Parent-child relationships in nutrient intake:

the Framingham Children’s Study13

Susan A Oliveria, R Curtis Ellison, Lynn L Moore, Matthew W Gil/man,
Ellen J Garrahie, and Martha R Singer

ABSTRACT Nutrient intake affects many ofthe identified During the first year ofthe Framingham Children’s Study we
risk factors for coronary heart disease (CHD). Although CHD collected detailed dietary data on parents and their 3-5-y-old
risk factors have been shown to aggregate within families, less children. The purpose of this paper is to assess familial aggre-
is known about the familial aggregation of nutrient intake. We gation of nutrient intake among these families.
analyzed diet records for an average of 9 d per subject on 87
mothers, 83 fathers, and 91 children aged 3-5 y. A statistically
Methods
significant but modest correlation (r < 0.50) was found between
parents’ and children’s intakes for most nutrients. The intake Sample
of nutrients was more strongly related between mothers and
children than between fathers and children, and there was a The current analysis uses data from the Framingham Chil-
stronger association with children’s values for parents consuming dren’s Study, a longitudinal study of factors related to the de-
more meals at home. The results ofthis study confirm that par- velopment ofdietary habits and physical-activity patterns during

ents’ eating habits have an impact on the nutrient intake of their childhood. The cohort was initially recruited after reviewing
preschool children; the study furnishes indirect support for di- records of second-generation participants in the Framingham
etary-intervention programs targeting families for the primary Heart Study, identifying a total of227 families with children or
prevention ofCHD. Am J C/in Nutr l992;56:593-8. grandchildren who were between the ages of 3 and 5 y during
1987 and who were residing within 64 km ofFramingham, MA.
Letters were sent to all 227 families with eligible children, asking
KEY WORDS Diet, nutrient intake, familial aggregation, them, if interested in participating in a longitudinal study, to
pediatrics attend one ofseveral informational meetings. Ofthe 127 couples
who attended a meeting describing the study, 106 agreed to par-

Introduction ticipate. Only one child from each family was eligible to partic-
ipate in the study; thus the study includes 106 children and their
mothers and fathers. All are white and generally considered
In recent years there has been increased interest in the cx-
middle class.
amination of the development of cardiovascular risk factors in
The research plan was approved and reviewed by the Insti-
children (1). Many investigators believe that cardiovascular-risk
tutional Review Boards of the University of Massachusetts
behaviors, such as dietary habits, are established early in child-
Medical Center and the Boston University School of Medicine.
hood and persist to adulthood (2-1 1). Lauer and Clarke (12),
For each phase ofthe study, parents signed an informed-consent
however, question the degree to which risk-factor tracking occurs
form and verbal assent was given by the child.
and the utility of screening for these risk factors. It is well doc-
umented that risk factors for coronary heart disease (CHD), such
Data collection
as blood pressure, serum lipoproteins, and obesity, aggregate
within families (1 3-23). Because patterns ofdietary intake may All 106 families who agreed to participate in the study were
affect these CHD risk factors (24-26), it is ofinterest to determine asked to complete four sets of 3-d food diaries, both for the child
the degree to which the intake of certain nutrients aggregates and for each parent, during the first year of the study. These
within families.
The family has been identified as having an important influ-
I From the Evans Section ofPreventive Medicine and Epidemiology,
ence on dietary behaviors (26, 27); research on the familial ag-
Boston University School of Medicine, Boston.
gregation of nutrient intake is sparse. Studies have found sig- 2 Supported by grant HL 35653 from the National Heart, Lung, and
nificant correlations between spouses in the intake of fats and
Blood Institute.
carbohydrates, but the association for intakes ofproteins, energy,
3 Address reprint requests to RC Ellison, Evans Section of Preventive
and types of foods is less clear (28, 29). For the few studies that Medicine and Epidemiology, Boston University School of Medicine, B-
have been conducted examining familial aggregation of nutrient 612, 88 East Newton Street, Boston, MA 021 18.
intake between parents and their children, similarities in nutrient Received November 19, 1991.
intake have been observed (30, 31-34). Accepted for publication April 4, 1992.

Am J C/in Nuir 1992:56:593-8. Printed in USA. © 1992 American Society for Clinical Nutrition 593

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 594 OLIVERIA ET AL

diaries were collected at 3-mo intervals to gather information or biases and, through feedback and discussion with the original
on seasonal variations in nutrient intake. The days of the week nutritionist, to help ensure accurate analysis of records.
for completing the initial set of food diaries were assigned at We collected at least one 3-d food diary for 97 children (60
random; each subsequent set of 3 d began on the day of the males, 37 females), 93 mothers, and 88 fathers. Data for all 12
week after the last day of the previous set, so information on all d were gathered on 53 children, 45 mothers, and 42 fathers. The
days of the week was collected from each participant. For each average number of days of collection was 9.6 for children, 9.3
set, children and parents were assigned the same days of the for mothers, and 9.0 for fathers. Random within-person van-
week, 1 wk apart. Written and verbal instructions were given ability renders nutrient information based on only a few days
by the study nutritionist to the primary food preparer of the of diet records relatively inaccurate. Therefore, we eliminated
household, in most instances the mother. Because of the chil- those subjects who completed only one set of 3-d food diaries,
dren’s young age, most food diaries were completed by the leaving data from 9 1 children, 83 fathers, and 87 mothers for
mother, with help from the child. For children in day care or analysis. The children averaged 4.0 y ofage and had body mass
kindergarten, adult personnel at these sites recorded foods con- indexes (BMIs) ranging from 1 1 .5 to 19.9, with a median of
sumed there. The food diary was reviewed for completeness and 16.2; there were 55 males and 36 females. The mothers averaged
follow-up telephone interviews were conducted to obtain missing 32.4 y of age and had BMIs ranging from 18.0 to 35.6 with a
or inadequate information on brand names, recipes, and portion median of 24.0. The fathers averaged 33.7 y of age and had
sizes (35). Food diaries were analyzed by using the Food Finder BMIs ranging from 20.5 to 37.2, with a median of 27.6.
program ofthe Center for Clinical Computing, Boston (36); this
Analysis
nutrient-analysis program furnishes information on the mac-
ronutrients, types of fat, and specific micronutrients (sodium, Mean intakes were calculated for each nutrient of interest for
potassium, and calcium) that relate to cardiovascular health. mother, father, and child, and then separately for sons and
For quality control, a 5% random sample of diaries was reana- daughters. In addition to the major macronutrients, we compared
lyzed by a second trained nutritionist to search for any errors other nutrients that have been suggested as contributing to the

TABLE 1
Nutrient intakes of fathers, mothers, and children5

Father Mother Son Daughter All children

(n = 83) (n = 87) (n = 55) (n = 36) (n = 91)

Energy(kJ) 9752±2281 7043± 1793 6707±945 6136± 1226 6481 ± 1096

Protein
(g) 94.4 ± 20.9 69.6 ± 13.7 56.8 ± 10.9 49.1 ± 9.5 53.7 ± 11.0
(% energy) 16.6 ± 3.0 17.1 ± 3.2 14.2 ± 1.7 13.6 ± 1.9 14.0 ± 1.8
Carbohydrates
(g) 251 ± 73.5 190 ± 58.3 215 ± 31.8 202 ± 49.0 210 ± 39.8
(% energy) 43.2 ± 7.8 45.0 ± 6.0 54. 1 ± 5.0 55.2 ± 5.8 54.6 ± 5.3
Total fat
(g) 95.8 ± 29.5 69.8 ± 21.9 59.1 ± 12.6 53.5 ± 13.9 56.9 ± 13.3
(% energy) 37.0 ± 5.9 37.2 ± 4.2 33.2 ± 3.9 32.9 ± 5.0 33. 1 ± 4.4
Saturated fatty acid
(g) 34_S ± 13.6 25.0 ± 8.6 22.5 ± 6.1 19.8 ± 6.2 21.4 ± 6.3
(% energy) 13.2 ± 3.1 13.3 ± 2.2 12.6 ± 2.4 12.2 ± 2.5 12.4 ± 2.4
Monounsaturated fatty acid
(g) 34.8± 11.0 24.5±7.8 21.0±4.3 18.9±4.9 20.2 ±4.7
(%energy) 13.4±2.4 13.0± 1.6 11.8± 1.4 11.7± 1.9 11.7± 1.6
Polyunsaturated fatty acid
(g) 17.1 ± 5.2 13.2 ± 5.0 9.2 ± 2.3 8.9 ± 3.0 9.1 ± 2.6
(% energy) 6.7 ± 1.7 7.0 ± 1.7 5.2 ± 1.0 5.5 ± 1.4 5.3 ± 1.2
Cholesterol
(mg) 357 ± 142 253 ± 71.8 203 ± 67.8 177 ± 59.5 193 ± 65.6
(mg/I) 36.6 ± 14.6 35.9 ± 10.2 30.3 ± 10.1 28.8 ± 9.7 29.7 ± 10.1
Sodium
(mg) 3295 ± 1053 2517 ± 803 2098 ± 396 1898 ± 460 2017 ± 432
(mg/I) 338± 108 357± 114 313±59.1 309±75.1 311 ± 66.7
Potassium
(mg) 2929 ± 659 2356 ± 601 2161 ± 390 2009 ± 527 2102 ± 452
(mg/I) 300 ± 67.7 334 ± 85.1 322 ± 57.9 327 ± 85.9 324 ± 69.7
Calcium
(mg) 891 ± 329 749 ± 279 846 ± 219 708 ± 177 792 ± 214
(mg/i) 91.4 ± 33.8 106 ± 39.6 126 ± 32.7 1 15 ± 28.9 122 ± 33.0

5 .: SD. Data are based on at least two completed 3-d food diaries (6 d) per subject.

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 PARENT-CHILD NUTRIENT RELATIONSHIPS 595

risk of cardiovascular disease; we included dietary cholesterol, TABLE 2

although its role in atherosclerosis is somewhat controversial Father-mother correlations for each nutrient5
(37, 38). Log transformations were performed on all nutrients
Nutrient r
to improve normality. To assess the association between nutrient
intake ofparent and child, simple Pearson correlation coefficients Energy O.39t
were computed for each nutrient, comparing the mother with Protein O.38t
her daughter or son and the father with his daughter or son. Carbohydrates O.44t
Each nutrient was then adjusted for total energy intake by the Total fat 0.39t
energy-adjusted method described by Willett (39). Partial cor- Saturated fatty acid O.S6t
Monounsaturated fatty acid 0.39t
relation coefficients were computed to compare the children’s
Polyunsaturated fatty acid O.38t
intake of each nutrient with that of their mothers and fathers,
Cholesterol 0.44t
controlling for total energy intake and age of each parent. The
Sodium 0.10
same analyses were done for both mothers and fathers related Potassium 0.07
separately to sons or daughters. Midparent values were created Calcium 0.34f
by averaging the father’s and mother’s intake for each nutrient;
partial correlation coefficients were then calculated between the S n = 83 spouse pairs. Except for total energy, Pearson correlations
midparent intake and the child’s intake for each nutrient of are adjusted for total energy intake.
interest. Correlations between fathers and mothers for each nu- Correlations are based on log-transformed data and on at least two
trient were also calculated. completed 3-d food diaries (6 d) per subject.

Information about the number of meals per week each parent t P 0.001.
ate at home was collected in a family interview. To examine the : P 0.01.
effect ofthe number ofmeals eaten at home on the parent-child
nutrient correlations, we calculated the correlation coefficients
separately for those whose parents ate fewer meals at home (less parent-child nutrient correlation coefficients tended to be higher
than the median) relative to those who ate more meals at home for almost all nutrients in those families in which the parent
(greater than the median). Because ofthe small number of sub- eats more meals at home, although the difference was statistically
jects, further stratification by sons and daughters was not done. significant only for cholesterol in the mother-child relation. Table
To estimate the likelihood that parents who eat high amounts 5 presents odds-ratio estimates that the child in the family will
offat, saturated fatty acids, or cholesterol will have children that have a high intake oftotal fat, saturated fatty acid, or cholesterol
eat high amounts ofthese nutrients, we used 3 X 2 contingency according to whether none, one, or both parents consume high
tables to calculate odds ratios (40) with 95% confidence intervals amounts of these nutrients. The table shows, for example, that
by using the test-based method of Miettinen (41). Both fat and children with both parents eating high amounts of saturated
saturated fatty acids were expressed as a percent oftotal energy. fatty acids were 5.5 times more likely to be eating a high amount
To classify parents and children as high or low with respect to ofsaturated fatty acids than children in families in which neither
total fat, saturated fatty acid, and cholesterol intake, values were parent was consuming a diet high in saturated fatty acids.
dichotomized at the median ofthe specific nutrient distribution
for parents and children.
Discussion
Results
This paper deals with the familial aggregation of nutrient in-
The mean (±SD) intake for each nutrient for each family take in a cohort oftypical, middle-class American families. The
member is presented in Table 1 . For fathers, total fat intake results provide additional insight into the extent of the parents’
ranged from 2 1% to 50% of energy and saturated fatty acids influence on children’s dietary behaviors, and suggest that dietary
ranged from 6% to 25% ofenergy; total cholesterol intake ranged behaviors related to CHD aggregate within families. In this study,
from 133 to 895 mg/d. Mothers’ total fat intake ranged from when both parents consumed a diet high in saturated fatty acids
29% to 49% of energy, saturated fatty acids ranged from 9% to or dietary cholesterol their children were much more likely to
23% of energy, and total cholesterol intake ranged from 1 1 1 to consume such a diet. Although saturated fatty acid is considered
449 mg/d. For children, total fat intake ranged from 22% to an important determinant of CHD, the importance of dietary
45% ofenergy, saturated fatty acid ranged from 6% to 17%, and cholesterol intake is less clear (37, 38). However, these results
total cholesterol intake ranged from 69 to 367 mg/d. Table 2 nevertheless demonstrate the tendency of a variety of nutrient-
shows that intakes ofall nutrients except sodium and potassium intake patterns to cluster within these families. The correlation
were moderately correlated between mothers and fathers, after coefficients obtained are modest, generally < 0.50, suggesting
adjustment for total energy intake and age. Parent-child con-c- that other environmental factors may also be important in in-
lations for nutrients are given in Table 3. In general, nutrient fluencing children’s nutrient intakes. Peers, siblings, and tele
intake was more highly correlated for mothers and their children vision programs have been identified as other influences on chil-
than for fathers and their children. Using midparent nutrient dren’s eating behaviors (42-44). We appreciate that the day-to-
intake values, we found a statistically significant (P < 0.05) cor- day within-person variability will attenuate these con-elation
relation between parent and child intake for all nutrients except coefficients. However, with 9 d offood records for each family
potassium. member, we have a large amount of nutrient data on each sub-
Stratification by the median number of meals that the father ject. This should result in less attenuation than that seen in other
or mother eats at home each week (Table 4) shows that the studies based on fewer assessments of dietary intake.

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 596 OLIVERIA ET AL

TABLE 3
Parent-child correlations for each nutrient5

Father Mother Midparent

Son Daughter Child Son Daughter Child Son Daughter Child

Nutrient (n= 50) (n = 33) (n= 83) (n= 54) (n= 33) (n= 87) (n = SO) (n = 33) (n= 83)

Energy 0.19 -0.03 0.16 0.03 0.22 0.17 0.16 0.10 0.20
Protein 0.25 0.25 0.34t 0.14 0.42t 0.29t 0.23 O.36f 0.37
Carbohydrates 0.25 0.03 0.18 0.28j 0.47t 0.37 0.3l 0.23 0.3lt
Total fat 0. 1S 0. 12 0. 15 OAOt 0.49t 0.46 0.25 0.36 0.32t
Saturated fatty
acid 0.40t 0.22 0.34t 0.43t 0.Slt 0.48 O.47 O.4l O.47
Monounsaturated
fatty acid 0.15 0.09 0.13 0.43 0.42t 0.43 0.26 0.30 0.29t
Polyunsaturated
fattyacid 0.06 0.18 0.10 0.3lt 0.3Sf 0.33t 0.19 O.4l O.27t
Cholesterol 0.45 0.10 0.34t 0A9 0.56 0.37 O.42t 0.30 0.4l
Sodium 0.16 0.21 0.18 0.27 0.44 0.30 0.27t 0.32 0.27t
Potassium 0.06 0.04 004 -0.05 0.43t 0.15 0.03 0.27 0.12
Calcium 0.15 0.33 0.21 0.22 0.30 0.29t 0.20 O.39j O.3Ot

S Except for total energy, Pearson correlations are adjusted for total energy intake and age of parent.
Correlations are based on log-transformed data and on at least two completed 3-d food diaries (6 d) per subject.
t P 0.01.
tP 0.05.
§P0.OOl.

We controlled for total energy intake to account for the dif- and age of the child, no adjustments were made for these co-
ferences in body size, physical activity, and metabolic efficiency variates.
among subjects. Adjustment for total energy intake and age of Because of the young children’s inability to complete their
the parent improved the nutrient correlations between the parent own diaries, it was necessary that the mother complete them.
and the child. Because this population is homogenous with re- As might be expected, the correlations for the mother and child
spect to race (all white), socioeconomic status (all middle class), were larger than for the father and child. These improved cor-
relations may be the result ofreporting bias (because the mothers
completed the child’s diaries) or truly reflect the environmental
influence of the mother on the child’s nutrient intake. Parent-
TABLE 4
child associations were higher for those parents who eat more
Parent-child correlations stratified by number of meals eaten at home
by parent5

Father-child Mother-child TABLE S

Effect of parents’ nutrient intake on child’s intake; odds-ratio
<l5meals l5meals <l8meals l8meals estimates of effect of parents’ nutrient intake on child’s nutrient intake
(n = 42) (n = 41) (n = 43) (n = 44)
All children
Energy 0.07 0.29 0. 1 1 0.35 (n = 83)
Protein 0.22 0.43 0.37 0.26
Carbohydrates 0.14 0.23 0.38 0.35 Parents’ total fat intake
Total fat 0.07 0.20 0.38 0.1
Both parents low intake (n = 29)t 1.0
Saturated fatty acid 0.20 0.43 0.30 0.56
One parent high intake (n = 27) 2.8 (1.3-6.1)
Monounsaturated
fatty acid 0.05 0. 19 0.40 0.46 Both parents high intake (n = 27) 2.8 (1.3-6.1)
Polyunsaturated Parents’ saturated fatty acid intake
fatty acid -0.01 0.27 0.29 0.38 Both parents low intake (n = 33)t 1.0
Cholesterol 0.20 0.43 0. 10 0.54t Oneparenthighintake(n = 21) 2.3 (1.1-5.0)
Sodium 0.24 0.13 0.25 0.33 Both parents high intake (n = 29) 5.5 (2.6-1 1.8)
Potassium -0.04 0.09 0.31 0.01 Parents’ cholesterol intake
Calcium 0.05 0.31 0.24 0.35 Both parents low intake (n = 28)t 1.0
One parent high intake (n = 27) 1.7 (0.77-3.7)
S Except for total energy, Pearson correlations are adjusted for total energy
Both parents high intake (n = 28) 6.3 (2.8-14.0)
intake and age of parent. Correlations are based on log-transformed data and on
at least two completed 3-d food diaries (6 d) per subject. Number of meals eaten
S To classify high vs low intakes, nutrients are dichotomized at the
at home per week are dichotomized at the median for the distribution. P values
are for differences between the correlations for parents eating at home less frequently median of the distribution for parents and children. 95% confidence
and those for parents eating at home more frequently. intervals in parentheses.
tP 0.05. t Referent category.

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 PARENT-CHILD NUTRIENT RELATIONSHIPS 597

meals at home, and the difference between mothers’ and fathers’ y olds than between parents and 1 1-y olds. Such observations
influence seems less among parents who eat more often at home. suggest that parent influence may have a stronger effect on eating
This argues against bias from mothers completing diaries as the behaviors of young children than of older children.
sole explanation for mother-father differences. We intend to fol- The highest correlation coefficients noted in this study were
low this cohort until the children reach adolescence; it will be for saturated fatty acids and cholesterol, nutrients generally con-
interesting to examine mother-child associations in the future sidered to relate to the development of cardiovascular disease.
when the children are able to complete their own food records. Even given that there is not perfect tracking of cardiovascular-
We appreciate that it is difficult to determine whether simi- risk factors from childhood to adulthood (12), most investigators
larities in nutrient intake indicate that the parent’s choices are have demonstrated that eating habits that influence dietary pat-
influencing those of the child, or whether the reverse occurs. terns in adulthood tend to be determined early in life (2-1 1).
Although it is true that parents may be influenced by the child, Thus, our results provide support for dietary-intervention pro-
parents are buying the majority of the food when the child is at grams focusing on young children. Although other sources of
this age, and to some extent control what the child has available influence such as peers, siblings, and television programs also
to eat. The issue of what influence the child has on the parent’s play important roles, nutrition interventions and health-pro-
buying patterns or nutrient intakes cannot be addressed with motion programs that target parents to modify the dietary be-
these analyses. haviors of their young children could help in efforts to prevent
We recognize that self-report of dietary intake through the cardiovascular disease later in life. B
use of food diaries has been shown to result in inaccuracies when
compared with careful observational methods. Among obese Appreciation is expressed to Walter Willett, Chairman ofthe Nutrition
Department, and Susan Hankmnson at the Harvard School of Public
subjects, underreporting tends to occur because of a subject’s
Health for guidance and suggestions in preparing this manuscript. We
desire to give the expected answer. However, it has been shown
also acknowledge the support oflaci Marmor and Mary Jo White in the
that food diaries tend to be reasonably accurate among popu-
collection of data for this study, and thank the Framingham Children’s
lations of nonobese individuals in industrialized countries (45). Study families for their continued participation.
The use of multiple diaries, and a compliant and literate pop-
ulation, tend to improve the accuracy when food diaries are
used to assess nutrient intake (39).
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