In reviewing the evidence base, we used recent systematic reviews that have addressed this topic area.^2–5 The review by Ventura and Birch, comprising 66 articles on associations between parental influences and child eating variables, showed that there is substantial evidence that parenting practices are important.⁴ Reviews by Van der Horst et al and Ferreira et al further show that home and family environments are important correlates of nutrition and physical activity behaviors among children and adoloscents.^3,5 However, all three reviews conclude that most of the available evidence is based on cross-sectional studies.

The physical home environment determines what is available in terms of food and opportunities for physical activity, the socio-cultural environment determines what is acceptable, and the economic environment what is affordable. Since the home and family micro-political environment cannot really be distinguished from the socio-cultural family environment, we focus here on the physical, socio-cultural and economic environments.

The home is where children spend much of their time, especially at a young age, and it is the place where children and adolescents eat the majority of their meals. The home environment strongly defines what foods and physical activity opportunities are available, especially for younger children.

Food availability

Home availability and accessibility of foods have been found to be associated with consumption among children and adolescents in different studies, especially as related to fruit and vegetable consumption.³ However, in studies where such associations were adjusted for other potential behavioral determinants such as motivational, ability-related and socio-cultural environmental factors, the association between availability and consumption are reduced, sometimes to insignificance.^6,7

Haerens et al investigated home environmental correlates of fat, soft drink and fruit consumption among adolescents.⁸ In line with findings from other studies,⁹ they found that boys with more unhealthy products available at home consumed more fat and more soft drinks. Girls who reported higher availability of healthy products at home ate more fruit.

Physical activity and sedentary behavior

Regarding sedentary behavior, a review by Govely and others² indicated that having a TV present in the bedroom was one of the most consistent correlates of TV viewing time among children and adolescents. Haerens et al investigated home and school environmental correlates of physical activity in adolescents.⁸ The environmental factors accounted for a significant, but modest 5% of the total 38% explained variance in boys and only 1% of 23% in girls. The availability of sports equipment at home was significantly associated with physical activity among boys only. De Bruijn¹⁰ examined the role of physical environmental factors and individual cognitive determinants in predicting physical activity in adolescents. Availability of local facilities were positively related to physical activity. Modeling these factors with the cognitive motivational factors derived from the theory of planned behavior, revealed that the environmental attributes were fully mediated by perceived behavioral control. In contrast, intention did not play a mediating role in the prediction of future physical activity.

We need to keep in mind that many physical activities and sedentary behaviors among children, such as playing outside after school, watching TV or playing on the computer, are typically routine. They are performed repeatedly, and to a certain extent automatically, in response to (physical) environmental cues. Imagine the child coming home from school, grabbing a snack, walking directly to the PC, turning it on and immediately starting to play a computer game or to chat with friends. The concept of habit may thus be important in trying to understand environmental influences on these behaviors, in addition to measures of availability and accessibility. A study in 2008¹¹ provided limited but intriguing early evidence to support the concept of habit as being important in dealing with physical activity and sedentary behavior in children and adolescents. The study showed a high level of habitual engagement in a child’s physical activity and sedentary behavior. Additionally, intentions proved to be strongly related to behavior in children with weak habits, but unrelated to behavior in those with strong habits.

The social-cultural environment

The aforementioned review studies clearly indicated that social-cultural environmental factors may be the strongest environmental determinants of children’s eating and physical activity behaviors, and family social-cultural factors are of key importance.

Food and eating

Eating is a social behavior, especially for children,¹² and observing the eating behaviors of others, especially parents, influences their own preferences and behavior. Such modeling of eating behaviors can even result in establishing preferences for foods or substances that are inherently disliked. A recent review of the literature on environmental correlates of nutrition behaviors in young people indicates that children’s and adolescents’ nutrition behaviors are consistently associated with those of their parents,¹³ and a second review also concluded that there was substantial evidence, also from experimental studies, that modeling has a significant influence on children’s eating behaviors.⁴ Parents further influence their offspring by actively encouraging, discouraging or controlling certain behaviors. Restricting children’s access to, for example high-fat or sugar-rich, foods may encourage rather than discourage preferences for such foods, especially if these same foods are also used to reward children for good behavior and for celebrations.¹²

However, a study conducted in Belgium indicated that clear restrictive family rules about high-fat foods during childhood were associated with healthier food choices in adolescence,¹⁴ and a recent cross-European study showed that parental demand as well as opportunities to eat fruit and vegetables were associated with higher intake levels in 11-year-old children, while “parental allowance” (i.e., parents allowing children to eat as much as they like), was not.^6,7 Haerens et al⁸ also found greater fruit intake in adolescent girls if parents set clear food rules at home. Two recent Dutch studies among adolescents showed that more restrictive parenting practices were associated with lower consumption of sugar-sweetened beverages.^3,15

The evidence from studies on the association between general parenting styles and children’s health behaviors is inconclusive.⁴ Some evidence suggests that authoritative parenting, that is, a parenting style characterized by high parental involvement as well as strictness, is associated with more positive health behaviors including higher fruit and vegetable intakes,^16,17 compared to adolescents who reported authoritarian (high strictness, low involvement) or neglectful (low strictness, low involvement) parenting styles. However, results of the Pro Children Study, investigating the relationship between general parenting styles and fruit and vegetable intake in 11-year-olds in four countries (Spain, Portugal, Belgium and the Netherlands) showed no differences in fruit and vegetable intake across parenting styles and only very few significances in social-environmental correlates.¹⁸

The study by Vereecken et al explored the impact of general parenting style and specific food-related parenting practices on children’s dietary habits.¹⁹ They found that general parenting style had no significant impact on dietary habits. In contrast, the food-related parenting encouragement through negotiation showed a significant positive impact, while pressure, catering on demand and permissiveness were practices with an unhealthy impact on the children’s dietary habits.¹⁹

As a result of these parenting practices and rules, as well as parents’ own food preferences and choices, parents influence what foods are available and accessible within the home environment. Availability and accessibility of foods have repeatedly been found to be associated with intake levels in children and adolescents.^4,20

As mentioned, taste preference is perhaps the strongest determinant of food choice. Some specific types of taste-preference learning strategies have been identified, and parents and the home environment are important for the implementation of such strategies. The example of learning to like high-energy foods is referred to as “taste-nutrient learning”. Taste-nutrient learning is an example of operant or instrumental conditioning: a stimulus (eating energy-dense, sweet and fatty food) is positively reinforced (“rewarded”) by the pleasant feeling of satiety. In the last decades, palatable energy-dense foods have become readily available and accessible for most children in Western countries. This abundance combined with our innate preference for energy-dense foods may be an important cause for the present-day obesity epidemic. Research shows that high-fat and sugar-rich foods are, indeed, among the most preferred foods among children and adolescents.²¹ Most fruits and especially vegetables have low-energy densities, and many vegetables have a somewhat bitter taste. Preferences for these foods are, therefore, not so easily learned.

Two other food preference-learning strategies are examples of classical conditioning and are referred to as “taste-taste learning” and “taste-environment learning”. If a new, unfamiliar, taste is combined with a taste for which a preference already exists, children will more easily learn to like the new taste. For example, children will more easily learn to like the somewhat bitter taste of tea or the sour taste of yoghurt or grapefruit, if these are first served with sugar. Such taste-taste learning already occurs in very early childhood. Children who are breastfed are introduced to a broader range of tastes than children who are formula-fed, since the taste of breast milk varies, depending on the diet of the mother. Breastfed children are likely to learn to like a wider range of tastes early in life.²²

Similarly, a liking for tastes that people are exposed to in pleasant physical or social environments are also learned. Foods first encountered as a child in a friendly, pleasant family environment, may become favorite foods for a lifetime. This strategy may indeed be used to teach children to learn to like “new” foods.

A fourth important learning strategy is observational learning or modeling: children learn to like the taste of foods that they see their parents, siblings, friends or other “important others” eat. As mentioned, recent reviews of the literature show that parental modeling is consistently associated with more healthful nutrition behaviors in young people.^23,24

Physical activity and sedentary behaviors

Similar findings apply to physical activity and sedentary behaviors. A review by Gorely² showed that parents TV viewing was a consistent correlate of TV viewing among children and adolescents. Likewise, a recent review by Ferreira and colleagues (2007) showed that parental physical activity and social support from parents were among the most consistent environmental correlates of physical activity in children.⁵ A study on the effect of general parenting styles on physical activity and sedentary behaviors conducted in four European countries found some evidence that higher levels of strictness were associated with lower levels of TV viewing during mealtimes and higher levels of physical exercise.²⁵ However, associations were not present in all countries, suggesting that the impact of parenting styles may be dependent on cultural context. Other studies that specifically looked at TV viewing and parenting, indicate that the “social co-viewing style” in which TV programs are watched together resulted in the highest levels of TV viewing among the children.²⁶

Permissive or disengaged parents, particularly, may put their children in front of the television set with food or drinks to distract them, while the parents do other household chores and have minimal interaction with their child. As a result, children may learn to associate television viewing with energy intake from a very early age.²⁷ Such conditioned relationships between behaviors would imply that television viewing may become an automatic cue for energy intake and that social environmental factors regarding screen-viewing may also influence energy intake. Indeed, in a recent study (2007), Kremers and colleagues, for example, showed that adolescent screen-viewing behavior is associated with consumption of sugar-sweetened beverages.²⁸ Furthermore, their study indicated that parental norms with regard to screen-viewing was also associated with adolescent sugar-sweetened beverage consumption. By restricting television and computer use, parents appeared to influence their children’s consumption. Such “clustering” of behaviors and their social-environmental correlates underlines the importance of an “energy balance-approach” in the study of determinants of weight gain.²⁹

The socio-economic environment

The home or family socio-economic position is also of crucial importance. Recent reviews of the literature further confirmed that different indicators of family socio-economic position, including parental education, income and job status, are all associated with less healthy diets and a lower likelihood of sufficient physical activity in children and adolescents.^3,30

But why is this the case? Is it because people from lower socio-economic positions have less to spend and cannot afford healthier foods and more active lifestyles? Recent research conducted in Australia indicates that perceived differences in price between more and less healthy foods, rather than actual price differences was associated with disparities in healthy eating between lower and higher socio-economic status group.³¹ Other studies indicate that healthier eating is not, by definition, more expensive eating. However, Drewnowski and others have argued that foods primarily based on cheap (or more accurately, highly subsidized) high-energy ingredients like palm oil and corn syrup, do provide the best value for money in terms of calories, and that eating such obesogenic foods does make rational sense for people with less money to spend.³² Drewnowski and others have also published empirical research showing that people choosing diets higher in fats and sugar paid less for food than people choosing healthier diets.³²

Evidence that knowledge would make a difference

Another possible reason for disparities in healthy eating and physical activity is lack of knowledge. Are the differences there because parents with lower education do not know what is good for their children?

Skills and abilities are, to some extent, dependent on practical knowledge. For example, knowledge of recommended intake levels and healthy alternatives for unhealthy choices help to enable voluntary dietary change. In order to make conscious dietary changes for, for example, better bodyweight maintenance, knowledge is necessary about which dietary changes will be most effective. Some knowledge about which foods are high in calories is helpful to be able to avoid high-calorie foods and for self-monitoring of caloric intake. Knowing why to eat healthily, knowing what healthy foods are, and being aware of the recommended intake levels are important. But knowledge in itself is unlikely to result in healthy food and nutrition choices, and associations between nutrition knowledge and dietary behavior have been found to be weak.³³

It is also possible that parents from lower socio-economic status groups have different parenting styles or parenting practices, which results in less healthy behaviors in their offspring. Vereecken et al (2004) explored whether differences in children’s food consumption by mothers’ educational level could be explained by mother’s consumption and other eating-related parenting practices.¹⁹ They revealed that SES differences in children’s fruit and vegetable consumption were completely mediated by differences in the mothers’ food consumption and parenting practices. This was, however, not the case for SES differences in soft-drink consumption. In addition, a recent Australian study showed that adolescents living in lower SES households reported greater availability of unhealthy foods at home and were more likely to be allowed to watch TV during mealtimes, while adolescents from higher SES households reported greater availability and accessibility of fruits.³⁴

Neighborhood SES and healthy foods and PA

It may also be that families from lower socio-economic positions live in neighborhoods where healthy foods and physical activity opportunities are less available.

While neighborhood inequalities in food availability have been reported, the evidence on the directions of effects is inconsistent. Some studies showed that there are fewer healthy choices available in stores in more deprived areas,^35–37 but other studies did not find such differences,^38,39 or found evidence that healthier options were better available in the more deprived neighborhoods.^40,41 It appears that the lower availability of healthy foods in the more deprived neighborhoods is especially apparent in US cities,⁴² but the majority of individuals in many Western countries—including those with less healthy diets—may have sufficient access to healthy foods.

Regarding physical activity, the review by Feirreira and others showed that neighborhood crime rates are associated with lower levels of physical activity among adolescents,⁵ but to date, very few studies have explored the relationship between the built environment and physical activity in youngsters. In contrast to the expectations and the studies in adults, Haerens et al found that participation in moderate to vigorous physical activity (MVPA) measured with accelerometers, was higher among students living further away from facilities that are attractive to adolescents.⁸ In line with the findings from Jago et al, no other environmental factors (environmental safety, environmental density, sedentary equipment) were found to be associated with participation in MVPA in adolescents.⁴³

The home and family environment is of key importance for behavioral nutrition and physical activity among children and adolescents. Evidence points out that the home and family physical (what is available), social-cultural (what is appropriate and acceptable), and economic (what is affordable) environments are associated with important nutrition, physical activity and sedentary behaviors that define energy balance.

It should be noticed, however, that the available evidence is mostly based on studies using rather weak research designs. Most studies on potential home and family environmental influences on eating and the physical activities of young people are cross-sectional, and such studies may tell us about associations, but provide no proof of causal relations. An association between, for example, parenting and children’s eating habits may indicate that parenting influences eating habits, but it may also mean that a child’s eating habits influences parenting practices. If children eat too much, too little, or the wrong things, parents are likely to adjust their parenting practices accordingly. Ventura and Birch presented a conceptual model in which they proposed that parenting, child eating and child weight status all influence each other bidirectionally.⁴

Nevertheless, the associations found in recent studies indicate that obesity prevention for children and adolescents should focus on promoting home and family environments that endorse healthy energy-balance-related behaviors. However, by far the most initiatives for obesity prevention among young people have used school-based approaches, and interventions aiming at home and family environments are scarcer and, thus, less well researched. Results from the process evaluation of the multi-component Pro Children intervention, including activities to get parents involved in the project, showed that a higher level of parental involvement was beneficial for the pupil’s fruit and vegetable intake as well as parental fruit and vegetable intake.^25,44 However, only a small proportion of the parents did actually participate in the parental activities.²⁵ Activities that the pupils and parents had to do together were most popular, such as going to the supermarket together, while very few parents did activities that they had to do on their own, such as parental meetings at school or visiting the Pro Children website. Therefore, more attention should be given towards finding strategies to get parents involved in school-based projects.

In summing up, this chapter has demonstrated the vast influence parent’s have on their children’s behavior, especially with regard to physical activity and food consumption. It is, therefore, essential for parents to model appropriate behavior in front of their children and encourage a physically active lifestyle rather then promoting sedentary behaviors, such as excessive television viewing and/or computer use. This should stem from the physical home environment (what foods they are providing?), the socio-cultural environment (what is considered acceptable foods?) and the economic environment (are the affordable foods appropriate?). On a wider scale, environmental factors, such as accessible and appropriate parks and footpaths should be available in all suburbs, regardless of the level of disadvantage. Future interventions may look towards dispelling the myth or belief that healthy foods are always more expensive, especially in lower SES areas.

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