Calcium knowledge, concern, and expectations for intake among parents of Asian, Hispanic, and Non-Hispanic white early adolescents
Mary Cluskey, Ph.D., R.D.,
Nutrition and Exercise Science
Oregon State University
Garry Auld, Ph.D., R.D.
Food Science & Human Nutrition
Colorado State University
Miriam Edlefsen, Ph.D., R.D.
Food Science and Human Nutrition
Washington State University
Sahar Zaghloul, MBB.Ch.Ph.D.,
Human Nutrition, Food and Animal Science
University of Hawaii at Manoa
Margaret A. Bock, Ph.D., R.D.
Family and Consumer Sciences
New Mexico State University
Carol J. Boushey, Ph.D., R.D.
Foods and Nutrition
Christine Bruhn, Ph.D.
Consumer Food Marketing Specialist
Food Science and Technology
University of California, Davis
Dena Goldberg, Ph.D., R.D.
Food and Nutrition Services
Carilion Roanoke Community Hospital
Scottie Misner, Ph.D., R.D.
State EFNEP/FSNEP Coordinator
University of Arizona
Beth Olson, Ph.D.
Food Science & Human Nutrition
Michigan State University
Marla Reicks, Ph.D., R.D.
Food Science and Nutrition
University of Minnesota
This study was designed to describe parental knowledge about calcium functions, food sources, intake adequacy, and requirements for stage of life cycle, as well as concerns and expectations about intake of calcium rich foods (CRF) by early adolescent children. Individual interviews were conducted with 201 Asian (n=54), Hispanic (n=57) and non-Hispanic white (n=90) parents of children aged 10-13 years. Qualitative data analysis procedures were used to generate common interview themes. Four knowledge sub-scores were constructed from responses to specific combinations of questions. The overall level of calcium-related parental knowledge was only moderate. Most parents were aware that calcium was required to build strong bones, while specific knowledge about calcium functions, requirements, and food sources was limited. Few parents set expectations for regular consumption of CRF by children. Having knowledge about calcium needs and food sources may be important motivators for parental efforts to provide CRF in the home and to create expectations for intake.
Keywords: parental calcium knowledge, concern, expectations, early adolescents, ethnic parents
Adolescent dietary calcium intake is important to assure adequate bone mineral accretion and peak bone density (Nieves 2005), yet evidence suggests that calcium intake begins to fall during adolescence (Fiorito et al. 2006). Obtaining adequate calcium helps ensure adequate mineralization of the skeleton to maintain bone health throughout life. Average calcium intakes failed to meet recommendations for both boys and girls aged 9-13 years (Moshfegh, Goldman, and Cleveland 2005), and varied with the race/ethnicity of the child (Lytle et al. 2002).
Family and parental factors influence adolescent calcium intake. Calcium intake of adolescents was associated with availability of milk with meals (Larson et al. 2006). Several studies have also shown that perceived parental modeling can influence food intake of adolescents (Wind et al. 2006; Young, Fors, and Hayes 2004; Martens, van Assema, and Brug 2005). Parents served as monitors and food gatekeepers for early adolescents and reinforced behaviors (Savage, Fisher, and Birch 2007; Hanson et al. 2005). Parental role modeling of milk consumption was related to milk consumption among young girls (Fisher et al. 2001).
The role of parental encouragement and support for eating behaviors of children and adolescents was associated with desired intake (Young, Fors, and Hayes 2004). Parental concern over their own health may drive adolescent eating behaviors, as mothers who began taking calcium supplements also increased calcium intake in their children (Winzenberg et al. 2006). Adolescents’ perceptions of maternal concern were positively associated with eating behaviors of adolescents (Boutelle et al. 2007).
Parental expectations and rule setting regarding food consumption also influenced nutritional intake (DeBourdeaudhuij 1997; Zabinski et al. 2006). About 41 percent of 10-year-old children indicated they were always obliged by parents to drink milk (DeBourdeaudhuij 1997). Zabinski et al. (2006) showed that fruits and vegetables and fat intakes among adolescents were correlated with household eating rules. Some families reported having no expectations for consuming milk with meals, which was considered a barrier to adolescents’ consumption of milk (Auld et al. 2002).
Parental nutrition knowledge has been linked to improved dietary intake by children in several studies (Blanchette and Brug 2005; Gibson, Wardle, and Watts 1998). A review of the literature regarding fruit and vegetable intake of 6- to 12-year-old children showed that parental knowledge of intake recommendations and skills were positively associated with children’s intakes (Blanchette and Brug 2005). Fruit intake among 9- to 11-year-old children was predicted by mothers’ nutritional knowledge, frequency of fruit consumption, and perception of the health benefits of fruits and vegetables (Gibson, Wardle, and Watts 1998). Variyam (2001) suggested that nutrition knowledge may act as a pathway through which maternal education can influence dietary intake among family members.
Little is known about how parental knowledge about physiological function, nutrient requirements, and dietary sources of calcium influences concerns for their own or their children’s calcium intakes. Knowing that adolescent dietary calcium intake is often inadequate may increase the likelihood of providing CRF in the household and encouraging intake. The purpose of this study was to describe parental knowledge about calcium functions, requirements and food sources, and parental concern and expectations about their children’s intakes of CRF. Qualitative data regarding these issues are limited and could serve to inform the development of interventions with parents to increase intake of CRF by early adolescent children.
A cross-sectional study conducted by researchers affiliated with twelve universities across the United States examined parental influences on calcium intake of early adolescents (10-13-year-old). Three racial/ethnic groups were sampled: non-Hispanic white (NHW), Hispanic, and Asian. Parents were recruited using convenience sampling to participate in semi-structured, audio-taped interviews about their adolescent child’s calcium intake. Institutional Review Board approval of the study protocol was obtained from each participating university. (For more detail on the study and methods and qualitative analysis, please see Auld et al. 2007; Cluskey et al. 2008).
Interviews focused on parents’ (1) knowledge of calcium functions and dietary sources of CRF; (2) knowledge of dietary calcium requirements and intake adequacy of children and adults; and (3) concern about their children’s calcium intakes and expectations for consumption of CRF. The majority of interviews were conducted in English; non-English interviews were translated into English when transcribed. Transcripts were standardized for format and imported in rich text format into NVivo® and coded at Colorado State University Nutrition Assessment and Evaluation Center, 2007. All NVivo® transcripts were coded by one of four trained coders. To ensure continued inter-coder reliability, the project manager rechecked coders after every tenth transcript; overall inter-coder reliability was 91 percent.
Quantitative analyses involved creation of four knowledge sub-scores from responses to a specific combination of interview questions. Up to 2 points were awarded for knowledge about calcium function, accurately indicating that calcium is linked to bone health (0.5 point), teeth (0.5 point), osteoporosis or brittle bones (0.5 point), or any other function (e.g., muscle contraction, blood pressure)(0.5 point). Up to 2 points were awarded for food sources, accurately selecting the number of servings needed to
meet calcium needs from CRF (milk, cheese, ice cream, sardines, pizza, greens). One point was awarded for knowledge of intake adequacy: recognizing that adults’ (0.5 point) and/or children’s (0.5 point) typical intakes reportedly failed to meet recommendations. Finally, when shown pictures representing stages of the life cycle (infancy, childhood, adolescence, adulthood, old-age, and pregnancy), one point was awarded for life-cycle stage requirement: correctly identifying adolescence as having the highest absolute calcium need; a 0.5 point was awarded to those answering that everyone needs calcium throughout the life cycle.
The maximum possible knowledge score was 6. Two researchers independently calculated knowledge scores for each transcript. Differences of more than 0.5 point were revisited until agreement was reached on the final score. Analysis of variance with LSD (least significant difference) was used to compare scores between the three ethnic groups and two genders using SAS (Statistical Analysis Software, version 9.1, 2001-2002, Cary, NC) procedures with an a level set at 0.05.
Subject demographic characteristics
Self-reported characteristics indicated the respondents (n=201) were primarily females (95 percent) of Hispanic (n= 57, 28 percent), Asian (n=54, 27 percent), and NHW (n=90, 45 percent) race/ethnicity. The education levels varied by respondent’s racial/ethnic group, with fewer Hispanic respondents reporting to be college graduates. Convenience sampling in areas with major universities may have resulted in well-educated respondent groups (58 percent of all respondents had graduated from college). The children of the respondents included both females (54 percent) and males (46 percent) between the ages of 10-13 years (mean: 11.6 ± 1.0). In some cases, children were of mixed race/ethnicity (n=33), with parents of different ethnicities. Each researcher completed from four to thirty-four interviews, with most conducting sixteen interviews. Interviews were approximately 60 minutes long and were conducted in community nutrition program settings or in rooms in university buildings. Respondents received grocery store vouchers valued at approximately $25 as an incentive to give their time.
The knowledge scores represent a composite of parent knowledge of calcium functions, food sources, life cycle stage requirement and knowledge of intake adequacy (Table 1). The general level of knowledge by most parents was moderate (mean score=3.2). Parents of NHW adolescents had significantly higher total knowledge scores (mean score=3.6), compared to Hispanic and Asian parents, whose average score was 50 percent or less of the possible total score. NHW respondents were more likely than Hispanic or Asian respondents to be aware of typically inadequate calcium intakes. Asian respondents were less likely to correctly answer questions about calcium functions than the other two groups. Hispanic respondents were less likely than NHW respondents to correctly identify adolescence as the life cycle stage with the highest calcium requirements.
Respondents earned higher scores on questions regarding calcium function than on other areas of calcium nutrition knowledge. Many parents were able to answer that an important function for calcium was forming strong bones and teeth, and for growth, and very rarely described any other physiological function of calcium. Calcium intake was known to prevent osteoporosis; however, Asian respondents were somewhat less likely to refer to this function. Respondents sometimes referred to media advertising regarding calcium. (“I hear on the radio and TV how important calcium is to avoid osteoporosis and to develop bones and teeth.” – parent of Hispanic male)
Food sources of calcium
Participants were shown a list of various CRF and asked to estimate the number of servings of each needed to provide 1,300 mg of calcium. Accuracy in recognizing the needed servings of milk (50 percent) and cheese (66 percent) suggest that dairy foods were readily recognized as CRF. Participants who failed this question typically overestimated the calcium content in dairy foods. Several were completely unsure and responded only by guessing. One parent remarked after failing to answer correctly:
“Personally, I would have no idea how much calcium is in a cup of milk, milligrams. I don’t know. And I bet a lot, nobody knows really. I know everything’s written on labels. My kids try to read those labels, which is cute … it would be interesting to know.” (parent of non-Hispanic white male)
In general, parents were unsure of the relative calcium levels in non-dairy CRF and few could accurately identify the servings needed to provide 1,300 mg of calcium. (“Well, I never thought of broccoli for calcium … because I never consider broccoli a source of calcium.” – parent of Asian female) When they did recognize greens, pizza, or sardines as calcium sources, they thought these foods had far more calcium than the foods actually did.
Knowledge of intake adequacy and life cycle stage requirement
Many knew that both children and adults fail to meet calcium intake recommendations, but some respondents (15 percent to 25 percent) thought adult calcium intakes are probably adequate. Parents in all groups commonly chose pregnancy, infancy, childhood, or old age as the time of greatest calcium need in the life cycle. Most parents could not identify the correct life cycle stage at which calcium requirements are highest.
Concern and expectations for calcium intake
Parents were asked about their awareness of and concern for the adequacy of their children’s CRF intakes, and if they have expectations about that intake for their children. Questions about concern for intake were asked both before and after seeing the answers to the number of food servings needed to meet calcium requirements. This was done to determine if knowledge of the numbers of servings needed to meet their children’s requirements would change their perceptions about the adequacy of their children’s intakes.
Many parents expressed little concern about their children’s calcium intakes and made similar comments such as
- “Okay, I know that he needs it, but how much is he getting and how much am I giving him. You don’t think about that.” (parent of non-Hispanic white male)
- “I think the schools are making sure that they kids have it (milk) available.” (parent of non-Hispanic white male)
- ‘I’m concerned … (but) I’m not to the point of monitoring the amount.’ (parent of Hispanic female)
Of those parents who expressed concerns about calcium intakes, parents were usually concerned if their children did not like to drink milk (more common in Asians) or consume other CRF. Others had concerns when their children were involved in sports, associating milk intake with having strength and strong bones.
Some parents indicated that they were concerned but not really worried about their children’s intakes. When asked why they were not worried about their children’s calcium intakes, parents’ responses could be categorized on the basis of believing that their children (1) eat well or have a generally balanced diet; (2) like milk or cheese or (3) get adequate amounts of milk at school. Yet, probing parents about their children’s typical diets often resulted in the revelation that parents weren’t really sure how much calcium their children consume, particularly at school.
Only a minority of parents had expectations that their children consume CRF on a regular basis (e.g., requiring them to have milk with dinner). About one- to two-thirds of parents expected milk to be an option at meals, but it was offered as a choice along with water or juice. Many parents indicated a desire to limit soda as a mealtime beverage, but few specified a rule about drinking milk with a specific meal.
When parents saw visuals showing the amount of CRF needed to meet an early adolescent’s calcium requirements, their concerns increased and they were less confident about the adequacy of that intake. More than one-fourth of parents were surprised that teens had the highest life cycle requirements, and several indicated that this increased their concern about their children’s intakes. For example, parents indicated
- “I didn’t know … when you see it on paper it is very surprising.” (parent of Hispanic male)
- “I just had no clue before, so now I know how many servings she would need of each food. It’s actually more than I expected.” (parent of non-Hispanic white female)
However, another one-fourth remained confident that their children were getting enough, justifying that they were “good eaters.” Some indicated that they would now be more attentive to their children’s actual consumption of CRF.
- “We will have to go home and look at the milk carton to see if she’s in that range, but I’ll just be more determined now.” (parent of non-Hispanic white female)
- “After seeing this, I will have to check on it … (and) to do a little tabulation and see which foods and see how much she has eaten of those foods.” (parent of non-Hispanic white female)
In the current study, the areas of knowledge that tended to be highest for all respondents included the relationship between calcium and bone/teeth/osteoporosis and the servings of dairy needed to meet calcium requirements. Less well-known across all groups was precisely how much food was needed to meet the requirement, non-dairy calcium sources, and the level of requirement for their adolescent children. These results are similar to other studies. Adolescent girls and women shared an awareness of the overall benefit of calcium consumption for preventing osteoporosis but lacked more in-depth calcium-related knowledge (Anderson, Chad, and Spink 2005). Similarly, New Zealand women were aware of the role of calcium in preventing osteoporosis but had less awareness of non-dairy calcium sources, the recommendation for calcium, and the amount of milk needed to meet the recommendation (von Hurst and Wham 2007).
In general, parents of NHW adolescents had scores that were significantly higher than the other groups; but not consistently higher across all knowledge topic areas. NHW parents tended to be more correct in knowing that intakes reportedly do not meet recommendations. It is unclear why differences in scores occurred between race/ethnic groups. Perhaps promotional advertising targeted toward NHW, cultural differences in health or somewhat lower education levels among the Hispanic respondents in this study contributed to the differences. Parent education level has been an important predictive factor for positive health behaviors for children in previous studies. Higher household education had a significant positive impact on fruit and vegetable consumption by Canadian adolescents (Riediger, Shooshtari, and Moghadasian 2007). The frequency of positive health behaviors of 6-year-old children such as intake of milk, fruit, and vegetables was also observed to be higher according to parent education level (Stenhammar, Sarkadi, and Edlund 2007.
Many parents were confident in their children’s calcium intakes, without being able to pinpoint specific calcium intake occasions. When parents were shown the correct numbers of servings of CRF to meet calcium needs, many indicated surprise at the amounts. Some became more concerned after learning about calcium and thought that they might be more attentive to or change their expectations about their children’s diets. These results are supported by others (Boutelle et al. 2007), who reported that higher levels of maternal concern for healthy eating were more likely to result in home environments that enabled healthy eating by adolescents. In addition, Winzengberg et al. (2006) showed that mothers who learned about their own osteoporosis risk were more concerned about their children’s calcium intakes.
Some parents justified their lack of concern for children’s calcium intakes, as they believed that generally eating well, liking milk, and eating at school assured adequacy of calcium intake. At the end of the interviews, some parents planned to follow up and investigate whether their children were actually eating CRF at school. Others have reported that parents believe that school meals have a high overall diet quality (Gordon et al. 2007), while some were unsure of what and how much their children ate in school (Lambert, Conklin, and Johnson 2002).
This large multi-state qualitative investigation using data collected from a cross section of parents from three targeted racial/ethnic groups provides a rich sample of adolescent parents. It is also one of few studies to explore the relationship between parental nutrient knowledge and resultant concerns or expectations for their children’s intakes of CRF. It is limited by using qualitative techniques to score parental calcium knowledge; however, using standardized methods to score responses and cross checking by multiple researchers enhanced the technique.
Another limitation includes potential sample bias; convenience sampling allows subject to self-select into the study, thus, those with greater interest in nutrition may have been more willing to participate. If so, such interest, as well as the relative higher education level of some of the sub-group, may have resulted in higher knowledge scores than a more random sample may have shown.
Conclusions and recommendations
The study suggests that many parents need education about calcium requirements and food sources, which may lead to parental efforts to provide CRF in the home and to create mealtime expectations for their intake. Parents indicated that the visuals used in the interviews showing the number of servings of food to meet calcium needs were very effective learning tools. Efforts to improve calcium consumption among adolescents might include parental communication that emphasizes how calcium functions over the life cycle, increases awareness of all CRF, and uses visuals showing the servings needed to meet dietary needs. Although some similarities were seen across the three parent groups, differences were also identified.
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Cite this article
Mary Ann Johnson, Sohyun Park, Dawn Penn, Jacquelyn W. McClelland, Katie Brown, and
Audrey Adler. 2008. Nutrition Education Issues for Older Adults. The Forum for Family and Consumer Issues, 13 (3).
Table 1. Knowledge scores according to racial/ethnic group.
[Table 1 Summary: This table provides calcium knowledge scores from respondents grouped by ethnicity, indicating total mean scores as well as scores broken down for calcium function, food sources, adequacy of intake and life cycle requirements. Statistical differences from ANOVA are indicated]
Knowledge Score (maximum)
(n = 201)
(n = 54)
(n = 57)
(n = 90)
|Calcium Function (2)||1.1 (0.1)||0.8 (0.1)a||1.2 (0.1)b||1.2 (0.0)b||<0.001|
|Calcium Food Sources (2)||1.1 (0.1)||1.2 (0.1)||0.9 (0.1)||1.2 (0.1)||>0.05|
|Intake Adequacy (1)||0.8 (0.0)||0.6 (0.0)a||0.7 (0.0)a||0.9 (0.0)b||<0.001|
|Life Cycle Stage Requirements (1)||0.3 (0.1)||0.3 (0.1)ab||0.2 (0.1)a||0.4 (0.0)b||<0.01|
|Total (6)||3.2 (0.1)||2.9 (0.1)a||3.0 (0.1)a||3.6 (0.1)b||<0.001|
Values in rows with different superscript letters are significantly different according to ANOVA.
* ANOVA and LSD testing reveal significant differences between groups for all scores except Calcium Food Sources. Different superscript letters reveal significant differences between ethnic groups
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