Abstract
Objective To conduct a systematic review of the effects of frequent family meals on psychosocial outcomes in children and adolescents, and to examine whether there are differences in outcomes between males and females.
Data sources Studies were identified through a search of MEDLINE (1948 to fifth week of June 2011) and PsycINFO (1806 to first week of July 2011) using the Ovid interface. The MeSH terms and key words used both alone and in combination were family, meal, food intake, nutrition, diets, body weight, adolescent attitudes, eating behaviour, feeding behaviour, and eating disorders. Bibliographies of papers deemed relevant were also reviewed.
Study selection The original search yielded 1783 articles. To be included in the analysis, studies had to meet the following criteria: have been published in a peer-reviewed journal in English; involve children or adolescents; discuss the role of family meals on the psychosocial outcomes (eg, substance use, disordered eating, depression) of children or adolescents; and have an adequate study design, including appropriate statistical methods for analyzing outcome data. Fourteen papers met inclusion criteria. Two independent reviewers studied and analyzed the papers.
Synthesis Overall, results show that frequent family meals are inversely associated with disordered eating, alcohol and substance use, violent behaviour, and feelings of depression or thoughts of suicide in adolescents. There is a positive relationship between frequent family meals and increased self-esteem and school success. Studies show substantial differences in outcomes for male and female children and adolescents, with females having more positive results.
Conclusion This systematic review provides further support that frequent family meals should be endorsed. All health care practitioners should educate families on the benefits of having regular meals together as a family.
Psychosocial dysfunction has become widely acknowledged as the most common chronic condition among children and adolescents.1,2 Given that adolescents’ psychosocial health problems have implications for adult morbidity, mortality,3 and development of other diseases,4,5 investigating methods that affect and alter the course of these issues merits attention. Adolescents’ healthy development is influenced by myriad family factors.6 Healthy family environments, including family connectedness (ie, feelings of love, warmth, and caring from parents) have been found to be protective against poor mental health or psychosocial outcomes, and the role of the family has long been studied as an important contribution to adolescent well-being.7–9 Interestingly, there is evidence that young males might respond differently than females do to family environments and dynamics.10–13
A simple, nonintrusive intervention that could easily be applied to increase healthy family environments is engaging in family meals. Family meals might serve as an arena for augmenting family cohesion,14–16 stability,17 and connectedness,8 or for enhancing adolescent developmental assets,18 such as problem-focused coping15 and social-emotional development.8 Moreover, family rituals and routines, like the family meal, might offer consistency and a venue for checking in with family members, and for learning and teaching healthy food behaviour and attitudes.19
Recent interest has been dedicated to investigating the importance of family meals and their positive effects on child and adolescent nutritional outcomes. Current research suggests that eating meals together as a family is beneficial to adolescents’ eating habits and that more frequent family meals have been found to lead to better dietary intake among children and adolescents.20–25 Several studies have also examined the relationship between family meals and children being overweight or obese with inconsistent results.26–29 One study reported that a higher frequency of family meals was associated with reduced odds of being overweight and of becoming overweight in the future,26 while other reports found that the frequency of family dinners was inversely associated with overweight status at baseline, but not with the likelihood of becoming overweight in the future.27,28
Researchers have also begun to study the role of family meals on markers of adolescent well-being, such as rates of substance use and disordered eating behaviour.19,30 These studies appear to vary in design and scope. A recent review by Skeer and Ballard looking at family meals and adolescent risk prevention showed a generally positive relationship between frequent family meals and decreased adolescent engagement in risk behaviour.31 The review also mentioned that adolescents’ sex had a substantial role in this relationship; sex seemed to influence the strength of family meals’ protective effects on risk behaviour, with female adolescents benefiting more than male adolescents did.
To our knowledge, no systematic review has been completed on the relationship between family meals and psychosocial outcomes in children and adolescents. As such, the purpose of this paper was to conduct a systematic review of the effects of family meals on psychosocial outcomes in children and adolescents, and to examine whether differences in outcomes between males and females have been studied. A study of this nature has the potential to increase knowledge of the importance of frequent family meals while providing evidence in support of an easy-to-implement prevention strategy or adjunctive treatment intervention.
DATA SOURCES
Studies were identified through a MEDLINE search (1948 to the fifth week of June 2011) and PsycINFO (1806 to first week of July 2011) using the Ovid interface. No date, language, age, or study design limits were imposed on the search. The bibliographies of papers deemed relevant were also reviewed for further relevant papers.
Study selection
To be included in the analysis, studies had to meet the following criteria: have been published in a peer-reviewed journal in English; involve children or adolescents; discuss the role of family meals on the psychosocial outcomes (eg, substance use, disordered eating, depression) of children or adolescents; and have an adequate study design that allowed for the relationship between family meals and psychosocial outcomes to be studied directly, including cross-sectional or longitudinal cohort studies and randomized control trials. Case studies, commentaries, and narrative reviews were excluded. Additionally, study design had to include appropriate statistical methods for analyzing outcome data. As the purpose of this review was to assess the effects of family meals on the psychosocial health outcomes of children and adolescents, studies were excluded if they only focused on the effect of family meals in the context of treatment, such as for eating disorders.
Two authors (M.H., H.W.) reviewed and compared the studies that met inclusion criteria for the following: study purpose, study sample and demographic characteristics, study design (longitudinal vs cross-sectional), and effect of family meals on outcomes measured (P ≤ .05 was used to determine significance). The studies were categorized according to the specified outcomes assessed, as well as differences between males and females.
SYNTHESIS
Figure 1 describes the articles that were identified, excluded, and included. Fourteen articles (7 longitudinal and 7 cross-sectional studies) met inclusion criteria (Table 1).15,16,18,19,30,32–40 These 14 articles were based on 9 different subject samples. Five of the papers (3 longitudinal, 2 cross-sectional) used data from Project EAT-I (Eating Among Teens) or EAT-II,19,36,38–40 and 2 longitudinal papers collected data from the Growing Up Today Study project.30,32 Other study data sources included the National Heart, Lung, and Blood Institute Growth and Health Study15 and the Controlling Overweight and Obesity for Life study.33 The remainder of the data were from individual studies. However, there is no duplication of data among these publications, as each article reviewed a different outcome or a specific group of the subject sample. Table 115,16,18,19,30,32–40 shows the data sources, data collection methodology, study response rates, and demographic information. Table 215,16,18,19,30,32–40 presents main findings of the studies reviewed.
Systematic review process: Articles that were identified, excluded, and included.
Design and characteristics of studies reviewed
Main findings of studies reviewed: A) Studies in which results differed between sexes; B) Studies in which sex was not specified.
Frequency of family meals
The reported family meal frequency rates in the reviewed studies varied from 32.9%16 to 60.6%.34 Reports of infrequent family meals (0 to 2 family meals per week) also varied, ranging from 11%35 to 33.1%.36 The varying results are likely influenced by many different factors (eg, age).24 Three longitudinal studies found that the frequency of family meals decreased as the adolescent progressed toward adulthood.32,34,35 Similarly, other factors such as geographic location and cultural issues have also been shown to affect results. For example, frequent family meals appear to be more common in Spain than in the United States or Britain, with 78% of youth in Spain reporting a high frequency of family meals37 versus only 45% of American youth18,38 and 32.9% of British youth.16 The only Canadian study reports a 70% prevalence of high family meal frequency35; however, it should be noted that the sample in this study is young (grades 6 to 8), which might be a contributing factor to this higher rate.
Disordered eating behaviour
Table 215,16,18,19,30,32–40 presents the main findings of the following discussion. Nine of the 14 studies reviewed explored the relationship between family meal frequency and disordered eating behaviour, including extreme weight-control behaviour (defined as ingestion of diet pills, self-induced vomiting, use of laxatives, or use of diuretics to control weight),15,18,19,32,33,38,39 less extreme weight-control behaviour (defined as fasting, eating very little food, using food substitutes, skipping meals, or smoking cigarettes to control weight),19,33,35,38 binge eating,15,18,19,32,37–39 and chronic dieting.19,32,35,38
In general, some studies report an inverse association between family meal frequency and extreme weight-control behaviour,15,19,32,38,39 less extreme weight-control behaviour,19,38 binge eating,15,32,38,39 and chronic dieting,19,32,38 with most studies maintaining statistically significant findings for females even after adjusting for factors such as family connectedness, sociodemographic characteristics, and personal and behavioural qualities.15,19,32,38,39
Conversely for males, most studies reported no significant association between frequent family meals and extreme weight-control behaviour,19,38,39 binge eating,19,38,39 or chronic dieting.19,38 Additionally, 1 longitudinal study indicated that frequent family meals were statistically significantly associated with a greater likelihood of less extreme weight-control behaviour, both before and after adjusting for a variety of variables.38
Studies that did not specify results by sex showed inconsistent results.18,33,35,37
Externalizing behaviour
Research has explored associations between family meal frequency and externalizing behaviour such as substance use and violence.
Substance use.
The substances examined in these studies included tobacco (cigarette smoking), marijuana, alcohol, and illicit drugs. For females, an inverse association between family meal frequency and use of cigarettes,15,34,36,40 alcohol,30,34,36,40 and marijuana34,36,40 was found, even after adjusting for demographic, familial, and parental characteristics, socioeconomic status, and earlier substance use variables.34,36,40
Study results were less consistent for males. Family meal frequency was negatively associated with cigarette, marijuana, and alcohol use in some studies34,36 but not in others.30,40 Table 215,16,18,19,30,32–40 shows results from studies that did not differentiate between sexes.16,18,33
Internalizing behaviour
Associations between family meal frequency and internalizing behaviour including body image, self-esteem, academic achievement, and depressive symptoms and suicidal thoughts are discussed here.
Body image concern.
Family meal frequency was inversely associated with both body dissatisfaction and drive for thinness15 and concern about high body weight.35 There were no studies that examined these variables in males.
Self-esteem or self-efficacy.
One study found a negative association between family meal frequency and low self-esteem in females but not in males.36 Another study (not sex specific) reported a positive association between frequent family meals and increased self-esteem, even after controlling for various familial factors,18 while a second study that was also not sex specific reported a positive association between frequent family meals and increased self-efficacy for healthy eating in various social environments.35
Academic achievement.
Frequent family meals were positively associated with a higher grade point average in both females and males in one study, and statistical significance was maintained in the female sample even after controlling for various demographic and familial factors. 36 Another study found a similar association between family meal frequency and commitment to learning, which also remained statistically significant after adjusting for family support and family communication.18
Depressive symptoms or thoughts of suicide.
One study reported a statistically significant negative association between family meal frequency and high depressive symptoms, as well as between family meal frequency and suicidal thoughts, in both females and males.36 This statistical significance was maintained even after adjusting for various demographic and familial factors. The only noted difference between the sexes was the existence of a statistically significant negative association between family meal frequency and suicide attempts in females that was not present in males. Two other non–sex-specific studies found a statistically significant inverse association between family meal frequency and depressive symptoms,18,33 with one study extending this association to include suicidal risk.18 Findings also remained statistically significant after controlling for similar factors.
DISCUSSION
The findings of this systematic review indicate that eating frequent family meals is associated with better psychosocial outcomes for children and adolescents. In general, frequent family meals were inversely associated with disordered eating, alcohol and substance use, violent behaviour, and feelings of depression or thoughts of suicide. There was a positive relationship between frequent family meals and increased self-esteem and commitment to learning or a higher grade point average. However, the findings also highlight the differences in outcomes for males and females, with females seemingly gaining more protective effects from frequent family meals than males do.
What do we know about the barriers that exist to having frequent family meals? Both parents’ and adolescents’ busy schedules41–45 are often cited as common reasons for less frequent family meals. In addition, there is a disparity of family meal frequency across socioeconomic levels. Neumark-Sztainer and colleagues found that lower socioeconomic status was associated with lower frequency of family meals,21 and Widome and colleagues found that food-insecure youth ate fewer family meals than food-secure youth.46 From 1999 to 2010, there was a decline in family meal frequency among adolescents from low socioeconomic status and an increase in frequency among adolescents from high-middle socioeconomic families.47
Despite our advances in some areas of understanding, it remains unclear exactly how family meals improve adolescent outcomes, especially for females. The relationship between family meals and psychosocial outcomes might in fact be bidirectional (ie, increased family meals lead to decreased odds of poor psychosocial outcomes but also that psychosocially healthier youth and families might simply engage in more family meals).
It is unclear why there are differences between the effects of family meals for males and females. Research has shown that males and females respond differently to family dynamics. For example, Crosnoe found that family instability magnified the socioemotional risks of obesity for girls but not for boys.11 Other researchers have also found that high-risk youths’ perception of their family connectedness being strong is associated with reduced odds of being sexually experienced and having initiated sex before the age of 13 for females but not for males.13 In addition, females respond differently to family economic problems than males do, and females are more sensitive to family disruptions (ie, parents’ negative moods) than males are.10 Griffin and colleagues found that some protective effects of parenting practices were limited to females and not males12; for example, frequent parent checking of homework was associated with less aggression in females but not males. If the mechanism of the positive effects of family meals is related to family connectedness and other similar family factors, it is therefore possible that males do not gain the same protective effect from frequent family meals because of their different response to family dynamics.31
Future studies should examine the specific mechanisms by which frequent family meals might lead to improved psychosocial outcomes in youth. Furthermore, research should continue to explore the barriers that exist to having frequent family meals, including socioeconomic implications.
Limitations
Limitations exist with all the individual studies reviewed. Regarding the results of the cross-sectional studies, we can infer associations but not causality. For example, those with concern about high body weight or those with already-established disordered eating or substance use or abuse, etc, might avoid family meals, and children and youth who are already doing well could be more likely to eat with their families. Many studies also relied on self-report survey data that have the potential of recall bias and social desirability bias. There might also be an unmeasured protective factor in families who dine together regularly that was not captured; there is the potential that other unmeasured confounders (eg, family structure) could explain the positive results. In addition, the overall generalizability of some of the samples is variable depending on the demographic variability of the samples. However, even with these limitations, together these studies produce patterns based on very large, often diverse, samples. The studies reviewed had sample sizes between 145 and 99 462, including different ethnicities, and many attempted to control results for potential confounders such as family connectedness. In addition, the longitudinal nature of some of the reviewed studies adds more powerful associations.
Conclusion
This review provides further support that frequent family meals are associated with better psychosocial outcomes for children and adolescents. Although more research is needed to prove causality, there are few risks to recommending that families strive to have frequent family meals. All health care practitioners should educate families on the potential effects of having regular meals together as a family. In addition, practitioners should explore any obstacles that might exist to having family meals and discuss potential strategies for their implementation.
Notes
EDITOR’S KEY POINTS
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This systematic review found that eating frequent family meals was associated with better psychosocial outcomes for children and adolescents. Frequent family meals were inversely associated with disordered eating, alcohol and substance use, violent behaviour, and feelings of depression or thoughts of suicide. There was a positive relationship between frequent family meals and increased self-esteem and commitment to learning or a higher grade point average.
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Findings also highlighted that females seemingly gained more protective effects from frequent family meals than males did.
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Given that psychosocial dysfunction is one of the most common chronic conditions among children and adolescents, health care practitioners should educate families on the benefits of having regular meals together. In addition, practitioners should explore any obstacles that might exist to having family meals and discuss potential strategies for their implementation.
Footnotes
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This article has been peer reviewed
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This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
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La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de février 2015 à la page e107.
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Contributors
Dr Harrison contributed to study design and acquisition of data, reviewed all articles included in the systematic review, interpreted data, and drafted the manuscript. Dr Norris contributed to study conception and design, and revised the manuscript. Dr Obeid participated in data analysis and interpretation, and contributed to drafting and revising the manuscript. Ms Fu contributed to data analysis, as well as drafting and revising the manuscript. Dr Weinstangel participated in data acquisition, reviewed articles included in the systematic review, contributed to data analysis, and helped with manuscript drafting. Dr Sampson participated in the study design and data acquisition, as well as drafting and revising the manuscript. All authors read and approved the final manuscript.
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Competing interests
None declared
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