1. Introduction
Dietary recommendations for children in the United States are based upon the Dietary Guidelines for Americans, which provide evidence-based recommendations for foods and beverages to consume to promote nutritional health and reduce risk of chronic disease [
1]. However, few children in the United States meet these federal dietary recommendations [
2]. Sixty percent and 93% of children fall short of recommendations for fruits and vegetables, respectively [
3]. The majority of children also consume excess energy from solid fat and added sugars [
2]. Unhealthy eating patterns are associated with excessive weight gain and may be predictive of disease risk and overall health status [
4]. To prevent excessive weight-gain and reduce the risk of chronic disease, it is recommended that children consume a diet rich in fruits and vegetables and limit consumption of added sugars and saturated fat [
4].
Parenting styles are associated with child dietary intake, as evidenced both by cross sectional and longitudinal studies [
5,
6,
7]. Parenting styles that are commonly referenced in the literature include authoritative, authoritarian, permissive, and neglectful styles [
5,
6]. Specifically, the authoritative parenting style, which is characterized by high levels of caregiver warmth and control over the feeding situation, is associated with healthier dietary intake among children [
5,
6].
Caregiver feeding practices and home environmental factors including caregiver role modeling of dietary behaviors, caregiver dietary intake, and home food availability have been found to be predictive of child diet in certain populations, such as those of higher-income, higher educational attainment, and urban populations [
8]. One systematic review of 37 studies of caregiver feeding practices found that caregiver role modeling, home food availability, and caregiver dietary intake were important predictors of child dietary intake for both healthy and unhealthy foods. However, the effectiveness of feeding practices may vary according to child age and parenting style. For example, caregiver feeding practices that are known to promote healthy dietary intake among children, when used in the context of different parenting styles may have different effects [
8]. Additionally, rewarding with verbal praise predicted child diet most strongly among children aged 6 and younger, while modeling and home food availability appear to predict food consumption among children aged 2–11 years old [
8], thus examining caregiver feeding practices, such as parental modeling and home food availability in diverse population and settings is critical. In addition, the literature suggests that educating caregivers of young children about the use of caregiver feeding practices may promote healthy eating and prevent unhealthy eating [
9], thus having evidence that demonstrates this along underserved populations, such as low-income, rural, Appalachian families may be a helpful strategy to reduce the nutrition-related health disparities seen in this population.
Caregiver role modeling of dietary behaviors (from here on referred to as modeling) is rooted in Bandura’s social cognitive theory and posits that children’s observations of caregiver eating behaviors can influence child diet [
10,
11]. Previous studies among children and adolescents aged 2–18 have defined modeling in two ways: (1) the level of importance caregivers place on modeling healthy eating behaviors and the frequency with which caregivers report these behaviors [
9,
12,
13,
14,
15,
16], and (2) caregiver dietary intake of specific foods [
17,
18]. The first definition of modeling captures caregiver’s reported dietary intake behaviors in addition to social factors, caregivers’ food-related attitudes, and behaviors around meal times, and is, therefore, used most commonly in the literature. Using this definition, modeling was positively associated with child dietary intake of fruits and vegetables, lower consumption of sugar sweetened beverages, sweets, and snacks, and is inversely associated with a child’s BMI z-score [
9,
12,
13,
14,
15,
16,
18,
19,
20,
21]. Fewer studies have assessed the modeling construct as caregiver dietary intake of specific foods [
17,
22]. In one study, healthier caregiver dietary intake was found to be positively associated with adolescent consumption of fruits and vegetables and negatively associated with sugar sweetened beverage consumption [
18]. Knowing the impact of both of these concepts of caregiver modeling among low-income, rural, Appalachian youths could be a key strategy to improving nutritional health in this population.
Home food availability refers to caregiver control over the types of food available at home. Previous studies have linked the availability of healthier food at home to higher child consumption of fruits and vegetables [
13,
17,
23,
24] and lower consumption of high-sugar/high-fat (HS/HF) snack foods among children in higher income, more educated, and urban populations [
17,
23], indicating that the availability of healthier foods in the home may play a role in developing child preferences for healthier foods in certain groups [
8]. Further, low fruit and vegetable consumption among children has been found to be associated with low availability of fruits and vegetables in the home and low caregiver socio-economic status [
25].
The Appalachian region is geographically located in the Eastern United States, surrounding the Appalachian Mountains. This region has a higher than average rural population and adult obesity and chronic disease rates, such as diabetes and cardiovascular disease, that exceed national averages [
26,
27]. Historically, the Appalachian region has been encumbered by high rates of poverty [
28]. Despite recent progress, the region as a whole continues to experience higher than national averages for both poverty and unemployment rates, exacerbating health disparities between Appalachian communities and other regions of the United States [
29].
The prevalence of obesity is higher among both low-income [
30] and rural populations [
31], and rural youths have 26–30% higher odds of obesity than urban youths, even after controlling for sociodemographic factors, health, diet, and exercise behaviors [
31,
32]. According to a study of demographic characteristics and diet quality, individuals with low socio-economic status are less likely to adhere to federal dietary recommendations [
33]. Furthermore, children living in rural areas tend to have poor adherence to dietary patterns compared to non-rural children [
34]. For example, according to national data, rural children consume an average of 90 more kilocalories per day and are less likely to consume any fruit or meet the daily recommendation for fruit when compared to urban children [
32].
Rural, Appalachian communities are at a high risk for poor diet quality and diet-related health disparities, and, therefore, should be considered as an important sub-population in future research. Specifically, little is known regarding this population’s use of feeding practices and how each of these factors relates to a child’s consumption of fruit, vegetables, and high-sugar/high-fat snack foods (e.g., candy, doughnuts, cookies, ice cream).
Previous studies of caregiver feeding practices have been conducted in non-rural settings and among higher income populations [
9,
13,
14,
15,
16,
18], thus limiting the generalizability of findings to this population. The aims of this study, therefore, were to describe the use of modeling, caregiver dietary intake, and home food availability; and to examine associations between modeling, caregiver dietary intake, and home food availability with child fruit consumption, child vegetable consumption, and child HS/HF snack food consumption, among families with young children in low-income, rural areas in Appalachian East Tennessee.
4. Discussion
This study offers a significant contribution to the literature as it is among the first to assess the use of caregiver modeling, caregiver dietary intake, and home food availability as measures of caregiver feeding practices in a rural, Appalachian population sampled from low-income communities. Prior to the completion of this study, little was known about the relationship between these factors and child food consumption in this population. These findings help to identify potential child health promotion strategies for use among low-income, rural Appalachian families.
The mean score of caregiver reports of modeling behaviors in the present study were consistent with cross-sectional findings from a study by Vaughn and colleagues in a non-rural sample of highly educated families with higher-incomes [
16]. Despite population differences, the reported use of modeling in this population was found to be similar to previous studies. However, one cross-sectional study found that low-income, rural mothers had poor alignment between their intent to promote healthier child dietary intake and the use of counterproductive feeding practices [
40]. Further research is needed to better understand how a low-income, rural context may shape the application of these caregiver feeding practices in interventions aiming to improve child dietary intake.
Caregiver modeling significantly predicted child consumption of vegetables, which is consistent with the current literature for other population groups in cross-sectional studies [
9,
12,
13,
14,
15,
16,
17,
18]. Modeling also inversely predicted HS/HF snack food consumption, meaning higher levels of parental modeling was associated with lower frequency of HS/HF snack food consumption. There was not a significant relationship identified between modeling and fruit intake in this study. Previous cross-sectional studies have reported that caregiver modeling is a predictor of higher child consumption for both fruits and vegetables [
9], and lower consumption of less healthy foods, such as soda or HS/HF snack foods [
16,
17]. However, studies often assess fruit and vegetable consumption as a combined category, limiting the ability to interpret results. The present study analyzed fruits and vegetables as individual variables, as children’s consumption patterns of fruit and vegetables differ, with the general consensus being that among children, fruit consumption is easier to modify than vegetable consumption [
3,
41], which is potentially due to a variety of factors such as preferences for the taste and texture of fruit, or that fruit is ready-to-eat and often consumed as a snack [
41,
42].
Caregiver dietary intake of fruit and vegetables were found to be significant predictors of child fruit and vegetable consumption, respectively. This is also consistent with current literature on caregiver modeling when measured as caregiver dietary intake in cross-sectional studies [
17,
18]. However, the literature assessing the relationship between caregiver dietary intake and child dietary intake patterns is limited when compared to other food-related parenting factors. While this is an important and novel finding of our study, further research is needed to confirm these findings, and to determine if this finding is generalizable to other groups.
The present study found that higher home availability of healthier foods was positively associated with child fruit consumption, which is consistent with reports from multiple previous cross-sectional studies [
13,
17,
23,
24,
43,
44]. Higher availability of healthier food was positively associated with child vegetable consumption. In a 2014 cross-sectional study by Loth and colleagues, home availability of healthier foods was associated with observed differences in child consumption of both fruits and vegetables [
17]. Similarly, another cross-sectional study found that overall higher diet quality, including high intake for both fruits and vegetables, was associated with home availability of healthier foods [
14].
Similar to a cross-sectional study by Hendy and colleagues [
44], the present study found that home availability of less healthy foods was associated with high child consumption of HS/HF snack foods. Based on this knowledge, limiting the availability of less healthy snack foods in the home may be a useful strategy to limit children’s consumption of HS/HF snack foods. Because children’s preferences develop over time and through multiple exposures to foods [
45], promoting a healthier home food environment may influence child dietary intake patterns both inside and outside of the home. While caregiver feeding practices such as home food availability and caregiver modeling may influence child dietary intake both inside and outside of the home, it is important to note that the relationships influencing child obesity and child diet quality are complex and multi-faceted [
46]. Therefore, while the percent of variability explained by the regression models in this study ranged from 10% to 27%, which is consistent with the literature [
8,
41], there is still a lot of variability in child fruit, vegetable, and HF/HS intake that was not explained by these models. Because of this, these results should be considered within the greater context of childhood nutrition interventions and the various factors at play, and additional research is needed to further explore influences on child dietary intakes.
This study is among the first to investigate modeling, caregiver dietary intake, and home food availability in a rural, Appalachian population in low-income communities. Despite the fact that this target population experiences nutrition-related health disparities [
26,
27], this population is one that can be difficult to reach and may not be well represented in the current literature. The assessment of modeling as two distinct constructs is a novel approach and should be further explored in future research. Finally, a key strength of this study was the separate dietary analysis of fruits and vegetables, which has not been done in much of the previous literature.
Key limitations to this study include the use of a convenience sample and cross-sectional data. The target population of this sample included caregivers of wide child age range (2–10 years old), across which developmental and dietary differences exist [
47]. However, child age was controlled for in all statistical models to account for potential developmental differences. Additionally, several factors in the models trended toward, but did not reach, statistical significance at the 0.05 level, which we hypothesize is related to the use of a small sample size. Furthermore, the use of diet screeners for caregiver and child diet, though common in this type of research, may lead to both underreporting and over reporting of intakes for certain food groups, resulting in an inaccurate representation of dietary patterns. However, the dietary assessment tools used in this study are validated and frequently used in the literature and national surveys.
Dietary behaviors are complex and are influenced by multiple factors. In this study we analyzed several important family- and household-level factors; however, it is important to note that there are other factors that may influence child dietary intake that were outside the scope of this study. For example, modeling behavior and dietary intakes of elder siblings, and family dietary restrictions or eating patterns (such as households following a vegan/vegetarian diet or avoiding certain foods due to food allergies) may also influence child dietary intake, and should be explored in future studies. Additionally, measurement and analysis of parenting styles as either direct predictors of child diet or potential moderators of the relationship between caregiver feeding practices and child diet were outside the scope of this study, but are important next steps in the research with this unique population. Child weight status is another factor that could be further explored. In this study, child height and weight were collected as caregiver-reported measures, and due to the limited accuracy of caregiver-reported height and weight observed in previous studies [
48], BMI was not included in statistical models. Finally, Cronbach’s alpha values for some scales were low (modeling, child vegetable consumption, and less healthy home food availability scores) indicating potential for unreliability in the scale [
49]. When indicated through statistical testing, steps were taken to increase Cronbach’s alpha values by removing items from scales. The scales used were drawn from validated measures that are commonly used in the literature, but because of low internal consistency of some scales, results should be interpreted with caution.