ABSTRACT
Background
Meal regularity is associated with many aspects of mental health. However, few studies have examined whether a relationship exists between meal regularity and self-esteem in children.
Objectives
The objective of this study was to determine whether an association exists between meal regularity and self-esteem in grade 5 children.
Methods
Among 4009 grade 5 students (mean age = 11.0 years ± SEM = 0.006) from the 2011 Children's Lifestyle and School Performance Study (CLASS-II; Nova Scotia, Canada), cross-sectional meal regularity survey data (family supper, supper in front of the television, supper alone, skipping breakfast, and skipping lunch) were collected using the Harvard Youth/Adolescent Food Frequency Questionnaire and examined in relation to self-esteem. Multilevel mixed-effects logistic regression was used to determine the ORs and 95% CIs associated with low self-esteem. Analyses were stratified by sex and adjusted for sociodemographic and lifestyle covariates.
Results
Compared to children who ate supper in front of the television or alone either never or less than once/week, children had greater odds of low self-esteem if 5 or more times/week they ate supper in front of the television (OR = 1.85; 95% CI, 1.40−2.43) or alone (OR = 4.23; 95% CI, 2.58−6.95). Compared to children who ate family supper 5 or more times/week, children who ate family supper never or less than once/week had greater odds of low self-esteem (OR: 1.97; 95% CI, 1.51−2.56). Skipping breakfast and skipping lunch were associated with greater odds of low self-esteem [OR = 2.92 (95% CI, 1.87−4.57) and OR = 4.82 (95% CI, 2.14−10.87) respectively].
Conclusions
In our study of grade 5 children, all 5 indicators of meal regularity tested are significantly and consistently associated with self-esteem.
Keywords: nutrition, meal regularity, meal skipping, eating environment, mental health, self-esteem, children
Introduction
Childhood mental illness is prevalent in North America, with an estimated 16.5% of children and youth ages 6–17 affected by a mental disorder in the United States (1). The onset of mental illness often occurs in childhood and adolescence, and is a serious public health concern (2, 3). Self-esteem is associated with mental health in children (4−6). Poor self-esteem may facilitate the development of mental health problems such as depression, anxiety, eating disorders, violence, aggressive behaviors, and high-risk behaviors (5). A recent prospective study of youth ages 13–18 reported that higher initial self-esteem predicted fewer psychiatric issues, including fewer symptoms of anxiety and depression, and attention problems (4).
Meal regularity may be a factor influencing childhood self-esteem and mental health (7−12). The term “meal regularity” refers to when and how people eat. Meal regularity is a different concept than diet quality, which refers to what people eat. To date, the majority of research connecting nutrition to self-esteem and mental health in children has focused on diet quality (13−19) or has focused solely on disordered eating (12, 20, 21). The result is a gap in the literature concerning how meal regularity is associated with self-esteem and mental health in children.
There are several socioenvironmental, socioeconomic, and physiological mechanisms that could link meal regularity to self-esteem in children, including the biological and hormonal effects of low blood sugar from fasting on a child's mood (22, 23) and the influence of family function on a child's dietary intake (24). Meal regularity may be a proxy for the child's home environment and the quality of their parental relationships (25).
To the best of our knowledge, no studies to date have tested for an association between family meals and self-esteem in elementary school−aged children, although 2 previous studies in middle school− and high school−aged participants have investigated family meals and self-esteem (11, 26). A study with 99 462 youths in grades 6 to 12 across the United States reported significantly higher self-esteem in those who reported eating 5–7 family meals per week compared to those who reported eating 0–1 family meals per week (11). Another study reported no significant association between family meals and self-esteem in 4746 American girls and boys aged 11–18 years (26). As far as we know, no studies to date have examined the association between eating supper alone or eating supper in front of the television and self-esteem in children. The objective of the present study is to determine whether an association exists between meal regularity (breakfast skipping, lunch skipping, eating family supper, eating supper alone, and eating supper in front of the television) and self-esteem in children.
Methods
This study used survey data from 4009 grade 5 children from the Children's Lifestyle and School Performance Study (CLASS-II). The CLASS-II survey was conducted in Nova Scotia (Canada) in 2011 using a population-based, cross-sectional design and questionnaires (27). After obtaining consent, a student survey and a Canadian-adapted Harvard Youth/Adolescent Food Frequency Questionnaire (YAQ) were administered to students (27). The YAQ has been independently assessed and validated for youth/adolescents by Rocket et al. (28). There were trained assistants who led students during administration of the surveys and measured each student's weight and height (27). A home survey containing questions about socio-demographics, health, and lifestyle was administered to parents (27). Informed consent was obtained from the parents and written assent was obtained from all children in the study. The present secondary analysis was approved by the human research ethics boards of Dalhousie University (#2018–4623) and the University of Alberta.
The mean age of grade 5 students in the study was 11.0 (SEM = 0.006). In Nova Scotia, most students attend public schools (27). There were 286 public schools with grade 5 children at the time of this study, and 269 schools participated (94.1% participation rate) (27). The survey completion rate was 67.4%, resulting in a final sample size of 4009 participants (29). Figure 1 presents a flowchart of the participants included and excluded in the CLASS-II.
FIGURE 1.
Flowchart of participants included and excluded in the mixed-effects logistic regression analysis of the association between meal regularity and self-esteem in grade 5 children from the 2011 Children's Lifestyle and School Performance Study.
To assess meal regularity, responses from the YAQ regarding meal skipping (breakfast and lunch) and the home eating environment (eating supper in front of the television, eating supper alone, and eating family supper) were examined. Table 1 contains survey questions from which variables were derived. To measure self-esteem, 10 items from the CLASS-II student survey (Table 2) were combined to create an aggregate variable (30). In brief, the 10 items examined appearance, abilities, emotions, peer acceptance, future hopes, and overall life satisfaction, and responses were scored as 1, 2, and 3, with a higher score indicating higher self-esteem (30). Scores were then totaled so that the overall score ranged between 10 and 30 (30). The Cronbach alpha for this composite scale is 0.70, suggesting internal consistency (31).
TABLE 1.
Survey questions and responses from the 2011 Children's Lifestyle and School Performance Study used to derive variables for the analysis
| Variable | Survey question | Survey response |
|---|---|---|
| Skipping breakfast | Where do you usually eat breakfast? | At home, at school, don't eat breakfast, or other |
| Skipping lunch | Which of the following best describes your lunch on a school day? | Bring a prepared lunch, buy lunch at school, eat lunch at home, don't eat lunch, or other |
| Eating supper alone | How many times a week (including weekdays and weekends) do you eat supper alone? | Never/<once, 1−2 times, 3−4 times, or 5 or more times |
| Eating supper in front of the television | How many times each week (including weekdays and weekends) do you usually eat supper in front of the TV? | Never/<once, 1−2 times, 3−4 times, or 5 or more times |
| Eating family meals | How many times each week (including weekdays and weekends) do you usually eat supper at the table with other people? | Never/<once, 1−2 times, 3−4 times, or 5 or more times |
| Food insecurity | The food we bought just didn't last and we didn't have the money to get more | Often true, sometimes true, never true, or prefer not to answer |
| Stressful life event | Has your grade 5 child experienced any event or situation in the past year that has caused him or her a great amount of worry or unhappiness? | Yes, no, unsure, or prefer not to answer |
| Parental education | What is the highest level of education you received? | No schooling, elementary, secondary, community/technical college, university, graduate university, or prefer not to answer |
| Household income | What is your current household income from all sources? | <$20 000, $20−40 000, $40−60 000, $60−80 000, $80−100 000, more than $100 000, or unsure/prefer not to answer |
| Family structure | How many people live in your household? | 2, 3, 4, 5, or more than 5 |
TABLE 2.
Self-esteem variables assessed in grade 5 children from the 2011 Children's Lifestyle and School Performance Study
| Variable | Item on student survey1 |
|---|---|
| Child's future looks good | My future looks good to me |
| Child likes the way they look | I like the way I look |
| Child likes themselves | I like myself |
| Child feels like they do not have friends | I feel like I do not have any friends |
| Child feels unhappy/sad | I feel unhappy or sad |
| Child worries a lot | I worry a lot |
| Child is in trouble | I am in trouble with my teachers |
| Child has trouble paying attention | I have trouble paying attention |
| Child has trouble enjoying themselves | I have trouble enjoying myself |
| Child has someone they can trust for advice | If I have problems there is someone I trust to go to for advice |
Item responses: "never or almost never", "sometimes", "often or almost always".
The primary endpoint of the present research was to determine whether an association exists between meal regularity (breakfast skipping, lunch skipping, eating family supper, eating supper alone, and eating supper in front of the television) and self-esteem in children. The present study was not prespecified when the CLASS-II was funded and the data were collected; however, for our specific study, which is a secondary data analysis, we did prespecify our endpoint and it did not change. Data were analyzed using multilevel logistic regression. Mixed-effects modeling was used to account for the possible effects of clustering within each school. Survey weights were used to ensure the results were applicable to the population. Models were stratified by sex, as mental health conditions are often distinct for boys and girls (32). Although the amount of missing data in the sample was low, ranging from 0–10.4% among variables, missing data were analyzed by a sensitivity analysis using multiple imputation to test for bias (Supplementary Table 1). A significance level of P = 0.05 was used for all analyses. Analyses were conducted using Stata 15.0.
The skipping breakfast and skipping lunch variables were binary, while the eating environment variables were categorical with 4 levels. The variable of self-esteem was originally measured on a scale from 10–30. However, this variable did not achieve normality after transformation and was therefore categorized into a binary variable, divided at the 15th percentile. This is a commonly used method in research of self-esteem, representing a similar statistical concept as 1 standard deviation below the mean (33), and has been employed in a previous study of self-esteem using the CLASS-II data (34).
Covariates, defined a priori, were added to the model simultaneously. Covariates were selected based on a review of the literature and past studies of meal regularity and included physical activity, rurality, food insecurity, stressful life event, parental education, total parental income, obesity, family structure, and diet quality. A composite physical activity variable was created from a subset of questions from the Physical Activity Questionnaire for Older Children (35). Rurality was assessed using postal codes from the CLASS-II home survey and classified as rural/urban through postal code second-digit identification. Food insecurity, stressful life event, parental education (highest level of education of the parent who completed the survey), household income, and family structure were assessed by questions from the CLASS-II home survey (Table 1). Sex of the child was reported by parents as either male or female. BMI was measured by first obtaining the child's height (no shoes, to the closest 0.1 cm) and weight (on a calibrated scale to the closest 0.1 kg) during the data collection process (29). Obesity was defined by the WHO, which provides specific BMI cut-off points for age and sex (36). Based on responses to the YAQ, a diet quality score (0–100; 100 = highest-quality diet) was assigned as assessed by the Diet Quality Index (37).
Results
A total of 4009 participants were included in the multilevel logistic regression analysis. Baseline characteristics were examined by calculating the frequency and proportion for each variable (see Table 3). The 15th percentile of self-esteem (measured on a scale from 10–30) was 22. The vast majority of girls and boys reported eating breakfast (96.2% and 97.4%, respectively) and lunch (99.1% and 99.0%, respectively). Most girls and boys reported eating supper alone “never or less than once a week,” and only 2.4% of girls and 3.1% of boys reported eating supper alone 5 or more times a week. Many girls and boys (59.6% and 57.8%, respectively) reported eating supper with their family 5 or more times a week, while eating supper in front of the television was more evenly distributed across response categories.
TABLE 3.
Participant characteristics of grade 5 children overall and by sex from the 2011 Children's Lifestyle and School Performance Study
| Variable | Overall frequency (%) | Girls’ frequency (%) | Boys’ frequency (%) |
|---|---|---|---|
| Sex | 3943 | 2008 (50.93) | 1935 (49.07) |
| Family income, n = 3886 | |||
| <$20 000/year | 248 (6.38) | 116 (5.96) | 123 (6.54) |
| $20–40 000/year | 541 (13.92) | 284 (14.60) | 249 (13.24) |
| $40–60 000/year | 568 (14.62) | 292 (15.01) | 269 (14.30) |
| >$60 000/year | 1920 (49.41) | 949 (48.79) | 944 (50.19) |
| Prefer not to answer | 609 (15.67) | 304 (15.63) | 296 (15.74) |
| Parental education, n = 3891 | |||
| Secondary school or lower | 703 (18.07) | 365 (18.75) | 324 (17.2) |
| Community college/technical school | 1545 (39.71) | 754 (38.73) | 766 (40.66) |
| University | 1021 (26.24) | 497 (25.53) | 507 (26.91) |
| Graduate university | 529 (13.60) | 277 (14.23) | 249 (13.22) |
| Prefer not to answer | 93 (2.39) | 54 (2.77) | 38 (2.02) |
| Rurality, n = 4009 | |||
| Rural | 1411 (35.20) | 695 (34.61) | 682 (35.25) |
| Urban | 2598 (64.80) | 1313 (65.39) | 1253 (64.75) |
| Family structure, n = 3899 | |||
| 2 members | 141 (3.62) | 65 (3.33) | 72 (3.82) |
| 3 members | 670 (17.18) | 337 (17.25) | 323 (17.14) |
| 4 members | 1758 (45.09) | 891 (45.60) | 845 (44.83) |
| 5 members | 879 (22.54) | 430 (22.01) | 437 (23.18) |
| >5 members | 451 (11.57) | 231 (11.82) | 208 (11.03) |
| Food insecurity, n = 3903 | |||
| Often | 144 (3.69) | 68 (3.48) | 71 (3.76) |
| Sometimes | 517 (13.25) | 271 (13.87) | 234 (12.39) |
| Never | 3188 (81.68) | 1586 (81.17) | 1559 (82.53) |
| Prefer not to answer | 54 (1.38) | 29 (1.48) | 25 (1.32) |
| Physical activity score, n = 4009 | |||
| ≤median score | 2004 (49.99) | 1080 (53.78) | 858 (44.34) |
| >median score | 2005 (50.01) | 928 (46.22) | 1077 (55.66) |
| Obesity, n = 3591 | |||
| No obesity | 2894 (80.59) | 1527 (84.27) | 1367 (76.84) |
| Obesity | 697 (19.41) | 285 (15.73) | 412 (23.16) |
| Diet Quality Index score, n = 3793 | |||
| ≤median score | 1898 (50.04) | 946 (48.91) | 952 (51.21) |
| >median score | 1895 (49.96) | 988 (51.09) | 907 (48.79) |
| Stressful life event, n = 3901 | |||
| Yes | 1164 (29.84) | 611 (31.25) | 537 (28.47) |
| No | 2604 (66.75) | 1278 (65.37) | 1283 (68.03) |
| Prefer not to answer | 133 (3.41) | 66 (3.38) | 66 (3.50) |
| Self-esteem score, n = 3675 | |||
| >15th percentile | 3028 (82.39) | 1574 (83.81) | 1454 (80.91) |
| ≤15th percentile | 647 (17.61) | 304 (16.19) | 343 (19.09) |
| Supper with family, n = 3760 | |||
| Never or <1/week | 457 (12.15) | 203 (10.59) | 254 (13.78) |
| 1−2 times/week | 523 (13.91) | 256 (13.35) | 267 (14.49) |
| 3−4 times/week | 571 (15.19) | 315 (16.43) | 256 (13.89) |
| 5+ times/week | 2209 (58.75) | 1143 (59.62) | 1066 (57.84) |
| Supper alone, n = 3776 | |||
| Never or <1/week | 2956 (78.28) | 1552 (80.62) | 1404 (75.85) |
| 1−2 times/week | 601 (15.92) | 266 (13.82) | 335 (18.10) |
| 3−4 times/week | 114 (3.02) | 60 (3.12) | 54 (2.92) |
| 5+ times/week | 105 (2.78) | 47 (2.44) | 58 (3.13) |
| Supper in front of the television, n = 3764 | |||
| Never or <1/week | 1509 (40.09) | 785 (40.80) | 724 (39.35) |
| 1−2 times/week | 1183 (31.43) | 620 (32.22) | 563 (30.60) |
| 3−4 times/week | 479 (12.73) | 248 (12.89) | 231 (12.55) |
| 5+ times/week | 593 (15.75) | 271 (14.09) | 322 (17.50) |
| Breakfast, n = 3781 | |||
| Eats breakfast | 3659 (96.77) | 1851 (96.16) | 1808 (97.41) |
| Does not eat breakfast | 122 (3.23) | 74 (3.84) | 48 (2.59) |
| Lunch, n = 3793 | |||
| Eats lunch | 3756 (99.02) | 1916 (99.07) | 1840 (98.98) |
| Does not eat lunch | 37 (0.98) | 18 (0.93) | 19 (1.02) |
Unadjusted analysis results can be found in Table 4. In the multivariable-adjusted analysis (Table 5), children who reported eating supper in front of the television 5 or more times a week had greater odds of low self-esteem compared to children who reported eating supper in front of the television never or less than once a week (OR = 1.85; 95% CI, 1.40−2.43). This relationship was observed to be 1.87 (95% CI, 1.27−2.74) among girls and 1.80 (95% CI, 1.23−2.64) among boys. Children who reported eating supper with family never or less than once a week had greater odds of low self-esteem compared to children who ate supper with family 5 or more times a week (OR = 1.97; 95% CI, 1.51−2.56). This association was observed to be 2.27 (95% CI, 1.54−3.33) among girls and 1.71 (95% CI, 1.20−2.43) among boys. Children who reported eating supper alone 5 or more times a week had greater odds of low self-esteem compared to children who reported eating supper alone never or less than once a week (OR = 4.23; 95% CI, 2.58−6.95). The observed associations among girls and boys were 4.36 (95% CI, 1.97−9.65) and 4.12 (95% CI, 2.15−7.90), respectively. Both skipping breakfast and skipping lunch were significantly associated with lower self-esteem in the overall adjusted analysis [OR = 2.92 (95% CI, 1.87−4.57) and OR = 4.82 (95% CI, 2.14−10.87), respectively], compared to not skipping these particular meals. The observed association between skipping breakfast and self-esteem was similar for girls (OR = 2.93; 95% CI, 1.58−5.41) and boys (OR = 2.89; 95% CI, 1.51−5.57). The observed association between skipping lunch and self-esteem was 5.33 (95% CI, 1.89−15.03) among girls and 3.78 (95% CI, 1.26−11.32) among boys.
TABLE 4.
The ORs and 95% CIs of low self-esteem in relation to meal regularity indicators overall and by sex for grade 5 children
| Overall | Girls | Boys | |||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | P | OR | 95% CI | P | OR | 95% CI | P | |
| Supper with family, n = 3631 | <0.001 | <0.001 | <0.001 | ||||||
| Never or <1 /week | 2.32 | 1.83−2.94 | <0.001 | 2.64 | 1.86−3.75 | <0.001 | 2.07 | 1.50−2.86 | <0.001 |
| 1−2 times/week | 2.03 | 1.58−2.60 | <0.001 | 2.49 | 1.76−3.52 | <0.001 | 1.66 | 1.21−2.29 | 0.002 |
| 3−4 times/week | 0.95 | 0.71−1.27 | 0.71 | 0.90 | 0.59−1.35 | 0.60 | 1.02 | 0.69−1.52 | 0.92 |
| 5+ times/week | 1.00 | 1.00 | 1.00 | ||||||
| Supper alone, n = 3649 | <0.001 | <0.001 | <0.001 | ||||||
| Never or <1 /week | 1.00 | 1.00 | 1.00 | ||||||
| 1−2 times/week | 1.93 | 1.53−2.43 | <0.001 | 1.95 | 1.36−2.79 | <0.001 | 1.90 | 1.42−2.54 | <0.001 |
| 3−4 times/week | 1.88 | 1.10−3.21 | 0.021 | 1.38 | 0.63−3.00 | 0.42 | 2.50 | 1.31−4.74 | 0.005 |
| 5+ times/week | 4.17 | 2.73−6.37 | <0.001 | 5.27 | 2.70−10.29 | <0.001 | 3.55 | 2.04−6.17 | <0.001 |
| Supper in front of the TV, n = 3634 | <0.001 | <0.001 | <0.001 | ||||||
| Never or <1 /week | 1.00 | 1.00 | 1.00 | ||||||
| 1−2 times/week | 1.03 | 0.81−1.31 | 0.83 | 1.08 | 0.77−1.52 | 0.65 | 1.00 | 0.72−1.38 | 1.00 |
| 3−4 times/week | 1.39 | 1.07−1.82 | 0.015 | 1.88 | 1.31−2.70 | 0.001 | 1.04 | 0.69−1.58 | 0.85 |
| 5+ times/week | 2.26 | 1.77−2.89 | <0.001 | 2.53 | 1.79−3.56 | <0.001 | 2.02 | 1.42−2.86 | <0.001 |
| Breakfast, n = 3650 | <0.001 | <0.001 | <0.001 | ||||||
| Eats breakfast | 1.00 | 1.00 | 1.00 | ||||||
| Does not eat breakfast | 3.06 | 2.03−4.61 | <0.001 | 3.54 | 2.03−6.18 | <0.001 | 2.81 | 1.53−5.15 | 0.001 |
| Lunch, n = 3658 | <0.001 | <0.001 | <0.001 | ||||||
| Eats lunch | 1.00 | 1.00 | 1.00 | ||||||
| Does not eat lunch | 5.00 | 2.22−11.24 | <0.001 | 7.02 | 2.54−19.44 | <0.001 | 3.43 | 1.22−9.61 | 0.019 |
| Family income, n = 3563 | <0.001 | <0.001 | <0.001 | ||||||
| <$20 000/year | 2.45 | 1.72−3.49 | <0.001 | 3.13 | 1.82−5.39 | <0.001 | 1.97 | 1.24−3.12 | 0.004 |
| $20−40 000/year | 1.97 | 1.48−2.62 | <0.001 | 1.80 | 1.20−2.71 | 0.005 | 2.23 | 1.58−3.16 | <0.001 |
| $40−60 000/year | 1.51 | 1.14−2.01 | 0.004 | 1.74 | 1.17−2.59 | 0.006 | 1.37 | 0.95−2.00 | 0.096 |
| >$60 000/year | 1.00 | 1.00 | 1.00 | ||||||
| Prefer not to answer | 1.22 | 0.92−1.61 | 0.16 | 1.17 | 0.79−1.75 | 0.43 | 1.28 | 0.88−1.85 | 0.20 |
| Parental education, n = 3568 | <0.001 | 0.009 | 0.002 | ||||||
| Secondary school or lower | 2.08 | 1.47−2.96 | <0.001 | 2.37 | 1.38−4.07 | 0.002 | 1.94 | 1.24−3.02 | 0.004 |
| Community college/ technical school | 1.64 | 1.20−2.23 | 0.002 | 1.77 | 1.08−2.90 | 0.025 | 1.57 | 1.10−2.24 | 0.013 |
| University | 1.22 | 0.89−1.67 | 0.22 | 1.41 | 0.85−2.33 | 0.18 | 1.07 | 0.70−1.62 | 0.76 |
| Graduate university | 1.00 | 1.00 | 1.00 | ||||||
| Prefer not to answer | 2.43 | 1.34−4.42 | 0.004 | 2.78 | 1.30−5.95 | 0.009 | 2.27 | 1.00−5.15 | 0.051 |
| Stressful life event, n = 3581 | 0.001 | 0.023 | 0.004 | ||||||
| Yes | 1.47 | 1.22−1.78 | <0.001 | 1.39 | 1.04−1.86 | 0.025 | 1.58 | 1.20−2.09 | 0.001 |
| No | 1.00 | 1.00 | 1.00 | ||||||
| Prefer not to answer | 1.89 | 1.23−2.92 | 0.004 | 2.06 | 1.08−3.93 | 0.028 | 1.72 | 0.96−3.10 | 0.068 |
| Obesity, n = 3467 | <0.001 | <0.001 | 0.025 | ||||||
| No obesity | 1.00 | 1.00 | 1.00 | ||||||
| Obesity | 1.77 | 1.44−2.16 | <0.001 | 2.34 | 1.69−3.24 | <0.001 | 1.36 | 1.04−1.78 | 0.025 |
| Diet Quality Index score, n = 3658 | <0.001 | 0.001 | 0.006 | ||||||
| ≤median score | 1.46 | 1.22−1.74 | <0.001 | 1.54 | 1.18−2.00 | 0.001 | 1.41 | 1.11−1.79 | 0.006 |
| >median score | 1.00 | 1.00 | |||||||
| Physical activity score, n = 3675 | <0.001 | <0.001 | <0.001 | ||||||
| ≤median score | 1.74 | 1.45−2.07 | <0.001 | 1.87 | 1.39−2.51 | <0.001 | 1.71 | 1.35−2.15 | <0.001 |
| >median score | 1.00 | 1.00 | 1.00 | ||||||
| Rurality, n = 3675 | <0.001 | 0.001 | 0.004 | ||||||
| Rural | 1.45 | 1.20−1.75 | <0.001 | 1.53 | 1.18−1.98 | 0.001 | 1.43 | 1.12−1.83 | 0.004 |
| Urban | 1.00 | 1.00 | 1.00 | ||||||
| Family structure, n = 3576 | 0.15 | 0.018 | 0.32 | ||||||
| 2 members | 1.08 | 0.64−1.83 | 0.77 | 1.69 | 0.87−3.27 | 0.12 | 0.61 | 0.26−1.40 | 0.24 |
| 3 members | 1.31 | 1.03−1.66 | 0.028 | 1.48 | 1.03−2.13 | 0.034 | 1.19 | 0.85−1.66 | 0.32 |
| 4 members | 1.00 | 1.00 | 1.00 | ||||||
| 5 members | 0.97 | 0.75−1.25 | 0.80 | 0.86 | 0.60−1.23 | 0.40 | 1.07 | 0.78−1.47 | 0.68 |
| >5 members | 1.14 | 0.80−1.62 | 0.47 | 0.92 | 0.56−1.50 | 0.73 | 1.39 | 0.91−2.14 | 0.13 |
| Food insecurity, n = 3580 | 0.001 | 0.094 | 0.008 | ||||||
| Often | 1.93 | 1.29−2.90 | 0.001 | 1.64 | 0.87−3.09 | 0.12 | 2.38 | 1.37−4.14 | 0.002 |
| Sometimes | 1.25 | 0.94−1.66 | 0.13 | 1.31 | 0.91−1.88 | 0.15 | 1.22 | 0.82−1.82 | 0.33 |
| Never | 1.00 | 1.00 | 1.00 | ||||||
| Prefer not to answer | 2.14 | 1.13−4.09 | 0.02 | 2.26 | 0.91−5.63 | 0.081 | 1.98 | 0.79−4.99 | 0.15 |
Data are from an unadjusted analysis using mixed-effects logistic regression. Self-esteem was originally measured as a score from 10−30. Self-esteem was categorized into a binary variable by dividing self-esteem scores at the 15th percentile (22).
TABLE 5.
The ORs and 95% CIs of low self-esteem overall and by sex in relation to meal regularity indicators for grade 5 children after adjusting for sociodemographic and lifestyle covariates
| Overall | Girls | Boys | |||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | p | OR | 95% CI | p | OR | 95% CI | p | |
| Supper with family, n = 3300 | <0.001 | 0.003 | 0.003 | ||||||
| Never or <1/week | 1.97 | 1.51−2.56 | <0.001 | 2.27 | 1.54−3.33 | <0.001 | 1.71 | 1.20−2.43 | 0.003 |
| 1−2 times/week | 1.73 | 1.33−2.24 | <0.001 | 2.10 | 1.43−3.08 | <0.001 | 1.45 | 1.03−2.05 | 0.033 |
| 3−4 times/week | 0.80 | 0.58−1.11 | 0.19 | 0.71 | 0.44−1.16 | 0.17 | 0.95 | 0.62−1.45 | 0.80 |
| 5+ times/week | 1.00 | 1.00 | 1.00 | ||||||
| Supper alone, n = 3320 | <0.001 | <0.001 | <0.001 | ||||||
| Never or <1/week | 1.00 | 1.00 | 1.00 | ||||||
| 1−2 times/week | 1.82 | 1.41−2.34 | <0.001 | 1.76 | 1.19−2.61 | 0.005 | 1.87 | 1.34−2.60 | <0.001 |
| 3−4 times/week | 1.95 | 1.11−3.42 | 0.020 | 1.31 | 0.58−2.99 | 0.52 | 2.62 | 1.36−5.05 | 0.004 |
| 5+ times/week | 4.23 | 2.58−6.95 | <0.001 | 4.36 | 1.97−9.65 | <0.001 | 4.12 | 2.15−7.90 | <0.001 |
| Supper in front of the TV, n = 3304 | <0.001 | 0.008 | 0.011 | ||||||
| Never or <1/week | 1.00 | 1.00 | 1.00 | ||||||
| 1−2 times/week | 0.94 | 0.72−1.23 | 0.66 | 0.96 | 0.65−1.42 | 0.85 | 0.94 | 0.66−1.33 | 0.72 |
| 3−4 times/week | 1.16 | 0.85−1.59 | 0.34 | 1.21 | 0.77−1.89 | 0.41 | 1.07 | 0.68−1.68 | 0.78 |
| 5+ times/week | 1.85 | 1.40−2.43 | <0.001 | 1.87 | 1.27−2.74 | 0.002 | 1.80 | 1.23−2.64 | 0.003 |
| Breakfast, n = 3319 | <0.001 | <0.001 | 0.001 | ||||||
| Eats breakfast | 1.00 | 1.00 | 1.00 | ||||||
| Does not eat breakfast | 2.92 | 1.87−4.57 | <0.001 | 2.93 | 1.58−5.41 | 0.001 | 2.89 | 1.51−5.57 | 0.001 |
| Lunch, n = 3326 | 0.002 | 0.002 | 0.018 | ||||||
| Eats lunch | 1.00 | 1.00 | 1.00 | ||||||
| Does not eat lunch | 4.82 | 2.14−10.87 | <0.001 | 5.33 | 1.89−15.03 | 0.002 | 3.78 | 1.26−11.32 | 0.017 |
Data are from an adjusted analysis using mixed-effects logistic regression. Self-esteem was originally measured as a score from 10−30. Self-esteem was categorized into a binary variable by dividing self-esteem scores at the 15th percentile (22). No significant interaction P values were observed between the meal regularity variables and sex. The model was adjusted for rurality, family structure, food insecurity, stressful life event, physical activity questionnaire score, Diet Quality Index score, obesity, highest parental education, and family income.
Discussion
In the present study, we observed significant associations between each meal regularity variable we studied (family supper, supper in front of the television, supper alone, skipping breakfast, and skipping lunch) and self-esteem in grade 5 children. The relationship with self-esteem was pronounced for eating supper alone (∼4-fold) and for skipping lunch, with children who reported skipping lunch having almost 5 times greater odds of low self-esteem compared to children who reported eating lunch.
To the best of our knowledge, the present study is the first to assess the relationship between meal regularity and self-esteem in elementary school−age children. However, the present study's findings of a positive association between meal regularity and self-esteem are in line with the results of previous research of meal regularity and other aspects of mental health. Past studies have demonstrated an association between family meals and numerous factors associated with mental health in children and youth, including depressive symptoms (26, 38), disordered eating (39, 40), and oppositional behaviour, reactive aggression, physical aggression, and nonaggressive delinquency (41).
In a study of 99 462 American youth from grades 6 to 12, Fulkerson et al. (11) reported that compared to participants who ate 0–1 family meals per week, participants who ate family meals 5–7 times per week had greater odds of better self-esteem (multivariable-adjusted OR = 1.40; 95% CI, 1.27−1.49). The only other study of this topic, by Eisenberg et al. (26), observed no significant association between family meals and self-esteem in 4746 American girls and boys aged 11–18 years. This discrepancy may be due to the differences in family meal comparison groups used in these studies. In the first and larger study, Fulkerson et al. (11) compared self-esteem among children reporting 0–1 family meals per week with children reporting 5–7 family meals per week. In contrast, Eisenberg et al. (26) examined self-esteem among children using a 1-unit difference in family meal frequency, which may not have been a large enough difference to observe a significant effect. The present study, which used comparison groups akin to Fulkerson et al. (11), provides results akin to Fulkerson et al. in direction and significance.
Family meals and childhood self-esteem are likely to be linked through a complex, bidirectional relationship situated within the context of socioenvironmental, socioeconomic, and physiological factors. Children who have better self-esteem may have better family function and better parental relationships and thus be more likely to eat more family meals (25). Family meals may foster better self-esteem in youth through indicators of family function, such as increased family communication, cohesion, relationship building, and trust (8, 42). A longitudinal study of 2379 children ages 9–19 years in the United States found that greater frequency of family meals over the first 3 years of the study facilitated better coping skills and family cohesion after 7–8 years (42). Children who eat alone or in front of the television may miss out on the potential benefits of family meals. Eating alone or in front of the television may also contribute to feelings of loneliness, which could influence self-esteem (43, 44). Other factors associated with family meals and self-esteem are academic performance (26), diet quality (38, 45, 46), and weight status (38). Although the present study included diet quality and weight status in the analysis, academic performance was not examined, and we cannot rule out that our findings were due to confounding by an unmeasured variable. However, there are plausible social and physiological mechanisms where meal regularity may influence self-esteem.
To the best of our knowledge, only 1 previous study has examined meal skipping and self-esteem outside of the context of disordered eating (47). This study, conducted among 692 Korean children aged 13–15 years by Park et al. (47), reported no significant correlation between the frequency of eating breakfast and self-esteem. In contrast, our findings for the association between both breakfast skipping and low self-esteem and skipping lunch and low self-esteem were significant in grade 5 children. It is possible that meal skipping in younger children may be more indicative of family dysfunction compared to meal skipping in older children, who are likely to have more independence and control over their dietary habits and meal choices, but little research has been conducted on this topic.
Findings from the present study were not always consistent between boys and girls, suggesting that sex and/or gender may play a role in the association between meal regularity and self-esteem. However, we observed no significant interactions between the meal regularity variables and sex. Other unmeasured social factors (such as potential sex or gender differences related to the impact of family cohesion on mental health) and/or unmeasured biological factors (such as potential sex differences in metabolic effects of fasting on mental health) may account for the inconsistencies observed by sex. Further research is necessary to elucidate mechanisms for potential sex and gender differences in the associations between meal regularity and self-esteem.
There are several limitations of the present research to acknowledge. As this study is cross-sectional, we cannot infer a causal relationship exists between meal regularity and self-esteem. Future research of meal regularity and self-esteem should employ a prospective study design and measurement of covariates. For self-esteem, categorization into a binary variable caused the loss of information regarding whether a dose-response relationship exists for the association with meal regularity. Future studies of self-esteem should use validated instruments with clinically relevant cut-points to measure self-esteem. Different methods of measuring self-esteem in children are described by Hosogi et al. (48). The use of a binary variable to report the child's sex which did not capture intersex children, no variable to capture gender, and lack of information about academic performance, parental mental health, and family function are other limitations of this research. Finally, as we tested multiple meal regularity variables, there is an increased potential for Type I error.
This study is novel for the contribution of knowledge of the association between meal regularity and self-esteem in grade 5 children. We used a robust sample size and collected data using validated assessment tools and methods (29). Further, many important factors were incorporated into the analysis, including socioeconomic status, food insecurity, diet quality, and physical activity. Data were analyzed overall as well as by sex, facilitating the ability to observe the association between meal regularity and self-esteem among boys and girls separately.
The relationship between meal regularity and self-esteem (an element of mental health) is likely bidirectional and exists within the context of socioenvironmental, socioeconomic, and physiological factors. Our findings provide novel evidence for a relationship between meal regularity and childhood self-esteem.
Supplementary Material
ACKNOWLEDGEMENTS
We thank Connie Lu for data validation and management and Sarah Loehr for her role as project coordinator of the Return on Investments for Kids’ Health.
The authors’ responsibilities were as follows – KFE, LEC, MA, LAC, OKL, and PJV: designed the research; PJV: conducted the research; KFE, MB, and SS: analyzed the data; KFE and LEC: wrote the paper; and all authors: read and approved the final manuscript content.
Author disclosures: KFE, MA, LAC, SS, MB, OKL, PJV, and LEC, no conflicts of interest.
Data Availability: Data described in the manuscript, code book, and analytic code will be made available upon request pending application and approval.
Notes
The study was supported by a Collaborative Research and Innovation Opportunities (CRIO) grant from Alberta Innovates Health Solutions to PJV and Dr A Ohinmaa (grant number 201300671). The 2011 Children's Lifestyle and School-Performance Study was funded through an operating grant by the Canadian Institutes of Health Research to PJV and Dr S Kirk (grant number FRN 93860).
Supplemental Table 1 is available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/ajcn/.
Contributor Information
Katherine F Eckert, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada; Department of Psychology & Neuroscience, Dalhousie University, Halifax, Canada.
Mark Asbridge, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada.
Leslie Anne Campbell, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada; School of Nursing, Dalhousie University, Halifax, Canada; Izaak Walton Killam Health Centre, Halifax, Canada.
Sam Stewart, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada.
Mark Bennett, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada.
Olivia K Loewen, Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Canada.
Paul J Veugelers, Population Health Intervention Research Unit, School of Public Health, University of Alberta, Edmonton, Canada.
Leah E Cahill, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada; Department of Medicine, Dalhousie University, Halifax, Canada; Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA.
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