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Published in final edited form as: J Acad Nutr Diet. 2022 Apr 5;122(12):2288–2294. doi: 10.1016/j.jand.2022.04.001

Exploring Mothers’ Perspectives About Why Grandparents in Appalachia Give Their Grandchildren Cariogenic Foods and Beverages: A Qualitative Study

Kevin C Lu 1,2, Zelda T Dahl 2,3, Robert J Weyant 2,4, Daniel W McNeil 2,5, Betsy Foxman 6, Mary L Marazita 2,7,*, Jacqueline M Burgette 2,8,*
PMCID: PMC9532469  NIHMSID: NIHMS1796007  PMID: 35395420

Abstract

Background.

Dental caries is the most common chronic childhood disease. Past studies reveal that grandparents provide their grandchildren with cariogenic foods and beverages (e.g., those with free sugars and/or modified starches). Qualitative research can help identify what drives this phenomenon.

Objectives.

To examine mothers’ explanations for why grandparents in north central and central Appalachia give their grandchildren cariogenic foods and beverages.

Design.

A qualitative study on children’s oral health in Pennsylvania and West Virginia from 2018–2020 was performed. In-person, semi-structured interviews were conducted. Qualitative data from interviews were recorded, transcribed, and then coded using NVivo. Data analysis for this study was performed using thematic analysis with iterative theme development.

Participants/setting.

The participants were 126 mothers of children aged 3–5 years from West Virginia (n=66) and Pittsburgh, Pennsylvania (n=60).

Main outcome measures.

Mothers’ perspectives about why grandparents give their grandchildren cariogenic foods and beverages.

Results.

In the study sample, 85% (n=107/126) of mothers named at least one of their children’s grandparents as a member of their social network responsible for their children’s oral health. From these interviews, 85% (n=91/107) of mothers discussed that grandparents gave their grandchildren cariogenic foods and beverages. The mothers described four themes to explain why grandparents gave their grandchildren cariogenic foods and beverages: 1) Privilege of the grandparent role; 2) Responsibilities of the grandparent role; 3) Symbol of care and affection; and 4) Limited consideration or understanding of the detrimental impact.

Conclusions.

Grandparents play a role in giving their grandchildren cariogenic foods and beverages, which could potentially contribute to childhood caries. Research is needed to develop effective social interventions to help some grandparents understand the implications of a cariogenic diet on their grandchildren’s oral health and/or decrease their provision of cariogenic foods and beverages.

Keywords: Grandparents, Child, Diet, Cariogenic, Social Determinants of Health, Qualitative Research

INTRODUCTION

Globally, dental caries is the most common chronic childhood disease.1 In the United States, the prevalence of total dental caries for children aged 2–5 years was 21% during 2015–2016.2 The Center for Oral Health Research in Appalachia Study Cohort 1 (COHRA1), which was conducted from 2000–2010, reported high prevalence of caries in young children living in West Virginia and Pennsylvania.3 Among the five-year-olds in COHRA1, 51% experienced some degree of dental caries.3

Dental caries is a diet-mediated disease. The World Health Organization (WHO) reports a positive association between dental caries and intake of free sugars, or “monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates.”4 The WHO recommends that children and adults reduce their intake of free sugars to less than 10% of total energy intake.4 In the United States, mean adjusted added sugars intakes remain above the WHO’s recommended level, with children consuming 17% of their total energy as added sugars in 2011–2012.5

Children’s diets, and consequently children’s risk of developing dental caries, can be influenced by parents6-8 and other family members.1 In the United States, for example, significant numbers of grandparents provide care for their grandchildren.9-12 Grandparents’ contribution to childcare is particularly important in the Appalachian region, which experiences higher rates of opioid misuse and overdose deaths than other parts of the country9,13 According to the 2019 U.S. Census Bureau American Community Survey, approximately 54% of grandparents in West Virginia and 35% of grandparents in Pennsylvania are responsible for their grandchildren if they live in the same household.12

Grandparents, however, do not always have a positive impact on children’s diet and health status.14 For instance, Li and colleagues14 found that children with grandparent caretakers have two times the odds of being overweight or obese compared to children with parent caretakers. Previous publications also report that some grandparents feed their grandchildren candy,15 fast food,15 and sugar-sweetened beverages.14-16 While studies suggest grandparents have reasons for giving their grandchildren food and beverage treats,15,17,18 there is a gap in the literature specifically about why grandparents give their grandchildren cariogenic foods and beverages (e.g., those with free sugars and/or modified starches). Therefore, this study aims to investigate mothers’ perceptions about why grandparents in north central and northern Appalachia give their grandchildren cariogenic foods and beverages.

METHODS

This cross-sectional qualitative study on children’s oral health in Pittsburgh, Pennsylvania and West Virginia was approved by the SMART institutional review board mechanism for the University of Pittsburgh and West Virginia University. A qualitative approach19 was used to explore explanations for social phenomena in the participants’ lived experiences. The participants, 126 mothers with at least one child aged 3–5 years, were recruited between 2018–2020 from the existing study population of the parent Center for Oral Health Research in Appalachia Study Cohort 2, which is described by Neiswanger and colleagues.3 All mothers provided informed consent and self-reported their family’s sociodemographic characteristics in a questionnaire before their interview.

Three trained female interviewers conducted one-hour, in-person, audio-recorded, semi-structured qualitative interviews using an interview guide with open-ended questions. One set of questions asked mothers to describe social connections who gave their children foods or beverages that are potentially harmful for children’s oral health (Figure 1). The mothers freely elaborated on social connections they chose to identify without prompting and commonly described candy, baked goods, juice, and soda as cariogenic foods and beverages. This study focuses on mothers’ descriptions of grandparents who gave their grandchildren large amounts of cariogenic foods and beverages and/or did not restrict their grandchildren’s intake of cariogenic foods and beverages. Qualitative data from these interviews are also the basis for other research on children’s oral health.20-22

Figure 1.

Figure 1.

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Excerpt from the semi-structured interview guide regarding children’s diet and the influence of mothers’ social connections on children’s diet

Interviews were transcribed verbatim (TranscribeMe, Los Angeles, CA), checked for accuracy, then imported into NVivo, a qualitative data analysis software for coding of textual data (QSR International, Melbourne, Australia, version 12). Data analysis was structured using template analysis, a qualitative approach that utilizes both deductive and inductive reasoning by combining a priori deductive codes with additional inductive codes to ensure all themes originated from the data.23 Iterative theme development was performed by the first, second, and senior authors, who achieved substantial intercoder reliability24 and met bimonthly to discuss emerging themes. Major themes were identified and refined through rigorous inductive writing of memos, an analytical technique used by qualitative researchers to fully engage with the data and document interpretations.19 Themes were also checked for consistency via constant comparative method25 with previously coded transcripts.19

The first author, who created a codebook and coded all transcripts using NVivo until theoretical saturation was achieved, is an undergraduate student with personal experiences interacting with grandparents, mothers, and children. The second author, who assisted in data interpretation by providing field notes and feedback, is a COHRA2 interviewer and has over eight years of expertise collecting primary data on children’s oral health from mothers. The principal investigator and senior author, who supervised data analysis, is an academic faculty member and clinician-scientist focusing on pediatric dentistry and health services research.

RESULTS

The 126 mothers of children aged 3–5 years were from West Virginia (n=66) and Pittsburgh, Pennsylvania (n=60). During their interview, 85% (n=107/126) of mothers spontaneously discussed at least one grandparent as a member of their social network responsible for their children’s oral health (Table 1). From these interviews, 85% (n=91/107) of mothers mentioned grandparents promoting cariogenic diet (Table 1). Mothers typically defined grandparents as the children’s biological grandparents and their partners. Some mothers cited multiple grandparents influencing their children’s diet.

Table 1.

Characteristics of mothers recruited from the Center for Oral Health Research in Appalachia Study who participated in the semi-structured qualitative interviews on their social networks responsible for child oral health (N=126).

Family Sociodemographic Characteristics n %
Child Age [Mean (SD)] 4.77 (1.02)
Child Dental Insurance
   Private 77 61%
   Public 18 14%
   None 31 25%
Mother's Education
   ≤ High School or Equivalent 18 14%
   Some College or Associate Degree 35 28%
   Bachelor's Degree 38 30%
   Master's, Doctorate or Professional Degree 35 28%
Mother’s Race and Ethnicity
   Non-Hispanic White 120 95%
   Hispanic White 5 4%
   Other 1 1%
Family Income
   Under $50,000 52 41%
   $50,000-99,999 47 37%
   $100,000 or more 20 16%
   Missing 7 6%
Grandparent Named as Member of Mother’s Social Network Responsible for Child Oral Health 107 85%
   Mother Reported that Grandparent Promoted a Cariogenic Diet to Child* 91 72%
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*

Mothers commonly cited that grandparents provided their grandchildren with large amounts of cariogenic foods and beverages (e.g., candy, dessert, juice, soda) and/or did not restrict their grandchildren’s intake of cariogenic foods and beverages.

Four themes emerged to describe mothers’ explanations for why grandparents give their grandchildren cariogenic foods and beverages: 1) Privilege of the grandparent role; 2) Responsibilities of the grandparent role; 3) Symbol of care and affection; and 4) Limited consideration or understanding of the detrimental impact.

Privilege of the Grandparent Role.

Mothers reported that grandparents justified giving their grandchildren cariogenic foods and beverages as a privilege of their role with the children. One mother said the grandparents gave her child candy because they claimed, ‘“we’re grandparents. That’s what we do.”’ The mother added, “I’m not going to be mean and deny that to them,” to describe how she did not want to interfere with the grandparents’ privilege to give the grandchild candy.

Even when grandparents did not promote a cariogenic diet, mothers accepted the role of grandparents as providers of cariogenic foods and beverages. One mother characterized her children’s grandmother as “not your typical grandma that shoves food in the kid’s face and then sends them home. She is not like that. She goes the healthier route.” The mother expressed that the grandmother’s feeding behavior diverges from her expectation that a “typical” grandmother gives children cariogenic foods and beverages.

Mothers described that another privilege of the grandparental role is to transcend the parents’ authority regarding feeding practices. According to one mother, when she asked the grandmother to give her children less cariogenic foods and beverages, “[the grandmother] thought I was being unreasonable, and she wanted to do what she wanted to do.” The mother added that the grandmother simply “doesn’t like to be told what to do” by the mother about what to feed the children. The grandmother’s own parents fed her children the foods that they wanted, so she now claims those rights as a grandmother herself.

Some grandparents generally complied with the mother’s dietary preferences for the children, but still occasionally exercised their ability to treat their grandchildren with cariogenic foods. One mother stated, “my mom definitely respects our decisions… She for the most, I’d say 90% of the time, enforces whatever I ask her to enforce. But there is that little bit of like, ‘Oh, let’s give her a peanut butter cup because I’m Grandma and I can do this.’” The mother perceived that the grandmother felt comfortable disregarding the mother’s rules because she believed her rights as “Grandma” were not completely subject to the mother’s command.

Responsibilities of the Grandparent Role.

Mothers described grandparents in the role of a secondary caretaker. Compared to the parents, grandparents had less frequent interaction with the children and different responsibilities. In the following quote, one mother described why the grandmother did not seem to care for her grandchildren’s oral health: “Since they’re not hers, I don’t think she worries as much… I feel like she’s like, ‘I’m Grandma. I don’t have to do that. You’re his mom.’” From the mother’s perspective, the grandmother believed her “Grandma” role excused her from parental responsibilities to care for children’s oral health, so she gave the children “junk food.”

Symbol of Care and Affection.

Mothers described that grandparents expressed their care and affection through a ritual of giving children cariogenic foods. In reference to a grandmother who had “bowls of candy sitting around her house,” one mother explained, “I think that her love language is just to treat people, give people things that they want. And I think she views that as ‘That’s a treat. If I give it to you, you’ll like me.’ I think that’s her thought process. And then she doesn’t really care if she gives them back to us and they’re all hyped up on sugar. It doesn’t enter her mind.” The mother described how the grandmother indulges her grandchildren with candy because it is her love language to treat them with something they enjoy. Another mother observed that her children’s grandparents provided cariogenic foods to transactionally receive the children’s affection. She stated “my parents will also say… ‘it’s a treat. You should have this.’ They think that because they want to give, they want to e-a-r-n like l-o-v-e through f-o-o-d.” Both mothers described grandparents using cariogenic foods as a symbol of love.

Mothers also reported that grandparents, especially those who infrequently interacted with their grandchildren, utilized cariogenic foods as tokens of affection to ingratiate themselves with their grandchildren. For instance, one mother said her children’s grandparents “don’t see [the children] very often,” so they rely on giving their grandchildren cariogenic foods because it is “an easy way to have a kid remember you.” The mother’s quote conveys that grandparents can quickly rekindle their relationship with their grandchildren through a ritual of giving children cariogenic foods.

Limited Consideration or Understanding of the Detrimental Impact.

Mothers observed that grandparents do not consider the impact of cariogenic foods and beverages on children’s oral health. One mother claimed the grandmother was “not concerned with whether or not [the child] just ate nothing but sugar for three days. That stuff just is not on her radar.” A different mother explained, “She wants people just to be happy and just have what they want. So that’s her mentality… Not really regarding anything else. Crazy enough, right, as a nurse?” In general, mothers observed that grandparents gave their grandchildren cariogenic foods and beverages because they overlooked the oral health detriments.

Mothers also described that grandparents do not fully realize their negative influence on children’s oral health. One mother remembered that her son’s grandmother expressed surprise when she learned about her grandson’s cavity and asked the mother “‘Well, what does he eat? How did it happen?’” Ironically, according to the mother, the same grandmother frequently contributed to her grandchildren’s cariogenic diet. The mother stated, “if [the grandmother] knows that they’re coming over, she’ll get specific things that they like,” including chocolate chip cookies and Oreos. The mother’s narrative suggests the grandmother did not evaluate the cariogenicity of the foods she provided when focusing on her relationship with her grandchildren.

Furthermore, mothers perceived that grandparents do not have up-to-date knowledge about healthy diets. One mother said that the grandmother “doesn’t really know that things are unhealthy and there’s a lot of sugar-laden foods that she gives [the children].” The same mother added the following quote about her children’s other grandmother: “despite her education level, they think, ‘Oh. It’s maple syrup, so it’s healthy. So [the children] can have it.’ … So they have a sort of a bad idea about what’s healthy for your teeth. Just because natural doesn’t mean it is.” The mother emphasized that both grandmothers gave their grandchildren cariogenic foods because they lacked knowledge about healthy diets, which prevented them from realizing the health consequences of those cariogenic foods.

DISCUSSION

Mothers perceived that grandparents have a rationale for giving their grandchildren cariogenic foods and beverages. Three of the study’s main themes are consistent with existing literature. Our first two themes – grandparents give their grandchildren certain foods and beverages because of the privileges and different caretaking responsibilities associated with the grandparental role – are similarly reported by a study on parents and grandparents from the Pacific Northwest of the United States15 and a study on grandparents from South Australia.17 Previous studies also describe our third theme that grandparents can express their love by indulging their grandchildren with food treats.17,18 We infer that grandparents capitalize on simple food offerings, like giving children candy, because food has a “universal quality” appropriate in many relationships.26

Our fourth theme that mothers believe grandparents do not consider or understand the impact of cariogenic foods and beverages on children’s oral health supports previous findings that grandparents27 and elderly adults28 lack knowledge about children’s oral health. However, this theme conflicts with other publications, which report that grandparents are conscious of the health implications of certain foods and beverages.15-17 The discrepancies may stem from differences in the data source. While previous publications15-17 described quotes from grandparents themselves, our study reported mothers’ observations of grandparents. This unique perspective allowed us to gather themes that may have been overlooked if grandparents self-reported their feeding practices.

Additionally, the frequency of interaction between grandparents and their grandchildren may differ among participants in previous studies15-17 and our study. Future research can quantify grandparents’ involvement and explore whether grandparents who spend more time with their grandchildren are less reliant on simple food offerings to bond with their grandchildren. This could support Farrow’s theory that grandparents are more likely to teach, model, and encourage healthy eating behaviors when they spend more time caring for their grandchildren.29

Overall, the results of this investigation are relevant to reducing poor diet quality, which is a shared risk factor for two childhood epidemics in the United States: obesity and dental caries. Consistent with theoretic frameworks on the social determinants of health,30-32 this study identified the relationship between children and their grandparents as a social determinant of child health due to the grandparents’ provision of cariogenic foods and beverages. For solutions to the global dental caries epidemic, the World Dental Federation states, “interventions that focus on modifying health behaviors and individual lifestyle choices have only limited success… because they ignore the wider social influences that determine these choices.”1 Therefore, we advocate that policymakers and health professionals remain cognizant of grandparents’ roles, responsibilities, and motives for giving children cariogenic foods and beverages when planning interventions.

Future interventions can encourage the important role of grandparents in their grandchildren’s lives and provide social support for grandparents to follow dietary recommendations for children. For example, grandparents can be asked to substitute cariogenic foods used to convey affection to their grandchildren for healthier snacks (e.g., fruit) and educational toys. These substitute rituals may require greater effort by grandparents to understand their grandchildren’s interests and hobbies, but they are arguably stronger representations of affection because they demonstrate the grandparents’ desire to protect their grandchildren’s oral health. We also echo the suggestion of previous publications27,28 that grandparents may need assistance understanding the implications of their feeding practices on children’s health. Providing personalized oral health education through health literacy techniques (e.g., teach-back, simple language)33,34 might encourage grandparents to adjust their feeding practices. Future research investigating grandparents’ perspectives can identify methods to best support grandparents in providing their grandchildren with a healthy diet.

This study has several limitations. First, the racial and ethnic homogeneity and geographic restrictions of the convenience sample do not allow us to extrapolate our findings to other populations. In some places in Appalachia, mothers may experience significant barriers to promoting optimal child oral health, such as low socioeconomic status, private non-fluoridated water supplies, and poor access to dental services.35 Second, we limited the results and quotes to the children’s biological grandparents and their partners, as identified by the mother. Future studies can investigate whether different familial and community-based grandparent figures have different reasons for giving children cariogenic foods and beverages. Next, the study participants were all mothers, so the results represent mothers’ perceptions about grandparents’ reasons for giving children cariogenic foods and beverages. Importantly, mothers’ perceptions of grandparents’ feeding behavior may be inconsistent with the grandparents’ actual behavior. Future studies can directly recruit grandparents and compare their reasons for giving children cariogenic foods and beverages with those provided by mothers in this study. Finally, the grandparents’ contribution to their grandchildren’s diet was assessed by the mothers. We do not know if the grandparents’ feeding behavior exposed children to free sugar levels that would increase the children’s caries risk or if the grandparents significantly impacted the children’s overall diets, which may have been primarily influenced by the children’s parents.

Our study has three main strengths. First, our qualitative approach allowed us to freely explore and appreciate the mothers’ stories and language. Second, we sourced all themes directly from the transcripts to accurately represent the mothers’ lived experiences. Third, we utilized quotes from mothers on why grandparents give their grandchildren cariogenic foods and beverages because they provide a critical outsider perspective to this grandparent-grandchild ritual. For instance, our theme that grandparents do not consider or understand the implications of cariogenic foods and beverages on children’s oral health may not have developed if we were limited to the grandparents’ perspectives.

CONCLUSION

This qualitative study provides insight regarding mothers’ explanations for why grandparents in north central and northern Appalachia give their grandchildren cariogenic foods and beverages. Our findings can help family members, health professionals, and community health workers better understand grandparents’ motives for giving children cariogenic foods and beverages and more effectively navigate future conversations with grandparents about the effects of a cariogenic diet on children’s oral health. Moreover, our findings support theoretic frameworks stating that relationships are a social determinant of health;30-32 and specifically, the relationship between children and their grandparents can be a social determinant of child health due to the grandparents’ feeding behaviors. Future research should explore whether social interventions involving grandparents sufficiently lowers child caries risk.

RESEARCH SNAPSHOT.

Research Question:

What are mothers’ explanations for why grandparents in Appalachia give their grandchildren cariogenic foods and beverages (e.g., those with free sugars and/or modified starches)?

Key findings:

In this cross-sectional qualitative study on mothers of children aged 3–5 years, over 70% of mothers (n=91/126) reported that grandparents promoted a cariogenic diet to their grandchildren. Mothers described that grandparents gave their grandchildren cariogenic foods and beverages as a privilege of the grandparent role and to demonstrate love. Mothers also discussed that grandparents lacked consideration or understanding of the impact of cariogenic foods and beverages on their grandchildren’s oral health.

Acknowledgments:

The authors express appreciation for the interviewers – Zelda Dahl, Natalie Marquart and Linda Brown – involved in primary data collection and all study participants for providing their unique narratives. We received permission from those named to be acknowledged for their contributions.

Funding Source:

This study was completed with the support of the Robert Wood Johnson Foundation Harold Amos Medical Faculty Development Program and the National Institute of Dental and Craniofacial Research (Grant Number R01 DE014899).

Footnotes

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

Conflict of Interest Disclosure: The authors have no conflicts of interest to disclose.

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