The Role of Social Relationships in Shaping Child and Adolescent Eating Behaviors: Implications for Health Practitioners

We are pleased to feature a research paper from a talented dietetic intern, Rachel Paul, who recently worked with the IFIC Foundation.  It is targeted for practicing dietitians but has interesting insights for many others, despite its technical nature.

 


A mother, worried about her overweight child’s health, forbids the child to eat dessert.

 

At a middle-school sleepover, one best friend tells the other that a certain food group “makes you fat.” Both girls decide to abstain from these foods.

 

A college student reads in a magazine that her celebrity idol is following an extreme diet. The student, worried about the recent weight she’s gained, decides to try the diet as well.

 

These explicit and implicit interactions are ubiquitous and potentially dangerous to a person’s food choices. Nutritional confusion, poor body image, chronic dieting, and even eating disorders are some possible negative outcomes. Many factors can impact eating decisions, such as culture, genetics, and the social relationships evident above.

 

Relationships with family members, peers, and role models, to name a few, influence an individual’s food decisions and beliefs at different levels. Many believe we, as humans, follow an innate sense of nutrition balance, which involves listening to our bodies to eat when we are hungry, and stop when we are full.1 While this system may seem obvious, many people may lose their innate regulation as time passes, based on their environment, culture, and other factors. One influence that may deter and encourage this intuition is social relationships. The following are some select studies that depict social influence on children and adolescents.

 

In 2013, Sparks and Radnitz examined the effects of parental restrictive feeding and child disinhibition (loss of control of eating under conditions that oppose self-control such as emotional distress or the presence of palatable food) on child body mass index (BMI). Their subjects were 229 low-income Latino and African American parents and child (2 to 5 years old) pairs. Parents completed the Children’s Eating Behavior Questionnaire and the Children Feeding Questionnaire, and researchers collected anthropometric data on both parents and children. They found that high parental restriction of food and high child disinhibition predicted higher child BMI (P=0.05), while high parental restriction and low child disinhibition predicted lower BMI values for children (P=0.01). Health practitioners should consider both parent and child eating behaviors, which may interact and produce maladaptive or positive weight outcomes when counseling families.

 

In 2005, Contento, Zybert, and Williams examined mothers’ methods to control their child’s eating. One hundred eighty-seven Latina women completed an Eating Inventory, which measured the mothers’ cognitive dietary restraint (the extent to which they believed they could exercise cognitive control over eating) and their disinhibition. The mothers also reported their food intake and their 5-7 year old child’s food intake with a food frequency questionnaire (FFQ). Mothers’ cognitive restraint was generally associated with more healthful food choices for themselves and their children (p<0.05). Further, mothers’ dietary disinhibition was associated with less healthful choices for themselves and their children (p<0.05). Health practitioners should consider parental cognitive dietary self-restraint as a potential method of improving food choices in children.

 

In 2011, Cardel et al. studied whether parental pressure toward their children to eat and parental restriction of food from their children were associated with their children’s adiposity. They used dual-energy X-ray absorptiometry (DEXA) to measure adiposity in 267 children aged 7-12 years old, and a Child Feeding Questionnaire to measure parental feeding practices with the children’s parents. They found that parental restriction of food significantly predicted child adiposity (p<0.0001). Health practitioners should discourage restriction of food and encourage balance, variety, and moderation to improve child health outcomes.

 

In 2011, Cutler et al. examined socio-environmental factors of dietary patterns in 4,746 adolescents. Dietary intake was assessed using the Youth/Adolescent Food Frequency Questionnaire and socio-environmental characteristics were assessed through a mailed survey specific to this study.  The researchers found that “socioeconomic status, family meal frequency, and home availability of healthful food were positively associated with the vegetable and fruit and starchy food intake and inversely associated with fast food patterns,” a pattern described in the research as containing foods such as “hamburgers, french fries, fried food, and non-diet soda.”(p<0.05).  Maternal, paternal, and peer support for healthful eating were positively associated with the vegetable and fruit intake (p<0.05). Health practitioners should target family meal frequency and parental and peer support for healthful eating behaviors to improve adolescents’ dietary quality.

 

In 2009, Fournier et al. compared weight-related risk behaviors of 3264 high school students based on their homeless status. Homelessness was defined as if the student did not live “at home with their parents,” evident by their answer in the Massachusetts Youth Risk Behavior Survey. The distribution of body mass index was similar among students who were homeless and non-homeless, but homeless students were more likely than non-homeless students to report disordered weight-control behaviors including fasting (OR=2.5, 95% CI 1.4–4.5) and diet pill use (OR=3.3, 95% CI 1.6–6.9). Health practitioners should encourage family support to reduce abnormal weight control behaviors in adolescents.

 

Implications for Health Practitioners:

 

Even though the breadth of studies in this area is limited, the ones completed offer important insights as to where future research can expand, as well as how to effectively implement behavioral interventions. As this body of literature continues to grow, health professionals should become aware of social factors that influence food choices, practices, and beliefs to better serve the populations in need.

 

Deciding how to approach weight issues with children and adolescents deserves careful attention; how the topic is handled can have serious implications. Body image disturbances can begin as early as preschool. Children and adolescences with positive body image may be more comfortable and confident in their ability to succeed, and may not obsess about calories, food, or weight. However, kids with a negative body image may feel more self-conscious, anxious, and isolated, and may be at greater risk for excessive weight gain and for eating disorders.

 

Parents and other adult role models can play important roles in promoting positive body image for children and adolescents. As health practitioners, it is important to discuss these issues when appropriate with parents. Here are some tips to help parents build positive relationships around food with their children:

 

  • Placate the parents. If working with an anxious parent, remind them that the parent does not carry all of the responsibility. According to registered dietitian and child feeding expert Ellyn Satter: “Adults are responsible for the foods and beverages that are served. They are also responsible for where the meal is served and for making meal times pleasant. Children are responsible for deciding whether to eat and how much to eat. As they get older, they can learn age-appropriate table manners and mealtime behaviors.”7
  • Encourage positive role model behaviors. Children learn to eat and develop lifelong, healthful eating habits by watching their parents as role models. Discuss how parents can incorporate a variety of foods into their own diets and onto the dinner table. Parents should openly talk about good tastes and benefits of various foods. In addition, address any issues parents may have about their own body image issues. For instance, if a child hears their parent talk about his/her latest diet, the child may absorb negative messages and attribute them to the child’s own life.
  • Talk about talking. If an overweight or obese child is elementary age or younger, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommends that the parent does not talk to the child about weight. Instead, making family lifestyle changes such as serving regular balanced meals and incorporating more fun physical activity into a habitual schedule is preferred. In addition, make sure all family members are on the same page with regard to healthful eating, as mixed messages about weight can have harmful consequences. Further, bribing, threatening, or punishing children about weight, food, or physical activity is discouraged – setting children up for shame can have disastrous results. If a child overtly or subtly mentions that (s)he is unhappy about his/her weight, encourage the parent to learn where the idea came from – such as from friends, bullies, relatives, or a media reference. The parent should confront the situation as soon as possible and reassure the child to focus on health, not weight.
  • If required, refer. Refer to psychologists and psychiatrists if the situation appears outside of your scope of practice. Can’t decide? The Academy of Nutrition and Dietetics released a new online “Scope of Practice Decision Tool” that encourages dietitians to answer a series of questions to determine if a particular activity is within his/her scope of practice.