individual behavioural and home environmental factors associated with eating behaviours in young adolescents

Accepted Manuscript Individual, behavioural and home environmental factors associated with eating behaviours in young adolescents Natalie Pearson, Paula Griffiths, Stuart J.H Biddle, Julie P Johnston, Emma Haycraft PII: S0195-6663(17)30004-1 DOI: 10.1016/j.appet.2017.01.001 Reference: APPET 3287 To appear in: Appetite Received Date: 12 August 2016 Revised Date: 21 December 2016 Accepted Date: January 2017 Please cite this article as: Pearson N., Griffiths P., Biddle S.J.H., Johnston J.P & Haycraft E., Individual, behavioural and home environmental factors associated with eating behaviours in young adolescents, Appetite (2017), doi: 10.1016/j.appet.2017.01.001 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain ACCEPTED MANUSCRIPT Individual, behavioural and home environmental factors associated with eating behaviours in young adolescents Natalie Pearson1, Paula Griffiths1, Stuart JH Biddle2, Julie P Johnston3, Emma Haycraft1 School of Sport, Exercise & Health Sciences, Loughborough University, UK; 2Institute of RI PT Sport, Exercise & Active Living (ISEAL), Victoria University, Australia; 3Department of Sport Science, School of Science and Technology, Nottingham Trent University, UK; Dr Natalie Pearson: n.l.pearson@lboro.ac.uk Dr Paula Griffiths: p.griffiths@lboro.ac.uk M AN U SC Prof Stuart JH Biddle: stuart.biddle@vu.edu.au 11 Dr Julie P Johnston: julie.johnston@ntu.ac.uk 12 Dr Emma Haycraft: E.Haycraft@lboro.ac.uk 13 TE D 10 Corresponding author: 15 Dr Natalie Pearson 16 School of Sport, Exercise & Health Sciences, 17 National Centre for Sport & Exercise Medicine, 18 Loughborough University, 19 Loughborough, 20 Leicestershire, 21 LE11 3TU 22 UK 23 Telephone: +44 (0) 1509 226448 24 Email: n.l.pearson@lboro.ac.uk AC C EP 14 25 26 27 Running title: Factors associated with eating in adolescents ACCEPTED MANUSCRIPT Abstract 29 This study aimed to examine individual, behavioural and home environmental factors 30 associated with frequency of consumption of fruit, vegetables and energy-dense snacks 31 among adolescents Adolescents aged 11-12 years (n=521, 48% boys) completed a paper- 32 based questionnaire during class-time which included a Food Frequency Questionnaire 33 assessing their consumption of fruit, vegetables, and energy-dense (ED) snacks, and items 34 assessing habits, self-efficacy, eating at the television (TV), eating with parents, parenting 35 practices, and home availability and accessibility of foods Multiple linear regression 36 analyses showed that eating fruit and vegetables while watching TV and home availability 37 and accessibility of fruit and vegetables were positively associated with frequency of fruit 38 consumption and vegetable consumption, while home accessibility of ED snack foods was 39 negatively associated with frequency of fruit consumption Habit for eating ED snack foods 40 in front the TV, eating ED snack foods while watching TV, and home availability of ED 41 snacks were positively associated with frequency of ED snack consumption This study has 42 highlighted the importance of a healthy home environment for promoting fruit and vegetable 43 intake in early adolescents and also suggests that, if snacking while TV viewing occurs, this 44 could be a good opportunity for promoting fruit and vegetable intake These findings are 45 likely to be useful for supporting the development of multi-faceted interventions and aid us in 46 knowing what advice to give to parents to help them to help their young adolescents to 47 develop and maintain healthy eating habits 48 Key words: Eating, home environment, adolescents, parents, energy-dense snacks, fruit, 49 vegetables SC M AN U TE D EP AC C 50 RI PT 28 ACCEPTED MANUSCRIPT Background 52 Adolescence is a significant developmental life stage where health behaviours are often 53 established and become habitual Unhealthy eating behaviours including snacking on energy- 54 dense foods and low intakes of fruit and vegetables are particularly common characteristics 55 of many adolescents’ diets, and have a significant impact on both immediate and long term 56 physiological and mental health conditions including obesity indicators [1], cancers [2, 3], 57 and mental health disorders [4, 5] Eating behaviours and habits developed during 58 adolescence tend to persist into adulthood [6], and thus decreasing the consumption of 59 energy-dense foods and increasing the consumption of fruits and vegetables during 60 adolescence are important targets for nutrition interventions Identifying potentially 61 modifiable factors of adolescent eating behaviours is imperative for the design of successful 62 interventions Furthermore, identifying eating behaviours that share modifiable factors is 63 potentially useful as eating behaviours not occur in isolation and such data could underpin 64 dietary interventions aiming to change multiple eating behaviours M AN U SC RI PT 51 65 Many potential correlates of adolescent eating behaviours have been identified For example, 67 review level evidence suggests that habit can determine food choices and eating behaviours 68 [7] [8], and that repeated (habitual) food choices and eating behaviours are often associated 69 with environmental cues – e.g., coming home from work or school [9] Self-efficacy is 70 another correlate of eating behaviour, with evidence suggesting that higher levels of self- 71 efficacy, that is, feeling confident in one’s ability to successfully undertake a task, are related 72 to health behaviour changes such as healthier eating behaviours [10] 73 Although adolescence is associated with increased autonomy, parents still typically provide 74 foods for children and are responsible for mealtimes [11] Eating meals as a family and 75 parental role modelling have both been associated with healthier adolescent eating behaviours 76 [12, 13] Availability and accessibility of foods are powerful predictors of consumption, with 77 greater availability and accessibility of fruits and vegetables being related to greater intake in 78 children and adolescents [14-16] Furthermore, not making unhealthy foods available or 79 accessible, i.e employing covert restriction, has been linked to lower intake of such foods 80 (Ogden et al., 2006) 81 Food-related parenting practices are commonly used by parents of adolescents [17] and also 82 relate to adolescents’ eating behaviours Pressure to eat certain foods, or finish meals, has 83 been associated with lower consumption of healthy pressured foods (e.g., soup; [18]) but AC C EP TE D 66 ACCEPTED MANUSCRIPT greater consumption of unhealthy foods (e.g., unhealthy snacks; [19]) in children and to less 85 healthy eating attitudes and behaviours [20] and greater weight [17] in adolescents 86 Restriction of foods can be associated with greater subsequent intake, particularly if the 87 restriction has been overt (e.g., “No, you can’t have another biscuit”) or if food has been used 88 as a reward [21] Parental use of restriction has also been linked to higher adolescent weight 89 [17] 90 Other health behaviours have been found to play an important role in determining eating 91 behaviours Behaviours – such as watching television whilst eating – have been related to 92 increased food consumption [22, 23] which, in turn, can lead to weight gain For example, 93 adolescents who watch TV whilst eating meals have been found to have less healthy diets 94 than those who not watch TV whilst eating meals [24] and TV viewing has been linked to 95 greater unhealthy snack food consumption in children and adolescents [25, 26] 96 While numerous factors have been identified as impacting eating behaviours, it is unlikely 97 that these exert their effects individually Given that theoretically based nutrition 98 interventions have been shown to be more effective than those without a theoretical 99 underpinning [27, 28], behavioural theories should be utilised to provide a framework for 100 studying factors associated with eating behaviours There is support for the use of social– 101 ecological models in understanding health behaviours [29] These posit that factors at the 102 individual (e.g habits), social (parental modelling) and physical (e.g availability of foods at 103 home) environmental levels interact to influence health behaviour [30, 31] Few studies have 104 examined the influence of correlates across multiple levels, and/or have examined the same 105 correlates for multiple eating behaviours, both of which are likely to be beneficial for the 106 development of multifaceted interventions to promote healthy eating Furthermore, where 107 studies have examined correlates at multiple levels of the social-ecological model, it is typical 108 that factors significant in a univariate model are entered into a multivariate model regardless 109 of their ‘level’ We are unaware of any study that has examined the effect of correlates of 110 multiple eating behaviours at each level separately (e.g factors significant at the individual 111 level all entered into a multivariate model to determine the contribution of each factor at the 112 individual level) before combining into one model Such information is important for 113 providing modifiable determinants to target in a multi-level intervention Using a social– 114 ecological framework, the present study aimed to examine individual, behavioural and home 115 environmental factors associated with the frequency of consumption of fruit, vegetables and 116 energy-dense snacks among young adolescents aged 11-12 years AC C EP TE D M AN U SC RI PT 84 ACCEPTED MANUSCRIPT Methods 118 Study Procedure and Participants 119 Cross-sectional data were collected between May 2013 and June 2014 Study procedures 120 were approved by the Ethical Advisory Committee of the host university Data were obtained 121 from young adolescents in their first year (Year 7) of secondary school (aged 11-12 years) 122 recruited from four secondary schools in the East Midlands region of the UK All students in 123 Year of participating schools were eligible and received an information leaflet to take home 124 for a parent or guardian with details of the study (n=683) Under existing ethical guidelines, it 125 was necessary to seek consent from parents for each child’s participation, and no information 126 could be accessed regarding characteristics of non-respondents Adolescent participants 127 provided assent before completing written questionnaires during class time In total, 562 128 pupils provided parental consent (82% response rate) and 521 were present on the data 129 collection days and completed the questionnaire (76% response rate) 130 Measures 131 Participants completed paper-based questionnaires during a school lesson under the 132 supervision of trained researchers and class teachers Participants provided their date of birth 133 and gender 134 Eating behaviours 135 Food intake was assessed using a Food Frequency Questionnaire (FFQ) This FFQ was 136 based on previously validated indices of food intake [32] but options were reduced to focus 137 on the specific foods of interest (namely, fruit, vegetables, and energy-dense snacks) and 138 assessed intake frequency during the past week Students indicated how frequently they 139 consumed eighteen food items during a usual week Seven response categories ranged from 140 ‘never’ to ‘more than three a day’ The frequency of consumption of the eighteen food items 141 in the past month was converted to a daily equivalent, which is an established method [33] 142 [10, 34] Daily equivalents were calculated as follows: never (0·00 per d); one-two days a 143 week (0·2 per d); 3-4 days a week (0·5 per d); five-six days a week (0·7 per d); once a day 144 (1.0 per d); twice a day (2.0 per d); three or more a day (3.0 per d) The daily intake of fruit, 145 vegetables, and energy-dense snacks was calculated by summing the daily equivalents for the 146 food items in each food group The estimated daily intake of ‘fruit’ included the summed 147 equivalence of five fruit items (apples, bananas, oranges, grapes and other fruit), the daily AC C EP TE D M AN U SC RI PT 117 ACCEPTED MANUSCRIPT equivalent of ‘vegetables’ included the summed equivalence of five vegetable items (carrots, 149 peas, broccoli, salad and other vegetables), the daily equivalence of ‘energy-dense snacks’ 150 included the summed equivalence of eight snack food items (potato crisps/potato chips, snack 151 crackers, sweets (candy), chocolate, chocolate biscuits, regular biscuits, muffins/cakes, cereal 152 bars) 153 Individual, behavioural, social and physical environmental factors 154 Individual 155 Adolescents were asked four questions about their habits for eating snack foods in front of 156 the television using the previously validated Self-Report Behavioural Automaticity Index 157 (SRBAI)[35]: ‘eating snack foods (e.g chocolate/biscuits/crisps) while watching television 158 (TV) is something I automatically’; ‘…without having to remember’; ‘…without thinking’; 159 ‘…before I realise I’m doing it’ They were asked the same four questions regarding eating 160 fruit and vegetables in front of the television Response options were given on a five-point 161 Likert scale, ranging from (1) ‘strongly disagree’ to (5) ‘strongly agree’ Responses were 162 summed separately to provide two habit scores, one for eating snacks in front of the TV 163 (Cronbach’s α=0.86) and one for eating fruit and vegetables in front of the TV (Cronbach’s 164 α=0.91) 165 Based on a previously used scale [10], adolescents were asked six questions about how 166 confident that would feel about reducing their energy-dense snack food consumption (i.e 167 snacks including chocolate, crisps, biscuits, sweets (candy)): ‘How sure are you that you 168 could not eat snack foods when you’re with your friends’; ‘…you’re with your family’; 169 ‘…after school’; ‘…when you’re alone’; ‘ …when you’re bored’; ‘…when you’re feeling 170 down’ They were asked the same six questions about not eating snack foods in front of the 171 television and about eating more fruit and vegetables Response options were given on a five- 172 point Likert scale, ranging from (1) ‘Not at all sure’ to (5) ‘very sure’ Responses were 173 summed separately to provide three self-efficacy scores, one for not eating energy-dense 174 snacks (Cronbach’s α=0.89), one for not eating energy-dense snacks in front of the TV 175 (Cronbach’s α=0.88), and one for eating more fruit and vegetables (Cronbach’s α=0.90) 176 Behavioural 177 Adolescents were asked how often they ate breakfast, lunch, dinner, energy-dense snacks and 178 fruit and vegetables while also watching the television during a typical week using a AC C EP TE D M AN U SC RI PT 148 ACCEPTED MANUSCRIPT previously used questionnaire by Matheson et al [36] Response options were given on a 180 four-point Likert scale ranging from (1) ‘Never’ to (4) ‘Every day’ The frequency of 181 consumption of the meals and snacks while watching TV was converted to a daily equivalent 182 Daily equivalents were calculated as follows: never (0·00 per d); one-two days a week (0·2 183 per d); 3-6 days a week (0·6 per d); everyday (1.0 per d) 184 Social environmental 185 Adolescents were asked how often, during a typical week, they ate the following with their 186 parents: breakfast, dinner, breakfast in front of the TV, dinner in front of the TV, and snacks 187 in front of the TV Response options were given on a five-point Likert scale ranging from (1) 188 ‘Never/less than once a week’ to (5) ‘Every day’ The frequency of consumption of the meals 189 and snacks with parents was converted to a daily equivalent Daily equivalents were 190 calculated as follows: never (0·00 per d); once a week (0.14); two-three times a week (0·36 191 per d); 4-6 days times a week (0·6 per d); everyday (1.0 per d) 192 Adolescents were asked questions regarding perceptions of parental pressure to eat, food 193 restriction, and food as a reward using items from the Kid’s Child Feeding Questionnaire 194 (KCFQ)[37] [38] For all items, response options were given on a three-point Likert scale: (1) 195 ‘No’, (2) ‘sometimes’, (3) ‘Yes’ Adolescents were asked to answer all questions about the 196 parent/caregiver who is typically responsible for feeding them/providing meals Adolescents 197 were asked seven questions regarding pressure to eat (e.g ‘If you say, “I’m not hungry” at 198 dinnertime, does your parent say, “You need to eat anyway”?’) Scores of the seven items 199 were summed and divided by seven to create the ‘pressure to eat’ score (Cronbach’s α=0.73) 200 Adolescents were asked seven questions regarding parental restriction (e.g ‘Does your parent 201 every say things like “you've had enough to eat now, you need to stop”?’) Scores of the 202 seven items were summed and divided by seven to create the ‘restriction’ score (Cronbach’s 203 α=0.71) Adolescents were asked two questions regarding parental use of food as a reward 204 (e.g ‘My parents let me have snacks (e.g sweets/chocolates) as a reward for good 205 behaviour’) Scores of the two items were summed and divided by two to create the ‘food as 206 a reward’ score (Cronbach’s α=0.75) AC C EP TE D M AN U SC RI PT 179 207 208 Physical environmental 209 Adolescents were asked four questions regarding availability of energy-dense snacks in the 210 home in the past week (e.g ‘how frequently were the following items available to you at ACCEPTED MANUSCRIPT home last week’: cakes/biscuits, crisps, chocolates, sweets), and two questions regarding the 212 availability of fruit and vegetables (fruit and vegetables) Response options were given on a 213 four-point Likert scale ranging from (1) ‘Never/rarely’ to (4) ‘Always’ Scores of the four 214 energy-dense snacks were summed to create the ‘home availability of energy-dense snacks’ 215 score (Cronbach’s α=0.84) and scores of the fruit and vegetables were summed to create the 216 ‘home availability of fruit and vegetables’ score (Cronbach’s α=0.83) RI PT 211 217 Adolescents were asked two questions regarding the accessibility of energy-dense snacks in 219 the home and four questions regarding accessibility of fruit and vegetables in the past week 220 (e.g ‘in the past week, were there any fruits that were prepared and ready for you to eat as 221 part of a meal or snack?’) Response options were given on a three-point Likert scale ranging 222 from (1) ‘No, never’ to (3) ‘Yes, always’ Scores of the two energy-dense snacks questions 223 were summed to create the ‘home accessibility of energy-dense snacks’ score (Cronbach’s 224 α=0.71) and scores of the four fruit and vegetable questions were summed to create the 225 ‘home accessibility of fruit and vegetables’ score (Cronbach’s α=0.70) M AN U SC 218 226 Statistical analysis 228 All analyses were conducted using the SPSS statistical software package 22.0 (SPSS Inc., 229 Chicago, IL, USA) Descriptive statistics were used to summarise the demographic and 230 eating characteristics of the sample Independent t tests were conducted to determine gender 231 differences in all variables EP 232 TE D 227 Unadjusted linear regression analyses (model 1) were conducted to examine associations 234 between the proposed individual, social and physical environmental factors and the eating 235 behaviours of interest (fruit, vegetable, and energy-dense snack consumption) As suggested 236 by Bursac et al [39], a p value of 0.25 was used to identify variables significant in Model 237 All individual factors that were significantly associated with the eating behaviour in the 238 unadjusted analyses (p