Deconstructing the family meal: Are characteristics of the mealtime environment associated with the healthfulness of meals served?

Abstract

Background:

Multiple studies and guidelines emphasize the benefits associated with family meals. However, family meals are not well-defined and little research has been conducted to determine whether mealtime characteristics are associated with the healthfulness of foods served.

Objective:

The objective of this study was to define and measure specific mealtime characteristics and examine whether these characteristics are associated with the healthfulness of meals served to young children from low-income families, as measured by the Healthy Meal Index (HMI).

Participants/setting:

Study participants included 272 Southeast Michigan young children from low-income families in 2011–2013.

Design:

In this cross-sectional study, parents video-recorded 757 mealtimes, which were coded for 4 mealtime variables and meal healthfulness using the Healthy Meal Index (HMI). Mealtime characteristics included: 1. Eating at a Table (vs. not); 2. Served Family Style (vs. not); 3. TV Off (vs. not) and 4. Parent Partakes (sits and eats or drinks with child) (vs. not). A Family Meal was defined as a meal which had all four measured mealtime characteristics

Main outcome measures:

All meals were scored using the HMI, which has two components: the HMI Adequacy score (based on the presence of foods that are recommended for a healthy diet) and the HMI Moderation score (based on the absence of foods recommended to be consumed in moderation), which are summed to obtain the HMI Total score.

Statistical analyses performed:

Generalized estimating equations tested the associations of mealtime characteristics with HMI scores, controlling for child sex and age, and parental education and race/ethnicity.

Results:

In adjusted models, Family Meals were positively associated with HMI Adequacy (p=0.02) and Total (p=0.05) scores. Eating at a Table was positively associated with HMI Moderation (p=0.01) and HMI Total (p=0.01) scores. Served Family Style was positively associated with HMI Adequacy scores (p=0.04). TV Off was associated with higher HMI Total Scores (p=0.05). Parent Partakes was not associated with HMI scores.

Conclusions:

Family Meals were associated with greater healthfulness of the foods served. Characteristics of the mealtime that are commonly utilized to define the family meal were differentially associated with meal healthfulness.

Introduction

Given the persistently high prevalence of overweight and obesity in children,¹ child feeding and dietary guidelines increasingly recommend shared family meals, without the television (TV) on and served “family-style”, as a strategy for improving children’s diet quality and reducing the risk of obesity.^2–6 Multiple studies have found positive health effects associated with family meals, such as lower risk of excessive weight gain,^7–9 more healthy eating habits,^8,10 and greater diet quality overall.^11–14 Studies also suggest that the presence of TV and other forms of media during mealtimes are associated with lower overall diet quality and greater body mass index among children.^15–19 Family-style service, allowing children to serve themselves from larger serving dishes, is believed to improve the child’s ability to eat in response to internal satiety cues by allowing children to decide what and how much to consume; however, different studies have found both positive and negative associations with food intake in preschoolers.^20–23

Family meals are hypothesized to improve overall dietary quality and weight status because parents serve food items that are healthier and more consistent with dietary guidelines.^14,24,25 While parents who report placing high value on family meals also self-report serving healthier foods at family dinners, few studies have actually assessed the healthfulness of the foods served during family meals.²⁶ While others have examined total energy consumption or the overall dietary quality of children’s food consumption in relationship to family meals,^{10–14,27,28} only one other study has examined the association between TV viewing and the healthfulness of meals served.¹⁹

Furthermore, there is no common criterion for defining a family meal²⁹. Different studies define and measure family meals in a variety of ways, which may lead to important factors within the mealtime environment being overlooked.²⁷ For example, some studies characterize a “family meal” by the presence of different family members living in the household, ranging from one parent to all members.^{7,9,10,12,13,27,30–32} A family meal may be also characterized by preparation style, i.e., prepared at home,¹¹ or by eating location, i.e., eaten within the dining room or kitchen,³³ on a table,³⁴ or simply “at home.”³⁵

Finally, family meal research has focused primarily on assessing adolescents,^{13,16,27,28,34,36,37} with few studies assessing the meals of preschool and school-aged children,.^38–40 who have yet to fully establish eating patterns and habits.^41,42 Young children from low income families are of particular interest due to increased barriers to family meals⁴³, lower access to healthy foods^44,45, and greater risk of food insecurity⁴⁶.

In summary, there are three major gaps within family mealtime research: the lack of studies that measure the healthfulness of meals served within the family mealtime; the limited understanding of the importance of different characteristics used to define the family meal; and the lack of research on young children from low-income families. To address the gaps in the literature, this study’s objective was to define and measure specific mealtime characteristics and examine whether these characteristics are associated with the healthfulness of meals served to young children from low-income families, as measured by the Healthy Meal Index (HMI).⁴⁷ The hypothesis of the study was that certain mealtime characteristics (Eating at a Table; Served Family-Style; TV Off and Parent Partakes) will be associated with higher meal healthfulness. A Family Meal variable (defined as meals in which all the previously mentioned mealtime characteristics are present) was hypothesized to be positively associated with HMI meal scores.

Materials and Methods

Participants and Recruitment

Participants in this cross-sectional study included 301 parent-child dyads who were originally recruited between 2009–2011 to participate in a study investigating stress and eating behavior in children.⁴⁸ The parent study included three to four year old children from low-income families recruited from Head Start preschool programs in Southeastern Michigan. Between 2009–2011 all children attending Head Start through several agencies in communities within one hour driving distance of the University of Michigan received flyers in their backpacks inviting the family to participate in a study of eating behavior. Two to four years later (2011–2013), primary caregivers were invited to participate in the current follow-up study seeking to understand how mothers feed their children.⁴⁷ Families were contacted for this follow up study by postcard or telephone. Those meeting the following criteria were eligible for inclusion: caregiver has less than a four-year college degree; caregiver fluent in English; child born at 35 weeks gestation or more and without significant perinatal or neonatal complications; child without history of food allergies, serious medical problems, or any form of disordered eating; child not in foster care. Child participants were originally recruited from Head Start programs; therefore, at the time of recruitment into the original study, they were three to four years of age and living in families with limited income. Child sex, date of birth, and parental education and race/ethnicity were collected at enrollment in the original parent study. The University of Michigan Institutional Review Board approved the study protocol and all participants provided written informed consent and child assent.

Measures

Home Mealtime Observation

As described elsewhere, caregivers were provided a video-camera and asked to describe and video record three typical dinnertime meals for their child on a weekday.⁴⁷ Requirements for the videotaped meal included: 1) the primary caregiving parent was at home and awake; 2) meal must occur at home; and 3) the primary caregiving parent must prepare the meal (even when preparation is defined as picking up “take out”). Following the meal, on the same night, parents received a follow-up telephone call from a trained research assistant asking them to list all foods available to the child during the meal. Participants were compensated ten dollars for each mealtime recording they attempted.

Healthy Meal Index

As described elsewhere,⁴⁷ the list of foods reported by the parent to the research assistant was coded into pre-determined food group categories by trained coders. Food categories were determined by the 2010 U.S. Dietary Guidelines for Americans, and included fruits, type of vegetable, type of grain, type of protein, type of dairy, sweets and desserts, type of beverage, and high saturated/trans-fat foods.⁴ The presence or absence of each main food group, sweets and desserts, and beverages were recorded, including details about the type of food item. Condiments and preparation methods, except whether a potato or meat was deep-fried, were not coded because this information was not uniformly available in the meal reports. A validation study in a sub-set of the sample demonstrated that the reported meals were highly consistent with the foods seen on the videotapes⁴⁷.

All meals were then scored using the HMI. The HMI is a validated tool for measuring the healthfulness of foods served to children in a single meal and has two components: the HMI Adequacy score (based on the presence of foods that are recommended for a healthy diet) and the HMI Moderation score (based on the absence of foods recommended to be consumed in moderation), which are then summed to obtain the HMI Total score (Table 1). For each score, higher values indicate healthier meals. The HMI Adequacy score has a range of 0 to 65, the HMI Moderation score has a range of 0 to 40, and the HMI Total score has a range of 0 to 105. Each individual food could fall into multiple points categories, depending on its characteristics. For example, chicken tenders would receive positive points for ‘Protein’ yet lead to zero points in the ‘Added & Saturated Fats’ and ‘Convenience foods’ categories. Foods fell into the ‘Healthy fats’ category if they were fish, avocado, or nuts, as fat content was not directly measured. Additionally, ‘Convenience foods” were categorized based on information provided about whether the meal was prepared at home by scratch or pre-packaged, take-out, frozen, or canned. Foods found to be nearly exclusively falling into the ‘Convenience foods’ category in the study population (such as pizza, chicken nuggets, and macaroni and cheese) were classified as such unless otherwise specified. HMI Adequacy, HMI Moderation, and HMI Total scores were calculated for each meal report individually and used as the outcome variables of interest in this study. The development and validation of the HMI system, as well as the coding and scoring details, is presented elsewhere.⁴⁷

Table 1: Scoring criteria for Healthy Meal Index⁴⁷.

Reprinted with permission from: Kasper, et. al. The Healthy Meal Index: A tool for measuring the healthfulness of meals served to children. Appetite. Volume 103, 1 August 2016, Pages 54–63.

HMI components	Awarded Scorea			Definition
	0	5	10
Adequacy Score
Fruit	N		Y	Fruit, excluding juice
Vegetables	N		Y	Vegetables, excluding fried potatoes
Vegetable Quality	N	Y		Dark Green/Red/Orange Vegetables & Legumes
Vegetable Variety	N	Y		≥2 types of vegetables
Grains	N	Y		Any whole or refined grain, excludes fried/salty snacks
Whole Grains	N	Y		Any whole grain, excludes fried/salty snacks
Dairy	N		Y	Dairy or dairy substitutes
Protein	N		Y	Meat, nuts, legumes, eggs, meat substitutes
Healthy Fats	N	Y		Fish, nuts, avocados
Moderation Score
Convenience Foods	Y		N	Take-out, fast food, prepackaged, and processed
SSB or Diet Drinks	Y		N	Drinks with added sugar, diet drinks, flavored milk
Added & Saturated Fats	Y		N	Fried foods, beef, pork
Desserts & Sweets	Y		N	Foods with high added sugar

^a.Y indicates the score awarded if the food was available at the meal and N indicates the score awarded if the food was unavailable.

Mealtime Characteristics

Four mealtime characteristics were coded from the videotaped mealtime events; 1) Eating at a Table; 2) Served Family-Style; 3) TV Off and 4) Parent Partakes (Table 2). Coders trained to an initial reliability criterion of Cohen’s κ > 0.70 (κ = 1.0 indicates exact agreement corrected for chance); 12% of videos were randomly selected and double-coded by two raters and inter-rater reliability by Cohen’s κ exceeded 0.70 for all codes.

Table 2:

Description of Videotaped Mealtime Characteristic Variables

Variable Name	Coding Description
Eating at a Table (vs. not)	Index child is eating at a kitchen or dining room table (i.e., child is sitting on a chair at a distinct table, child is not sitting on a couch, sofa, or floor)
Served Family-Style (vs. not)	Food is served in bulk on serving dishes or in containers (i.e., casserole dish, pizza box, Chinese food boxes, etc.) and placed on a dining room or kitchen table from which the parent serves others and/or index child serves self
TV Off (vs. not)	TV is not audible during the meal (even if the TV is not visible)
Parent Partakes (vs. not)	“Throughout the meal, the index parent sits down and eats or drinks anything (including visual or audible evidence of her/him eating or drinking nearby during the meal, even if parent is cut off from the frame)
Family Meal (vs. not)	Meets all of the following criteria: Eating at a Table; Served Family Style; TV Off; Parent Partakes

A Family Meal was defined as one in which all of the following conditions were met: 1) Eating at a Table; 2) Served Family Style; 3) TV Off and 4) Parent Partakes.

Data Analysis

Unadjusted bivariate associations were conducted to compare the dyads who did and did not provide videos. Unadjusted bivariate associations were also conducted on demographic characteristics – child sex, child age, parental race/ethnicity, and parental education – as well as each of the four mealtime characteristics and the Family Meal variable with HMI Adequacy, HMI Moderation, and HMI Total scores, utilizing generalized linear models that accounted for repeated measures within subjects. Generalized estimating equations estimated the association of mealtime characteristics with HMI Adequacy, HMI Moderation, and HMI Total scores. Generalized estimating equations account for the repeated mealtime measures within families. For each of the three HMI score outcomes, two models were constructed: one which included all four mealtime characteristics simultaneously (to reduce potential confounding) and the other which tested the Family Meal variable as a main effect, controlling for the demographic variables. Selection of potential confounders was based on the probable relationship between the confounder with the mealtime characteristics and meal healthfulness. For all models, the level of significance was α ≤ 0.05 and all statistical tests were two-tailed. All analyses were conducted in SAS (Version 9.3, 2011, SAS Institute Inc.)⁴⁹.

Results

Of the 301 caregivers who agreed to videotape dinners and provide meal reports by phone, all provided complete demographic information; however, 29 did not complete at least one videotaped meal and meal report. Participating families did not differ from non-participants (those who did not provide at least one video tape) when compared on child sex and age, and parental race/ethnicity or education.

The analytic sample for this study included 272 parent-child dyads with 757 mealtime observations and associated meal reports. Table 3 presents descriptive characteristics of the sample. The sample had approximately equal numbers of boys and girls with a mean child age just under six years. A majority of parents were non-Hispanic White women (only two primary care giving parents in this sample were fathers). There was equal representation between those with and without some education beyond a high school diploma.

Table 3:

Demographic Characteristics of 272 Parent-Child Dyads from Southeast Michigan Head Start families from a cohort investigating stress and eating behavior in children in 2011–2013

	N (%) or Mean (SD)
Child Sex
Female	134 (49.3)
Male	138 (50.7)
Mean Child Age in Months	70.9 (8.4)
Parental Race/Ethnicity
White, non-Hispanic	187 (68.8)
Black, non-Hispanic	43 (15.8)
Hispanic	22 (8.1)
Biracial, non-Hispanic	18 (6.6)
Native American or Pacific Islander	2 (0.7)
Parental Education
High School Diploma or GED or less	128 (47.1)
More than High School	144 (52.9)

Mealtime characteristics are described in Table 4. A majority of meals (86.0%) were consumed at a table. Dinner was served family-style in just over one fifth of all meals. The TV was off in 52.6% of the meals. The parent partook in 72.8% of the meals. According to the unadjusted bivariate analysis (Table 4), HMI Total scores were higher for all mealtime characteristic variables in the anticipated direction (p≤0.05). Healthy Meal Index Adequacy scores were higher for Family Meals and each of the family meal components, except for Parent Partakes. Healthy Meal Index Moderation scores were higher for meals eaten at a table and meals in which the parent partook but not for meals served family-style, meals with the TV off, or Family Meals.

Table 4:

Bivariate Associations^a of Mealtime Characteristics with HMI Adequacy, Moderation, and Total scores during 757 Observed Family Meals in 272 Southeast Michigan Parent-Child Dyads in 2011–2013

	Healthy Meal Index Scores Mean (SE)
	Nb (%)	Adequacy	p	Moderation	p	Total	p
Total Sample	757 (100)	35.0 (0.39)	-	22.4 (0.33)	-	57.4 (0.52)	-
Eating at Table			0.002		0.004		<0.001
• Yesc	651 (86.0)	35.5 (0.5)		22.9 (0.4)		58.4 (0.72)
• No	106 (14.0)	31.8 (1.1)		19.9 (0.9)		51.8 (1.4)
Served Family-Style			0.002		0.82		0.03
• Yesc	159 (21.0)	37.6 (1.0)		22.3 (0.8)		59.8 (1.3)
• No	598 (79.0)	34.3 (0.5)		22.5 (0.4)		56.9 (0.7)
TV Off			0.003		0.19		0.002
• Yesc	398 (52.6)	36.2 (0.6)		22.9 (0.5)		59.1 (0.8)
• No	359 (47.4)	33.7 (0.6)		22.0 (0.5)		55.7 (0.8)
Parent Partakes			0.13		0.04		0.02
• Yesc	551 (72.8)	35.4 (0.5)		23.0 (0.4)		58.3 (0.7)
• No	206 (27.2)	33.9 (0.8)		21.2 (0.8)		55.2 (1.4)
Family Meal			0.01		0.58		0.02
• Yesc	114 (15.1)	37.6 (1.2)		22.9 (0.8)		60.4 (1.4)
• No	643 (84.9)	34.5 (0.5)		22.4 (0.4)		57.0 (0.6)

^a.Generalized liner models, accounting for repeated measures within participants

^b.Number of meals included in models

^c.Reference group for models

Adjusting for all demographic variables in models including all mealtime characteristic variables, only Served Family Style and Family Meals were associated with HMI Adequacy scores (p=0.04 and 0.02, respectively) (Table 5). Eating at a Table (β(SE)= 2.7(1.1); p=0.01) was the only mealtime characteristic variable associated with HMI Moderation scores. Eating at a Table (β(SE)= 4.6 (1.7); p=.01), TV Off (β(SE)= 2.1 (1.1); p=0.05), and Family Meals (β(SE)= 3.0(1.5); p=0.05) were associated with HMI Total scores.

Table 5:

Multiple Linear Regression Models of Association of Mealtime Characteristics with HMI Adequacy, Moderation, and Total scores in 757 Observed Meals across 272 Southeast Michigan Parent-Child Dyads in 2011–2013

	Adequacy		Moderation		Total
Covariatesa	β (SE)	p	β (SE)	p	β (SE)	p
Model 1b
Eating at Table	1.9 (1.3)	0.14	2.7 (1.1)	0.01	4.6 (1.7)	0.01
Served Family-Style	2.3 (1.1)	0.04	−1.2 (0.9)	0.18	1 (14)	0.49
TV Off	1.6 (0.8)	0.06	0.5 (0.7)	0.46	2.1 (1.1)	0.05
Parent Partakes	0.3 (1)	0.79	1.4 (0.9)	0.11	1.6 (1.3)	0.23
Model 2c
Family Meal	2.7 (1.2)	0.02	0.4 (0.9)	0.66	3.0 (1.5)	0.05

^a.A positive response (yes) to each covariate is the reference category and is compared to the alternative (no).

^b.Model 1 includes all four mealtime characteristic variables, controlled for child sex (male as reference), child age (6–8 years as reference), parental education (greater than high school/GED as reference), parental race/ethnicity (non-Hispanic white as reference).

^c.Model 2 includes the Family Meal variable, controlled for child sex, child age, parental education, parental race/ethnicity.

Discussion

This study assessed mealtime characteristics and their association with the healthfulness of meals served in a population of young children from low-income families. In unadjusted models, all mealtime characteristics were independently associated with HMI Total scores, and all but Parent Partakes were associated with HMI Adequacy scores, while only Eating at a Table and Parent Partakes were associated with higher HMI Moderation scores. In adjusted models that included all mealtime characteristics, Eating at a Table was positively associated with HMI Moderation and HMI Total scores. Served Family Style was positively associated with HMI Adequacy scores. Meals served with the TV off had higher HMI Total scores. Family Meals, which were defined as meals which met all of the recommendations, i.e., Eating at a Table, Served Family-Style, TV Off, and Parent Partakes were positively associated with HMI Adequacy and Total scores.

Although Eating at a Table was associated with higher HMI Moderation and Total scores in this study and has been included as a component of a family meal in previous studies³⁴, there is not any comparable literature that examines whether Eating at a Table, as a stand-alone variable, impacts meal or dietary quality. One might speculate that meals eaten at a table, rather than elsewhere, could be more planned or thought-out and thus healthier. Alternatively, some families may not own a table or have room for a table, and these families might differ from other families by socioeconomic status or in the importance they place on meals.

Meals Served Family-Style were associated with higher HMI Adequacy scores. One possible reason that a meal might have higher HMI Adequacy scores, but not HMI Moderation scores could be that the meal has greater overall variety of foods served. The greater number of healthy foods would lead to a higher HMI Adequacy score, while the greater number of unhealthy foods would lead to a lower HMI Moderation score.

The finding that having the TV off during the meal was associated with higher HMI scores is consistent with other studies. In a recent study which utilized direct meal observation, Trofholz et. al. found that having the TV on during the meal was associated with lower healthfulness of foods served during the meal, using an index similar to the HMI.¹⁹ In a study of preschool children, FitzPatrick and colleagues found that each night the TV was on during dinner was associated with lower frequency of serving fruits or vegetables.³⁸ The findings regarding TV are also consistent with literature on the negative associations between TV-viewing and overall diet quality.^15–17

Surprisingly, Parent Partaking was not associated with HMI scores. As family participation is a key component of the current definition of a family meal in the literature, these findings differ from the current understanding of the mechanisms through which family meals affect diet quality. For example, Burgess-Champoux et. al., found that eating regular family meals, defined as meals in which ‘all or most of the family’ ate together, was positively associated with dietary intake of vegetables, calcium-rich foods, fiber, and several vitamins and minerals in a longitudinal study of adolescents; however the healthfulness of meals served was not assessed.¹⁰ Fink and colleagues found that children consuming five family meals per week, as defined as meals which were shared by members of the household and prepared at home, had lower overall intakes of sugar sweetened beverages and greater fruit and vegetable intake.¹¹ These may suggest that the association of family presence at meals with overall diet quality works through a different pathway than healthfulness of the meals served, such as greater family functioning and parental support, which impact a child’s ability to make healthful decisions in choosing which food to consume.^32,50

The finding that Family Meals were associated with HMI scores is consistent with previous literature examining the association between family meal frequency and overall diet quality.^11–14 However, this study adds to the literature by elucidating some of the potential mechanisms driving those previously observed associations. In particular, there are two novel components to this investigation that expand our understanding of the family meal. First, in this study, individual components which are commonly used to define a family meal were assessed. Second, the association between family meals and meal healthfulness, one hypothesized pathway between family meals and diet quality, is able to be examined.

When a family meal is broken down into its defining components, the underlying factors of a family meal that may be driving the observed associations can be identified. This allows researchers to identify which components of a family meal may be important to promote. It also shines light on a major flaw in the assumption that increasing the frequency of family meals can improve child nutrition just because the two are associated. While this study examines only a piece of that puzzle, here one can see more easily that there is not a true logical pathway that leads from the variables used to define a family meal and meal healthfulness. Sitting at a table, eating without TV, serving meals family style, or the presence of a parent cannot directly change the healthfulness of foods served at the meal. There is more likely an underlying factor at play within a parent’s behavior, knowledge, and beliefs that leads to both the meal environment and the healthfulness of foods served at a meal. For example, parents who are more invested in their children’s health may be more likely to serve healthier meals and also to follow recommended feeding practices, such as eating at a table, serving family style, having the TV off, and partaking in the meal. Socioeconomic status may also affect parents’ ability to access, purchase, and prepare healthful meals, as well as affect their ability to be present at meals, sit at a table, or serve meals family style. While most studies, including this one, do attempt to control for socioeconomic factors, these variables cannot fully capture the extent of variability in socioeconomic status within a population.

The second major aspect of this study that furthers the family meal literature is that the outcome was the food served at an individual meal; whereas the other studies have examined overall dietary intake as the outcome^11–14. As many previous studies have demonstrated an association between family meals and dietary intake^11–14, it is now important for the field to gain a better understanding of the mechanisms that drive that association. This study demonstrates that one piece of that pathway may involve the association between family meals and meal healthfulness. However, there are a multitude of other potential pathways that also need to be investigated further. Some future questions to be addressed include: do children choose more healthful foods to consume during family meals, and if so, why?; and do children who regularly participate in family meals choose more healthful foods outside of family meals and if so, why? Understanding these pathways is crucial to designing effective interventions.

It is important to note that the HMI scores, calculated based on the presence or absence of foods served to children at a meal, do not account for quantities served or consumed. Current feeding guidelines recommend that children are presented with a variety of healthful foods and allowed to decide how much to eat.^5,50–53 The goal of such advice is to increase acceptance of a variety of foods by increasing exposure to different types of healthy foods and to increase the child’s reliance on using their internal hunger and satiety cues to dictate how much food to consume. The HMI allowed for better assessment of whether parents were following feeding recommendations than a measure of dietary intake, which would be confounded by an individual child’s preference. There is evidence that the healthfulness of foods served during the meal, is highly correlated with consumption during the meal, as Trafholz et. al. recently found the meal healthfulness was associated with overall diet quality and also that the presence of individual food groups during a meal was associated with greater dietary consumption of those food.,³⁷ However, some aspects of parental feeding practices that have been shown to affect the quantity of food that a child consumes, such as responsive feeding (whether a parent responds to hunger cues vs. employing pressure, restriction, or indulgent feeding practices) were not included in this study.^5,54

The present study has several strengths. First, the use of direct observation from videotaped dinners at home provides a more detailed examination of characteristics within the family mealtime environment in a naturalistic setting that may not be apparent within a laboratory setting, using in-person observation, or using self-reported measures from parents.⁵⁵ The natural setting within the home also allows for greater variability of characteristics, as the meals are not staged. Additionally, use of a validated instrument, i.e. the HMI, allowed for the measurement of the healthfulness of meals served. This study included young children during a critical time for the development of eating habits and adds findings on a different study population to family mealtime literature⁴².

Results from the present study must be interpreted with caution, in light of limitations. Cause and effect cannot be determined from a cross-sectional study and unmeasured confounding variables may have affected the results. Participants may have modified their behavior and meal content due to awareness of being videotaped, which would have led to an upward bias of the estimates. Recall bias during phone interviews after meals could have also occurred. Furthermore, the portion size of the foods assessed using the HMI was not recorded and the HMI did not measure preparation method or the presence of condiments. Another difference between this study and other previous studies that examined the association of eating together as a family is that, in this study, only whether the enrolled parent was present, sitting and eating or drinking at the table was examined and not whether other family members were present^{7,9,10,12,13,27,30–32}. It is possible that the presence of other family members or guests may have been associated with the healthfulness of food served. Additionally, preparation style of the meal (such as whether the meal was cooked from scratch in the home), which has been utilized in another study as a defining characteristic of a family meal¹¹, could not be assessed. Although, the sample was restricted to low-income families, as a result of the recruitment strategy from Headstart agencies, additional income data was not available. Finally, this study was cross-sectional, prohibiting establishment of temporality, and may not be generalizable to children outside the ages of four to eight years, to other race/ethnicities or cultures, or to families of higher income.

Conclusions

This study furthers the family meal literature by examining specific meal characteristics that are associated with meal healthfulness. Through a more nuanced examination of these structural characteristics, one can better understand the pathways through which Family Meals are associated with overall diet quality. Future intervention studies should investigate whether changes in the meal environment (such as eating at a table, with the TV off, and serving meals family style) can positively impact the healthfulness of foods served in the meal. Additionally, the associations between the healthfulness of meals served with overall dietary quality and risk of obesity should be studied, in order to allow for a better understanding of how changes in meal healthfulness can impact overall health.

Research Snapshot.

Research Question:

Are characteristics of the mealtime environment associated with the healthfulness of foods served during the meal in a population of young children from low-income families?

Key Findings:

In this cross-sectional, observational study of 272 children who were videotaped in the home during three typical mealtimes, the following variables were positively associated with meal healthfulness scores: Family Meal, Eating at a Table, Served Family Style and TV Off.