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. Author manuscript; available in PMC: 2025 Feb 1.
Published in final edited form as: J Nutr Educ Behav. 2023 Dec 23;56(2):100–109. doi: 10.1016/j.jneb.2023.10.018

HOUSEHOLD FOOD INSECURITY AND MATERNAL-TODDLER FRUIT & VEGETABLE DIETARY CONCORDANCE

Carol Duh-Leong 1,*, Robin Ortiz 1,2,3,*, Mary Jo Messito 1, Michelle W Katzow 4, Christina Kim 1,2, Radhika Teli 1,2, Rachel S Gross 1,2
PMCID: PMC10922249  NIHMSID: NIHMS1943580  PMID: 38142387

Abstract

Objective:

To examine whether prenatal or concurrent household food insecurity influences associations between maternal and toddler fruit and vegetable (FV) intake

Design:

Application of a life course framework to an analysis of a longitudinal dataset

Setting:

Early childhood obesity prevention program at a New York City public hospital

Participants:

156 maternal-toddler dyads self-identifying as Hispanic or Latino

Variables Measured:

Maternal and toddler FV intake was measured using CDC dietary measures at toddler age of 19 months. Household food insecurity (measured prenatally and concurrently at 19 months) was measured using the USDA Food Security Module.

Analysis:

Regression analyses assessed associations between adequate maternal FV intake and toddler FV intake. Interaction terms tested whether prenatal or concurrent household food insecurity moderated this association.

Results:

Adequate maternal FV intake was associated with increased toddler FV intake (B= +6.2 times per week, 95% CI: 2.0, 10.5, p=0.004). Prenatal household food insecurity was associated with decreased toddler FV intake (B= −6.3 times per week, 95% CI: −11.67, −0.9, p=0.02). There was a significant interaction between the level of maternal-toddler FV association (concordance or similarity in FV intake between mothers and toddlers) and the presence of food insecurity such that maternal-toddler FV association was greater when prenatal household food insecurity was not present (B= −11.6, p=0.04).

Conclusions and Implications:

Strategies to increase FV intake across the life course should examine how timing of household food insecurity may affect intergenerational maternal-child transmission of dietary practices.

Background

Fruits and vegetables deliver vital nutrients and prevent chronic conditions like cardiovascular disease and cancer over the life course.1,2 Given that 80-90% of children in the United States (US) fail to meet fruit and vegetable intake standards, major research efforts have focused on increasing fruit and vegetable intake early in life.3-5 Current approaches suggest that parents, as gatekeepers of food and role models of dietary content, shape a child’s dietary practices and that parent-child diets are likely to have concordance, or consistency and agreement in quality and content.6 Reviews of these studies show that while dietary influences become increasingly complex in school-age and adolescence, parental dietary content is still likely an important driver of a child’s dietary content particularly during the earlier school and preschool years.6,7 However, there is a gap in evidence establishing maternal-child dietary concordance prior to preschool when dietary routines are established8,9 and when disparities in healthy dietary content emerge.10 Examining maternal-child dietary concordance beginning in toddlerhood, when children have first transitioned away from their milk-based diet to solid foods, would inform strategies to optimize maternal-toddler nutrition from the start.

Maternal-toddler dietary patterns exist within a broader dynamic household context that may change over time based on economic and societal circumstances.11 Household food insecurity, or insecure access to food due to economic disadvantage, reflects a psychological experience of not being able to meet basic needs. Direct associations between household food insecurity and a child’s dietary content have been inconsistent with a few studies detecting associations but the majority reporting null results.12 However, food insecurity in adults has been found to decrease dietary quality likely due to decreased access to fresh fruits and vegetables,13 which in turn may weaken parent modeling and increase gatekeeping of fruits and vegetables for their toddlers.12 Pregnancy is a vulnerable time period where experiences of household food insecurity have been shown to have lasting effects beyond pregnancy, influencing trajectories of maternal-child health outcomes.14,15 After birth and early in life, a child’s dietary routines are embedded within a feeding interaction between a parent and toddler.16 Stress from household food insecurity during toddlerhood may interfere with a parent’s capacity to respond dynamically to a toddler’s feeding cues, which are foundational to positive and healthy transitions to solid foods.17 Understanding whether maternal-toddler dietary concordance is affected by whether household food insecurity occurs prenatally or in toddlerhood would inform the strategic timing of nutritional interventions as they increasingly emphasize a multi-generational approach.18

To address these gaps, we examined data from maternal-toddler dyads participating in a primary care-based early child obesity prevention program designed for Hispanic families at a New York City (NYC) public hospital. We applied a life course framework19,20 to design our study, which posits that experiences during sensitive periods of development have an outsized impact on the health of shared lives (e.g., a parent and toddler) over the life course. We hypothesized that 1) there would be maternal-toddler fruit and vegetable dietary concordance in our sample: adequate maternal fruit and vegetable intake would increase toddler fruit and vegetable intake; 2) experiences of prenatal and concurrent food insecurity would not only decrease fruit and vegetable intake in mothers and toddlers but also moderate and diminish maternal-toddler dietary concordance.

Methods

Study Design and Setting.

This study applied life course principles (Table 1) to a secondary analysis of maternal and toddler data from the Starting Early Program obesity prevention trial. The Starting Early Program is a health care-based intervention where bilingual English/Spanish-speaking registered dietitians and certified lactation counselors provide individual and group-based support for healthy nutrition, lifestyle, and stress reduction. The original Starting Early Program randomized controlled trial is the only large-scale trial of early child obesity prevention to show child weight impacts in families at high risk for obesity.21,22 The Starting Early Program-Prenatal cohort is a single-arm feasibility study that expands the original Starting Early Program model by adding 8 new sessions during pregnancy to the pediatric sessions of the original model. These group sessions expanded a family-centered, strengths-based program to a multi-generational approach that also focuses on the pregnant person’s health and wellbeing with dietary counseling in coordination with prenatal and pediatric health care visits.

Table 1:

Application of Life Course Principles to our Overall Study Design

Principle Approach Application
Health is a multi-level process Multi-level We examine associations between variables at multiple levels. Maternal-toddler dietary concordance is at the parent and child level. Household food insecurity is at the household level.
Family-centered Our main outcome and study question acknowledges that family health outcomes are interconnected; findings would contribute to knowledge about the family context of fruit and vegetable consumption.
Equity-focused and Anti-racism We acknowledge institutional racism as a contributor to disproportionate rates of household food insecurity among Hispanic families in the US. Findings interpreted within the context of cultural assets and experiences.
Health occurs in stages Longitudinal effects We examine the effects of antecedent experiences of food insecurity during pregnancy on maternal-toddler dietary concordance.
Developmentally focused We focus on toddlerhood, a phase when children have transitioned from milk-based feeding to a solid food diet, when dietary routines are being established and disparities emerge.
Strategically timed We aim to generate knowledge about two key time periods – pregnancy and toddlerhood – to contribute to future knowledge about impactful intervention timing
Health is a positive process Optimization We selected fruit and vegetable intake rather than a health problem (e.g., obesity) as our outcome, because this is a positive variable that optimizes health over the life course.
Strengths-based Framing healthy rather than unhealthy dietary practices in the parent as a predictor variable highlights parent strengths as a contributor to health.
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Table 1 outlines our application of key life course principles to our study design.20 A life course framework approaches health as a positive developmental process occurring at multiple levels (e.g., child, parent, household) and stages (e.g., prenatal, toddlerhood).19,20 Our study design engaged these principles to approach health as multi-level (e.g., family-centered, equity-focused), occurring in stages (e.g., with longitudinal effects), and as a positive process (e.g., a strengths-based approach to defining our variables).23

To address our research questions, we first examined associations between maternal and toddler fruit and vegetable intake to assess concordance. We then examined direct associations between timing of household food insecurity with maternal-toddler fruit and vegetable intake and then applied moderation analyses to test whether experiences of household food insecurity in pregnancy or toddlerhood diminished associations between maternal and toddler intake.

Participants.

Pregnant participants were eligible for the Starting Early Program-Prenatal cohort if they were in the first trimester of pregnancy, self-identified as Hispanic or Latina, were English or Spanish speaking, and intended to have prenatal and pediatric care at Bellevue Hospital Center, the flagship public hospital of New York City. We use the term Hispanic in this manuscript to describe our Spanish-speaking sample, acknowledging the limitations of using either Hispanic or Latina to generalize any sample of individuals as well as the limitations posed by not knowing if somebody considers themselves to be Hispanic White, Hispanic Black or Multiracial (race and ethnicity was assessed only as part of the eligibility criteria). Exclusion criteria included severe illness (e.g., mental illness/substance use), current residence in the shelter system, age less than 18 years, or uncertainty of last menstrual period.

Interested and eligible participants enrolled between December 2018 and February 2020. We recruited and enrolled 233 participants that completed the prenatal baseline assessment. This secondary analysis was completed with dietary data collected from the 157 participants that were followed with their children up to child age 19 months (67% retention). We performed a complete case analysis with 156 participants without missing data for our variables of interest. The Institutional Review Board at NYU Grossman School of Medicine and NYC Health + Hospitals/Bellevue deemed the study to be minimal risk and approved it with an expedited review. Written informed consent was required from adult parent participants, child assent was not required from their infants or toddlers.

Weekly Toddler Intake of Fruits and Vegetables.

We assessed weekly toddler intake of fruits and vegetables when the child was 19 months old. We used questions from the Center for Disease Control (CDC)’s Infant Feeding Practices Study II, which assesses infant feeding and care practices.24 To assess weekly fruit intake, mothers were asked, “In the past 7 days, how many times has your toddlers eaten fruit?” To assess weekly vegetable intake, mothers were asked, “In the past 7 days, how many times has your toddler eaten vegetables?” There are limited guidelines to define adequate fruit and vegetable intake for toddlers. The US Department of Agriculture (USDA) recommends an “increased amount of vegetables and fruits25” and CDC recommendations for fruit and vegetables do not begin until 2 years of age.26 However, parentfacing suggestions endorsed by the American Academy of Pediatrics (AAP) recommend incorporating fruits and vegetables 2 times a day each as part of snacks and meals.27 In our sample, consistent with these suggestions, the top quartile of fruits and vegetables intake was 4 times a day (2 times a day for fruits and vegetables, respectively). To preserve granularity and detail in our analyses, we evaluated this variable continuously as well as using these cutoffs.

Adequate Maternal Fruit and Vegetable Intake.

Our binary predictor variable was adequate maternal fruit and vegetable intake assessed when their toddler was 19 months old. We used the dietary assessment from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS),28 which collects data about health-related behaviors and conditions. The BRFSS contains 5 items that assess the number of times respondents consumed fruits and vegetables by day, week, or month: 1) fruit (non-juice); 2) canned beans (e.g., baked, garbanzo); 3) dark green vegetables (e.g., broccoli, spinach); 4) orange-colored vegetables (e.g., sweet potatoes, carrots); and 5) other vegetables that are not fried (e.g., corn, eggplant). Using BRFSS cutoffs used in prior literature as well as nutrition recommendations from the American Heart Association and the USDA, we defined adequate maternal fruits and vegetable intake as 5 or more times a day.29-32

Household Food Insecurity.

We assessed household food insecurity in pregnancy and in toddlerhood using the USDA Core Food Security Module.33 This module includes 10 questions about household food security over the previous 12 months. We described household food insecurity by levels (high food security, marginal, low, and very low), but given insufficient variability across these levels, we classified households as food insecure if they reported 3 or more food insecure conditions, the validated dichotomous cutoff by the USDA.33

Study Covariates.

We modeled study covariates referencing prior work on maternal-child diets and food insecurity.7,34,35 We adjusted for maternal age, education (high school or less, more than high school completion), marital status (single, married or living as married), household size (adults and children), and years in the US (US born, less than a decade, more than a decade in the US). We also adjusted for whether the toddler was firstborn given that mothers may feed children differently based on prior feeding experiences. Finally, we adjusted for intervention dose because a core component of the Starting Early Program-Prenatal intervention is dietary counseling.

Statistical Analysis.

First, we summarized sociodemographic and dietary information in our sample. To test maternal-toddler dietary concordance, we referenced studies assessing dietary concordance in other dyads (e.g., parent-child, spouses).36-39 We did not utilize methods that assessed the extent of precise dietary agreement given that maternal-toddler dietary practices occur at distinct developmental stages with different dietary needs. Instead, we adopted approaches that used adjusted regression analyses to test if maternal fruit and vegetable intake was associated with toddler intake. We also created a maternal-toddler dietary concordance variable as has been done prior36-39 indicating when dyads both had either adequate or inadequate intake based on cutoffs defined above.

We then performed adjusted regression analyses to examine whether timing of household food insecurity was associated with maternal-toddler fruit and vegetable intake as well as maternal-toddler dietary concordance. We categorized a predictor variable as neither (no food insecurity prenatally or in toddlerhood), prenatal only (yes in prenatal, no in toddlerhood), toddlerhood only (no in prenatal, yes in toddlerhood), both (yes in prenatal, yes in toddlerhood).

We examined moderation by running models with interaction terms defined for the binary predictor (adequate maternal fruit and vegetable intake) and a binary moderator (presence or absence of household food insecurity prenatally or concurrently). We stratified models for significant interaction terms: in the presence and absence of household food insecurity, we tested for whether maternal intake was associated with toddler intake, adjusting for the same covariates. In these models, we also controlled for household food insecurity in the time period not being tested as a moderator (e.g., when testing prenatal household food insecurity as a moderator, we included concurrent household food insecurity as a covariate alongside others described above). Statistical analyses were performed using Stata/SE version 15 (Stata Corp, College Station, TX).

Results

Study Sample.

Table 2 displays a summary of our sample characteristics. In our sample of self-identified mothers, the mean age was 30.8 years (Standard Deviation [SD] = 6.0). Less than a quarter (23.1%) were born in the United States, and almost three quarters (71.8%) were born in Central American countries. About a quarter (25.6%) had less than a high school education. Over a quarter (27.6%) of toddlers and 17.3% of mothers had adequate fruit and vegetable intake. The majority (73.1%) of maternal-toddler dyads had fruit and vegetable dietary concordance (both adequate or inadequate intake of fruits and vegetables).

Table 2:

Sociodemographic Characteristics of Maternal-Child Dyads Followed into Toddlerhood From the Starting Early Program-Prenatal Cohort (n=156)

n (%) or mean (SD)
Maternal
Age 30.8 (6.0)
Less than high school education 40 (25.6)
U.S. born 36 (23.1)
 Mexico 56 (35.9)
 Ecuador 32 (20.5)
 Dominican Republic 8 (5.1)
 Other-Central America (Guatemala, El Salvador, Costa Rica, Honduras, Columbia) 16 (10.2)
 Other-South America (Peru, Venezuela, Paraguay) 8 (5.1)
Married or Living as Married 115 (73.7)
Toddler
First child 59 (37.8)
Assigned female sex at birth 65 (42.0)
Household Food Insecurity 1
Prenatal Food Insecurity (yes/no) 33 (21.2)
  High food security 88 (56.4)
  Marginal food security 35 (22.4)
  Low food security 25 (16.0)
  Very low food security 8 (5.1)
Concurrent Food Insecurity in Toddlerhood (yes/no) 44 (28.2)
  High food security 84 (53.9)
  Marginal food security 28 (17.9)
  Low food security 32 (20.5)
  Very low food security 12 (7.7)
Food Insecure both prenatally and in toddlerhood (yes/no) 16 (10.3)
Dietary Data
Maternal Daily Intake2
  Fruit 1.6 (2.9)
  Total Vegetables 2.1 (2.0)
   Beans 0.5 (0.8)
   Green Vegetables 0.7 (0.8)
   Orange Vegetables 0.4 (0.5)
   Other Vegetables 0.6 (1.2)
Toddler Weekly Intake3
  Times Fruit Eaten Per Week 12.0 (6.2)
  Times Vegetables Eaten Per Week 8.2 (5.4)
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1

Assessed using the United States Department of Agriculture Core Household Food Security Module

2

Assessed in mother when child is 19 months old using the Center for Disease Control’s Behavioral Risk Factor Surveillance System

3

Assessed of toddler at 19 months by mother using the Center for Disease Control’s Infant Feeding Practices Study II

Maternal-Toddler Fruit and Vegetable Dietary Concordance.

Table 3 displays how toddlers of mothers with adequate fruit and vegetable intake consumed fruits and vegetables on more occasions per week than toddlers of mothers without adequate intake (p=0.004). We found similar results for fruits (p=0.03) and vegetables (p=0.003) individually. When examining whether adequate maternal fruit and vegetable intake was associated with adequate toddler intake, we found that adequate maternal intake increased odds of adequate toddler fruit and vegetable intake (p=0.001) and adequate vegetable intake (p=0.003), but not odds of adequate fruit intake.

Table 3:

Maternal FV Intake Predicts Child FV Intake Demonstrating Maternal-Toddler Fruit & Vegetable Dietary Concordance (n=156)

Maternal
Predictor		 Toddler Dietary Outcome
Adequate Fruit and Vegetable Intake1 Change in weekly fruits and vegetables intake1 B, 95% CI Change in weekly fruit intake1 B, 95% CI Change in weekly vegetable intake1 B, 95% CI
+ 6.2**
(2.0, 10.5)		 + 2.9*
(0.3, 5.5)		 + 3.3**
(1.1, 5.6)
Odds of adequate weekly fruits and vegetables intake2 4+/week; aOR 95% CI Odds of adequate weekly fruit intake2 2+/week; aOR 95% CI Odds of adequate weekly vegetable intake2 2+/week; aOR 95% CI
4.8**
(1.9, 12.6)		 1.9
(0.7, 4.7)		 4.5**
(1.7, 12.1)
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1

Assessed of toddler at 19 months by mother using the Center for Disease Control’s Infant Feeding Practices Study II, continuous unstandardized B assessed with linear regression adjusted for maternal age, education, marital status, years in the US, firstborn status, number of household members, and intervention dose

2

Dichotomous cutoffs guided by American Academy of Pediatrics suggestions, odds of adequate toddler weekly intake assessed with logistic regression adjusted for maternal age, education, marital status, years in the US, firstborn status, number of household members, and intervention dose

*

p<0.05

**

p<0.01

Household Food Insecurity and Maternal-Toddler Fruit and Vegetable Intake.

Table 4 displays how prenatal household food insecurity had associations with decreased weekly toddler fruit and vegetable intake (p=0.02), even when controlling for experiences of household food insecurity concurrently in toddlerhood or at both time points. We did not detect associations between timing of household food insecurity and adequate maternal fruit and vegetable intake or maternal-toddler dietary concordance.

Table 4:

Prenatal Household Food Insecurity Associated with Decreased Weekly Toddler FV Intake

Household Food
Insecurity Timing		 Outcome
Prenatal Toddler n Weekly Toddler Fruit and Vegetable Intake
(Continuous, B, 95% CI)1
No No 95 REFERENCE
Yes No 17 −6.3*
(−11.7, −0.9)
No Yes 28 −0.9
(−5.4, 3.5)
Yes Yes 16 −3.8
(−9.3, 1.8)
Prenatal Toddler n Adequate Maternal Fruit and Vegetable
Intake (Dichotomous, aOR 95% CI)2
No No 95 REFERENCE
Yes No 17 0.9
(0.2, 3.7)
No Yes 28 0.3
(0.1, 1.6)
Yes Yes 16 0.4
(0.1, 2.1)
Prenatal Toddler n Maternal-Toddler Dietary Concordance
(Dichotomous, aOR 95% CI)3
No No 95 REFERENCE
Yes No 17 1.3
(0.4, 4.5)
No Yes 28 1.2
(0.4, 3.3)
Yes Yes 16 1.0
(0.3, 3.6)
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1

Assessed of toddler at 19 months by mother using the Center for Disease Control’s Infant Feeding Practices Study II, continuous unstandardized B assessed with linear regression adjusted for maternal age, education, marital status, years in the US, firstborn status, number of household members, and intervention dose

2

Assessed in mother when child is 19 months old using the Center for Disease Control’s Behavioral Risk Factor Surveillance System; adequate defined as at least 5 per day. Assessed with logistic regression adjusted for maternal age, education, marital status, years in the US, firstborn status, number of household members, and intervention dose

3

Maternal-Toddler fruit and vegetable concordance defined as both mother and child having adequate or inadequate fruit and vegetable intake. Dichotomous cutoff of 4x/day guided by American Academy of Pediatrics suggestion.

*

p<0.05

Moderation by Household Food Insecurity.

Unadjusted interaction terms were statistically significant for household food insecurity at both time points (Prenatal [B= −11.5, p=0.03]; Toddlerhood [B=−11.5, p=0.048]). Adjusted interaction terms were only statistically significant for prenatal household food insecurity (Figure 1, B= −11.6, p=0.04). Figure 1 displays how prenatal household food insecurity moderated maternal-toddler fruit and vegetable dietary concordance, diminishing the association between adequate maternal intake and toddler intake of fruits and vegetables. Stratified analyses showed that when prenatal food insecurity was not present, adequate maternal intake increased toddler fruits and vegetables intake 8.7 more times per week [95% CI: 3.8, 13.5, p=0.001]. When prenatal food insecurity was present, adequate maternal intake was not associated with toddler fruits and vegetables intake [B = −1.4 times per week, 95% CI: −11.5, 8.6, p=0.7].

Figure. Moderation of Maternal-Toddler Fruit &Vegetable Dietary Concordance.

Figure

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Prenatal food insecurity moderates association between maternal and toddler fruit and vegetable intake (Interaction term, B= −11.6, p=0.04). Significant stratified associations marked with **p<0.01

Discussion

In a sample of mother-toddler dyads participating in an early obesity prevention program supporting Hispanic families at a NYC public hospital, we detected fruit and vegetable dietary concordance: maternal fruit and vegetable intake was positively associated with toddler fruit and vegetable intake. Experiences of prenatal household food insecurity diminished the association between maternal and toddler fruit and vegetable intake. These findings encourage future studies to not only examine how the promotion of maternal nutrition may be an important component of toddler nutrition, but also to assess how experiences of household food insecurity may influence the longitudinal development of dietary patterns for both mothers and their children.

Despite ample evidence supporting parental dietary content as a predictor of child dietary content in early school and preschool years, few have examined these associations before age 2 years when dietary routines are established.6,8,9,34,40,41 Furthermore, many of the studies in preschool children have limitations in their interpretation of maternal-child dietary associations because maternal diets were measured prenatally and not concurrent to when the toddler diets were assessed. For example, prenatal diets are associated with child food preferences at age 5 years, and researchers have subsequently hypothesized that prenatal dietary exposures influence future child flavor preferences around fruits and vegetables.42,43 One smaller study (n=52) found that the majority of the effect of prenatal diet on toddlers at ages 2-3 years was mediated through maternal postnatal diet, particularly for fruits and vegetables.44 Our findings bolster this theory with data in a younger age group (19 months), and by collecting maternal dietary data at the same time point as toddler dietary data to increase temporal plausibility that early dietary patterns have learned behavior components as well as preferences potentially established in utero. Our data, which implies that this process may begin as early as 19 months of life, also supports future studies to follow maternal-child dyads longitudinally to examine how maternal-child dietary patterns may converge and diverge by developmental stage.

We detected associations between prenatal household food insecurity and decreased toddler weekly intake of fruits and vegetables. These significant child-level results contribute to the balance of current literature showing inconsistent effects of household food insecurity on child diet content and quality. While prior interpretations hypothesize that inconsistent associations are due to intrahousehold re-allocation buffering the adverse effects of household food insecurity to benefit pregnant family members or young children,12 our findings taken together suggest additional complex factors may be at play particularly around fruit versus vegetable consumption. For example, adequate maternal fruit and vegetable intake increased odds of adequate toddler vegetable intake but not fruit intake. Sensory profiles show that vegetables are characterized by relatively high bitterness (an instinctively disliked taste) compared to other food categories like fruits.5 Thus, toddlers may welcome fruits more readily than vegetables, which may require additional maternal consumption to increase potent exposure and associative conditioning to encourage vegetables preferences.28,29 It may be cost and time prohibitive for under-resourced families to repeatedly expose toddlers to healthful foods with the aim of expanding diets with a variety of fruits and vegetables. Interventions to financially support families in purchasing fruits and vegetables have demonstrated modest success,45-47 and this data supports future investments in supplementing nutritional support with financial support to account for anticipated waste during fruit and particularly vegetable introduction.

This study enrolled parents and toddlers from Hispanic families. In the US, Hispanic families have been disproportionately impacted by food insecurity, particularly in households with young children.23 More than three-quarters of mothers in our sample were born outside the US in Latin American countries with unique immigrant experiences. These families likely have community-specific cultural routines and beliefs around fruits and vegetables that would influence interpretation of our findings. Prior studies show that immigrant parents are often navigating bicultural feeding advice and values when developing feeding practices,48 and that immigrant and first-generation mothers adopt different degrees of pressuring and indulgent feeding styles.49

In moderation analyses, we found that only prenatal household food insecurity diminished the association between maternal and toddler weekly intake of fruits and vegetables. This reinforces prior work highlighting pregnancy as a vulnerable time period to experience economic and material hardships, which has been found in the past to increase obesogenic feeding styles after birth as well as decrease maternal perceptions of control around their child’s health.50,51 Experiences of household food insecurity have been associated with increased parenting stress,35,52 which is known to curtail parenting capacity and decrease the quality of parent-child interactions, potentially influencing whether parent dietary content is mirrored by the toddler.30,31 Pregnancy has also been found to be a time when parenting self-efficacy (i.e. individual confidence in parenting ability) develops,53 and the experience of household food insecurity may hinder maternal confidence from self-identifying as a caregiver role model.

In contrast to prenatal household food insecurity, we did not find a significant moderation effect in concurrent household food insecurity after adjusting for covariates. This reinforces existing literature highlighting pregnancy as a critical time period, but also suggests limitations in our measurement of food insecurity. For example, more details of household food insecurity experiences are needed: prenatal household food insecurity may represent more prolonged adult food insecure experiences or families may allocate food differently in response to household food insecurity during toddlerhood than during pregnancy. We were also limited by our use of the 10-question module, which omits 8 questions that query more about child-level food insecurity.33 Household food insecurity may also reflect overall household economic challenges, which can interfere with shared mealtimes and toddlers may have multiple caregivers who feed them if parents have jobs with unpredictable hours. Our findings support future work to disentangle how food insecurity, stress, and caregiving practices may influence maternal-child dietary concordance.

These findings must be interpreted within the additional limitations of this study not already discussed, which include study setting, sampling, and measurement. The study takes place in a maternal-child obesity prevention program, which may increase selection bias for participants receptive to obesity prevention and therefore with higher likelihood of fruit and vegetable intake. While we adjusted for program dose, a general population may still be less likely to have adequate fruit and vegetable intake than our sample. Our study sample was made up of Hispanic families, which decreases generalizability as racial and ethnic groups may have their own cultural assets and structural disadvantages that influence dietary content. Our dietary measurement tools assessed the number of eating occasions, rather than actual serving sizes and was also parent-reported, which is vulnerable to recall bias. Thus, these findings support future studies to replicate findings using 24 hour dietary recalls or observed feeding sessions.

Implications for Research and Practice

Overall, our findings contribute to mounting evidence that maternal and child nutritional wellness are interconnected early in life, and that more work is needed to understand the adverse effects of household food insecurity on nutrition. These findings contribute evidence showing that multi-level, longitudinal factors are complex and may interact with each other particularly during important life stages like pregnancy and toddlerhood. Given that prenatal household food insecurity was associated with divergence of maternal-child dietary patterns in our sample, future life course strategies to alleviate economic hardship may consider using a multi-level dyadic framework to conceptualize concordance of maternal-child fruit and vegetable consumption patterns (healthy concordant, unhealthy concordant, mother-healthy discordant, and child-healthy discordant).

Applying life course principles to our study design facilitates interpretation and application of our findings, which highlight the value of incorporating family contextual factors into the optimization of child nutrition. In this population of mostly immigrant families, these findings support future work to consider how upstream structural barriers to food resources may impact immigrant families with young children. Future qualitative work may also examine maternal perceptions of how their own dietary content should align with their children’s dietary content within the context of their cultural assets and beliefs.

In this study of mothers and toddlers from an obesity prevention program supporting Hispanic families at a NYC public hospital, we found that adequate maternal consumption of fruits and vegetables was associated with greater weekly intake of fruits and vegetables in toddlers, and that this association was moderated by experiences of prenatal household food insecurity. These findings inform clinicians, researchers, and program stakeholders currently developing strategies to increase fruit and vegetable intake across the life course. Immediately, clinicians may promote maternal fruit and vegetable intake hand-in-hand with toddler fruit and vegetable intake, encourage shared healthy meals, and support referrals to community resources to mitigate household food insecurity. Prenatal and pediatric providers may also develop partnerships to deliver dyadic dietary counseling modeled off of other prenatal-pediatric models like Healthy Steps.54 We encourage researchers to develop dyadic frameworks to conceptualize how social determinants of health may influence concordance of maternal-child dietary patterns rather than just maternal or child outcomes in isolation. These findings support testing life course-based interventions that address economic and material hardships like household food insecurity and examine how social determinants of health broadly influence the intergenerational maternal-child transmission of dietary practices.

Acknowledgments:

We are grateful to the Starting Early Program participants and staff for their important contributions. This work is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture 2017-68001-26350 and the NYU KiDS Foundation. Dr. Duh-Leong acknowledges support from training grants by the National Center for Advancing Translational Sciences, National Institutes of Health 2KL2TR001446-06 and the Life Course Intervention Research Network (Health Resources and Services Administration) UA6MC32492. The funders/sponsors did not participate in the work.

Footnotes

Publisher's Disclaimer: 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.

This study was approved by the Institutional Review Board of NYU Grossman School of Medicine. Informed consent was obtained for all study participants.

Financial Disclosure Statement: The authors have no financial relationships relevant to this article to disclose.

Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

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