by Betty Lucas, MPH, RD, and Cristine Trahms, MS, RD, University of Washington, Seattle, WA

From the Winter 2008 issue of National PKU News.

“Mealtime is important family time.” We have all heard that phrase and probably sometimes wonder why it is so important, especially since families are so busy and time together is hard to come by. Is the family meal really an opportunity to improve diet and health? Or is the advantage of the family meal to develop social skills and family cohesiveness? In other words, does eating together really make a difference? We believe so!

Families whose children have PKU may think that the concept of “family meals” does not directly apply to them because not all family members are eating the same foods at a meal. But family meals are as important for PKU families as for any other family—maybe even more so, since mealtime provides not only an important opportunity for education about the diet but it reinforces the idea that food differences do not deter family togetherness.

As those of you who are a part of the PKU community know well, mealtime sometimes can be challenging for all family members. But we believe that the family meal is such an important aspect of family life that to try to answer the question posed above, and others related to family meals, we have gathered information from three sources: 1) articles in the popular press, 2) research articles by health professionals, and 3) parents of children with PKU (through a questionnaire to the PKU Listserv support group.)

Recently, the popular press has “weighed in” on the importance of family meals. For example, in a provocative Seattle Times article, Daniel Hong (1) put it this way: “Would you be interested in a program for your kids that improves academic performance, reduces risky behavior, promotes physical well-being, stabilizes emotions, and eventually enhances your family relationship, all at no cost? The program is often called ‘the wonder meal’ or ‘the miracle meal,’ but I call it ‘the real happy meal.’ Hong goes on to say that this result requires “something invisible—namely, your commitment and time.”

Stated this way, the family meal has an enormous impact on family life, including health and wellness. Is this promise “too good to be true?” Does the family meal really have this level of impact on the lives of our children? If we want accomplished children in our families, should we “change our ways” as soon as possible and start nightly family dinners if that is not our current practice?

Frequency of Family Meals

How often families eat a meal together depends on the age of the children in the family and the background of the family. A 1991 general telephone survey of families of children 12 to 17 years old found that about 1/4 of families ate family dinner together every day, about 1/2 of the families ate dinner together 4 to 6 times per week, and the remaining 1/4 of families ate dinner as a family 1 to 3 days per week. The frequency of family dinner decreased as the children entered their teens, twice as many 12-year-old children as 17-year- old children have dinner with their families (2).

Family background also plays an important factor in family meals. Boys were noted to sit down for a family dinner more often than girls; and of the reported family backgrounds, Asian American youth more likely to have dinner with their family, and Caucasian American youth are the least likely to do so.

Parade Magazine (3) reported on the recent Parade poll and noted that 25% of families reported eating together every night; an additional 34% of families eat together most nights. Three quarters of the families reported that they ate together on Sunday night. The Parade data suggested that 78% of families have a family dinner at least a few times a week. Also, 69% say that they enjoy the family dinner and looked forward to family meals. Twenty-five percent said family dinners are at a restaurant; and 23% wished they could have a family meal more often.

Family Meals and Nourishment

The family meal has been promoted as the foundation for healthful food choices. Over 1,700 high school students were surveyed and reported strong associations between family meals and healthful meals. For example, a greater number of family meals per week was strongly related to an increased intake of fruits and vegetables and a significantly decreased intake of soft drinks. Further, more frequent family meals indicated a higher priority in families for meal structure and social eating and this positive effect lasted into adulthood (4).

However, regardless of the source of the food, eating together enhances the nourishment of the meal. Teens in homes with fewer than three fast food family meals per week with their families were more likely to eat vegetables and milk with these meals than teens that ate fast food meals without their families (5).

Adolescents and the Importance of Family Meals

About 1,000 US adolescents and their parents were asked about their family mealtime environment. Parents ascribed a higher value to the family meal than did the adolescents. Younger adolescents were more likely to eat with their families than older adolescents. The older adolescents reported that they enjoyed the family meal, but scheduling conflicts interfered with eating with their family regularly (6).

The family meal seems to have a powerful developmental role beyond food and nourishment. In research language, the frequency of family dinner is an “external developmental assessment” or “protective factor” that may curtail high-risk behaviors among youth. In other words, among the nearly 100,000 6th to 12th grade students who were surveyed, with consideration for differing family constellations, the more frequently the family had dinner together the less often the adolescent engaged in high-risk behaviors. The high-risk behaviors measured included substance use, sexual activity, depression/suicide, violence, antisocial behaviors, school problems, and binge eating/purging (7). For younger kids ( middle school age) family meals were also a protective factor that supported the development of communication skills and led to greater academic success (8).

Family Meals and Television Watching

Perhaps a less powerful but important aspect of family meals is whether the television is on or off during the meal. The more hours a preschool age child watches television while eating, the greater the liklihood that they will consume more food (9). Children who watched more television and ate fewer family meals were more likely to be overweight by the third grade. (10). The quality of the family dinner appears to be influenced by whether or not the television is turned on. Each night that the family ate dinner together was positively associated with serving fruits or vegetables at the meal. Serving fruits or vegetables decreased with each night the television was on during dinner (11). Teens also reported poorer nutritional intake during family meals that included television watching (12).

However, watching television during family meals was associated with a more healthful diet than not eating regular family meals at all. The biggest factor is not whether the TV is on or off, but whether the family is eating a meal together. Children and teens eat better quality food when they are not alone.

Overall Benefits of Family Meals

Nutrition researchers have long been interested in the family meal and its impact on the health and well-being of children. Eating meals as a family can actually improve children’s food habits and nutrient intake; parents can model the social behavior they expect; and children and teens will develop social skills and behaviors. We learn our food preferences, our pace of eating, our interaction with others, and our habits of activity at a very young age. Sitting down to dinner with your family will help family members eat a more healthful diet, develop social skills, and possibly avoid high-risk behaviors. In summary, mealtime is important family time. The most important part of family mealtime is simple—it’s the family being together.

Getting Started

It’s never too early to start having regular family meals, especially since young children want to try what their parents and older siblings eat. Pull the high chair to the table with the rest of the family, even though the infant may only have a few finger foods. Start slow—perhaps weekend breakfasts with toddlers might be more relaxed. For preschool children, include foods they like as well as new ones (with you modeling eating and enjoying the “new” food); turn off the TV.

School age children often enjoy helping with the food preparation or setting the table; they like making meals “special” with candles, place mats, etc; and they can be expected to carry on a conversation. Family meals don’t have to be elaborate or even have hot foods—it’s being together that counts.

Infants, children and adolescents all depend on regular meals. Regular meals provide the sense to children that their basic needs will be taken care of and that others care about them. Foods offered only when your child asks for something to eat are not considered to be a family meal.

What in some families is called “helpy-selfy” is alright as an occasional event, but does not meet emotional, developmental, or nourishment needs when it is a regular practice at the exclusion of family meals.

If you present meals at a more or less regular time and offer a variety of food in a pleasant and matter-of-fact way, your child will grow up to like a range and variety of foods. Your child will also be comfortable and self-assured about choosing appropriate PKU-friendly foods in a variety of social and community settings. Regular family meals and the social interaction they provide are essential for helping your child or adolescent choose to eat the right amount and type of foods to get the body that is right for him or her—not too fat, not too thin, but just right and with excellent blood phe levels!

Meal Practices Among PKU Families

On the PKU Listserv, we asked members to tell us about their family meals. Many of you responded with very thoughtful answers and we thank you for sharing with the PKU community. In fact, your responses were so generous that printing all of them would take many more pages than we have available in the newsletter. So we will share some that are representative of the group.

Your responses reflected the ages of your children; whether or not you lived in a rural or urban area, family employment and schedules, and the willingness to include a variety of meal needs into the family meal. This diversity of family situations, while maintaining a commitment to the family meal, we found to be heartwarming.

Making family meals a priority and creating the expectation of regular family meals

More than half of the people who responded reported that the family had an evening meal together six or more times per week; another one third noted they had dinner together 4-5 times/week. Typical responses were:

• We try to eat dinner together at home every night during the week. It doesn’t always happen with school and activities, but it is our goal.
• Usually we eat all together as a family at the dinner table since this is the best time we can really be together and go over the days’ events.
• The only time we don’t eat together is during sports season because of practice and game times. If one child is absent we still have a family meal. We usually have the TV off for our dinner meal.
• We have tried to make family mealtime very important from the beginning. Whether our young son is eating with us or not, we always have him sit in his highchair.

Family Meal Preparation and Encouraging Responsibility

Who prepares the meals at home most often?

Mom won in this category “‘hands down.” Most families report that mom plans the meals and prepares most of the food for the entire family. Wonderfully, many families have shared cooking responsibilities, which includes all of the children in the family. Kids have a variety of responsibilities depending on age, skills, and number of children in the family. Typical responses were:

• I am responsible for meal planning and preparation; my children help me select some options, such as vegetables, or choosing one of two different meal options. They also set the table and clear their dishes.
• Both my husband and I work, so in order to minimize stress I try to plan out the meals ahead of time. Whatever we eat I try to incorporate a similar meal for her as well. For example, if we have spaghetti, then she has spaghetti. I realize she has specific dietary needs but our meals can resemble one another if it is possible.
• My son loves to help in the kitchen. I have a few special kid’s knives purchased from Pampered Chef so he can help with the cutting of veggies/breads, etc. He loves to sauté foods on the stove and helps bake and mix batters for me. He is a super help in the kitchen, even when it comes to cleaning up!
• My 16 year-old daughter helps with food preparation. She will peel vegetables, cut up onions, whatever I ask her to do. Also, if I have planned something for my husband and myself that she cannot have, she will prepare something for herself.
• My daughter loves to help with dinner. She’ll cut veggies for me, like carrots or celery. If we have mashed potatoes, she gets to do the mashing. When we have grilled cheese and tomato soup, she is always in charge of the sandwiches. Her grilled cheese consists of a slice of low pro bread, buttered on both sides and grilled. She also makes the regular grilled cheese. If I’m not home to make dinner she will generally make her own. She usually makes pasta or rice, soup and sandwiches.

How Do PKU Families Manage Eating Out?

Again, family practice depends on age of child or children, family resources, and location. Some families eat out very seldom; about 40% of families reported that they eat out frequently—at least once or twice a week; and another one-third noted that they eat out from once to three times per month.

Typical responses were from families who have developed innovative ways to include all family members in a “no fuss” manner.

• We usually eat out together about 1 or 2 times a week and we try to make Sunday dinner a tradition at Grammy’s house.
• We usually go out to eat once or twice each week. We try to either go someplace that has items my son can eat or else we take special items for him to eat.
• We eat out approximately 3 times a month. With my son being older, he usually orders the buffet so he can get the salad and a baked potato.
• We eat “take-out” or in a restaurant about 2-4 times/month and have found which restaurants have microwaves and have learned which have PKU-friendly menus.

Summary of PKU Family Responses

In the PKU community, the family meal seems to be “alive and well,” at least among families who responded to our questionaire. Families and their children are flexible and creative in providing a healthy and supportive family environment for all of their children.

Based on the research reviewed here and the testimony of listserv members, there are many ways to achieve family togetherness and a healthy family meal. Family togetherness and family role modeling appears to be a more powerful motivation for the family meal than the food. The habits of eating together developed in childhood will continue to support good health into adulthood.

 

Parents’ Most Important Role

From the very beginning, parents and family members model important roles for children. The adults in a child’s life model what to do, what not to do, and how to handle daily life. This modeling plays a very important role in a child’s growth and development and sets the tone for children’s behavior. If a parent is a positive role model for healthy food choices, regular meals, and physical activity habits, children are more willing and more likely to do the same.

As a parent it is often easier to promote the axiom “do as I say” instead of “do as I do.” Parents whose children have PKU may find themselves drawn to an authoritative approach to food and eating because of the prescribed parameters of food and medical food intake. This type of authoritative parenting can work against successful nourishment and parenting interactions around food choices. Many children will see the “demand” that a certain food be eaten at a certain time as a “turf “matter and many will rebel and refuse the food. On the other hand, modeling positive behaviors teaches children about appropriate foods choices, and appropriate portion sizes of foods without the authoritative approach. It also emphasizes shared responsibility for nourishment and behavior; that is, everyone in the family has a role in the family meal (for example, food preparation, choosing the amount of food to eat, clearing the dishes from the table).

The PKU families in our survey noted that positive strategies for meals in their family included: offering food with a positive, but neutral tone; offering a choice of fruits and vegetables for all family members at meals; assuring that each family member had appropriate “milk” to drink at each meal; having a regular rotation among family members in choosing the vegetable or, perhaps, the dessert for the meal; and assuring that each person in the family had an age and skill appropriate role in the meal preparation and clean-up. Children who are actively involved with their families in any aspect of the family meal have a head start on developing self-confidence in social situations outside of the immediate family.

Resources

A valuable resource for families and health care professionals alike is the Bright Futures series of materials at www.brightfutures.aap.org (American Academy of Pediatrics). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was developed to provide comprehensive health supervision and parent guidelines with detailed anticipatory guidance for ages and stages of development. Bright Futures provides guidelines that focus on physical activity, nourishment, and health behaviors for each age and stage.

Another important resource is Ellyn Satter (www.ellynsatter.com), a nutritionist who has researched and taught about the importance of family meals for decades. She provides some essential concepts that apply to all family members, regardless of health status. A monthly newsletter (Family Meals Focus) and well-researched guidelines are provided atwww.ellynsatter.com/newsletter.htm.

References

1. Hong D. The Happiest Meal of All. Seattle Times, Nov 24, 2006.
2. Rockett HRH. Family Dinner: More Than Just a Meal. J Amer Diet Assoc. 107: 1498-1501, 2007.
3. Schnurnberger L. The Truth about Family Meals. Parade Magazine Nov 11, pages 10-11, 2007.
4. Larson NI et al. Family meals during Adolescence are Associated with Higher Diet Quality and Healthful Meal Patterns during Adulthood. J Amer Diet Assoc. 107: 1502-1510, 2007.
5. Boutelle KN et al. Fast food family meals: relationships with patent and adolescent food intake, home food availability and weight status. Public Health Nutr 10: 16-23, 2007.
6. Fulkerson JA et al. Adolescent and parent views of family meals. J Amer Diet Assoc 106: 526-532, 2006.
7. Fulkerson JA et al. Family dinner meal frequency and adolescent development: relationships with developmental assets and high-risk behaviors. J Adolesc Health 39: 337-345, 2006.
8. Gillman MW et al. Family dinner and diet quality among older children and adolescents. Arch Family Med 9: 235-240, 2000.
9. Francis L et al. Does Eating during television Viewing Affect Preschool Children’s Intake? J Amer Diet Assoc 106: 598-600, 2006.
10. Gable S et al. Television Watching and Frequency of Family Meals are Predictive of Overweight Onset and Persistence in a National Sample of School-Aged Children. J Amer Diet Assoc. 107: 53-61, 2007.
11.Fitzpatrick E et al. Positive effects of family dinner are Undone