Influences on School-Age Children's Milk and Soft Drink Intake
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INFLUENCES ON SCHOOL-AGE CHILDREN’S MILK AND SOFT DRINK INTAKE by ARAX BALIAN Submitted in Partial Fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Adviser: Dr Elizabeth Madigan Frances Payne Bolton School of Nursing CASE WESTERN RESERVE UNIVERSITY January, 2009 i CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of ________________________________________________________Arax Balian candidate for the _____Ph.D___________________________ ____ degree*. (signed) __________________________________Elizabeth Madigan _______________ (chair of the committee) __________________________________Donna A. Dowling _______________ ____________________________Susan Tullai-McGuinness_ ____________________ ____________________________________Hope Barkoukis _____________ _________________________________________________ _________________________________________________ (date) ___________November________________________ 14, 2008 *We also certify that written approval has been obtained for any proprietary material contained therein. ii Dedication This dissertation is dedicated to the memory of my father who would have been so proud of my accomplishments. It is also dedicated to my husband, Armand, who has provided me with his love and support and my children, Areen and Ayk, who have been the source of my inspiration. iii Table of Contents Page Table of Contents ---------------------------------------------------------------------------- iii List of Tables --------------------------------------------------------------------------------- vii List of Figures -------------------------------------------------------------------------------- viii Acknowledgements -------------------------------------------------------------------------- ix Abstract --------------------------------------------------------------------------------------- xi CHAPTER I: Introduction ------------------------------------------------------------------ 1 Introduction ----------------------------------------------------------------------------------- 1 Problem --------------------------------------------------------------------------------------- 2 Background and significance --------------------------------------------------------------- 3 Milk and soft drink intake among American children ------------------------- 3 Effects of milk and soft drink intake on children’s health -------------------- 6 Purpose ---------------------------------------------------------------------------------------- 9 Theoretical framework ---------------------------------------------------------------------- 9 Study concepts ---------------------------------------------------------------------- 15 Definition of terms ------------------------------------------------------------------ 18 Research questions --------------------------------------------------------------------------- 20 Significance of the study -------------------------------------------------------------------- 21 CHAPTER II: Review of the Literature -------------------------------------------------- 23 Overview of Childhood Overweight and Obesity --------------------------------------- 23 Dietary Recommendations and Guidelines for Children ---------------------- 28 iv Cognitive development ---------------------------------------------------------------------- 31 School-age children’s cognitive development ---------------------------------- 31 Cognitive development, health beliefs, and food choice ---------------------- 34 Factors influencing school-age children’s milk and soft drink intake ---------------- 36 School-age children’s milk and soft drink intake ------------------------------- 36 Influencing factors investigated in this study ----------------------------------- 46 Other influences --------------------------------------------------------------------- 63 Summary for literature review ------------------------------------------------------------- 66 CHAPTER III: Methods -------------------------------------------------------------------- 68 Design ----------------------------------------------------------------------------------------- 68 Setting ----------------------------------------------------------------------------------------- 68 Sample ----------------------------------------------------------------------------------------- 69 Sample size determination ------------------------------------------------------------------ 70 Sampling procedure --------------------------------------------------------------------------- 72 Measurement --------------------------------------------------------------------------------- 72 Questionnaires ----------------------------------------------------------------------- 73 Outcome variables ------------------------------------------------------------------ 78 Influencing factors ------------------------------------------------------------------ 78 Covariates --------------------------------------------------------------------------- 82 Procedure ------------------------------------------------------------------------------------- 84 Pilot study ---------------------------------------------------------------------------- 84 Main study --------------------------------------------------------------------------- 85 Data analysis ---------------------------------------------------------------------------------- 86 v Description --------------------------------------------------------------------------- 86 Preliminary analysis ---------------------------------------------------------------- 86 Analysis of research questions ------------------------------------------------------ 87 Protection of human subjects --------------------------------------------------------------- 90 CHAPTER IV: Results ---------------------------------------------------------------------- 92 Description ------------------------------------------------------------------------------------ 93 Demographic characteristics ------------------------------------------------------ 93 Description of eating behaviors and patterns of milk and soft drink intake --------------------------------------------------------------------------------- 94 Description of study variables ----------------------------------------------------- 99 Preliminary analysis ------------------------------------------------------------------------- 100 Analysis of research questions --------------------------------------------------------------- 102 The Theory of Planned Behavior constructs -------------------------------------- 102 Gender, ethnicity, and BMI differences ----------------------------------------- 110 Summary -------------------------------------------------------------------------------------- 120 CHAPTER V: Discussion ------------------------------------------------------------------ 122 Discussion of Results ------------------------------------------------------------------------ 122 Description of eating behaviors and patterns of milk and soft drink intake --------------------------------------------------------------------------------- 122 Analysis of research questions ------------------------------------------------------ 127 Prediction of milk/soda drinking behaviors ------------------------------ 127 Prediction of intention ------------------------------------------------------- 129 vi Prediction of attitude, Subjective norm, and perceived behavioral control ----------------------------------------------------------- 131 Gender, ethnicity, and BMI differences -------------------------------- 135 Implications for practice, theory and policy ---------------------------------------------- 138 Implications for practice ----------------------------------------------------------- 138 Implications for theory ------------------------------------------------------------- 138 Implications for policy ------------------------------------------------------------- 139 Limitations of the Study -------------------------------------------------------------------- 140 Recommendations for Future Research --------------------------------------------------- 141 Summary -------------------------------------------------------------------------------------- 142 APPENDIX A: Demographic Characteristics Form: Tell me about yourself-------- 144 APPENDIX B: 24-hour dietary recall for milk and soft drink intake ---------------- 145 APPENDIX C: Milk Intake Questionnaire ---------------------------------------------- 147 APPENDIX D: Soda Pop Intake Questionnaire ----------------------------------------- 154 BIBLIOGRAPHY --------------------------------------------------------------------------- 161 vii List of Tables Page Table 1: Summary of findings about school-age children’s milk and soft drink intake ------------------------------------------------------------------ 39 Table 2: Summary of relationships between influencing factors and milk and soft drink intake ------------------------------------------------------------- 47 Table 3: Ranges of the items in the Milk Intake Questionnaire from the Pilot study ------------------------------------------------------------------------- 75 Table 4: Ranges of the items in the Soda Pop Intake Questionnaire from the Pilot study-------------------------------------------------------------------------- 76 Table 5: Frequencies of demographic characteristics of the study sample ---------- 94 Table 6: Frequencies of eating behaviors and patterns of milk and soft drink intake ------------------------------------------------------------------