Impact of food accessibility on eating and anthropometric outcomes among rural parent-child dyads: a secondary data analysis of a mindful eating intervention

Abstract

Objective

This study examined the effects of food accessibility on eating habits, home eating environment and anthropometrics among rural parent-child dyads.

Design

This secondary data analysis utilised baseline and post-intervention data from a mindful eating intervention trial. Parents completed an online survey assessing their sociodemographics, height, weight, eating habits, food resource management behaviours, child feeding attitudes and practices, home eating environment and household food insecurity. Trained data collectors measured children’s height, weight, percent body fat and skin carotenoids at childcare centres. Using Geographic Information System tools, food accessibility was estimated by linking participants’ zip codes to Zip Code Tabulation Areas.

Results

A total of 154 rural parent-child dyads from low-income households were successfully recruited from 26 Head Start childcare centres in the USA. The children’s mean age was 47.16 months (SD=6.56) while parents averaged 32.68 years old (SD=8.00). About one-third of the parents were single and nearly a third had an annual family income below US$20 000. Additionally, 44.2% of parents were unemployed and over half only had an education level of high school or below. Mixed-effect models revealed that at baseline, limited access to full-service restaurants and greater access to limited-service restaurants were related to higher BMI z-scores (p=0.021, 0.040) and percent body fat (p=0.020, 0.032) in children. Longitudinal analyses using pre-post intervention data indicated that parents’ increases in fibre intake from baseline to post-intervention were correlated with less access to limited-service restaurants (p=0.034), while their improved food resource management behaviours over time were associated with greater access to grocery stores/supermarkets (p=0.043) after accounting for other types of food access. Additionally, more access to convenience stores was associated with increases in perceived parental weight (p=0.027) over time.

Conclusions

These findings suggest that food accessibility influences both dietary behaviours and health outcomes, with grocery stores and full-service restaurants having positive impacts, while limited-service restaurants and convenience stores have detrimental effects.

Trial registration number

The clinical trial associated with the study’s data is registered at ClinicalTrials.gov under the identifier NCT05780008 on 27 February 2023.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Longitudinal data from rural parent-child dyads with low-socioeconomic status were analysed using robust mixed-effects models.

• Food accessibility was objectively categorised into four subgroups: grocery stores/supermarkets, convenience stores, full-service restaurants and limited-service restaurants, using Geographic Information System data.

• The study incorporated both subjective and objective measures to assess eating habits, home eating environment and anthropometrics.

• The lack of a control group may threaten internal validity.

• The study did not assess changes in food accessibility over time, limiting the ability to capture longitudinal relationships.

Introduction

The food environment encompasses the conditions under which consumers interact with the food system, including the availability, affordability, quality and healthfulness of foods, as well as broader issues related to food insecurity.¹ Within this environment, food insecurity, defined as limited or uncertain access to safe, nutritious food, has detrimental impacts on physical and psychological well-being, such as obesity,² poor mental health³ and chronic illnesses.⁴ In the USA, food insecurity disproportionately affects low-income families with children (38.7%), far exceeding the national average of 13.5%.⁵ While food insecurity is more prevalent in rural communities,⁶ it is not exclusively tied to poverty.⁷ Other dimensions of the food environment, particularly food accessibility, also play a critical role.

Food accessibility refers to the availability, affordability and proximity of nutritious foods essential for healthy living.⁸ Proximity to specific food outlet types significantly influences families’ eating habits.⁹ Living in areas with a high density of ready-to-eat food outlets has been associated with adverse health outcomes, including heart failure,¹⁰ type 2 diabetes and obesity.¹¹ For example, residing near convenience stores often leads to increased consumption of processed foods such as snacks and sweets,¹² whereas access to grocery stores is correlated with healthier eating habits, as demonstrated during the coronavirus disease 2019 (COVID-19) pandemic in predominantly African American rural communities.¹² Despite these identified associations, the influence of proximity to restaurant types, both full-service and limited-service, on family food acquisition decisions, eating behaviours and anthropometric outcomes remains underexplored.

The relationship between food accessibility and food security is also shaped by the everyday decisions parents make when obtaining food for their families.¹³ Parents must navigate various considerations when choosing between cooking meals at home or relying on ready-to-eat foods. Barriers such as time constraints, food costs and diverse family food preferences often outweigh the perceived benefits of healthy eating.¹⁴ Given these competing demands, the home eating environment, including parental feeding practices and food resource management behaviours, plays a central role in shaping children’s dietary patterns and weight outcomes. A healthy home food environment is strongly associated with increased fruit/vegetable (F/V) intake and reduced risks of overweight and obesity.¹⁵ However, it is unclear whether and how families’ external food accessibility influences parents’ ability to establish a healthy home eating environment.

To address these gaps in literature, this secondary data analysis used longitudinal data from a previously published clinical trial¹⁶ to examine how food accessibility (ie, grocery stores/supermarkets, convenience stores, full-service restaurants and limited-service restaurants) was related to eating habits (F/V, fibre, sweets, sugar-sweetened beverages, skin carotenoids), elements of the home eating environment (food resource management behaviours, parents’ child feeding attitudes and practices, overall home eating environment, food insecurity) and anthropometric outcomes (body mass index (BMI), BMI-z score, percent body fat) among rural parent-child dyads participating in a mindful eating intervention programme.

Methods

Design

 This was secondary data analysis of data available from a clinical trial conducted with 200 rural children aged 3–5 years old and their parents, as previously reported.¹⁶ Only participants with available home address zip code data were included in the analysis. The clinical trial received approval by a university institutional review board, ensuring adherence to ethical standards. Parental informal consent and child verbal assent when reaching 5 years old were obtained prior to any data collection.

Setting and sample

Children and parents were recruited from 26 rural Head Start childcare classrooms through a study recruitment flyer distributed by teachers. Head Start is a US federally funded programme serving children aged 3–5 years from low-income families. This flyer provided information on the study’s purpose, activities, compensation for participation and a QR code for enrolment, along with study team contact details. Teachers encouraged parents to reach out to the study team for any questions. Children aged 3–5 years old without any health conditions preventing them from making dietary behaviour changes were eligible to participate in the study.

Intervention

The 14-week Eat My ABC mindful eating programme¹⁶ consisted of 14 structured lessons delivered by trained Head Start classroom teachers, with each lesson lasting about 20 min. Following an alphabet-based sequence, the programme introduced children to 26 different F/Vs. Each lesson engaged children in exploring two foods through the five senses (sight, touch, hearing, smell and taste) and concluded with a taste-testing activity grounded in mindful eating principles. After completing the tasting component, children created a ‘home connection’ letter using themed stickers to communicate to their parents what they had learnt in class.

Data collection and measures

After providing informal consent, parents completed an online survey via Qualtrics assessing their sociodemographic characteristics including their home address zip code, height, weight, eating habits, food resource management behaviours, child feeding attitudes and practices, home eating environment and household food insecurity. Then, trained data collectors scheduled an in-person data collection appointment to measure children’s height, weight, percent body fat and skin carotenoids at childcare centres. Data collection occurred at baseline and post-intervention.

Food accessibility

Food outlet data were obtained from the ArcGIS Business Analyst’s Points of Interest dataset,¹⁷ which designated a geographic point for each food outlet’s location on the map. To integrate these data with demographic information, we extracted the 2020 Zip Code Tabulation Areas (ZCTAs) from the US Census Bureau’s TIGER/Line database.¹⁸ Geographic Information System (GIS) tools were then used to match each family’s reported zip code to its corresponding ZCTA. To estimate food accessibility, we applied a place-based approach.¹⁹ A 10-mile buffer polygon was generated around each ZCTA, creating a zone to summarise the spatial distribution of food outlets. We then aggregated counts within each buffer zone to determine the number of accessible food outlets for each family. To adjust for the population density, counts per food outlet group were converted to counts per 1000 population.

Food accessibility was categorised into four distinct groups: (1) grocery stores/supermarkets, defined as large retail establishments offering a wide selection of food and beverages, based on the Supplemental Nutrition Assistance Program (SNAP) dataset²⁰; (2) convenience stores, self-service stores primarily carrying quick-access food items, also based on the SNAP dataset²⁰; (3) full-service restaurants, classified by the North American Industry Classification System (NAICS) code 722511, representing establishments that provide food services to seated customers who typically pay after eating²¹; and (4) limited-service restaurants, represented by NACIS code 722513, referring to establishments where customers order food, pay before eating, and may dine on-site, take out or have food delivered. Examples include fast-food restaurants, pizza shops and other quick-service venues.²¹ The rationale for this classification is that each type of food outlet represents a unique food environment, with distinct purchasing patterns and nutritional implications, that would be obscured if categories were collapsed into fewer groups.

Anthropometrics

Children’s height and weight were measured using a Shorr Board (Shorr Productions, Maryland, USA; to the nearest 0.1 cm) and a Seca 874 scale (seca GmbH & Co. KG, Hamburg, Germany; to the nearest 0.01 kg), respectively. Their percent body fat was measured using the Tanita BF-689 scale (Tanita Corporation, Tokyo, Japan), accurate to 0.1%. For all measurements, children removed shoes, socks and bulky clothes to ensure precision. Parents’ BMI was calculated based on self-reported height and weight, using the formula weight (kg)/height (m²). Children’s sex- and age-adjusted BMI z-scores were calculated using the Centers for Disease Control and Prevention growth charts.²²

Eating habits

Children’s intake of fruits, vegetables, sweets and sugar-sweetened beverages was measured using adapted questions from the Eating at America’s Table Study All-Day Screener.²³ The response options ranged from ‘1 time per month or less’ to ‘6 or more times per day’. In addition, children’s skin carotenoids, an indicator for F/V intake, were assessed using the Veggie Meter (Longevity Link Corporation, Utah, USA). Each child’s non-dominant pointer finger was scanned three times for an average value. Parents’ F/V and fibre intake was assessed with the 10-item Block Fruit-Vegetable-Fiber Screener.²⁴ Each survey question had six response choices including ‘less than 1/week’, ‘once a week’, ‘2–3 times a week’, ‘4–6 times a week’, ‘once a day’, and ‘2+a day’. Cronbach’s alpha was 0.67 for the child survey and 0.70 for the parent screener in this study.

Parent food resource management behaviours

The 9-item Expanded Food and Nutrition Education Programme Checklist²⁵ was employed to measure parents’ food resource management behaviours. This tool evaluated practical behaviours such as shopping with a list, planning meals and preparing foods, which were integral to effectively managing food resources. An example question was “I shop with a list.” It is a 5-point Likert scale with responses of “no,” “sometimes,” “often,” “very often” and “almost always.” In this study, Cronbach’s alpha was 0.55.

Parents’ child feeding attitudes and practices

The 28-item Child Feeding Questionnaire²⁶ was used to measure parents’ child feeding attitudes and practices. This is a 5-point Likert scale with response options ranging from “never” to “always.” It contained seven subscales including perceived responsibility, perceived parent weight, perceived child weight, concerns about child weight, restriction, pressure to eat and monitoring. The overall scale yielded a Cronbach’s alpha of 0.82 in this study. 

Home eating environment

Home eating environment was assessed using the 10-item Family Nutrition and Physical Activity Screening Tool.²⁷ This is a 4-point Likert scale evaluating obesogenic eating environment and practices including family meals, family eating practices, food choices, beverage choices and restrictions/reward. It included responses ranging from “never/almost never” to “very often/always.” Cronbach’s alpha was 0.51 in this study.

Household food insecurity

Household food insecurity was assessed using the 18-item US Household Food Security Survey Module.²⁸ It contained questions with two response choices of “yes” and “no” or three levels of “often true,” “sometimes true,” and “never true.” The Cronbach’s alpha was 0.82 in this study.

Patient and public involvement

Patients, parents and community stakeholders were not involved in the design, conduct, reporting or dissemination planning of this secondary data analysis. The dataset used in this study was derived from a previously conducted clinical trial,¹⁶ in which programme development and implementation were informed by input from Head Start staff and participating families to ensure cultural and community relevance. However, no additional patient or public engagement occurred for the present analysis because it relied exclusively on existing data.

Data analysis

All data analyses were conducted using IBM SPSS Statistics V.27. Study variables were described using means, SDs, ranges, frequencies and percentages. To examine the relationships between outcome variables and food accessibility (access to grocery stores/supermarkets, convenience stores, limited-service restaurants and full-service restaurants), mixed-effect models were performed by adjusting for the random effects of daycare centres and classrooms, because children were nested within these units. Clustering can lead to correlated observations among children within the same centre or class due to shared environments, routines and instructional practices. Hessian convergence estimation and Kenward-Roger approximation for degree of freedom were used in the model analysis. Similar models were applied to examine the correlations between food accessibility and outcome changes from baseline to post-intervention. Results with a p value≤0.05 were statistically significant.

Results

Demographics

 The study included 154 children and parents (table 1). Children’s mean age was 47.16 months (SD=6.56) while parents averaged 32.68 years old (SD=8.00). Most participants were non-Hispanic and White. About one-third of the parents (n=50) were single and nearly a third (n=50) had an annual family income below $20,000. Additionally, 44.2% of parents (n=68) were unemployed and over half (n=84) only had an education level of high school or below. On average, each household had 2.45 children (SD=1.06).

Table 1. Sociodemographic characteristics of parent-child dyads (N=154).

Characteristic	Mean	SD
Child age (months, range 35–64)	47.16	6.56
Parent age (years, range 21–67)	32.68	8.00
Number of children per household	2.45	1.06
Food accessibility (per 1000 population)	11.50	16.80
Grocery stores/supermarkets	1.21	1.46
Convenience stores	5.41	9.06
Full-service restaurants	5.21	7.00
Limited-service restaurants	4.89	7.06
Children	n	%
Sex (male)	77	50.0
Ethnicity (Hispanic)	12	7.8
Race
White	133	86.4
Black or African American	1	0.6
American Indian or Alaskan Native	4	2.6
Multiracial	15	9.7
Other	1	0.6
Parents	n	%
Sex (male)	4	2.6
Ethnicity (Hispanic)	7	4.5
Race
White	141	91.6
Black or African American	2	1.3
American Indian or Alaskan Native	3	1.9
Multiracial	5	3.2
Other	3	1.9
Marital status
Married/partnered	91	59.1
Separated/divorced/widowed	13	8.4
Single	50	32.5
Family annual income
Under US$20 000	50	32.5
US$20 000–US$29 999	38	24.7
US$30 000–US$49 999	40	26.0
US$50 000 or above	26	16.9
Employment status
Full time	47	30.5
Part time	39	25.3
No	68	44.2
Education level
Less than high school graduate	12	7.8
High school graduate	72	46.8
Some college	41	26.6
Technical school or community college degree	15	9.7
Bachelor’s degree	9	5.8
Graduate or professional degree	5	3.2

Food accessibility and baseline outcome 

The average food accessibility was 11.50 (SD=16.80) outlets per 1000 population. On average, areas where participants resided had 1.21 (SD=1.46) grocery stores/supermarkets, 5.41 (SD=9.06) convenience stores, 5.21 (SD=7.00) full-service restaurants and 4.89 (SD=7.06) limited-service restaurants per 1000 population.

As demonstrated in table 2, higher BMI z-score and percent body fat in children were significantly correlated with less access to full-service restaurants (B=−0.13, p=0.021; B=−0.48, p=0.020) and more access to limited-service restaurants (B=0.13, p=0.040; B=0.56, p=0.032) after adjusting for other types of food access.

Table 2. Baseline associations of food accessibility with anthropometrics, eating habits and elements of home eating environment.

Outcome	Grocery stores /supermarkets		Convenience stores		Full-service restaurants		Limited-service restaurants
	B	P value	B	P value	B	P value	B	P value
Anthropometrics
Child BMI (n=153)	0.18	0.526	−0.03	0.700	−0.24	0.024	0.24	0.060
Child BMI-z (n=153)	0.09	0.554	−0.02	0.649	−0.13	0.021	0.13	0.040
Child % body fat (n=138)	−0.03	0.965	−0.07	0.669	−0.48	0.020	0.56	0.032
Parent BMI (n=149)	−0.40	0.709	−0.23	0.424	−0.80	0.840	0.52	0.269
Eating habits
Child fruit intake (times/day) (n=153)	0.01	0.981	−0.08	0.102	0.04	0.590	0.09	0.280
Child vegetable intake (times/day) (n=153)	0.09	0.611	−0.07	0.112	−0.03	0.696	0.13	0.089
Child sweet intake (times/day) (n=153)	−0.01	0.911	0.05	0.073	0.02	0.707	−0.07	0.109
Child sugar-sweetened beverage intake (times/day) (n=153)	−0.09	0.446	0.02	0.523	−0.01	0.865	−0.01	0.889
Child skin carotenoids (n=137)	−4.47	0.692	−4.34	0.136	−1.22	0.752	6.87	0.148
Parent F/V intake (servings/day) (n=153)	0.27	0.204	−0.09	0.128	−0.03	0.669	0.11	0.228
Parent fibre intake (mg/day) (n=153)	0.21	0.737	−0.28	0.080	−0.05	0.841	0.47	0.085
Elements of home eating environment
Parent food resource management behaviours (n=153)	−0.04	0.594	−0.04	0.042	0	0.987	0.07	0.041
Parents’ child feeding attitudes and practices
Perceived responsibility (n=153)	−0.11	0.109	−0.04	0.025	−0.03	0.199	0.10	<0.001
Perceived parent weight (n=153)	0.05	0.444	−0.02	0.235	0.05	0.073	−0.03	0.365
Perceived child weight (n=153)	−0.01	0.799	0.01	0.648	−0.02	0.224	0.01	0.449
Concerns about child weight (n=153)	−0.06	0.401	−0.01	0.622	−0.02	0.425	0.04	0.256
Restriction (n=153)	0.18	0.137	0.02	0.475	−0.02	0.679	−0.07	0.226
Pressure to eat (n=153)	0.17	0.165	0.05	0.126	−0.06	0.153	−0.04	0.411
Monitoring (n=153)	0.02	0.874	−0.03	0.367	0.01	0.803	0.03	0.684
Home eating environment (n=153)	−0.38	0.416	−0.28	0.025	−0.02	0.916	0.52	0.009
Household food insecurity (n=153)	−0.36	0.484	−0.07	0.614	−0.22	0.239	0.34	0.132
Adult food insecurity (n=153)	−0.32	0.425	−0.05	0.651	−0.15	0.300	0.25	0.162
Child food insecurity (n=153)	−0.03	0.860	−0.03	0.456	−0.06	0.267	0.09	0.145

Significance of the bold entries: p<0.05

BMI, body mass index; F/V, fruits/vegetable.

After controlling for accessibility to other types of food stores, increased access to convenience stores showed a non-significant trend toward children’s higher sweet intake (B=0.05, p>0.05) and parents’ lower fibre intake (B=−0.28, p>0.05). Greater access to limited-service restaurants demonstrated non-significant associations with children’s higher vegetable intake (B=0.13, p>0.05) and parents’ higher fibre intake (B=0.47, p>0.05).

Parents with perceived better food resource management behaviours had significantly less access to convenience stores (B=−0.04, p=0.042) but more access to limited-service restaurants (B=0.07, p=0.041). Parents’ higher perceived responsibility to child feeding was significantly related to less access to convenience stores (B=−0.04, p=0.025) and more access to limited-service restaurants (B=0.10, p<0.001). Furthermore, a healthier home eating environment perceived by parents was significantly associated with less access to convenience stores (B=−0.28, p=0.025) and more access to limited-service restaurants (B=0.52, p=0.009).

Food accessibility and outcome changes

Children’s changes in anthropometric outcomes were not significantly related to food accessibility. Parents’ increased fibre intake from baseline to post-intervention was correlated with less access to limited-service restaurants (B=−0.59, p=0.034), while their perception of higher weight was linked to greater access to convenience stores (B=0.03, p=0.027) after accounting for accessing other food stores. Additionally, their improvement in food resource management behaviours was significantly associated with their greater access to grocery stores/supermarkets (B=0.12, p=0.043) after controlling for accessibility to other types of food stores.

Table 3 indicates that lower access to limited-service restaurants showed a non-significant trend toward improvements in food resource management behaviours (B=−0.04, p>0.05) and home eating environment (B=−0.28, p>0.05). Similarly, less access to convenience stores indicated a non-significant association with increased parental restriction on children’s eating (B=−0.06, p>0.05).

Table 3. Relationships between baseline food accessibility and changes in anthropometrics, eating habits and home eating environment from baseline to post-intervention.

Outcome changes*	Grocery stores /supermarkets		Convenience stores		Full-service restaurants		Limited-service restaurants
	B	P value	B	P value	B	P value	B	P value
Anthropometrics
Child BMI (n=151)	−0.03	0.835	−0.03	0.468	0.04	0.378	0.002	0.975
Child BMI-z (n=151)	−0.01	0.909	−0.004	0.843	0.04	0.249	−0.02	0.525
Child % body fat (n=122)	−0.15	0.631	0.02	0.860	−0.03	0.782	0.04	0.768
Parent BMI (n=147)	−0.35	0.536	0.11	0.475	0.16	0.448	−0.25	0.351
Eating habits
Child fruit intake (times/day) (n=153)	0.11	0.561	0.04	0.474	−0.01	0.847	−0.06	0.492
Child vegetable intake (times/day) (n=153)	−0.07	0.656	0.01	0.857	−0.004	0.945	0.001	0.992
Child sweet intake (times/day) (n=153)	0.13	0.194	−0.01	0.740	−0.03	0.510	0.01	0.809
Child sugar-sweetened beverage intake (times/day) (n=153)	0.13	0.250	0.03	0.367	−0.04	0.341	−0.02	0.647
Child skin carotenoids (n=121)	−1.77	0.887	0.43	0.915	2.07	0.625	−3.50	0.451
Parent F/V intake (servings/day) (n=152)	−0.32	0.146	0.04	0.509	0.08	0.319	−0.13	0.210
Parent fibre intake (mg/day) (n=152)	−0.67	0.262	0.19	0.240	0.31	0.169	−0.59	0.034
Elements of home eating environment
Parent food resource management behaviours (n=153)	0.12	0.043	0.01	0.367	−0.01	0.805	−0.04	0.092
Parents’ child feeding attitudes and practices
Perceived responsibility (n=153)	0.07	0.319	0.02	0.224	0.01	0.650	−0.04	0.151
Perceived parent weight (n=153)	−0.03	0.498	0.03	0.027	−0.03	0.068	0.01	0.793
Perceived child weight (n=153)	−0.01	0.736	−0.003	0.710	0.01	0.334	−0.01	0.736
Concerns about child weight (n=152)	0.004	0.963	0.02	0.482	0.03	0.396	−0.05	0.225
Restriction (n=152)	−0.08	0.462	−0.06	0.057	0.06	0.151	0.03	0.531
Pressure to eat (n=152)	−0.09	0.372	−0.02	0.446	0.06	0.115	−0.01	0.844
Monitoring (n=152)	0.09	0.525	−0.01	0.824	−0.06	0.259	0.05	0.423
Home eating environment (n=153)	0.53	0.180	0.06	0.538	0.002	0.988	−0.28	0.092
Household food insecurity (n=153)	0.14	0.765	0.05	0.660	0.16	0.372	−0.20	0.290
Adult food insecurity (n=153)	0.16	0.659	0.01	0.890	0.08	0.550	−0.09	0.557
Child food insecurity (n=153)	7E-5	1.00	0.04	0.330	0.06	0.285	−0.10	0.092

Significance of the bold entries: p<0.05

^*Outcome changes=post–baseline.

BMI, body mass index; F/V, fruits/vegetable.

Discussion

This secondary data analysis explored how access to various food venues including grocery stores/supermarkets, convenience stores, full-service restaurants and limited-service restaurants affected anthropometrics, eating habits and the elements of home eating environment among rural parent-child dyads in a mindful eating intervention. Results highlight some important insights, particularly the detrimental influence of limited-service restaurants and convenience stores on children’s anthropometric outcomes, parents’ eating habits and home eating environment. Conversely, access to grocery stores/supermarkets and full-service restaurants showed positive associations with children’s anthropometric outcomes and home eating environment, underscoring the importance of improving healthy food accessibility in rural communities.

As expected, increased access to limited-service restaurants, encompassing quick-service venues such as fast-food restaurants and pizza shops, was significantly associated with children’s higher anthropometric outcomes (eg, BMI z-score and percent body fat). However, this finding contrasts with a meta-analysis of 87 studies showing no significant relationship between access to fast-food restaurants and weight-related outcomes in children.²⁹ One plausible reason is that the current study considered a broader category of quick-service venues beyond fast-food chains. This comprehensive definition may capture a wider spectrum of dietary influences, including variations in menu offerings and meal sizes, which are not confined to traditional fast-food outlets. Another possible reason is that this study controlled for the accessibility of other food outlets (eg, grocery stores, convenience stores, full-service restaurants). As food outlet access is often highly interrelated (r=0.80–0.95), failing to adjust for these interdependencies in previous studies may have diluted or obscured associations between limited-service restaurants and weight outcomes.

Furthermore, the limited-service restaurant accessibility also significantly hindered parents’ improvement in fibre intake post-intervention, even after accounting for other types of food access. This finding aligns with a Canadian national study, which demonstrated that eating food away from home was associated with decreased consumption of fibre.³⁰ Similarly, the study’s results also indicate the potential adverse impact of accessing limited-service restaurants on the intervention’s improvements on parents’ food resource management behaviours and home eating environment. Limited-service restaurants typically emphasise calorie-dense, nutrient-poor menu items, contributing to dietary habits lacking essential nutrients like fibre. Such patterns underscore the challenge of improving dietary quality in environments dominated by these establishments.

Interestingly, the baseline association between accessing limited-service restaurants and improved parents’ food resource management behaviours and home eating environment presents a nuanced picture. While convenience and affordability may drive short-term adaptive behaviours, such as increased F/V consumption, especially among rural White Americans,³¹ these initial benefits do not appear to sustain over time. Research suggests that reliance on limited-service restaurants often hampers the establishment of healthy eating habits,³² leading to health problems such as obesity, diabetes and cardiometabolic diseases.^{33 34} In addition, limited-service restaurants’ affordability and perceived convenience may inadvertently disincentivise home cooking, exacerbating poor home eating environment.⁹ Overall, these results emphasise the critical needs of addressing the adverse impacts associated with proximity to limited-service restaurants. Strategies could include zoning restrictions to limit density, community education initiatives promoting home cooking and incentive programmes encouraging grocery store patronage. Moreover, incorporating environmental and systemic considerations into dietary interventions is essential for promoting equitable health outcomes and mitigating the challenges posed by unhealthy food environments.

Access to convenience stores was significantly linked to parents’ poorer food resource management behaviours, lower perceived responsibility for child feeding and an unhealthier home eating environment. Prior literature has found that proximity to convenience stores is positively associated with children’s unhealthy eating behaviours such as increased intake of high-fat and high-sugar foods, particularly in low-income households,¹² which may stem from parents’ reduced engagement in effective food management and child feeding, including decreased restriction on children’s eating, as shown in this study. Moreover, time and transportation constraints often compel parents to rely on non-perishable goods from convenience stores,³⁵ further deteriorating the home eating environment. One potential strategy to address these issues is implementing improved food labelling at convenience stores. Evidence suggests that nutrition claims or warning labels can significantly influence parents’ purchasing decisions, even in virtual store settings.^{36 37} Such interventions could help guide healthier food choices and mitigate the adverse effects of convenience store accessibility on family nutrition.

The study highlights the potential benefits of grocery store and supermarket accessibility in fostering healthier dietary habits. Greater access to these venues was associated with significant improvements in parents’ food resource management behaviours, which are instrumental in mitigating food insecurity.³⁸ It is consistent with prior research showing that increasing access to grocery stores/supermarkets can enhance community residents’ intake of F/V and fibre.³⁹ Moreover, access to full-service restaurants was associated with lower child anthropometric outcomes, possibly due to their relatively nutrient-dense food options compared with limited-service venues.⁴⁰ However, restaurant meals often exceed calorie recommendations and may present affordability challenges for low-income households.⁴¹ These insights advocate for programmes and policies enhancing access to healthy food options, particularly grocery stores and supermarkets, as critical strategies to drive dietary improvements and address health disparities in rural communities.

Unexpectedly, the study found no significant associations between family food accessibility and children’s eating habits, including both proxy-reported dietary intake and objectively measured skin carotenoids. One plausible explanation is that parents may not be able to accurately report their Head Start children’s dietary intake, because these children receive free meals and snacks at preschool and typically eat only dinner at home. Consequently, parental reports may capture only a small portion of children’s daily intake. Another explanation is that the relationship between external food accessibility and young children’s eating behaviours may be substantially confounded by the home eating environment, which is largely shaped and regulated by parents.^{42 43}

The minimum associations between food accessibility and parents’ own eating habits somewhat align with findings from a prior review with 19 studies, which found generally weak relationships between food environments and health eating behaviours.⁴⁴ Although our study did not identify strong direct correlations between food accessibility and dietary intake, the observed associations with some elements of the home eating environment suggest that external food access may influence eating behaviours indirectly by shaping parental practices and household food contexts, mechanisms that may ultimately facilitate behaviour change and affect weight-related outcomes over the long term.

Limitations

The study has several limitations that should be considered. The absence of a control group likely reduced the internal validity, as it did not account for potential contextual confounders. Proxy-reported outcomes are prone to social desirability and recall biases, potentially lowering the reliability of measurements such as the Expanded Food and Nutrition Education Program Checklist (α=0.55) and the Family Nutrition and Physical Activity Screening Tool (α=0.51). The low internal consistency reliability of the two scales may increase measurement error and diminish statistical power, potentially masking associations between food accessibility and these outcomes. Because alternative validated instruments were not available in the dataset, results involving these measures should be interpreted with caution. Furthermore, the study did not assess changes in food accessibility, limiting the ability to capture longitudinal relationships with anthropometrics, dietary habits and home eating environment. Lastly, the focus on rural children and families with low socioeconomic status restricts the generalisability of findings to broader populations.

Conclusions

While the study’s results warrant further investigation across diverse populations, they consistently highlight the detrimental influence of limited-service restaurants and convenience stores on childhood obesity, eating habits and home eating environment. Conversely, enhanced access to grocery stores/supermarkets and full-service restaurants was associated with improvements in home eating environment. These results underscore the pivotal role that the food environment plays in shaping dietary behaviours and health outcomes within families. Future efforts may focus on regulating parents’ food resource management and child feeding behaviours through regulating nutrition claims and implementing warning labels, promoting home cooking and increasing access to healthy foods. Additionally, incorporating important environmental and systemic factors is essential for developing effective dietary interventions.

Data availability statement

Data are available upon reasonable request.