Duration: 10/01/2014 to 09/30/2019

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

Need as indicated by stakeholders

While recent data indicate a plateau in the rate of childhood obesity, the number of obese older children and adolescents remains high, with prevalence at 33-34% (Ogden et al., 2012). Obese children are at a high risk for developing serious physical diseases including diabetes (Li et al, 2009; CDC, 2011), bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem (Daniels et al, 2005; Office of Surgeon General, 2010; Dietz, 2004). Children and adolescents who are obese are more likely than their normal weight counterparts to be obese adults (Freedman et al, 2009; Guo et al, 1999) leading to increased risk for chronic diseases in adulthood. The direct annual medical costs associated with childhood obesity were estimated at $14.3 billion (Trasande and Chatterjee, 2009). In addition to direct and indirect costs, obesity is associated with lower educational achievement (Hammond & Levine, 2010).

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 early adolescents (10-13 years) is influenced by various personal, behavioral and environmental factors (Larson et al. 2013) with parents/caregivers playing a prominent role in food decision-making. Food choices are made by early adolescents during eating occasions with parental supervision and during independent occasions when parents/caregivers are not present. Early adolescents may have independent eating occasions at home, in school or other environments away from home including friends’ homes, restaurants or convenience stores.

The Department of Labor Statistics Time Use Studies (USDL Bureau of Labor, 2012) reported that trends in consumption behavior in the U.S. are undergoing an interesting shift. Over the past 30 years, the frequency of family meals has decreased by 33%. The frequency of primary eating (focused eating/drinking without engaging in another activity, more typical of meal eating) is also decreasing while frequency of secondary eating and drinking (eating/drinking while engaging in another activity) is increasing. Snacking or non-meal eating makes up 27% of caloric intake for 7-12 year olds, exceeding 500 kcals/day (Piernas & Popkin, 2010). Snacks are made up largely of salty snacks and sweets and sweetened beverages (Sebastian et al., 2010). Secondary eating/drinking and non-meal eating are more likely to be independent eating occasions. However, there is no published evidence investigating the occurrence or food choices for independent eating among adolescents. While meal frequency was associated with increased total energy intake and eating beyond 3 times/day was associated with higher BMI in adults (Howarth et al, 2007), this relationship has not been well-established among children or adolescents. A review of the literature by Larson and Story (2013) found an association between frequency of snacking and higher energy intake and energy from sugars but not with BMI among adolescents. The relationships between meal frequency, snacking, energy intake and BMI are unclear in adolescents (Ritchie, 2012; Howarth et al, 2007). Having more information about their eating frequency patterns, choices and intake might shed light on this question.

Parental practices influence early adolescent’s eating behaviors and therefore play an essential role in preventing obesity. Our preliminary work on calcium-rich food and beverages (CRF/B) showed that specific parental practices were associated with calcium intake including expectations about CRB choices, making CRF/B available and role modeling CRF/B consumption. Similar associations have been observed between parental practices and intake of other healthful foods by children and adolescents including fruits and vegetables (Hingle et al. 2012; Rasmussen et al. 2006). However, little is known about how various parental practices influence intake when parents are with the child and are supervising the eating occasion versus those occasions when they are not with the child and are not supervising the eating occasion. Since children at this age will have eating occasions that occur at home and away, at school and with friends, there will be times when they are making independently-determined food choices. We will operationally define this unsupervised eating as: independent eating occasions. Early adolescent eating behaviors need to be examined during independent eating occasions to determine if the influence of parental practices endures in the absence of parental oversight. A better understanding of the extent to which parental practices influence food choice and eating behaviors of early adolescents in general as well as at independent eating occasions is necessary to inform the development of interventions to promote positive parental practices that may assist in weight management.

Importance of the work and consequences if the proposed work is not done

It is necessary to further explore the impact of parental practices and its effects on early adolescent eating behaviors during independent eating occasions. In the first phase (Objective I), formative qualitative research methods will be used to explore the behaviors around independent eating occasions among adolescents, including the extent to which they report how parents’ rules, expectations, modeling and availability of foods influences their choices and behaviors. Among parents, we will seek to identify the extent to which they are aware of the food choices and behaviors that their children make while they are eating independently. This data collection aims to understand the phenomena of eating related parental practices; how parents are motivated or impeded in practicing them, how they are successfully implemented, and if children’s eating is impacted positively when parents utilize various positive practices.

In Objective II, quantitative methods will be employed to identify associations between parental practices and food and beverage choices, eating behaviors, and weight among early adolescents with attention to examining independent eating occasions. An appropriate, validated instrument does not currently exist to measure these associations, therefore we need to develop and test a questionnaire to determine which parental practices should be promoted.

Results from Objectives I and II of our study will provide a broader understanding of the influences that determine the frequency of positive parental practices and the effects of these practices on obesogenic behaviors of early adolescents. These findings will allow us to identify realistic strategies and motivators in order for parents to promote positive practices. Ultimately, sharing how best to influence early adolescents’ eating behaviors and particularly those when the parent is absent would be valuable in trying to shape healthful food intake among early adolescents to prevent obesity.

The technical feasibility of the work

The project has significant potential to develop and implement an evidenced-based investigation to better understand the behavior of both parents and their early adolescents. Behaviors occur when there is perceived benefit to practicing the behavior. In the case of this research effort, we have to determine if parental practices translate into improved intakes of early adolescents; how early adolescents may respond to those practices when making independent decisions about eating, and identify strategies that convince parents that the practices provide some immediate value or benefits. Parents may be challenged by failing to perceive as beneficial practices that have more long-term than immediate rewards. They may need to be convinced that the costs of behavior change are low (parents might find that the time and effort to exercise the desired practices are too challenging or difficult). They may also need to recognize that practices are supported or obstructed by others (spouses, siblings, friends, teachers, coaches, etc. as well as the child, who may create barriers that need to be considered). The initial formative analysis will enhance the likelihood for success and improve our ability to identify the most effective ways to motivate parents to engage in practices that ultimately result in adolescent healthy eating behaviors at both supervised and unsupervised eating occasions.

An endeavor of this kind requires a high level of expertise and experience. The research team members for this project have collaborated successfully together on two or more Agricultural Experiment Station (AES) funded multistate projects, building some of the justification for this research effort. The diversity of expertise and experience is very functional for this team, and their history of organizing a collaborative project in which all researchers are involved has been successful. Our multistate team has completed previous studies and published results based on interview, focus group, nominal group process and other qualitative approaches (Edlefsen et al. 2008; Cluskey et al 2008; Richards et al, in press). We have also published results of studies based on quantitative approaches (Reicks et al. 2011; Reicks et al. 2012; Cluskey et al, in press) that have involved large samples of parents and early adolescent dyads. Finally, since submitting the original version of this proposal, Dr. Glade Topham, a marriage and family therapist and professor of Human Development and Family Sciences at Oklahoma State University, has shared with us his interest in joining our team. His insights will provide the necessary perspective of a social scientist.

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 participants in seven states, with ten researchers who have positions as faculty, most with research experience in community nutrition and/or eating behavior. Several have appointments within Extension allowing good opportunities for access to a potential population of subjects. These researchers represent a cross-section of geographic areas within the United States with opportunities for reaching diverse ethnic groups from which the project can explore, focus and tailor behavior change strategies. Finally, this group has 10+ years of experience conducting a collaborative investigation allowing for a large number of subjects to be reached. They understand what it takes to assure that all researchers follow an identical protocol and have been successful with this approach in both W-1003 and W-2003.

Likely impacts from successfully completing the work

While we know from our work on W-1003 that there is an association between some parental practices (rules/expectations, availability) and calcium intake among early adolescents (Reicks et al, 2012), we have not studied how parental practices impact early adolescent eating behavior in supervised and independent eating occasions and effects on weight status. In W-2003, parents provided some insights into their motivations for parental practices, but we did not explore the child’s perspective about how they respond to the parental practices. From both W-1003 and W-2003 we have a good understanding of calcium-related parenting practices. In the proposed project we plan to explore how similar practices might impact obesogenic energy-dense and low-nutrient dense food choices and unhealthy eating behaviors of early adolescents during independent eating occasions. Identifying associations between positive parental practices and obesogenic behaviors will provide a rationale for education and communications that encourage the use of those parental practices. Ultimately all efforts to better understand and promote adolescent healthy eating behaviors are important in the prevention of obesity.

The group’s history with this audience and the intent to carry on this project utilizing outcomes from the previous projects will substantially fill the research gap about how to encourage parental practices that result in children choosing healthy foods during independent eating occasions. If the proposed work in W-3003 is not done, we may miss the ability to provide parents of early adolescent children strategies that lead to healthier eating among their children. We will also risk facing more adverse consequences with respect to health, psychosocial, and economical issues for early adolescents in the near future.

Related, Current and Previous Work

There is limited evidence about how adolescents eat when they are making food choices without the direct influence of their parents, who are primary influencers of their choices and consumption behavior as children (Savage et al., 2007). US children and adults are consuming food more frequently throughout the day and more at each occasion (Popkin and Duffey, 2010); a rise that parallels the rise in obesity and increases in portion sizes (Piernas and Popkin, 2011). That consumption is occurring as primary eating or meal occasions but increasingly as secondary eating which may nor may not be mealtime eating. Additionally, while evidence shows that most families (58%) consume about 5 or more meals/week together, (National Center on Addiction and Substance Abuse (CASA), 2011), others report the percentage consuming shared family meals decreases among lower SES groups (Neumark-Sztainer et al., 2013). The 1994-96 CFSII data reveal a mean of 4.5 daily eating occasions/day (Ritchie, 2012). Adolescents (10-13 y.o.) who are at the age of becoming more independent are likely making food choice decisions on their own at some of those other daily eating occasions.

The NHANES data also shows a shift in meal patterning with a reported prevalence of snacking at 98% among 2-18 year olds (Ritchie, 2012). Challenged by a lack of standard definition for ‘eating occasion’, ‘meal’ or ‘snack’, studies have not consistently been able to tie increased snacking to obesity (Ritchie, 2012; Howarth et al., 2007). However, frequency of eating and snacking are both increasing and what and how much food adolescents choose and consume when they are outside of their parental influence is not known. How parents may have shaped those eating decisions with their previous behaviors, like healthy food consumption modeling, rules or habits and availability is not known.

Parental influence on food intake has been well established. Child food preferences are established at an early age and have both a biological and environmental basis for which parents plays a significant role (Birch, 1999). Caregivers are powerful socialization agents as they select the food, serve as models of intake and use practices that encourage the development of eating patterns and behaviors (Savage et al, 2007).

Modeling establishes exposure and familiarity to foods and shapes intake. Children are more likely to sample an unfamiliar food after seeing an adult do so (Savage et al., 2007), and more likely if it is their mother rather than a stranger. Modeling can be both positive and negative and its impact depends upon the relationship with the role model and observer and the emotional response of the observer (Gibson et al., 2012). Not only is presence of the parent important but the parent’s behavior when eating the foods as well (Klesges, 1991).

Modeling of food is bi-directional; dietary behaviors are influenced by one another (children influence their parents and parents influence their children) (Coesens, 2010). The extent of influence of parents on their children’s behavior is not clear. Klesges (1991) found that both the threat of parental monitoring and actual parental presence decreases children’s intake of non-nutritious foods. While mothers are often strong role models, fathers (Coesens, 2010), teachers (Perrikou, 2013), siblings and peers (Contento, 2006; Palfreyen et al., 2012; Noorgard et al., 2013) may also be influential. Gregory et al. (2010) found parental role modeling of healthy food was associated with less food fussiness in children and food interest among pre-schoolers. Rozin reported that among Mexican families, older family members were more influential (Rozin, 1990). Noorgard et al (2013) found adolescents (10-16 y.o.) choose and consume snacks that are consistent with their self-image and socialization with peers. Younger adolescent’s food choices were more influenced by peers (Selvy et al, 2011).

Much of the modeling research work is based on survey research and is ambiguous. It has not focused on distinguishing between intentional, unintentional and verbal modeling and has not measured the use and effectiveness of various modeling strategies (Palfreyman, et al, 2012). The effects of modeling are difficult to separate from effects of availability and food exposure (Gibson et al., 2012). Parents have to be motivated to be role models and a key issue in establishing parental practices is getting parents to adopt such practices (Beltran et al, 2011).

Parents have food restrictions (can’t have) and obligations (should take or eat) that dictate their food rules or expectations for food choices for their children (deBourdeaudhuij, 1997). One study found that children selected foods differently when they knew they were being watched by their parents (Klesge, 1991). Brown and Ogden (2004) suggest that rules that are modeled by parents may be more influential than trying to enforce rules. Contento et al. (2006) suggest that rules may be of more value at home, as it is more difficult to control food away from home.

Food choice decision making within the family is very complex (Contento et al., 2006). Interviews with 108 adolescents (11-18 years) show that food choice decisions were driven primarily by taste and familiarity (Contento et al., 2006). Rules were drivers for choosing vegetables (17%) and milk (12%). Children reported that they had a sense of having high control over their food choices, with the least choice for the dinner meal when they ate with their family (Contento, 2006). Adolescents reported frequencies of different strategies for managing choices: choices were similar among family members because of a family history of eating together (33%); members negotiated choices (e.g., taking turns choosing dinner menu items; 33%); members chose independently (I make and eat what I want; 20%); or an authoritarian parent imposed what was consumed (10%).

Most daily eating behaviors consist of habits, and habitual behaviors are fundamentally different from non-habitual behaviors. Eating behavior is considered habitual as it occurs primarily in the same time and place from day to day (VaRiet, 2011). Situational or environmental cues, but also social cues (presence of others) and psychological cues (mood) also trigger behavior. College students ate more popcorn in the cinema context than in the meeting room context (VaRiet, 2011). Habit is a strong predictor of snack, fruit and vegetable, soft drink, meat, fish, and chip consumption (VaRiet, 2011).

Based on previous work completed by this multi-state group, we believe that parental practices or behaviors that include role modeling of healthy food choices, establishing healthy eating habits or expectations about their child’s choices and making healthy choices available need to be better understood. Our previous work has demonstrated that higher calcium-rich food intake is associated with these eating-related parental practices (Reicks et al, 2012). This project proposal is strengthened by the history of this group in using similar methodology when establishing a Motivator-Barrier Questionnaire to test the association between calcium intake and various motivators and barriers (including parental practices) to calcium intake. Qualitative methodology has been used by this group previously, after which an instrument was developed to collect data among parent adolescent pairs investigating the relationship between motivators and barriers to calcium rich food consumption and calcium intake in early adolescents (Reicks et al, 2011). This proposed project has similarities in method and conceptual model.

A CRIS search using “parent” and “early adolescent” as keywords resulted in two studies that involved parental practices on early adolescent’s eating behaviors. The closest match was a study led by one of our current AES team members, Banna JL (PROJ NO: HAW02026-H, 2013-2017). The study aimed to identify cultural attitudes and beliefs on weight and body image, diet and physical activity in early adolescents (ages 9-13) in Hawaii and their parents; and examine the associations between early adolescents' and parents' cultural attitudes and beliefs on weight and body image, diet and physical activity and early adolescents' dietary intake or Body Mass Index. The other study was led 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. Our proposed study has a more specific scope, i.e., to target parents of early adolescent children ages 10-13, and identify parental practices that positively influence early adolescent children’s eating behaviors during independent eating occasions.

The work exploring parental practices and their impact on children’s intakes, weight and eating behaviors is not well established. In particular, a focus on what occurs in those occasions when the child is making independent choices and not in the presence of the parent needs more clarity. What strategies do parents use to model healthy food intake? How can the behavior of modeling or creating rules and expectations be measured and how do those behaviors impact children’s food intake? How often do early adolescents make independent food choices and are there parental expectations for choices that they make? How compliant are they with their parental rules? How do role modeling, food choice rules or expectations and food availability translate into food choices when a child is on their own or with peers or siblings at an eating occasion? How can parents be more motivated and overcome the barriers they perceive to practicing positive eating related parental behaviors? Having a greater understanding of this phenomenon fosters the ability to communicate and promote effective practices and strategies to parents for managing healthy eating among their youth.

The behavior of eating is influenced by our changing lifestyles as well as the varied contexts in which we eat, the people with whom we interact and other environmental factors. Clearly examining all of the circumstances surrounding a behavior, including perceived and real costs, barriers and benefits will allow for interventions to best change targeted behaviors. Exploring the child’s perception about how their parental behavior influences them gives a perspective that can be used to motivate and educate parents to practice these behaviors. With a broader understanding of the behavior, we can attempt to provide products (programs, knowledge, and/or messages) that may serve as realistic parental practice strategies and motivators.

Objectives

1. Explore and identify key parental practices (role modeling, making healthy foods available, and setting rules/expectations and other practices) that may impact eating behaviors and food choices during independent eating occasions and weight among low-income, multi-ethnic early adolescents.
   
2. Examine the association between key parental practices and positive eating behaviors during independent eating occasions among low-income, multi-ethnic early adolescents
   
3. Examine the association between key parental practices and early adolescents’ weight.
   
4. Develop communications for parents and nutrition professionals
   

Methods

Target audience: We will recruit a convenience sample of parents and their early adolescent children (10-13 years) through fliers, announcements, personal contacts and presentations through children’s sports teams, Boys and Girls Club, and other community-based locations and programs (e.g., 4-H, churches, Girl/Boy Scouts, etc.). Parents will have primary responsibility for food acquisition and preparation for early adolescents. As in W-1003 and W-2003, we will recruit a multiethnic group of children and parents with the intention of recruiting approximately equal numbers of Asian, Hispanic, non-Hispanic White and non-Hispanic Black children and parents. Sampling techniques will be employed to provide ethnic and socioeconomic representation within a targeted assigned number of survey pairs per state. This can be easily accomplished because researchers in different states work with a variety of families from different backgrounds based on geographic locations. Objective I: Formative Evaluation: Interview early adolescent children and their parents All states will participate in data collection for Objective I which will be led by the Oregon and Utah. Approximately 40-50 parents and their early adolescent children will be recruited to participate in the formative interview portion of the study. Parents and children will be interviewed separately by two interviewers at the same time and in the same location. This will be convenient for participants and will allow us to capture conversation among both regarding the child’s previous day’s eating occasions. Parents will provide insights into their parental behaviors and the respective perceived responses to that behavior by their early adolescent children. We are interested in interviewing parents who are successful as well as striving to be successful at using parental strategies to encourage healthy eating with their adolescent children. We will assess the level of success using three to five questions in a method similar to that used by Kapsak et al (2013). We believe that parents who are successful may provide strategies that can be shared with other parents and nutrition educators. Those that are striving to be successful in promoting healthy eating among their adolescent children will provide understanding about barriers that need to be understood and addressed in order to motivate or find solutions for those parents. The content of the formative session will include using an interview protocol, in which parents and children will be asked about their food intake and eating behavior using a qualitative 24-hour recall method. This recall will be include food choices for all eating occasions during the past day using a modified multiple pass approach to the 24-hour recall (Guenther, Kott, & Carriquiry, 1997). A 24-hour recall grid will be developed, in a columnar format where we record responses to questions about each eating occasion. We will interview both children and parents about the child’s consumption for the previous day and the context around the eating occasion and food choices. Children interviews: For each eating occasion in all contexts (home, school, with friends, etc), participants will be asked about the context and information about each eating occasion over the 24 h. period, including who was present, the location, time of day and day of the week, other activities engaged in while eating, who prepared the food or where it was acquired, and the duration of the occasion. For each item(s) consumed, questions will be asked to describe the item, motivation for consuming, relationship between the consumption of the item and health/weight, the availability of foods/beverages to choose from while in the home, reflection on parental thoughts and rules about the choice and quantity allowed and if it was restricted or encouraged, and if a parent or other co-eaters would make the same choice. The qualitative 24-hour recall methodology used in the proposed study will be adapted from a similar approach used by Sobal et al. (2012) and the Day in the Life Questionnaire (DILQ; Edmunds and Ziebland, 2002; Wallen, 2008). To enhance early adolescents’ ability to recall foods and drinks consumed on the previous day, the DILQ will be used as a framework, which will allow the interviewer to guide the interviewee through the previous day, using child-friendly graphics to ask questions such as “Did you have something to eat or drink for breakfast?” At the end of the interview, they will review the day and details about each eating occasion, and finally verify the interviewer's summary of eating for the day. Reviewing the previous day multiple times may enhance the recall of events and information that may be forgotten or omitted in one quick summary. Parent interview: Parents will also be asked about their child’s past 24 hour intake and the extent to which parents strive to establish behavioral practices (availability, role modeling, rules/expectations), particularly in reference to the child’s eating occasions. Parents will also be asked about the home food environment, with attention to the liberties or restrictions and availability of foods, both healthy and less-healthy; parental food acquisition behaviors relative to food purchases and the influence of the child upon those purchases. Questions and probes will be based on behavioral checklists in the literature including the 15-item Parental Modeling of Eating Behavior Scale (Palfreyman, et al, 2012) which may help identify the use of verbal monitoring; unintentional modeling; and consequences of parental behaviors. The parental formative session will include: A 24 hour recall of their child’s intake will be collected from parents, looking for similar or matching responses from parents about the child’s food choices and behaviors with respect to: the location and whether the occasion was supervised, what the parent thought their child would choose and why, availability of foods/beverages, and whether the parent would make the same food choices if present. Questions about the use and benefits and barriers to practicing parental behaviors to influence their child’s eating behavior will also be included: duration of using various practices, perceptions of their impact, how eating away from home impacts choices, and rules/encouragement used for independent occasions. We will explore the extent to which the parent tries to be aware of their child’s food choices and eating behavior during independent eating occasions. Questions will also be asked to gather input from parents about specific strategies used to role model, to establish routines or expectations and to provide healthy choices. The formative evaluation will be analyzed using a thematic analysis approach (Braun and Clarke, 2006), which is a qualitative analysis method that includes transcription of the recorded interview, researchers independently reviewing qualitative data with subsequent discussion and reconciliation of differences in coding, sorting of segments of transcripts using a computerized software (such as QSR Internationa NVivo, London), and summarizing the data into key themes. Objective II: Quantitative Data Collection: Examine the association between key parental practices and positive eating behaviors during independent eating occasions among low-income, multi-ethnic early adolescence using quantitative methods. Objective III. Quantitative Analysis: Examine the association between key parental practices and early adolescents’ weight. The proposed research to accomplish Objectives II and III will build on previous research conducted in W-1003 and W-2003 and in the first phase of the current project and will utilize quantitative methodologies. The calcium motivator-barrier questionnaire (MBQ-P) for parents (Reicks et al. 2011) that was developed and validated in the previous W-1003 project will be used as a model. The MBQ-P consists of items that were combined into several scales to assess the frequency of parent practices associated with child calcium intake based on our previous qualitative research (Cluskey et al. 2008; Edlefsen et al. 2008). Calcium intake was assessed with a calcium-specific food frequency questionnaire (FFQ). In this proposed project, a parent practice questionnaire will be developed based on findings from Objective I. We will validate the questionnaire with parents to assess the frequency of parent practices and their association with eating behaviors and food intake of early adolescents during independent eating occasions and with their weight. For Objectives II and III, All states will participate in the collection of a total of 400 parents/child pairs, and led by the states of Minnesota and Hawaii. Parents will complete a parent practice survey (100 for each race/ethnic group – Asian, Hispanic, non-Hispanic White and non-Hispanic Black children); and their adolescent child will complete a food frequency questionnaire to estimate the quality of the child’s diet. The probability is 90 percent that the study will detect a relationship between the independent and the dependent variables at a two-sided 0.05 significance level, if the true change in soft drink consumption (dependent variable) is 0.163 cans soft drink/day by early adolescents per unit change in the parenting practice of making healthy beverages available in the home (independent variable). This is based on our unpublished data that justifies the assumption that the standard deviation of the independent variable is 0.5 and the standard deviation of the dependent variable is 0.5 based on our previous studies with calcium-rich foods. In W-1003, 660 parent/child pairs completed questionnaires in person providing enough statistical power to determine associations between calcium intake of children and parent practices. We will recruit a convenience sample of parents and their early adolescent children (10-13 years) through fliers, announcements, personal contacts and presentations through children’s sports teams, Boys and Girls Club, and other community-based locations and programs that specifically target low-income parents (e.g., 4-H, churches, Girl/Boy Scouts, Supplemental Nutrition Assistance Program Education, Expanded Nutrition and Education Program, food pantries, etc.). Development and testing: Based on analyses of data from the parent and child interviews, a parent practice questionnaire will be developed and tested to identify parent practices that may be related to intake of less healthful foods by early adolescents during independent eating occasions. The parent practice questionnaire will be field-tested for reliability with a small sample of 100 parents completing the questionnaire online via a Qualtrics survey platform twice one week apart. A principal components analysis will be done to identify predetermined common scales. We believe that scales will be developed based on factors that have been shown to influence intake of calcium-rich foods (Reicks et al, 2012) and fruits and vegetables (Rasmussen et al. 2009) by early adolescents, including making foods available and accessible, role modeling intake, and setting expectations. If other practices are identified in the formative phase of this study, scales will also be developed for these practices. Internal consistency of scales will be tested using Cronbach alpha correlation analysis. Validation: Early adolescent children of parents who complete the parent practice questionnaire will complete the Block Kids Food Screener (BKFS). Validity of the parent practice questionnaire will be determined by examining associations between scale scores and food intake by children from the BKFS. The BKFS is a 41-item, two-page FFQ developed by NutritionQuest (Berkeley, CA, USA) which has been tested against 24-hour recall data in children and found to have good agreement for foods groups and nutrients (Hunsberger et al. 2012). The questionnaire will be self-administered to 10-13 year-old children in an electronic format. 1) Food intake: BKFS asks the subject to reflect on the frequency and quantity of foods and beverages consumed during the previous week. The frequency of consumption ranges from ‘none’ to ‘every day’. Quantities consumed are assessed with three to four categories related to food type. For example, the BKFS asks subjects to report cold cereal quantity as the number of bowls consumed per day. Subjects also provide information on the type of cereal typically eaten and the type of milk typically consumed. The BKFS is used to estimate the intake of fruit, vegetables, dairy, whole grains, protein sources (meat, poultry and fish in ounce equivalents), saturated fat and sources of added sugars. 2) Frequency of independent eating occasions Children will be asked to report on the typical number of independent eating occasions they experience on a daily and weekly basis. 3) Eating-related behaviors made during independent eating occasions Children will be asked to report frequency and choices for snacks or non-meal eating, adherence to parental rules and expectations, asking parents to stock healthy foods in house and school or lunch meal choices, etc.). Data collection: An initial in-person meeting will be conducted with the parent and child to 1) explain the study procedures, 2) obtain informed consent and assent, 3) weigh and measure the child, and 4) to provide instructions about how to complete the electronic parent practice questionnaire and Block Kids Food Screener online at home or in a community location such as a local library. Researchers collecting height and weight data from children will be trained in anthropometric data collection according to standard procedures (CDC, 2004; Lohman et al. 1988). Height will be measured barefoot using a stadiometer (Seca 202, Hanover, MD) to the nearest 0.1 cm. Weight will be measured barefoot and in light clothing on a digital scale to the nearest 0.1 kg (Tanita BWB-800P, Arlington Heights, IL). Measurements will be done twice and a mean calculated for analysis. Children’s BMI z-score and BMI percentile for sex and age will be calculated using CDC growth curves (CDC, 2011). The parent practice questionnaire will be completed by parents in an electronic format via a Qualtrics survey platform (maintained at one University). The BKFS will also be completed by children in an electronic format via use of an online integrated system for data collection and food group/nutrient analysis maintained by NutritionQuest, Berkeley, CA. Data analyses: NutritionQuest will analyze intake data from children and provide raw data and mean intakes of food groups and nutrients to researchers for a fee. Multiple regression analysis will be used to predict the child's food intake and BMI z-score and BMI percentile for sex and age from relevant parent practice scales identified using the parent practice questionnaire. The food and nutrient intakes of interest include fruit and vegetable intake, whole grain foods, saturated fat and added sugars. Univariate analysis of individual scales will be used to identify the most salient factors as being positively associated with the child's intake or negatively associated with the child's intake in separate models. For example, a scale of 'parents' expectations' may positively influence a child's intake of sweets; whereas an environmental factor, such as having soft drinks in the home may negatively influence a child's intake of sweets. Frequency of independent eating occasions and responses to questions regarding adherence to parental rules, etc. will also be tested for associations with child’s food intake, BMI z-score and BMI percentile for sex and age. Gender and ethnicity will be co-variates in each model. The Social Cognitive Theory would predict that parent practices would make a significant contribution to the food/nutrient intake and eating behavior of children. The models will be repeated with frequency of intake of selected foods and nutrients as the dependent variable. A Objective IV: Dissemination: Develop communications and share with Extension and other mediums for communication All states will contribute to Objective IV, and lead by the states of Oregon, Arizona and Ohio. The strategies and benefits identified through this project can be incorporated into programs that teach parenting skills and behaviors for all ages of children and can be used in messaging and programs supported by Extension and other governmental agencies and for health care and public health professionals. We will establish best practices and disseminate findings through multiple avenues, including, eXtension – specifically, the Families, Food, and Fitness Community of Practice, (FFF CoP) for utilization by students, researchers, clinicians, professors, and the general public. To this end, after the initial development phase, we will provide online access to the X intervention curriculum, including the parent fact sheets and newsletters. We will also provide webinar training for Extension staff and other youth and family practitioners to become equipped in delivering the X curriculum. In addition, we will disseminate findings from the X study via webcasts, podcasts, and other social media outlets linked to eXtension. Next, we will assist with editorial management of new knowledge content in the areas of nutrition and physical activity for children (grades K-8) on the FFF coP website. Finally, we will develop childhood obesity prevention articles on a quarterly basis that 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 driven to the articles via social media (Facebook, Twitter, Pinterest). All of the above activities will be coordinated by existing OSU Extension IT staff with input from an Extension staff member with specific expertise in applying social media to Extension system. 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 X and through national 4-H conferences, events, and publications (e.g., Journal of Youth Development). Finally, research findings from this project will be disseminated in presentations at local, state, and national professional meetings and also manuscripts in peer-reviewed journals (e.g., Journal of Nutrition Education and Behavior, Journal of Extension).

Measurement of Progress and Results

Outputs

• Data from the interviews will provide information about the barriers, rewards and costs parents perceive in practicing or not practicing parental behaviors to influence healthy eating and weights in their children
• Data from the interviews will also provide information about how children perceive and comply with parental practices regarding eating behaviors and food choices during independent eating occasions
• A method to quantify parental practices of role modeling, creating rules and expectations and availability of healthy foods in the home with respect to creating healthful eating behaviors during independent eating occasions among early adolescent children
• The best parental practices and strategies that are most conducive to healthy food intake and eating behavior during independent eating occasions among early adolescent children and thus, healthy weights in children.

Outcomes or Projected Impacts

• Food and beverage choices made by children at all eating occasions are of concern for healthy eating and for the prevention of obesity in youth. How parental practices translate into children’s choices is an unknown area of investigation and more research is needed. These parental practices will result in an overall improvement in intakes of calcium rich foods/beverages, whole grain foods, fruits and vegetables and decreased consumption of high fat and sugar foods, and energy-dense foods/beverages among children. The nutrient density of non-meal eating occasions will also be improved among children. Parent outcomes will include an increased frequency of supportive parental behaviors (such as setting expectations and making healthful foods available).
• The short-term impact of this project includes the application strategies for multiethnic parents/caregivers to influence their early adolescent children to maintain healthy weights and establish and/or maintain healthy eating behaviors both during supervised and independent eating occasions. Medium-term impact includes increasing/continuing practices that encourage healthy food choices. Long-term impact includes prevention of unhealthy weight gain among early adolescents through maintenance of healthy eating behaviors, supported by positive parental practices. The significance of the project includes the direct cost savings in obesity-related health care costs associated with childhood obesity and the indirect costs associated with loss of school time, poor health and parental work loss with unhealthy children. There is social cost in our failure as a society to teach our children to value healthy eating and lifestyles. Our culture and social environment support and perpetuate behaviors. There is social value in teaching children to make healthy food and eating behaviors and determining how parents can best promote these behaviors will be impactful to society.

Milestones

(2014): Develop screening tool to assess parents as successfully practicing parental behaviors or not; develop methods for qualitative interviews including method for 24 hour recall and questions for children and parents, conduct interviews

(2015): Analyze qualitative data; develop questionnaire based on qualitative results; determine final recruitment needs for quantitative data; assign targets for survey recruitment

(2016): Establish method for pilot testing; implement testing of an electronic pilot test questionnaire format; evaluate pilot test results; recruit parent/child pairs for survey completions

(2017): Analyze survey data; evaluate results; determine parental practices exhibiting most impact on children’s weight, intakes and behaviors

(2018): Plan and develop future intervention components to share with others in cooperation with state partners

(2019): Develop manuscripts and grant proposal development.

Projected Participation

View Appendix E: Participation

Outreach Plan

Direct teaching: Parental strategies to influence independent healthy food choices among their early adolescent children can be integrated into SNAP-Ed and EFNEP lessons, 4-H summer camps, and/or Extension workshops/seminars.

Indirect teaching: We will make the output (such as the new questionnaires) and results of the project available to peers through refereed publications in nutrition and health journals and professional presentations at annual meetings of nutrition, health and education societies.

Organization/Governance

The multi-state group has a history of using a collaborative approach in implementing their research projects. Each participant will be involved 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 for conducting interviews, and developing and testing questionnaires. Specific team members will take the lead in directing activities under each project objective, as it relates to their professional area of expertise. Mary Cluskey and Rickelle Richards will be the team leaders for objective #1; Marla Reicks and Jinan Banna for objectives #2 and #3; and Siew Sun Wong and Carolyn Gunther for objective #4. Other team members will volunteer to assist the team leaders on carrying out these objectives, as related to their area of expertise. Data will be collected in individual states and aggregated for analysis by a subgroup of researchers. Findings will be shared with the entire project team. Research team subgroups will develop several manuscripts, reports and presentations.

Efforts will be made to increase participation of researchers from other states. The group has successfully recruited a social scientist, Glade Topham to join the project. Dr. Topham is an Associate Professor in Human Development and Family Studies at Oklahoma State University, and his expertise in children and families will be a valuable contribution to the project. In addition, we will continue to recruit participants to join the project so that we include a broader national reach.

An executive committee will be formed annually by group consensus methods with, a chair, chair-elect, and secretary. The chair will serve for at least a two-year term and will manage meetings, submit reports and plan the agenda for the annual meeting. The chair-elect will succeed the chair and support the chair in performing his/her duties and serve for at least a two-year term. The secretary will distribute documents prior to meetings, provide minutes describing the discussion and actions suggested during the meetings, maintain an updated members rosters, and help the chair/chair-elect prepare the accomplishments report. The secretary will succeed the chair-elect.

Several members of the research team have Cooperative Extension appointments. The nature of their involvement includes nutrition education activities such as collecting and analyzing interviews (needs assessment) and developing and testing questionnaires for program development, implementation and evaluation with community audiences. This work is well aligned with research and scholarship expectations for Cooperative Extension involvement and general responsibilities.

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Attachments

Land Grant Participating States/Institutions

AZ, DC, GA, HI, IA, KS, MN, MT, OR, WY

Non Land Grant Participating States/Institutions

Brigham Young University, Ohio State University, The George Washington University, University of Connecticut