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9 Lessons I've Learned About Feeding Kids
Author: Jill Castle
Date: Jan. 23, 2018
From: USNews.com
Publisher: U.S. News and World Report, L.P.
Document Type: Article
Length: 1,260 words
Content Level: (Level 5)
Lexile Measure: 1340L
Full Text:
A successful, balanced approach involves more than just making healthy food choices.
By Jill Castle
When I had my first child, I thought I knew everything there was to know about (https://health.usnews.com/health-news/blogs/eatrun/articles/2016-09-01/5-mistakes-parents-make-when-feeding-their-kids) feeding kids. I was a pediatric dietitian, had years of
experience working in top-notch hospitals, and was confident in my knowledge. However, it turned out, I had a lot to learn.
With a slow-growing, selective eater as my first child, I found that feeding a child was challenging, and it required me to get creative.
My background in pediatric nutrition was immensely helpful in nourishing my four kids, but the flexible approach I developed as a
mom and a childhood nutritionist has been invaluable to my work with families.
My career has taught me that every child is a different eater, healthy food doesn't guarantee a healthy child, and nutrition guidance
must be flexible for families to succeed in raising healthy children.
Here are nine lessons about feeding kids that I've learned over the years:
Simple menus get the job done.
Parents can cook up gourmet meals and have the "healthiest" food available at home, but some kids just won't eat. When kids come
to the table and balk at a meal, it may mean that foods are too foreign or challenging for them. The solution: Simplify. While it's
important to (https://health.usnews.com/health-news/blogs/eat-run/2015/10/26/what-sensory-therapists-can-teach-us-about-feedingpicky-kids) gently challenge children with a variety of new foods, be sure to include familiar, liked foods at the table so kids feel
confident and comfortable with the meal. The path to palatable food for kids is keeping the menu simple and familiar.
[Read: (https://health.usnews.com/wellness/for-parents/articles/2017-02-16/is-your-approach-to-feeding-your-kids-all-wrong)
Is Your Approach to Feeding Your Kids All Wrong?]
Food balance wins.
Getting kids to eat a balanced diet, one that showcases (https://health.usnews.com/health-news/blogs/eat-run/articles/2017-05-23/9plant-based-proteins-you-should-be-eating) proteins, vegetables, fruit, (https://health.usnews.com/health-news/blogs/eatrun/articles/2017-04-05/which-whole-grain-is-healthiest) whole grains, healthy fats, dairy (or non-dairy substitutes), and some
indulgent foods such as sweets and treats is the ultimate goal. Not only does a balanced, wholesome diet do a good job of covering
the nutritional requirements for children and promoting their growth, it encourages their fullness and satisfaction after eating, which
can (https://health.usnews.com/wellness/for-parents/articles/2017-07-05/why-do-kids-eat-when-theyre-not-hungry) reduce excess
eating.
All foods can fit.
According to the Centers for Disease Control and Prevention, about 16 percent of children's and teens' total caloric intake comes
from added sugars. (Note that these are not naturally occurring sugars, such as those found in fruit and milk; rather they are from
sugar added to foods.)
I believe there is room for sweets, treats and other indulgent foods in a child's diet. However, one must strike a healthy balance
between wholesome, nutritious foods and indulgent foods. I teach the 90/10 rule, where 90 percent of foods eaten in a day are
wholesome and nutritious and 10 percent are indulgent, such as sweets or fried foods. This balance allows kids to enjoy tasty,
indulgent foods, but places the emphasis on healthy fare in their diet.
Don't let worry keep you from taking a balanced approach.
Parents worry about their children's eating, health and weight. Some are afraid their children's eating habits will cause
(https://health.usnews.com/health-care/for-better/articles/2017-08-17/childhood-obesity-not-just-your-childs-problem) unhealthy
weight gain, (https://health.usnews.com/health-news/patient-advice/articles/2016-01-26/what-to-do-if-your-childs-weight-gain-falters)
poor growth or unsavory eating habits that will lead to problems later. While worry is normal, fear-based feeding is not, and can cause
eating problems for children.
For example, a parent may be afraid that a child is gaining too much weight or eating too many sweets. As a result, the parent may
react by tightly controlling food access and portion sizes, hoping this will help. However, the child may respond to this restrictive way
of feeding by becoming overly focused on food, sneaking food that has been forbidden or overeating when he or she gains access to
it.
[Read: (https://health.usnews.com/wellness/for-parents/articles/2017-04-03/what-parents-need-to-know-about-extremepicky-eating) What Parents Need to Know About Extreme Picky Eating.]
No system or structure equals chaos.
When parents report their kids are constantly hungry and asking for more food, or they're in the pantry grabbing snacks and grazing
all day, I know the food system and feeding structure in the home is off. Not only is this chaotic for parents and kids, this lack of
routine may encourage a diet that favors unhealthy snacks and treats and overeating. Parents do well with feeding their kids when
they focus on a balanced diet and have a regular daily schedule for meals and snacks.
(https://health.usnews.com/wellness/for-parents/articles/2017-12-27/5-non-dieting-resolutions-families-can-keep) Family
meals are powerful.
Today's families are busy. Time to cook is tight, meals suffer, and as a result, the family meal takes a back seat. Yet, coming together
as a family for a meal gives children an opportunity to connect with their parents, explore food, learn manners and develop a sense of
routine and predictability. I believe family meals are a key ingredient to healthy development in children, from establishing a healthy
relationship with food to learning what to eat and how much. Furthermore, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4013176/)
research in teens indicates family meals are linked to healthier eating and weight, better academic performance and fewer risk-taking
behaviors.
Keep kids guessing.
Variety is the spice of life. Eating the same foods day in and day out gets boring -- for kids and adults. So be sure to incorporate the
element of surprise and make eating meals and snacks enjoyable. This will keep kids entertained, and it may entice them to try new
food. Rotate through different after-school snacks each day or put a variety of nutritious foods on a platter at snack time. These are
fun, creative ways to serve snacks, and they encourage a varied, healthy diet. Another idea: Add new foods to the menu regularly.
Exposing children to new food is key in helping them learn about, taste and like a wide variety of food.
Get kids involved.
From (https://health.usnews.com/health-news/blogs/eat-run/2015/10/02/8-ways-to-get-cooking-with-your-kids) helping in the kitchen
to sharing their input on the weekly menu or choosing between two food options, kids who are involved in making decisions about
what they eat are more likely to be cooperative when food is served. When kids are allowed to help prepare food, they are more likely
to eat it. When kids get to choose between this snack or that snack, they complain less and eat better. Kids like to have a say in food
matters; it's part of their developmental process.
[See: (https://health.usnews.com/wellness/family/slideshows/12-questions-you-should-ask-your-kids-at-dinner) 12
Questions You Should Ask Your Kids at Dinner.]
Know how to feed your kids.
We place high regard on what kids eat. However, in focusing intently on food choices, parents may lose sight of how they feed their
kids -- or that daily interaction around food with their children. For instance, place too much pressure on a child to eat or try a new
food, and the child may refuse to eat, become pickier or even overeat. Research also shows that routinely offering dessert in
exchange for a bite of vegetables may promote a child's preference for sweets and make vegetables seem less palatable over time.
So pay attention to more than what foods you serve, since how you feed your children has the power to undermine or reinforce
healthy eating habits.
Jill Castle is a premier childhood nutrition and feeding expert who invites parents and professionals to think differently about feeding
kids. Known as a paradigm shifter who blends current research, practical application and common sense, Jill serves on the Board of
Advisors for Parents magazine, is the author of "Eat Like a Champion" and "Fearless Feeding," hosts a podcast and writes a blog
called "The Nourished Child," and is a sought-after speaker. Watch her TEDx talk,
(https://www.youtube.com/watch?v=EFpHZQq0qDQ&t=13s) The Nutrition Prescription for Healthier Kids, and learn more about Jill at
(http://www.jillcastle.com/) JillCastle.com.
Copyright: COPYRIGHT 2018 U.S. News and World Report, L.P.
http://www.usnews.com/
Source Citation (APA 6th Edition)
Castle, J. (2018, January 23). 9 Lessons I've Learned About Feeding Kids. USNews.com. Retrieved from
https://link.gale.com/apps/doc/A524634495/OVIC?u=lirn50909&sid=OVIC&xid=a0703035
Gale Document Number: GALE|A524634495
Maternal and Child Health Journal (2018) 22:958–967
https://doi.org/10.1007/s10995-018-2472-7
Challenges and Facilitators to Promoting a Healthy Food Environment
and Communicating Effectively with Parents to Improve Food
Behaviors of School Children
Hiershenee B. Luesse1
· Rachel Paul2 · Heewon L. Gray3 · Pamela Koch2 · Isobel Contento2 · Victoria Marsick4
Published online: 14 February 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract
Background Childhood obesity is a major public health concern and families play an important role. Improving strategies
to reach parents and directing tailored nutrition education to them is needed. Purpose To investigate the challenges and
facilitators to promoting a healthy environment at home and to identify communication preferences to inform intervention
strategies for effectively reaching low-income urban minority families. Procedure Semi-structured focus group interviews
were conducted with four groups involving 16 low-income urban parents (94% female; 88% Hispanic/Latino, 12% African
American) of elementary school children. Interviews were transcribed and analyzed applying Social Cognitive Theory and
using in-vivo coding. Main Findings The most common barriers to parents providing healthy foods to their children were
accommodating child preferences and familial opposition. Parents showed intentionality to engage in healthy behaviors,
and often shared procedural knowledge for reaching health goals. The analyses of desired communication channels yielded
major preferences: tailored information, information provided through multiple mediums, appropriate duration/frequency
of messages, and presented from a voice of authority. Conclusion and Implication While parents expressed desires to be
healthy, the home food environment presented substantial challenges. Multi-media supports such as workshops, flyers, and
text messaging may be useful to facilitate the sharing of information to minimize the tensions between intentionality and
reaching desired goals to be healthy. Some parents thought that information received through text messaging could be easily
shared and would act as a voice of authority to support child behavior change.
Keywords Home environment · Childhood obesity · Social cognitive theory · Qualitative study
Significance
Childhood obesity is a major public health issue with high
prevalence in African American and Hispanic subgroups.
School-based programs have been targeted as effective
* Hiershenee B. Luesse
hb2407@tc.columbia.edu
Rachel Paul
rachel.paul@tc.columbia.edu
Heewon L. Gray
hlgray@health.usf.edu
Pamela Koch
pak14@tc.columbia.edu
Isobel Contento
irc6@tc.columbia.edu
Victoria Marsick
marsick@tc.columbia.edu
13
Vol:.(1234567890)
venues to reach children. However, for elementary schoolaged children, both the home and school are influential settings for healthy dietary intake. Among the school-based
interventions that incorporate a family component, considerable variability exists across studies and a systematic
1
Research, Evaluation, Strategy Consulting, 8RES, LLC, 8
West 87th Street, #7, New York, NY 10024, USA
2
Department of Heath & Behavior, Teachers College,
Columbia University, 525 West 120th Street, New York,
NY 10027, USA
3
Department of Community and Family Health, College
of Public Health, University of South Florida, 13201 Bruce
B. Downs Blvd, Tampa, FL 33612, USA
4
Department of Art and Humanities, Teachers College
Columbia University, 525 West 120th Street, New York,
NY 10027, USA
Maternal and Child Health Journal (2018) 22:958–967
approach for how best to reach and involve families has yet
to be determined, particularly because reaching parents
or families, can be difficult. For these reasons, improving
strategies to reach parents and providing culturally-relevant
and tailored nutrition education are valuable in supporting a
coordinated approach for school and family settings.
This study reveals that although parents demonstrate
some behavioral capacity to provide healthy foods to their
children, they are still hindered by social pressures of other
family members and picky eating. However, parents felt that
acceptable forms of communication, which could be easily
shared with other family members, would help to validate
their efforts making it easier to provide healthy foods without resistance.
Introduction
Childhood obesity is a major public health issue. In 2011,
17% of American children and adolescents (aged 2–19) were
obese, with higher prevalence rates seen among Hispanic
(22.4%) and non-Hispanic Black (20.2%) racial and ethnic groups (CDC Health Disparities & Inequalities Report
(CHDIR) 2013). A child suffering from obesity is 6.2 times
more likely to become an obese adult than his/her non-obese
counterpart and is at increased risk of diet-related health
conditions including cardiovascular, metabolic, and psychosocial illnesses (Herman et al. 2009). These health disparities are alarming and indicate how our social and physical
environments can have pronounced effects on disadvantaged
and minority children.
For elementary school-aged children (aged 6–14), the
home and school are influential settings for healthy dietary
intake (Baranowski et al. 1993; Cullen et al. 2000). Schools
provide continued and intensive contact with children and
the provision of food (Cullen et al. 2000). However the home
environment influences a significant proportion of the foods
consumed by children, especially for younger cohorts (Carlson et al. 2002; Mazur et al. 2003). Parents and families
influence children’s food intake in a number of ways, prominent among them being that they provide food for their children. The availability and accessibility of healthy foods at
home are highly correlated with intake in elementary schoolaged children (Rasmussen et al. 2006). In addition, parents
shape their children’s health-related practices through their
modeling of healthful practices; their knowledge of nutrition, and the meal structure and eating patterns established
in the home. These practices influence children’s development of lifelong habits (Lindsay et al. 2006). Although the
majority of childhood obesity prevention programs exist
in school settings, they show better outcomes when they
are coupled with a family component (Lindsay et al. 2006;
Wu et al. 2013). Among the school-based interventions that
959
incorporate a family component, considerable variability
exists across studies and a systematic approach for how
best to reach and involve families has yet to be determined
(O’Connor et al. 2009).
Reaching parents or families, however, can be difficult
and is especially the case for low-income and minority families, given the social, cultural, and economic environments
in which they live. Language and communication can also
pose a barrier for cultural minority families (Daniel-White
2002; Sohn and Wang 2006); and time constraints and logistical problems such as lack of childcare, transportation, and
scheduling conflicts often exist (Hoover-Dempsey et al.
2005; Kim 2009). Cultural attitudes and practices related
to food and feeding vary among ethnic groups, which can
contribute to differences in obesity patterns in children, and
how willing a family is to accept or reject nutrition education (NE) information, especially if it is designed without
cultural considerations (Liontos 1991). Lastly, economically
disadvantaged parents may also have greater feelings of
inadequacy or negative experiences with schools rendering
them less receptive to communication (Kumanyika 2008).
For these reasons, improving strategies to reach parents and
providing culturally-relevant and tailored nutrition education
are valuable in supporting a coordinated approach to health
promotion programming for school and family settings.
Text messaging is one of the most prevalent cell phone
activities; an estimated 85% of African-Americans and
87% of Hispanics/Latinos send and receive text messages
(Duggan and Rainie 2013). The use of text messaging has
emerged as a direct channel to reach parents at home (Fjeldsoe et al. 2009; Patrick et al. 2009; Sharifi et al. 2013; Webb
et al. 2010). For example, the mHealth campaign used text
messaging as an effective means of reaching racial and ethnic minorities to remind them to receive flu vaccinations
(Phillips et al. 2014) and Hyun and Glanz (2013) have used
text messaging to encourage healthy physical activity behavior in African American adults. However gaps in the academic literature still remain for researchers and practitioners
on how to best use text messaging to support the delivery
of heath messaging related to dietary intake and how this
channel might be used with minority parents to encourage
favorable and healthy food environments for children in the
home (Wu et al. 2013).
The social cognitive theory (SCT) provides a suitable
theoretical framework for studying the home environment
because it emphasizes the simultaneous and dynamic interaction of personal, behavioral, and environmental factors
on behavior (Bandura 1986; McAlister et al. 2008). This
theory has been commonly used in school-based and community-based settings to understand intake of healthy foods
with elementary school children, parents, and parent–child
dyads (Brown and Ogden 2004; Cullen et al. 2000; Neumark-Sztainer et al. 2003; Robinson-O’Brien et al. 2009;
13
960
Thompson et al. 2003). Key theoretical concepts in understanding healthy behaviors in a family’s home environment include the following: (a) personal factors: outcome
expectations (beliefs about the consequences of a behavior), attitudes (favorable or unfavorable judgments about
a given behavior), self-efficacy (confidence in abilities to
execute desired behavioral outcomes); (b) behavioral factors:
behavioral capability/competence (ability to execute given
behaviors); and (c) environmental factors: social environment (family, networks, and support) and the availability
and accessibility of food.
The purpose of this qualitative study is to determine (a)
perceptions of what facilitators and barriers exist for improving the healthfulness of the home environment of families
with elementary school children, and (b) to determine if text
messaging could be a suitable way to reach parents with food
and dietary information. An in-depth exploration of perceptions of parents can provide important information for both
researchers and practitioners for how to build in supports to
reinforce school-based NE programs at home.
Methods
Study Setting and Population
We conducted four focus groups with parents of elementaryaged children attending public elementary schools in low
SES communities of New York City. Focus groups were held
from November 2013 to January 2014. A purposeful sample
of two schools with a population of Hispanic/Latino and
African-American, and traditionally underserved students,
and with which the researchers had already established relationships were selected for this study.
Recruitment and Enrollment
The sample of participants was recruited by each elementary
school’s parent coordinator through direct outreach and by
research assistants through presentations at parent association meetings and through English and Spanish-speaking
research assistants’ direct outreach with parents at schools.
Parents were then screened for eligibility and invited to
attend a focus group in their preferred language.
Parents were eligible to participate in the study if they
(1) had at least one child attending the elementary school;
(2) lived with the child attending the school; and (3) could
verbally communicate fluently in either English or Spanish.
Focus Group Protocol and Data Collection
A study team, including experienced NE researchers, created
the focus group script, informed by standard focus group
13
Maternal and Child Health Journal (2018) 22:958–967
techniques (Krueger and Casey 2009; Vaughn et al. 1996),
study team discussions, and constructs of the SCT (Bandura 1986). Through several iterations, the script ultimately
included 12 open-ended core questions derived from study
aims and based on the constructs (personal, behavioral, and
environmental) and the target mediators (outcome expectations, self-efficacy, behavioral capability/competence,
social support) of the SCT (see Table 1 for how constructs
and target mediators were utilized). These questions were
supplemented with broad questions about the topic (before
asking the focal questions), probes, follow-up questions, and
member checks during the focus groups.
The focus group script spanned two domains: (1) the
home environment: exploring motivational and facilitating determinants of consuming healthful foods in the home
focusing on drinks, snacks, fruit and vegetable intake, and
general meals; and (2) communication methods: exploring
current and possible means of communication for reaching
parents to bolster healthful food practices focusing on types
of communication, use of communications, and text messaging to communicate health messages. Each focus group
began with a clarification of terms to be used throughout the
discussion, having participants define “meals” and “snacks,”
so as to not bias the discussion, and by providing a definition
of “text message” for the participants to clarify the specific
means of electronic communication.
Two focus groups were conducted in Spanish and two in
English, based on the language preference of participants.
Spanish focus groups were moderated by a native Latina
behavioral nutrition researcher (PhD), fluent in Spanish and
with experience in group facilitation. English focus groups
were conducted by trained female research assistants (MS)
with a working relationship with the schools. All participants gave their informed consent prior to their inclusion
in the study. One to two trained co-moderators and research
assistants took extensive notes for the duration of the focus
group discussions. Their notes included nonverbal and verbal responses (gestures, heightened expression, tone, and
language) related to displays of emotion (e.g. sarcasm,
anger, frustration) (Ryan and Bernard 2003; Vaughn et al.
1996), pauses in speech, and group consensus or disagreement (Ryan and Bernard 2003). Research staff convened
immediately after each focus group to discuss major themes
elucidated in the focus group discussions and took note of
the meta-themes generated.
Focus groups were conducted in empty classrooms in the
school where the parents’ children attended, were held for
90 min, and were audio recorded. All focus groups began
with a brief introduction of the moderators and co-moderators and an explanation of their reasons for undertaking
this research. After each focus group, participants completed
a brief socio-demographic survey and received a $10 gift
card for their participation. The focus groups were held in
Maternal and Child Health Journal (2018) 22:958–967
961
Table 1 Focus group interview guide and social cognitive theory constructs and mediators related to each question
Home Food Environment
Question
SCT construct
Target SCT mediators
Please tell me about some of the drinks that your child really likes? That you
have at home?
Do you prepare the snacks for your child? Please name for me some of the
foods that your child has for snack
Do you prepare the meals that your child has? Please describe some typical
meals at your house
How do you decide when it’s time to give your child a snack?
What kinds of things make it difficult to get your child to eat vegetables?
How would you feel if somebody from your child’s school made suggestions
to change the way you have a meal?
Environmental
Social support; modeling
Behavioral
Behavioral capacity/competence
Behavioral
Behavioral capacity/competence
Personal
Physical outcome expectations; attitudes
Personal/Environmental Self-efficacy
Personal/Environmental Attitudes; social support
Communication techniques
Question
SCT construct
What nutrition information have you received in the past?
How would text messaging nutrition information help you?
What are some reasons why you would not want to receive nutrition information
via text message?
What are reasons that teachers would want to give parents nutrition information?
What are some reasons parents would want to receive nutrition information?
Environmental
Personal
Personal
Social support
Self-efficacy/barriers; attitudes
Self-efficacy/barriers; attitudes
Personal
Personal
Attitudes
Self-efficacy attitudes
the early morning. Teachers College Columbia University
Institutional Review Board (IRB) approved all procedures
(Protocol # 15-087).
Analysis
Focus groups were audio recorded and transcribed verbatim. Spanish transcriptions were then translated to English
by a native Latina behavioral nutrition researcher. All transcriptions were reviewed along with their audio recording
a minimum of two times by the lead investigator to ensure
accuracy and along with field notes to translate and further
explain transcribed text with nonverbal and verbal responses.
All transcriptions were imported into Dedoose® software
(Dedoose 2014–2017, SocioCultural Research Consultants,
LLC). The lead researcher developed an initial codebook of
themes using a framework analysis approach (Ritchie and
Spencer 2002) that included a priori themes based on key
mediators from the SCT (outcome expectations; attitudes;
social norms; behavioral capability/competence; availability;
accessibility; family support); definitions of these mediators,
taken from Contento (2015), were used to identify codes
within the transcripts. Meta-themes elucidated from and
noted after each focus group discussion were integrated into
the codebook as described below.
The lead investigator coded the transcripts applying the
initial codebook. Additional in-vivo codes, identified using
open-coding and margin-coding techniques to identify repetition, indigenous typography or categories, metaphors or
analogies, transitions, similarities and differences, linguistic connectors, and missing data (Ryan and Bernard 2003)
were added to the codebook as new themes emerged. A final
codebook was then created by the lead investigator. All transcripts were reviewed for inclusion of all applicable codes
from the final codebook by two independent coders who
applied the coding scheme and met to resolve differences
by discussion. Analysis involved the systematic comparison
of coded segments across all four focus groups transcripts
to identify convergent, salient, and/or unique themes using
DeDoose software.
Results
Of the 20 participants recruited, four dropped out for scheduling reasons. Thematic saturation was reached after four
focus groups with four participants in each (n = 16 total)
as indicated by no new emerging themes in the last focus
group. Participants were all Hispanic and African American
racial/ethnic groups (94% female; 88% Latino;12% African
American; average 41 ± 7 years of age). See Table 2 for
demographic distributions.
Home Food Environment
Analyses yielded the following major themes in parents’
perceptions about the home-food environment related to
parents’ outcome expectations and social environment: (1)
13
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Maternal and Child Health Journal (2018) 22:958–967
Table 2 Participant characteristics
Variable
Coping with Child Dislike of Vegetables
Mean (range
or proportion)
Age [years (range)]
Gender
Female
Ethnicity
African American
Hispanic
40.4 (29–51)
15 (93.75%)
6 (37.5%)
10 (62.5%)
the importance of parents modeling desired behaviors; and
(2) coping with satisfying children’s dislike of vegetables.
Modeling Desired Behaviors
The majority of participants recognized the importance of
modeling good behavior to form good habits in their children, especially with respect to increasing vegetable consumption. Many discussed their personal roles and strategies. Some parents mentioned the importance of starting
these good habits in early childhood. Some mentioned
resistance from other family members as negatively influencing social and family norms around eating vegetables,
often sabotaging their own intentions to encourage healthy
behavior. Table 3 provides direct quotes.
Child preferences and dislikes were mentioned most as a
major consideration in meal preparation and the provision of
foods. Many parents customize and alter cooking practices
to accommodate their child’s dislikes and preferences and
express frustration and exhaustion with the subsequent time
and financial burdens. All parents exemplified procedural
knowledge and readily shared steps/strategies for overcoming these barriers in feeding their children. Table 4 provides
direct quotes.
Definitions and Uses of Snacks
Although participants all defined meals similarly, there was
variability in the way in which snacks were understood and
therefore provided inside and outside the home. Some participants defined snacks based on the type of food that was
provided (e.g. chips, crackers, cookies, fruits); some considered snacks as inherently unhealthy while others considered
them as inherently healthy.
Other participants defined snacks based on the portion
size but not composition of the food (e.g. smaller than a
meal and composed of any foods, for example half a burrito or a small portion of rice and beans). Others defined
snacks based on a temporal component (e.g. the time of day
in which it was offered, e.g. in between meals). In these
circumstances, snacks could range from a volume of food
Table 3 The Importance of Modeling Desired Behaviors
Theme
Direct quotes
Social and family norms Maria: “Listen, you know what it is with vegetables and kids? Well, […] I even have to just put it on their plate from
very young, even if they don’t eat it. Eventually, […] they’re gonna get used to it. Most kids will eat what their
parents eat.”
Toya: “Now if I make some meal or something like a sauce like we make it in Mexico, for instance, adobo with […]
pork adobo and some sauces […], instead of having tortillas […] I wash one of those long lettuce and I put it complete. […] Now when they see I eat these kind of things they also crave it and they eat it.”
Amanda: “My husband comes ‘Oh, take away that junk. Don’t put it in here.’ And I say no, I’m going to eat right here
and I sit down and eat and I eat my green beans.”
Table 4 Coping with children’s dislikes
Theme
Direct quotes
Shondra: “I cook a lot of lentils but not beans because my little one doesn’t really like beans. The older one, he does like beans but
PreferI make mostly lentils because […] he likes that. […] But I mainly do lentils because he will eat them.”
ences and
Dislikes Maria:”She don’t like carrot, she don’t like [clears her throat], she don’t like carrots. And I make stew and I saw her, she’s picking
out all the carrots and like what… I said you don’t take some, she won’t eat carrots’ [sighs with exasperation].”
Behavioral Alexis: “They [eat] vegetables but mostly [because] I put them in the soup […] until they all become indistinguishable. […] So if I
put cauliflower, broccoli… I mush it without [the children] seeing… and they are eating everything. For instance, the older one,
Capabilhe will not have any meat, no meat at all. So I make the soup. I make fish soup or beef soup and I mush everything and since he
ity/Comdoesn’t see anything… Kids, you know, they eat by what they see and since he doesn’t see anything in the soup he has it and he
petence
says, “Mom, this is delicious.”
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Maternal and Child Health Journal (2018) 22:958–967
typically smaller than provided at a meal to a volume equivalent to a full meal.
Some participants defined snacks based on pragmatic
considerations, such as what is convenient (what is available, easy to divide up and serve, and easy for their children
to assemble and prepare on their own). Table 5 provides
direct quotes.
Communication Techniques
Analysis revealed major themes related to health communications’ content, logistics of delivery, and tone of messages. Specifically, themes included: (1) the importance of
tailored and personalized messaging, (2) temporal strategies,
(3) multimodal communication efforts, and (4) creating a
voice of authority. Table 6 provides direct quotes.
Content of Health Communications: Tailored
and Personalized
Parents expressed a need for tailored and personalized messages for health information. Participants felt that the more
personalized a message was, the more likely that it would
be used and hold attention. Suggestions included tailoring
messages in communication channels that parents already
frequently used such as e-mail, websites, text messages, and
social media sites like Facebook, as well as messaging in
parents’ primary language.
They preferred advice that related to particular themes
rather than general information about healthy behaviors
which were successful in health promotion programs they
had experienced in the past.
963
Additionally, the use of pictures was mentioned as important to ensure that low literacy parents have improved access
to the content. Generally, examples of useful visual and written information included (1) healthful cooking techniques,
(2) recipes for healthful and inexpensive meals, and (3)
information on appropriate portion sizes.
Health Communication Logistics: Temporal Strategies
Some participants indicated that written information sent
home may be helpful as long as it was infrequent, e.g. on
a monthly basis. Some parents were strongly opposed to
receiving text messages, while others thought they would
be helpful. There was some consensus that text messages
received in the evening would be a suitable time.
Health Communication Logistics: Multiple Channels
Participants suggested that communications should be provided in more than one forum: e.g. text messages providing links to websites and using e-mail in addition to text
messaging; using flyers, posters, calendars, and workshops/
demonstrations.
Inclusion of a Voice of Authority
Participants noted that nutrition information from a figure
outside the family would provide a “voice of authority.”
They anticipated greater responsiveness from their children
simply because the source of information was from someone
other than themselves as parents. This idea seemed to alleviate tensions and exasperations that parents felt trying to
Table 5 Definitions and use of snacks
Theme
Direct quotes
Type of foods
Mira: “He can have some Doritos, some chips […] or he can have like a banana or an apple.”
Lavinia: “I was diagnosed with diabetes plus high cholesterol. So I cook no salt, no sugar, no snacks. So we don’t
give snacks at home.”
Diana: “I buy sometimes some of those little boxes of cookies that come with like Mickey Mouse or Winnie the
Pooh, animal crackers! Or I give granola bars to give them something healthy.”
Suki: “[…] always have fruits, they’ll get, you know, an apple or something like that.”
Serving Size or Time of Amanda: I give her, you know, like I give her a lot of things but it’s small portions. I portion it out. I don’t think she
Day Provided
needs six pieces of bacon. I give her one, one piece of bacon, one piece of sausage, an egg
Harden: “Yeah. It depends on the attitude one has that day. A good soup, some rice, that is very good. I give them a
small bowl or some little plate of something.”
Suki: “Yeah, it’s the same thing. They’ll drink their juice when they get home; they get a snack, always have my
fruits, they’ll get, you know, an apple or something like that.”
Edna: My daughter gets a snack at bedtime. That’s it. The only time of the day she gets a snack is bedtime
Pragmatic Considerations Maria: Cereal, fruit, one granola bar, sometimes some Jell-O if I have Jell-O. Sometimes I have Jell-O. Anything that
I have there
Jennifer: “Well, like I said, I give my kids money every day ‘cause I’m working and my son will get a pizza for a
snack or my daughter go and grab two bags of chips for a dollar and that’s what they have.”
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Maternal and Child Health Journal (2018) 22:958–967
Table 6 Health communications’ content, logistics of delivery, and tone of messages
Theme
Direct quotes
Content of Health Communications: Tailored and Personalized Edna: “Like Diana said, you send them a flyer with the information to an
internet site to parents where they can communicate and ask questions for help
there where the help would be, the explanation and all.”
Delma: “One more thing also. We are many parents that speak Spanish, and
many of us we can read some of it but maybe there is one word we do not
understand and that changes the sentence. So it is important to send it in Spanish.”
Diana: “We usually have parent workshops, sometimes through handouts, when
we give away pamphlets about some themes, something that is already in
place, different themes, those could be good options.”
Suki: “[…] always have fruits, they’ll get, you know, an apple or something like
that.”
Health Communication Logistics: Temporal Strategies
Jessica: “Depending on how many you are going to send because sometimes
there you go back and forth sending messages and hear the machine going
“ting, ting, ting” every second. Sometimes it good, sometimes yes and sometimes not.”
Health Communication Logistics: Multiple Channels
Jessica: “The papers that they send home. Sometimes I look at the papers
and sometimes the children do not even bring them home. So I would want
both ways, you can see it from the papers or see it in the computer. […] Yes,
because sometimes one cannot arrive and see the papers or go on a computer,
so you can have them in the phone, also.”
Edna: “That could be good, once in a while, a text message. I try to get into the
Internet […] I try to navigate […] I try to use it as much as possible and if my
phone is not good enough to get the information I want other means to try to
get the exact information.”
Mirna: “Not the parents ‘cause they think the parents just don’t want them to
Inclusion of a Voice of Authority
have certain stuff, and they’re like oh, you just don’t want me [to have this].
And at least when somebody else comes in and teaches them about everything, no, they were not just talking, talking, ‘cause we don’t want to spend
the money.”
Delma: “Yes, because if I had explained to my son what you explained, forget
about it, but since it was you who explained, he came and told me. So it is
good because sometimes the kids listen more to their teachers, the people that
go and talk to them than to us, their parents.”
implement healthful behavior change, and was seen as proof
to validate their efforts.
Discussion
Home Food Environment
This study applied the SCT as a framework for exploring
the home food environment from the perspective of parents
of elementary school-aged children. Parents primarily discussed their outcome expectations, behavioral capability/
competence, and the influence of others, indicating that
these mediators may be important to address in nutrition
interventions with parents of children. Reynolds et al. (2002)
have demonstrated through mediation analysis that parental
change in outcome expectations and behavioral capability/
competence may increase intake of fruits and vegetables in
elementary school-aged children. However, findings from
13
this study suggest that despite demonstrations of behavioral
capability/competence for providing and preparing fruits and
vegetables, parents felt other barriers persisted in making it
difficult to encourage fruit and vegetable intake with their
children.
A large proportion of the parents in our study indicated
that pickiness posed a major barrier to their child’s consumption of fruits and vegetables and they commonly
accommodated their children’s mealtime requests and struggled to prepare acceptable healthy foods. In a similar study,
Slusser et al. (2011) demonstrated that parents found cost,
getting their kids to eat healthy foods, and easy access to fast
foods were the most common barriers to providing healthy
foods for their family. Although cost and accessibility issues
were mentioned by parents in this study, they were not the
prominent barriers.
Other research with low-income African-American,
White, and Hispanic mothers (but to a lesser degree with
middle-income mothers) found a similar dynamic of
Maternal and Child Health Journal (2018) 22:958–967
parents accommodating their child’s preferences and dislikes through individualized meal preparation (Sherry et al.
2004). Parents in this study aimed to improve the acceptability of certain foods by adding flavors, like sweeteners,
and modifying preparation to hide vegetables to encourage
liking, as seen elsewhere (Cullen et al. 2000; Mascola et al.
2010). Although these strategies are well intended, they may
be counterproductive to developing long-term healthy habits
and could create greater neophobia (Carruth and Skinner
2000) and picky eating syndrome over time (Mascola et al.
2010). Galloway et al. (2003) have demonstrated that picky
eating behaviors are derived from insufficient exposure to
novel flavors; other research demonstrates that parenting
style, the use of rewards and punishments, and excessive
restriction of certain foods over others may also influence
dietary intake of fruits and vegetables in children (Birch
et al. 2007). Collectively, these factors may be of importance
in developing health promotion materials for members of
this cohort.
In general, parents felt that setting a good example as
models for healthy eating was important, and that introducing vegetables early and allowing their children to “get used
to them” was encouraged. However, parents felt their social
environments had a great impact on food practices at home
(rather than their own modeling) with other family members
setting “bad examples.” A body of literature exists supporting this phenomenon and suggests that social support of all
family members for healthy eating is an essential component
to sustained healthy patterns of children (Ball et al. 2010;
Kiernan et al. 2012). An emphasis on family may be particularly important with Hispanic families who are strongly family-centric and for whom community-focused interventions
may generate more culturally appropriate health promotion
programs (Gruber and Haldeman 2009). In a similar study
with a predominantly Hispanic population, Slusser et al.
(2011) found that parents expressed a desire for educational
materials that engage the entire family, especially fathers.
Even though parents faced many challenges with respect
to picky eating, they were also eager to share procedural
knowledge and skills with each other about food preparation, shopping, and improving their children’s health, demonstrating high behavioral capability/competence. Research
shows that parents have a high level of interest in peer-led
education, in which parents share resources and disseminate
healthful practices, indicating an area of research that could
further be developed (Duncanson et al. 2014).
This study demonstrates that parents may already recognize their important role in modeling positive food behaviors, and have procedural knowledge and skills and selfefficacy for preparing and providing fruits and vegetables
but need help in addressing other challenges, such as getting
their children to eat healthfully and dealing with unsupportive family members.
965
Lastly, ethnic differences and differences in acculturation
emerged in the definitions and use of snacking among our
participants. Most African American parents and Hispanics born within the USA tended to identify snacks as chips,
cookies, bars, and fruits compared to parents born to Latin
America who tended to define snacks as any food provided
either in smaller portions or at specific times in the day;
which were often similar to what might be considered meal
time foods. Some research indicates that degree of acculturation leads to decreased diet quality in people immigrating
to the United States (Pérez-Escamilla 2009). Native born
Americans or families with greater acculturation to the
American lifestyle may be more likely to consider snacks
a daily routine, usually involving the provision of highlyprocessed foods, such as chips, candy, and soda, contributing
to an increase in the proportion of discretionary calories that
make up their children’s diets.
Above tailoring nutrition education interventions to different cultural and socioeconomic practices, it may also be
important to ensure that foods and concepts are understood,
defined, and used in similar ways.
Communication Techniques
Parents reported general acceptability and enthusiasm for
personalized and tailored communications. They felt communications that they could share with their children and
friends would validate their efforts to engage in healthier
behaviors, and could act as a persuasive means of encouraging others in their lives as it could provide a “voice
of authority.” Parents indicated that multiple forums of
communication were important to them, and expressed the
need for bilingual print, and the use of images to address
literacy issues. Some parents were opposed to text messaging due to the associated costs and inconsistent cell
service and were not interested in providing their contact
information, while others thought that it was preferable
because of the immediate, brief, and sharable nature of a
text message. Although cellular phones are increasing in
ubiquity and the socioeconomic divide to access is narrowing, privacy issues related to legal status in the country
may have been a reason for some additional opposition
to text message use in our cohort. Previous studies have
already demonstrated success with respect to text messaging interventions in promoting behavior change for parents
(Kharbanda et al. 2010; Sharifi et al. 2013). Sharifi et al.
(2013) demonstrated that parents of children enrolled in
obesity prevention programs felt supported through text
messaging. However, unlike in our study, their parents
preferred text messaging to other forms of communication (including paper or e-mail). Parents in these studies
who were accepting of text messaging suggested limiting
13
966
frequency, and reserving messages for particular times of
the day as suggestions to increase acceptability (Kharbanda et al. 2010; Sharifi et al. 2013).
These findings indicate the importance of tailoring
nutrition communications for culturally diverse and/or lowincome populations. Tailoring communication may need to
consider use and penetration of cell phones, the need for
bilingual communications, and using multimodal forms of
communication. Finding acceptable forms of communication to provide health-information that parents can easily
share with other family members, may help validate and support their efforts to make healthy changes at home. Platforms
that interact with all family members may also be more culturally appropriate and help to increase buy-in, especially
for Hispanic families.
Strengths and Limitations
Data collected in the focus groups were based on selfreport and were not verified by other means. Additionally,
translations of audio files from Spanish to English were not
back translated for accuracy although all audio files were
reviewed a minimum of two times in the translation and transcription process. Also, generalizability is limited because
of the small sample size. Although a range of Latino and
African-American parents were involved, and representative of people found in low-income New York neighborhoods, participants with lower literacy or that may have
been undocumented were not represented in our sample.
Further research should include efforts to recruit a more
broadly representative group of Hispanic and AfricanAmerican parents. Although this study focused primarily
on text messaging, other researchers and the food industry
have also been successful in reaching parents via the Internet and social media. Further research may also expand on
this work to determine how these other platforms might be
received alongside text messaging with this cohort. Though
the number of participants per group was small, the number
of focus groups was based on saturation of information from
the participants. Additionally, the use of SCT as a broad
framework allowed for cultural and socioeconomic factors
to be considered in the home food environment with minority participants.
Many of the feeding practices revealed in our focus
groups need to be examined further, preferably in experimental studies to help elucidate the mechanisms for their
use. Examples of topics needing further study include the
preparation of different meals to accommodate picky eaters,
and successfully navigating “saboteurs” to healthy practices
at home. The application of text messaging and other supportive communication means to help families effectively
manage these concerns is also warranted.
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Maternal and Child Health Journal (2018) 22:958–967
Acknowledgements The authors thank parent coordinators for their
technical assistance with this study. A portion of this study has been
presented in abstract form at the Society for Nutrition Education and
Behavior conference in Wisconsin, 2015.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
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