Appetite 41 (2003) 265–272

www.elsevier.com/locate/appet

Research Report

Evaluation of strategies used by family food preparers

to influence healthy eating
Emily Bourciera, Deborah J. Bowenb,*, Hendrika Meischkec, Carol Moinpourb
a
Center for Health Education and Research, University of Washington, Seattle, WA 98115, USA
b
Fred Hutchinson Cancer Research Center, P.O. Box 19024, MP-200, Seattle, WA 98109, USA
c
Department of Health Services, University of Washington, Seattle, WA 98115, USA
Received 3 November 2002; revised 9 February 2003; accepted 24 May 2003

Abstract
The family may exert powerful influence on family members’ eating habits, though there is very little conclusive literature regarding the
specific mechanisms. The authors investigated how often family food preparers use particular strategies to encourage their families to eat
more healthily and then related these strategies to healthy eating outcomes in children. We identified significant differences in strategy use
between family age subgroups, and we included strategy types in multiple linear regression models to predict differences in families with
children. Results indicate that discussing healthy food related to ‘Pressuring’ strategies and discussing healthy eating related to ‘Feeling and
looking good’ predicted healthy eating outcomes. Findings have implications for designing dietary interventions to have the largest public
health impact.
q 2003 Elsevier Ltd. All rights reserved.
Keywords: Family food preparers; Social influences; Faith communities

Introduction 1990; Nader et al., 1983; Rozin, 1991; Rozin & Millman,
1987). Dietary interventions that involve families do tend to
Differences in people’s diets are thought to account for have more positive effects on dietary behavior change than
more variation in cancer incidence than any other factor, interventions that do not incorporate families (Crockett,
including cigarette smoking (Truswell, 1985; Wynder & Mullis, Perry, & Luepker, 1989; Lytle et al., 1996; Nader
Gori, 1977), cardiovascular disease, and diabetes (World et al., 1989; Patterson et al., 1988; Sorensen et al., 1999).
Cancer Research Fund and American Institute for Cancer Eating habits established in childhood can influence eating
Research, 1997). Due to the strength of scientific consensus, behavior in adulthood and may be important determinants of
several learned bodies have advocated reducing total fat chronic disease and cancer in later life (Gibson, Wardle, &
intake and eating more high-fiber foods such as fruits and Watts, 1998; Hupkens, Knibbe, Van Otterloo, & Drop,
vegetables (Hunter et al., 1996; Nixon, 1990; US Depart- 1998; Tuttle, 1998). Researchers pose that parents, and
ment of Human and Health Services, 1990; US Department especially the family food preparers, or FFPs, play an
of Human and Health Services, 2000). important role in what children eat (Hupkens et al., 1998).
Children are also dependent upon FFPs for most nutritional
Family influences on children’s eating needs (Tuttle, 1998). A recent review of influences on
preschool children’s fruit, vegetable, and juice consumption
The family may exert powerful influence in shaping and provides an excellent framework for considering FFP
maintaining family members’ eating habits and food influences on consumption (Nicklas et al., 2001). Specific
preferences (Baranowski & Nader, 1985; Golan & Weiz- methods of influence in this review include making food
man, 1998; McCann, Retzlaff, Dowdy, Walden, & Knopp, available, structuring meals for children, modeling healthy
food choices, parent –child socialization and communi-
* Corresponding author. cation, and specific techniques used by parents to change
E-mail address: dbowen@fhcrc.org (D.J. Bowen). children’s behaviors. Many of these methods are born out by
0195-6663/03/$ - see front matter q 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/S0195-6663(03)00104-1
266 E. Bourcier et al. / Appetite 41 (2003) 265–272

the broader literature on parental influence, which has years or older, planned to stay in the area for the next
identified successful strategies such as exposing children to two years, attended their FCs at least twelve times in the
a variety of healthy foods and snacks, affective reactions to past year, and agreed to complete the baseline survey.
fruits and vegetables, overseeing planning and assembly of
preparation (Crockett, Mullis, & Perry, 1988; Golan & Survey administration
Weizman, 1998), conveying attitudinal conviction that
increasing fruits and vegetables by children could reduce We administered the baseline survey via telephone
their risk for cancer (Gibson et al., 1998), verbal immediately following the screening survey if possible. In
encouragement, approval for eating food, and discussion a few cases follow-up telephone calls were made as needed
about food (Gemson, Sloan, Messeri, & Goldberg, 1990; to complete the baseline survey. We randomly selected one
Hertzler, 1983; Sallis, Prochaska, Taylor, Hill, & Geraci, half of the 60 members selected within each FC to complete
1999). Overtly controlling behavior about food and the family portion of the baseline survey. The family portion
restricting the amount of food tend to have negative of the baseline survey assessed global rating items for fruit,
influences on children’s eating (Birch, McPhee, Shoba, vegetable, and fat consumption, ways in which the FFPs
Steinberg, & Krehbiel, 1987; Crockett, 1995; Crockett et al., may have tried to encourage their families to eat healthy
1988; Hertzler, 1983). foods, and how often they discussed healthy food choices in
The two objectives of this study were to measure the relation to different value contexts.
frequency of strategies used by FFPs and to identify
strategies related to higher fruit and vegetable consumption Measures
and lower fat consumption of family members. We
hypothesized that FFPs would use multiple strategies, with Global dietary fat and fruit/vegetable rating items. We
simply making healthy foods available used more fre- asked each FFP two global rating items to assess children’s
quently than more complicated strategies like communicat- consumption, if appropriate. If the FFP lived with children,
ing healthy messages. We further hypothesized that the we asked the two global rating items of only one randomly
values parents gave to foods would influence the strategies selected child in the 5 –12 age range and one randomly
used to promote healthy consumptions and, therefore, be selected child in the 13 –17 age range. We did not ask global
related to consumption. food ratings for children aged 0 –4. We used FFP ratings of
children’s eating due to the evidence that parents can rate
children’s food habits with a reasonable degree of accuracy
Methods (Van Horn et al., 1990). One item measured fat consumption
and the other measured fruit/vegetable consumption. The
The present research is part of Eating for a Healthy Life, study team created these items based on the style of the Fat
an ongoing, NCI-funded, randomized controlled trial at the and Fiber Behavior Questionnaire (Shannon, Kristal, Curry,
Fred Hutchinson Cancer Research Center. The trial is a & Beresford, 1997) and the style of a single item from
dietary intervention with faith communities (FCs) in Seattle, follow-up assessment in the 5-a-Day Study (Beresford,
Washington. The baseline survey, which was the first step in Shannon, McLerran, & Thompson, 2000). The two items
the evaluation plan, provided the data presented here. were, “In the past three months, how many servings of fruits
and vegetables did you usually eat each day?” and “How
Recruiting FCs often do you eat foods that are high in fat, like fried foods,
cheese and butter, and cakes and cookies?” We scored all
We identified eligible FCs from a list provided by the responses on a four-point Likert scale from 1 (very little of
Church Council of Greater Seattle using criteria of size the time) to 4 (all of the time).
(between 100 and 1000 members), geographic location (zip Family structures. We measured family structure by
code within a one-hour drive of the research center), and asking FFPs questions about the age of children living
lower socioeconomic base (FCs with zip codes in targeted with them and whether they lived with a partner/spouse.
census tracts). From the pool of eligible FCs, we selected a We asked, “Are there any children who live with you?” If
random sample of sixteen FCs and administered the baseline the respondent answered yes, we asked, “How many are
survey to a sample of members. less than 5 years old?” “How many are 5 through 12 years
old?” and “How many are 13 through 17 years old?” We
Sampling study participants defined four subgroups based on age of the child(ren) in
the home. This classification identified households that
Study staff randomly sampled 60 households from each had a child (or children) in only one age group (0 –4, 5–
FC. Interviewers conducted brief telephone screening 12, or 13– 17) as well as those with no child(ren) between
interviews with selected members to determine eligibility. the ages of 0 –17. We also asked, “Who lives with you?”
Participants were eligible to participate in the survey if they to assess whether the respondent lived with a spouse or
were the family food preparer in their household, were 18 partner.
 E. Bourcier et al. / Appetite 41 (2003) 265–272 267

Strategies to influence eating behavior. We asked and household income. We asked, “What is your date of
questions about plausible strategies FFPs might use to birth?” “In what race or ethnic category do you primarily
influence healthy eating behaviors in family members. We consider yourself?” “What is your gender?” “What is your
modified some questions from other research and created current marital or partner status?” and “Including income
questions based on the literature. We asked participants, “In provided by you, your partner/spouse, and any other person
the past month, how much of the time did you use the living in your household, which range of figures comes
following strategies to encourage your family to eat more closest to your total household income before taxes for the
healthy foods?” We asked about thirteen strategies and past calendar year?”
scored responses on a four-point scale from 1 (very little) to
4 (all of the time). We asked participants how often they Data analyses
used “suggesting places to eat out that have healthy
selections” and “involving them in selecting foods” as We coded the questions and processed the data using
strategies. We modified these two items from a family food SPSS software. We calculated demographic descriptive
interaction scale (Gillespie & Achterberg, 1989). We asked statistics for the study cohort, including age, gender, marital
participants two items modified from a household support status, household income, and ethnicity. We also looked at
for healthy eating scale (Sorensen et al., 1999). Specifically, the demographics of those living with a child only between 0
we asked how often participants used “making a positive and 4 years old, those living with a child only between 5 and
comment when a family member eats something healthy” 12 years old, those living with a child only between 13
and “bringing home healthy foods for your family to try” as and 17 years old, and those living with no children between 0
strategies. We used two items concerning rules that had to and 17 years old. Using ANOVA, we determined which
be followed if one did not like the food placed in front of demographic variables were significantly different between
them. We modified these items from a family food rules family age groups.
scale (De Bourdeaudhuij & Van Oost, 1998). We asked We performed a factor analysis of principal components
participants how often they used “trying to make them finish with varimax rotation on the thirteen strategy items and on
everything on their plate” and “making them try a little of an the five value context items in order to find relationships
unfamiliar food” as strategies. To measure the extent to among the sets of items for possible scale formation.
which FFPs modeled eating healthy foods as a strategy to Criteria for the factor analyses were as follows: each item
encourage family members to eat more healthy foods, we had to load above 0.5 on one factor and not above 0.3 on any
asked participants how much of the time they used “eating other factor, and each final factor needed an eigenvalue
more healthy foods to set a good example” as a strategy. We above 1 to be kept in the final analyses.
asked participants how often they used “getting them to eat We calculated frequencies and means of strategies used
food you make, rather than eat away from home,” “sharing by FFPs for influencing healthy eating, both for the entire
information about healthy eating,” and “making a negative sample and for family age subgroups. The final analytic step
comment when a family member eats something unhealthy” was to predict differences in families with children 5 – 12
as strategies. We measured the use of bribing, monitoring, and 13 –17 years old using Cohen and Cohen’s (1983)
and persistence using items that asked participants how methods of hierarchical regression. We included the two
often they used “offering a bribe to get them to eat a healthy value contexts first, then the three strategy types as
food,” “monitoring what your family members eat,” and predictors in multiple linear regression models. We tested
“serving a food again until your family tries it” as strategies. to see if any demographic variables were significantly
In addition to strategy questions, we asked one quantitative correlated with any of the healthy eating outcomes. None
question also modified from the family food interaction was significantly related so demographic values were not
scale (Gillespie & Achterberg, 1989) about mealtime included in the final models.
interaction. The item asked, “Over the past month, how
many meals per week did you share with your children?”
Family value contexts for discussing healthy eating. To Results
assess the expression of motivators about healthy eating
used by FFPs, we created five questions that asked Responses to survey approaches
participants, “When you discuss healthy food choices with
your family, how often is it in relation to 1) preventing A total of 2275 households were selected for approach to
illness, 2) good performance at school/work, 3) physical form the evaluation cohort at baseline. Of those households,
strength, 4) feeling good about yourself, and 5) staying thin 927 were eligible, and 870 of these eligible households
or other physical appearance issues.” We scored responses provided surveys. A total of 1098 households were
on a four-point scale from 1 (very little of the time) to 4 (all ineligible for the survey (1% out of age range, 4% unable
of the time). to conduct telephone interview, 3% due to language
Demographics. We assessed demographic information of barriers, 58% due to low RO attendance, 4% due to out of
participants, including age, ethnicity, gender, marital status, area address, and 32% indicating that they no longer
268 E. Bourcier et al. / Appetite 41 (2003) 265–272

belonged to the RO). The overall response rate for this current marital/partner status ðF ¼ 15:0; df ¼ 3,236; p ,
survey was 80%. We randomized approximately half of 0:01Þ:
these participants (435) to complete the family portion of
the survey. Of these 435, 153 were not living with a child Scale creation for strategies and values
under 18 or a partner, and so were ineligible to receive the
family section. The remaining 282 were eligible to receive The factor analysis on the thirteen strategy items showed
the family portion of the survey, and they formed the the presence of three factors. One factor, labeled ‘Reliance
evaluation cohort for this study. on self,’ consisted of four items: ‘getting them to eat food
you make,’ ‘setting an example,’ ‘bringing home foods,’
and ‘monitoring’ (reliability ¼ 0.66). The second factor,
Demographics of sample
labeled ‘Pressuring,’ consisted of four items: ‘making a
negative comment,’ ‘trying a little food,’ ‘offering a bribe,’
Table 1 contains the family age subgroups and demo- and ‘serving a food again until your family tries it’
graphic values. The sample was middle-to-older age (reliability ¼ 0.52). The third factor, labeled ‘Positive,’
(average age was 54 years old), and the majority were consisted of four items: ‘making a positive comment,’
white, female, and either married or partnered. Households ‘sharing information,’ ‘suggesting healthy places to eat out,’
with a child under 18 living in the home averaged a moderate and ‘involving in selection’ (reliability ¼ 0.63).
household income between $51,000 –70,000. This differed The factor analysis of the five value contexts showed the
from the overall study population, which averaged a presence of two separate factors. One factor, labeled
moderately low income between $31,000 – 50,000. Of the ‘Feeling and looking good,’ consisted of two items: ‘feeling
FFPs who completed the survey, 46% lived with at least one good about yourself’ and ‘staying thin or physical
child under 18, 9.2% lived with a child only between 0 – 4 appearance issues’ (reliability coefficient 0.58). The second
years, 13.8% lived with a child only between 5 –12 years, and factor, labeled ‘Physical/mental performance,’ consisted of
8.9% lived with a child only between 13– 17 years. FFPs who three items: ‘good performance at school/work,’ ‘physical
had a child (or children) in the 0– 4, 5– 12, and 13– 17 age strength,’ and ‘preventing illness’ (reliability coefficient
groups differed significantly from FFPs with no children 0.66).
aged 0 – 17 according to age ðF ¼ 62:3; df ¼ 3,236; p , Table 2 presents scale means for the strategy and value
0:01Þ; ethnic category ðF ¼ 3:0; df ¼ 3,236; p , 0:05Þ; and scales by age of child in home. The most commonly used

Table 1
Characteristics of sample

Variable Total cohort Household only has child Household only has child Household only has child Household has no child
ðn ¼ 282Þ 0–4 ðn ¼ 26Þ 5– 12 ðn ¼ 39Þ 13–17 ðn ¼ 25Þ 0–17 ðn ¼ 151Þ

Mean age** (yrs) 54.4 35.4 46.2 48.4 64

Gender (%)
Male 16.3 7.7 15.4 12 20.7
Female 83.7 92.3 84.6 88 79.3
Marital status** (%)
Married/have partner 93.3 100 74.4 88 100
Do not have spouse/partner 6.7 0 25.6 12 0
Household Income (%)
, $15,000 0.7 0 2.6 4 0
$15,000– 30,000 11.4 3.9 7.7 4 12.7
$31,000– 50,000 24.8 23.1 15.4 20 28
$51,000– 70,000 20.2 15.4 28.2 36 18
$71,000– 99,000 15.6 19.2 20.5 16 13.3
$100,000 or above 15.6 30.8 18.0 12 12
Refused 11.7 7.7 7.7 8 16
Ethnicity* (%)
White 85.1 73.1 94.9 72 89.3
Black 5.3 15.4 2.6 4 4.7
Asian or Pacific Islander 6 11.5 0 12 4.7
American Indian 0.4 0 0 4 0
Hispanic 0.4 0 0 0 0
Multi-ethnic 1.4 0 0 0 1.3
Other 1.1 0 2.5 4 0

* p , 0:05; * * p , 0:01:
 E. Bourcier et al. / Appetite 41 (2003) 265–272 269

Table 2 predicted fat consumption. All other predictors were

Strategies and value scores (mean, SD) for healthy eating nonsignificant.
Age of child(ren) in home In the second regression we predicted children’s fruit and
vegetable consumption using the two value scales in the first
0–4 years 5 –12 years 13 –17 years step and adding the three strategy scales in the second step.
ðn ¼ 26Þ ðn ¼ 39Þ ðn ¼ 25Þ In the first step, ‘Feeling and looking good’ significantly
predicted fruit/vegetable consumption. The second step
Strategy scale
Reliance on self 2.6 (0.5) 2.8 (0.5) 2.6 (0.6) adding ‘Pressuring’ was a significant strategy prediction of
Pressuring* 1.6 (0.4) 1.8 (0.5) 1.5 (0.5) fruit/vegetable consumption, but the ‘Feeling and looking
Positive 2.0 (0.5) 2.3 (0.6) 2.4 (0.8) good’ scale became nonsignificant. This change in import-
Value context ance with the addition of the ‘Pressuring’ strategy scale is
Physical/mental performance 1.6 (0.6) 2.0 (0.5) 2.3 (0.7) clear evidence of mediation, in that the influence of ‘Feeling
Feeling and looking good 2.4 (0.8) 1.9 (0.7) 2.2 (0.9) and looking good’ occurred through the strategy of
*Significant effect of family type on scale score ðp ¼ 0:0001Þ: ‘Pressuring’.

strategy was to rely on the FFP to show or lead the child in

healthy eating. The least commonly used strategy was to Discussion
pressure children directly to eat healthy foods. Only
‘Pressuring’ was related significantly to age of target This study examined how FFPs may try to influence the
child, increasing in children aged 5– 12 years. dietary habits of children living with them. We hoped to
The final analytic step of regression models to predict identify what strategies FFPs use to try and influence
healthy eating in children is presented in Tables 3 and 4. healthy eating in their children. We also hoped to shed more
FFP age, gender, marital status, income, and ethnicity were light on the relationship between strategies used by FFPs
not significantly correlated with any of the outcomes so we and the actual consumption of healthy foods.
did not include these variables in the models. Strategies
included in all models were ‘Reliance on self,’ ‘Pressuring,’ Strategies most frequently used by FFPS
‘Positive,’ and the value contexts ‘Physical/mental per-
formance’ and ‘Feeling and looking good.’ The first The most commonly used strategies had much to do with
regression model predicted children’s consumption of fat. FFPs taking responsibility for the children’s healthy eating
The first regression step regressed children’s fat themselves by using strategies like bringing home healthy
consumption on the value context variables, hypothesizing foods, making food, monitoring what their families eat, and
that they provide background for the choice of food preparer trying to set a good example. This finding could be explained
strategy. The FFP ‘Physical/mental performance’ value by FFPs feeling that they do have a lot of control over what
significantly predicted children’s fat consumption, but the their family members eat. The strategies that were pressuring
‘Feeling and looking good’ value did not. In the second step, in nature were used less frequently than the positive interaction
both the value scales and the specific strategy scales were strategies, as predicted. The pressuring strategies, like making
entered into the regression equation. The ‘Physical/mental a negative comment when a family member eats something
performance’ still significantly predicted fat consumption. unhealthy, making them finish everything on their plate, and
In addition, the ‘Reliance on self’ strategy significantly offering a bribe to get them to eat a healthy food, were used less

Table 3
Strategies and value context predictors of fat consumption in children

Step 1 Step 2

B SE P B SE P

Value contexts
Physical/mental performance 22.37 0.13 0.03* 22.36 0.04 0.01**
Feeling and looking good 21.21 0.18 0.06 0.14 0.10 0.23
Strategies
Reliance on self – – – 21.35 0.07 0.02*
Pressuring – – – 20.07 0.08 0.61
Positive – – – 0.03 0.10 0.83
R2 ¼ 0:21 R2 ¼ 0:17

*Significant at the 0.05 level; **significant at the 0.01 level.

270 E. Bourcier et al. / Appetite 41 (2003) 265–272

Table 4 fruit/vegetable consumption is not direct, making interven-

Strategies and value context predictors of fruit/vegetable consumption in tion strategies along these lines difficult.
children
The use of ‘Pressuring’ strategies related to physical
Step 1 Step 2 appearance may be complicated because, by this age, many
children have concerns about independence, control over their
B SE P B SE P own lives, and weight. Girls especially begin to balance
hormonally driven weight gain with diet concerns, dietary
Value contexts
Physical/mental performance 1.31 0.03 0.0* 0.20 0.05 0.08
restriction, and eating disorders. At least three studies have
Feeling and looking good 2.41 0.04 0.004** 0.21 0.03 0.19 shown that parental attempts to control and restrict children’s
food intake increases with increasing child obesity, especially
Strategies
Reliance on Self – – – 0.20 0.12 0.28
if the child is a girl (Fisher & Birch, 1999a,b; Johnson & Birch,
Pressuring – – – 1.44 0.04 0.02* 1994). There is a growing body of evidence suggesting that
Positive – – – 0.04 0.10 0.82 FFPs who worry about and try to control their own weight may
R2 ¼ 0:08 R2 ¼ 0:32 also try to control their daughters’ weight in ways that may
*Significant at the 0.05 level; **significant at the 0.01 level. include restrictive control in child feeding, discussing healthy
eating in terms of lowering fat, encouraging daughters to diet,
frequently than the positive interaction strategies. The FFPs and providing coaching on how to do so (Birch & Fisher, 2000;
might simply be choosing strategies that work because Pike & Rodin, 1991).
previous research showed that when a child experiences a
negative meal situation, it decreases the child’s preferences for Limitations
the food consumed under the negative circumstances (Casey
& Rozin, 1989). One limitation to be addressed in future research is the
reporting of children’s eating by the FFP. It was beyond the
Strategies and family subgroups scope of the study to measure dietary habits of all family
members directly. One study did address parent – child
We hypothesized that the family subgroups (based on concordance in reporting (Van Horn et al., 1990) and
age of children living with the FFP) would have a significant concluded that agreement was sufficient to have confidence
effect on which strategies were most commonly used. There in the child report for future research.
was a significant difference between frequency of ‘Pressur- The findings of this study are limited by the nature of self-
ing’ strategies for the 5 – 12 age group, but we did not see an reported data from FFPs who may consciously or uncon-
effect of family subgroup on the other strategies in the sciously give socially desirable responses. FFPs may want to
subgroups 0 –4, 5 – 12, or 13– 17. In our study, strategy of answer in a socially desirable way, to appear as if they are
family influence was mostly consistent across age groups as ‘doing the right thing.’ Limitations of the internal validity of
was the report of values. this study included the moderate reliability of strategy
subscales and the small sample sizes of the family subgroups.
Strategies and values related to healthy eating in children Limitations to the external validity of this study are that all
participants were members of a FC, middle-to-older age,
The regression models provided evidence for the import- primarily White, and married or living with a partner.
ance of values and specific strategies and, in the case of fruit The strategies surveyed in this study do not represent an
and vegetable consumption, a mediating relationship. For fat, exhaustive list. Although FFPs surveyed in this study did
valuing ‘Physical/mental performance’ and the strategies most indicate they used the strategies presented, there may be
reliant on the FFP significantly and independently predicted other strategies that FFPs use, which they would use more
fat consumption of the children. This could be a positive route often than any strategies presented here and which may be
to consider when planning interventions: instead of a focus on more effective at predicting teenagers’ consumption of
appearance, valuing performance could be enhanced and fruits/vegetables and fat.
promoted to lower fat consumption. Using strategies that rely
on the food preparer to reduce fat consumption may reflect the Implications for practitioners
relative complexity of fat sources in food.
Fruit/vegetable consumption models indicate that The findings shed light on which specific mechanisms of
appearance-oriented values predict consumption and that family support and interaction actually influence dietary
the strategy of pressuring children mediates the relationship habits of children. Practitioners can continue to increase the
between appearance values and fruit/vegetable consump- impact of a dietary intervention that involves FFPs by
tion. FFPs may be hoping that increasing fruit/vegetable promoting or developing specific strategies to increase
consumption will improve appearance and that pressuring healthy eating in children.
children will improve consumption. The relationship of The findings suggest targeting families with children to
appearance (perhaps appearance as it relates to obesity?) to emphasize discussing healthy food related to physical and
 E. Bourcier et al. / Appetite 41 (2003) 265–272 271

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