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Family Influence Adolescent Eating Habits
Promoting healthy eating habits can prevent adolescent obesity in which family may play a significant role. Ten themes on how family influences adolescent dietary KAP were found: Knowledge—(1) parental education, (2) parenting style, and (3) family illness experience; Attitudes—(4) family health, (5) cultivation of preference, and (6) family motivation; Practices—(7) home meals and food availability, (8) time and cost, (9) parenting style, and (10) parental practical knowledge and attitudes.
2. Family Influence Adolescent Eating Habits
The family factors can be categorized into 10 themes under the adolescent dietary KAP framework: Knowledge—(1) nutrition education, (2) child involvement, and (3) family illness experience; Attitudes—(4) family health, (5) cultivation of preference, and (6) family motivation; Practices—(7) food preparation and availability, (8) time and cost, (9) parenting style, and (10) parental practical knowledge and attitudes. Table 1 summarizes the findings.
|KAP Constructs||Family Influence|
|Adolescent Knowledge||Nutrition education||Education on nutrition benefits 
Education on undesirable consequences of unhealthy eating 
Advice on healthy food choice 
Fostering cooking skills 
|Inconsistent message between parents and school |
|Child involvement||Education during mealtimes and grocery shopping 
Good communication with adolescents (e.g., open discussion, fun style) 
|Adolescents having minimal responsibility in diet-related tasks 
Limited ability for food discussion in parents with poor role model 
|Family illness experience||Emphasis on diet-related health risks experienced by family members with health problems ||Health-related topics as a taboo in families with illnesses |
|Adolescent Attitudes||Family health||Perceived importance of diet-related health risks in family members with health problems 
Modeling of positive outcome of healthy eating 
|Cultivation of preference||Cultivate taste preference for healthy food 
Reducing temptation of unhealthy foods by limiting sedentary time 
Home cooking perceived as more hygienic than street foods 
|Family preference on low cost/ unhealthy foods |
|Family motivation||Family modeling of healthy eating habits 
Encouragement and praise 
Parental concern on adolescent’s health 
Adolescent acting as a role model in the family 
|Family modeling of unhealthy eating habits 
Lack of parental concern on adolescent dietary issues (e.g., body weight is not important for the young) 
Busy parents lacking time for encouragement 
|Adolescent Practices||Food preparation and availability||Provision of healthy home meals 
Home availability of healthy food/ unavailability of unhealthy foods 
|Unhealthy home meals 
Home availability of unhealthy/ unavailability of healthy foods 
|Time and cost||Controlling access (e.g., increased access to ready-to-eat FV and healthier drinks, storing unhealthy snacks out-of-reach) 
Limiting the budget of junk food 
|Convenience of packaged and takeaway foods over home cooking  and time barrier for preparing FV and healthy beverages 
Financial preferences on affordable but unhealthy foods 
Easy accessibility of unhealthy food shops and restaurants 
|Parenting style||Rules and monitoring of mealtimes  and snacking 
Authoritative practices (e.g., reasoning, regular meal schedule) 
Child involvement with limited/ guided choices 
Grocery shopping without adolescents to avoid their request on unhealthy foods 
|Unstructured practices (e.g., accommodating family taste preference, lack of monitoring at mealtimes  and snacking 
Restriction on snacking 
Treats and bribes of unhealthy foods by family members 
Atmosphere of meals with dissatisfying family relation 
|Parental practical knowledge and attitudes||Healthy cooking skills/ varying food presentation 
Healthy home food availability by health-conscious parents 
|Lack of nutrition knowledge to make healthy choices or provide appropriate amounts 
Lack of cooking skills to provide healthy and tasty meals with variety 
Lack of parental concern on healthy eating 
2.1. Adolescent Knowledge
Many studies found nutrition education by parents on both types of knowledge is a facilitator for adolescents to eat healthily, specifically, education on nutrition benefits. For example, disease prevention, weight loss and growth , health consequences of unhealthy eating such as heart and kidney problems , and healthy food choice and cooking skills . However, parents with inaccurate knowledge can deliver messages that are inconsistent with what is taught at school, which confuses the adolescents .
Communication between parents and adolescents is important in education , whereas child involvement in meal planning and discussion facilitates effective communication. Four parenting strategies were identified: (1) mealtime and grocery shopping being used as opportunities to teach adolescents nutritional knowledge, such as reading food labels ; (2) open discussion on diet-related health outcomes ; (3) teaching adolescents about self-regulation ; (4) providing nutritional information in a casual and fun way . Conversely, excluding adolescents from grocery shopping and meal preparation due to their busy study schedules served as a barrier to adolescents’ acquisition of practical nutritional knowledge . Parents also perceived that the ability of food discussion was limited by their own poor eating habits .
2.2. Adolescent Attitudes
Adolescents have become more aware of the negative impacts of unhealthy eating from the experience of health problems, particularly obesity, diabetes mellitus, and heart diseases, among the family members in the US studies . Belief in healthy eating was, on the other hand, enhanced by observing positive outcomes from family members consuming healthy foods such as fruit and vegetables .
Cultivating preference for healthy food was a commonly found family facilitator, particularly in studies where participants were young adolescents . Communication on nutritional information influenced their food interpretation and preference for health . Parents could broaden adolescents’ taste preferences and acceptance by exposing them to a wide variety of nutritious foods at an early age  and by making healthy eating fun, for example, choosing vegetables in certain colors during shopping  as well as providing fewer food choices at home . To tackle the taste preference for junk food, parents tried to reduce these temptations by limiting sedentary time and engaging their adolescents in activities such as sports and hobbies . Hygienic concerns could encourage adolescents, particularly in rural areas, to eat at home instead of food stalls on the streets . One barrier hindering adolescents’ preference for healthy food was family’s prioritizing either low cost or unhealthy food .
Family norm and role modeling can be both facilitators of and barriers to healthy eating in adolescents. Aside from listening to their parents’ advice, adolescents also choose their food by observing their parents’ and siblings’ eating habits of both healthy  and unhealthy foods . Parents who followed the same rules as they told their children enhanced the formation of the family norm . Parents’ verbal encouragement and compliments served as positive reinforcement for healthy eating habits . Examples include setting expectations on diet , family support on trying healthy foods for the first time , making healthy eating their family lifestyle , describing the taste of healthy foods , and communication between parents regarding adolescent eating habits . Parental encouragement could be initiated by their concerns around adolescents’ health, in particular weight gain and illnesses from eating unhealthy foods , which formed the subjective norm in their children .
In addition to family members’ preference for unhealthy foods [40,46,72], another important family barrier that impedes healthy eating was not prioritizing health in the family [42,50,51]. Some parents had cultural beliefs suggesting that thinness is a sign of sickness and convinced adolescents that body weight is not an important indicator of health [42,78], while some considered food choice was adolescents’ own responsibility, hence not providing sufficient guidance on healthy eating [42,79]. The busy schedule of working parents limited their chances to talk to their children and therefore made it difficult to encourage healthy eating among adolescents . Nevertheless, two studies on low-income families found that the unhealthy eating habits in parents motivated some adolescents to eat healthily in order to be the role models for the family [77,78].
2.3. Adolescent Practices
Many studies identified home meals as an important facilitator of healthy eating . Subjects regarded food prepared at home as healthy due to better variety, freshness, and reduced uses of sugar, oil, and salt . Apart from home meals, food availability also influenced adolescent food choice at home. Parents could manage the food supply to provide more healthy foods and to restrict food with insufficient nutrients . Failure of some families to provide healthy meals  or stock healthy foods at home  is explained in more depth in the following themes.
Time and cost for healthy food were important barriers to healthy food provision at home. A tight schedule and long working hours of parents prevented them from preparing family meals, encouraging adolescents to consume takeaway, fast, and prepackaged food instead of fresh foods . Some adolescents explained that more preparation work such as washing, cutting, and cooking is required for fresh production, as compared to ready-to-eat junk food and sugary drinks . Easy accessibility of restaurants and food shops further attracted families to eat unhealthy food through takeaway or when they were eating out . Peeling fruit and vegetables as well as cutting them into ready-to-eat pieces can overcome the ‘inconvenience’ barrier, especially among young adolescents . Preparing portable water in the refrigerator provided a healthier alternative to sugary drinks on hand , while keeping snacks in a locked cabinet restricted the accessibility to young adolescents .
Although low food budget might limit the purchase of junk snacks in some Western studies , it was also an important barrier to the purchase of more costly healthy food such as fruit, vegetables, and organic products, especially among low-income families who might choose unhealthy high-energy food because of its lower cost .
Several key parenting practices were highlighted in various studies, which could be facilitating or inhibiting adolescents’ eating habits, depending on the parenting styles. Setting family rules facilitated healthy eating in adolescents during home meals and snacking. Some examples of rules include: having vegetables with every dinner, finishing everything on the plate, and serving the same meal to all family members , as well as restricting the consumption of unhealthy snacks in terms of quantity and frequency, and drinking water between glasses of juice . Some parents further monitored their adolescents’ eating practices by verbally checking on food purchases or consumption , tracking food stock at home , and requesting adolescents to seek permission before eating unhealthy food . Several authoritative parenting strategies were proposed: (i) controlling or providing supervision on food choices such as asking adolescents to at least try a few bites of healthy food ; (ii) encouraging or prompting adolescents to try healthier alternatives with reasoning ; (iii) having regular meal schedules and eating with family ; (iv) setting a snacking allowance ; (v) being responsive to adolescents’ preference, especially on nutritious foods . Except for one Canadian study that found parents preferred grocery shopping alone to prevent requests for junk foods by adolescents , involving them in meal planning, shopping and preparation with limited/ guided choices, such as selecting from a list of food choices, and washing and cutting fresh produce , was perceived as a facilitator to their eating habits.
Unstructured practices are a major barrier to healthy eating practices in adolescents. Accommodating taste preference of family members, usually towards fast food , a lack of monitoring when not eating together at a table , and failing to negotiate for healthy eating  could counteract the benefits of home meals. The lack of parental supervision also encouraged adolescents’ unhealthy snacking habits as their food choice tended to be based on taste preferences and minimal preparation effort . Family members, especially grandparents, might provide adolescents with unhealthy foods as treats and bribes , and these items such as chocolates, candies, and pizza were often used as rewards for good academic performance, helping out with chores, or even eating healthy foods . On the other hand, over-restriction could have an opposite effect on adolescents as they might want the restricted food items more and consume them on other occasions when they are not monitored . Some adolescents with poor family relationships mentioned that the unpleasant atmosphere of eating with their family sometimes prevented them from eating at home .
The perception of home meals as inferior in taste with little variation  could be the result of insufficient knowledge on the range of healthy food choices and inadequate skills to prepare tasty, healthy meals. To facilitate healthy eating at home, some parents highlighted the importance of cooking skills to better the presentation of healthy food, for example, hiding fruit and vegetables in soup, stew, or smoothies , while others would modify recipes, attempting to use healthier cooking methods, optimizing food choices, and preparing meals at lower costs . A number of US studies reported that a high level of health awareness in parents was essential to maintaining a healthy food environment at home .
- Parents lack of nutritional knowledge, or concern, were barriers to providing healthy meals for adolescents . Disagreement on the interpretation of nutrition guidelines, such as the perceived definition of a serving among different family members , was an additional barrier to a healthy home food environment.
3.1. Parental Knowledge
3.2. Parental Attitudes
3.3. Parenting Style
3.4. Lack of Time
3.5. Cost Concern
This entry is adapted from 10.3390/nu13113717
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