoes—but not French fries.” “Fruits like apples, oranges, bananas, grapes, peaches, applesauce—but not juice.”
None
Once a Week
2-6 Per Week
Once a Day
More Than 1 Per Day
5.2
8.1
29.6
29.1
28.0
4.0
3.8
19.3
35.2
41.3
a
All figures are percentages.
Financial Need. Parents may have difficulty paying for monthly bills, transportation, and other expenses. Four questions addressed the families’ capacity to provide payment for basic services over the past year (utilities, rent, transportation, and health care; 0 = never; 2 = 2+ times). Parent Interaction With Child. Playing with a parent promotes learning and secure attachment for children. Quality parent–child interactions are critical for healthy child development. Four questions asked about the frequency (0 = none; 4 = 6+ times) of parent engagement in various activities (toys/games, counting/singing, arts/ crafts, and talking) with the child over the past week. Parent School Readiness Promotion. Parents act as the first teacher for their child and play an important role in teaching basic concepts to their children to promote school readiness. Questions measured parents’ efforts to teach their child by asking about the frequency (0 = none; 4 = 6+ times) of purposeful interactions to work on 4 foundational areas (numbers, alphabet, colors, shapes/sizes) over the past week. Parent Provision of Experiences. Family activities in the community have many benefits for children. Parents receive social support, children are exposed to a broader range or settings and people, and the family bond grows stronger. Community-sponsored, free events are equally beneficial to activities associated with a cost. Six questions asked if parents had taken their child to places or events (library, movie theatre, sporting event, play/concert/show, zoo/aquarium, museum/gallery/historical site, and community event) over the past month and year (0 = no; 1 = yes).
Data Analysis Composite scale scores were created for each construct by summing across item responses. All scales were scored such that higher values indicated greater levels of
the construct. A regression analysis was conducted to determine the explanatory power of parenting on FV consumption beyond Financial Need. Available cases with all information (92% of full sample) were included and analyzed using SPSS Version 19. A follow-up analysis using full information maximum likelihood confirmed that missing data patterns did not affect results.
Results Table 1 details the parents’ report of child FV intake in the home. A hierarchical regression model predicting FV intake was evaluated whereby Financial Need was entered into in a first block followed by Parent Interaction, Parent School Readiness Promotion, and Parent Provision of Experiences in a second block. Financial Need was a significant predictor of FV consumption, R2 = .02, β = −.11, p < .05. However, the addition of the 3 Parenting variables in block 2 produced a model with significantly greater predictive power (R2change = .07, P < .01). Parent School Readiness Promotion (β = .16, P < .01) and Parent Provision of Experiences (β = .15, P < .01) each exhibited a unique influence on FV Intake in the presence of the other variables. Financial Need was not a significant predictor of FV intake in the presence of the Parenting variables. As seen in Table 2, the full model accounts for a significant portion of variance in child FV intake, F(4, 405) = 9.98, R2 = .09, P < .01.
Discussion Findings support previous studies showing that FV consumption is below recommended levels among lowincome children. For this low-income sample, parenting behaviors were more predictive of child FV intake than indicators of financial need. These findings are also consistent with previous research that interventions providing free/subsidized FV are not effective at altering dietary behaviors.9 Linking families with needed financial
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
799
Swindle et al Declaration of Conflicting Interests
Table 2. Hierarchical Regression Predicting Fruit and Vegetable Consumption.a Predictor Step 1 Financial need Step 2 Financial need Parent stimulation Parent school readiness promotion Parent provision of experiences
2
b (Standard Error)
β
−.19 (.07)*
−.11*
−.13 (.07) .03 (.04) .09 (.03)**
−.09 .05 .16**
.02*
.14 (.05)**
.15**
.07**
ΔR
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is funded in part by Agriculture and Food Research Initiative Competitive Grant No. 2011-68001-30014 titled “Interventions for Obesity Prevention Targeting Young Children in At-Risk Environments: An Integrated Approach” from the US Department of Agriculture, National Institute of Food and Agriculture.
a
Final model: F(4, 405) = 9.98; R2 = .09. *P < .05. **P < .01.
References
support (eg, WIC [Women, Infants and Children], SNAP [Supplemental Nutrition Assistance Program]) is an important, but insufficient, step for practitioners to partner with families in improving nutrition for children. This study illustrates that pediatric nutrition takes place in a broader parenting context. Parents struggling in the area of nutrition are likely struggling in other parenting domains. The American Academy of Pediatrics recommends anticipatory guidance during well-child visits to counsel with parents about behavior changes that will decrease the risk of adverse outcomes for the child.10(pp159-190) Of the 5 priority areas, 2 are related to obesity risk and reduction. FV intake is specifically targeted as a topic for “prevention counseling at well visits and at any other patient-physician encounters.”10(p187) Results of this study suggest that education and counseling of parenting behaviors more broadly during well visits are critical for FV intake. In some situations, health professionals should consider referrals to parenting intervention or training programs for parents of children presenting with a lowquality diet or overweight. Addressing the broader parenting context is a novel extension of the American Academy of Pediatrics’ anticipatory guidelines for care management, one that is likely to have positive impacts on medical and developmental issues aside from FV intake. Further study is needed on addressing parenting in clinical settings. Future research should study communication with parents during well visits and clinical visits to support parenting behaviors. Evaluation of the impact of clinical interventions targeting parenting behaviors on children’s FV intake is warranted to support the conclusions of this study.
1. Miller P, Moore RH, Kral T. Children’s daily fruit and vegetable intake: Associations with maternal intake and child weight status. J Nutr Educ Behav. 2009;43:396-400. 2. Rovner AJ, Nansel TR. Are children with type 1 diabetes consuming a healthful diet? A review of the current evidence and strategies for dietary change. Diabetes Educ. 2009;35:97-107. 3. Lorson BA, Melgar-Quinonez HR, Taylor CA. Correlates of fruit and vegetable intake in US children. J Am Diet Assoc. 2009;109:474-478. 4. Lytle LA, Seifer S, Greenstein J, McGovern P. How do children’s eating patterns and food choices change over time? Results from a cohort study. Am J Health Promot. 2000;14:222-228. 5. Healthy People 2020: nutrition and weight status. http:// healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=296. Accessed May 15, 2013. 6. Rasmussen M, Krølner R, Klepp KI, et al. Determinants of fruit and vegetable among children and adolescents: A review of the literature. Part I: Quantitative studies. Int J Behav Nutr Phys Act. 2006;3:22. 7. Ward-Begnoche WL, Thompson J. Economic considerations in treating overweight youth. J Ark Med Soc. 2008;105:43-45. 8. Whiteside-Mansell L, Bradley RH, Conners NA, Bokony PA. The Family Map: Structured interview to identify risks and strengths in head start families. NHSA Dialog. 2007;10:189-209. 9. Delgado-Noguera M, Tort S, Martinez-Zapata MJ, Bonfill X. Primary school interventions to promote fruit and vegetable consumption: a systematic review and meta-analysis. Prev Med. 2011;53:3-9. 10. Tanski S, Garfunkel LC, Duncan PM, Weitzman M, eds. Performing Preventive Services: A Bright Futures Handbook. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
Downloaded from cpj.sagepub.com at The University of Hong Kong Libraries on May 10, 2015
