epubs.surrey.ac.ukepubs.surrey.ac.uk/810936/1/Home environment.docx  · Web viewWord count: 8666 (inc refs and abstract) There are no conflicts of interest. Address for correspondence:

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Ogden, J., Dalkou,M., Kousantoni, M., Savona Ventura, S., Reynolds, R (in

press) Body weight, home environment and eating behaviour across three

generations of women: a quasi-longitudinal study in four Mediterranean and

non-Mediterranean countries. Australian Psychologist

Body weight, home environment and eating behaviour across three generations

of women: a quasi-longitudinal study in four Mediterranean and non-

Mediterranean countries. In press Australian Psychologist

Jane Ogden, Marianna Dalkou, Marianna Kousantoni, Stephanie Savona Ventura,

Rebecca Reynolds

Running head: Home environment and eating behaviours in women

Date: 02/02/2016

Word count: 8666 (inc refs and abstract)

There are no conflicts of interest

Address for correspondence: Jane Ogden, Professor in Health Psychology, Department of Psychology, University of Surrey, Guildford, Surrey, GU2 7XH, UK. Telephone: +44 (0)1483 68 6929. Fax: +44 (0)1483 300800. Email: [email protected]

Description of lead author

The lead author Professor Jane Ogden is a Professor of Health Psychology at the University of Surrey and is interested in the control and loss of control over eating, aspects of weight concern, the development of dietary habits in childhood and the medical and surgical management of obesity

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Abstract

Objective: A quasi-longitudinal design was used to explore how changes in the home

environment reflect body weight and eating behavours in three generations of women

across two non-Mediterranean (UK and Australia) and two Mediterranean countries

(Greece and Malta). Method: A within- and between-subjects design was used. The

within-subjects factor was generation (daughters, mothers and grandmothers). The

between-subjects factor was nationality (Mediterranean (Malta, n=135 and Greece,

n=106) vs non-Mediterranean (UK, n=120 and Australia, n=96). Body Mass Index

(BMI), eating behaviour and aspects of the home environment were assessed using

questionnaires for family triads. Results: There were consistent differences by

generation in terms of BMI, eating behaviour and most aspects of the home

environment, with daughters being lighter but reporting less healthy diets in terms of

drinks, snacks, meals and food preparation than either their mothers or grandmothers

and a lower endorsement of parental control over food, a lower belief in controlling

forms of parenting and a lower belief in the mothers’ autonomy over their daughter.

Further, those from Mediterranean countries were heavier and reported poorer diets

and a stricter approach to the home environment. The results also indicate that a shift

between the generations was more marked in Mediterranean countries with more

pronounced differences occurring between daughters, their mothers and

grandmothers. Conclusion: Increased weight may be associated with a less managed

home environment and poorer eating behaviours which are particularly apparent in

those from Mediterranean countries where daughters may be reacting against their

more controlling family culture.

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Key words: eating behaviour, family characteristics, home environment, longitudinal,

obesity, parental control

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Introduction

Worldwide rates of obesity have increased over the past 50 years affecting both

children and adults. Some countries have shown a gradual consistent increase over

time as each generation has become heavier than the last. For example in England,

obesity prevalence in adults rose from 14.9% to 24.9% between 1993 and 2013

(Public Health England, 2015). Similarly, in Australia, the prevalence of adult

overweight and obesity increased from 57% in 1995 to 63% in 2011-2 (Australian

Institute of Health and Welfare, 2015). In contrast, other countries have shown a

more profound recent increase in the prevalence of obesity, which is particularly

apparent in those which have traditionally shown low body weights due to their

Mediterranean diets and active lifestyles. For example, lifestyle surveys of 1,000

adults (in 2003) and 2,000 adults (in 2007) in Malta concluded that there was an

increase from 60% to 62.4% in just four years in the prevalence of overweight and

obesity (National Statistics Office, 2003; 2009). Such figures rank Malta as the

country with the highest percentage of obese men and the third highest among

females within the European Union (National Statistics Office, 2009). Furthermore, in

2002, the prevalence of obesity in Maltese children was 33.3%, exceeding the 31.9%

reported among American children (Janssen et al., 2005) and, in 2004, Malta was

rated as having the highest obesity rates in the European Union, with an overweight

rate of over 35% (Lobstein et al., 2004). Likewise, rates of adult and child obesity

have also increased dramatically in Cyprus (Savva et al., 2014) and Greece (Tambalis

et al., 2010), suggesting a shift away from their traditional lifestyles over the past few

decades (OECD, 2012; Yannakoulia, 2004). For example, the prevalence of child and

adolescent obesity in Cyprus was higher in 2010 at 8.1% compared to 2000, when it

was 5.9% (Savva et al., 2014).

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Over the past few decades, research highlights a deterioration in the diets of both

adults and children. For example, large surveys in the US, UK, across Europe and in

Australia indicate that nowadays, children’s diets tend to exceed dietary

recommendations for total fat, saturated fat, dietary cholesterol, sugar (mostly from

fizzy drinks), snacking and total energy intake and the majority eat fewer than the

recommended intake of fruit and vegetables (Australian Bureau of Statistics, 2012;

Bellizzi, 1993; Buttriss, 1995; Nicklas, 1995; Office for National Statistics, 2002;

Wardle, 1995). In parallel, young people’s diets show a similar pattern and are also

now not meeting the recommended intakes and are particularly high in saturated fat

and sugar and low in fruit and vegetables, e.g. a meal of soft drink, burger and chips

(Australian Bureau of Statistics, 2012; Office for National Statistics, 2002; Wardle et

al., 1997). Likewise, some studies in Cyprus indicate a decrease in adherence to a

more traditional Mediterranean diet in children and adolescents (Kontogianni et al.,

2010; Lazarou et al., 2009) and suggest that a less traditional diet is associated with

higher body weights (Kontogianni et al., 2010). Surveys of the diets of adults show

that these are also too high in sugar, fat, salt and alcohol and deficient in fruit and

vegetables, iron and vitamin D (Australian Bureau of Statistics, 2012; Bellizzi, 1993;

Office for National Statistics, 2002).

Investigating the underlying causes of overweight and obesity is of particular

concern due to the increased risk of morbidity (e.g. type II diabetes and heart disease)

and mortality that results from excess weight (Romera-Corral et al., 2006). The

present study therefore aimed to address possible contributing factors to body weight

changes in both Mediterranean and non-Mediterranean countries, with a focus on

eating behaviour and aspects of the home environment, and whether these factors

differ across three generations of women: daughters, mothers and grandmothers.

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One aspect of the home environment that has received particular interest is the

use of parental control to manage a child’s food intake. For example, Casey and

Rozin (1989) found that 40% of parents believed that restricting access to certain

foods would decrease their child’s preference for these foods. In line with this,

control practices have been conceptualised into different constructs by different

authors. For example, Birch and colleagues (2001) have carried out a number of

studies exploring the impact of control and developed the Child Feeding

Questionnaire, which operationalised control in terms of monitoring, restriction and

pressure to eat. In a similar vein, Wardle and colleagues (2002) categorised control in

terms of providing food in response to a child’s emotional distress, using food as a

reward, applying pressure to eat or applying restrictions upon eating. In contrast,

Ogden and colleagues (2006) focused on the restrictive aspects of parental feeding

practices and categorised this into two main types of control termed covert and overt

control. Covert control was defined as when the child is unaware of the restriction

placed upon them, such as managing their environment through choosing not to buy

unhealthy foods or only taking children to restaurants that sell healthy options,

whereas overt control was defined as a form of control that the child is aware of.

Using these frameworks, research has explored the impact of parental control

on a child’s diet and several studies suggest that control can be problematic. For

example, research has concluded that parental restriction is associated with weight

gain and higher levels of body fat in children (Clark et al., 2007; Spruijt-Metz et al.,

2002). Similarly, studies indicate that restrictive feeding practices increase children’s

preference for the restricted food (Ogden et al., 2013) and promote overeating when

restricted foods are freely available (Fisher & Birch, 1999; Fisher et al., 2000).

Furthermore, research has also shown that parental restriction may cause children to

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restrain their own eating which can paradoxically lead to uncontrolled eating (Erskine,

2007; Fedoroff et al., 1997). Likewise parental pressure has been associated with the

development of dietary restraint and disinhibition (Carper et al., 2000; van Strien &

Bazelier, 2007) with possible explanations being that pressurising a child to eat may

be autonomy-limiting (Lewis & Butterfield, 2005), which undermines self-regulation

(Constanzo &Woody, 1985).

In contrast, however, some studies suggest that parental control may actually

reduce weight and improve eating behaviour. For example, Brown and Ogden (2004)

reported that greater parental control was associated with higher intakes of healthy

snack foods and Ogden and colleagues (2006) concluded that whereas overt control

was associated with an increased intake of healthy snacks, covert control was linked

to a decrease in unhealthy snacks. Similar results were also found in another sample

of parents with small children (Brown et al., 2008).

Parents, however, not only manage their children’s diets but also parent in a

more general way and it is possible that such parenting practices may have changed

over recent decades in ways that could influence diet and body weight. Most

research exploring parenting highlights three key parenting styles which describe

different approaches to childcare (Baumrind, 1966). First, research describes an

authoritarian parenting style which involves restricting a child’s autonomy in order to

force them to behave in ways that the parent thinks is correct. In contrast, the

authoritative parent believes that the child should have autonomous self-will and

therefore accept the child’s differences, but also set standards for future conduct by

using reason, power and reinforcement to achieve the objective. Finally, the

permissive parent behaves in a non-punitive way and is accepting of the child’s

desires, actions and impulses, presenting themselves as a resource that the child may

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use as they please, and not a model to follow or an active agent that is responsible for

shaping their behaviour. Some research indicates changes in parenting styles over

the past few decades, suggesting that although parents have become more controlling

in terms of their child’s activities and access, there has been a shift towards more

permissive approaches away from a more traditional authoritarian perspective

(Gardner et al., 2012). Furthermore, research also illustrates a link between general

parenting styles and the ways in which food is managed in the home, suggesting that

permissive parenting results in permissive feeing or ‘nutritional neglect’, whereas

more authoritarian parenting may be associated with a more controlling approach to

food (Hughes et al., 2005; Patrick et al., 2005). It is possible that such changes in

parenting practices and their links with feeding styles may have contributed to

changes in eating behaviour and obesity.

The final aspect of the home environment that has been explored in the

context of diet and body weight is the mother-daughter relationship, with a focus on

processes such as boundaries, projection and enmeshment. For example, Crisp and

colleagues (1980) argued that undefined boundaries within the family and the

existence of an enmeshed relationship between mother and daughter may relate to

eating problems. Similarly, Smith and colleagues (1995) suggested that a close

relationship between mother and daughter may result in enmeshment and problems

with separation in adolescence. Further, Minuchin and colleagues (1978) and Bruch

(1974) also argued that although optimum autonomy does not mean breaking all

bonds between mother and daughter, mother–daughter relationships which permit

poor autonomy for both parties may be predictive of future psychopathology. To

assess some of these constructs, Ogden and Steward (2000) directly explored the

impact of aspects of the mother–daughter relationship on weight concern and

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concluded that those daughters whose mothers did not believe in either their own or

their daughter’s autonomy and showed a tendency to project their own expectations

onto their daughters were more likely to be dissatisfied with their bodies. In a similar

vein, Baker and colleagues (2000) highlighted a role for perceived direct criticism

from the mother as predictive of weight-loss behaviours in the daughters, and Hanna

and Bond (2006) concluded that negative comments was a better predictor than family

conflict of a number of different aspects of disordered symptomatology including

drive for thinness and body dissatisfaction. Accordingly, changes in the mother –

daughter relationship over time may help to explain changes in eating behaviour and

weight problems.

In summary, the past few decades has seen changes in levels of obesity and

eating behaviours across a number of countries. Much research has highlighted the

role of the home environment as possible explanatory variables for these changes,

including the role of parental control over diet and aspects of parenting including

general parenting styles and the mother-daughter relationship. To date, however,

most research has used cross-sectional designs to explore associations between

current diet and body weight and aspects of the home environment. Such designs

cannot inform an understanding of changes over several decades nor can they

contribute to our understanding of causality. In contrast, other studies have used

longitudinal designs but with follow-ups only up until five years which, although

enable some tentative conclusions about causality to be made, again shed little light

on the longer-term changes apparent over the past few decades. Therefore, in order

to understand the possible processes involved in changes in diet and body weight,

longer-term studies are needed. Given that these changes have already occurred,

however, prospective designs would not be feasible or appropriate. Accordingly, the

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present study utilised a quasi longitudinal design across triads of three generations of

women; daughters, mothers and grandmothers from individual family groups as a

means to explore differences across these generations and their potential impact on

changes in diet and body weight. In addition, the study explored these trans-

generational differences across four countries which were chosen due to their

different pattern of obesity development and their different histories in terms of

traditional diets. The four countries selected were two Mediterranean countries

(Malta and Greece), who have recently have shifted away from their more traditional

Mediterranean lifestyles and shown a more dramatic recent increase in obesity

prevalence, and the UK and Australia to reflect non-Mediterranean countries which

have shown a more gradual increase in obesity.

Method

Design

A within- and between-subjects design was used. The within-subjects factor was

generation (daughters, mothers and grandmothers). The between-subjects factor was

nationality (Mediterranean (Malta and Greece) vs non-Mediterranean (UK and

Australia)). The key outcome variables were BMI, eating behaviour and aspects of

the home environment (eating parental control, parenting style, mother–daughter

relationship). Ethics approval was obtained from the University ethics committees.

Participants

The sample consisted of family triads of daughters, their mothers and grandmothers.

The inclusion criterion for the daughter was that she was aged between 16 and 34

years old. The daughter in turn recruited their mother and grandmother. Daughters

were asked to take part if they considered their nationality and that of their mother

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and grandmother to be the nationality of their country of residence (ie UK; Australia;

Greece; Malta). Initially approximately 70 questionnaire packs were distributed in

each country. The response rates were higher in Malta (n=45; 64%) and Greece

(n=53; 76%) than the UK (n=20; 28%) or Australia (n=15; 21%) as these daughters

had more regular contact with their mothers and grandmothers. An additional 30

questionnaires were then administered in the UK and Australia. All those returned

from Greece and Malta described themselves as Greek and Maltese respectively. Of

those returned in the UK 4 triads contained at least one member who did not

described themselves as British (Danish n=2; Asian n=2). These were deleted. Of

those returned from Australia, 27 daughters, 30 Mothers and 26 Grandmothers

described themselves as solely Australian. Some reported joint nationality (daughters

n=6; mothers n=3; Grandmothers n=7) including Australian and Chinese /

Argentinian / Greek / Sri Lankan / Finnish / British. These were included resulting in

33 triads. However one triad described themselves as Italian which was deleted.

Completed questionnaires after deleting these participants brought response rates to:

UK: n=40, 40% and Australia: n=32; 32%.

Procedure

Questionnaire packs consisting of matched questionnaires for daughters, mothers and

grandmothers were handed to daughters through universities and schools in the four

countries. A daughter was recruited if she was aged over 16 and if she believed that

she would see both her mother and grandmother within the next month. It was

clarified that the aim of the study was to capture three generations of women. The

mother therefore needed to be her own mother, but the grandmother did not have to be

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her mothers’ mother. Questionnaires were translated into Greek and Maltese for

these populations.

Measures

Daughters, mothers and grandmothers were given a matched questionnaire consisting

of the following measures. Where appropriate, mean scores were computed for each

construct and reliability was assessed using separate Cronbach’s alpha for daughters,

mothers and grandmothers.

1. Demographic data

All participants described their age, height, weight (to calculate BMI). They were

also asked ‘What is your nationality?’ Daughters were also asked to report the last

time they lived at home with their parents (still living at home; less than 24 months;

more than 24 months) and mothers were asked to describe their social class (working;

lower-middle; upper-middle; upper).

2. Eating behaviour

Participants completed a measure of their eating behaviour measured in terms of their

drinks, snacks, meal intake and food preparation in terms of the following: i)

unhealthy drinks (3 items: eg. Squashes / soft drinks; Dα=0.01; Mα=0.01; Gα=0.1); ii)

healthy drinks (2 items: eg. Natural tea; Dα=0.1; Mα=0.3; Gα=0.3); iii) unhealthy

snacks (4 items: eg. Cakes; Dα=0.6; Mα=0.6; Gα=0.6); iv) healthy snacks (5 items:

eg. Fresh fruit; Dα=0.5; Mα=0.6; Gα=0.4); v) unhealthy meals (5 items: eg. White

bread; Dα=0.6; Mα=0.6; Gα=0.6); vi) healthy meals (7 items: eg. Brown bread;

Dα=0.7; Mα=0.7; Gα=0.6); vii) unhealthy preparation (6 items: eg. Processed foods;

Dα=0.6; Mα=0.6; Gα=0.5); viii) healthy preparation (5 items: eg. Cooked meals at

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home; Dα=0.4; Mα=0.1; Gα=0.3). Answers were given on an eight-point Likert scale

(Never or less than once a month; Less than once a week; Once a week; 2-4 days a

week; 5-6 days a week; Once a day, every day; 2-3 times a day, every day; More than

3 times a day, every day). All items were developed from the World Health

Organisation 2001/02 protocol (Currie et al., 2001), the Inchley and colleagues (2001)

food frequency questionnaires, the 7-day food diary (Gregory et al., 2000) and

consumer market research report data (Mintel, 2003). These scales have been used in

previous research to assess both parents’ and children’s diet and have been shown to

be consistently reliable (eg. Brown et al., 2008; Brown & Ogden, 2004; Dickens &

Ogden, 2014; Ogden et al., 2006).

3. Aspects of the home environment

Participants completed measures of the home environment in terms of the following

constructs.

i) Parental control: Participants completed beliefs about parental control over food

in terms of the following constructs: Overt Control: 4 items (eg. ‘Parents should be

firm about what their child should eat?’: Dα=0.8; Mα=0.8; Gα=0.8); Covert Control:

5 items (‘Parents should avoid buying biscuits and cakes and bringing them into the

house for a meal or snack’: Dα=0.7; Mα=0.8; Gα=0.7); Pressure to eat: 4 items

(‘Parents should make their child eat all of the food on their plate’: Dα=0.6; Mα=0.5;

G=0.6); Monitoring: 6 items (eg. ‘Parents should keep track of the sweets their child

eats’: Dα=0.7; Mα=0.8: Gα=0.8); Restriction: 3 items (eg. ‘Parents should keep some

foods out of reach’: Dα=0.3; Mα=0.3: Gα=0.3); Reward: 3 items (eg. ‘Parents should

use food to cheer up their child when unhappy’: Dα=0.6; Mα=0.6; Gα=0.6). All items

were taken from existing measures and amended so that they were phrased in the

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abstract and could be similarly completed by all three generations (ie. ‘Parents

should…’ rather than ‘I tend to …’). Items relating to overt and covert control were

taken from Brown and colleagues (2008) and Ogden and colleagues (2006) and those

relating to pressure to eat, monitoring, restriction and reward were taken from Birch

and colleagues (2001). All items were rated on a five-point Likert scale ranging from

‘Never’ (1) to ‘Always’ (5). Mean scores were computed with higher scores

reflecting greater use of each form of control.

ii) Parenting styles: Participants completed a measure of their beliefs about parenting

using the Parenting Styles Questionnaire (Robinson et al., 1995). This assesses three

components of parenting style: i) strict parenting style (also known as authoritarian),

(3 items eg. ‘Parents should shout when they disapprove of their child’s behaviour’:

Dα=0.4; Mα=0.5; Gα=0.7); ii) authoritative parenting style (3 items eg ‘Parents

should be responsive to their child’s feelings and needs’: Dα=0.7; Mα=0.7; Gα=0.7);

iii) permissive parenting style (3 items eg. ‘Parents should give into their child when

he / she causes a commotion about something’: Dα=0.4; Mα=0.1; Gα=0.3). Each

item was rated using a five-point Likert scale ranging from Never (1) to Always (5).

iii) Mother-daughter relationship: Participants completed a questionnaire relating to

their beliefs about the relationship between mothers and daughters. This consists of

three subscales: i) daughter’s autonomy which describes the extent to which a

daughter should have control over her own choices (3 items eg. ‘A child is allowed to

choose his / her own friends’; Dα=0.4; Mα=0.4; Gα=0.4); ii) mother’s autonomy

which describes the extent to which a mother should have control over her daughter’s

choices (three items eg. ‘A mother should have the final say in her child’s social

activities’; Dα=0.7; Mα=0.3; Gα=0.3); iii) mother’s body concern which describes

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the extent to which a mother has the right to express concern over her daughter’s body

shape (3 items eg. ‘It is right for a mother to voice her concerns about her child’s

weight’; Dα=0.7; Mα=0.6; Gα=0.6). These items were taken from previous research

exploring the impact of aspects of the mother-daughter relationship on weight concern

(Ogden & Steward, 2000) and were each rated on a five-point Likert scale ranging

from Totally Disagree (1) to Totally Agree (5).

Data analysis

SPSS (IBM Corporation, 2013) was used to analyse the data. For comparison,

participants were classified as Mediterranean (Greece, Malta) and non-Mediterranean

(UK, Australia). First, participant demographics and BMI were described and

differences by generation and nationality explored using RMANOVA. Differences in

eating behaviour and aspects of the home environment (parental control, parenting

styles and mother-daughter relationships) were then evaluated across the three

generations and by nationality using RMANOVA with generation (daughter /

mother / grandmother) as the within-subjects factors and nationality (Mediterranean

vs non-Mediterranean) as the between-subjects factor. Post hoc planned comparison t

tests were used to assess where specific differences lay. A cut of p<0.05 was used for

post hoc tests.

Results

1. Participants’ demographics

The sample consisted of triads of three generations of women from Malta (n=45),

Greece (n=53), UK (n=40) and Australia (n=32). The mean ages by generation were

as follows: daughters: 21.7yrs (SD=3.8); mothers: 51.1yrs (SD=5.7); grandmothers:

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77.3yrs (SD=7.9). The majority of the daughters were still living at home (n=114;

67.1%), whereas some had been living independently for up to 2 years (n=22; 12.9%)

and some had left home more than 2 years ago (n=34; 20.0%). In terms of social

class, the majority of mothers described themselves as upper middle (n=80; 47.1%),

although a large minority described themselves as either working class (n=28; 16.5%)

or lower middle class (n=57; 33.5%). A small minority described themselves as

upper class (n=5, 2.9%).

2. The impact of generation and nationality on BMI

The results showed a main effect of both generation (F=36.85; p<0.001) and

nationality (F=13.26; p<0.0001) on BMI. Post hoc t tests showed that that daughters

(mean=22.9; SD 4.07) were significant lighter than both their mothers (mean=26.33;

5.17) and their grandmothers (mean=26.77; SD=5.14) (all p values<0.05) but that

there was no difference between mothers and grandmothers (p>0.05). Further, those

from non-Mediterranean countries were lighter (mean =24.24; SD=2.93) than those

from Mediterranean countries (mean=26.1; SD=3.33), (p<0.05). There was no

generation by nationality interaction.

3. The impact of generation and nationality on eating behaviour and aspects of

the home environment

Differences in eating behaviour and aspects of the home environment by generation

(GEN) and nationality (NAT) are shown in tables 1-3.

-insert tables 1,2 and 3 about here–

Main effects of generation (ME GEN)

i) Eating behaviour (Table 1)

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The results showed significant main effects of generation for all measures of eating

behaviour. Post hoc t tests showed that daughters consumed poorer diets and

specifically consumed fewer healthy snacks, fewer healthy drinks, more unhealthy

snacks and unhealthy drinks and were more likely to use unhealthy food preparation

techniques than either their mothers (all p values<0.05) or grandmothers (all p

values<0.05). Daughters also consumed fewer healthy meals than their mothers

(p<0.05) and were less likely to use healthy methods of food preparation than their

grandmothers (p<0.05). Results for mothers and grandmothers were comparable for

healthy and unhealthy snacks and drinks (all p values>0.05). Mothers, however,

consumed more healthy meals and fewer unhealthy meals than grandmothers (all p

values<0.05), and grandmothers used more healthy methods of preparation (p<0.05)

and fewer unhealthy methods of food preparation than mothers (p<0.05).

ii) Parental control (Table 2)

The results showed main effects of generation for overt, covert, restriction and

pressure as forms of parental control over food. Post hoc t tests showed that

daughters reported lower endorsement of all four of these forms of control compared

to their grandmothers (all p values<0.05), but whereas they were also different to their

grandmothers for restriction and pressure (all p values<0.05) they were comparable to

their mothers (all p values>0.05). No main effects of generation were found for

reward or monitoring.

iii) Parenting style (Table 3)

The results showed a significant main effect of generation for both the strict and

authoritative parenting styles but not for a permissive parenting style. Post-hoc t tests

showed that ratings for both a strict and permissive parenting style were different

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between grandmothers compared to both mothers (p<0.05) and daughters (p<0.05)

but similar between mother and daughters (p>0.05). Whilst a belief in a strict

parenting style decreased down through the generations and was greatest in

grandmothers, the belief in an authoritative style showed the reverse pattern and was

lowest in grandmothers.

iv) Mother-daughter relationships (Table 3)

The results showed a significant main effect of generation for all aspects of the

mother-daughter relationship. Post hoc t tests showed significant differences between

all generations for both the mother’s right to express body concern and the belief in

daughter’s autonomy (all p values<0.05). The results also showed significant

differences between the daughter’s beliefs about their mother’s autonomy compared

to their mother (p<0.05) and a difference between the mother’s beliefs and the

grandmother’s beliefs (p<0.05). Overall, the endorsement of mother autonomy and

mothers’ right to express body concern increased up through the generations and was

highest in grandmothers, whereas an endorsement of daughter autonomy decreased up

through the generations and was highest in daughters.

Main effects of nationality

i) Eating behaviour (Table 1)

The results showed significant main effects of nationality for all aspects of eating

behaviour, apart from healthy snacks and healthy meals. The means showed that

those from Mediterranean countries reported poorer diets which were higher in

unhealthy meals and unhealthy drinks, lower in healthy drinks and less likely to

involve healthy means of preparation. Those from the non-Mediterranean countries

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did, however, consume more unhealthy snacks and used more unhealthy means of

food preparation.

ii) Parental control (Table 2)

The results showed significant main effects of nationality for overt, covert, reward

and monitoring, but not for restriction or pressure. The means showed that those

from Mediterranean countries reported greater endorsement of overt and covert

control and reward, but a lower endorsement of monitoring.

iii) Parenting style (Table 3)

The results showed a significant main effect of nationality for both authoritative and

permissive parenting style, but not for a strict parenting style. The results showed

that those from Mediterranean countries showed greater endorsement of authoritative

parenting styles and those from the non-Mediterranean countries reported greater

endorsement of permissive styles.

iv) Mother-daughter relationships (Table 3)

The results showed significant main effects of nationality for all aspects of the

mother-daughter relationship. Whereas those from the Mediterranean countries

showed a stronger belief in the mother’s right to comment on her daughter’s body

size, those from non-Mediterranean countries reported greatest endorsement of both

mother’s and daughter’s autonomy.

Interactions between generation and nationality

i) Eating behaviour (Table 1)

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The results showed significant interactions between generation and nationality for

unhealthy food preparation, but no other measure of food intake. Post hoc t tests

showed that daughters reported higher levels of unhealthy food preparation in all

countries compared to their mothers (all p values<0.05) and grandmothers (all p

values<0.05). However, whereas mothers and grandmothers were comparable in non-

Mediterranean countries (p>0.05), mothers reported greater use of unhealthy

preparation compared to grandmothers in the Mediterranean countries (p<0.05). This

indicates that whilst the use of unhealthy food preparation methods has increased

across the three generations regardless of nationality, with this increase being greatest

for daughters, there is also a significant increase between mothers and grandmothers

in Mediterranean countries as well.

ii) Parental control (Table 2)

The results showed significant generation by nationality interactions for reward,

monitoring and pressure as forms of parental control. For both reward and pressure

post hoc t tests showed minimal differences between the generations for those from

non-Mediterranean countries (p>0.05), whereas participants from Mediterranean

countries showed consistent differences between the generations with grandmothers

reporting greater endorsement of these forms of controlling food compared to the

daughters (p<0.05). In contrast, for monitoring, the results showed no differences

across the generations for those from Mediterranean countries (all p values>0.05) but

significant differences between the grandmothers and daughters for the non-

Mediterranean countries (p<0.05). This suggests that whereas the use of reward and

pressure as a means to control a child’s food has become less common in recent

21

generations in Mediterranean countries, monitoring has become less common in non-

Mediterranean countries.

iii) Parenting styles (Table 3)

There were no generation-by-nationality interactions for parenting style, with those

from both Mediterranean and non-Mediterranean countries showing a similar increase

towards stricter forms of parenting across the generations.

iv) Mother-daughter relationships (Table 3)

The results showed significant generation by nationality interactions for a belief in

mother autonomy and the right of a mother to express her concern about her

daughter’s body shape. Post hoc t tests showed that for mother autonomy, whereas

those from Mediterranean countries showed a consistent difference across the three

generations (all p values<0.05) indicating a steady change in beliefs, those from non

Mediterranean countries showed a difference between daughters and both their

mothers (p<0.05) and grandmothers (p<0.05) but not between their mother and

grandmother (p>0.05) indicating a more recent shift. For beliefs about body shape

whereas those from Mediterranean countries showed differences between daughters

and both their mothers (p<0.05) and grandmothers but not between mothers and

grandmothers (p>0.05) a different pattern was shown for those from non-

Mediterranean countries. In particular, whereas grandmothers were different to both

daughters (p<0.05) and mothers (p<0.05) daughters and mothers were comparable

(p>0.05).

Discussion

22

The present study aimed to explore differences in BMI, eating behaviour and aspects

of the home environment across three generations of women. Further, the study also

explored the impact of nationality and involved four countries selected as either

Mediterranean (Malta and Greece) or non-Mediterranean (UK and Australia), so as to

explore whether nationality and adherence to a more traditional lifestyle could

illuminate differences in obesity prevalence.

In terms of differences across the generations, the results showed that although

daughters were lighter than their mothers and grandmothers, they generally reported

less healthy eating behaviour. In particular, the daughters reported less healthy diets

than both their mothers and grandmothers in terms of drinks, snacks, meals and food

preparation. In general, the results from mothers and grandmothers were

comparable, except that mothers showed healthier meal intakes and grandmothers

showed healthier modes of food preparation. The results also showed consistent

differences across the generations for aspects of the home environment in terms of

parental control, parenting styles and the mother –daughter relationship. In

particular, an endorsement of attempts to control food intake by overt or covert

control, restriction or pressure, increased across the generations, as did the

endorsement of both strict and authoritative parenting styles, a belief of a mother’s

own autonomy and the mother’s right to comment on her daughter’s body shape. The

only aspect of the home environment to show the reverse pattern was an endorsement

of the daughter’s autonomy which was, predictably, greatest in daughters. In sum,

the results indicate that the younger generation of daughters had a less healthy diet

(although were still lighter), a less controlling attitude to food and parenting and a

stronger belief in the daughter’s compared to the mother’s autonomy, whereas

23

grandmothers and mothers had a healthier diet and a more controlling approach to the

home environment.

The results also showed differences by nationality and indicated that in

general those from the Mediterranean countries were heavier and least healthy in

terms of their drinks, meals and food preparation and in the main endorsed a more

controlling home environment. Furthermore, those from Malta and Greece reported

the highest BMIs. Those from the UK and Australia did, however, consume more

unhealthy snacks and were more likely to use unhealthy methods of food preparation.

They were also more likely to endorse monitoring as a method of parental control and

showed greater endorsement of both the mother’s and daughter’s autonomy. These

results suggest strong differences between nationalities and in the main reflect the

ways in which Mediterranean countries have more unhealthy diets and tend to endorse

more traditional, controlling and hierarchical approaches to the home environment

compared to the non-Mediterranean participants.

Finally, the study explored whether changes across the three generations

varied according to nationality. The results from this analysis were complex and

varied but in general provide some insights into changes across the generations and

whether the greatest changes occur between daughters and their mothers, or between

mothers and the grandmothers. Overall, the results showed that UK and Australian

triads showed the least differences between generations, and although daughters were

mostly different to their grandmothers in terms of diet and beliefs about the home

environment, similarities were often found between daughters and their mothers. In

contrast, families from the Mediterranean countries showed more marked differences

between the generations, not only between daughters and grandmothers, but also

24

between mothers and grandmothers and mothers and daughters. Generational

changes seem to therefore have occurred more clearly in Mediterranean countries than

in the UK or Australia.

Over the past fifty years there has been a profound increase in the rates of

obesity across the Western world. The results from this quasi longitudinal study

provide some insights into the role of both eating behaviour and home environment

on this shift in body weight. First, in terms of eating behaviour, the results indicate

clear differences across the generations with daughters showing poorer diets in terms

of snacks, meals, drinks and food preparation. Furthermore, the results also indicate

that the diets of those participants from Mediterranean countries were generally less

healthy, apart from their consumption of snacks and unhealthy food preparation,

which was higher in non-Mediterranean countries. This provides support for the

deterioration in eating behaviours over the past few decades (Australian Bureau of

Statistics, 2012; Bellizzi, 1993; Office for National Statistics, 2002; Wardle, 1995). It

also suggests that the marked increase in obesity, particularly in Mediterranean

countries such as Greece and Malta, must be linked to changes in diet (National

Statistics Office, 2009).

Second, in terms of the home environment, the results also indicate a clear

shift across generations towards a less controlling model for parental control over

food, parenting styles and the mother-daughter relationship. These results provide

empirical evidence for changes in parenting beliefs and the mother–daughter

relationship, with a shift towards more permissive and liberal approaches (Gardner et

al., 2012). They also indicate that beliefs about control over food have also changed

towards a similarly less controlling perspective. Accordingly, as the prevalence of

25

obesity has increased and diets have deteriorated, home environments have become

less controlling, suggesting that the increase in obesity may have been facilitated

through a shift towards a more permissive family. In particular, at a time when the

obesogenic environment has been making it easier to overeat and under-exercise, a

more controlling family life may have been more beneficial to prevent weight gain.

Those from Mediterranean countries, however, showed both poorer diets and

endorsed a more traditional and controlling family life, which appears contradictory to

the above suggestion. Perhaps this conflict can be understood in terms of the degree

of difference across generations and the changing nature of relationships in more

traditional countries such as Greece and Malta compared to family life in the UK and

Australia. The results not only indicated differences between Mediterranean and non-

Mediterranean participants but also how those from Mediterranean countries showed

greater disparity within the family triads. In particular, although daughters from both

Mediterranean and non-Mediterranean countries similarly endorsed a less controlling

home environment, those from Greece and Malta showed a stronger shift away from

the beliefs of both their mothers and grandmothers. Greece and Malta both have a

recent history of closer knit families, who stay living close by and often share the

responsibility of child care. Furthermore, their culture reflects more traditional set of

boundaries and control and children often remain at home until they marry, and even

then, may well live in close contact to either their own or their partner’s family. In

contrast, non-Mediterrannean countries tend to show a more mobile and laissez faire

approach to family life and although some children may well stay at home whilst

studying, they tend to have more independence even when within the family home. In

terms of eating behaviour, therefore, it could be argued that for all participants there

has been a shift towards unhealthy eating habits in part relating to a shift towards a

26

less controlling home environment. But whereas for those from non-Mediterranean

countries this has been a steady shift in attitudes caused by the gradual passage of

time, in Mediterranean countries these changes reflect a more dramatic recent shift in

attitudes as the younger generations of daughters feel the need to react against the

stronger controlling views of the family they are still under the control of.

Accordingly, a less controlling home environment in terms of parental control over

food, parenting styles and the mother-daughter relationship may be associated with

poorer diets and potential weight gain for all participants, but in Mediterranean

participants this shift may also reflect a reaction against traditional family life and a

more dramatic change not only in attitudes to family relationships but also to eating

habits.

There are however, several limitations which this study that need to be

considered. First, although collected from three generations, the data is cross-

sectional and conclusions about causality or even association cannot be made.

Accordingly, parallel shifts in obesity, diet and the home environment may have

occurred but do not necessarily imply that a shift in one variable caused a shift in

another. Therefore whilst data collected across generations offers a contemporary

snapshot of beliefs and behaviours, it is not clear whether these views are constant

and reflect the views held in the present day, or the past. Second, although changes in

the prevalence of obesity have been reliably documented, this data is at the population

level whereas our data is from the individual. This leads to the problem of the

ecological fallacy and again conclusions about causality need to be cautious. Further,

our measure of ‘nationality’ was limited and simplistic. In particular, we asked

participants to describe ‘what is your nationality’ and asked for responses from those

who had a consistent nationality across all three generations. Accordingly, we

27

included those who described themselves as ‘British’, ‘Greek’, ‘Maltese’ or

‘Australian’ and it is highly likely that their nationality was more complex than this.

In fact, some of our ‘Australian’ sample, in particular, described joint nationality and

therefore many well hold many of the cultural beliefs and practices of our other

groups which could cause contamination between our samples. In addition, although

we have triads of women from one family, it may have been that the grandmothers

were not the mothers of the mothers. This was our inclusion criteria as a means to

enhance recruitment, yet has implications for concluding generational transmission

between generations. Our aim however was to access three generations across a

period of time rather than three generations that were biologically connected. There

are therefore some problems with our methodology. Given that changes in obesity

have occurred over the past 50 years, however, and that data on eating behaviours and

the home environment was not collected either at this time or subsequently, the

present quasi longitudinal design provides some preliminary insights into potential

relationships between the variables studies.

To conclude, rates of obesity have increased over the past 50 years across

most of the Western world, but this increase has been particularly marked in recent

years in Mediterranean countries such as Greece and Malta. The results from this

quasi longitudinal study showed a deterioration in diets in terms of snacks, drinks,

meals and food preparation across three generations of women and that the diets of

those from Mediterranean countries tended to be the least healthy. Further, the

results indicates that beliefs about the home environment have become increasing

permissive in terms of parental control over food, parenting styles and the mother-

daughter relationships. It would therefore seem that the increase in obesity parallels

not only a deterioration in eating habits but also reflects a move towards less parental

28

control in a number of domains. Perhaps in a time of the obesogenic environment a

more controlling home environment would have been beneficial to help prevent the

rise in body weight. However, given that the poorest diets were also found with the

Mediterranean daughters who also reported more controlling family members, a

history of too much control by families in the past may offer daughters an opportunity

for rebellion which in turn may have exacerbated the obesity crisis as food becomes

the perfect tool to use to rebel against their traditional lifestyle. In summary, some

level of control in a home environment may be helpful to ameliorate the impact of an

obesogenic environment. But a history of too much control may have paradoxically

exacerbated the obesity crisis in those countries that had the diet the rest of the world

was aiming for: the Mediterranean diet.

29

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