Family influence on healthy eating among Chinese adolescents : a mixed methods study

Abstract

Healthy eating is important in preventing adolescent obesity and future non-communicable diseases. Unfortunately, adherence to dietary recommendations has been poor in this age group. Family plays an essential part in helping adolescents to develop healthy eating habits, with major influences from parental characteristics and food parenting practices. In-depth studies on family influence on adolescent healthy eating habits in Asian families are lacking, this research aimed to explore how family influences adolescent eating habits from the perspectives of the adolescents and the parents in the Chinese cultural context using a mixed methods approach. The first study involved qualitative interviews with 25 parent-adolescent dyads to explore their Knowledge, Attitudes and Practices (KAP) and family facilitators and barriers to healthy eating. The results informed the development of a quantitative survey to establish the major family factors. A 44-item KAP of Healthy Eating questionnaire (KAP-HEQ) and two 10-item questionnaires on Parent Attitudes towards Adolescent Eating Habits (PAAEH) and Food Parenting Practices (FPP), respectively, were developed through expert panel reconciliation and lay-subject evaluation. The questionnaire survey was completed online by 121 parent-adolescent dyads. The data on the first 60 dyads were analysed to confirm the reliability and validity of the three questionnaires. The effects of parental characteristics and food parenting practices on adolescent KAP of Healthy Eating were analysed by multivariable regressions on the data from all 121 parent-adolescent dyads. The qualitative study found the key KAP gaps in adolescents were insufficient knowledge of dietary recommendations, perceived low susceptibility to diet-related health risks, unhealthy snacking and food choices in restaurants, and insufficient fruit and vegetable intake. The key family facilitators to healthy eating included positive parental attitudes towards healthy eating, healthy food provision at home, and parental supervision; the barriers were parental deficiency in dietary knowledge, time and cost concerns, and limited family discussion on food-related issues. Useful strategies were associated with an authoritative parenting style of incorporating healthy ingredients in adolescents’ favourite recipes, cultivating food preferences, and involving adolescents in meal preparation. The KAP-HEQ, PAAEH, and FPP questionnaires demonstrated good internal consistency (Cronbach’s alpha > 0.7) and test-retest reliability (ICC > 0.7); the KAP-HEQ had 80% item scaling success and construct validity in known-group comparison. Quantitative survey showed a high correlation between Attitude and Practice scores in the dyads. Adolescent KAP scores were positively correlated with parental knowledge and practices, food parenting practices, and parental chronic disease and employment, while negatively with a household size of 4 or above. Parenting style by Regulation had a positive effect but Autonomy Granting had a negative effect on adolescent Knowledge and Attitude scores. The findings suggested four specific family strategies to guide interventions to promote healthy eating in adolescents in the Chinese cultural context – practical nutrition education for parents, role-modelling healthy eating practices, food parenting practices (food availability and supervision), and adoption of a parenting style by Regulation. The new Chinese KAP-HEQ can be applied to identify the KAP gaps and to evaluate the effectiveness of interventions.