| | Family Meals and Substance Use: Is There a Long-Term Protective Association?Received 12 October 2007; accepted 11 January 2008. published online 11 April 2008. Abstract PurposeTo examine 5-year longitudinal associations between family meal patterns and subsequent substance use in adolescents. MethodsA total of 806 Minnesota adolescents were surveyed in public schools in 1998–1999 (mean age, 12.8 years) and again by mail in 2003–2004 (mean age, 17.2 years) as part of a longitudinal population-based study. Logistic regression was used to estimate the odds of tobacco, alcohol, and marijuana use at follow-up for adolescents reporting regular family meals at baseline compared with those without regular family meals, adjusting for family connectedness and prior substance use. ResultsFamily meal frequency at baseline was associated with significantly lower odds of cigarette smoking, alcohol use, and marijuana use at follow-up among female adolescents, even after adjusting for baseline substance use and additional covariates. Family meals were not associated with use of any substance at follow-up for male adolescents after adjusting for baseline use. ConclusionsResults from this study suggest that regular family meals in adolescence may have a long-term protective association with the development of substance use over 5 years among females. Parents should be encouraged to establish a pattern of regular family meals, as this activity may have long lasting benefits A social ecological perspective suggests that factors operating at multiple levels may be powerful influences on health behaviors, and social cognitive theory in particular posits that health behaviors are shaped by characteristics of the individual and the environment [1], [2], [3], [4]. The family context is an especially salient environmental influence for young people; numerous studies have established various aspects of family functioning, such as family connectedness, communication, support, conflict, and parenting style, as important predictors of adolescent health and health behaviors [5], [6], [7]. Family meals provide a venue for parents to connect with their adolescents on a regular basis, communicate with them about their daily activities, monitor their adolescents' whereabouts and moods, and serve as role models for their children. Indeed, family meals during adolescence have been found to be associated with numerous health benefits. Adolescents who regularly eat with their family members tend to have better dietary intake. Studies have shown that frequency of family meals is positively associated with intakes of nutrients and of fruits, vegetables, and calcium-rich foods, and negatively associated with consumption of soft drinks and fried foods [8], [9], [10]. Family meal frequency has also been inversely associated with a variety of high-risk behaviors including disordered eating, sexual activity, antisocial behavior, violence, school problems, and lack of psychosocial well-being [11], [12], [13], [14]. In addition several cross-sectional studies have shown that family meals are negatively associated with cigarette smoking, alcohol use, and marijuana use [15], even after controlling for other family factors and sociodemographic variables [13], [14]. Most studies regarding the health benefits of family meals have used a cross-sectional design [8], [9], [11], [13], [14], [15] or a relatively short-term prospective follow-up [16]. Cross-sectional findings regarding substance use lay important groundwork but raise the question of reverse causality: that is, young people who are using substances may intentionally avoid family meals to avoid censure for this behavior, rather than family meals exerting a protective effect against substance use. Recent longer-term prospective studies have examined eating-related outcomes [17], [18], but to our knowledge the long-term effects of family meals on adolescent substance use behavior have not been investigated. The present study therefore builds upon our earlier cross-sectional research regarding family meal frequency and substance use. We examine family meal patterns over 5 years and their association with initiation of substance use as young people transition from middle school to high school age. We hypothesize that regular family meals during early adolescence will be protective against substance use in middle adolescence, 5 years later. Furthermore, in our previous work we found that it was important to adjust for family connectedness, a well-known protective factor for numerous risk behaviors in adolescence [5], [6], [19], [20], [21], [22], to understand the contribution of family mealtime variables beyond reports of general connectedness; we therefore include appropriate adjustments for family connectedness. This study also examines all associations separately by gender, as research has indicated that males and females experience family functioning differently (e.g., females may have higher levels of communion and interpersonal concern in close relationships than males [23]), and male and female adolescents have different rates of health-jeopardizing behaviors, with males tending more toward externalizing behaviors and females exhibiting more internalized distress, such as depression [24], [25]. In addition our previous work on family meals has shown stronger associations with disordered eating behavior for females than for males [11]. Given these gender differences, we anticipate a stronger association between family meals and substance use for females compared with males. Methods  The sample included 366 male adolescents (45.4%) and 440 female adolescents (54.6%) who were surveyed at two time points 5 years apart (mean age at follow-up, 17.2 years; range, 15–18 years). Data come from Project EAT-II, a longitudinal study of eating patterns and related socioenvironmental, personal, and behavioral factors among adolescents. In Project EAT-I, 1608 middle-school students (grades 7 and 8) at public schools in the metropolitan area of the Twin Cities, Minnesota, completed surveys and anthropometric measures during the 1998–1999 school year. All students in selected health, physical education, and science classes were invited to participate, and 81.5% of students whose names were included on class lists completed surveys. Schools were selected with the goal of obtaining a racially/ethnnically and economically diverse sample; the original cohort of middle school students was 35.7% white, 22.8% African-American, 7.6% Hispanic, 22.0% Asian, 6.3% Native American, and 5.6% mixed or other race. Project EAT-II aimed to re-survey all original participants to examine changes in eating patterns as these individuals progressed from early to middle adolescence. The original Project EAT survey was developed by the study team based on social cognitive theory and focus group discussions with adolescents [3], [26], [27], [28]. The survey went through multiple revisions based on input from a team of experts, adolescent members of the University of Minnesota Youth Advisory Board, and 68 students in grades 7–10 who pre-tested the survey. The survey was further pilot-tested among 161 students in grades 7–10 twice over a 2-week interval to assess test–retest reliability. Based on the findings, additional modifications were made to further improve the questions. The Project EAT-I survey was revised for use in Project EAT-II, with approximately two-thirds of the items retained as in the original survey. Substance use variables were identical on both surveys. Mailed surveys were used for data collection from April 2003 to June 2004. All study protocols were approved by the University of Minnesota's Institutional Review Board Human Subjects Committee. Additional details about the Project EAT-I and EAT-II surveys and data collection measures are available elsewhere [29], [30], [31]. Of the original cohort of middle-school students, 448 participants (27.9%) were lost to follow-up, primarily because of missing contact information. Of the remaining 1160 participants contacted, 806 completed surveys, representing 50.1% of the original cohort and 69.5% of those contacted for Project EAT-II. The follow-up sample was more likely to be of white ethnicity and in the upper socioeconomic status (SES) categories than the original baseline sample. However there were no significant differences in family meals or family connectedness, or in regular cigarette smoking or alcohol use at baseline between adolescents who responded and those who did not respond at follow-up. Adolescents who did not respond at follow-up (including those who could not be contacted) were significantly more likely to have used marijuana regularly at baseline (6.3%) compared with those who responded (3.1%; Chi-square = 8.4, p < .01). The final sample was racially/ethnically and socioeconomically diverse. The ethnic/racial background of the participants was as follows: 47.0% were white, 16.3% African-American, 6.4% Hispanic, 22.9% Asian, 3.7% Native American, and 3.8% mixed or other race. Nearly one-third (30.9%) of the sample was of low or low-middle socioeconomic status. Measures Frequency of family meals was assessed with the question, “During the past 7 days, how many times did all or most of your family living in your house eat a meal together?” Response categories were as follows: never; one to two times; three to four times; five to six times; seven times; and more than seven times. Those reporting five or more family meals per week were considered to have “regular family meals”; the cut-point of five meals was selected to represent a majority of days per week and to be comparable to those in previous studies [11], [14], [15]. This item had a test–retest correlation of .70. Family connectedness was assessed with four survey items [19]. Two questions asked, “How much do your feel your [mother, father] cares about you?” and two asked, “Do you feel you can talk to your [mother, father] about your problems?” Response options were “not at all, a little, somewhat, quite a bit, very much.” No particular instructions were given to define mother or father, so participants were free to interpret the question in the context of their own family situation and to provide responses for one or two parental figures. Scores from two items (where questions regarding a single parent were completed) or four items (where questions for two parents were completed) were averaged to create connectedness scores ranging from 1–5, with higher scores indicating greater connectedness to family (Cronbach's α = .69). Test–retest correlations for individual questions ranged from .70–.82. Substance use was measured with the item: “How often have you used the following [cigarettes, alcohol, marijuana] during the past year (12 months)?” [19]. The five response choices for each substance were: “never,” “a few times,” “monthly,” “weekly,” and “daily.” Test–retest correlations for these three substance use items ranged from .77–.81. Each substance was dichotomized into at least monthly use vs. less frequent or nonuse. Race/ethnicity was assessed with one item: “Do you think of yourself as (1) white, (2) black or African-American, (3) Hispanic or Latino, (4) Asian American, (5) Hawaiian or Pacific Islander, or (6) American Indian or Native American?” and respondents could choose multiple categories. Respondents were grouped as white, African-American, Asian, and mixed/other racial groups for further analysis; other racial/ethnic groups could not be considered individually because of the small numbers [9]. Five levels of SES were based, for most respondents, on the highest educational level attained by either parent. Response categories for questions on parental educational level were: (1) did not finish high school, (2) finished high school or graduation equivalency degree, (3) some college, (4) finished college, (5) Masters degree or doctorate (Ph.D.), and (6) don't know. Other variables used to assess SES included family eligibility for public assistance (yes/no/don't know); eligibility for free or reduced-cost school meals (yes/no/don't know); and employment status of mother and father (full-time/part-time/not working/don't know). An algorithm was developed to avoid classifying youth as high SES, based on parental education levels, if they were on public assistance, were eligible for free or reduced-cost school meals, or had two unemployed parents. These variables were also used to assess SES in cases for which there were missing data or “don't know” responses for both parents' educational levels. Using the method of classification and regression trees, these other variables were found to be predictive of parental education and reduced the number of missing SES values to an acceptable level [29], [32]. SES levels as reported by adolescents in Project EAT-I were compared with SES levels as reported by a subsample of 861 parents of participating adolescents in Project EAT who were interviewed by telephone; correlations were found to be acceptable (r = .68). Data analysis Logistic regression was used to estimate the odds of using each substance at follow-up for those reporting regular family meals at baseline compared with those without regular family meals. Two models were run for each substance. In the first, family connectedness, race/ethnicity, and SES were included as covariates to examine the total direct association of baseline family meals and personal characteristics with subsequent substance use. The second model further adjusted for use of the three substances at baseline, to establish temporal ordering of meals and substance use and to account for the uptake of different substances by those already using a single substance. All analyses were stratified by gender because of our previous findings that some cross-sectional associations differed by gender [13]. Results Approximately 60% of the sample (59.5% of males and 61.2% of female adolescents) reported five or more family meals per week at the baseline assessment. As shown in Table 1, a minority of participants reported at least monthly use of each substance at follow-up, ranging from 11.7% of females reporting marijuana use to 25.5% of females reporting cigarette smoking. Family meal frequency at baseline was significantly associated with cigarette smoking, alcohol and marijuana use at follow-up for females (Table 2). Female adolescents reporting regular family meals had odds of cigarette smoking, alcohol use, and marijuana use at follow-up that were approximately half the odds for females who did not report regular family meals at baseline (Model 1). Odds ratios ranged from .47–.49. After adjusting for baseline substance use to establish temporality (Model 2), the magnitude of significant associations was only minimally affected, and odds ratios ranged from .48–.52 for females' substance use. Family meals were not significantly associated with use of any substance at follow-up for males after adjusting for baseline use. Certain covariates (race/ethnicity and prior substance use) were also associated with females adolescents' substance use at follow-up (Table 2). Discussion Results from this study suggest that regular family meals in adolescence may have a long-term protective association with the development of substance use over 5 years among female adolescents. Middle-school female adolescents reporting at least five family meals per week were significantly less likely to report regular use of cigarettes, alcohol, and marijuana during their high school years than their counterparts whose families did not have regular meals, even after accounting for earlier substance use. These findings are consistent with previous cross-sectional work indicating an inverse association between family meal frequency and substance use [13], but the prospective design extends this body of research by establishing temporal ordering of baseline family meal frequency and subsequent substance use. Family meals are emerging as a valuable protective factor in the lives of young people. Importantly, the present finding regarding family meals is independent of more general family functioning, which may underlie family meal patterns as well as contribute to involvement or avoidance of risk behaviors in adolescence [5], [6], [19], [20], [21], [22]. Thus whether young people report that that they have strong or relatively poor relationships with their parents, regular family meals may offer some protection against initiation of substance use. This study's findings also are in line with our previous findings suggesting that family meals may be associated with more benefits for females than for males. Although measures were not available to explore reasons behind this difference in the current study, existing theory and research point to differences in the way that males and females interact with family members in a variety of domains [23]. Females may, for example, be more attuned to subtle emotional support offered during family meals, resulting in a more profound protective effect for females than for males. This study's findings raise the question of the pathways through which family meals might influence substance use initiation. An abundance of research has shown that parental monitoring is inversely associated with adolescent substance use behaviors [33], [34]. Simply having adolescents at home for meals may increase the possibility of parental monitoring, which may deter or delay initiation of substance use. In addition, regular family meals enhance the opportunities for discussions about high-risk behavior, such as smoking cigarettes and drinking alcohol, and for directly communicating parental values. Future studies with a broader array of family-related variables are needed to identify specific mechanisms of action that would suggest appropriate points for family-based interventions to decrease substance use. Study strengths and limitations This study has several strengths that improve our ability to draw meaningful conclusions from the data. The longitudinal study design helps to determine temporal ordering of family meals and uptake of substance use: to our knowledge, this is the first study that is able to establish family meal frequency as an inhibitor of substance use development. We were also able to control for the potential confounding effect of family connectedness on the relationship between family meals and subsequent substance use, which is an advantage over much of the existing research on this topic. The large diverse sample is another advantage, in that results are expected to be generalizable to a broad spectrum of adolescents. Several limitations must also be considered in interpreting these findings, however. First, this study did not include measures of family functioning beyond general family connectedness, such as parental monitoring, family conflict, parental substance use, or single-parent vs. two-parent household status, all of which may be important contributors to family meals and substance use initiation. We were therefore unable to explore various mediational pathways or to speculate as to the reasons underlying the study findings. Second, although similar measures of family meal frequency have been used in numerous studies, the measure has not been validated against a more objective criterion. It is possible, for example, that “most of [the] family” ate a meal together but that the adolescent respondent did not attend. Likewise were are unable to discern which family members attended meals, and we note that the dynamic may be different depending on which parent(s), sibling(s), or other family members participated. The past-week time frame of the item was selected to minimize recall bias, but we must acknowledge that even though the item has good test–retest reliability over 2 weeks, this short period may not accurately represent a longer time frame. Third, this study relied on self-reported substance use, as this was the only feasible type of assessment for a large epidemiologic study of adolescents. Finally, although the response rate among those who were contacted at follow-up was good, the follow-up sample was more likely to be of white ethnicity and in the upper SES categories than the original baseline sample. This likely results from the greater mobility of participants in the lower SES and nonwhite groups, who were heavily represented in the baseline sample. Our concerns about this discrepancy are lessened for this specific analysis, however, in that baseline family meal frequency and family connectedness did not differ between responders and nonresponders at follow-up. Study implications Future studies on family meals should investigate the mechanisms underlying the observed protective association between family meals and substance use behavior. The context of the meal may be as important as the frequency in terms of how family meals inhibit substance use initiation. The benefits described here could be attributable to time spent with family vs. with friends, or to the experience of ongoing family ritual, or to exposure to the values and expectations of parents. Characteristics of family meals, such as television viewing, eating at the table, or orderliness may also contribute to relationships with adolescent well-being. A confirmatory study assessing family meals and substance use at several time points is also warranted to determine whether these factors are associated in a more sophisticated longitudinal analysis. If so, interventions designed to increase family meals may be appropriate. This study adds to the body of literature suggesting that parents should be encouraged to establish a pattern of regular family meals, as this activity may have long-lasting benefits in terms of adolescent substance use. Parents may benefit from being informed that they can continue to influence their children's behavior throughout the teen years, and that family meals can provide a venue for this influence. Creative ideas, flexibility, and support at the family level and at the broader community level may be needed to help parents implement regular family meals as teens mature, spend more time with friends, and engage in more activities outside of the home. Acknowledgments This study was supported by Grant No. R40 MC 00319-02 (to D.N.-S.) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Service Administration, U.S. Department of Health and Human Services, and from the General Mills Bell Institute of Health and Nutrition. References [1]. 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a Division of Adolescent Health and Medicine, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota b Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota c School of Nursing, University of Minnesota, Minneapolis, Minnesota  Address correspondence to: Marla E. Eisenberg, Sc.D., M.P.H., Division of Epidemiology and Community Health, 1300 South Second Street, Suite 300, Minneapolis, MN 55454.
PII: S1054-139X(08)00094-3 doi:10.1016/j.jadohealth.2008.01.019 © 2008 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved. | |
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