W4003: Parental practices supporting positive eating behaviors during independent eating occasions among early adolescent children
(Multistate Research Project)
W4003: Parental practices supporting positive eating behaviors during independent eating occasions among early adolescent children
Duration: 10/01/2019 to 09/30/2024
Statement of Issues and Justification
Need as indicated by stakeholders
The prevalence of obesity among older children (9 - 11 years) and adolescents (12 - 15 years) in the U.S. was 18.5% and 20.6%, respectively, based on nationally representative data from the 2015-2016 National Health and Nutrition Examination Survey (NHANES) (Skinner et al., 2018). Obesity prevalence was higher among Hispanic (26.7%) and black (22.0%) adolescents compared to non-Hispanic white (16.3%) and Asian adolescents (9.1%) (Ogden, et al., 2018). Obesity prevalence was also higher among adolescents whose head of the household had ≤ high school diploma (22.3%) compared to some college (18.1%) or a college degree (11.6%). Obesity can cause serious consequences among children and adolescents including type 2 diabetes, dyslipidemia, hypertension, sleep-disordered breathing, nonalcoholic fatty liver disease, and polycystic ovarian syndrome (Gurnani, Birken, & Hamilton, 2015; Han, Lawlor, & Kimm, 2010). A review of existing longitudinal studies showed that children and adolescents who were obese were more likely to remain obese as adults leading to obesity-related complications in adulthood (Kelsey, Zaepfel, Bjornstad, & Nadeau, 2014).
Positive energy balance can result from obesogenic behaviors including excessive sedentary activity and overconsumption of palatable, highly available energy-dense foods. The frequency of these behaviors among children and adolescents is influenced by various personal, behavioral and environmental factors (Larson, Wall, Story & Neumark-Sztainer, 2013) including food-related practices of parents/caregivers. The Social Cognitive Theory (SCT) is an interpersonal theory that focuses on mutual interactions of personal, behavioral and environmental factors (Glanz, Rimer, & Viswanath, 2008). SCT has commonly been applied to eating behaviors of children and adolescents based on the reciprocal interaction between behaviors and the home social and physical environments shaped by food-related parenting practices. Obesogenic eating behaviors among early adolescents (11-14 years) may occur during eating occasions with parental supervision and during independent occasions when parents/caregivers are not present (Reicks et al. 2015). Early adolescents may have independent eating occasions at home, or in other environments away from home including friends’ homes, restaurants or convenience stores. The frequency of independent eating occasions among early adolescents is a concern because food choices during these occasions may be less healthful than when parents/caregivers are present, leading to potential development of overweight or obesity.
Several factors can influence the frequency of independent eating occasions among early adolescents (Pliner & Bell, 2009). Since the 1960s, the diversity in family structure has increased with more single-parent households and households with fewer children (Pew Research Center, 2015). The presence of one or more adults in the household may affect the availability of a parent to eat meals with children. The participation of mothers and fathers in the work force and work schedules may also affect the ability of families to eat meals together. In 2017, the labor force participation rate for mothers and fathers with children under age 18 was 71.1% and 92.8%, respectively (US Bureau of Labor Statistics, 2018). Of employed mothers, 79.0% of those with children 6 to 17 years old worked full time. NHANES data from 2007-2010 showed that the prevalence of having 0-2, 3-6, and ≥7 family meals per week was 18%, 32% and 50%, respectively among the US population with 2 or more individuals living in the household (Newman, Tumin, Andridge, & Anderson, 2015). A population-based study involving adolescents reported that the percentage consuming shared family meals was lower among lower socioeconomic status (SES) groups (Neumark-Sztainer et al., 2013). The share of US households’ food budgets spent on food away from home was greater than 50% in 2017 (Saksena et al., 2018). NHANES data from 2003-2006 showed that the contribution of snacking to total energy intake among 7-12 and 13-18 year olds was 26% and 27%, respectively (Piernas & Popkin, 2010). Collectively, these factors may contribute to a greater number of independent eating occasions for early adolescents and a greater likelihood of overweight and obesity.
The contribution to energy intake and overall diet quality from foods and beverages consumed during independent eating occasions among early adolescents is not well established. In addition, the distribution of independent eating occasions between meal versus snack occasions is not known. In general, children in the US consumed food more frequently throughout the day and more at each occasion than 30 years ago (Popkin & Duffey, 2010); a rise that paralleled the rise in obesity and increases in portion sizes (Piernas & Popkin, 2011). More frequent eating occasions may be an indication of more frequent snacking occasions. Data from girls in the 10-year National Heart, Lung, and Blood Institute Growth and Health Study showed that snack eating frequency through adolescence was about 1-1.1 snacks per day. Snacking occasions likely include foods that have been shown to be high energy-dense including desserts, salty snacks (chips and crackers) and candy, based on NHANES 2003-2006 data from older children and adolescents (Piernas & Popkin, 2010).
The influence of particular parenting practices during independent eating occasions among early adolescents is not known. A review of studies examining associations between parenting practices and child snacking showed that restriction and home availability were associated with child snack intake, whereas studies involving pressure to eat, monitoring and modeling were limited and yielded inconsistent findings (Blaine, Kachurak, Davison, Klabunde, & Fisher, 2017). Parenting that fosters autonomous or intrinsic motivation in youth is of particular interest when considering early adolescent unsupervised eating behaviors. Autonomy-supportive parenting includes providing a clear rationale for the desired behavior, providing choice, and avoiding using pressured or coercive language (Ryan & Deci, 2000). Autonomy supportive parenting has been shown to lead to increased intrinsic motivation, greater receptivity to parent influence (Grolnick, 2003), increased perceived behavioral control, and increased frequency of FV intake (Dwyer et al., 2017; Girelli, Hagger, Mallia, & Lucidi, 2016; Parks et al., 2018) among adolescents.
Importance of the work and consequences if the proposed work is not done
Only a few studies have examined the frequency of independent eating occasions and eating behaviors of adolescents during these occasions. These studies have shown that more frequent independent eating occasions have a negative association with dietary intake and weight status among adolescents. For example, in a nationwide sample of U.S. adolescents (12-17 years) based on the Family Life, Activity, Sun, Health and Eating (FLASHE) Study data, eating alone was associated with greater intake of junk food and sugary beverages, lower home availability of fruits and vegetables, lower perceived parent support, and overweight/obesity (Reicks et al., 2019). A Japanese study reported that eating dinner alone was associated with overweight in adolescent girls but not boys (Shirasawa et al., 2018). In addition, little is known about how food-related parental practices influence early adolescent intake during independent eating occasions, especially among low-income, multiethnic early adolescents. A better understanding of the extent to which parenting practices influence food choice and eating behaviors of early adolescents during independent eating occasions is necessary to inform the development of interventions to promote positive parenting practices that may assist in obesity prevention.
An appropriate, validated instrument did not exist to identify associations between parenting practices and eating behaviors of early adolescents during independent eating occasions. Therefore, the W-3003 Multistate project conducted individual interviews with 51 early adolescents (10-13 years) and their parents to identify parenting practices and explore their influence on eating behaviors during independent eating occasions. The W-3003 project team used the interview results to develop survey items for parents and early adolescents, followed by cognitive testing to refine survey items and testing for reliability and validity using an online panel. In Objective 1 of the W-4003 project, these surveys will be administered to a larger online panel of parent/early adolescent (11-14 years) dyads to identify associations between parenting practices and food and beverage choices, eating behaviors, and weight with attention to intake during independent eating occasions.
Results from Objective 1 will provide a broad understanding of the influence of parenting practices on obesogenic behaviors of early adolescents during independent eating occasions. These findings will be used to develop digital communications for parents and early adolescents to enable healthy food choices during independent eating occasions among early adolescents (Objective 2). For Objective 3, the digital communications will be implemented and tested for effectiveness in a pilot intervention to promote positive parenting practices and improve early adolescent dietary intake during independent eating occasions. For Objective 4, a grant proposal will be developed to implement a full-scale intervention based on pilot test results. The intervention aim will be to determine how parents can influence early adolescents’ eating behaviors when the parent is not present to shape healthful food intake and prevent obesity. If the proposed work for W-4003 is not done, the goal of providing parents of early adolescent children with strategies that lead to positive parenting practices that promote healthier eating among early adolescents during independent eating occasions will not be achieved. In addition, the risk of adverse consequences of overweight and obesity will not be reduced with respect to health, psychosocial, and economical issues for early adolescents in the near future.
The technical feasibility of the work
Research team members for the W-4003 project have successfully collaborated on two or more Agricultural Experiment Station (AES) funded multistate projects (W-1003, W-2003 and W-3003) to study influences of parenting practices on parent and early adolescent dietary behaviors. The team has previously developed, tested and implemented survey instruments involving parent/early adolescent dyads across 10-12 states to identify calcium rich food and beverage (CRF/B) related parenting practices associated with CRF/B intake among early adolescents. The diversity of expertise has functioned well for this team in the past and is expected to contribute to the feasibility of developing and pilot testing digital communications for parent/early adolescent dyads regarding parenting practices that influence eating behavior of early adolescents during independent eating occasions. For example, within their own institutions team members have conducted interventions with parent/early adolescent dyads involving in-person cooking interventions (Overcash et al., 2018; Rogers et al., 2017), meal planning using meal calendar websites (Jones, 2018; Jones, Evich, & Gaskins, 2017), and experiential learning in a virtual world environment (Meng, Wong, Manore, & Patton-Lopez, 2018). This multistate team has completed previous studies and published results supporting successful collaborative projects in which all researchers were involved. These studies were based on interview, focus group, nominal group process and other qualitative approaches (Edlefsen et al., 2008; Cluskey et al., 2008; Richards et al., 2014), as well as quantitative approaches surveying large samples of parent/early adolescent dyads (Vyduna et al. 2016; Reicks et al. 2011; Reicks et al., 2012; Cluskey et al., 2015; Banna et al., 2019). The team includes nutrition researchers and Cooperative Extension Nutrition Specialists, as well as a marriage and family therapy researcher and a developmental/health psychologist, who all work together to provide expertise from a family social science perspective.
Advantages for doing the work as a multistate effort
This project has several advantages for being implemented as an AES multistate project. This particular research group has 12 participants in 9 states and the District of Columbia. Researchers have positions as faculty with research experience in community nutrition, eating behavior, and family dynamics including parent-child relationships. Several have appointments within Extension, which provides opportunities for broad access to potential participants. Researchers represent a cross-section of geographic areas within the U.S. with opportunities for reaching low-income, multiethnic groups from which the project can explore, focus and tailor behavior change strategies. Finally, this group has 13+ years of experience working together to conduct collaborative investigations reaching a large number of participants. Researchers understand how to successfully assure that all researchers follow an identical protocol and have been successful with this approach in previous multistate projects, W-1003, W-2003, and W-3003.
Likely impacts from successfully completing the work
Parenting practices influence early adolescent’s eating behaviors and therefore play an essential role in preventing obesity. Little information is available regarding how parenting practices influence early adolescents’ eating behaviors during independent eating occasions. The proposed W-4003 project is expected to result in the identification of food-related parenting practices associated with healthful dietary intake during independent eating occasions and healthy weight status among low-income, multiethnic early adolescents from both a parent and child perspective (Objective 1). Identifying associations between positive parenting practices and obesogenic behaviors will provide a rationale for the development of digital communications that encourage the use of those parenting practices (Objective 2). An intervention will be developed and pilot-tested to determine the effectiveness of the digital communications to impact obesogenic energy-dense and low-nutrient dense food choices and unhealthy eating behaviors of early adolescents during independent eating occasions (Objective 3). A grant proposal to take the intervention full-scale will be developed based on the results of the pilot test (Objective 4). The ability to build on findings from previous multistate projects (W-1003, W-2003, and W-3003) will allow the team to encourage parenting practices that result in early adolescents choosing healthy foods during independent eating occasions thereby addressing the need to improve diet quality and prevent obesity.
Related, Current and Previous Work
Related, Current and Previous Work
Parental influence on food intake has been well established (Vaughn et al., 2013; Vaughn et al., 2016). Preliminary work among Hispanic, Asian and non-Hispanic white early adolescents in W-1003 and W-2003 showed that home availability of calcium-rich foods (CRF), parental rules and expectations for their early adolescents’ intake of beverages, and parents’ calcium intake/role modeling were positively associated with early adolescents’ calcium intake (Banna et al., 2019). Significant cultural differences were observed with parental role modeling identified as a significant factor associated with intake only among Hispanic dyads. Similar associations have been observed between parenting practices and intake of other healthful foods by children and adolescents including fruits and vegetables (Hingle et al., 2012).
Information is limited regarding the frequency of independent eating occasions among early adolescents, how food choices made during these occasions affect overall diet quality and weight status, and how food-related parenting practices influence early adolescent food choices during independent eating occasions. The W-3003 project team addressed this gap in the literature by first developing and testing an individual interview data collection protocol, which was implemented across all states and the District of Columbia (n = 51 parent/early adolescent dyads). The interviews were conducted with early adolescents and parents after early adolescents took photos of all foods and beverages consumed over a 24-hour period. Scripted interview questions asked early adolescents to describe each eating occasion based on the photos to provide information about the type and source of food and beverages consumed and eating context (location, time, who the child was with). Early adolescents were asked open-ended questions regarding parenting practices that influenced intake during these occasions. Parents completed surveys to assess 1) whether parents considered themselves succeeders or strivers regarding helping their child eat healthy foods when they were not present, 2) frequency of parenting practices such as role modeling, making healthy foods available, restriction and monitoring, and 3) general parenting measures. Quantitative analyses were used to determine if succeeder versus striver parents differed in the reports of practices used to get their early adolescent to make healthy choices when they were not present. Parents also answered open-ended interview questions regarding what they “say and do to get their early adolescent to eat healthy” during independent eating occasions. Qualitative analysis procedures were used to identify parenting practices that influenced early adolescent dietary intake during these occasions.
The majority of parents were 35 – 54 years, had some college or technical school, had annual incomes below $44,999, were women and were multiethnic. The majority of early adolescents were female (57%) and 10-11 years (66%). Early adolescents (n = 46) reported on a total of 279 eating occasions over a 24-hour period with 172 as independent eating occasions (Banna et al., 2018). More than half (65%) were classified as “snacks”. The most frequent foods consumed during independent eating occasions were sweet snacks (cakes, cookies) (15%), grains (bread, pasta) (13%), fruits (9%), salty snacks (chips) (8%), dairy (milk, cheese) (8%) and sugar-sweetened beverages (7%). Most independent eating occasions occurred at home (72%) while watching TV/surfing the internet (32%), hanging out with a friend (16%) or doing something else (21%).
Parent survey results showed that parents who perceived being successful at getting their early adolescent to make healthy food choices when they were not around used strategies of monitoring children’s intake of sweets, high-fat foods, and healthy CRF foods (Richards et al., 2018). Succeeders reported having less availability of sweet and savory convenience foods at home, and that their early adolescent frequently limited sugary drinks when they were not around. Mean ± SD early adolescent BMI z-score was significantly lower for early adolescents of parent succeeders than strivers. Based on the individual interviews, parents reported that the most common practices they used to influence intake during early adolescent independent eating occasions were setting expectations for intake of healthy foods, making healthy foods available and accessible, and teaching children about healthy foods (Gunther et al., accepted with minor revisions). Other less common practices were role modeling, pressuring to eat, and monitoring intake. Based on the early adolescent interviews, early adolescents reported that their parents controlled what was available and had rules regarding what they could eat during independent eating occasions.
The results of the parent and early adolescent interviews were used to develop a series of survey items to assess frequency of use of the practices identified from interviews and their associations with early adolescents’ dietary intake. Cognitive interviews were conducted with 10 parent/early adolescent dyads to assess comprehension and clarity of the items. Revisions were made to both surveys based on feedback from parents and early adolescents. Parent and early adolescent surveys items will be tested for reliability and validity as part of the W-3003 project among ~ 100 parent/early adolescent dyads, through an online Qualtrics panel. Parents of early adolescents (11-14 years) will be recruited through the Qualtrics panelist database; parents will be asked to have their early adolescent complete the early adolescent survey. Other eligibility criteria (assessed via screening questions) include the parent having primary responsibility for food acquisition and preparation for the early adolescent (11-14 years), earning ≤ 185% of the poverty guidelines in the past year, and being comfortable reading English. To ensure racial/ethnic diversity in our sampling, quotas will be set for race/ethnicity for Asian, Black or African American, Hispanic, White or Caucasian, Native American and Hawaiian or Pacific Islander. Quotas will be determined based on our previous work with these racial/ethnic groups in the survey development phase for W-3003. Parents’ and early adolescents’ perceptions about the level of ease in completing the survey and the length of time it takes will be assessed. Plans to collect the pilot test data include survey administration in January of 2019 and data analysis and further revision of survey items from February to September 2019. Following revision based on testing results, the surveys will be conducted with a larger sample of parent/early adolescent dyads (n = ~400 dyads) as part of the W-4003 project beginning in October 2019 (Objective 1 of the W-4003 proposal).
The W-3003 team used the FLASHE Study data to examine relationships between frequency of adolescents’ eating alone (dependent variable) and dietary behavior, weight status and perceived parental support (independent variables) (Reicks et al. 2019). The FLASHE Study collected data from a U.S. nationwide sample of parent-adolescent (12-17 years) dyads via web-based surveys in 2014 to report demographic characteristics, weight, family meal characteristics, dietary behavior, home food availability, and perceptions of parenting practices. Logistic regression analyses were used to test for associations between variables. About 20% of adolescents reported experiencing independent eating occasions (often eating alone) (n = 343) versus not often eating alone (n = 1309). Adjusted odds of adolescents often eating alone were significantly higher for non-Hispanic black compared to non-Hispanic white adolescents (OR = 1.7) and for overweight or obese compared to normal or underweight adolescents (OR = 1.6). Adjusted odds of adolescents eating alone were significantly lower for those who reported that fruits and vegetables were often/always available in the home (OR = 0.65), for those who perceived that parents had expectations about fruit and vegetable intake (OR = 0.71), and for those who agreed with parental authority to make rules about intake of junk food/sugary drinks (OR = 0.71). Adjusted odds of adolescents eating alone significantly higher for those who reported that sweets were often/always available in the home (OR = 1.4). Junk food and sugary drink daily intake frequency was positively associated with often eating alone. Often eating alone was related to being overweight/obese, having less healthy dietary intake, and perceptions of less supportive food-related parenting practices. Another cross-sectional survey provided additional information about the relationship between independent eating occasions and overweight among adolescents. This study was conducted among 890 seventh grade students in Ina, Japan (2011-2012) to examine whether associations existed between eating dinner alone and being overweight based on measured height and weight (Shirasawa et al. 2018). Students were classified as not eating dinner alone, eating dinner alone ≥ 1-2 times/week or eating dinner alone ≥ 3 times/week. Among overweight girls, a significantly increased OR (OR = 2.78) was observed among girls who ate dinner alone ≥ 1-2 times/week compared to those who did not eat dinner alone; the same association was not observed for boys. The proportion of students who reported eating dinner alone ≥ 1-2 times/week was about 11% for girls and 15% for boys. Maternal employment was 72% for mothers of girls and 66% for mothers of boys; 13% of girls and 16% of boys reported being an only child. About 10% of girls and 16% of boys were classified as overweight.
Prior to developing digital communications for parents to address early adolescent food intake during independent eating occasions (Objective 2), additional information must be obtained regarding frequency of independent eating occasions and the situations underlying the frequency of these occasions (Objective 1). In addition, information is needed regarding practices that parents use to encourage healthy food intake during these independent eating occasions, motivators and barriers to these practices, and early adolescents’ compliance with these practices (Objective 1). A greater understanding of these occasions will enable more effective promotion of positive parenting practices to parents for managing healthy eating among youth. Exploring the early adolescent’s perception about how their parental behavior influences them gives the interventionist perspective that can be used to motivate and educate parents to practice these behaviors. With a broader understanding of the behavior, digital communications can be developed for parents and early adolescents that serve to improve parenting practices and motivate parents to engage in these practices (Objective 2).
An intervention based on digital communications commonly used in eHealth/mHealth interventions may be desirable versus a more labor-intensive intervention involving in-person sessions only (Objectives 2 and 3). An eHealth/mHealth intervention has scalability advantages of being deliverable across broad geographic areas, with digital media options and platform (may be multiple) that are most feasible and effective in reaching the target audience that meet the research sample size and specific demographic characteristics.
Digital medium options include interactive voice response (IVR) based on computerized voice phone prompts, email, social media, mHealth apps for phone/tablet computing, text-based messaging, and telemedicine via video conferencing. uHealth approaches include pervasive and ubiquitous computing, wearable computing (such as smart watch with body sensors) and domotics (home automation or smart home technology). Criteria for co-selection (by both the researchers and the users) from the various digital media options and platform for use in Objective 2 and 3 will prioritize these criteria: low-cost, scalable, secure, and effective (e.g., easy to use, easy to understand, engaging, low error, and motivates learning) to promote positive parenting practices that result in early adolescents choosing healthy foods and beverages during independent eating occasions.
Several reviews have provided positive results regarding eHealth and mHealth interventions for parents (Hammersley, Jones, & Okely, 2016), adolescents (Hsu, Rouf, & Allman-Farinelli, 2018) and adults (McCarroll, Eyles, & Ni Mhurchu, 2017). For example, a systematic review of eHealth interventions for parents that focused on child and adolescent (0-18 years) overweight and obesity identified eight studies over a 20-year period that used an eHealth medium in an obesity prevention or treatment trial (Hammersley, Jones, & Okely, 2016). Of the seven studies that reported on dietary outcomes, four showed improvements in at least one dietary measurement compared with the control. Dietary outcomes included fruit and vegetable intake, nutrition knowledge, total energy intake, fat intake and intake of “fattening” foods. Studies using an Internet intervention also included in-person or telephone counseling, lessons or a camp. Other studies used IVR or telemedicine. In seven of the eight studies, both the parent and child or adolescent were actively involved in the intervention. Intervention duration was typically less than 6 months. Larger, high quality studies of longer duration were suggested by the authors to determine the effectiveness of eHealth interventions for parents. A systematic review of social media interventions for adolescents to promote positive nutrition behaviors identified seven interventions for participants 13-18 years (Hsu, Rouf, & Allman-Farinelli, 2018). Of the seven interventions, five showed improvement in at least one nutrition behavior compared to control. Nutrition behaviors included fruit or vegetable intake or sugar-sweetened beverage intake. Social media included older versions of the technology such as purpose-built discussion boards or chat rooms versus newer platforms (i.e., Facebook). The authors suggested that better quality interventions were needed with longer term follow up. Another systematic review identified 23 mHealth interventions to promote healthy eating among adults (McCarroll, Eyles, & Ni Mhurchu, 2017). Five of eight trials reported small positive effects on healthy eating. The authors suggested a need for more rigorous methods with longer term follow up.
The development of digital communications (Objective 2) will be informed by findings from Objective 1 regarding effective parenting practices applied during independent eating occasions, and previous work completed by W-3003 research team members and others including mobile apps, virtual parenting supervision/coaching, virtual food preparation experiences for early adolescents (e.g., through augmented/virtual reality), and online planning tools.
An example of a mobile application that showed efficacy in a dietary intervention was an app designed to increase vegetable intake by overweight adults (Mummah et al., 2017). The Vegethon mobile app involved goal setting, self-monitoring and feedback and used elements such as fun, surprise, choice, control, social comparison and competition to motivate adults to participate. Compared to the wait-list control group, those using the app increased daily vegetable consumption by two and one servings as assessed by a FFQ or 24-hour recalls, respectively. Robbins, Krebs, Jagannathan, Jean-Louis and Duncan (2017) used data from a national cross-sectional survey of adult mobile phone users in the US without any health conditions to show that about 39% had between one and five apps. About 21% of those without a health condition reported using a health app ≥ two times per day. Downloading a health app was more likely (OR = 3.8) among those with self-reported very good health compared to individuals with self-reported poor health. These findings indicated that downloading apps to a mobile phone or tablet computer is common among US adults. In addition, surveys by the Pew Research Center found that 34% of adults have downloaded an app to their cell phone or tablet computer for a child to use (Lenhart, 2012). Results did not show that downloading apps for children differed by race, ethnicity or income, whereas other reports suggested that higher income families were more likely to download and use apps with their children compared to lower income families. Those reporting that they have downloaded apps for children indicated that the apps were for entertainment (46%), learning or education (31%) or for both education and entertainment (22%).
Virtual parenting coaching/supervision interactions could be used to influence food choices made by early adolescents during independent eating occasions. For example, parents and adolescents could have conversations about healthy options via phone calls, texts, video calls, or social media. Food choices and availability could be monitored via programmed virtual reminders and/or provision via smart home technology if available. Food, beverage or meals purchased online could be tracked via debit/credit card activity, including fast food purchased and eaten at home, or food delivered to the home. However, to our knowledge, studies are not available regarding the use of virtual parent coaching/supervision to influence early adolescent food choices during independent eating occasions.
Digital/virtual cooking experiences have been used with children and adolescents through videos designed to improve cooking skills and cooking self-efficacy. For example, an intervention tested among school-aged minority children (3rd – 5th grade) in Los Angeles schools resulted in improving self-efficacy to cook and eat (Bell et al., 2018). The intervention included gaming sessions and lessons in school and at home using an existing nutrition- and gardening-focused curriculum. Surgenor et al. (2017) also showed that video technology improved comprehension of the cooking process and promoted confidence in cooking skills regarding meal preparation among women.
A project team member, Dr. Blake Jones and colleagues conducted focus group interviews with parent of school-aged children. Feedback from parents indicated that many struggled to provide healthy, consistent, or home-cooked meals for their families in the evening. This was primarily because of a lack of meal planning complicated by a time crunch in the short turnaround between getting home from work and school and having a meal prepared for hungry parents and children. As a result, many parents discussed using unhealthy meal options such as ordering pizza, cooking prepackaged and unhealthy frozen dinners in the microwave, or just snacking for dinner. Dr. Jones and colleagues used this feedback to develop a web-based meal calendar tool that allowed parents and children to plan their meals for a week in advance using a simple drop-down menu where children could help choose healthier options for meals and snacks from picture options of foods (Jones et al., 2017. When they selected the foods, they were provided with the ingredients, instructions for cooking or preparing the meals, and age-appropriate child tasks. Using these options, parents were able to engage with children in discussing, planning, and preparing healthier meals and snacks. A similar calendar system could easily be constructed to focus primarily on planning snacks for early adolescents during independent eating occasions. This would allow parents to provide direction and monitoring of the options, and to encourage healthier choices by planning snacks in advance. Instructions could be included for preparation tasks that early adolescents and parents are comfortable with early adolescents performing.
To further engage the users, other potential mobile app features may include goal setting, motivation quotes, facts (such as statistics about global food consumption), myth busters, and stories about the day in the life of an early adolescent or parent.
A CRIS search (January 2019) using “parenting” and “early adolescent” as keywords resulted in 24 records. Thirteen were W-2003 and W-3003 projects completed or in the process of being completed by the current investigators proposing W-4003. Six projects involved parenting but not in the context of eating behaviors (adoption and well-being, conflict management, teen parenting, behavioral and emotional problems, psychological and physiological processes, child achievement). Three studies involved the influence of parenting practices on early adolescents’ eating behaviors, all led by Marla Reicks, a current W-3003 team member. The first is the current PROJ NO: MIN-18-120, 2017-2022 using publicly-available, nationally representative diet and physical activity data (NHANES) to determine relationships between parent dietary and physical activity behaviors (as proxies for parenting practices) and their characteristics regarding age of children, being a father or mother, cultural background, and resources to meet recommendations. The second is the current PROJ NO: MIN-FD-E07, 2016-2021 conducting a randomized, controlled intervention study with Latino families to increase father involvement in positive parenting practices to address youth energy balance-related behaviors. The third is the completed PROJ NO: MIN-18-101, 2014-2017 which evaluated relationships between parental factors and early adolescent sugar-sweetened beverage intake and weight status. An additional completed study was led by Bates, JS (PROJ NO: OHOW-2013-02242, 2013-2018) which aimed to enhance the father-adolescent relationship, increase healthy eating episodes and decrease unhealthy eating episodes, and increase community involvement in changing patterns of food consumption. Another study was completed by Onstad et al. (PROJ NO: 6250-51000-038-01A, 1999-2004 and extended with PROJ NO: 6250-51000-047-01A, 2004-2005). The study focused on how environmental, personal and parental factors influence 3-15 year-old, multiethnic children’s fruit, juice and vegetable intakes in the prevention of childhood obesity and chronic diseases. The proposed study (W-4003) uses SCT as a theoretical framework to target parents of early adolescents (11-14 years) and the early adolescents to identify and apply parenting practices that positively influence early adolescents’ eating behaviors during independent eating occasions. The proposed project has a more specific scope compared to the other current and previous studies and does not overlap with their study aims.
Examine the association between key parenting practices and positive eating behaviors during independent eating occasions among low-income, multi-ethnic early adolescents.
Develop digital communications for parents and/or early adolescents such as mobile apps, virtual parent coaching/supervision, virtual cooking experiences, and online planning tools that promote parenting practices that support healthy food choices during independent eating occasions among early adolescents (11-14 years).
Implement and evaluate a pilot intervention for parents and early adolescents (11-14 years) to promote positive parenting practices during independent eating occasions and to improve early adolescent dietary intake during these occasions based on digital communications developed in Objective 2.
Prepare grant proposals to modify intervention components and implement a full-scale intervention and disseminate findings to health professionals.
In the previous multistate projects - W-1003, W-2003, W-3003, researchers in all states have participated in the work involved in each objective based the development of identical protocols for data collection and involvement in work groups that have analyzed data are reported results. For the current project (W-4003), all states will participate in the work involved in all objectives, with one exception (KS will not participate in Objective 2).
Objective 1. Examine the association between key parenting practices and positive eating behaviors during independent eating occasions among low-income, multi-ethnic early adolescents (from W-3003).
After the survey is pilot tested as part of W-3003, we will make any necessary revisions and then use the survey to collect data from a larger sample of parent/early adolescent dyads. We plan to assess parenting practices associated with intake of foods consumed by early adolescents during independent eating occasions and with BMI based on self-reported height and weight. The finalized parent and early adolescent surveys will be completed by parent/early adolescent dyads in an electronic format via a Qualtrics survey platform. Parents of early adolescents (11-14 years) will be recruited through a Qualtrics panelist database; parents will be asked to have their early adolescent complete the early adolescent survey (n = ~400 dyads). Sample size calculations will be made to verify that 400 dyads is an adequate sample size after identifying relevant parenting practices and their variability during the pilot testing phase being completed for W-3003. Adjustments will be made if necessary to assure that the sample size is adequate for the stated purpose of Objective 1. However, similar studies of relationships between parenting practices and youth dietary intake have been conducted with sample sizes ranging from 300-400 parent/child dyads (Conlon et al., 2019; Schnettler et al., 2018). Eligibility criteria (assessed via screening questions) include 1) being the parent who has primary responsibility for food acquisition and preparation for their early adolescent (11-14 years), 2) earning ≤ 185% of the poverty guidelines in the past year, and being comfortable reading English.
Qualtrics maintains a diverse Panel Database allowing researchers to choose a nationwide sample with the target demographic characteristics needed for a particular study. Respondents for the pilot testing phase of Objective 2 (n = 204) were from 39 states (78% of total states) with 1 – 7 respondents from each of the states represented by the W-3003 research team. With assistance from Qualtrics, we will use quotas similar to those used in the pilot testing phase among a national sample of early adolescents for race (Asian (~20%), Black or African American (25%), White or Caucasian (~50%), Native American and Hawaiian or Pacific Islander (~5%)) and ethnicity (Hispanic (25%)).
The Institutional Review Board for Human Subjects at one station will review the research protocol involving informed consent for parents, parental permission, and assent for early adolescents. Parents will provide informed consent to take the parent survey and parental permission prior to the early adolescent being able to access the early adolescent survey. Early adolescents will assent to participate. Survey components for parents will include: 1) parenting practices items with 5 – point agree/disagree and never/always response option scales (developed and tested as part of W-3003), 2) the USDA six-item food security module (ERS, USDA 2012), 3) self-reported weight and height, and 4) demographic questions regarding age, sex, ethnicity, education, employment, income, household composition, and food assistance. Survey components for early adolescents will include: 1) frequency of independent eating occasions, 2) parenting practice items (developed and tested as part of W-3003), 3) self-reported weight and height, 4) the FLASHE Study 27-item food frequency questionnaire (NCI, 2017), and 5) demographic questions regarding age, sex, and ethnicity.
Parenting practice item responses will be scaled according to parenting practice (i.e., availability, setting expectations, etc.) and collapsed into binary variables for analysis based on findings regarding reliability and validity from the W-3003 project. Early adolescents’ BMI z-score and BMI percentile for sex and age will be calculated using CDCP growth curves (CDCP, 2011). Mean daily intake food frequency scores will be calculated as the average number of times per day that foods in selected food groups were eaten. Before combining food items into the daily food frequency scales, each item response will be converted to a daily frequency: Never = 0; 1-3 times in past 7 days = 0.29; 4-6 times in past 7 days = 0.71; 1 time per day = 1; 2 times per day = 2; 3 or more times per day = 3. The items included in each daily intake food frequency scale were defined in the FLASHE users’ guide (NCI, 2017). Food groups included junk food, convenience/fast food, sugar-sweetened beverages, sugary foods, fatty meats, all detrimental foods, fruits and vegetables and all beneficial foods. Multiple regression analysis will be used to predict the early adolescents’ food group intake and BMI z-score and BMI percentile for sex and age (dependent or response variables) from relevant parenting practice scales and frequency of independent eating occasions (independent of explanatory models). Univariate analysis of individual scales will be used to identify the most salient factors as being positively or negatively associated with the early adolescent's intake in separate models. For example, a scale of 'parents' expectations' may negatively influence an early adolescent's intake of sugar-sweetened beverages; whereas an environmental factor, such as having soft drinks in the home may positively influence an early adolescent's intake of sugar-sweetened beverages. Age, sex and ethnicity will be co-variates in each model. The models will be repeated with frequency of intake of food groups as the dependent variable.
Survey data based on similar items completed by both parent and early adolescents represents cross-sectional, dyadic data. Dyadic data have various sources of interdependence and require the use of flexible analytic tools to address these complexities. These tools may include path or multilevel modeling. Assistance with dyadic analysis will be requested from the Departments of Statistics at participating universities. In addition, sample code for preparing data files and conducting dyadic analyses are available from the FLASHE Study dyadic resources page (https://cancercontrol.cancer.gov/brp/hbrb/flashe-dyadic-analysis.aspx).
Objective 2. Develop digital communications for parents and/or early adolescents such as mobile apps, virtual parent coaching/supervision, virtual cooking experiences, and online planning tools that promote parenting practices that support healthy food choices during independent eating occasions among adolescents (11-14 year olds).
Project work group teams will be identified to develop specific digital communications based on the findings from Objective 1, previous experience, and interest among the target audience. Experts within the cooperating institutions are available in public health and IT departments. In addition, several online toolkits and other resources are available that support the development and use of digital communications for public health interventions. An example is the Parenting2Go App developed by the US Department of Veteran Affairs at https://itunes.apple.com/us/app/parenting2go/id804311274?mt=8.
Development of digital communications
Dr. Carolyn Gunther will lead a work group to develop digital/virtual cooking experiences for early adolescents based on the findings from Objective 1 adapted from existing evidence informed and field tested cooking curricula (e.g., Simple Suppers, iCook, Cooking Matters, etc) and other open-access resources (e.g., YouTube videos, cookbooks such as America’s Test Kitchen – The Complete Cookbook for Young Chefs). The cooking experiences would be applicable to early adolescents for use during independent snacking occasions. For instance, topics specific to early adolescents such as practicing safety will be incorporated (e.g., safely using knives and hot stovetops and ovens, safely handling raw foods (meat, chicken, fish and eggs). Each lesson will incorporate theory-based methods and strategies for changing behavior (e.g., hands-on activities, gaming, goal setting, teach-back). All content will be tailored specifically to low-resource audiences (e.g., budget friendly recipes, basic kitchen appliances/utensils) and culturally sensitive (e.g., ‘actors’ from racially/ethnically diverse backgrounds).
Dr. Blake Jones will lead a work group to develop strategies for encouraging children to plan snack options in advance based on findings from Objective 1 using a snack calendar tool. The calendar tool would also provide parental monitoring of early adolescents’ choices and options. The planned options may (or may not) be selected on a given day or time, based on how hungry that early adolescent is at that time, but at least the options can be pre-selected so that the parent and early adolescent have a plan. This advanced planning will give parents the time to purchase or prepare options for the early adolescents and, ideally, it would provide opportunities for the early adolescents to have a say in what choices they would prefer. The goal of the planning tool would be to not only help parents and early adolescents plan and prepare healthy options for eating, but would act as a natural catalyst for initiating discussions about healthy eating between parents and early adolescents.
Objective 3. Implement and evaluate a pilot intervention for parents and early adolescents (11-14 years) to promote positive parenting practices during independent eating occasions to improve dietary intake of early adolescents during these occasions based on digital communications developed in Objective 2.
Upon approval by individual Institutional Review Boards (IRB), each site will recruit a convenience sample of parent/early adolescent (11-14 years) dyads according to the sampling approach described below. Inclusion criteria for parents are: 1) being the parent of an early adolescent (11-14 years) who resides in the household at least half of the time, 2) being the adult responsible for food acquisition and preparation in the early adolescent's household, 3) earning ≤ 185% of the poverty guidelines in the past year and/or eligible for food assistance programs, 4) speaking English/being comfortable speaking English, and 5) household smartphone and internet access. Parental consent and youth assent will be obtained prior to data collection. The type of IRB-approved incentive/compensation for participation may vary in different sites.
Sample size calculations will be completed for each intervention program including consideration of the particular intervention component(s) and outcomes of interest. Work group members will complete the sample size calculations based on the type of data collected and the distribution, what they consider a meaningful difference in the outcome variables and variability. In other studies this multistate group has conducted (e.g., Banna et al., 2018; Cluskey et al., 2015; Reicks et al., 2011), a recruitment plan has been developed with partner states indicating the number and type of participants they could recruit based on geographic location and availability of participants by sociodemographic characteristics such as sex, age and race/ethnicity. Therefore, the sampling approach for Objective 3 will take into account the total sample size needed based on sample size calculations, recruitment strategies, the ability of individual states to recruit a specified number of participants according to inclusion criteria, and the capacity of individual states to implement the intervention program(s). A standardized protocol will be developed for each intervention program to maintain consistency of implementation across sites. A subgroup of states may elect to implement one or more intervention programs depending on their capacity and interests.
Frequency of supportive parenting practices during independent eating occasions assessed based on parenting practice scales that were developed and tested as part of W-3003 at baseline and post-intervention among parent/early adolescent dyads.
- Eating behavior change will be assessed among early adolescents by collecting and comparing baseline and post-intervention data based on the FLASHE Study 27-item food frequency questionnaire (NCI, 2017). These questions assess intake over the past 7 days.
- Use of the digital communications throughout the intervention period will be monitored in several ways, for example, the number of participants who viewed digital content and responses to questions regarding usability, satisfaction, exposure, influence, engagement and intention to act.
Overall feasibility will be assessed based on participant responses to the digital communications content and delivery methods. Preliminary effectiveness will be assessed based on changes in frequency of supportive parenting practices and early adolescent eating behaviors.
Objective 4. Prepare grant proposals to revise and implement a full-scale intervention and disseminate findings to health professionals.
Grant proposals informed by findings from W-4003 objectives 1, 2 and 3 will be prepared and reviewed at the 2023 and 2024 annual meetings. The proposals will include plans to revise the intervention based on the pilot test findings, implement the successful elements in a full-scale intervention within the participating states and the District of Colombia and disseminate findings to health professionals. A writing team of at least 4 researchers will be responsible for developing/writing proposals. All team members in the W-4003 group will provide input. Potential funders include USDA AFRI Childhood Obesity Prevention funding and NIH funding via programs such as PA-18-152: Reducing Health Disparities Among Minority and Underserved Children.
Dissemination: All states and the District of Columbia will contribute to the development of communications to disseminate findings, intervention protocols and materials from the W-4003 project to Extension and other organizations. Findings will be disseminated in the following ways:
(1) The supportive parenting practices identified through this project will be incorporated into parenting programs and messages that teach parenting skills and behaviors for early adolescents supported by Extension and other governmental agencies and for health care and public health professionals.
(2) Best practices based on the findings from W-4003 will be developed by the group and disseminated through multiple avenues, including, eXtension – specifically, the Families, Food, and Fitness Community of Practice, (FFF CoP) for use by students, researchers, clinicians, professors, and the general public. Best practices, applied findings, products, and professional development opportunities resulting from this project will also be made available through 4-H professionals and stakeholders in Extension and through national 4-H conferences, events, and publications (e.g., Journal of Youth Development).
(3) Study intervention findings will be disseminated via webcasts, podcasts, and other social media outlets linked to eXtension.
(4) Webinar training will be provided for Extension staff and other youth and family practitioners to become equipped in delivering the curriculum.
(5) Findings will be included as new knowledge content in the areas of nutrition and physical activity for children (grades 5th-8th) on the FFF CoP website.
(6) Childhood obesity prevention articles will be published on the eXtension CoP FFF website and cross-listed with other related CoPs (e.g., Community Nutrition Education, Family Caregiving, and Parenting). Audiences will be alerted to the articles via social media (Facebook, Instagram, Twitter, Pinterest) after consideration of privacy concerns are addressed.
(7) Research findings from this project will be disseminated in presentations at local, state, and national professional meetings and also via manuscripts in peer-reviewed journals (e.g., Journal of Nutrition Education and Behavior, Journal of Extension)
All of the above activities will be coordinated by existing Oregon State University Extension IT staff with input from Extension staff members with specific expertise in applying social media to Extension system.
Measurement of Progress and Results
- 1) A questionnaire tested for reliability and validity to identify parenting practices associated with healthy eating behaviors among early adolescents during independent eating occasions.
- 2) Survey results indicating which parenting practices should be promoted to improve eating behaviors among early adolescents during independent eating occasions.
- 3) An instrument to assess potential improvements in parenting practices that positively influence eating behaviors among early adolescent children during independent eating occasions based on a single group pre-post study design or a randomized, controlled intervention design with pre-post assessment.
- 4) Digital communications that can be used to promote parenting practices that positively influence eating behaviors among early adolescents during independent eating occasions, such as mobile apps, online planning tools and virtual cooking experiences.
- 5) Pilot intervention results based on implementation of digital communications to promote parenting practices that positively influence eating behaviors among early adolescents during independent eating occasions scalable to a large population.
- 6) Grant proposals to fund a large-scale intervention based on pilot intervention results.
Outcomes or Projected Impacts
- Increased frequency of supportive parenting practices regarding eating behaviors among early adolescents during independent eating occasions.
- Improvement in eating behaviors overall and during independent eating occasions among early adolescents including reductions in intake of junk food, convenience/fast food, sugar-sweetened beverages, sugary foods, fatty meats and increases in intake of fruits and vegetables and beneficial foods (based on the FLASHE Study defined food groups) (NCI, 2017).
Milestones(2019):To complete W-3003: Analyze qualitative data; develop questionnaire based on qualitative results; conduct cognitive testing for new parent and early adolescent survey items; establish method for pilot testing; implement testing of an electronic pilot test questionnaire format; evaluate pilot test results.
(2020):To continue work as W-4003: Implement main survey, analyze survey data; evaluate results; determine parental practices exhibiting most impact on early adolescents’ weight, intakes and behaviors, develop manuscripts.
(2021):Plan and develop intervention components based on digital communications such as parent and early adolescent apps that serve as an organizing framework for virtual/digital parent coaching/supervising, snack preparing, and calendar snack planning experiences.
(2022):Design, implement and evaluate a pilot intervention based on digital communications such as an app, food preparation experiences, and a snack calendar system. Report results via manuscripts, develop draft grant proposals to implement the intervention among a broad range of participants.
(2022):Design, implement and evaluate a pilot intervention based on digital communications such as an app, food preparation experiences, and a snack calendar system. Report results via manuscripts, develop draft grant proposals to implement the intervention among a broad range of participants.
(2024):Share educational materials and resources with others in cooperation with state partners. Finalize grant proposals at the annual 2024 meeting and submit to potential funding sources.
Projected ParticipationView Appendix E: Participation
We will make the results of the project available in an accessible manner to intended users of the information through refereed publications in nutrition and health journals and presentations made at annual meetings of nutrition, health and education professional societies, and eXtension Families, Food, and Fitness Community of Practice (FFF CoP).
An executive committee will be formed annually by group consensus methods with a Chair and Reporter. The Chair manages meetings, submits reports and plans the agenda for the annual meeting. The Reporter provides minutes describing the discussion and actions suggested during the mettings. Administrative guidance will be provided by an assigned Administrative Advisor and a CSREES Representative.
Each approved member will cooperate in the design of the project, collection and analysis of data and co-authoring of publications and presentations that result from this work. The research team will use common protocols to accomplish each objective. Data for Objective 1 will be collected using a national Qualtrics panel; data for Objective 3 will be collected in individual states and aggregated for analysis by subgroup of researchers as applicable to the study design, specific intervention components and target audience. Findings will be shared with the entire project team. Research team subgroups will develop several manuscripts, reports and presentations.
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