Individual and family correlates of calcium-rich food intake among parents of early adolescent children.

Abstract

Most adults do not meet calcium intake recommendations. Little is known about how individual and family factors, including parenting practices that influence early adolescents' intake of calcium-rich foods, affect calcium intake of parents. This information could inform the development of effective nutrition education programs.
To identify individual and family factors associated with intake of calcium-rich foods among parents of early adolescents (aged 10 to 13 years).
A cross-sectional survey was used with 14 scales to assess attitudes/preferences and parenting practices regarding calcium-rich foods and a calcium-specific food frequency questionnaire (2006-2007).
A convenience sample of self-reporting non-Hispanic white, Hispanic, and Asian (n=661) parents was recruited in nine states. Parents were the primary meal planner/preparer and completed questionnaires in homes or community settings.
Predictors of calcium intake from three food groupings-all food sources, dairy foods, and milk.
Multivariate regression analyses identified demographic, attitude/preference, and behavioral factors associated with calcium intake.
Most respondents were women (∼90%) and 38% had a college degree. Education was positively associated with calcium intake from all three food groupings, whereas having an Asian spouse compared to a non-Hispanic white spouse was negatively associated with calcium intake only from all food sources and from dairy foods. Expectations for and encouragement of healthy beverage intake for early adolescents were positively associated with calcium intake from dairy foods and milk, respectively. Parental concern regarding adequacy of intake was negatively associated, whereas perception of health benefits from calcium-rich foods was positively associated with calcium intake from all food sources and from dairy foods. Between 20% and 32% of the variance in calcium intake from all food groupings was explained in these models.
Individual factors and positive parenting practices may be important considerations for nutrition education programs targeted to parents.

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RESEARCH
Original Research
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Individual and Family Correlates of
Calcium-Rich Food Intake among Parents of
Early Adolescent Children
MARLA REICKS, PhD, RD; MIRIAM EDLEFSEN BALLEJOS, PhD, RD; L. SUZANNE GOODELL, PhD, RD; CAROLYN GUNTHER, PhD;
RICKELLE RICHARDS, PhD, MPH, RD; SIEW SUN WONG, PhD; GARRY AULD, PhD, RD; CAROL J. BOUSHEY, PhD, MPH, RD;
CHRISTINE BRUHN, PhD; MARY CLUSKEY, PhD, RD; SCOTTIE MISNER, PhD, RD; BETH OLSON, PhD; SAHAR ZAGHLOUL, PhD, MBBS
ABSTRACT
Background Most adults do not meet calcium intake recom-
mendations. Little is known about how individual and family
factors, including parenting practices that influence early ad-
olescents’ intake of calcium-rich foods, affect calcium intake of
parents. This information could inform the development of
effective nutrition education programs.
Objective To identify individual and family factors associ-
ated with intake of calcium-rich foods among parents of
early adolescents (aged 10 to 13 years).
Design A cross-sectional survey was used with 14 scales to
assess attitudes/preferences and parenting practices re-
garding calcium-rich foods and a calcium-specific food
frequency questionnaire (2006-2007).
Participants/setting A convenience sample of self-reporting
non-Hispanic white, Hispanic, and Asian (n?661) par-
ents was recruited in nine states. Parents were the pri-
mary meal planner/preparer and completed question-
naires in homes or community settings.
Main outcome measures Predictorsofcalciumintakefromthree
food groupings—all food sources, dairy foods, and milk.
Statistical analyses performed Multivariate regression anal-
yses identified demographic, attitude/preference, and be-
havioral factors associated with calcium intake.
Results Most respondents were women (?90%) and 38% had
a college degree. Education was positively associated with
calcium intake from all three food groupings, whereas hav-
ing an Asian spouse compared to a non-Hispanic white
spouse was negatively associated with calcium intake only
from all food sources and from dairy foods. Expectations for
and encouragement of healthy beverage intake for early
adolescents were positively associated with calcium intake
from dairy foods and milk, respectively. Parental concern
regarding adequacy of intake was negatively associated,
whereas perception of health benefits from calcium-rich
foods was positively associated with calcium intake from all
food sources and from dairy foods. Between 20% and 32% of
the variance in calcium intake from all food groupings was
explained in these models.
M. Reicks is a professor, Department of Food Science and
Nutrition, University of Minnesota, St Paul. M. E. Ballejos is
an associate professor, Washington State University Puyallup
Research and Extension Center, Puyallup. L. S. Goodell is an
assistant professor, Department of Food, Bioprocessing, and
Nutrition Sciences, North Carolina State University, Raleigh.
C. Gunther is director of research and an adjunct assistant
professor, Department of Human Nutrition, Ohio State Uni-
versity, Columbus. R. Richards is an assistant professor, De-
partment of Nutrition, Dietetics, and Food Science, Brigham
Young University, Provo, UT. S. S. Wong is an assistant pro-
fessor and extension nutrition specialist, Department of Nu-
trition, Dietetics, and Food Sciences, Utah State University,
Logan. G. Auld is a professor, Department of Food Science
and Human Nutrition, Fort Collins, CO. C. J. Boushey is an
associate professor, Department of Foods and Nutrition, Pur-
due University, West Lafayette, IN. C. Bruhn is a consumer
food marketing specialist, Department of Food Science and
Technology, University of California, Davis. M. Cluskey is an
associate professor, Department of Nutrition and Exercise
Science, Oregon State University, Corvallis. S. Misner is an
associate nutrition specialist and state Expanded Food Nutri-
tion Education Program/Supplemental Nutrition Assistance
Program-Education coordinator, Department of Nutritional
Sciences, University of Arizona, Tucson. B. Olson is an asso-
ciate professor and extension specialist, Department of Food
Science and Human Nutrition, Michigan State University,
East Lansing. S. Zaghloul is a senior research scientist and
affiliate professor, Kuwait Institute for Scientific Research,
Safat, Kuwait; at the time of the study, she was an associate
professor, Department of Agricultural Sciences, University of
Hawaii, Honolulu.
Address correspondence to: Marla Reicks, PhD, RD,
Department of Food Science and Nutrition, University
of Minnesota, 1334 Eckles Ave, St Paul, MN 55108.
E-mail: mreicks@umn.edu
Manuscript accepted: September 21, 2010.
Copyright © 2011 by the American Dietetic
Association.
0002-8223/$36.00
doi: 10.1016/j.jada.2010.11.020
376
Journal of the AMERICAN DIETETIC ASSOCIATION
© 2011 by the American Dietetic Association

Page 2

Conclusions Individual factors and positive parenting prac-
tices may be important considerations for nutrition edu-
cation programs targeted to parents.
J Am Diet Assoc. 2011;111:376-384.
F
recommendation for calcium intake, based on national
dietary intake data from 1999-2002 (1). Mean daily cal-
cium intakes of Asian women living in Auckland, New
Zealand, were at about 70% of recommended levels (2).
Adult bone health is optimized with an adequate intake
of dietary calcium and vitamin D within a healthy diet
(3); therefore, long-term calcium intake that is below
recommendations is a concern. Dairy foods, including
milk, are important sources of calcium for many adults
(4,5). However, intake may be marginal for some race/
ethnic groups because dairy foods are often associated
with real or perceived lactose intolerance (4) or not in-
cluded in basic cultural food patterns (6,7). Despite such
concerns, a large percentage of people who might be lac-
tose intolerant still rely on dairy foods as their main
calcium source (8,9). Because food sources of calcium vary
by race/ethnicity, evaluating both individual and environ-
mental factors that influence intake by race/ethnicity is
important. When research resources are limited, exam-
ining factors that influence calcium intake among those
at highest risk may be a priority. For example, results
from a previous longitudinal study involving healthy ad-
olescents (aged 9 to 25 years) showed that Asian, His-
panic, and non-Hispanic white youth had significantly
lower areal and volumetric bone density at all skeletal
sites than African American youth (10), indicating possi-
ble group differences in risk of developing osteoporosis.
Calcium intakes among adults may be mediated by
household composition, including the presence of children
and their dependence on adults in the home for food
acquisition and preparation. The Social Cognitive Theory
proposes that individual, behavioral, and socioenviron-
mental factors interrelate to influence behavior (11). In-
dividual factors such as perceptions of health benefits or
concern about the adequacy of calcium intake (12), knowl-
edge of calcium sources, concerns about weight gain from
eating calcium-rich foods (13,14), and dairy or milk intol-
erance (15) may directly or indirectly influence calcium
intakes by parents. Behavioral factors, such as eating
food away from home, may also play an important role.
Lack of time and work stress can lead parents to eat more
meals in the car or at restaurants rather than at home
(16). Food prepared and consumed away from home tends
to contain less dietary calcium per kilocalorie than food
prepared and consumed at home (17). Socioenvironmen-
tal factors that may influence calcium intake by parents
include parenting practices that enable intake of calcium-
rich foods by children in the household.
Research studies have examined the influence of vari-
ous parenting practices on children’s dietary intake, in-
cluding making healthy foods available, role modeling,
setting rules and providing encouragement, and eating
dinner together (18-22). However, few studies have ex-
amined how parenting practices that enable improved
ewer than half of non-Hispanic white (46%) and only
about one third of Mexican-American (33%) men and
women aged ?19 years in the United States meet the
intake of healthy foods by children may also affect intake
among parents themselves. In one study, Tibbs and col-
leagues (23) found that for African-American parents,
parental modeling of healthful dietary behaviors was pos-
itively related to their own fruit and vegetable intake and
negatively related to energy intake from fat. Mothers
involved in a previous osteoporosis intervention trial (24)
reported making efforts to increase calcium intake among
their children. Other mothers indicated that making cal-
cium-rich foods accessible and role modeling were strat-
egies that could improve calcium intake among children
(25). Therefore, having calcium-rich foods available and
role modeling intake would be expected to improve cal-
cium intake of parents as well as children. Surprisingly,
studies to examine this phenomenon are very limited.
The purpose of this study was to identify associations
between parental and household factors and calcium in-
take from three food groupings (all food sources, dairy
foods, and milk) in Asian, Hispanic, and non-Hispanic
white parents of early adolescent children.
METHODS
Study Design and Sample Recruitment
This cross-sectional study involved administering sepa-
rate questionnaires to a convenience sample of children
aged 10 to 13 years and the adult responsible for food
acquisition and preparation in the child’s household. In
most cases (98%), the adult respondent was the child’s
parent; therefore, the adult respondent is referred to as
“parent” throughout this article. Other inclusion criteria
included having lived in the United States for at least 12
months; being able to read/speak English; and self-iden-
tifying as non-Hispanic white, Hispanic or Latino, or
Asian or Asian American, or a mixture of any of these
three groups. Due to variation in race/ethnic group dis-
tribution within the recruitment area of each state, the
recruitment goals for race/ethnic groups reflected the dis-
tribution of each area. A total of 661 parents from nine
states (Arizona, California, Colorado, Hawaii, Michigan,
Minnesota, Oregon, Utah, and Washington) completed
paper-based questionnaires during 2006-2007. This arti-
cle focuses on information from adult respondents only.
Participants were recruited using fliers, verbal an-
nouncements, written announcements in bulletins or
newsletters, personal contacts, and presentations at
groups. Organizations and groups involved in this study
included Cooperative Extension Service (eg, Expanded
Food Nutrition Education Program, Supplemental Nutri-
tion Assistance Program-Education, and 4-H), faith-
based groups, after-school programs, sports teams, scout-
ing groups, and adult groups. The study protocols were
approved by the institutional review board of each par-
ticipating university, and each participant provided writ-
ten informed consent.
Data Collection
A standardized data collection protocol was developed
and used to administer questionnaires in a consistent
manner across sites. Researchers met with parents and
children to administer questionnaires in the home or in
community settings (eg, community centers, libraries,
March 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION
377

Page 3

and athletic facilities). In four states, all questionnaires
were administered by researchers in person only; how-
ever, in five states researchers also used mailed packets
to collect completed questionnaires from 14% to 50% of
parents in their respective states. Parents took an aver-
age of 30 minutes to complete the questionnaire in indi-
vidual or group settings. In return for participation, par-
ents weregiven cash,
merchandise per each institution’s remuneration guide-
lines. All questionnaires were completed in English with
no translation services provided.
giftcertificates/cards,or
Questionnaire Development
In-depth interviews were previously conducted with
about 200 non-Hispanic white, Hispanic, and Asian par-
ents/caregivers of early adolescent children to assess par-
enting practices regarding consumption of calcium-rich
foods by children (26), meal patterns at home and away
from home (27), and knowledge regarding calcium needs
for parents and adolescents (13). Findings from the inter-
views were used to develop items for a quantitative
parent questionnaire based on two major constructs: at-
titudes/preferences regarding parental intake of calcium-
rich foods, and socioenvironmental factors regarding
child intake of calcium-rich foods. Items were tested for
clarity and understanding and revised as needed based
on results from individual cognitive interviews with 32
parents (nine Asian, 10 Hispanic, and 13 non-Hispanic
white) across seven states. Items were used to construct
14 scales that described the two major constructs. These
scales met standards for psychometric properties with
modest to acceptable Cronbach’s ? coefficients for inter-
nal consistency (.50 to .79) and Pearson correlation test–
retest reliability coefficients ranging from 0.68 to 0.85.
Items included in scales were also reviewed for appropri-
ateness of content by nutrition experts at 10 universities.
Measurements and Variables
Questions were included on the questionnaire regarding
demographic information about parent, spouse, and 10-
to 13-year-old child (Table 1). The 14 scales constructed
from questionnaire items assessed eight individual vari-
ables based on parent attitudes and preferences regard-
ing parental intake of calcium-rich foods, and six family
variables based on parenting practices and perceptions
regarding calcium-rich food intake by children (Table 2).
Parent knowledge regarding calcium requirements and
sources, the frequency of eating food away from home or
prepared away from home, and eating meals together was
also assessed.
Calcium intake (estimated milligrams per day) was
measured using a semiquantitative calcium-specific food
frequency questionnaire (FFQ) (n?79 items or groups of
items) developed for Asian, Hispanic, and non-Hispanic
white youth (28). Major categories included beverages;
dairy products; combination foods; vegetables, grains,
and nuts; seafood; and other foods. For each food item or
group of items, a commonly used portion size was listed
with a question asking how often the food item was con-
sumed during the past month. The number of frequency
responses ranged from four and seven responses ranging
from “Never or less than once per month” to “Four or
more servings per day.” A calcium value was assigned to
each food item on the FFQ based on frequency of con-
sumption, serving size, and calcium level of the various
foods allocated to each food item. The instrument
performed well when used with adult women as esti-
mates for calcium intake were comparable to those ob-
tained from 2-day food records (r?0.52) (29).
Data Analysis
Data were analyzed using SAS software (version 9.2,
2002-2008, SAS Institute Inc, Cary, NC). Participants
who selected multiple ethnic groups were classified as
non-Hispanic white, Hispanic, or Asian if one of these
groups was also selected. Those who chose Asian and
non-Hispanic white, or Hispanic and non-Hispanic white,
were classified as Asian or Hispanic, respectively. In in-
stances where Asian and Hispanic were both selected
(n?3), the predominant ethnic group of the sampling
location was used for classification as either Asian or
Hispanic. Data from parents not specifying race/ethnicity
(n?22) and whose calcium intakes were outside estab-
lished cutpoints (?100 or ?2,500 mg/day) (n?17) were
excluded from analysis for a sample size of 622 for this
analysis. Implausible dietary intake data were excluded
to facilitate the identification of associations between in-
dividual and family variables and calcium intake. De-
scriptive statistics (means and standard deviations) were
used to examine daily intake of calcium from all food
sources, dairy foods, and milk by race/ethnic group. Anal-
ysis of variance was performed to characterize the sample
across race/ethnic groups for the quantitative variables
(age of child and calcium intakes) followed by Duncan’s
multiple range test for post hoc analysis. For the categor-
ical variables (eg, demographic and household factors) ?2
tests were used.
Separate multivariate regression models were used to
identify the factors that were associated with each of
three dependent variables (calcium intake from three
food groupings: all food sources, dairy foods, and milk).
Significance was set at P?0.05. Demographic variables
(age and sex of child; age, sex, and education level of
parent; household size and composition; race/ethnicity
and employment of parent and spouse/partner; participa-
tion in federally funded nutrition assistance programs;
likelihood of speaking English at home; and likelihood
that the respondent and/or close family members were
born outside the United States) were entered as explan-
atory variables, as were parent attitudes/preferences re-
garding parental intake of calcium-rich foods, parental
practices and perceptions regarding calcium-rich foods
intake of the child, parental calcium knowledge, and fam-
ily behavioral factors regarding eating away from home
and eating meals together as a family. A backward selec-
tion procedure was used to eliminate factors that were
not significantly associated with the dependent variables.
The models were adjusted for sampling design by retain-
ing state indicator variables in the models.
RESULTS
Most respondents were women (?90%), about half were
older than age 40 years, about two thirds were em-
378
March 2011 Volume 111 Number 3

Page 4

Table 1. Selected characteristics of Asian, Hispanic, and non-Hispanic white (NHW) parents of early adolescent children aged 10-13 years (not
adjusted)
Total
n?622 Characteristics of parents/household
Asian
n?110
Hispanic
n?227
NHW
n?285
P
value
4 ™™™™™™™™™™™™ mean?standard deviation ™™™™™™™™™™™™ 3
11.6?1.1 11.4?1.2x
4 ™™™™™™™™™™™™™™™™™™™™ n (%)b™™™™™™™™™™™™™™™™™™™ 3
Age of child (y)a
11.6?1.2xy
11.7?1.1y
0.032
Sex of childa
Boy
Girl
Age group of parent
18-40 y
41-51? y
Sex of parent
Male
Female
Education of parent
High school or less
Some college or technical school
4-y college or advanced degree
Employment status of parent
No formal employment
Part-time employment
Full-time employment
Employment status of spouse
No employment
At least part-time employment
Participation in federally funded nutrition programsc
Single parent household
Number of children <18 y in the home
1 child
2 children
3 children or more
Parent/family members born outside the United States
Respondent
One parent of respondent
One grandparent of respondent
No parent, grandparent or respondent
Language spoken at home
No English
Another language more than English
Another language and English equally
English more than another language
English only
Years lived in United States
?10
?10
Race/ethnicity of spouse
Asian
Hispanic
NHW
Other
281 (45.2)
341 (54.8)
51 (46.4)
59 (53.6)
96 (42.3)
131 (57.7)
134 (47.0)
151 (53.0)
0.545
302 (48.8)
317 (51.2)
41 (37.3)
69 (62.7)
164 (72.9)
61 (27.1)
97 (34.2)
187 (65.9)
?0.001
63 (10.2)
553 (89.8)
14 (13.0)
94 (87.0)
12 (5.3)
213 (94.7)
37 (13.1)
246 (86.9)
0.010
184 (29.9)
196 (31.9)
235 (38.2)
13 (11.8)
32 (29.1)
65 (59.1)
134 (60.6)
65 (29.4)
22 (10.0)
37 (13.0)
99 (34.9)
148 (52.1)
?0.001
155 (25.5)
110 (18.1)
342 (56.3)
25 (22.9)
15 (13.8)
69 (63.3)
68 (31.3)
38 (17.5)
111 (51.2)
62 (22.1)
57 (20.3)
162 (57.7)
0.077
51 (9.9)
466 (90.1)
165 (26.6)
87 (14.2)
12 (12.6)
83 (87.4)
20 (18.2)
11 (10.1)
19 (10.2)
167 (89.8)
112 (49.8)
30 (13.5)
20 (8.5)
216 (91.5)
33 (11.6)
46 (16.3)
0.508
?0.001
0.002
124 (20.1)
261 (42.4)
231 (37.5)
33 (30.0)
47 (42.7)
30 (27.3)
27 (12.2)
83 (37.4)
112 (50.5)
64 (22.5)
131 (46.1)
89 (31.3)
?0.001
192 (31.6)
64 (10.5)
112 (18.4)
240 (39.5)
62 (56.9)
16 (14.7)
24 (22.0)
7 (6.4)
116 (54.2)
31 (14.5)
26 (12.2)
41 (19.2)
14 (4.9)
17 (6.0)
62 (21.8)
192 (67.4)
?0.001
65 (11.8)
53 (9.6)
74 (13.4)
62 (11.2)
298 (54.0)
12 (11.8)
15 (14.7)
13 (12.8)
20 (19.6)
42 (41.2)
53 (25.5)
38 (18.3)
58 (27.9)
31 (14.9)
28 (13.5)
0 (0.0)
0 (0.0)
3 (1.2)
11 (4.6)
228 (94.2)
?0.001
21 (3.8)
531 (96.2)
7 (6.9)
95 (93.1)
14 (6.7)
194 (93.3)
0 (0.0)
242 (100.0)
?0.001
84 (16.2)
179 (34.3)
236 (45.4)
21 (4.0)
75 (79.0)
2 (2.1)
15 (15.8)
3 (3.2)
1 (0.5)
166 (88.3)
13 (6.9)
8 (4.3)
8 (3.4)
11 (4.6)
208 (87.8)
10 (4.2)
?0.001
aCharacteristics of children of parent respondents, all other characteristics are for parent respondents.
bNumbers do not always add up to 100% due to rounding and missing data.
cFederally funded programs included Special Supplemental Nutrition Program for Women, Infants, and Children; Supplemental Nutrition Assistance Program; Supplemental Nutrition
Assistance Program; or free/reduced-price school meals.
xyValues with different superscripts (x, y) indicate significantly different means between race/ethnic groups.
NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation.
March 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION
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Table 2. Description of measures to assess parental attitudes/preferences and practices/perceptions regarding parent and early adolescent
intake of calcium-rich foods (CRF)
Individual variables (Cronbach ?)
Parent attitudes and preferences regarding parental intake of calcium-rich foods
questionnaire itemsab
Mean?SDc(n?622)
Culture/tradition (??.50)
Concern about cost (??.57)
Liking/taste (??.60)
I grew up eating/drinking ______ (cheese; yogurt; milk; pizza; dark-green leafy vegetables).
____ is/are expensive (cheese, yogurt, milk, pizza, dark-green leafy vegetables).
I like the taste of ______ (cheese, yogurt, milk, tofu). Dark-green leafy vegetables (like collard
greens, kale, and bok choy) taste good. I don’t know how to fix ______ (dark-green leafy
vegetables, tofu) so my family will like them (reverse-coded).
Yogurt upsets my stomach; milk makes me sick. I heat milk to make it easier to digest. I eat
cheese or yogurt because milk upsets my stomach.
_______is/are good for me (cheese, yogurt, milk, pizza, tofu, dark-green leafy vegetables); milk is
a good source of protein. ____ gives me calcium (cheese, milk). Pizza is healthy, if you have
healthy toppings.
________is fattening (cheese, milk, pizza). I think lower-fat dairy foods are better for weight
control than higher-fat dairy foods.
If I don’t get enough calcium, I could have weak bones as I get older; I am concerned that I am not
getting enough calcium; I am not getting enough calcium because I don’t eat dairy products.
_________is a quick and easy snack (cheese, yogurt). Pizza is a quick, easy meal for my family. It
is easy to combine cheese with other foods, in sandwiches, tacos, melted on vegetables, etc.
3.5?0.6
3.1?0.7
3.5?0.6
Dairy/milk intolerance (??.62)
1.9?0.7
Health benefits (??.60)
4.0?0.5
Concern about weight (??.60)
3.6?0.6
Concern about adequacy of intake
(??.73)
Ease of use/ convenience (??.67)
3.4?0.7
4.2?0.6
Family variables (Cronbach ?)
Parent practices/perceptions regarding early adolescent intake of calcium-rich foods
questionnaire itemsab
Mean?SD (n?622)
Making CRF available (??.71)How often do you keep these foods in your home for your child: cheese; yogurt; cereal and milk;
macaroni and cheese; milk; chocolate milk; juice with added calcium. How often do you have
these beverages in your home (reverse coded): Regular soda pop; diet soda pop; fruit drinks like
Kool-Aiddor Sunny Delighte.
I think it is important to talk to my child about eating healthy; I tell my child that dairy foods are
good for him/her; My child is encouraged to eat healthy foods when he/she sees me eating
healthy foods; By making healthy foods available at home, I encourage my child to eat healthy. I
want my child to eat healthy now so he/she will have good eating habits when h/she is older.
How often do you allow your child to drink these beverages in your home: (reverse coded)
Regular soda pop; diet soda pop; fruit drinks like Kool-Aiddor Sunny Delighte.
How often do you try to get your child to do the following: drink milk with _______ (breakfast;
snacks; lunch; dinner; when we go out); drink tea with ______ (meals; snacks) (reverse coded);
drink water with (meals; snacks) (reverse coded); drink less soda pop.
My child gets calcium _________ when served in school (in foods; from milk)
3.5?0.5
Encouragement (??.75)
4.4?0.5
Beverage expectations (??.79)
3.5?0.5
3.1?0.6
Access to CRF based on location
(??.73)
Importance of calcium sources
(??.65)
Family meal description (??.68)
How important is eating these foods in helping your child get the calcium he/she needs: (macaroni
and cheese; pizza; milk; yogurt; cheese; dark green leafy vegetables; tofu)
Our family schedules are too busy for us to eat together; our family eats meals together in front of
the TV; at dinner everyone in our family is going in different directions, grabbing and running to
eat on their own.
3.0?0.6
3.8?0.7
Other family variablesOther questionnaire itemsab
Mean?SD (n?622)
Parent calcium knowledge
ScoreCups of milk a 10- to 13-year-old child needs to drink each day to get the calcium he or she
needs; cups of broccoli to get same calcium as 1 cup milk; most 10- to 13-year-old
_______(boys; girls) are not getting enough calcium. Boys need more calcium than girls. If
people don’t get enough calcium in their diet, a vitamin and mineral pill can help. When you are
an adult, you don’t need calcium every day.4.0?1.6
Family behavioral
Factors
Eating food away from home/food
prepared away from home
Family meals
How often does your family usually eat a meal out, get fast food or take out, or have food
delivered?
In the past week, how many days did most of your family living in your house do the following: (Eat
breakfast [B] together; eat lunch [L] together; eat dinner [D] together)?
2.4?0.9
B: 2.8?1.3
L: 2.2?1.0
D: 4.2?1.0
aResponses for all variables were reported as 1?strongly disagree, 5?strongly agree and don’t know except for the following: Access to CRF based on location (1?strongly disagree,
4?strongly agree & don’t know); making CRF available, beverage expectations, and family meal description (1?never, 5?always); importance of calcium sources (1?not at all
important, 5?extremely important); parent knowledge score (1 point if correct, 0 if incorrect–7 total points); eating food away from home/food prepared away from home (1?once every
2 to 3 months, 5?5 or more times per week); and family meals (1?never, 5?every day).
bDon’t know responses were considered missing data.
cSD?standard deviation.
dKraft Foods, Northfield, IL.
eSunny Delight Beverages Co, Cincinnati, OH.
NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation.
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ployed full or part-time, and 38% had a college degree
(Table 1). Hispanic parents tended to be younger, less
educated, more likely to participate in food assistance
programs, and have more children in their homes com-
pared to Asian and non-Hispanic white parents. About
half of the Asian and Hispanic respondents indicated
they were born outside the United States; however,
most (93%) indicated they had lived in the United
States for more than 10 years. About 12% of Asian and
26% of Hispanic respondents reported not speaking
English at home.
Mean scores (Table 2) regarding perceived health ben-
efits and convenience of calcium-rich foods were high (?4
of 5). Mean scores also indicated that parents made
calcium-rich foods available (3.5), encouraged intake
(4.4), and set beverage expectations for children (3.5).
Mean dietary calcium intake from all food sources
among Asian and Hispanic parents was lower than non-
Hispanic white parents (702 and 857 vs 994 mg/day,
respectively) (P?0.001). The same pattern was observed
based on dairy and milk food groupings.
Multivariate regression analyses showed that the three
models explained between 20% and 32% of the variance
in calcium intake by parents from all three food group-
ings (Table 3). Parent education was positively associated
with calcium intake from all three food groupings in
separate models. Having an Asian spouse compared to a
non-Hispanic white spouse was negatively associated
with calcium intake from all food sources and dairy foods.
Being an Asian or Hispanic parent compared to a non-
Hispanic white parent was negatively associated with
calcium intake from milk. Calcium intake from all foods
was inversely associated with the likelihood that the par-
ent or close family member was born outside the United
States, while intake from dairy foods and from milk was
positively associated with the likelihood of speaking Eng-
lish in the home and with the number of adults in the
home, respectively.
Table 3. Multivariate linear regression models for total calcium intake from food, dairy foods, and milk among parents of early adolescent
children and parent/household characteristics, attitude/preferences, practices/perceptions, and behavioral factors
Total Dietary Calcium
(mg/d) (R2?0.264,
P<0.001)
?a?SEb
P valueVariables
Total Calcium from Dairy
Foods (mg/d)
(R2?0.323, P<0.001)
?a?SEb
Total Calcium from
Milk (mg/d) (R2?0.201,
P<0.001)
?a?SEb
P valueP value
Intercept
Characteristics
Parent education
Asian spouse (reference - NHWcspouse)
Likelihood of parent/family members born
outside United States
Likelihood of speaking English at home
Number adults in home
Asian (reference - NHW)
Hispanic (reference - NHW)
Parent attitude/preferences about CRFd
intake
Concern over adequacy of own calcium
intake
Health benefits
Perception of ease of use/convenience
Liking/taste
Perceived dairy/milk intolerance
Parenting practices/perceptions regarding
child intake of CRF
Perception of child’s access to CRF based on
location
Parent’s expectations for child’s intake of
beverages
Parental encouragement
Family behavioral factors
Frequency of eating food away from home or
food prepared away from home
?394?275 0.153
?803?241 0.001
?304?1730.079
176?64
?311?67
0.006
?0.0001
96?44
?156?58
0.032
0.008
93?39 0.017
?65?220.004
35?17 0.038
62?26
?136?42
?127?39
0.018
0.001
0.001
?150?34
215?65
159?57
?0.0001
0.001
0.006
?139?25
143?52
89?40
?0.0001
0.006
0.026
?50?210.021
79?27
?65?21
0.004
0.002
83?34 0.01478?34 0.003
92?38 0.016
73?310.019
91?430.034
a? represents differences in average calcium intakes (mg/d) among parents based on variables as labeled and adjusted for state of residence.
bSE?standard error.
cNHW?non-Hispanic white.
dCRF?calcium-rich foods.
NOTE: Information from this table is available online at www.adajournal.org as part of a PowerPoint presentation.
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Parental concern over the adequacy of their own intake
was negatively associated with intake of calcium from all
three food groupings (Table 3). Parents’ perception that
calcium-rich foods were convenient to use was positively
associated with intake of calcium from all food sources
and from dairy foods. The perception that calcium-rich
foods conveyed health benefits was positively associated
with intake of calcium from all foods and dairy foods.
Intake of calcium from milk was negatively associated
with concern about dairy or milk intolerance, and posi-
tively associated with liking the taste of calcium-rich
foods.
Of the parenting practices/perceptions regarding intake
of calcium-rich foods by children, only the perception that
children’s access to calcium-rich foods was based on location
(where calcium-rich foods were consumed) was positively
associated with intake of calcium from all foods and from
milk (Table 3). Parental encouragement of and expectations
for child’s intake of beverages were positively associated
with calcium intake from milk and dairy foods, respectively.
The frequency of eating food away from home or food pre-
pared away from home was positively associated with cal-
cium intake from all food sources.
DISCUSSION
It was expected that calcium intake of parents would be
strongly associated with helping their children obtain
adequate calcium or having positive perceptions regard-
ing benefits of calcium for children. However, individual
factors involving parents’ own calcium intake were more
important predictors. Similarly, Larson and colleagues
(30) showed that individual factors (eg, attitudes regard-
ing health and nutrition and taste preference for milk)
were positively associated with calcium intake among
young adults. In another study of postmenopausal
women, concern regarding one’s own health based on
learning results from a bone density screening test, pos-
itively influenced the decision to increase calcium intake
(31). In our study, low calcium intake among parents was
associated with concern about adequacy, indicating an
awareness that intake was less than adequate. Because
awareness of health risks may be an important precursor
for positive dietary change (12,31), parental education
should focus on increasing awareness regarding ade-
quacy of calcium intake and related health risks.
Previous studies have shown that adults with greater
educational attainment were more likely to have health-
ier diets compared to less educated adults (32,33), similar
to findings in our study where parent education level was
positively associated with calcium intake. These results
may be mediated by concern about food costs given that
education is associated with income (34). In support of
this concept, Turell and Kavanagh (35) showed that the
likelihood of purchasing healthy foods was lower with
less educational attainment. The findings may also be
mediated by less dietary knowledge consistent with an-
other study where maternal education was a significant
predictor of mothers’ nutrition knowledge and health-
attitude scores (36).
Cultural considerations are important individual/de-
mographic variables associated with food intake. In our
study, lower intake of calcium from dairy foods was as-
sociated with having an Asian spouse compared to a
non-Hispanic white spouse. Similarly data from a cross-
sectional survey of women of Chinese ethnicity living in
the United States showed that most husbands/male part-
ners preferred a traditional Chinese diet (90%) and in
some households (19%) they exerted a strong influence on
dietary intake of the whole family (37). In addition, cal-
cium intake from milk was negatively associated with
being an Asian or Hispanic parent compared to reference
non-Hispanic white parents or with higher dairy/milk
intolerance scores. This finding was consistent with re-
ports indicating a high incidence of dairy/milk intoler-
ance in Asian and Hispanic groups (4). Although the
dietary tools used in this study were validated with Asian
populations (28), an ongoing effort is needed to capture
calcium-rich foods consumed by the diverse Asian popu-
lation found in the United States.
Making calcium-rich foods available for children in our
study was not associated with parental calcium intake,
indicating that parents may not have consumed these
foods themselves. It is possible that they perceived them
to be child-oriented (eg, string cheese, portable yogurt, or
chocolate milk), did not tolerate these foods, or believed
the foods provided too much energy (14,15). Parents gen-
erally agreed that they were concerned that calcium-rich
foods were “fattening,” which has also been noted with
other adults (14).
Although the calcium-specific FFQ was intended for
use by early adolescent children, it has also performed
well when used with adult women (29) and the FFQ
allowed for relative comparison across race/ethnic groups
based on the calcium values of the foods within the ques-
tionnaire. The foods on the FFQ represented commonly
consumed foods by adolescents and the possibility exists
that the FFQ may have lacked some primary calcium food
sources uniquely common among adults, such as sour
cream. Considering the wide variety of ethnic foods on the
FFQ, there is no reason to believe there would be a
differential bias between the race/ethnic groups with re-
gard to this matter.
A limitation of this study is that although the sample
was diverse, it was a nonrandom convenience sample and
therefore generalizability to other parental groups is lim-
ited. Whereas all participants indicated they met the
inclusion criteria of being able to read/speak English, a
proportion of Asian (12%) and Hispanic parents (26%)
reported not speaking English at home, even though
about 93% reported living in the United States for ?10
years. A 2007 Pew Hispanic Center report indicated that
length of residence in the United States was related to
the ability of Hispanic immigrants to speak English well
(38) and that although a majority of foreign-born Hispan-
ics (52%) indicated they speak only Spanish at home, only
28% said they speak only Spanish on the job. This may
indicate that parents in our study reported not speaking
English at home because of preference rather than abil-
ity. However, results from our study must be interpreted
based on the possibility that some proportion of Asian
and Hispanic parents had difficulty reading and under-
standing the questionnaire.
African-American parents were not included in the
sample, which also limits generalizability to a broad
range of parents. Because research resources were lim-
ited among investigators, a decision was made to address
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needs of those at highest risk of developing osteoporosis.
Several recent studies have shown that hip fracture risk
is higher and bone mineral density is lower in Asian,
Hispanic, and non-Hispanic white adults and adolescents
compared to African Americans (39,40). Bachrach and
colleagues (10) also showed that Asian, Hispanic, and
non-Hispanic white youth had significantly lower bone
density than African American youth at all skeletal sites.
Additional research is needed to examine relationships
between individual and family variables and parent cal-
cium intake in other race/ethnic groups.
CONCLUSIONS
The findings of this study indicate that interventions to
improve calcium intake and prevent osteoporosis for par-
ents should focus on individual factors such as concern
about health, dietary adequacy, and benefits from eating
calcium rich foods to motivate parents to improve their
own calcium intake. Relying on the belief that parents’
intake of calcium-rich foods would be higher due to prac-
tices to promote their children’s intakes may not be an
effective means to address parental calcium intake. Be-
cause intake of calcium from dairy foods and milk was
dependent on race/ethnicity of parent or spouse, it may be
important for dietetics practitioners to tailor education
based on whether some population groups tolerate dairy
products and whether they drink milk. Parent education,
which may be associated with employment and income,
was an important predictor of calcium intake from food
sources; therefore, strategies to promote calcium intake
should address economical food choices. Additional re-
search is needed to better understand unexpected find-
ings, including the lack of a relationship between paren-
tal calcium intake and making calcium-rich foods
available for children, and the positive relationship be-
tween parental calcium intake and frequency of meals
eaten away from home.
STATEMENT OF POTENTIAL CONFLICT OF INTEREST:
No potential conflict of interest was reported by the au-
thors.
FUNDING/SUPPORT:This
through money appropriated by Congress through the
Hatch Act to the Agricultural Experiment Stations of
land grant universities for multistate research projects.
projectwas funded
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