Children’s food choices and dietary quality depend on the interaction of individual characteristics and contextual environmental factors . This study investigated the relation of FFE with FNL in Chinese school-age children, the results showed family caregivers and their educational level and nutrition literacy, were significantly related with children’s FNL and overweight risk.
Most of children’s eating behaviors occur with families in and around home, so family food environment is the most relevant contextual factor and focused increasingly. Several models have been proposed to conceptualize the FFE [6; 20; 25], overlapping constructs within these models are the basis for our developed conceptual framework of FFEQ-SC, including physical environment (healthy/unhealthy food availability), sociocultural environment (such as caregiver’s FNL, family feeding patterns, meal practices, and eating rules), and family sociodemographic characteristics (family caregiver and their educational level). The results of the study showed overall 68.9% of the children’s families had a higher level of total FFE (≥ P60 of total score), among those dimensions, most of the family caregivers were children’s mother (71.4%) or father (27.1%), more families restricted (61.3%) or enforced (20.2%) their children to eat or not to eat certain foods than permissive pattern (18.5%), most of the families had eating rules (65.3%) and good meal practices (68.9%), and 78.2% of the families supplied their children more healthy foods than unhealthy foods. Because of the differences of FFE model and assessment instrument, the FFE factors could not be compared directly among studies. A cross-sectional survey in 396 parents of 3 to 5 year-old children of Australia showed the majority of families (87%) ate most meals at a table, 59% of parents restricted dessert when their child did not eat dinner, 29% rewarded their child with dessert for finishing dinner, only 4% of parents allowed their child to access snacks themselves, fewer than half of those households (39%) kept both fruit and vegetables in a ready-to-eat, accessible format . An observational cohort study of 699 American children aged 6 to 11 years and their parents showed a high use of encouragement/modeling and restrictive feeding practices and a high availability of low-calorie/nutrient-dense foods in the home, other parenting and food availability measures were near the middle of the possible score range . Above studies draw a consistent conclusion that more families restricted children’s eating compared with permission pattern, but the availability of family foods were different, that might be related with other family sociodemographic characteristics and sociocultural factors including family economic status, parent’s educational degree, nutritional knowledge and so on.
Undoubtedly, the potential impact of the FFE on children’s food choices and diet quality is particularly relevant [12; 13; 15; 16; 22; 30]. A systematic review (14 studies published between 1994 and 2017) indicated family environmental factors (household food availability, caregivers’ nutritional knowledge and family income) were consistently associated with children's food consumption and micronutrient intake . But it is noteworthy that behind the dietary behavior and intake, the individual knowledge, skills and behaviors required to plan, manage, select, prepare and eat foods, which is defined as FNL, may play an important role [1; 27]. A cross-sectional study of 101 parent-child dyads showed that for every 1% increase in Nutrition Literacy Assessment Instrument for Parents (NLit-P), there was a 0.51 increase in child diet quality (Healthy Eating Index) .Till now few studies focused on the effect of FFE on individual FNL. The study developed a validated and reliable FNLQ-SC to analyze relations of different FFE factors with children’s FNL. The results showed that FFE factors, including family sociodemographic characteristics, family caregiver and their educational level and nutrition literacy, family eating rules, and family healthy food availability, were positively related with children’s FNL scores. Especially the family caregiver (father), and caregiver’s educational level and nutrition literacy, were consistent and significant predictors of children’s FNL, including cognitive and skill domains. The FNL assessment of 803 students aged 10–12 years in Iran also identified significant associations between total FNLIT and parent’s education. Among FNL dimensions, the score of children’s healthy “eating” was positively related with family caregiver (father), caregiver’s educational level and nutrition literacy, family economic status, and eating rules. Systematic review and other studies presented similar results that caregivers’ nutritional knowledge, education and family income were consistently associated with children's healthy food consumption and dietary pattern [14; 21; 22]. Our results furtherly showed the children with higher level of caregiver’s FNL were less likely to be overweight or obesity (OR = 0.043, 95%CI: 0.292–0.981, P < 0.05). These findings highlight the importance of targeting and nutritional knowledge of family caregivers by education to facilitate the capacity of children to obtain, process, and understand nutrition information and skills, which are essential to make appropriate nutrition decisions and maintain a good diet and health in children. Intervention studies also demonstrated that a change in the food environment was associated with a change in children's eating behavior, dietary intake and obesity [10; 19; 28; 29].
In the study there were not significant relations of family feeding patterns and food availability with children’s healthy “eating” score, which were presented in other studies [15; 21], Cochrane review showed parents’ child-feeding practice may lead to small increases in fruit and vegetable consumption in children . The inconsistency of results might be due to the differences of FFE assessment and dietary investigation methods, which need to be explored furtherly. Also the study did not show any significant relations of family feeding patterns and meal practices with children’s FNL, and future research should adopt more rigorous methods to advance the field.
Overall, previous studies focused on the impact of food environment on eating behavior and food choice, this study furtherly explored relations of FFE factors with individual knowledge and skill (FNL) to make appropriate nutrition decisions, the results might help to understand the interplay of contextual factors and personal behaviors among children. The study conclusively showed FFE, especially caregivers and their educational level and nutrition literacy, were significantly related with children’s FNL and overweight risk. The findings highlight the importance of targeting nutritional knowledge and skill of family caregivers to facilitate the knowledge and ability of children to plan, select, prepare and eat foods, to maintain a healthy diet and good health.
Considering the limitation of sampling, sample size and confounders control, the food environment and nutrition literacy assessment questionnaires were not widely used, the conclusion of the study should be verified furtherly in another population.