Childhood Obesity and Interpersonal Dynamics During Family Meals
- Jerica M. Berge, PhD, MPH, LMFT, CFLEa,
- Seth Rowley, BSb,
- Amanda Trofholz, MPHa,
- Carrie Hanson, MSc,
- Martha Rueter, PhDc,
- Richard F. MacLehose, PhDb, and
- Dianne Neumark-Sztainer, PhD, MPH, RDb
BACKGROUND: Family meals have been found to be associated with a number of health benefits for children; however, associations with obesity have been less consistent, which raises questions about the specific characteristics of family meals that may be protective against childhood obesity. The current study examined associations between interpersonal and food-related family dynamics at family meals and childhood obesity status.
METHODS: The current mixed-methods, cross-sectional study included 120 children (47% girls; mean age: 9 years) and parents (92% women; mean age: 35 years) from low-income and minority communities. Families participated in an 8-day direct observational study in which family meals were video-recorded in their homes. Family meal characteristics (eg, length of the meal, types of foods served) were described and associations between dyadic (eg, parent-child, child-sibling) and family-level interpersonal and food-related dynamics (eg, communication, affect management, parental food control) during family meals and child weight status were examined.
RESULTS: Significant associations were found between positive family- and parent-level interpersonal dynamics (ie, warmth, group enjoyment, parental positive reinforcement) at family meals and reduced risk of childhood overweight. In addition, significant associations were found between positive family- and parent-level food-related dynamics (ie, food warmth, food communication, parental food positive reinforcement) and reduced risk of childhood obesity.
CONCLUSIONS: Results extend previous findings on family meals by providing a better understanding of interpersonal and food-related family dynamics at family meals by childhood weight status. Findings suggest the importance of working with families to improve the dyadic and family-level interpersonal and food-related dynamics at family meals.
- family meals
- direct observation
- family dynamics
- childhood obesity
- IFIRS —
- Iowa Family Interaction Rating Scales
- SES —
- socioeconomic status
What’s Known on This Subject:
Family meals are protective for child health, but there are inconsistent findings in relation to child weight status. More research is needed examining why family meals are protective for child health and whether there are differences by child weight status.
What This Study Adds:
The current mixed-methods study used direct observational methods to examine family dynamics during family meals and child weight status. Results indicated that positive family interpersonal and food-related dynamics during family meals were associated with reduced prevalence of childhood obesity.
Cross-sectional and longitudinal research over the past decade has consistently shown that having frequent family meals is associated with a number of health benefits for children (ie, increased fruit and vegetable intake,1–3 lower levels of extreme weight-control behaviors,4 better psychosocial health5). These protective associations in children have been found across genders, races/ethnicities, and socioeconomic status (SES).1–3 Furthermore, some studies have shown significant associations between the frequency of family meals and reduced risk of childhood obesity, although findings have been inconsistent across studies.6–8 Looking in-depth at characteristics of family meals may help identify key protective factors related to family meals. For example, examining dyadic (eg, parent-child, child-sibling) and family-level interpersonal and food-related dynamics at family meals, such as communication, group enjoyment, parental food intrusiveness, and characteristics of family meals, such as who is present at the meal, number of distractions (eg, electronics, leaving the table), or length of the meal, may give a more comprehensive understanding of the characteristics of family meals that increase their protective nature.
In addition, given the high prevalence of childhood obesity,9–12 it is important to know whether significant differences in family meals exist between households with children who are overweight/obese and children who are nonoverweight. Examining interpersonal and food-related dynamics between family members during family meals may lead to identifying modifiable factors in the home that could inform childhood obesity intervention development aimed at increasing the frequency of family meals and improving the emotional quality of meals, as well as inform recommendations for providers working with families with school-aged children.
There has been limited previous research examining family dynamics during family meals. Two cross-sectional direct observational studies examined family functioning during family meals with children who are overweight and found that families with an overweight/obese child had difficulties with managing family conflict and task accomplishment during family meals compared with families with nonoverweight children.13,14 Findings from a pilot study, which led to the current study, suggested that more positive interpersonal interactions among family members during family meals were associated with lower BMI percentile and more healthful dietary intake in adolescents.15 Thus, limited results suggest that family dynamics during family meals may be associated with youth weight and weight-related behaviors; however, these studies were conducted in small samples, were not racially/ethnically or socioeconomically (SES) diverse, and included older children and adolescents.
In addition, although these previous studies measured family functioning, they did not examine dyadic and family-level food-related dynamics (eg, food hostility, food communication, parental food intrusiveness), which may provide a more in-depth look at multiple family members’ behaviors at family meals, including behaviors specifically related to eating. Furthermore, previous direct observational research on family meals has not examined associations by child weight status, which may provide insight into interpersonal and food-related risk and protective factors for childhood obesity at family meals.13–15
The current study builds on and expands the previous literature on family meals by using direct observational methods in a diverse sample of children to address the following research questions:
What are common characteristics of family meals (eg, length of meal, electronics used at meal, television viewing at meal, people present at meal) among school-aged children and across child weight status of school-aged children?
What types of dyadic and family-level interpersonal (eg, communication, relationship quality, behavioral control, enjoyment) and food-related (eg, parental food control, food intrusiveness, food permissiveness) dynamics occur during family meals?
Is there an association between dyadic and family-level interpersonal and food-related dynamics during family meals and childhood weight status?
The main hypothesis of the study, based on tenets from Family Systems Theory,16,17 is that families with more positive interpersonal (ie, parent-child, child-sibling) and food-related dynamics during family meals will have children who are less likely to be overweight/obese.
Sample and Study Design
The Family Meals LIVE! study is a 2-year, mixed-methods, cross-sectional study designed to identify key risk and protective factors for childhood obesity in the home food environment. Family Meals LIVE! was guided by Family Systems Theory, which recognizes multiple levels of familial influences (ie, parent, sibling, family-level) on a child’s eating behaviors.16–18 Direct observational data were collected including the following: video-recordings on iPads (Apple, Cupertino, CA) of family meals, qualitative interviews, three 24-hour dietary recalls on the target child with primary caregiver assistance, and a home food inventory. In addition, surveys were conducted with 1 parent and the target child. All participating family members consented or assented their participation in the study. All study protocols were approved by the University of Minnesota’s Institutional Review Board.
Children (N = 120) and their families from 4 primary care clinics serving primarily diverse and low-income families in Minneapolis/St Paul participated in Family Meals, LIVE! in 2012–2013. A recruitment letter from the primary care doctor was sent to the child’s primary caregiver inviting participation in the Family Meals LIVE! study. Children and their families were eligible to participate if the child was between the ages of 6 and 12 years old, family members spoke and read English, and if the family ate at least 3 family dinners per week (to ensure that we would be recruiting families who “normally” ate family meals together). On the basis of previous literature suggesting inconsistencies in the protective nature of family meals by weight status, we stratified recruitment by weight status (>5th and <85th BMI percentile = nonoverweight; ≥85th BMI percentile = overweight/obese) to learn how family meals may function differently in these households.6,19
Of the 120 participants, 53% were boys and 47% were girls, with an average age of 9 years (SD: 3.3 years; range: 6–12 years) (see Table 1). The majority of parents/guardians were mothers or other female guardians (90%) and were ∼35 years old (SD: 7.5 years; range: 25–65 years). The racial/ethnic backgrounds of the participating children were as follows: 74% African American, 18% white, 9% American Indian, 6% Asian, and 3% mixed or other race/ethnicity; parents were similarly diverse. More than 50% of the children were from very low SES households (<$20 000). The majority of parents had finished high school but had not attended college, and ∼50% of parents were working full or part time.
Families participated in 2 home visits (Fig 1). During the first home visit, families were asked to record 8 consecutive days of family dinner meals to capture both weekdays and weekends. They were told to eat as they normally do, including moving to locations within the house where they typically eat their meals (eg, family room). In addition, families were told that the main aim of the study was to learn more about what a “modern day” family meal looked like and that there was no “right” or “wrong” way to have a family meal.
The majority of families (n = 118) completed all aspects of data collection; only 2 families had difficulties with video-recording all meals, due to the target child being unavailable for 3 meals, and recorded 5 meals (3 weekdays and 2 weekends). In addition, in a few families (n = 12), there were some observational days skipped due to other events (eg, Tuesday night one family had a child’s band concert and didn’t record a meal). In these specific situations, the family’s observation period was extended to obtain the full 8 days of observation.
Coding of Video-Recorded Data
Six research team members who were blinded to the study hypotheses were extensively trained on the Iowa Family Interaction Rating Scales20 (IFIRS; Table 2) coding system used to code the dyadic and family-level interpersonal and food-related dynamics at family meals. Practice video-recordings were used until coders reached 95% reliability with a gold standard and then 95% interrater reliability among coders. Coding was completed for up to 6 dyads present at the family meal (ie, mom–target child, mom-sibling, secondary caregiver–target child, secondary caregiver–sibling, sibling-sibling, mom–secondary caregiver) and for the overall family group. Consistent with the IFIRS coding protocol, the family meal recording was watched and coded separately for each dyad at the family meal. In a few families (n = 5), parents would get the meal started for the children and then eat their own meal in the adjoining family room (usually because there was not room at the table). In these situations the parent was still able to be seen, either on the far side of the video screen and/or when they went back and forth to check on the child(ren) eating dinner. Thus, we were still able to code interactions between parents, children, and siblings.
On the basis of direct observational literature showing that it is important to allow participants a “sensitizing period” to give them time to acclimate and become less reactive to the observation (ie, engage in more representative behavior), the first day of the 8-day family meal video-recordings was excluded.21
All IFIRS interpersonal family dynamics variables coded are listed in Table 2. IFIRS variables that represented positive family functioning included the following: group enjoyment, relationship quality, warmth, communication, parental influence, and positive reinforcement. IFIRS variables that represented negative family functioning included hostility, lecture/moralize, silent/pause, indulgent/permissive, inconsistent discipline, and intrusiveness/control. The interpersonal and food-related family dynamics scores were derived from the dyadic-level scores according to the following formula: percentage of dyad-level relationship scores from each meal with scores greater than or equal to the midpoint score (≥5 on a scale of 1 to 9). For example, in a 3-person family meal consisting of a mother and 2 children, there are 3 dyads and 6 dyad-level score assessments (1 assessment in each direction). If the mother is coded with a warmth score of 8 toward each child, 1 child is coded as a 6 toward the mother, and all other warmth scores are <5, then their family-level measure of warmth is 50% (3 of 6 scores ≥5). This scoring scale allows for creating a family-level variable that accounts equally for each family member’s contribution to the overall interpersonal atmosphere, while giving equal weight to families with differing numbers of family members present. IFIRS responses from 1 weekday (Wednesday) and 1 weekend day (Saturday) were averaged for each family to obtain a more complete picture of an average meal experience across 1 week.
Outcome Variable: Child Weight Status
All anthropometric measurements were completed following standardized procedures.22 Height was assessed to the nearest 0.1 cm by using a stadiometer and weight to the nearest 0.1 kg by using a calibrated scale. To ensure interrater reliability, both measures were taken twice, and agreement of <1 cm for height and 0.5 kg for weight was required. BMI percentiles were calculated with the use of Centers for Disease Control and Prevention guidelines.23
Childrens’ and parents’ race/ethnicity and age were assessed by self-report. Race/ethnicity was assessed with the item “Do you think of yourself as 1) white, 2) black or African-American, 3) Hispanic or Latino, 4) Asian-American, 5) Hawaiian or Pacific Islander, or 6) American Indian or Native American?,” and respondents were asked to check all that applied. Participants who checked 2 race options were included in the “mixed/other” category. Parent and child age was calculated by using self-reported birth date and survey completion date.
Descriptive statistics for study variables included means and SDs for continuous variables and frequencies and percentages for categorical variables. Demographic data, including gender, race/ethnicity, age, SES, parent educational level, and parent work status were compiled and presented. For descriptive characteristics of the family meals (Table 3), each family contributed 1 weekday and 1 weekend observation. We accounted for these repeated observations by using generalized estimating equation models with an independent correlation structure. For categorical variables with >2 levels, we present statistical tests for the comparison of each level versus all other levels of that variable (eg, the difference in parents serving the meal versus all other serving styles for overweight versus nonoverweight).
Independent variables were modeled by using separate regressions. Target child overweight status was modeled by using a Poisson regression. Relative risks and 95% confidence intervals were estimated for each exposure. The adjusted probability of overweight/obese was also calculated from each regression model. Crude and adjusted models were run. The adjusted models were adjusted for child- or home-specific characteristics (ie, race/ethnicity, grouped as black/African American, white, American Indian, and other/mixed; age; and gender) and parent characteristics (ie, parent BMI) to address potential confounders. Sampling weights were computed for every individual in this study to reflect the sampling design. Weights were calculated as percentages of the overall sample on the basis of the following characteristics: child BMI, gender, age, and recruitment location. The inverse of these sampling fractions was included as a weight in all analyses to allow estimates to reflect the clinic-level population. Statistical analysis was conducted by using Stata (version 13, 2013; StataCorp, College Station, TX).
Descriptive Characteristics of Family Meals
The average length of a family meal was ∼16 minutes (Table 3). At least 1 parent (mean: 1.4) and 2 children (mean: 2.3; range: 0–6) were present at family meals; 85% of parents were mothers and 53% of siblings were sisters. More than half of the family meals took place in the kitchen or dining room, and 28% of family meals took place in either the family room or another room in the house (eg, office, bedroom). Approximately 61% of families had some type of screen-time device on during the meal (eg, television, cell phone, computer, handheld game). Furthermore, in the majority of families, parents preplated family members’ meals rather than using a family-style or child-directed (ie, child tells parent what he/she wants and parent plates the child’s portion) service style.
There were some differences in family meal logistics by weight status. Children who were overweight/obese had shorter meal times (13.5 vs 18.2 minutes; P = .02) and ate family meals less often in the kitchen (55% vs 80%; P = .03) and more often in other rooms, such as the family room (30% vs 17%; P = .01) or offices or bedrooms (15% vs 3%; P = .04). In addition, children who were nonoverweight were more likely to have a father/stepfather at the meal (52% vs 18%; P = .01). No other family meal characteristic significantly differed by child weight status.
Associations Between Interpersonal and Food-Related Family Dynamics at Family Meals and Child Weight Status
Interpersonal Family Dynamics.
Unadjusted analyses and analyses adjusted for demographic characteristics indicated significant associations between the majority of interpersonal family-level dynamics and parent-level dynamics at family meals and child weight status. Specifically, more positive measures (eg, group enjoyment, relationship quality, warmth/nurture) were associated with reduced prevalence of child overweight/obesity and more negative measures (eg, hostility, indulgent/permissive, inconsistent discipline) were associated with increased prevalence of child overweight/obesity (Table 4). For example, the warmth relative risk of 0.69 in Table 4 indicates that for each additional 10% of relationship dyads coded as having high levels of warmth during family meals there was a 31% lower prevalence of childhood overweight (P < .01), after adjusting for child age, race/ethnicity, and gender. The hostility relative risk of 1.09 indicates that for each additional 10% of relationship dyads coded as having high levels of hostility during family meals there was a 9% higher prevalence of childhood overweight (P < .01), after adjusting for child age, race/ethnicity, and gender.
Food-Related Family Dynamics.
Unadjusted analyses and analyses adjusted for demographic characteristics indicated that the majority of food-related family-level dynamics and parent-level dynamics at family meals were inversely associated with child weight status, such that family dynamics tended to be more positive in families of nonoverweight children and more negative in families of overweight/obese children (Table 4). For example, the food communication relative risk of 0.84 indicates that for each additional 10% of relationship dyads coded as having high levels of food-related communication during family meals there was a 16% lower prevalence of childhood overweight (P = .05), after taking into account the influence of child age, race/ethnicity, and gender.
When additionally adjusted for the primary caregiver’s BMI, some results for family- and parent-level interpersonal dynamics and food-related dynamics were attenuated. For example, lecture/moralize, parental influence, food hostility, food communication, food intrusiveness, parental food indulgent/permissive, and parental food inconsistent discipline were no longer significantly related to child overweight/obese status. However, many of the significant patterns found in the earlier results held. For example, group enjoyment, relationship quality, and warmth were still significantly associated with a reduced prevalence of overweight/obesity in children and hostility, parental indulgent/permissive, parental inconsistent discipline, and food lecture/moralizing were still significantly associated with an increased prevalence of overweight/obesity in children.
Results showed that family meals were relatively short, included multiple family members with at least 1 parent and sibling, were eaten primarily in the kitchen, and were parent-plated. These characteristics of family meals may be helpful for intervention researchers or health care providers to share with parents when trying to help families increase the frequency of family meals without a lot of burden. For example, having short meals (ie, 20 minutes) may be more manageable for families than longer meals and thus may encourage families to prioritize family meals.
Furthermore, results indicated that the majority of positive family- and parent-level interpersonal and food-related dynamics (eg, group enjoyment, relationship quality) during family meals were associated with a reduced prevalence of childhood overweight. In addition, the majority of negative family- and parent-level interpersonal and food-related dynamics (eg, hostility, parent indulgent/permissiveness, food-related parent inconsistent discipline) during family meals were associated with an increased prevalence of childhood overweight. Previous research on the home environment and Family Systems Theory corroborate these findings.16–18 For example, previous research has shown that high family functioning (eg, good communication, positive interpersonal relationships, good problem-solving skills) is associated with lower adolescent BMI, more fruit and vegetable intake, and frequent family meals.16 Thus, it would be important for interventions that aim to reduce childhood obesity, or increase family meals, to pay attention to training families how to attend to both interpersonal dynamics and food-related dynamics at family mealtimes.
Findings from this study both corroborate and extend previous limited direct observational research on family meals. Specifically, previous research has suggested that family meal frequency is protective for children in relation to dietary intake1–3; the current study identified potential mechanisms via interpersonal and food-related dynamics during family meals that should be further researched to help explain why family meals are protective. Specifically, future research should explore whether interpersonal family and food-related dynamics between certain family members (eg, siblings versus parent/child) are more strongly associated with a reduced risk of childhood obesity. In addition, it would be important to examine the combined influence of the quality of the food served at family meals and the quality of the interpersonal atmosphere during family meals in relationship to childhood obesity and dietary intake.
This study had several strengths. First, a more in-depth assessment of family interpersonal and food-related dynamics at family meals was attained via the use of direct observational methods. In addition, bidirectional measures (ie, coding ≥2 people’s interactions with each other) of family and parent variables were used to capture a more systemic measure of family dynamics, which is rarely done. However, there are also study limitations. First, the study was cross-sectional and temporality cannot be implied. In addition, we conducted many tests of hypotheses and although estimation, rather than statistical significance, is our main interest, multiple comparisons can be problematic and results should be interpreted with this in mind. Our small sample size also limited our ability to fully adjust for all possible confounders. Furthermore, although we used a sensitizing period for video-recording family meals, families may still have modified their behavior because they were being video-recorded.
This study identified characteristics of family meals (eg, interpersonal and food-related dynamics) through direct observational methods that may help explain the inconsistencies found in previous studies regarding the frequency of family meals and childhood obesity status. Future longitudinal research is needed to corroborate study results. There are also implications for health care providers and public health researchers who work with families and children. First, it would be important for providers to simply ask parents whether they are having family meals (e.g., during a well-child visit) in order to highlight the importance of family meals. Second, providers could offer a more concrete picture regarding the characteristics of family meals (e.g., family meals can be as short as 20 minutes) so that parents feel they are more doable. Third, providers could discuss specific behaviors parents should encourage around the table (e.g., communication; such as telling parents they can have each family member tell a high and a low from their day) to help families participate in more family meals. In addition, public health researchers who use family-based interventions may want to focus on promoting positive (eg, group enjoyment, relationship quality) versus negative (eg, hostility, parental inconsistent discipline) interpersonal dynamics during family meals to help more families benefit from the protective nature of family meals.
- Accepted August 21, 2014.
- Address correspondence to Jerica M. Berge, PhD, MPH, LMFT, CFLE, Department of Family Medicine and Community Health, 717 Delaware St SE, Minneapolis, MN 55414. E-mail:
Dr Berge is the principal investigator on the grant and conceptualized the study, assisted with data analysis and interpretation, and wrote all drafts of the manuscript; Mr Rowley conducted the data analysis and critically reviewed the manuscript; Ms Trofholz assisted with data acquisition and interpretation of the data and critically reviewed the manuscript; Ms Hanson assisted with coding of the data and interpretation of findings and critically reviewed the manuscript; Dr Rueter assisted with the training of coders on the IFIRS coding system and critically reviewed the manuscript; Dr MacLehose assisted with the conceptualization of the study and the data analysis and critically reviewed the manuscript; Dr Neumark-Sztainer assisted in conceptualizing the study, contributed to the study design, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institute of Child Health and Human Development, or the National Institutes of Health.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by grant R21DK091619 from the National Institute of Diabetes, Digestive, and Kidney Diseases (principal investigator: Dr Berge). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2014 by the American Academy of Pediatrics