Date of Degree
Doctor of Public Health (DPH)
Health Policy and Management
family meals, childhood obesity, dietary quality, HEI-2010, FoodAPS, SNAP eligible
Between 20 and 21% of US children 6-19 have obesity. Children residing in households eligible for the Supplemental Nutrition Assistance Program (SNAP) are exposed to vulnerable socioeconomic conditions, often living in low-resourced households and communities. These children are at a high risk for obesity, and thus to obesity-related comorbidities as well as adulthood obesity. The US Department of Agriculture (USDA) recommends family meals as well as diets meeting the American Dietary Guidelines as an obesity prevention strategy. These are connected; the dominantly theorized pathway by which family meals protect against childhood obesity is through the diet quality of the family meal. Yet, little is known about the relationship between family meal frequency and its relationship with childhood obesity among children residing in SNAP-eligible households. Moreover, it is not known whether distinguishing SNAP-eligible participating and SNAP-eligible nonparticipating households would more effectively target interventions. Likewise, research using small samples has shown that a healthful home food environment protects against childhood obesity. However, little is known about this relationship in SNAP-eligible households specifically. This dissertation aims to fill these gaps by examining how family meals and childhood obesity are connected among children residing in SNAP-eligible households. The specific aims are to 1) investigate the association between family meal frequency and childhood obesity including interaction by SNAP status, 2) analyze the relationship between dietary quality of household grocery purchases and childhood obesity, and 3) determine if dietary quality of household grocery purchases mediates the association between family meal frequency and childhood obesity.
The presented studies are cross-sectional, secondary data analyses utilizing a nationally representative sample of children aged 6 to 17 years from the USDA’s Food Acquisition and Purchase Survey (FoodAPS) data (2012-2013). The subsample for all three studies was comprised of children residing in SNAP-eligible households. The first study based on a sample of 1,441 children analyzed the relationship between family meal frequency (i.e., the number of meals “all or most family members” sat down and ate together in the past seven days) and childhood obesity (BMI ≥95th percentile respective to age and gender). Family meal frequency was operationalized into a three-level categorical variable (0-2, 3-6, and ≥7 family meals/week). The analysis included an interaction term to evaluate the association between family meal frequency and childhood obesity by SNAP participation status. The second and third studies used a sample of 1,134 children. The second study examined the association between childhood obesity and dietary quality of purchased groceries utilizing Healthy Eating Index (HEI) 2010, a measure of dietary alignment with the Dietary Guidelines for Americans (scores range from 0-100). Using a cutoff of 50, HEI was dichotomized into poor diet and not poor diet. The analyses for the first two studies implemented logistic regressions due to the binary outcome for obesity (i.e., yes and no). The third study investigated the mediation of dietary quality of grocery purchases on the relationship between family meal frequency and childhood obesity. It utilized Baron and Kenny’s approach for mediation analysis, incorporating three regressions (two logistic and one linear) and a Spearman’s correlation analysis. The outcome for one of the regressions was HEI total score in the continuous form, requiring a linear regression. Analyses for all three studies were run using SAS-callable SUDAAN 11.0.3 (SAS version 9.4) to address complex multi-stage survey sampling and nesting of children within households. Adjusted prevalence rations are reported in the first two studies and beta coefficients are presented in the final study. Significance was set at a p value less than 0.05.
Approximately 24% of the sampled children had obesity and just over half resided in households that engaged in ≥7 family meals/week and participated in SNAP (51% and 52%, respectively for the first study). Similarly, nearly 24% of the children sampled in the second and third studies had obesity and about half lived in SNAP-participating households. The mean HEI total score for household grocery purchases was 48.5 (analyzed in studies 2 and 3). Across all studies, children with obesity were significantly more likely to reside in households where the main household food shopper or preparer had no college education (study 1: p=0.009; studies 2 and 3: p=0.017). In the first study, obesity prevalence was significantly lower among children exposed to households that had ≥7 family meals/week compared to those in households that engaged in 0-2 family meals/week (Adjusted Prevalence Ratio [APR] 0.66; 95% CI 0.456, 0.965). A similar result was observed in the second study, which included HEI total score for household grocery purchases as a covariate (APR=0.682; 95% CI 0.480, 0.969). Additionally, a significant and negative association between 3-6 family meals/week and obesity prevalence was evident when compared to 0-2 family meals/week (APR=0.556; 95% CI 0.350, 0.884). The analysis of interaction by SNAP participation status did not yield significant results; thus, this factor did not moderate the relationship between family meal frequency and childhood obesity nor the association between dietary quality of household purchased groceries and childhood obesity. Obesity prevalence was significantly lower among children whose households’ purchased groceries had HEI total scores above 50 (not poor diet; analyzed in study 2). However, the continuous form of HEI total score in the third study did not show a significant association between dietary quality of household purchased groceries and childhood obesity (discussed in Chapter 4). The third study’s mediation results for HEI total score (i.e., dietary quality of household purchased groceries) met only one of four conditions for mediation, which was a significant finding for the association between family meal frequency and childhood obesity (3-6 family meals/week: β= -0.612, 0.278 SE, p=0.035 and ≥7 family meals/week: β= -0.753, 0.342 SE, p=0.035; the referent was 0-2 family meals/week). Thus, the alternative mediation hypothesis was rejected.
Childhood obesity prevention is dependent on evidence- and family-based interventions to successfully support the most at-risk populations. Family meals, a highly recommended strategy, has the potential to protect children who reside in low-resourced households from obesity. However, the context in which family meals occur is complex. Recommendations should acknowledge the resource constraints of families who experience vulnerable socioeconomic circumstances even when they receive benefits to supplement their food budgets. Public health strategies intended to prevent childhood obesity should be based on a more expansive understanding of the benefits family meals have on children living in SNAP-eligible households and of the connection between family meals and the dietary quality of purchased groceries. Moreover, further mediation explorations addressing other dietary factors (e.g., junk food purchases and foods acquired for free) as well as non-dietary factors (e.g., family cohesion) are essential to develop family-centered and more targeted preventive strategies. Enhancing the efficacy of programs such as SNAP has the potential to improve the health of Americans young and older for decades to come.
Rodriguez, Noemi, "Association Between Childhood Obesity, Family Meals, and Dietary Quality Among US Children Aged 6 to 17 Years Residing in SNAP-Eligible Households" (2022). CUNY Academic Works.
Available for download on Monday, December 30, 2024