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Scientific Papers and Presentations from the HOME Plus study and HOME pilot study

Fulkerson JA, Neumark-Sztainer D, Story M, Gurvich M, Kubik MY, Garwick A, Dudovitz B. The Healthy Home Offerings via the Mealtime Environment (HOME) Plus study: Design and methods. Contemp Clin Trials.2014;38(1):59-68. doi: 10.1016/j.cct.2014.01.006.

Abstract

Background
Informed and engaged parents and healthful home environments are essential for the health of youth. Although research has shown health benefits associated with family meals, to date, no randomized controlled trial (RCT) has been developed to examine the impact of a family meals intervention on behavioral and health outcomes.

Methods/Design
The Healthy Home Offerings via the Mealtime Environment (HOME) Plus study is a two-arm (intervention versus attention-only control) RCT being conducted in Minneapolis/St. Paul. Built on previous pilot research, HOME Plus aims to increase the frequency and healthfulness of family meals and snacks and reduce children's sedentary behavior, particularly screen time, to promote healthier eating and activity behaviors and prevent obesity. HOME Plus is delivered to families in community settings. The program includes 10 monthly sessions focused on nutrition and activity education, meal planning and preparation skill development. In addition, five motivational goal-setting phone calls are conducted with parents. The primary outcome measure is age- and gender-adjusted child BMI-z score at post-intervention by treatment group. Secondary household-level outcomes include family meal frequency, home availability of healthful foods (fruits/vegetables) and unhealthful foods (high-fat/sugary snacks) and beverages (sugar-sweetened beverages), and the quality of foods served at meals and snacks. Secondary child outcomes include dietary intake of corresponding foods and beverages and screen time.

Conclusions
The HOME Plus RCT actively engages whole families of 8-12 year old children to promote healthier eating and activity behaviors and prevent obesity through promotion of family meals and snacks and limited media use.

Draxten M, Fulkerson J, Friend S, Flattum C, Schow R. Parental role modeling of fruits and vegetables at meals and snacks is associated with children's adequate consumption. Appetite. 2014;78:1-7. doi: 10.1016/j.appet.2014.02.017.

Abstract
Research has shown that parental role modeling of healthful eating behaviors is positively correlated to children's dietary intake and fruit and vegetable (F&V) preferences. The purpose of this study is to (1) examine associations between parent and child report of parental role modeling of F&V consumption at snacks and dinner and (2) determine whether parental role modeling is associated with children meeting daily F&V recommendations. Parent-child dyads (N = 160) participating in the HOME Plus study completed baseline surveys on parental role modeling of F&V at snacks and dinner. Children also completed 24-hour dietary recalls. Spearman correlations and chi-square/Fisher's exact tests were used to examine relationships between parent and child report of parental role modeling of F&V at snacks and dinner and whether children met daily recommendations. On average, children consumed less than three daily servings of F&V with only 23% consuming the recommended servings. Statistically significant correlations were seen between parent and child report of parental role modeling fruit at dinner and green salad at dinner. Children who reported parental role modeling of vegetables at snack and salad at dinner were significantly more likely, than those who did not, to meet daily F&V recommendations. Parents who reported role modeling fruit at snack were significantly more likely to have children who met daily F&V recommendations. Results indicate that children are aware of their parents' eating behaviors and on occasion report this behavior similarly to their parents. Parents should be encouraged to utilize the opportunity to role model healthful dietary intake, especially at snacks, where consumption of F&V appears low.

Friend S, Fulkerson JA, Neumark-Sztainer D, Garwick A, Flattum CF, Draxten M. Comparing childhood meal frequency to current meal frequency, routines and expectations among parents. J Fam Psychol.2015;29(1):136-40. doi: 10.1037/fam0000046.

Abstract
Little is known about the continuation of family meals from childhood to parenthood. This study aims to examine associations between parents' report of eating family meals while growing up and their current family meal frequency, routines, and expectations. Baseline data were used from the Healthy Home Offerings via the Mealtime Environment (HOME) Plus study, a randomized controlled trial with a program to promote healthful behaviors and family meals at home. Participants (160 parent/child dyads) completed data collection in 2011-2012 in the Minneapolis/St. Paul, MN metropolitan area. Parents were predominately female (95%) and white (77%) with a mean age of 41.3 years. General linear modeling examined relationships between parents' report of how often they ate family meals while growing up and their current family meal frequency, routines, and expectations as parents, controlling for parent age, education level, and race. Parental report of eating frequent family meals while growing up was positively and significantly associated with age, education, and self-identification as white (all p < .05). Compared to those who ate family meals less than three times/week or four to five times/week, parents who ate six to seven family meals/week while growing up reported significantly more frequent family meals with their current family (4.0, 4.2 vs. 5.3 family meals/week, p = .001). Eating frequent family meals while growing up was also significantly and positively associated with having current regular meal routines and meal expectations about family members eating together (both p < .05). Promoting family meals with children may have long-term benefits over generations.

Flattum C, Draxten M, Horning M, Fulkerson JA, Neumark-Sztainer D, Story M, Garwick A, Kubik MY. HOME Plus: Program design and Implementation of a family-focused, community-based intervention program to promote the frequency and healthfulness of family meals, reduce children’s sedentary behavior, and childhood obesity. Int J Behav Nutr Phys Act. 2015;12:53. doi: 10.1186/s12966-015-0211-7.

Abstract

Background
Involvement in meal preparation and eating meals with one's family are associated with better dietary quality and healthy body weight for youth. Given the poor dietary quality of many youth, potential benefits of family meals for better nutritional intake and great variation in family meals, development and evaluation of interventions aimed at improving and increasing family meals are needed. This paper presents the design of key intervention components and process evaluation of a community-based program (Healthy Home Offerings via the Mealtime Environment (HOME) Plus) to prevent obesity.

Methods
The HOME Plus intervention was part of a two-arm (intervention versus attention-only control) randomized-controlled trial. Ten monthly, two-hour sessions and five motivational/goal-setting telephone calls to promote healthy eating and increasing family meals were delivered in community-based settings in the Minneapolis/St. Paul, MN metropolitan area. The present study included 81 families (8-12 year old children and their parents) in the intervention condition. Process surveys were administered at the end of each intervention session and at a home visit after the intervention period. Chi-squares and t-tests were used for process survey analysis.

Results
The HOME Plus program was successfully implemented and families were highly satisfied. Parents and children reported that the most enjoyable component was cooking with their families, learning how to eat more healthfully, and trying new recipes/foods and cooking tips. Average session attendance across the ten months was high for families (68%) and more than half completed their home activities.

Conclusions
Findings support the value of a community-based, family-focused intervention program to promote family meals, limit screen time, and prevent obesity.

Fulkerson JA, Friend S, Flattum C, Horning M, Draxten M, Neumark-Sztainer D, Gurvich O, Story M, Garwick A, Kubik MY. Promoting healthful family meals to prevent childhood obesity: HOME Plus, a randomized controlled trial. Int J Behav Nutr Phys Act. 2015;12:154. doi: 10.1186/s12966-015-0320-3.

Abstract

Background
Family meal frequency has been shown to be strongly associated with better dietary intake; however, associations with weight status have been mixed. Family meals-focused randomized controlled trials with weight outcomes have not been previously conducted. Therefore, this study purpose was to describe weight-related outcomes of the HOME Plus study, the first family meals-focused randomized controlled trial to prevent excess weight gain among youth.

Methods
Families (n = 160 8-12-year-old children and their parents/guardians) were randomized to intervention (n = 81) or control (n = 79) groups. Data were collected at baseline (2011-2012), post-intervention (12-months post-baseline) and follow-up (21-months post-baseline). The intervention included ten monthly group sessions (nutrition education; hands-on meal and snack planning, preparation, and skill development; screen time reductions) and five motivational, goal-setting phone calls. The main outcome was child body mass index (BMI) z-score.

Results
General linear models, adjusted for baseline values and demographics, showed no significant treatment group differences in BMI z-scores at post-intervention or follow-up; however, a promising reduction in excess weight gain was observed. Post-hoc stratification by pubertal onset indicated prepubescent children in the intervention group had significantly lower BMI z-scores than their control group counterparts.

Conclusions
The study used a strong theoretical framework, rigorous design, quality measurement and a program with high fidelity to test a family meals-focused obesity prevention intervention. It showed a modest decrease in excess weight gain. The significant intervention effect among prepubescent children suggests the intervention may be more efficacious among relatively young children, although more research with appropriately powered samples are needed to replicate this finding.

Trial Registration
This study is registered at www.clinicaltrials.gov NCT01538615. Registered 01/17/2012.

Horning M, Fulkerson JA, Neumark-Sztainer D, Friend S. Associations among nine family dinner frequency measures and child weight, dietary, and psychosocial outcomes. J Acad Nutr Diet. 2016;116(6):991-9. doi: 10.1016/j.jand.2015.12.018.

Abstract

Background
Family meal frequency has been consistently and significantly associated with positive youth dietary and psychosocial outcomes, but less consistently associated with weight outcomes. Family meal frequency measurement has varied widely and it is unclear how this variation might impact relationships with youth weight, dietary, and psychosocial outcomes.

Objective
This study assesses how five parent/caregiver-reported and four child-reported family dinner frequency measures correlate with each other and are associated with health-related outcomes.

Design/Participants
This secondary, cross-sectional analysis uses baseline, parent/caregiver (n=160) and 8- to 12-year-old child (n=160) data from the Healthy Home Offerings via the Mealtime Environment (HOME) Plus trial (collected 2011 to 2012). Data were obtained from objective measurements, dietary recall interviews, and psychosocial surveys.

Outcome Measures
Outcomes included child body mass index z scores (BMIz); fruit, vegetable, and sugar-sweetened beverage intake; dietary quality (Healthy Eating Index-2010); family connectedness; and meal conversations.

Statistical Analyses Performed
Pearson correlations and general linear models were used to assess associations between family dinner frequency measures and outcomes.

Results
All family dinner frequency measures had comparable means and were correlated within and across parent/caregiver and child reporters (r=0.17 to 0.94; P<0.01). In unadjusted analyses, 78% of family dinner frequency measures were significantly associated with BMIz and 100% were significantly associated with fruit and vegetable intake and Healthy Eating Index-2010. In adjusted models, most significant associations with dietary and psychosocial outcomes remained, but associations with child BMIz remained significant only for parent/caregiver- (β±standard error=-.07±.03; P<0.05) and child-reported (β±standard error=-.06±.02; P<0.01) family dinner frequency measures asking about "sitting and eating" dinner.

Conclusions
Despite phrasing variations in family dinner frequency measures (eg, which family members were present and how meals were occurring), few differences were found in associations with dietary and psychosocial outcomes, but differences were apparent for child BMIz, which suggests that phrasing of family dinner frequency measures can influence associations found with weight outcomes.

Draxten M. Flattum C, Fulkerson JA. An example of how to supplement goal setting to promote behavior change for families using motivational interviewing. Health Commun. 2016; 31(10):1276-83. doi: 10.1080/10410236.2015.1062975.

Abstract
The purpose of this study was to describe the components and use of motivational interviewing (MI) within a behavior change intervention to promote healthful eating and family meals and prevent childhood obesity. The Healthy Home Offerings via the Mealtime Environment (HOME) Plus intervention was part of a two-arm randomized-controlled trial and included 81 families (children 8-12 years old and their parents) in the intervention condition. The intervention included 10 monthly, 2-hour group sessions and 5 bimonthly motivational/goal-setting phone calls. Data were collected for intervention families only at each of the goal-setting calls and a behavior change assessment was administered at the 10th/final group session. Descriptive statistics were used to analyze the MI call data and behavior assessment. Overall group attendance was high (68% attending ≥7 sessions). Motivational/goal-setting phone calls were well accepted by parents, with an 87% average completion rate. More than 85% of the time, families reported meeting their chosen goal between calls. Families completing the behavioral assessment reported the most change in having family meals more often and improving home food healthfulness. Researchers should use a combination of delivery methods using MI when implementing behavior change programs for families to promote goal setting and healthful eating within pediatric obesity interventions.

Loth K, Fulkerson JA, Friend S, Horning M, Neumark-Sztainer D. Directive and non-directive food-related parenting practices: Associations between an expanded conceptualization of food-related parenting practices and child dietary intake and weight outcomes. Appetite;2016. doi: 10.1016/j.appet.2016.07.036

Abstract
This study examines associations between an expanded conceptualization of food-related parenting practices, specifically, directive and non-directivecontrol, and child weight (BMI z-score) and dietary outcomes [Healthy Eating Index (HEI) 2010, daily servings fruits/vegetables] within a sample of parent-child dyads (8-12 years old; n=160). Baseline data from the Healthy Home Offerings via the Mealtime Environment (HOME Plus) randomized controlled trial was used to test associations between directive and non-directive controland child dietary outcomes and weight using multiple regression analyses adjusted for parental education. Overall variance explained by directive and non-directive control constructs was also calculated.  Markers of directive control included pressure-to-eat and food restriction, assessed using subscales from the Child Feeding Questionnaire; markers of non-directive control were assessed with a parental role modeling scale and a home food availability inventory in which an obesogenic home food environment score was assigned based on the types and number of unhealthful foods available within the child’s home food environment.  Directive control: Food restriction and pressure-to-eat were positively and negatively associated with BMI z-scores, respectively, but not with dietary outcomes. Non-directive control:An obesogenic home food environment was inversely associated with both dietary outcomes; parental role modeling of healthful eating was positively associated with both dietary outcomes.  Neither non-directive behavioral construct was significantly associated with BMI z-scores. Total Variance:Greater total variance in BMI-z was explained by directive control; greater total variance in dietary outcomes was explained by non-directive control. Including a construct of food-related parenting practices with separate markers for directive and non-directive control should be considered for future research. These concepts address different forms of parental control and, in the present study, yielded unique associations with child dietary and weight outcomes.

Horning M, Fulkerson JA, Friend S, Story M. Reasons parents buy prepackaged, processed meals: It is more complicated than "I don't have time." JNEB;2016.

Abstract
Objective
To investigate reasons parents purchase prepackaged, processed meals and associations with parental cooking self-efficacy, meal-planning ability, and home food availability.

Method
This secondary data analysis uses HOME Plus study data from parents of 8-12 year old children (n=160). Associations between reasons parents purchase prepackaged, processed meals and the outcomes were assessed with Chi-square, Fisher’s exact, and t-tests.

Results
The most frequently endorsed reasons for purchasing prepackaged, processed meals included lack of time (57%) and family preferences (49%). Five of 6 reasons were associated with lower parental cooking self-efficacy and meal planning ability, some reasons were associated with less-healthful home food environments, and few reasons varied by sociodemographic characteristics.

Conclusions and Implications
Given lower cooking self-efficacy and meal-planning ability are associated with most reasons reported for purchasing prepackaged, processed meals, strategies to increase these attributes for parents of all backgrounds may reduce reliance on prepackaged
processed meals for family mealtimes.

Kubik M, Gurvich O, Fulkerson JA. Parent weekend but not week day TV-viewing time associated with rule-setting to limit the TV-viewing time of 8 to 12 year olds. Preventing Chronic Disease (received an extension)

Abstract
Introduction
Television (TV) viewing remains popular among adults and children, with child TV-viewing time positively associated with parent TV-viewing time. Efforts to limit the TV-viewing time of children typically target parent rule-setting. However, little is known about the association between parent TV-viewing practices and rule-setting.

Methods
We used baseline height/weight and parent survey data collected between 2011 and 2015 from parents and their 8 to 12 year old child (N=212 parent/child dyads) who were participants in two community-based obesity prevention intervention trials conducted in metropolitan Minnesota. Multivariable binary logistic regression analysis was used to assess the association between parent TV-viewing time on week days or weekend days dichotomized as ≤ 2 hours per day versus ≥ 2.5 hours per day and parent rules limiting child TV-viewing time.

Results
Child mean age was 10 (1.4), mean body mass index (BMI) percentile was 81(16.7), about half were boys and 40% were non-White. Parent mean age was 41(7.5), mean BMI 29(7.5), most were female and 36% were non-White. Parents who limited their TV-viewing time on weekend days to ≤ 2 hours per day were almost three times more likely to report setting rules limiting child TV-viewing time than parents viewing ≥ 2.5 hours per day (P=0.01). A similar association was not seen for parent week day TV-viewing time.

Conclusion
For most adults and children, meaningful reductions in sedentariness will require reductions in TV-viewing time. Family-based interventions to reduce TV-viewing time that target child and parent and the TV-viewing practices of both are needed.


 

Pilot work

Fulkerson, JA, Rydell S, Kubik MY, Lytle L, Boutelle K, Story M, Neumark-Sztainer D, Dudovitz B, Garwick A.  Healthy Home Offerings via the Mealtime Environment (HOME): feasibility, acceptability, and outcomes of a pilot study. Obesity. 2010 Feb;18;S:69-74.doi: 10.1038/oby.2009.434.

Abstract
The primary objective was to develop and test the feasibility and acceptability of the Healthy Home Offerings via the Mealtime Environment(HOME) program, a pilot childhood obesity prevention intervention aimed at increasing the quality of foods in the home and at family meals. Forty-four child/parent dyads participated in a randomized controlled trial (n = 22 in intervention and n = 22 in control conditions). The intervention program, held at neighborhood facilities, included five, 90-min sessions consisting of interactive nutrition education, taste testing, cooking skill building, parent discussion groups, and hands-on meal preparation. Children (8-10-year olds) and parents (89% mothers) completed assessments at their home at baseline, postintervention, and 6-month follow-up, including psychosocial surveys, anthropometry, 24-h dietary recalls, and homefood availability and meal offering inventories. Feasibility/acceptability was assessed with participant surveys and process data. All families completed all three home-based assessments. Most intervention families (86%) attended at least four of five sessions. Nearly all parents (95%) and 71% of children rated all sessions very positively. General linear models indicated that at postintervention, compared to control children, intervention children were significantly more likely to report greater food preparation skill development (P < 0.001). There were trends suggesting that intervention children had higher consumption of fruits and vegetables (P < 0.08), and higher intakes of key nutrients (all P values <0.05) than control children. Obesity changes did not differ by condition. Not all findings were sustained at 6-month follow-up. Obesity prevention programming with families in community settings is feasible and well accepted. Results demonstrate the potential of the HOME program.

 

Fulkerson JA, Kubik MY, Rydell S, Boutelle KN,, Garwick A, Story M, Neumark-Sztainer D, Dudovitz B. Focus groups with working parents of school-aged children: What’s needed to improve family meals? J Nutr Educ Behav. 2011;43(3):189-93. DOI: 10.1016/j.jneb.2010.03.006

Abstract
Objective
To conduct focus groups to identify parents' perceptions of barriers to family meals and elucidate ideas to guide the development of interventions to overcome barriers.

Methods
Focus groups were conducted with a convenience sample of 27 working parents in urban community settings.

Results
Parents reported enjoying the sharing/bonding at meals, but they reported limited time for meal preparation and frequent multi-tasking at mealtime. They wanted their children's help with meal preparation, but they were concerned about the time and "mess" involved. They were frustrated with the limited range of food items their children would eat. Preferred program ideas included feeding tips/recipes, meal planning/preparation, and changing food offerings.
CONCLUSIONS AND IMPLICATIONS: Findings indicate a need for creative programs and professional nutrition guidance to facilitate family engagement in planning and cooking quick, healthful meals; development of skill building; and increasing healthful food consumption.