We offer this report as a glimpse into a family routine that holds promise for affecting child health: family mealtimes. Although mealtimes lasted on average only 18 minutes, we found significant relations between time spent in specific forms of mealtime interactions and child health variables. In addition, our results highlight that the intertwined nature between socioeconomic risk and children’s health cannot be ignored, as we found strong associations for child ethnicity and maternal education in relation to asthma symptoms and child quality of life. We frame our discussion by considering the relative time spent in different types of family interactions during the course of a mealtime, the potential for specific types of mealtime behaviors to be associated with different types of health variables, the social roots of children’s health in a socio-demographic context, and potential applications to practice and policy.
The bulk of family mealtime interactions were divided between some form of activity (e.g., getting up and down from the table, talking on the phone, watching television) or communication about personal events (e.g., school happenings, whether the family should get a new puppy, homework assignments). It was the relative amount of time spent in these two types of interaction that distinguished families from different ethnic backgrounds, maternal education, single versus dual adult households, child quality of life, severity of asthma symptoms, and adherence to the asthma treatment regimen. When family members were more engaged with each other and demonstrated an interest in daily events during their mealtime conversations, child asthma symptoms were less likely to be severe and adherence to the medical regimen was likely to be greater. When mealtimes were characterized by more distractions, asthma symptoms were more pronounced. Of course, it is not possible to effectively communicate about personal events of the day if attention is turned to the television or catching up with a best friend on a cell phone. In terms of asthma symptoms and medical adherence, it may be that mealtime conversations afford one opportunity to observe wheezing, coughing, and to check in on whether the child has taken his or her medication that day. These brief encounters may have long term consequences for the child’s health.
This observational study also underscores how the socio-demographic context of raising a child with a chronic health condition cannot be ignored. Families in which the primary caregiver had less education, children were non-Latino non-white, or there was only one adult caregiver in the household experienced more action during mealtime and less time spent catching up on the day’s events. These are also the children believed to be at greatest risk for poorly controlled asthma and most likely to use the emergency room for healthcare (Chen, et al., 2003
). Researchers have pointed out that a more comprehensive understanding of health disparities requires attention to environmental factors that add to the chronic stress associated with compromised health in low income, minority, under-resourced individuals (Adler & Rehkopf, 2008
). An interesting characteristic of chronically stressed environments that has been linked to compromised physical and mental health includes the relative amount of “hubbub” or inconsistent, socially non-responsive activities apparent in the family home (Evans, Gonnella, Marcynyszyn, Gentile, & Salpekar, 2005
). Recent research suggests that lack of organization, or chaos, can disrupt learning and portend for poor socio-emotional development (Johnson, Martin, Brooks-Gunn, & Petrill, 2008
). The action we observed during mealtime interactions are consistent with this notion, as they often included a “hubbub” of movement by multiple members of the family that made it difficult to follow conversations. Conversely, when conversations were sustained there was the appearance of a more organized mealtime.
The glimpse of family life we obtained through our observations suggests that potentially important mechanisms of protection or risk in chronically stressed environments may involve organizational and communication features of shared family mealtimes. Historically, the study of family routines has included a focus on their organizational features as a protective force from disruptions in the outside world. Indeed, family mealtimes as a set aside time for the family group evolved in response to the challenges of juggling work and school schedules in middle class families (Cinotto, 2006
). However, our results also indicate that while organizing daily routines may be an avenue of protection, a tailored and culturally sensitive approach is necessary for families who are stressed by managing a chronic illness, are under-resourced economically and educationally, and have few means of social support.
There was one class of mealtime behaviors that was relatively infrequent that nevertheless were related to child health and socio-demographic variables: behavior control. Behavior control was modestly related to the severity of asthma symptoms and varied by child ethnicity and single vs. dual parent household status. Single parents were more likely to engage in some form of behavior control than households with another caregiver present. Behavior control was the only mealtime behavior that significantly interacted with education and ethnicity to predict one of the child health indicators, child quality of life. Consistent with previous reports that have found intrusive or indulgent parenting styles more prevalent in African American or low income families (Faith, et al., 2004
; Hughes, et al., 2008
) our results indicated that the relationship between more controlling mealtime behavior and child health depended on socio-demographic context. More specifically, time spent in behavior control was particularly deleterious to child QOL in the context of lower maternal education. In other words, children in families with less educated mothers experienced more social, emotional, and activity impairments due to asthma, particularly in the context of more controlling parenting. Likewise, more time in behavioral control was deleterious to child quality of life and medication adherence, but only for non-Hispanic white families; white children experienced less impairment in social, emotional, and activity functioning due to asthma compared to minority children, but only in the context of low behavior control. Thus, the impact of higher behavior control was most pronounced in the context of other socio-demographic risk factors (minority status and lower mother education). Consistent with other reports that have highlighted the complexity with which family interaction and socio-demographics may interact (McLoyd, Cauce, Takeuchi, & Wilson, 2000
), the role that behavior control during mealtime may play for promoting health for some children deserves further elucidation.
In interpreting these results, it is important to note that our assessment of behavior control focuses on how parents attempt to manage behavior in ways that are most commonly thought of as intrusive and harsh. Although there may be some overlap with what is typically captured in parenting style scales concerned with “strict” styles of parenting (e.g., of authoritarian parenting), the fact that we did not find the same protective role in more disadvantaged families suggests we are not measuring the same construct. Instead, we believe that we are capturing a family dynamic that may be specific to mealtime settings and has been found to vary by socio-demographic context. Hughes and colleagues (Hughes, et al., 2006
; Hughes, et al., 2008
) report both indulgent and restrictive feeding styles in low income parents of young children. Whether our coding system accurately reflects important variations along dimensions of behavior control will require further investigation across families that are diverse not only in socio-economic status but also in developmental status of their children. We also note that this was a relatively infrequent behavior in our observations, which may be due to the definitions used in our coding scheme (e.g., our purposeful separation of behavior control from positive communication) or to the nature of the behavior itself that requires very little time to get the message across.
Although we were able to demonstrate modest effects of mealtime communication patterns on child quality of life above and beyond maternal education and general family functioning, these findings were very limited. We believe this does not detract from the potential contribution of the family mealtime to promoting health. Rather, it suggests that mealtime is but one proximal routine that may be associated with child health. Previous research has indicated that family routines tend to cluster together (McLoyd, Toyokawa, & Kaplan, 2008
) and that disruptions in one routine, such as mealtime, can influence other routines such as bedtime (Fiese, Winter, Sliwinski, & Anbar, 2007
). Mealtimes represent a regular event for the vast majority of families with young, school age and adolescent children (Bradley, et al., 2001
). Thus, they provide an optimal setting for public health initiatives and prevention efforts and we hope this is a focus for the future. We also believe that future studies concerning the unique elements of routines such as how they begin and end over time, serve as communal goal setting environments, provide unique opportunities for sharing information, and provide a means to cope with stressful transitions would be fruitful.
There are several limitations to our study, including the single observation of one mealtime. Our method is consistent with other reports (Dickstein, et al., 1998
) and 90% of the families reported that the recorded meal was “typical” or “very typical” of their usual mealtimes. Nevertheless, future efforts are warranted to determine whether multiple observations reveal the same pattern of results. We were also limited by the information we had available on socioeconomic context. Neighborhood poverty, parental work pressures, and access to healthy foods have been found to play a significant role in family mealtimes (Fiese & Schwartz, 2008
). We recognize that this report is but one snapshot of a multifaceted setting embedded in a complex socio-cultural context. Future studies could add to our understanding of how culture, economic context, and the home environment (Harrison, et al., in press
) may also influence patterns of mealtime interaction associated with child health.
Raising Healthy Children: Implications for Policy and Practice
We believe there are several practical implications suggested within our findings and the related literatures. First, it is important to emphasize that family mealtimes last only about 18 minutes, on average, and are casual affairs. The notion that family meals must be complicated, elaborate affairs can dissuade parents from engaging in this important activity. Second, families need guidance and support in creating communication strategies for their mealtimes. It may not be enough to suggest that families eat together four or more times a week if they come prepared to criticize, control, or avoid conversation altogether. Our analyses of time spent in this brief encounter suggests that families who spent seven or more minutes, on average, disengaged with each other by watching television, talking on the phone, or being otherwise disengaged from the mealtime conversation had children who experienced poorer health. These can also be families who experience more economic and parenting pressures in their lives by virtue of being single parents and having less educational resources available to them. This suggests a need to assist families to more effectively communicate and find compelling ways to remain at the table while shutting out distractions, a notion that may be particularly necessary in our current culture so often espousing the virtues associated with “multitasking.”
There are also developmental challenges to understanding how to construct healthy family mealtimes, both to researchers (methodologically) and to families (practically). From a methodological perspective, our study included families who ranged in size from two to 11, with ages of the children present at meals ranging from two months to 21 years. Methodologically, an average age approach does not reveal the interactional complexity and developmental demands placed on a family system with toddlers and school age children, infants and adolescents, four children under the age of five, or a set of twins. This is the reality of family mealtimes that statistical strategies have yet to successfully unravel. From a practitioner and curriculum perspective, it would be helpful to have succinct and useful guidelines to offer families for managing behaviors at different developmental periods as well as communication tips that extend across two or more age ranges. This will require not only careful thought but a theoretical framework to guide evidence based approaches.
Finally, there are active steps that policy makers can take in making family mealtimes a priority for communities and their constituents. There are opportunities for local, state, and federal governments to work toward incorporating family mealtimes into the public health agenda. Examples include food labeling, access to healthy foods in low income neighborhoods, public service announcements promoting healthy family mealtimes, and support for education programs (Fiese & Schwartz, 2008
). State and federal governments subsidize food programs to children through WIC, SNAP, and school lunch programs. Incorporating healthy ways of relating during shared mealtimes in addition to evidence based nutrition practices is practical, has the opportunity to reach a large number of children, and is also based on an increasingly large evidence base. Just as children’s safety became a national priority through campaigns and legislation surrounding seat belt use, raising awareness and investing in public support for healthy family mealtimes would not only be money well spent but may also be as simple as ABC.