Appetite 134 (2019) 69–77

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Appetite
journal homepage: www.elsevier.com/locate/appet

Moderating effects of family environment on overweight/obese adolescents’ T

dietary behaviours
Nicole S. Carberta,b,∗, Mariana Brussonia,b,c, Josie Gellerd,e, Louise C. Mâssea,b
a
School of Population and Public Health, University of British Columbia, Canada
b
British Columbia Children's Hospital Research Institute, Canada
c
Department of Pediatrics, University of British Columbia, Canada
d
St. Paul's Hospital Eating Disorders Program, Canada
e
Department of Psychiatry, University of British Columbia, Canada

ARTICLE INFO ABSTRACT

Keywords: Background: The familial environment can influence adolescents' risk for obesity. However, we do not fully
Dietary quality understand the mechanisms through which parents can influence overweight/obese adolescents' dietary beha-
Adolescent obesity viours, specifically whether parenting practices (e.g., rules or routines) and/or their own dietary behaviours are
Parenting practices associated with their overweight/obese adolescent's dietary quality.
Parental modeling
Objectives: This study examined whether parenting practices and/or parental modeling of dietary quality are
Family functioning
associated with overweight/obese adolescents’ dietary quality while considering the moderating effects of
Parenting styles
parenting styles and family functioning.
Methods: Baseline data from 172 overweight/obese adolescents and one of their parents who enrolled in a
lifestyle modification intervention were analyzed [mean age = 13.1 (1.8); mean BMI z-score = 2.70 (0.83)].
Parent-adolescent dyads completed three 24-hr dietary recalls online. An index of dietary quality was computed
by summing the scores for different food categories assessed in the dietary recall over 3 days. Parents completed
questionnaires about their family functioning, dietary parenting practices (i.e., whether child eats breakfast
everyday), and styles (authoritative and permissive). Path analysis was used to model interrelationships among
the variables using the Stata software version 13.
Results: Parental modeling of dietary quality was significantly associated with adolescent dietary quality.
Additionally, parenting styles significantly moderated parental modeling, such that an authoritative parenting
style in conjunction with modeling healthy eating habits was associated with better adolescent dietary quality.
Conclusions: This work suggests that parental modeling of health behaviours is important; however, it is ne-
cessary to consider the broader emotional/relational context into which modeling is expressed since parenting
styles moderated these effects. This study provides insight into how parenting styles may alter the effectiveness
of parental modeling and highlights the need to account for parenting styles to improve the efficacy of current
family-based interventions.

1. Introduction among children, obesity-related intervention programs that target

It has been well established that the adoption and maintenance of
children's dietary behaviours are influenced by the familial environ-
ment (Crockett & Sims, 1995; Gruber & Haldeman, 2009; Patrick &
Nicklas, 2005; Shepherd et al., 2006; Story, Neumark-Sztainer, &
French, 2002). Parents, in particular, act as agents of change as they
play a key role in shaping the home food environment, with this role
changing at different stages of their child's development (e.g., child-
hood to adolescence). To help foster healthy eating environments
parents have been identified as a key for success (Darling & Steinberg,
1993; McLean, Griffin, Toney, & Hardeman, 2003). Although evidence
suggests that family-based interventions can be an effective, albeit short
term, means of improving children's eating behaviours (Lindsay,
Sussner, Kim, & Gortmaker, 2006), less is known regarding the effec-
tiveness of these interventions among overweight and obese adoles-
cents (Al-Khudairy, 2017). Overweight and obese adolescents are often
targeted by lifestyle modification interventions, as they are at increased
risk for a number of serious health problems (e.g., diabetes and heart

∗
Corresponding author. BC Children's Hospital Research Institute, 4480 Oak Street, Rm F514, Vancouver, BC, V6H 3V4, Canada.
E-mail address: ncarbert@bcchr.ubc.ca (N.S. Carbert).

https://doi.org/10.1016/j.appet.2018.12.034
Received 25 February 2018; Accepted 20 December 2018
Available online 24 December 2018
0195-6663/ © 2019 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
N.S. Carbert et al.
disease) (Amed et al., 2010; Reilly & Kelly, 2011; Singh, Mulder, Twisk,
van Mechelen, & Chinapaw, 2008). Associations between specific home
environment factors and overweight or obese adolescent diets, how-
ever, have been inconsistent, thus limiting our understanding of what
influences their dietary behaviours (de Vet, de Ridder, & de Wit, 2011).
Thus, further understanding family or parent-level mechanisms is es-
sential to develop effective intervention strategies to manage over-
weight or obese adolescent dietary outcomes.
The mechanism through which parents can influence their child's
dietary behaviours can be through specific food-related parenting
practices and their own behaviours such as modeling healthy eating
habits (Pearson, Biddle, & Gorely, 2009; van der Horst et al., 2007).
Parenting practices are active strategies parents employ to elicit certain
behaviours from their children that are typically context dependent
(e.g., applying rules about eating) (Darling & Steinberg, 1993). Evi-
dence suggests that parents who adopt more supportive eating practices
(i.e. encouragement, access/availability) have been associated with
increased fruit and/or vegetable consumption in children while more
restrictive or controlling practices have been associated with unhealthy
eating habits such as desire and consumption of restricted foods when
they become available (Pearson et al., 2009). This is especially im-
portant to consider since findings suggest that parents of overweight
children use more maladaptive control or management food strategies
compared to parents of non-overweight children (Kremers, Brug, de
Vries, & Engels, 2003). Similar to the parenting practice literature, re-
cent reviews found parents' healthy and unhealthy eating behaviours
were positively associated with adolescents eating behaviours (van der
Horst et al., 2007) (Pearson et al., 2009). Less is known, however,
whether these influences remain important in adolescence and even less
has been studied among overweight/obese adolescents (Watts, Masse,
Barr, Lovato, & Hanning, 2014).
In addition to these direct parental influences, more context-specific
influences, such as parenting styles and family functioning are thought
to play a role in shaping adolescents' health behaviours. Parenting
styles refer to the ways parent interacts with their child and are char-
acterized by varying degrees of warmth and demand that are typically
classified into four prototypes: authoritative, authoritarian, permissive,
and neglectful (Darling & Steinberg, 1993). Family functioning on the
other hand refers to how family subsystems (i.e., spousal, parent-child,
and sibling relationships) interact with one another to influence the
overall behaviour of the family system (McIntyre, 1966). Despite lim-
ited research, models suggest that parenting styles and family func-
tioning may operate at a more global level and moderate the effects of
parenting practices and parental modeling on adolescents’ dietary be-
haviours (Kitzmann, Dalton, & Buscemi, 2008; Patrick, Hennessy,
McSpadden, & Oh, 2013).
According to conceptual models, parenting styles and family func-
tioning have the potential to alter how children view their parents and
potentially modify how children respond to their parents' socialization
efforts (Darling & Steinberg, 1993; Rhee, 2008). In other words, par-
enting styles and family functioning can either have a positive or ne-
gative impact on these mechanisms (practices and modeling) performed
by parents. For example, parents’ limits around junk food may come off
as very controlling to the child if parents have strict rules and the child
is expected to follow them. In comparison, limit setting may be ex-
perienced as very nurturing if the emotional/relational context of the
parent-child relationship includes age-appropriate dialogue about the
reasons for limits, consideration for revising limits, and opportunities
for involving the child in the decisions (Hennessy, Hughes, Goldberg,
Hyatt, & Economos, 2010). In terms of family functioning, Kitzmann
and colleagues (Kitzmann et al., 2008), suggest that parents who in-
volve their children in activities such as food preparation might be quite
successful in families with high levels of family functioning because
they are already used to interacting together and enjoy spending time
together. As a result, this may be an effective way for the child to adapt
more healthy eating habits compared to families who spend less time
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Appetite 134 (2019) 69–77
Fig. 1. Moderating effects of parenting styles and family functioning on re-
lationships between both parenting practices and parental modeling on ado-
lescent dietary behaviours.
together and have low levels of family functioning. However, further
exploration of these more global dimensions is necessary to understand
whether context plays a role in achieving certain health behaviours
among overweight or obese adolescents.
Given that past research has explored parenting practices and par-
ental modeling separately with respect to adolescent dietary quality,
limited research has explored the extent to which both factors are im-
portant while considering the moderating effects of parenting styles and
family functioning. Therefore, this study explores the relationship be-
tween parenting practices, parental modeling, and adolescent dietary
quality in the context of these higher level familial factors. We con-
structed a research model in which parental modeling, parenting
practices, and dietary behaviours, as well as parenting styles and family
functioning were considered (Fig. 1). In line with Bronfenbrenner's
ecological model (Bronfenbrenner, 2009) and suggestions from others
(Darling & Steinberg, 1993; Kitzmann et al., 2008; Larsen et al., 2015;
Patrick et al., 2013; Rhee, 2008) we conceptualized parenting style and
family functioning as potential moderators, implying that the delivery
and impact of specific parenting practices and parental modeling on
adolescent health behaviours can vary depending on these higher level
conditions.
The aims of the study are as follows: 1) To determine whether
parenting practices are associated with adolescents' dietary behaviours
while considering the moderating effects of parenting styles and family
functioning; 2) To determine whether parental modeling of dietary
behaviours are associated with adolescents' dietary behaviours while
considering the moderating effects of parenting styles and family
functioning; and 3) To determine whether both parenting practices and
parental modeling of dietary behaviours are associated with adoles-
cents’ dietary behaviours, while considering the moderating effects of
parenting styles and family functioning when included in the same
model.
2. Materials and methods
2.1. Participants
172 parent-adolescent pairs who completed the baseline visit of an
E-health lifestyle modification intervention targeted at the family were
the participants for this study. Overweight or obese adolescents (aged
11–16) and one parent were recruited from the Metro Vancouver area
of British Columbia (BC), Canada. Around 68% of participants were
recruited by means of advertisements, namely newspapers (62%) and
parenting magazines, Facebook, or Craigslist (5%). Another 28% of
participants were recruited through referrals from the BC Children's
N.S. Carbert et al.
Hospital Endocrinology and Diabetes Clinic (13%) and Centre for
Healthy Weights Shapedown program in BC (15%). The remaining 5%
of participants were recruited by word of mouth. To ensure the majority
of the population of interest was captured, paid advertisements were
placed in free local newspapers at subway exits, bus terminals, and fast
food outlets.
Certain inclusion criteria had to be met to participate in the main
study, including: being an overweight or obese adolescent based on
WHO cut-points (Shields, 2005) and having a parent consent to parti-
cipate in the intervention with the adolescent. Additionally, partici-
pants had to have internet access at home, live in the greater me-
tropolitan area of Vancouver (BC), not plan to move within the three
year study period, and be fluent in English. Participants were excluded
from the analysis if any of the following were present: comorbidities
that required medical attention, health problems that prevented ado-
lescents from being physically active, a history of psychiatric problems
or substance abuse; use of medication that affects body weight, or a
diagnosis of Type 1 diabetes.
2.2. Procedures
The study protocol was approved by the University of British
Columbia's Behavioural Research Ethics Board and the University of
Waterloo. Parents and adolescents were contacted via telephone to
assess interest and eligibility in the study. Eligible participants came to
the BC Children's Hospital evaluation center in Vancouver, where they
were briefed about the study and filled out consent forms. At this visit,
participants also completed a baseline assessment and parents com-
pleted a series of surveys pertaining to their parenting practices, par-
enting styles, and family functioning. Additionally, parents and ado-
lescents completed three online 24-h dietary recalls. One was
completed at the evaluation center and the two others at home. Data
collection ensured that 24-h recalls included one weekday and one
weekend day, to ensure accuracy. Further intervention details can be
found in the Mâsse and colleagues (Masse et al., 2015) article. This
study focused only on data from baseline assessment.
2.3. Measures
2.3.1. Parenting practices
Behaviour-specific parenting practices were measured with the fa-
mily nutrition & PA screening tool (Ihmels, Welk, Eisenmann, & Nusser,
2009). The original tool included 15 items that asked two opposing
statements (e.g., whether families eat or do not eat regularly at fast food
places) and once a statement was selected participants indicated whe-
ther this was true or very true for them (internal consistency = 0.70
and score significantly associated with BMI categories of children
(Ihmels et al., 2009). As this study examined specific parenting prac-
tices, we validated a 4-factor structure (PA, eating, breakfast, and
screen time) in our sample with confirmatory factor analysis ([X2
(df = 38) = 59.28; p = 0.015; Root Mean Square Error of Approxima-
tion (RMSEA) = 0.062 and 90% CI = 0.028–0.091; Comparative Fit
Index (CFI) = 0.892; Standardized Root Mean Square Residual
(SRMR) = 0.070]; Cronbach's alphas: 0.60, 0.64, 0.55, 0.33 for PA,
eating, breakfast, and screen time practices, respectively). For these
analyses, two scales related to dietary parenting practices were used.
The first measured eating practices with four items that asked whether
the child drinks sodas, whether the family regularly eats at fast-food
restaurants, consumes pre-packaged food or meals, and eat desserts.
The second measured breakfast practices and included two items that
asked whether the child eats breakfast every day and whether the fa-
mily eats breakfast together.
2.3.2. Parenting styles
Cullen's authoritative parenting scale was used to assess parenting
styles (Cullen et al., 2001). The original measure includes 16 items
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Appetite 134 (2019) 69–77
across two subscales: authoritative (11 items) and negative (5 items)
parenting styles. The 2-factor structure was previously validated with
principal component analyses in a sample of ethnically diverse parents
and grade 4 to 6 students. The authoritative and negative subscales
explained 30% and 11% of the item variance, had internal consistencies
of 0.72 and 0.73, and Pearson test-retest of 0.53 and 0.82, respectively.
Initial confirmatory factor analysis in the present sample, did not sup-
port the original structure [X2 (df = 89) = 187.6, p < 0.00;
RMSEA = 0.084 and 90% CI 0.067–0.101; CFI = 0.844; SRMR
= 0.080]. Based on modification indices and conceptual relevance, the
authoritative and negative subscales were reduced to 10 and 3 items
respectively; however the “negative subscale was renamed “permissive”
parenting as it aligned best with the content of the items. The new
factor structure was supported by confirmatory factor analysis
[X2 (df = 62) = 109.8, p < 0.00; RMSEA = 0.070 and 90% CI
0.048–0.091; CFI = 0.919; SRMR = 0.067] in the current sample and
the Cronbach's alphas were 0.85 and 0.59 for authoritative and per-
missive parenting styles, respectively. Examples of items measuring
authoritative parenting were as follows: “I want to hear about my
child's problems” and “I tell my child when he/she does a good job on
things.” Examples of items measuring permissive parenting were: “It is
hard for me to say ‘no’ to my child” and “I can be talked into things
easily.” A four point Likert type scale was used where 1 indicated
“Never” and 4 “Always.” Items 1–10 were summed, with a higher score
indicating a more authoritative style. Items 11–13 were also summed,
with a higher score indicating a more permissive parenting style. For
the analyses, each subscale (authoritative and permissive) was dichot-
omized based on the median and two categories were created for each
scale. Although an equal split in participants was achieved for the au-
thoritative style (High = 78; Low = 82), this was not achieved for
permissive style (High = 50; Low = 120) as a large number of in-
dividuals (n = 70) scored at the median (i.e., score of 6). Since the scale
ranged from 3 to 12, these participants were grouped into the low
permissive group.
2.3.3. Family functioning
Family functioning was assessed using the Family Adaptability and
Cohesion Evaluation Scale IV (FACES IV) (Olson, 2011). The original
measure is a 42-item self-report instrument that is composed of six
subscales assessing the overarching dimensions of cohesion and flex-
ibility (Olson, 2011). Four scales assess the lower and upper extremes of
cohesion (disengaged and enmeshed) and flexibility (rigid and chaotic).
The remaining two scales assess balanced cohesion and balanced flex-
ibility. Balanced levels of cohesion and flexibility indicate healthy fa-
mily functioning whereas unbalanced levels of cohesion and flexibility
are associated with problematic family functioning. The six-factor
structure of the scale was validated using exploratory factor analysis on
a sample of US college students with a mean age of 28. According to
Olson's study, the internal consistency for each of the scales were as
follows: 0.89 for balanced cohesion, 0.84 for balanced flexibility, 0.77
for enmeshed, 0.87 for disengaged, 0.86 for chaotic, 0.82 for rigid.159
For the current sample, the internal consistency for each of the scales
was as follows: balanced cohesion = 0.59, balanced flexibility = 0.56,
enmeshed = 0.72, disengaged = 0.75, chaotic = 0.84, rigid = 0.59.
Examples of items from each of the six scales are as follows: Balanced
Cohesion: “Family members are involved in each others' lives” and
Family members feel very close to each other”; Balanced Flexibility:
“Our family tries new ways of dealing with problems” and “My family is
able to adjust to change when necessary”; Enmeshed: “We spend too
much time together” and “We resent family members doing things
outside the family”; Disengaged: “We get along better with people
outside our family than inside” and “Family members seem to avoid
contact with each other when at home”; Rigid: “There are strict con-
sequences for breaking the rules in our family” and “Our family has a
rule for almost every possible situation”; Chaotic: “We never seem to
get organized in our family” and “Our family feels hectic and
N.S. Carbert et al. Appetite 134 (2019) 69–77

Table 1 vegetable and fruit, whole fruit, dark green and orange vegetables, total
Formulas for ratio scores. grain products, whole grains, milk and alternatives, meat and alter-
Ratios Score (use percentiles) natives, and unsaturated fats). The remaining three categories were
present in smaller amounts (saturated fat, sodium, and other foods
Cohesion Ratio Balanced Cohesion/(Enmeshed + Disengaged)/2 which include solid fat, alcohol, and sugar). For the ‘other food’ com-
Flexibility Ratio Balanced Flexibility/(Chaotic + Rigid)/2
ponent, saturated and trans-fat were used as a proxy for solid fats and
total sugar was used as a proxy for added sugar. An HEI score was
created by summing the scores for the eleven food categories. Since
disorganized.” A five-point Likert scale was used where 1 indicates
parents and adolescents completed three 24-h dietary recalls (one at
“Strongly Disagree” and 5 “Strongly Agree.” Therefore, a maximum raw
evaluation center and two at home during one weekday and one
score of 35 could be obtained for each of the six scales. Raw scores were
weekend day), an average of three HEI scores were used to assess their
converted into individual percentile scores, using the conversion chart
dietary quality. A maximum score of 100 could be obtained, with a
developed by Olson.159 As shown in Table 1, these percentile scores
higher score indicating better dietary quality. Forty-six children and
were then used to compute individual ratio scores for cohesion and
forty-four parents had only 1-day food records, while forty four chil-
flexibility. The Cohesion Ratio is calculated by dividing the Balanced
dren and parents had only 2-day food records. For these cases, HEI was
Cohesion percentile score by the average of the two unbalanced scales
calculated based on the available information.
(Disengaged and Enmeshed). The Flexibility Ratio is calculated by di-
viding the Balanced Flexibility percentile score by the average of the
2.3.5. Data analysis
two unbalanced scales (Rigid and Chaotic). For the analyses, cohesion
All analyses were conducted in Stata 13 using path analysis. A full
and flexibility ratio was dichotomized and those with ratios above the
information maximum likelihood estimation procedure was used to
median on both of these ratios represented the high family functioning
handle missing values. To analyze aim 1, separate models were run to
group. Those who were below the median on both of these dimensions
examine whether breakfast and eating-related parenting practices had a
or were above the median for one ratio but not the other, represented
direct effect on adolescents’ dietary behaviours while considering the
low family functioning. Therefore, families that scored > 1.9 on the
moderating effects of parenting styles and family functioning. Breakfast
cohesion ratio and > 1.4 on the flexibility ratio were classified in the
and eating parenting practices were entered as independent variables
high family functioning group. Families below the median on both of
and adolescent dietary quality (computed using three 24-h dietary re-
these dimensions or above the median for one ratio but not the other
calls) was entered as the dependent variable. Next, parenting styles
were placed into the low family functioning group.
(authoritative and permissive) and family functioning variables were
Table 2 provides a visual of these classifications. Due to an unequal
entered into the analyses. Interaction terms were then entered into the
number of categories (1 high vs. 3 low), an equal split among partici-
analysis one at a time for each of the corresponding models and re-
pants was not achieved, resulting in 49 families with high family
mained in the model if significant with a p value < 0.1. Additionally,
functioning and 110 with low family functioning.
all variables were standardized prior to including them to address the
issue of convergence. Each model adjusted for the following covariates:
2.3.4. Dietary quality measured by 24-h dietary recall
adolescent age, adolescent sex, and parent income. Similar analytical
Both parents and adolescents completed three self-administered
procedures were conducted for the second aim which assessed the di-
online 24-h dietary recalls developed by the University of Waterloo that
rect effect of parental modeling as well as the third aim which analyzed
assessed everything they consumed the previous day (Hanning et al.,
direct effect of both parenting practices and parental modeling to-
2009). Participants chose from more than 900 brand or generic food
gether.
items. If a particular food item was not on the list, participants were
To ensure assumptions of linear regression were met, bivariate
allowed to substitute it with a similar item. To determine accurate
scatter plots and residual plots were assessed for each model. The
portion sizes, photographs were used to assist the participants. Ad-
magnitude, depicted by the Standard Coefficient (SC) of a path and p-
ditionally, participants could select common toppings associated with
value associated with it explained the significance of the path.
certain foods (e.g., spreads on toast). Once participants confirmed their
selection, a final screen showed their individual intakes in comparison
3. Results
with the current Canada's Food Guide to Healthy Eating re-
commendations. Validation of the web-based tool was conducted
The demographic characteristics of the adolescents and their par-
against a dietician administered dietary recall among an ethnically di-
ents (n = 172) are highlighted in Table 3. On average, adolescents were
verse sample of 11–14 year olds with an interclass correlation coeffi-
13 years old and equally split by sex. Families in the sample were
cient of 0.56 for total energy intake (Hanning et al., 2009). Nutrient and
comprised predominantly of mothers, with an average age of 46 years.
Canadian food group estimates were retrieved using the Food Processor
Additionally, families ranged in household income, educational at-
software package (version 8.0, ESHA Research, Salem, OR, 2002) that
tainment, marital status, and ethnicity.
uses the 2007 Canadian Nutrient File (Government of Canada HC,
Parents' and adolescents’ dietary quality averaged around 65%,
2016). Mean nutrient and food category estimates were used to com-
which is considered inadequate (Table 4). As shown in Table 4, the
pute a Healthy Eating Index (HEI) score (Garriguet, 2009). The HEI
majority of parents scored high on the authoritative parenting style
measured dietary quality (adequacy and moderation) based on re-
scale, and the middle of the permissive parenting scale, the majority of
commended intakes in Canada's Food Guide (Bush, Martineau, Pronk, &
parents scored in the middle of the scale as they had an average score of
Brulé, 2007). The food participants reported in the 24-h dietary recall
6.0 on a scale that ranged from 3 to 12. In terms of family functioning,
were sorted into eleven different categories. The Food Guide re-
the majority of parents were balanced on both the cohesion and flex-
commends eight of these to be present in larger amounts (total
ibility ratios as the mean ratios were both greater than 1.
Table 5 presents the association of eating and breakfast parenting
Table 2
practices on adolescents' dietary quality and whether the association
Classification based on cohesion and flexibility ratios.
was moderated by parenting styles and family functioning. As shown in
High Flexibility Ratio Low Flexibility Ratio model 1 (excluding the moderators), breakfast parenting practices were
significantly associated with adolescents' dietary quality, which means
High Cohesion Ratio High Family Functioning Low Family Functioning
Low Cohesion Ratio Low Family Functioning Low Family Functioning that more healthful breakfast parenting practices were associated with
more healthful dietary habits in youth. As the moderators were added

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N.S. Carbert et al. Appetite 134 (2019) 69–77

Table 3
Demographic characteristics of adolescents and their parents.
Demographic Characteristics (%) Mean ± SD [Range]

Adolescent Age (Year) 13.1 ± 1.8 [11–16]

N = 172
Adolescent Sex Female 55.2%
N = 172 Male 44.8%
Adolescent Body Mass Index 30.9 ± 6.0 [21.6–56.8]
N = 172
Parent Age (Year) 45.7 ± 6.2 [31–66]
N = 172
Parent Sex Female 84.3%
N = 172 Male 15.7%
Parent Body Mass Index 30.3 ± 7.3 [18.3–69.0]
N = 172
Household Income ≤$60,000 or less 34.9%
$60,001-$100,000 33.7%
N = 169 ≥$100,001 31.4%
Parent Education High school or less 17.4%
Trade certificate/diploma 41.3%
N = 172 Bachelor degree 18.6%
Above Bachelor degree 22.7%
Parent Marital Status Married/Common-Law 70.9%
N = 172 Single/Widowed/Separated/Divorced 29.1%
Ethnicity White 48.0%
East/Southeast Asian 13.5%
N = 171 South Asian 12.3%
Aboriginal 10.0%
Other 16.4%

SD=Standard deviation, % = Percentage.

association was moderated by parenting styles and family functioning.

Table 4
As shown in model 1 (excluding the moderators), the association be-
Descriptive statistics for parenting practices, parental modeling, adolescent
tween parental modeling of dietary behaviours and adolescents' dietary
dietary quality, parenting styles, and family functioning.
quality and whether the association was moderated by parenting styles
Independent Variables n Mean ± SD [Range] and family functioning. As shown in model 1 (excluding the mod-
Parenting Practices
erators), parental modeling of dietary behaviours was significantly as-
Eating 160 2.9 ± 0.7 [1.5–4] sociated with adolescent dietary quality. Specifically, parental mod-
Breakfast 166 2.7 ± 0.9 [1–4] eling of healthy dietary behaviours was associated with improvements
in adolescents’ dietary quality. As moderators were added into the
Parental Modeling
model, a significant authoritative style by parental modeling interac-
Dietary Quality Score 165 65.1 ± 9.8 [36.2–86.4]
tion emerged for adolescent dietary quality. Fig. 3 illustrates this in-
Dependent Variables teraction and shows parental modeling of healthy dietary behaviours
was positively associated with dietary quality among adolescents and
Adolescent Health Behaviours
this association was more pronounced if parents used a more author-
Dietary Quality Score 169 63.9 ± 9.1 [39.1–83.8]
itative parenting style compared to a less authoritative style. Therefore,
Moderators it appears that a more authoritative parenting style combined with
Parenting Style parental modeling of healthy dietary behaviours was associated with
Authoritative 160 34.8 ± 4.3 [21–40] improved dietary quality among overweight/obese adolescents.
Permissive 170 6.0 ± 1.4 [3–11]
Both adolescents’ age and parent income were significant covariates
Family Functioning in the final model.
Cohesion ratio 168 2.1 ± 0.63 [0.88–4.4] Table 7 presents the association of both parenting practices and
Flexibility ratio 162 1.4 ± 0.35 [0.68–3.1] modeling related to eating with adolescents' dietary quality and whe-
ther these associations are moderated by parenting styles and family
functioning. Model 1 (excluding the moderators) suggests that parental
into the model, a significant family functioning by breakfast parenting modeling of dietary quality was the only factor associated with ado-
practices interaction emerged and the main effect of breakfast par- lescents' dietary quality. Specifically, parental modeling of healthy
enting practices was no longer significant. Fig. 2 illustrates the family dietary habits was associated with better adolescents' dietary quality.
functioning by breakfast practices interaction and suggests that break- As the moderators were added into the model, a significant author-
fast parenting practices were positively associated with adolescents’ itative style by parental modeling interaction was observed. Yielding an
dietary quality and this association was more pronounced among fa- interaction virtually identical to that in Fig. 3, this interaction shows
milies with high levels of family functioning compared to those with parental modeling of healthful dietary habits was positively associated
low levels of family functioning. However, this effect was in the op- with dietary quality among adolescents and this association was more
posite direction when parents used less healthful breakfast practices. pronounced among adolescents whose parents used a more author-
Both adolescent age and parent income were significant covariates in itative style than those who used a less authoritative style. However,
the final model. this effect is in the opposite direction when parents model less healthful
Table 6 presents the association between parental modeling of dietary intake. In addition, a trend towards significance was observed
dietary behaviours and adolescents' dietary quality and whether the

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Table 5
Association between nutrition parenting practices and adolescents’ dietary quality.
Adolescent Dietary Quality

Model 1 Final Model

SC (SE) SC (SE)

Independent variables Eating Practices 0.03 (0.08) p = 0.74 0.03 (0.08) p = 0.74
Breakfast Practices 0.18 (0.08) p = 0.02 0.05 (0.09) p = 0.60

Moderators Authoritative Style – −0.13 (0.08) p = 0.10

Permissive Style
Family Functioning
Authoritative Style * Eating Practices
Permissive Style*
Eating Practices
Family Functioning* Eating Practices
Authoritative Style* Breakfast Practices
Permissive Style* Breakfast Practices
Family Functioning* Breakfast Practices
– 0.09 (0.07) p = 0.24
– −0.03 (0.08) p = 0.65
– NS
– NS
– NS
– NS
– NS
– 0.23 (0.09) p = 0.01

Covariates Adolescent sex −0.10 (0.07) p = 0.16 −0.10 (0.07) p = 0.18

Adolescent age −0.14 (0.08) p = 0.060 −0.18(0.08) p = 0.02
Parent income 0.21(0.07) p = 0.00 0.24(0.07) p = 0.00

SC=Standardized Coefficient; SE=Standard Error; NS=Not significant.

Model 1: Test association between nutrition parenting practices and adolescents' dietary quality and accounts for the following covariates—adolescent age, ado-
lescent sex, parent income.
Final Model: Adds to model 1 test of moderation and keeps effects that are significant at p < 0.1.
*Denotes interaction term.

and parenting practices, such as home availability of foods (i.e., fruits

Fig. 2. Graph showing how the association between adolescents' dietary quality
and breakfast parenting practices was moderated by family functioning.
for authoritative parenting style (p = 0.09) as well as a permissive style
by eating practices interaction (p = 0.07) on adolescents’ dietary
quality.
4. Discussion
Research on family-level mechanisms that influence overweight or
obese adolescents’ dietary quality has been fairly limited as most stu-
dies have focused on younger children. Although the majority of the
research has considered the influence of parenting practices and mod-
eling independently (Kitzmann et al., 2008; McIntyre, 1966), this study
indicated that, when considered jointly, parental modeling may be an
important influence of overweight/obese adolescent dietary quality;
while a trend towards a significant association was also observed be-
tween parenting practices and dietary quality. Although the theoretical
model proposed in Fig. 1 was not fully supported in this study, our
study nonetheless adds to the literature by providing evidence for the
idea that familial context, specifically parenting style, may act as a
moderator.
The majority of the literature suggests that both parental modeling
and vegetables) are associated with adolescents' intake of fruits, vege-
tables, and their dietary intake in general (Campbell et al., 2007;
Hanson, Neumark-Sztainer, Eisenberg, Story, & Wall, 2005; Loth,
MacLehose, Fulkerson, Crow, & Neumark-Sztainer, 2013). The current
study did not examine intake of specific dietary components but instead
examined the whole diet, which may partly explain the discrepancies
with the findings of the previous study. Other work suggests that par-
enting strategies such as encouraging, restrictive, or negotiating prac-
tices - along with parental modeling - are related to dietary quality
among overweight or obese adolescents (Vereecken, Haerens, De
Bourdeaudhuij, & Maes, 2010; Watts, Lovato, Barr, Hanning, & Mâsse,
2015). However, further studies are needed to verify whether both
parenting practices as well as parental modeling are consistently asso-
ciated with adolescents’ dietary quality, given that a trend towards
significance was observed for parenting practices.
One of the main hypotheses of this study was that family func-
tioning would moderate the relationship between parenting practices
and/or parental modeling and adolescents' dietary behaviours. Family
functioning emerged as a significant moderator for the relationship
between breakfast parenting practices and adolescents’ dietary quality,
but this association disappeared when both parenting practices and
parental modeling were entered into the model. According to past lit-
erature, limited studies have examined the moderating effects of family
functioning (Kitzmann et al., 2008; Loth et al., 2013). Although not
directly targeting overweight/obese adolescents, Loth and colleagues
found significant effect modification by overall family functioning for
the association between family meals and unhealthy weight control
behaviours (e.g., eating very little food or skipping meals) (Loth et al.,
2013). Although no extant research has examined the moderating effect
of family functioning in the treatment of pediatric obesity, a review by
Kitzmann and colleagues points to indirect evidence for this assertion
(Kitzmann et al., 2008). For instance, correlational research suggests
that compared to normal-weight children, overweight/obese children
are more likely to experience more family conflict and less family co-
hesion (Vereecken et al., 2010; Watts et al., 2015) Although the di-
rectionality of this association remains unclear, this pattern suggests
that families with an overweight child may need additional help to

74
N.S. Carbert et al.
Table 6
Association between parental modeling of a healthful diet and adolescent dietary quality.
Independent variable Parental Modeling (Diet)
Moderators Authoritative Style
Permissive Style
Family Functioning
Authoritative Style* Parental Modeling (Diet)
Permissive Style* Parental Modeling (Diet)
Family Functioning* Parental Modeling (Diet)
Covariates Adolescent sex
Adolescent age
Parent income
SC=Standardized Coefficient; SE=Standard Error, NS=Not significant.
Model 1: Test association between parental modeling (diet) and adolescents' dietary quality and account for the following covariates—adolescent age, adolescent sex,
parent income.
Final Model: Adds to model 1 test of moderation and keeps only effects that are significant at p < 0.1.
*Denotes interaction term.
Fig. 3. Graph showing how the association between adolescents' dietary quality
and parental modeling of a healthful diet was moderated by an authoritative
parenting style.
effectively manage or support the health behaviours of their child
(Kitzmann et al., 2008). While this review suggests family functioning is
an important moderator for adolescent health behaviours, the evidence
is currently mixed and sparse (Kitzmann et al., 2008; Stevenson,
Doherty, Barnett, Muldoon, & Trew, 2007). Although family func-
tioning was not found to moderate any of the parent-adolescent asso-
ciations, this may be partly explained by the characteristics of the
sample, which predominantly included families that were mostly ba-
lanced on both the cohesion and flexibility scales. Thus, families in each
high or low functioning group may not have been sufficiently different.
Future studies should ensure a more diverse sample in terms of family
context to further examine the potential role of family functioning.
In terms of dietary quality, a number of studies have supported the
notion that food parenting strategies are related to healthier eating
when exercised in an authoritative parenting context (Joyce & Zimmer-
Gembeck, 2009; Lessard, Greenberger, & Chen, 2010). Interestingly, in
our study, this was only apparent for those adolescents whose parents
modeled the most healthful dietary habits. Thus, it may be that parents
with an authoritative style are better able to influence their adolescents'
health behaviours when they model more healthful behaviours in
conjunction with a more authoritative style. Thus, a parents' style has
the potential to alter how children view their parents’ behaviours and
ultimately respond to these behaviours.
75
Appetite 134 (2019) 69–77
Adolescent Dietary Quality
Model 1 Model 2
SC(SE) SC(SE)
0.37 (0.07) p = 0.00 0.16 (0.10) p = 0.10
– −0.11 (0.07) p = 0.12
– 0.09 (0.07) p = 0.18
– 0.05 (0.08) p = 0.52
– 0.28 (0.10) p = 0.00
– NS
– NS
−0.09 (0.07) p = 0.18 −0.09 (0.07) p = 0.17
−0.13 (0.07) p = 0.05 −0.15 (0.07) p = 0.03
0.19 (0.07) p = 0.05 0.21 (0.07) p = 0.00
When it comes to examining the effectiveness of family-based inter-
ventions, mixed results have been reported (Lindsay et al., 2006; Masse &
Watts, 2013). One reason may be that interventions have not accounted for
certain factors, such as parenting styles, which may alter the effectiveness of
parental modeling targeted in the intervention. For instance, it may be
helpful for interventionists to educate parents on how different parenting
styles can elicit different eating behaviours in conjunction with modeling to
elicit healthful dietary behaviours from their overweight/obese adolescents.
Therefore, the efficacy of obesity interventions may be improved if inter-
ventions not only target parenting factors such as parental modeling, but
also emphasize the importance of family context in shaping adolescents’
dietary behaviours to ultimately manage weight outcomes.
The findings of this study should be interpreted in light of its lim-
itations. First, due to the cross-sectional nature of the study, it is diffi-
cult to make any inferences about causality. For instance, observed
associations may be bi-directional since parents and children constantly
shape and reshape each other through their mutual actions and reac-
tions (Kerr & Stattin, 2000; O'Connor, 2002). Additionally, self-reported
dietary recall is subject to social desirability, which suggests that
overweight or obese adolescents may not accurately report their diets.
Despite this challenge, the private and anonymous feature of the web-
based dietary recall tool may have helped attenuate such bias. Third,
measurement issues were present among the parenting measures. Our
study was limited to examining only two parenting styles, rather than
the four developed by Baumrind (authoritative, permissive, author-
itarian, and neglectful) (Maccoby & Martin, 1983), thus, the true par-
enting style of the parent may not have been documented. Additionally,
as authoritative parenting style was assessed on a continuum (low to
high), we were unable to know the extent to which the high end of the
authoritative style scale was measuring an unhealthy parenting style
(e.g., a very controlling style such as authoritarian). The measures
employed were previously validated and modifications were made for
this study. Finally, our sample were overweight or obese adolescents
who volunteered to participate in a lifestyle modification intervention.
Although study findings may only generalize to those families willing to
participate in a weight loss intervention and change their lifestyles,
overweight/obese adolescents are understudied and are targeted by
treatment interventions, and thus are an important group to consider.
In conclusion, our study not only demonstrated the importance of
targeting parenting factors such as parental modeling, but highlighted
the importance of family context in shaping overweight/obese adoles-
cents’ dietary behaviours.
N.S. Carbert et al. Appetite 134 (2019) 69–77

Table 7
Final model results for path analysis models predicting adolescent dietary quality from parenting styles, family functioning, eating practices, breakfast practices, and
parental modeling of dietary quality.
Adolescent Dietary Quality

Model 1 Model 2

SC(SE) SC(SE)

Independent Variables Eating Practices 0.01 (0.07) p = 0.93 −0.06 (0.08) p = 0.45
Breakfast Practices 0.12 (0.07) p = 0.12 0.12 (0.07) p = 0.10
Parental Modeling (Diet) 0.35 (0.07) p = 0.00 0.14 (0.10) p = 0.17

Moderators Authoritative Style – −0.12 (0.07) p = 0.09

Permissive Style
Family Functioning
Permissive Style* Eating Practices
Authoritative Style* Eating Practices
Family Functioning* Eating Practices
Authoritative Style* Breakfast Practices
Permissive Style* Breakfast Practices
Family Functioning* Breakfast Practices
Authoritative Style* Parent Modeling (Diet)
Permissive Style* Parental Modeling (Diet)
Family Functioning* Parental Modeling (Diet)
– 0.12 (0.07) p = 0.10
– −0.04 (0.08) p = 0.58
– 0.15 (0.08) p = 0.07
– NS
– NS
– NS
– NS
– NS
– 0.29 (0.10) p = 0.00
– NS
– NS

Covariates Adolescent sex −0.10 (0.07) p = 0.15 −0.08 (0.07) p = 0.21

Adolescent age −0.11 (0.07) p = 0.13 −0.14 (0.07) p = 0.04
Parent income 0.18 (0.07) p = 0.01 0.23 (0.07) p = 0.00

SC=Standardized Coefficient; SE=Standard Error; NS=Not significant.

Test association between eating practices, breakfast practices, and parental modeling (diet) on adolescents' dietary quality while considering the following covariates:
adolescent sex, age, and parent income.
Final Model: adds to model 1 test of moderation and keeps only effects that are significant at p < 0.1.
*denotes interaction term.

Conflicts of interest
The authors declare that they have no competing interests.
Funding
The data collection for this study was funded by a peer-reviewed
grant that LCM received from the Canadian Institutes of Health
Research (CIHR) of Nutrition, Metabolism and Diabetes and the Health
Research Foundation (Funding Reference Number 92369). In addition,
during the study period, LCM and MB received salary support from the
BC Children's Hospital Research Institute (BCCHR). LCM also received
salary support from the Michael Smith Foundation for Health Research.
Acknowledgements
The authors wish to acknowledge the contribution of Maria Valente
for overseeing the data collection of this study and for Dr. Judith
Fitzgerald de Niet for her help in data collection.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.appet.2018.12.034.
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