DEVELOPING EDUCATIONAL MESSAGES: A QUALITATIVE STUDY WITH ASIAN
INDIAN MOTHERS TO UNDERSTAND THEIR ATTITUDES, BARRIERS, AND
FACILITATORS IN PRACTICING CHILD FEEDING BEHAVIORS
By
Shabnam Riyazali Momin

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Human Nutrition
2012

ABSTRACT
DEVELOPING EDUCATIONAL MESSAGES: A QUALITATIVE STUDY WITH
ASIAN INDIAN MOTHERS TO UNDERSTAND THEIR ATTITUDES, BARRIERS, AND
FACILITATORS IN PRACTICING CHILD FEEDING BEHAVIORS
By
Shabnam Riyazali Momin
A dramatic increase in the prevalence of childhood overweight has been observed among
all ethnic and racial groups. The risk of overweight for Asian Indian children increases with
longer residence and acculturation to the US. In addition, a shift to a higher proportion of Asian
Indians born in the US is likely to result in higher rates of overweight in Asian Indian children.
Parents, particularly mothers, are key in developing a home environment that fosters healthful
eating among children via use of specific child feeding behaviors. Positive feeding behaviors
such as regular family meals, parental modeling of healthy eating, and availability and
accessibility of healthy foods at home are shown to have healthy nutrition outcomes in children.
Negative behaviors such as letting children watch TV while eating may lead to overconsumption
of energy. Negative behaviors which are also controlling such as pressuring children to eat,
offering one food as a reward to eat another, and restricting children’s consumption of certain
foods may increase children’s risk for overweight by disrupting their natural ability to selfregulate energy intake.
This study was conducted into two stages: 1) assessment stage and 2) message
development and testing stage. Using the Theory of Planned Behavior as a conceptual
framework, the first stage used qualitative methodology to assess how Asian Indian mothers’
underlying beliefs about expected outcomes of feeding behaviors, perceived behavioral control,
and subjective norm influenced their feeding behaviors. In-depth interviews were conducted with

27 Asian Indian mothers (of children 5-10 years old) using projective techniques. The findings
revealed that Asian Indian mothers were highly motivated by nutrition outcomes when practicing
all feeding behaviors. Cultural beliefs related to religion, ethnic identity, and traditional foods
also influenced the practice of feeding behaviors. Pressuring to eat was often practiced despite
the perception of ineffectiveness. Use of food rewards and TV to control children’s food intake
despite the clear understanding of undesirable nutrition outcomes was found.
In stage two, nine nutrition education messages were adapted from those developed by
the United States Department of Agriculture and 29 new messages were developed based on
behavioral beliefs, facilitators, and barriers unique to Asian Indian mothers identified in stage 1
of this research. These messages were tested using cognitive interviews with ten AI mothers for
comprehensibility, agreeability with the information, and feasibility of acting on the message.
Mothers were receptive to 31 messages, with minor revisions made to five messages to improve
clarity and increase acceptability. Two messages that received strong negative responses were
deemed inappropriate for this population. Nutrition professionals working with Asian Indian
families may use the final messages in education materials to help mothers develop healthy child
feeding practices.

Copyright by
SHABNAM RIYAZALI MOMIN
2012

This dissertation is dedicated to my sweet daughter Ziya, for she is my strength and motivation
to continue helping mothers accomplish their child feeding goals.

v

ACKNOWLEDGEMENTS
This dissertation would not have been possible without the support and assistance from
several people. I would like to express my deepest gratitude to my advisor, Beth Olson, who
accepted me as her graduate student and provided several opportunities to develop and hone my
skills as a researcher. Her continuous encouragement, guidance, and support from the initial to
the final level enabled me to complete this dissertation successfully. I also owe my deepest
gratitude to my committee member Kim Chung for not only providing me with the
understanding of qualitative research, but also her constant motivation made me work harder
each day. Her unique approach toward teaching helped me think about the subject matter in a
way I would not normally have thought. I must also thank my committee members Millie
Horodynski and Mike Hamm for their support and encouragement. Their constructive criticism
during the conceptualization of my research project, proposal writing, and dissertation writing
was invaluable and helped me develop the end product that I have today.
This research would not have been possible without the financial support from the
Michigan Agricultural Experiment Station. I also thank the department of Food Science and
Human Nutrition for supporting my education. Additionally, I would also like to thank, India
Cultural Society, Bharatiya temple, Indian Council, and www.miindia.com who graciously
provided me the avenues through their organizations to recruit the participants for my research.
My special thanks to Subeda Shaik who allowed me use her family pictures for research. I am
also very grateful to all the participants of this study who offered their time and shared their
thoughts to make this study possible.

vi

My gratitude goes to all my friends and colleagues in the lab, Tan Chow, Tracie Bolton,
and Sarah Hojonacki whose help with reviewing my materials and developing my thoughts will
always be appreciated. I miss those deep conversations with Tan Chow where I was actually able
to figure out some complicated things pertaining to my research. My thanks to Lindsay Angst for
her assistance in analysis of qualitative data.
I would like to thank my friends and family in the US and in India for having immense
confidence in me. My parents who have been a driving force behind my education since I was a
child. I cannot thank them enough for the sacrifices they have made to make my education
possible. My mother-in-law who lived with us for four months to care for my baby girl so I could
focus on completing my dissertation. I am also very grateful to Aunt Sully, and my dear friend
Fahmida who took care of my daughter while I was writing my dissertation.
Finally, special thanks to my daughter Ziya Momin and my husband Riyaz Momin.
Thank you Ziya for letting me spend your much deserved time on my dissertation. I will never be
able to thank Riyaz enough for his patience, encouragement, technical support, and always
offering his shoulder to vent during those tough times. Riyaz, this would not have been possible
without you!

vii

TABLE OF CONTENTS
LIST OF TABLES ................................................................................................. ix
LIST OF FIGURES ............................................................................................... xi
CHAPTER ONE: INTRODUCTION ..................................................................... 1
Review of Related Literature ...................................................................................6
Asian Americans and Asian Indians in the US ............................................6
Immigration of Asian Indians to the US and their Characteristics ..............7
Acculturation and Eating Patterns of Asian Indians ....................................9
Health Issues Concerning Asian Indians ...................................................10
Prevalence of Childhood Overweight in the US ........................................12
Health Issues Concerning Childhood Overweight .....................................14
Ecological Model of Childhood Overweight .............................................15
Home Food Environment and Parents’ Role in Feeding Children ............18
Family meals ......................................................................................18
Television viewing and eating............................................................21
Food availability and accessibility .....................................................21
Parental modeling ...............................................................................23
Parenting styles and feeding Styles ....................................................25
Parenting practices and feeding Practices ..........................................27
Parenting beliefs of Asian Indians ......................................................32
Parental beliefs about food and health ...............................................34
Parental motivations and barriers to health-promoting behaviors......36
Project Justification................................................................................................38
Theoretical Framework for Research.....................................................................40
CHAPTER TWO: CHILD FEEDING BEHAVIORS OF ASIAN INDIAN
MOTHERS ............................................................................................................45
Abstract ..................................................................................................................45
Introduction ............................................................................................................46
Methods..................................................................................................................48
Study Design ..............................................................................................48
Interview Guide .........................................................................................49
Interview Process .......................................................................................49
Data Analysis .............................................................................................50
Results ....................................................................................................................51
Discussion ..............................................................................................................58
Implications for Research and Practice..................................................................61
CHAPTER THREE: DEVELOPING AND TESTING NUTRITION
MESSGES FOR ASIAN INDIAN MOTHERS ....................................................64
Abstract ..................................................................................................................64
Introduction ............................................................................................................65
viii

Methods..................................................................................................................66
Step1 ..........................................................................................................67
Step 2 .........................................................................................................67
Step 3 .........................................................................................................68
Results ....................................................................................................................69
Discussion ..............................................................................................................75
Conclusions and Implications for Practitioners .....................................................78
CHPATER FOUR: CONTRIBUTIONS, RECOMMENDATIONS,
LIMITATIONS, AND CONCLUSIONS ..............................................................85
Contributions..........................................................................................................85
Recommendations for Future Research .................................................................87
Strengths and Limitations ......................................................................................88
Conclusions ............................................................................................................90
Appendix A: Interview Guide for Research Stage1 ..............................................92
Appendix B: Demographic Form...........................................................................95
Appendix C: Interview Picture Cards for Stage 1 .................................................98
Appendix D: Suinn-Lew Asian Self-Identity Acculturation Sscale
(SL-ASIA)............................................................................................................101
Appendix E: Coding Structure .............................................................................106
Appendix F: Additional Themes from Stage 1 ....................................................126
Appendix G: Interview Guide for Research Stage 2 ...........................................129
Appendix H: Frequency Sheets for Message Development ................................130
BIBLIOGRAPHY ................................................................................................142

ix

LIST OF TABLES
Table 2-1: Demographic Information of Participants ............................................63
Table 2-2: Coding Structure and Code Definitions .............................................106
Table 2-3: Themes for Availability, Accessibility and Restricting
Consumption of Certain Foods ............................................................................126
Table 2-4: Themes for Evaluation of Behavioral Beliefs and
Subjective Norm ..................................................................................................128
Table 3-1: Nutrition Messages Related to Mealtime Environment .......................79
Table 3-2: Nutrition Messages Related to Food Availability and
Accessibility at home .............................................................................................81
Table 3-3: Nutrition Messages Related to Controlling Child
Feeding Behaviors .................................................................................................83
Table 3-4: Frequency Sheet for Family Meals ....................................................130
Table 3-5: Frequency Sheet for Parental Modeling .............................................132
Table 3-6: Frequency Sheet for Food Availability ..............................................133
Table 3-7: Frequency Sheet for Food Accessibility ............................................135
Table 3-8: Frequency Sheet for TV Viewing while Eating .................................136
Table 3-9: Frequency Sheet for Pressuring Children to Eat ................................137
Table 3-10: Frequency Sheet for Using Food as Rewards ..................................139
Table 3-11: Frequency Sheet for Restricting Consumption of Certain Foods.....140

x

LIST OF FIGURES
Figure 1-1. Research Stages .....................................................................................5
Figure 1-2. Ecological Model of Childhood Overweight ......................................17
Figure 1-3. Theory of Planned Behavior ...............................................................42
Figure 1-4. Theory of Planned Behavior Applied to Child Feeding Behaviors ....43
Figure 2-1. Family meal .........................................................................................98
Figure 2-2. Parental modeling................................................................................98
Figure 2-3. Making healthy foods available ..........................................................98
Figure 2-4. Making healthy foods accessible ........................................................99
Figure 2-5. TV viewing and eating .......................................................................99
Figure 2-6. Pressuring children to eat ....................................................................99
Figure 2-7. Offering food rewards .......................................................................100
Figure 2-8. Restricting children’s consumption of certain foods ........................100

xi

CHAPTER ONE:
INTRODUCTION
Worldwide, the prevalence of overweight among children has increased dramatically. In
particular, the United States is at the top of prevalence rankings. According to the NHANES
data, the prevalence of overweight among children and adolescents, defined as the Body Mass
index (BMI) at or above the 95th percentile of the gender-specific BMI growth charts
(Kuczmarski et al., 2002), increased significantly between 1999-2000 and 2003-2004 (Ogden et
al., 2006). Over this period the prevalence of overweight increased from 10.3 to 13.9% for
children aged 2-5 year, from 15.1 to 18.0% for children aged 6-11 years and from 14.8 to 17.4%
for adolescents aged 12-19 (Ogden et al., 2006). Although the recent data from NAHANES
showed that the prevalence of childhood overweight has been steady over the period of ten years,
the rates still remain high (Ogden et al., 2010). The prevalence of childhood overweight is rising
in all ethnic and racial groups in the US (Ogden et al., 2008).
Asian American is one of the largest, most diverse, and fastest growing ethnic minority
populations in the US (US Bureau of Census, 2010). There are fewer US data on the health and
weight status of Asian American children compared to the children of other ethnic groups
(Popkin & Udry, 1998; Thorpe et al., 2004). Using the 85th percentile as a cutoff point for
overweight, the National Longitudinal Study of Adolescent Health reported that 20.6% of the
Asian American adolescents were overweight (Popkin & Udry, 1998) and a study of New York
elementary school children reported the rate of overweight was 30.2% for Asian American
children (Thorpe et al., 2004). Although the rates of childhood overweight reported in these
studies were lower compared to other ethnic groups, the risk of overweight in Asian Americans

1

increases with acculturation to the US (Lauderdale & Rathouz, 2000), duration of residence in
the US, and birth in the US (Popkin & Udry, 1998).
The epidemic of overweight and obesity inflicts significant disadvantages on both the
individual and the society due to increased risk of disease and death, and health care costs
(Allison, Zannolli, & Narayan, 1999; Must & Strauss, 1999). Asian Indians, in particular, are at a
high risk of chronic health conditions such as diabetes, hypertension, cardiovascular disease and
associated complications from these conditions (Dowse et al., 1990; Kim et al., 1976; McKeigue
et al., 1989; Ramachandran et al., 1992; Singh et al., 2001). In addition, in adults, a BMI below
the usual cutoff for obesity is associated with higher health risks in people of Asian origin when
compared to other populations (Misra, 2003). Therefore, a lower prevalence of overweight in
Asian American children does not necessarily reflect an equivalent lower level of health risk.
Asian Indians make up the third largest Asian population, and represent one of the fastest
growing populations in the United States (US Bureau of Census, 2010). By the year 2050, the
number of Asian Indians living in the United States is predicted to be at two million (Bouvier &
Agresta, 1985; O’Hare & Felt, 1991). It is also estimated that the proportion of overweight in
Asian Indians will increase with more US-born Asian Indians and longer residence in the US
(Lauderdale & Rathouz, 2000). As a result, research addressing this population is critically
important. Unfortunately, practically no health education or promotion intervention has been
designed in the US to prevent overweight specifically for Asian Indian community (Sharma,
2006).
Although the etiology of overweight is mulifactorial, parental role in feeding children has
been implicated as an important influential factor in affecting children’s eating and weight status
(Patrick & Nicklas, 2005; Rhee, 2008; Ventura & Birch, 2008). Parents, particularly mothers are

2

critical in fostering healthful eating among children via several ‘child feeding behaviors’ (Patrick
& Nicklas, 2005; Ritchie et al., 2005). Studies have shown relationships between children's food
choices and direct feeding behaviors such as pressuring children to eat, restricting children’s
consumption of certain foods, and offering one food as a reward for eating another (Birch &
Fisher, 1998). Behaviors indirectly related to feeding children by providing an environment such
as, parental modeling (Birch & Marlin, 1982), making healthy foods available and accessible at
home (Baranowski et al., 1999), having regular family meals (Gillman et al., 2000), and allowing
children to watch television viewing during eating (Francis & Birch, 2006) also influence
children’s eating habits. Targeting these feeding behaviors that are relevant to childhood
overweight is a highly promising strategy for childhood obesity prevention (Lindsay et al.,
2006). However, studies on child feeding behaviors of Asian Indians living in the US are limited.
Parental child feeding behaviors have been targeted in health and nutrition education
programs aimed at childhood overweight prevention. Recently, United States Department of
Agriculture (USDA) and Food and Nutrition Services developed nutrition messages to address
most, but not all, child feeding behaviors (United States Department of Agriculture [USDA],
2008). These messages were developed based on qualitative assessment of child feeding
behaviors of low-income Caucasians, African Americans, and Mexican American mothers; they
may not be applicable or may need to be adapted for use with Asian Indian mothers.
Construction of clear, effective, and culturally relevant messages, therefore, requires a careful
assessment of current child feeding behaviors of Asian Indian mothers.
This study was conducted in two stages (Figure 1-1). Stage 1: the assessment stage
consists of theory driven assessment (Theory of Planned Behavior) of underlying motivators and
barriers in practicing child feeding behaviors. Theory of Planned Behavior (Ajzen, 1991)

3

explains the behavior by examining perceived motivations, social context, and facilitators and
barriers in relation to the behavior. Stage 2: the message development stage consists of
development and testing culturally appropriate educational messages containing
recommendations for appropriate feeding behaviors. Information in stage 1 was used a guiding
framework for developing the messages.

4

Identify & understand underlying factors that influence
Asian Indian mothers’ practice of child feeding behaviors

•
•

Framework – Theory of Planned Behavior

Qualitative assessment of child feeding behaviors

Stage 1:
Formative
Assessment

Develop nutrition messages addressing child feeding
behaviors for Asian Indian mothers

Test nutrition messages with Asian Indian
mothers

Refine messages

Final messages

Figure 1-1. Research Stages

5

Stage 2:
Message
Development

The remainder of this chapter is devoted to reviewing relevant literature to provide the
reader with an understanding of the research area and emphasize the need for research study.
First few sections provide an overview of Asian Indians including their background, immigration
history and demographic and cultural characteristics, dietary acculturation and eating habits, and
health issues concerning Asian Indians. The next few sections discuss prevalence of childhood
overweight in the US and associated health concerns. An ecological model of childhood
overweight followed by home food environment and parental role in feeding children is
discussed to provide an understanding of importance of eight child feeding behaviors studied in
this research. Finally, parental beliefs about food and health of children followed by motivators
and barriers in health promoting behaviors are provided.

Review of Related Literature

Asian Americans and Asian Indians in the US
The term Asian refers to people having origins to any of the original populations of the
Far East, South East Asia, or the Indian subcontinent (Barnes & Bennett, 2002). Asian
Americans are a heterogeneous population living throughout the United States, and are
characterized by a wide variety of languages, dialects, and cultures. Asian population is one of
the largest, most diverse, and fastest growing ethnic minority populations in the US (US Bureau
of Census, 2012). According to the US Bureau of Census (2012), the total Asian population in
the US increased by 43% from 10.2 million to 14.7 million (2012). Asian Indians are the people
who originate from India. India is an ancient country immersed in diversity in terms of caste,
religious groups, and languages (Kakar, 1978; Ross, 1967). They are part of the larger subgroup
of Asians known as South Asians. In addition to Indians, South Asians include people from
6

Pakistan, Bangladesh, Nepal, Burma, Sri Lanka, Afghanistan, Bhutan, and the Maldives. Asian
Indians make up the third largest Asian population, and represent one of the fastest growing
populations in the US (US Bureau of Census, 2010). By the year 2050, the number of Asian
Indians living in the US is predicted to be at two million (Bouvier & Agresta, 1985; O’Hare &
Felt, 1991).

Immigration of Asian Indians to the US and their Characteristics
In the US, as a result of the 1965 Immigration Act, visas were extended to Asian Indians
who were mainly college-educated urban middle-class professionals, or to those who sought
advanced university training as graduate students (Das & Kemp, 1997). Since then the number of
Asian Indians grew rapidly in the US. Asian Indians are often characterized as being a part of
model minority with the human capital characteristics necessary for socioeconomic success. For
example, Asian Indians are more highly educated than the overall US population. The data from
the US Bureau of Census (2000) show that highest percentage of Asian Indians (64%) have a
Bachelor’s degree compared to other Asian groups in the US and the total US population. India
was under British rule for about 200 years and till today English has continued to remain as one
of the official languages used in India for higher education, and to conduct official businesses
and commercial transactions. As a result, Asian Indian immigrants especially coming from urban
areas of India to the US are proficient in both spoken and written English language (Dasgupta,
1989; Mehta & Belk, 1991; US Bureau of Census, 2000).
There is a highest percentage (77%) of Asian Indian men in the labor force compared to
men from other Asian groups in the US and the total US population, and 54% of Asian Indian
women are in the labor force (US Bureau of Census, 2000). Typically, Asian Indians are

7

described occupationally as belonging to the professional and managerial class (Fernandez &
Liu, 1986). Compared to 34% of the overall US population and 45% of the total Asian
population, 60% of Asian Indians were in management, professional, and related occupation (US
Bureau of Census, 2000). In addition, Asian Indian men ($ 51, 904) and women ($35,173) had
the highest median earning of all Asian men/women and all US workers. The median annual
income of Asian Indian families was also higher ($70, 849) than the median of all families in the
US as well as all other Asian families in the US. While the overall US poverty rate was 12.4 %,
it was 9.9 % for Asian Indians, which was also lower than all other Asian population in the US
(US Bureau of Census, 2000). Low-income, poverty levels, and higher unemployment rates are
not likely to exist among this group of immigrants (Khairullah & Khairullah, 1999). These
characteristics suggest that Asian Indians have assimilated very well economically into
American society.
Studies show that Asian Indian immigrants have a tendency for bicultural functioning
mainly because of their prior experience with the British colonial rule of India (Kurian & Ghosh,
1983; Saran, 1985; Wakil, Siddique, & Wakil, 1981). Although, Asian Indians are fluent in
English and have had some exposure to Western values (Leonard-Spark & Saran, 1980), studies
have also reported that some Asian Indian immigrants in Western cultures continue to hold on
their traditional values, beliefs, and expectations as a part of their lifestyle. Therefore, they tend
to maintain a relatively collectivistic orientation (i.e. emphasizing the extended family,
traditional gender roles, obedience to elders, and group interdependence), many years after
immigration (Patel, Power, & Bhavnagri, 1996; Segal, 1991; Sodowsky, Kwam, & Pannu, 1995).
In general, the pattern commonly noted for many Asian Indian immigrants is that they tend to
affirm their ethnicity, often by ‘reinventing’ Indian culture on foreign soil (Dasgupta, 1998).

8

Thus, Asian Indian immigrants may be more ‘Indian’ than the people they left behind and/or
may retain a sense of a culture that no longer exists in India (Dasgupta, 1998). These
characteristics suggest that Asian Indians do not culturally assimilate completely into American
society.
Religion is an important facet of Asian Indian culture and, as such, is a potential
influence on acculturation preferences (Mulatti, 1995). Asian Indian immigrants as a group tend
to be highly religious, often more so in the host society than they were in India (Williams, 1988).
Research on Asian Indian and other immigrant groups has found that religious activities serve to
reinforce participants’ ethnicity, bind them more closely to their particular ethnic group, and
familiarize the next generation with their heritage and traditions (Dasgupta, 1998; Sheth, 1995;
Williams, 1988).

Acculturation and Eating Patterns of Asian Indians
The term ‘acculturation’ refers to the process by which racial/ethnic minority individuals
adapt to the dominant culture and the resulting changes in their beliefs, values, and behavior
from coming in contact with the new culture and its members (Sam & Berry, 1995). “Dietary
acculturation” refers to the process that occurs when members of a migrating group adopt the
eating patterns/food choices of the new environment (Negy, 1992; Satia et al., 2001). Research
indicates that as a part of acculturation process, Asian immigrants may retain certain traditional
foods, find new ways to use traditional foods, exclude other foods, and/or consume new (nontraditional) foods (Pan et al., 1999) resulting in healthful and/or unhealthful dietary changes.
Very few studies have examined the dietary intake of Asian Indian population in the US.
Early studies have found that acculturative changes in Asian Indian’s eating patterns include

9

altered vegetarian status and meal patterns, changes in the frequency of use of Asian Indian
foods, and inclusion of other ethnic foods (Gupta, 1976; Karim et al., 1986). According to Raj
(1999), consumption of traditional mixed dishes based on cereals, legumes, and/or vegetables
decreased after coming to US due to lengthy preparation time required for many dishes. Frequent
consumption of non-traditional foods such as cola beverages, pizza, mayonnaise, and cookies
was observed among one third of the respondents. Jonnalagadda and Diwan (2002) found that
the nutrient intake of Gujarati Asian Indian immigrant showed both inadequacies and excesses of
select macro and micronutrients suggesting that these nutrient inadequacies and excesses can
impact the overall health and risk of chronic diseases of these individuals. There were significant
differences in macronutrient intake based on the duration of stay in the United States. Another
study by Jonnalagadda et al. (2005) indicated the dietary intake of Asian Indian does not meet
the established US dietary guidelines. A survey of food consumption practices among Asian
Indian adults in the New York City and Washington, D.C. areas showed that acculturation of this
population in the US has led to more frequent selection of American or other ethnic foods for
main meals and replacement of traditional sweets with cookies, doughnuts, and other Western
pastries. Research has shown that dietary changes are associated with increased risk of
abdominal obesity, diabetes, and cardiovascular disease, along with certain cancers (breast,
colorectal, and prostrate), demonstrating possible negative influence of dietary acculturation
(Wahlqcist, 2002).

Health Issues Concerning Asian Indians
Many studies have reported high rates of diabetes, coronary heart disease (CHD), and
hypertension among South Asians worldwide. Studies in the United Kingdom have found that

10

South Asians' risk of CHD death is as much as 40% above whites, and that they have a 2 to 3
fold higher incidence of hypertension and diabetes compared to white population in the UK
(Cappuccio et al., 1997; Cappuccio et al., 2002). Studies of South Asians in the United Kingdom
(Landman et al., 2001) and other countries (Dowse et al., 1990; Middelkoop et al., 1999) have
shown a high prevalence of diabetes and a few studies of South Asians in the United Kingdom
found lower Body mass indices (BMI) despite high rates of diabetes (Patel et al., 1999). The
South Asian Association for Regional Cooperation (SAARC) reported that cardiovascular
disease mortality and morbidity, as well as non-insulin-dependent diabetes, among expatriate
South Asian populations are higher than in any other expatriate ethnic group worldwide
(Srivastava, 2002).
Studies suggest that Asian Indians in particular, are at increased risk for any level of
obesity and central fat distribution, when compared to European descent persons (Dowse et al.,
1990; Kim et al., 1976; McKeigue et al., 1989; Ramachandran et al., 1992). Health issues facing
the Asian Indian immigrant population include diabetes, hypertension, cardiovascular disease,
and the associated complications from these conditions. A study conducted in 1996 including
1,688 immigrants Asian Indians reported a higher prevalence of CHD and non-insulin dependent
diabetes Mellitus compared to the US White population (Enas et al., 1996). Other studies,
however, have found high rates of CHD but not hypertension among Asian Indians (Enas et al.,
1996; Jha et al., 1993)
Studies have also noted a difference in the prevalence of chronic diseases in native and
immigrant Asian Indians in the western countries. Asian Indian immigrants in several western
countries, such as UK and Canada, have been found to be at greater risk of morbidity and
mortality as compared to the native and other immigrant populations (Anand et al., 2000;

11

McKeigue et al., 1989; McKeigue et al., 1991). In immigrant Asian Indians, prevalence of
hypertension (12-20%), diabetes (6-8%), and coronary heart disease (7-14%) has been found to
be higher than native rural Indians residing in India and Western populations (Singh et al., 2001).
Another major concern for Asian Indians in the US and in western countries is the
increased risk of becoming overweight. Many immigrants originate from the countries where the
prevalence of overweight is lower than it is in the US (Gordon-Larson et al., 2003; Singh et al.,
2001), and they are in better health than their counterparts who were born in the US (Frisbie et
al., 2001). However, these health advantages decrease with their duration of residence. The
likelihood of becoming obese increases the longer the immigrants live in the US (Gordon-Larson
et al., 2003; Frisbie et al., 2001). Studies have found that the prevalence of obesity among adult
immigrants living in the US for the last 15 years approached that of adults born in the US
(Gordon-Larson et al., 2003; Ogden et al., 2006; Wee, 2004). This evidence indicates that after
immigration to the US, the immigrants are more likely to become obese and develop negative
health conditions.

Prevalence of Childhood Overweight in the US
The prevalence of overweight and obesity is considered as an important public health
issue in the US (Healthy People 2020, 2010). Healthy People 2020 identified overweight and
obesity as 1 of the 10 leading health indicators. According to the recent estimates of the
prevalence of overweight, 10.7% of children aged 2 to 5 years and 17% of children aged 6 to 11
years are overweight in the US (Healthy People 2020, 2010). Data from two NHANES surveys
(1999–2000 and 2003–2004) show that the prevalence of overweight is increasing: for children
aged 2–5 years, prevalence increased from 10.3% to 13.9%; for those aged 6–11 years,

12

prevalence increased from 15.1% to 18.8%; and for those aged 12–19 years, prevalence
increased from 14.8% to 17.4%. Although the recent data from NAHANES showed that the
prevalence of childhood overweight has been steady over the period of ten years, the rates still
remain high and are not declining (Ogden et al., 2010). Recent research conducted by Basu
(2010) forecasted the distribution of BMI in children (6–17 years) in the US by age group, sex,
and race over the period 2004–2014. This research showed that among children, stabilities within
BMI categories were low during 2004–2005, and compared with 2001–2002, transition
probabilities into overweight class 2 from other BMI categories increase substantially. Forecast
predicted significant increases in the risk of overweight category among children 6 to 9 years old
(5% to 14% in 5 years), with a greater increase anticipated in males.
There are few US data on the health and weight status of Asian Americans compared to
other ethnic groups. Gordon-Larsen and colleagues (2003) studied the data from 13,113 U.S.
adolescents from grades 7-12 enrolled in the National Longitudinal Study of Adolescent Health
and found the prevalence of overweight in Asian American male teens as 22.8% and female
teens as 10.4%. A study of New York elementary school children used BMI-for-age at or above
85

th

percentile as a cutoff for overweight. They found overweight rates of 14.4% and obesity

rates of 30.2% for Asian American from kindergarten to fifth grade (Thorpe et al., 2004). The
National Longitudinal Study of Adolescent Health has reported a high prevalence of overweight
(20.6%) in Asian American adolescents in grade 7-12 using 85

th

percentile as a cutoff for

overweight (Popkin & Udry, 1998). Although, these studies reported a lower rate of overweight
compared to other ethnic groups, the risk of overweight in Asian Americans increases with
acculturation to US (Lauderdale & Rathouz, 2000). According to the National Longitudinal
Study of Adolescent Health, Asian American adolescents born in the US to immigrant parents
13

are more than twice as likely to be overweight as foreign-born adolescents who move to the US
(Popkin & Udry, 1998).

Health Issues Concerning Childhood Overweight
The epidemic of overweight and obesity inflicts significant disadvantages on both the
individual and the society due to increased risk of disease and death, and health care costs
(Allison, Zannolli, & Narayan, 1999; Must & Strauss, 1999; Reilly et al., 2003; Finkelstein,
Fiebelkorn, & Wang, 2003). Childhood overweight has numerous psychosocial, physical, and
economic consequences. Childhood overweight affects self-esteem and has negative
consequences on cognitive and social development (Tremblay et al., 2000). Conditions such as
type 2 diabetes, diabetes mellitus, hypertension, and hypercholesterolemia, which were primarily
seen in adults, are becoming more common among children as the prevalence of overweight
increases (Must & Strauss, 1999). Because childhood overweight often persists into adulthood, a
rising number of adults will be at increased risk of these conditions as well as of cardiovascular
disease, osteoarthritis, and certain types of cancer (Manson & Bassuk, 2003). In general, obesity
epidemic constitutes a substantial decrease in quality of life and life expectancy and accounts for
billions of dollars in health care spending (Fontaine & Redden, 2003; Katzmarzyk & Janssen,
2004).
Lauderdale and Rathouz estimated (2000) that the proportion of overweight Asian Indian
children will increase with more US born Asian Indians and longer residence in the US, which
can be predicted to be very high due to the rapid influx of Asian Indians in the US over the past
years and in the future (Robert, New York Times, 2008). As a result, the number of Asian Indian
children with health complications associated with overweight will also increase. In addition, due

14

to the existing high risk of health conditions such as CHD, hypertension, and diabetes at a lower
BMI, the rise in prevalence of overweight will put Asian Indians in an exceedingly worse
situation than ever. The most effective way to reduce the rising trend in overweight is to
intensify the efforts to prevent overweight among children. Unfortunately, there are limited
health education or intervention programs to reduce overweight specifically for Asian Indians
(Sharma, 2006). This could also be due to the paucity of information on Asian Indian population
in the US. Furthermore, most of the current intervention programs in the US are targeted to lowincome groups. Asian Indians, in general, are affluent and are not welfare recipients and
therefore are not the primary target for most of the current overweight prevention efforts.

Ecological Model of Childhood Overweight
Davison and Birch (2001) developed the ‘Ecological Model of Predictors of Childhood
Overweight’ to better understand the influence of multiple factors on the development of
childhood overweight (Figure 1-2). This model is based on the Ecological Systems Theory (EST)
by Bronfenbrenner (1988). According to this model, child’s behavioral patterns such as dietary
intake, physical activity and sedentary behaviors (such as television viewing) can place a child at
a risk of overweight. Davison and Birch referred these factors as ‘child-risk factors’. The
development of child-risk factors, in turn, is shaped by several environmental factors at micro
and macro level. At micro level two major environmental factors comprise of home environment
(such as child feeding practices, food availability in the home, parent dietary intake, etc.), and
school environment. These factors at micro level are closest to the child and contain structures
with which the child is in direct contact and therefore can be directly influenced. The home
environment includes parenting styles and family characteristics such as child feeding practices,

15

types of food available in the home, nutritional knowledge of parents, parent dietary intake, etc.
The school environment includes characteristics such as structured periods for activity, dietary
quality of lunches, etc. At macro level these factors consist of community, demographic and
other societal characteristics (such as ethnicity, socio economic status, accessibility of
convenience food and restaurants, etc.). The child is not in direct contact with these structures
but they can influence child’s development by affecting the structures in the microenvironment.

16

Adapted from Davison, K. & Birch, L. (2001). Obesity Reviews, 2, 159-171.

Community, demographics, and
society
SES

Famil
y

Ethnicity
Child feeding
practices

Family TV
viewing

Child

School
meals

Work hours

Parent
dietary
intake

Leisure time

Dietary
intake

Foods
available and
accessible

Recreational
facilities

Child
Weigh
t

Sedentary
behaviors

Parent
activity
School PE
programs

Physical
activity
Nutrition
Knowledge

Encouragement
of activity
Neighborhood
safety

Convenience foods and
restaurant

Figure 1-2. Ecological Model of Predictors of Childhood Overweight

17

Family
activity

Home Food Environment and Parents’ Role in Feeding Children
The Ecological Model elucidates that the etiology of childhood overweight is
multifactorial (Davison & Birch, 2001) and in consensus with several other researchers, it
implicates parental role in feeding children as an important influential factor in affecting
children’s eating and weight status (Davison & Birch 2001; Patrick & Nicklas, 2005; Rhee,
2008; Ventura & Birch, 2008). Parents are the key agents to develop a home environment,
through various behaviors, that fosters healthful or unhealthful eating among children. Parents
shape their children’s home food environment in a variety of ways – by determining the meal
structure (Gillman et al., 2000), by the foods they make available and accessible (Baranowski et
al., 1993; Baranowski et al., 1999), by direct modeling influences, by the way they interact with
the children in the eating context - feeding styles and practices (Birch & Fisher, 1998), and by the
extent of media exposure at home (Coon et al., 2001). A focus on home food environment and
parents’ role in feeding children provides an important context and a promising area for targeting
childhood overweight prevention efforts (Patrick & Nicklas, 2005; Ritchie, 2005).
The next few sections review literature pertaining to each of the eight child feeding
behaviors assessed in this study. Although, the findings of these studies are primarily obtained
from studying Caucasians, African Americans, and Mexican Americans, attempts have been
made to review the few studies that are available on Asian Americans or Asian Indians for
relevant sections.

Family meals. Family meals are an important component of the family food
environment as they offer family members an opportunity to interact while they eat together.
Gillman et al. (2000) reported that eating family dinners was associated with healthful dietary

18

intake patterns, including more fruits and vegetables, less fried foods and soda. In adolescents,
the presence of the family at the dinner meal has been positively associated with the
consumption of fruit, vegetables, and dairy foods, and lower likelihood of skipping breakfast
(Videon & Manning, 2003). In Another study, family meal frequency during adolescence
predicted higher intakes of fruit, vegetables, dark-green and orange vegetables, and key nutrients
and lower intakes of soft drinks (P<0.05) during young adulthood (Larson et al., 2007). Parents
can influence children’s eating habits by controlling where the meals are eaten and with whom.
Companionship at mealtime, establishing a positive atmosphere and modeling appropriate
feeding behaviors have been shown to increase children’s intake of basic food groups (Stanek,
Abbot & Cramer, 1990). Eating together engenders family conversations about healthy eating
(Gillespie et al., 1989). Conversation at family dinners is an opportunity to provide nutritional
information to children by the parents. The opportunity to observe parents and sibling eating and
enjoying foods encourages children’s consumption of those foods, and the factor parental
modeling can come into play (Campbell, Crawford, & Hesketh, 2007). The foods served at a
family dinner are less likely to be ready-prepared foods (Gillman et al., 2000). Thus, a positive
social interaction and comments about food during meal may increase healthy eating behaviors
(Hendy & Raudenbush, 2000).
Research has highlighted the importance of family meals for child’s diet quality.
However, Campbell et al. (2002) showed that parents’ work commitments and busy schedule
make it difficult for families to have meals together. More educated parents find it difficult to
cook evening meals. Boutelle et al. (2003) showed that 30% of the families were too busy to eat
together as a family most nights. Almost half of the adults reported that adults’ and children’s
schedules made it difficult to have meals together. Similar findings were reported by Neumark-

19

Sztainer (2003) in which almost half of the surveyed adolescents reported that difficult schedules
prevented families from eating together on a regular basis.
Most studies assessing meal frequency and its influence of children’s and adolescents’
food intake either did not include Asian American or they included Asian American in very low
proportions such that no valid conclusions could be made for Asian Americans (Neumark
Sztainer, 2003; Videon & Manning, 2003. In a qualitative study (Cluskey et al., 2008), Asian
parents reported lower frequency of dining out and they were least likely to describe their child’s
activities as impacting family meals. Neumark-Sztainer (2003) also indicated that Asian
American families reported the highest frequency of family meals. Similarly, in a recent study
Asian American teens reported eating more family meals per week than did their White, African
American, Hispanic, and Native American counterparts (Neumark-Sztainer, 2006). Boutelle et
al. (2006) reported that Asian American parents and Asian American adolescents were less likely
to report purchase of fast-food meals for dinner. In another study, the predictors of the
importance that Asian mothers gave to family meals were based on health motivations as well as
need to eat familiar food (Marquis & Shatenstein, 2005). Mamun et al. (2005) examined
maternal attitude toward family meals and adolescents’ overweight in Australia. He found that
Asian mothers were less likely than White mothers to feel that eating together was not important.
Mothers who reported that eating together was not important were more likely that their child
consumed a lot of fast food and soft drinks and watched more television. However, it is not
known if all these findings are applicable to Asian Indians since these studies included Asian
Americans in general.

20

Television viewing and eating. Family meals increase the opportunity to have healthful
dietary intakes; however viewing television (TV) during mealtime can dilute this effect. By age
17, the average US child has spent 15,000 to 18,000 hours watching television compared to
12,000 hours in school (Anderson et al., 1998). Children consume a significant proportion of
energy during television viewing (Matheson et al., 2004). A recent randomized clinical trial
showed that reducing television viewing can lower BMI in young children by changing the
energy intake (Epstein et al., 2008). Higher frequency of television viewing during meals is
associated with lower fruit and vegetable consumption, higher fat consumption (Boutelle et al.,
2003; Coon et al., 2001), and increased energy intake (Wiecha et al., 2006). Consumption of
high-fat food, savory snacks, and sweet snacks increases with hours of television watched
(Campbell, Crawford & Ball, 2006; Woodward et al., 2006). Television viewing might influence
the diet of the children by increased exposure to food advertisements, and an increased requests
and preferences for the advertised foods (Borzekowski & Robinson, 2001; Taras et al., 1989).
Television viewing also provides a context that encourages frequent snacking or overeating
(Francis, Lee, & Birch, 2003) and parents who allow greater TV exposures are more likely to
have poor knowledge of, or less concerns about nutrition (Coon et al., 2001). Francis and Birch
(2006) reported that food consumption while watching TV results in increased energy intake in
pre-school children. The possible mechanism for increased energy intake while watching TV
could be explained by another study that showed TV viewing during mealtime overrides the
physiologic signals of satiation and satiety in 14 year old boys (Bellissimo et al., 2007).

Food availability and accessibility. Availability of foods at home is the strongest
predictor of future consumption of those foods by children (Reinaerts et al., 2007). In general,

21

children are more likely to eat the foods that they are served most often, and they tend to prefer
to eat foods that are readily available in the home (Birch, 1982). Children’s food preferences and
consumption are learned through repeated exposure to foods (Birch, 1992; Logue et al., 1988;
Pliner et al., 1992). Because parents are responsible for making food available to children, they
can have a profound impact on children’s preferences and hence consumption of foods.
Qualitative research on adolescents suggests that availability of unhealthful foods has been a
barrier to making healthy food choices. (Neumark-Sztainer et al., 1999; O’Dea, 2003).
Qualitative and quantitative studies of adolescents have consistently reported that the adolescents
perceive the availability of fruits, vegetables and dairy foods and the absence of unhealthful
alternative to influence their intakes of these foods (Auld et al., 2002; Hill et al., 1998; NeumarkSztainer et al., 1999; O’Dea, 2003). Parents reported that fruit, juice and vegetable availability
and accessibility was significantly correlated to their fruit, juice and vegetable intake at home
among lower income fourth and fifth grade African American and Euro-American children
(Baranowski et al., 1993) and for predominantly Euro-American third-grade girls (Reynolds et
al., 1999). Gable and Lutz (2000) found that parents who reported a greater availability of sweets
in the home indicated their children ate more fats and sugars. Availability of chips and salty
snacks was positively associated with children’s eating of these foods, and presence of bread was
negatively associated with children’s sugar and junk food intake.
Other research has demonstrated the importance of not only availability but also
accessibility of healthier foods on children’s food consumption (Baranowski et al., 1999; Cullen
et al., 2003). When foods are easily accessible and ready to be eaten, children are more likely to
eat them. For example, when foods are in accessible locations (i.e., locations easy for the child to
reach such as in a bowl on a table or on a lower shelf in the refrigerator) and in age-appropriate

22

sizes (e.g., apple wedges, carrot sticks) children are more likely to eat them (Baranowski et al.,
1999; Cullen et al., 2003).

Parental modeling. Parental modeling is defined as a process of observational learning
in which the behavior of the parents acts as a stimulus for similar behavior in their child. The
concept of modeling is a core construct of Bandura’s social cognitive theory (Bandura, 1971).
Parental modeling is thought to occur through four functions: observational learning,
disinhibiting or inhibiting behavior, facilitating similar response and setting cognitive standards
for self-regulation (Perry & Furukawa, 1980; Rosenthal et al., 1979). Observational learning
occurs when a model exhibits a novel response, and the observer learns the behavior for the first
time. The second function, disinhibiting or inhibiting behavior, occurs when the observer sees
the negative or positive consequences of a model’s action, which then serves to strengthen or
weaken the inhibition of responses by the observer. The third function is facilitating similar
response, which occurs when the behavior of the model serves as a cue for the observer’s
actions. Finally, setting cognitive standards for self-regulation is defined as providing standards
for the observer to judge adequacy of performance.
Early studies suggest that toddlers are more likely to sample unfamiliar foods after they
have seen an adult eating the food, and they are more likely to eat when they see their mother
eating rather than a stranger (Harper & Sandres, 1975). Similarly, two-to five-year-old children
accept a novel food more quickly than when adults eat a similar food rather than when adults eat
a different food (Addessi et al., 2005). The mother’s own food behaviors - with regard to time of
eating, types of food liked or disliked, and place where eating occurred in the home - were
correlated with the child’s food behaviors (Seagren & Terry, 1991). Parents’ behaviors with

23

regard to dietary characteristics, food preferences, food intake and intake regulation (e.g., dietary
inhibition), eating-related attitudes, and body dissatisfaction are likely to be related to these same
behaviors in children (Perry et al., 1980; Brown & Ogden, 2004). Parental consumption is a
significant predictor for determining their child’s intake of fruits, vegetables, and dairy foods.
Children’s intake of fruits and vegetables was positively related to parents’ intake of fruit and
vegetables (Fisher et al., 2002; Gibson et al., 1998), and parents’ modeling of healthful dietary
behaviors was associated with lower dietary fat intake (Tibbs et al., 1990). Furthermore, the
importance of parental modeling is supported by the success of child weight control programs
where parents are targeted as a primary agent of change. In these programs parents are
encouraged to adopt healthy eating behaviors themselves and therefore model these behaviors for
their children (Epstein et al., 1990; Golan & Crow 2004; Golan et al., 1998).
Research has shown that children not only model their parents’ food intake, but also their
attitude toward food, their body dissatisfaction and dieting behaviors. For example, mothers of
girls with anorexia showed greater body dissatisfaction than mothers of non-disordered girls
(Hall & Brown, 1982). Likewise, dieting daughters were more likely to have dieting mothers
(Pike et al., 1991) and parents who reported dietary inhibition or problems controlling their own
intake were likely to have daughters who showed similar patterns (Cutting et al., 1999). Children
also resemble their parents in food neophobia (Pliner & Pelchat, 1986; Pliner & Pelchat, 1991).
Research therefore emphasizes the role of observational learning with a particular role for parent
attitude and behavior. Children’s attitude toward food, choices in food selection and timing of
meals are in great part a result of parental modeling.

24

Parenting styles and feeding styles. Parenting style refers to the behavioral methods
used by parents to establish, maintain, modify or control children’s behaviors. The patterns of
parental behaviors have been conceptualized in terms of amount and quality of two underlying
dimensions - demandingness (or parental control) and responsiveness (or parental support)
(Maccoby & Martin, 1983). In the domain of general parenting, demandingness refers to the
extent to which parents show control, maturity demands, and supervision in their parenting.
Responsiveness refers to the extent to which parents show affective warmth, acceptance and
involvement. Based on these two dimensions, parenting can be classified as one of the four
specific parenting styles: 1) Authoritative style (high demandingness and high responsiveness) is
characterized by personal involvement, nurturance, reasoning and structure; 2) Authoritarian
style (high demandingness and low responsiveness) is characterized by restrictive, punitive,
rejecting and power assertive behaviors; 3) Indulgent style (low demandingness and high
responsiveness) is characterized by warmth and acceptance in conjunction with a lack of
monitoring of child behavior; 4) Uninvolved style (low demandingness and low responsiveness)
is characterized by little control and involvement with the child. Studies on parenting styles have
demonstrated that authoritative parenting style is associated with the most positive
developmental outcomes in children (Darling & Steinberg, 1993; Maccoby & Martin, 1983).
Hughes and colleagues (2006) explained feeding styles based on the definition of
parenting styles by focusing exclusively on parenting styles related to child feeding behaviors.
Therefore, similar to parenting styles, feeding styles can be determined by a combination of the
two underlying dimensions of demandingness and responsiveness. In the feeding domain,
demandingness refers to how much the parent encourages eating and responsiveness refers to
how the parent encourages eating, that is, in a responsive or non-responsive way (Hughes et al.,

25

2005). Similar to the parenting styles, feeding styles represent the caregiver’s approach to
maintaining or modifying children’s behaviors with respect to eating. Birch and Fisher (1995)
identified three child-feeding patterns that follow Baumrind’s (1971) taxonomy of parenting
styles: authoritative, permissive, and authoritarian.
Authoritarian feeding is characterized by attempts to control the child’s eating with little
regard for the child’s choices and preferences (Patrick et al., 2005). Researchers describing
authoritarian feeding styles have reflected on parental attempts to one-sidedly control the child’s
food intake and eating practices through commands, instructions (Hepstinstall et al., 1987),
directives, coercion or restriction (Johnson & Birch, 1993). Authoritarian parenting practices
include using food to pacify, reward (Birch, Zimmerman, & Hind, 1980; Baughcum et al., 1998),
punish, or prompt children to eat when not hungry (Casey & Rozin, 1989).
Permissive feeding is characterized by what might be termed “nutritional neglect”,
whereby the children are allowed to eat whatever they want in whatever quantities they want
(Patrick et al., 2005). With permissive feeding, little or no structure is provided, and choices are
limited only by what is available (Birch & Fisher, 1995). Permissive feeding has been associated
with drinking less milk and lower consumption of all nutrients except fat (Anliker et al., 1992;
Eppright et al., 1970).
Finally, Authoritative feeding represents a balance between authoritarian and permissive
feeding styles whereby the child is encouraged to eat healthy foods, but is also given some
choices about eating options (Patrick et al., 2005). Research describing authoritative feeding
styles suggests using discussion, negotiation, reasoning (Iannotti et al., 1994), providing
rationales (Cousins, Power, & Olvera-Ezzell, 1993; Heptinstall et al., 1987), and praising the
child (Stanek, Abbot & Cramer, 1990). Authoritative feeding style attempts to shape or guide a

26

child’s behavior, thereby facilitating the development of dietary self-control, and is associated
with consumption of more fruits and vegetables and lower intake of “junk foods” (foods high in
fat and sugar; as defined by the authors) in children (Gable & Lutz, 2000).

Parenting practices and feeding practices. Parenting styles describe parent-child
interactions across a wide range of situations, whereas parenting practices by definition are
domain-specific (Darling & Steinberg, 1993). According to Ventura & Birch (2008), parenting
practices are less trait-like and more responsive to context. Therefore, within a parent, parenting
style is consistent but parenting practice can differ across children within the same family
depending on child’s age, gender, eating behavior, and weight status. When parenting practices
are applied to the child-feeding context, they represent specific behavioral strategies that parents
employ to control what, how much, or when their children eat. Therefore, feeding practices
include behaviors such as pressuring children to eat, using food rewards, restricting access to
select foods or groups or use of food to pacify or control.
The greatest focus to date has been on authoritarian feeding styles that encompass
controlling feeding practices such as limiting access to desired foods, promising a child desert if
she eats her vegetables, or encouraging a child to clean his plate (Birch & Marlin, 1982; Birch
Zimmerman, & Hind, 1980; Fisher & Birch, 1999a; Fisher & Birch, 1999b). These feeding
practices can have unintended consequences that may result in the development of unhealthy
eating practices among children. Parental attempts to control the food intake of children through
these feeding practices have been shown to lessen children’s responsiveness to energy density
and meal size (Birch et al., 1993).

27

Children who were instructed to clean their plates were less responsive to energy density
cues than children who were taught to focus on internal cues of hunger and fullness (Birch et al.,
1987; Johnson & Birch, 1993). When parents force the child to "clean your plate," the child may
learn that the amount of food remaining on the plate and not the internal physiological cues
signaling hunger or satiety, is most relevant to determining how much to eat. Perhaps by shifting
the emphasis from internal to external cues, controlling child-feeding practices can alter
children's responsiveness to hunger and satiety cues and to the energy density of the diet.
Child feeding practices that encourage children to consume a particular food increase
children's dislike for that food (Birch & Marlin, 1982; Birch, Zimmerman, & Hind, 1980;
Newman & Taylor, 1992). Many of the foods that parents encourage children to consume are the
fruits and vegetables they would like to see consumed with greater frequency and in greater
quantities. Fisher et al. (2002) indicated that parental pressure to eat fruit and vegetables
discourages intake among young girls. Hertzler (1983) noted that parents' feedback to children
about eating more vegetables was associated with children's preferences for fewer vegetables.
Restricting children’s access to foods high in fat and sugar increased children’s
preferences for those foods (Fisher & Birch, 2000; Fisher & Birch, 1999b). Restricting children’s
access to certain foods may have undesired effect of drawing attention and increasing children’s
desire for those foods (Fisher & Birch, 1999b; Ritchie et al., 2005). Therefore, children may be
more likely to seek and consume restricted foods when they are outside of parental control.
Children may become excited when restricted foods are available, so that self-control is not
exercised and eating becomes frenzied (Fisher & Birch, 1999a; Fisher & Birch, 1999b). Children
may not develop the essential awareness of hunger and satiety, which enables them to regulate
their own food intake (Baughcum et al., 1998; Ritchie et al., 2005). Furthermore, restriction, in

28

particular is also associated with overweight and weight gain in several studies (Clark et al.,
2007; Faith et al., 2004; Ventura and Birch, 2008).
Another controlling child feeding practice is the promise to reward the child with food
item commonly liked by children (such as sweets) if the child cleans his plate. Thus, parents use
an external factor or food reward to encourage eating irrespective of the child being full rather
than relying on the internal cues of hunger and satiety. Birch et al. (1987) demonstrated that
rewarding children if they “cleaned their plate” resulted in less responsiveness to energy density
and thereby greater caloric consumption. External rewards can also have unintended effects on
the development of food preferences. When parents use food items such as dessert as a reward if
the child eats her vegetables, it increases the value or liking for the dessert item and decreases the
preference for the required item (vegetables) (Birch & Marlin, 1982; Birch Zimmerman, & Hind,
1980; Newman & Taylor, 1992).
Research has shown that controlling child feeding practices are associated with children’s
weight status (Klesges et al., 1991). Parental control of when, what, and how much children eat
may teach children to ignore their feelings of satiety, and may lead to increased levels of energy
intake (Johnson & Birch, 1994), which in turn could lead to overweight (Fisher & Birch, 2000).
According to the model of Costanzo and Woody (1985), parents are most likely to
control children’s behaviors when they are concerned about a child’s weight. External control in
feeding results in lack of internal cues, the child eats beyond satiety which in turn is related to
increased body mass (Johnson & Birch, 1994). Fisher and Birch found that young children’s
weight for height predicted the degree to which mothers reported restricting their child’s intake
of snack foods (Fisher & Birch, 1996). Fisher and Birch (1999a) tested and confirmed this overcontrol hypothesis in several studies. Spruijt-Metz et al. (2002) evaluated the relationship

29

between mother child-feeding practices and children’s adiposity in African American and
Caucasian children aged 11 years. The pressure to eat and concern for a child’s weight explained
15% of the variance in the total fat mass in children.
However, the literature reveals many inconsistencies. Studies on samples representing
different socioeconomic groups failed to detect a positive relationship between parental control
and children’s weight status (Baughcum et al., 2001; Gable & Lutz, 2000). Robinson et al.
(2001), in a sample of 792 8-9-year-old children with diverse socio-economic and ethnic
backgrounds also did not find a positive relationship between parental control behavior and
children’s weight status. A review of 16 selected studies on the relationship between restriction
and weight status concludes that the findings are inconsistent across studies (Faith et al., 2004).
The discrepancy between these findings may relate to the methodological differences across
studies, including differences in sample size, age, subjects, and measurement of feeding practices
(Faith et al., 2002; Moens, Bert, & Soetens, 2007).
A recent study that used both self-report and observation of mealtime family functioning
reported that parents of 7-13 year old overweight children reported more control on their
children’s feeding behavior compared to parents without overweight children. However,
observations at mealtime indicated that in families with an overweight child, control strategies
were twice as prevalent and less parental support was displayed (Moens, Bert, & Soetens, 2007).
These results are based on cross sectional studies and do not determine causality, so it is unclear
whether parents’ child-feeding behaviors influence children’s eating habits or vice versa. Faith et
al. (2004), in a longitudinal study, concluded that parental feeding styles and child BMI depends
on child overweight predisposition. Among children predisposed to overweight, elevated child

30

weight appears to elicit restrictive feeding practices, which in turn may produce additional
weight gain.
In summary, controlling child-feeding practices can have negative and unintended effects
on children's food preferences. It is likely that such practices foster rather than prevent the
development of childhood overweight and eating problems, although additional research is
needed to confirm this point (Birch & Fisher, 1998). Satter (1986) has discussed an alternative to
such controlling child-feeding practices based on her extensive clinical work. She suggested a
“trust” paradigm instead of the “control” paradigm for understanding feeding practices and child
weight. She suggested a division of responsibility between parent and child in which it is the
parent’s responsibility to supply the child with the healthful array of foods and a supportive
eating context, and it is the child’s responsibility to decide when and how much to eat. Children
are innately equipped to monitor their own food intake and to determine when they are satiated
(Birch & Fisher, 1995). This suggests that when parents offer a nutritious array of foods, children
can serve themselves without parental coercion and interferences.
To the knowledge of researcher, limited studies have been done to specifically identify
what type of feeding practices are used by Asian American or Asian Indian mothers. Studies
involving South Asian (that include Asian Indians) suggests that South Asian mothers tend to use
controlling feeding practices more often than Caucasians (Hackett & Hackett, 1994;
Jambunathan, 2002). Furthermore, Asian Indian parents hand feed their children much longer
than American parents do to ensure that they eat adequate and right foods (Londhe, 2006). Since
studies focusing on Asian Indian mothers’ feeding behaviors are minimal, the next section
attempts to draw general idea about parenting styles by reviewing parenting beliefs of Asian
Indians.

31

Parenting beliefs of Asian Indians. Asian groups share relatively common values,
beliefs, and parenting styles that originated from the philosophical principles of Confucianism.
Confucian principles emphasize the importance of social order and hierarchy, loyalty, respect for
and deference to older family members, obedience, and obligation to the family (Kitano &
Daniels, 1995; Min, 1995). Asian American parents have been described as more hierarchical,
less democratic, and more controlling than parents from other ethnic backgrounds, particularly
when compared to Caucasian families (Chao & Tseng, 2002; Uba, 1994). Parenting styles among
Asian parents have been variously described as ‘‘authoritarian’’, ‘‘controlling’’, ‘‘restrictive’’
and ‘‘hostile’’ (Steinberg, Dornbusch, & Brown, 1992; Lin & Fu, 1990).
Asian Indian parents follow an authoritarian pattern of parenting. Asian Indian parents
also lay a great deal emphasis in their parenting practices on familial bonds, dependence on and
loyalty to the family, obedience, religious beliefs and achievement (Kakar, 1978). Studies also
stress that Asian Indian parents place a high value on academic achievement (Khatri, 1975; Rao
McHale, & Pearson, 2003) and family interdependence, discourage autonomy and emphasize the
importance of extended family and respect and obedience of elders (Dasgupta, 1989; Helwig &
Helwig, 1980; Rao, McHale, & Pearson, 2003; Wakil, Siddique, Wakil, 1981). Asian Indian
children are usually complimented and positively reinforced for behaviors such as completing
chores, academic achievement, and exhibiting self-control (Kakar, 1978). Research has indicated
that the Asian Indians strongly encourage their children to be reticent, dependent, not to display
emotions, and to exhibit self-restraint (Kakar, 1978).
According to Asian Indian psychologists (Dasgupta, 1998; Ranganath & Ranganath,
1997), a primary difference between Asian Indian and European American cultural belief system
lies in the concept of the self. Asian Indians tend to be allocentric, where the self and the family

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are integral, rather than have separate concepts, as is characteristic of a Western belief system.
Child-rearing practices emphasize close family bonds with parents highly involved in their
children's lives. Individuals of all ages are expected to make sacrifices and to contribute to the
honor and welfare of the family (Jambunathan & Counselman, 2002). By contrast, European
American families tend to be nuclear. Children are generally viewed as transitional members
who by adolescence and beyond are expected to individuate and pursue their own interests
(Triandis et al., 1988). Compared to most Asian groups, European American parents tend to be
less involved in their children’s lives (Lin & Fu, 1990).
In a study of Korean American immigrants, Farver & Lee-Shin (2000) found that mothers
with assimilated or integrated acculturation styles began to resemble European American
families in their child-rearing styles. Likewise, in a study of Asian Indian families, Patel, Power
& Bhavnagri (1996) found parents who were more acculturated, adopted relatively
‘Americanized’ child rearing attitudes and behaviors, and were more likely to encourage
‘American characteristics in their children, than were parents who were less acculturated.
Jambunathan (2002) compared parenting attitudes of Asian Indian mothers living in the US and
those living in India. She found that that the Asian Indian mothers living in the US had lower
inappropriate expectations and tended not to reverse roles with their children. The results also
showed that the Asian Indian mothers living in India favored the use of corporal punishment
more than their counterparts in the US These results indicated that mothers living in the US had
more authoritative parenting attitudes and those living in India had more authoritarian ones. She
argued that Asian Indian mothers in the US with authoritarian parenting attitude may find that
their children suffer under those social disabilities found in European American families who use
similar parenting styles. Thus, many of the Asian Indian parents in the US adopt authoritative

33

parenting styles, which balance their traditional cultural expectations and values with demands of
the new, majority culture.

Parental beliefs about food and health. Research has emphasized the role of mothers’
beliefs about diet and health in determining children’s diet quality. Gibson et al. (1998) showed
that mothers of children aged 9-11 years considered taste to be of greatest importance in
choosing what to eat for themselves, followed by consideration of health and well-being and then
disease prevention. However, in choosing food for their children, mothers considered health to
be the most important followed by taste and then prevention of disease. Mothers’ ratings of the
importance of “general health and well being” and “prevention of disease” were significantly
correlated with children’s diet as assessed by 3-day food diaries. Mothers with low ratings of
importance of disease prevention in choosing foods for their children had children who
consumed a higher percentage of fat and less fruits and fruit juice (Gibson et al., 1998). Parents
who perceive that their child might develop a risk for a certain disease or who are concerned
about the child’s health may be more likely to promote healthy eating behaviors in children.
Contento et al. (1993) found a positive relationship between maternal health motivation
and the quality of children’s diet. Contento and colleagues segmented families according to the
importance of beliefs about healthfulness of foods and this segmentation predicted children’s diet
quality. They found that the group of mothers who emphasized food selection criteria based on
their own health beliefs were significantly more knowledgeable about which foods are healthful
or likely to cause heart disease than their taste-oriented counterparts which, in turn, was
correlated with children’s dietary intake. The diets of children in health-oriented families were
significantly lower in calories, total fat, saturated fat, and sucrose and higher in vitamin A and

34

fiber than those in taste-oriented families even when mothers’ knowledge was held constant
(Contento et al, 1993). A focus on health may lead parents to purchase more healthful foods and
make them readily accessible in the home, which are both important determinants of children’s
preferences for and intake of such foods. Individual’s awareness that certain health problems are
related to dietary practices, and that they can be prevented by making healthy food choices at an
early age may influence their behaviors. This type of knowledge may motivate a person to learn
more about nutrition and adopt healthy eating behaviors.
Reimer et al. (2001) studied the relationship between child feeding strategies and stage of
change for fruit and vegetable consumption in African American women with children under the
age of 12 years. The Transtheoretical Model (Prochaska, Redding, & Everse, 1997) was used to
identify the stages of change for fruit and vegetable consumption. Mothers who were in the later
stages of change such as preparation, action, and maintenance (the mothers had made or
maintained changes in consumption of fruits and vegetables) reported that they were concerned
that their child should eat healthy but did not force children to eat fruits and vegetables, and used
positive child feeding strategies. These mothers reported the importance of role modeling and
other strategies for feeding fruits and vegetables, such as buying and keeping fruit and vegetables
on hand for snacks, replacing junk foods with fruits and vegetables, adding vegetables to meals,
and to provide at least one vegetable. Women in the early stages of change such as precontemplation and contemplation (the mothers were not interested in changing behavior or
anticipating making a change or actively seeking the change) did not raise concerns about
nutrition and health issues for children. According to the Transtheoretical Model, these women
may have inadequate information about diet and health relationships or they may have more
barriers that result in lower intake of fruits and vegetable for themselves and their children.

35

Parents who are aware that a particular eating behavior has health implications may
presumably try to influence the corresponding aspect of child’s diet by performing the desired
behaviors. However, Alderson & Ogden (1999) found that mothers of 5-11 year olds were
motivated by the long-term health and nutritional value in choosing foods for their children, but
reported that they fed less healthy foods to their children than they ate themselves. This points
toward a genuine gap between motivation and behavior and indicates a role of other factors that
might impede the performance of desired behaviors by mothers. This gap between health
motivation and behavior could be explained by potential constraints in performing a behavior,
and hence the lack of translation of motivation into behavior (Ajzen, 1991; Armitage & Conner,
2000; Conner & Norman, 1996).

Parental motivations and barriers to health-promoting behaviors. To better
understand the gap between health motivation and health promoting behaviors of parents, this
section provides review of studies that assessed motivators and barriers in practicing parental
behaviors that promote healthy eating in children. Studies determining parental motivations and
barriers to health-promoting behaviors are scarce. Parents state that work schedules, cost of food,
perceived inadequate time to shop, plan, and prepare nutritious meals, or a combination of these
have been shown to be barriers to nutritious eating habits (Omar, Coleman, Hoerr, 2001). Hart et
al. (2003) showed that parents of 7-12 year olds reported that school environment and peers were
largely responsible for poor diet and lack of exercise among primary school children. However,
parents were not aware about the influence of home environment on children’s dietary intake and
physical activity. Parents reported short-term benefits of healthy behaviors such as shiny hair,
skin, and teeth, and failed to recognize the long-term health benefits of healthy eating behaviors.

36

Few studies have focused on parental views on home food environment and its influence on
child’s food choices. Cullen et al. (2000) showed that parents of 9-12 years old children
representing three major ethnic groups – African American, European American and Mexican
American – reported that fruits, juice and vegetables (FJV) and low-fat versions of a variety of
foods were available at home but not accessible to children. Parents expected that children of this
age group to prepare their own food or ask for help. Parents also reported that barriers such as
lack of time on weekdays to prepare healthy meals were the reasons for not eating healthy foods
at home. Campbell, Crawford, & Ball, (2006) determined parental perspectives on factors that
influence child’s food choices and their decision-making about food provided to their 5-6 year
old children. The motivations for having family meals, as reported by parents, were: to provide
opportunities for family discussion, learning about table manners, learning about proper meals,
and parental modeling. The food made available to children was also seen to influence what the
child ate. Yet some parents believed it was the parents’ role to determine what foods were made
available to the child, while others offered food on the basis of the child’s taste and preference.
Some of the beliefs of parents that influenced their food decisions were: children have specific
food preferences, children have particular tastes, children may not eat enough if the foods they
want were not available, peace at mealtime is priority, and media influence children’s food
choices. For feeding strategies, parents reported that using foods as a reward was a practical
solution to children’s food fussiness.
In summary, these studies discussed in this section suggest that parents are likely to have
low behavioral control in helping their children consume a healthy diet due to the large number
of perceived barriers and small number of perceived facilitators and benefits of these behaviors.
It is likely that parents are aware about the importance of their feeding behaviors and health

37

outcomes of healthy eating patterns, but the barriers perceived by them may deter the
performance of those behaviors. For example, parental beliefs that children will not eat enough if
they are not served the foods they like, may affect parents’ decision about which foods to
purchase.

Project Justification
During the past decades, US has witnessed a dramatic increase in the prevalence of
overweight, which has become a major public health crisis (Ogden et al., 2010). Childhood
overweight predisposes an entire generation to an increased risk of chronic diseases and
disabilities and is a severe threat to the economic well being of the nation (Huang & Horlick,
2007). Overweight and obesity are associated with coronary heart disease, several types of
cancers, type 2 diabetes, stroke, arthritis, breathing disorders, and psychological disorders
including depression (Surgeon General’s Report, 2010). In immigrant Asian Indians, prevalence
of hypertension (12-20%), diabetes (6-8%), and coronary heart disease (7-14%) has been found
to be higher than native rural Indians residing in India and Western populations (Singh et al.,
2001). According to U.S. Bureau of Census (2010), Asian Indians make up the third largest
Asian population, and is one of the fastest growing immigrant populations in the United States.
By the year 2050, the number of Asian Indians living in the United States is predicted to be at
two million (Bouvier & Agresta, 1985; O’Hare & Felt, 1991). It is estimated that the proportion
of overweight and obesity in Asian Indians will increase with more US-born Asian Indians and
longer residence in the US (Lauderdale & Rathouz, 2000).
Prevention of obesity could be the key strategy for controlling the current epidemic of
obesity. Several factors have been attributed to the cause of childhood obesity epidemic (Davison

38

& Birch, 2001). Many researchers have emphasized that home environment and parents’
behaviors have a significant impact on children’s eating habits and weight status and offer a
promising area for targeting childhood overweight prevention efforts (Patrick et al., 2005; Rhee,
2008; Ventura & Birch, 2008). However, little is known about the Asian Indians’ home food
environment and role of parents in developing children’s eating habits.
There is a need to identify effective and culturally appropriate interventions due to
disparities in behavioral practices based on race and ethnicity. To develop effective health and
nutrition programs for this population, it is important to fill the gap in literature by understanding
the child feeding behaviors of Asian Indian mothers and the factors that influence the practice of
these behaviors.
This dissertation was completed in two stages. The first stage sets out to assess the child
feeding behaviors of Asian Indian mothers using the theory of planned behavior. The eight child
feeding behaviors assessed in this dissertation have shown to be significantly important in
affecting children’s eating habits and weight. The theory of planned behaviors was used a
conceptual framework since it has shown potential to predict health behaviors by targeting the
underlying factors that influence a particular behavior, and develop effective behavior change
interventions (Armitage, 2005; Conner, Norman, & Bell, 2002; Noar & Zimmerman, 2005;
Campbell et al., 2000; Rothman, 2004). Theory of planned behavior not only predicts the attitude
toward a specific behavior but it also predicts non-volitional behaviors by incorporating
perceptions of control over performance (perceived behavioral control) of the behavior as an
additional predictor (Ajzen, 1991). Qualitative methodology was employed to explore child
feeding behaviors and the underlying factors.

39

The second stage of this research consisted of developing and testing nutrition messages
for Asian Indian mothers to help them identify appropriate behaviors in feeding their children.
The findings from stage 1 about Asian Indian mothers’ current practices of child feeding
behaviors, behavioral beliefs, barriers, and facilitators in practicing child feeding behaviors were
used to construct culturally appropriate messages.

Theoretical Framework for Research
Theory of Planned Behavior (Ajzen, 1991) was used as a framework for the assessment
stage as well as the message development stage. Theory of Planned Behavior (TPB) is a
modified version of the Theory of Reasoned Action (Ajzen & Fishbein, 1980) and is based on
the expectancy value model that addresses the problem of incomplete volitional control over
behaviors (Blue, 1995). According to TPB (Figure 1-3), behavior is best predicted by intention to
perform a behavior. Intention, in turn, is determined by behavioral attitude (favorable or
unfavorable), subjective norm (perception of social pressures to perform or not perform the
behavior), and perceived behavioral control (perception of ease or difficulty of performing the
behavior). The TPB was applied to this research to understand the influence of each construct on
the child feeding behaviors of Asian Indian mothers (Figure 1-4). The first construct of the TBP
– ‘behavioral attitude' – consisted of behavioral belief and evaluation of behavioral belief.
‘Behavioral belief’ was assessed by exploring mothers’ beliefs about the expected nutrition
outcomes of their feeding behaviors. ‘Evaluation of behavioral belief’ was assessed by exploring
mothers’ beliefs about importance of expected nutrition outcomes for children’s current and
future health (i.e. the value placed on nutrition outcomes). ‘Subjective norm’ was assessed by
exploring sources of information or advice on feeding children (normative belief) and the extent

40

of compliance with that information or advice (motivation to comply). ‘Perceived behavioral
control’ was assessed by exploring perceived facilitators and barriers (Control belief) that make
the performance of feeding behaviors easier or more difficult for the mothers (Perceived power).

41

Ajzen, I. (1985). From intentions to actions: A theory of planned behavior, 11-39.

Behavioral Belief
Behavioral
Attitude
Evaluation of
Behavioral Belief

Normative Belief
Subjective
Norm
Motivation to
Comply

Control Belief

Perceived
Behavioral
Control

Perceived Power

Figure 1-3. Theory of Planned Behavior

42

Behavioral
Intention

Behavior

Adapted from Ajzen, I. (1985). From intentions to actions: A theory of planned behavior, 11-39.
Behavioral belief
Mother’s beliefs about the expected
nutrition outcomes of their feeding
behaviors

Behavioral
Attitude

Evaluation of behavioral belief
Mothers’ beliefs about importance of
children’s nutrition outcomes for their
current and future health

Perceived power & Control belief
Facilitators and barriers that make the
practice of child feeding behaviors easy
or difficult

Normative belief
People from whom mothers receive
information on child feeding behaviors

Perceived
Behavioral
Control

Subjective
Norm

Motivation to comply
The extent to which mothers comply
with the information

Figure 1-4. Theory of Planned Behavior Applied to Child Feeding Behaviors

43

Child Feeding
Behaviors
Family meals
TV during mealtime
Food availability
Food accessibility
Parental modeling
Pressuring to eat
Rewarding with food
Restricting
consumption of certain
food

The next chapters of this dissertation, written as research articles, describe methods,
results, and discussion for stage one and stage two of this research. Chapter two, written as
manuscript focused on five child feeding behaviors – family meals, parental modeling,
pressuring to eat, offering food rewards, and allowing TV viewing while eating since these
findings were different from those already reported in the literature and bring out the cultural
distinctiveness of Asian Indian mothers. Findings not included in this chapter (three child
feeding behaviors – availability, accessibility of healthy foods, and restricting children’s
consumption of certain foods, beliefs about health and nutrition, and subjective norm) are
attached as tables in Appendix F. Chapter three, written as manuscript, describes the
development and testing of nutrition messages for Asian Indian mothers. Finally, chapter four
provides contributions, recommendations, limitations and conclusions that can be drawn from
this research.

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CHAPTER TWO:
CHILD FEEDING BEHAVIORS OF ASIAN INDIAN MOTHERS

Abstract
Objective: To understand current practice of child feeding behaviors, and underlying factors
influencing these practices in Asian Indian mothers.
Design: Qualitative inductive design using in-depth interviews.
Setting: Asian Indian community and religious organizations in Michigan.
Participants: Twenty-seven immigrant Asian Indian mothers of children ages 5-10 years.
Phenomena of Interest: Feeding behaviors, beliefs about nutritional outcomes, perceived
behavioral control.
Analysis: thematic analysis using coding and display matrices.
Results: Mothers were motivated by nutrition outcomes when practicing positive and negative
controlling feeding behaviors. Outcomes related to preservation of Indian culture and values
also influenced feeding behaviors. Pressuring to eat was often practiced despite the perception
of ineffectiveness. Use of food rewards and TV to control children’s food intake despite the
clear understanding of undesirable nutrition outcomes was found.
Conclusions and Implications: Asian Indian mothers need effective child feeding strategies that
are culturally appropriate. Integrating cultural beliefs in nutrition education could help support
existing motivation and behavior modification.
Key Words: Asian Indian, feeding behaviors, culture.

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Introduction
The prevalence of childhood overweight is rising in all ethnic populations in the US.
Several factors contribute to the development of childhood overweight. Previous research shows
that parents are active in creating a child’s eating environment through use of specific child
feeding behaviors; these in turn influence child eating habits (Ritchie et al., 2005; Patrick &
Nicklas, 2005). ‘Positive child feeding behaviors’ such as family meals and parental modeling
of eating healthy food improve children’s dietary quality (Rhee, 2008; Ventura & Birch, 2008).
Eating meals as a family is linked to higher intakes of fruits, vegetables, dairy food, and vitamins
and minerals (Gillman et al., 2000; Neumark-Sztainer et al., 2003; Videon & Manning, 2003).
The ability of parents to model and enforce rules that encourage healthy eating has been
suggested to contribute to better dietary intakes during family meals (Rhee, 2008). ‘Negative
child feeding behaviors’ such as eating while watching TV adversely affects children’s energy
intake, which may lead to overweight (Francis & Birch, 2006). Negative child feeding behaviors
that are also controlling, such as pressuring a child to eat or offering one food as a reward for
eating another can also result in negative outcomes by disrupting a child’s natural ability to selfregulate energy intake (Rhee, 2008).
The majority of the child feeding research has been conducted with white, middle class
populations (Faith et al., 2004). Research has included minorities such as African Americans
and Mexican Americans in low proportions, and only a few studies have focused exclusively on
these groups (Clark et al., 2007). In addition, research on child feeding behaviors of recent
immigrants is limited. Child feeding survey instruments are typically developed on white and
well-educated populations, and therefore may measure constructs that are inappropriate for other
populations, or lack constructs that are unique to other race and ethnic groups (Jain et al., 2004;

46

Lindsay et al., 2011). Therefore, programs for childhood overweight prevention that are based
on the current body of research may not be appropriate for diverse populations.
We sought to investigate child feeding behaviors of Asian Indian immigrant mothers in
the United States. Asian Indians, a subgroup of Asian Americans, are one of the largest and
fastest growing Asian populations in the US (US Bureau of Census, 2010). In addition, the risk
of childhood overweight for Asian Indian immigrant children is directly related to the number of
years of residence in the US (Lauderdale & Rathouz, 2000; Popkin & Udry, 1998). Asian
Indians are therefore an important population to study as a shift to a higher proportion of Asian
Indians born in the US is likely to result in higher rates of overweight and associated health
problems in Asian Indian children (Lauderdale & Rathouz, 2000).
The literature on child feeding behaviors of Asian Indian immigrant mothers is limited.
Compared to whites, Asian Indian parents have been shown to hand feed their children much
longer (Londhe, 2006) and use controlling feeding practices more often (Hackett & Hackett,
1994; Hinton, 2010). The reasons for these differences are not known. As such, research
involving this understudied population is needed to understand the factors that drive their
practice of child feeding behaviors.
The Theory of Planned Behavior (TPB; Ajzen, 1991) is a useful framework for this work
as it allows for the exploration of the underlying intentions associated with various behaviors.
The TPB assumes that behavioral intentions are determined by people’s underlying beliefs about
expected outcomes of a behavior, as well as perceived control over the particular behavior and
social pressures. The theory is content-free in that it does not specify the particular beliefs or
constructs. Rather, the actual beliefs must be obtained from the target group itself, using openended elicitation techniques (Contento, 2010).

47

This work seeks to explore the underlying beliefs of Asian Indian mothers associated
with five behaviors that are central to the literature on child feeding. By understanding the
underlying beliefs, constraints, and social pressures that are associated with these behaviors,
educators may develop strategies to address these behaviors in this rapidly growing immigrant
population and improve child feeding practices. A qualitative, ethnographic approach was used
to allow for the emergence of themes that are most important to the study population about these
behaviors. The research therefore reports on 1) current child feeding behaviors employed by
Asian Indian mothers, 2) their beliefs and expectations about desirable and undesirable outcomes
of feeding behaviors, 3) perceived behavioral control, or the perceived ease or difficulty in
practicing feeding behaviors, and 4) perceived pressure to comply with the expectations of
significant others regarding these behaviors (e.g. parents, friends, spouse).

Methods
Study Design
The study protocol was approved by the Institutional Review Board at Michigan State
University. A purposive sample of 27 Asian Indian immigrant mothers residing in Michigan in
the Detroit metropolitan area and the city of Lansing and surrounding suburbs was recruited
using criterion sampling (Patton, 2002). Eligibility criteria included mothers of Asian Indian
origin who had: 1) lived in the US for at least one year, 2) had at least one child between the ages
5-10 years; and 3) were the primary meal preparer. Participants were recruited from a religious
center (Bharatiya Temple), Asian Indian organizations (Indian Cultural Society and India
Council), and a website (www.miindia.com) for Asian Indians using fliers, emails and
advertisements. Prior to the interview, informed written consent was obtained from the

48

participants. Face-to-face in-depth interviews were conducted by the first author (SM) from
March 2009 to December 2009. Participants also completed a demographic questionnaire and
the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn et al., 1987) to measure
their acculturation level. Participants received a $25 gift card to a grocery store.

Interview Guide
The interview guide used projective techniques to assess mothers’ attitudes toward the
five behaviors of interest. Projective techniques avoid questioning participants directly about
their own behaviors. Rather, verbal or visual stimuli such as pictures or stories are used to elicit
thoughts about a particular behavior (Churchill, 1995). Participants respond to the stimuli and
ascribe their behavior to a third person by using the ego defense mechanism of projection, and
thereby reveal their own unconscious beliefs and feelings about the situation (Churchill, 1995;
Loudon & Della Bitta, 1993; Solomon, 1994). Use of projective techniques encourages
participants to connect themselves with the hypothetical characters, express their perspective
regarding the character’s behaviors and attitudes in a non-threatening manner, and reduces the
likelihood of responding with a socially desirable answer. In this study, participants were shown
culturally relevant pictures and read brief narratives with culturally relevant names and
situations. They were asked to interpret the behavior of Arti, an Asian Indian mother, engaging
in various feeding behaviors with her child.

Interview Process
Picture cards that showed each of the five feeding behaviors were presented to the
participants: family meals, modeling of healthy eating, pressuring the child to eat, offering a food

49

reward for finishing the meal, and television viewing during meals. The cards were presented
three times. The first time, information was solicited to understand current practices of the five
feeding behaviors by asking open-ended questions such as “Where do you see this happening?”
“How often do you think this would happen in Arti’s house?” The second time, expectations
about outcomes of a behavior were explored. The participants were asked questions such as
“Why is it important for Arti to do this?” “How would Arti’s behavior in this picture make a
difference to what or how much the child eats?” The third time the participants were asked
“Would it be easy or hard for Arti to perform the behavior?” “What makes it easy or hard for
Arti to perform the behavior?” The goal was to understand perceived ease or difficulty in
practicing a given behavior. Finally, a short narratives about Arti illustrating two different
situations – one in favor of practicing the behavior and other making the behavior difficult to
perform, were read to the participants. The end of the story was left ambiguous and the
participants were asked to complete the story by expressing their thoughts about how Arti would
handle this situation. This revealed participants’ decision to practice a behavior in a difficult
situation. Open ended questions such as who do you talk to about child feeding, and what kind
of information you receive from people about child feeding were asked to assess social pressures
(subjective norm).

Data Analysis
Interviews were recorded and transcribed verbatim.
Coding. A “start list” of codes (Miles and Huberman 1994) was developed based on the
concepts of interest from the TPB. As the transcripts were reviewed, new themes emerged and
the specifications of new codes were developed and added to the codebook. Upon successive

50

review of data, both new and start list codes were revised, and refined to fit the data until the
code structure was finalized. All transcripts were coded by the first author (SM) using the final
code structure. A trained second coder used the final code structure to independently code 33%
of the transcripts. Inter-rater reliability of coding procedure between the coders was 0.95. All
transcripts were systematically coded using QSR NVivo version 8.0 software.
Data displays. Coded statements from each participant transcript were extracted by
theme using NVivo 8. Summary statements were developed for each transcript that captured the
main ideas for each theme. In the final step a conceptually clustered matrix was developed
(Miles and Huberman, 1994). A matrix listing themes along the rows and participants along the
columns was prepared. Summary statements prepared in the previous step for each participant
were recorded under the corresponding theme on the matrix. The authors reviewed the matrices
by theme across all participants and identified patterns and trends associated with each behavior.

Results
Asian Indian mothers in our sample were primarily well educated and middle- or higherincome. Over 60% of the mothers were categorized as overweight or obese based on self
reported height and weight. Although the mothers had resided in the US on an average for 10
years, the mean acculturation score was low indicating that the sample was Asian Indian
identified (Table 2-1).
The qualitative analysis focused on identifying emergent themes related to the mothers’
beliefs about expected outcomes of each behavior, their perceptions about control over the
behavior, and social pressures associated with each behavior. During the interviews, major
themes emerged that pertained to the mothers’ expected outcomes and behavior control, but little

51

information related to social pressures (or subjective norms) emerged. The following sections,
therefore, describe the mothers’ reports on 1) current practice of each behavior, 2) expected
outcomes of practicing each behavior, and 3) the perceived ease or difficulty in practicing the
behavior. Results are presented separately for positive feeding behaviors (family meals and
parental modeling) and negative feeding behaviors (pressuring to eat, using food rewards, and
eating while watching TV).

Positive Behaviors
Family meals. The majority of mothers (21/27) reported having regular family meals
when all family members were home. Dinner was often referenced and featured home-cooked
Indian dishes.
Mothers reported two highly desirable outcomes of family meals: promoting children’s
consumption of healthy foods and the preservation of Indian identity. Mothers (17/27) believed
that traditional Indian meals that typically include a wide variety of foods such as vegetables,
rice, roti (Indian flat bread), and dal (lentils) are healthy and well balanced with important
nutrients and major food groups. In addition, over half of these mothers (10/17) considered
consumption of traditional Indian foods to be integral to developing and maintaining an Indian
identity. One woman who felt strongly about serving her children Indian meals remarked, “Food
habits are nothing but your identity. I know many families that have separate meals for their
children, but it’s not good.” Mothers therefore desired their children to be familiar with, as well
as accept and consume, Indian dishes. They believed that family meals encouraged consumption
of Indian foods since they could expose their children to a variety of Indian dishes, talk to them
about Indian foods and nutrition, and model the consumption of Indian dishes.

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Over 70% of mothers (19/27) reported that practicing family meals was difficult since
cooking Indian meals was perceived to be an elaborate and time consuming process. However,
they reported using several strategies to make family meals possible on a regular basis. One
strategy viewed as crucial by most was meal planning and advance preparation including cutting
vegetables, preparing roti dough, or soaking and boiling lentils in advance to make quick meals.
“I cut up all the vegetables the night before. So, I have everything ready the night before, like,
make the roti dough. If I’m making any kind of lentil, I usually soak them the night before. So
when I come home the next day, all I have to do is cook ‘em.” Some mothers reported cooking
two or three meals during weekends, partial cooking, preparing one dish such as a vegetable
curry in the morning before leaving for work, following easy recipes, and preparing one-pot
Indian meals such as one vegetable curry and roti instead of elaborate meals. Spouses helping
with meal preparation and children helping with setting the table were also identified as making
family meals easier.

Parental modeling. Mothers frequently discussed parental modeling in the context of
family meals. The majority (14/27) stated that family meals provided a good opportunity for
parents to engage in positive role modeling behaviors such as eating healthy Indian foods,
avoiding negative comments about any food, trying certain foods despite their dislike, and
expressing their feelings about how much they liked certain foods.
They also (14/27) believed that modeling the consumption of Indian dishes during
mealtime resulted in desirable nutrition outcomes in children by creating a sense of familiarity,
acceptance, and liking for those foods in children. Mothers felt that these outcomes were
important given children’s exposure to western foods at school and through their peers.

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A majority of mothers (22/27) reported that modeling the consumption of healthy foods
was easy as they regularly ate dinner with their children and they liked and were willing to eat
those foods.

Negative Behaviors
Pressuring children to eat. The majority of mothers (16/27) reported that they
frequently pressured their children to eat specific types and amounts of food. They also revealed
pressuring strategies that ranged from mild to extreme. At one extreme, one mother reported
“My son always says I’ll vomit, I’ll vomit, if you give me this vegetable. I’ll vomit! I say, “Okay,
I don’t care if you vomit, but you finish (your food). You have to put it (food) in the trash
(anyway)…. So, you eat it, and then you go and vomit…….. I want them to finish their food.”
Common pressuring strategies reported by mothers included nagging the child to finish the food,
not allowing the child to leave the table unless they finish the food, threatening to take away TV
or playing with friends, serving uneaten food for breakfast or the next meal, and spoon feeding to
get the child to finish the meal.
Mothers reported that they (16/27) used pressuring when they were concerned that a child
would not eat enough because they were not aware of their own hunger. They also felt that
children were often picky and would focus on only one food in a meal while rejecting others if
they were not pressured.
Mothers also showed concern that their children resisted Indian food. Almost half of
those who pressured (7/16) believed that children’s exposure to American fast foods in school, as
well as the spices used in Indian preparations were responsible for children’s aversions to Indian
foods, “The moment they start going to school or to daycare, that is the time they resist eating

54

Indian food. So it becomes difficult to give them Indian food. Because the moment they start
eating (chicken) nuggets in school, or macaroni and cheese, they’re somehow drawn towards
that kind of food, because it’s tastier.” Mothers reported that they used pressuring as part of an
on-going power struggle over the consumption of Indian dishes.
Most mothers (21/27) believed that pressuring children to finish food on their plate was
important to help children learn the value of not wasting food and to not overfill their plates.
Almost all mothers who used pressuring (13/16) said that it was important to respect food for
religious reasons and to show consideration for people who must struggle to feed their families.
To them, it was inappropriate and disrespectful to leave any food on the plate. Said one mother,
I tell her to clean (the plate). You need to bring some values in them. They have to appreciate
what people are struggling for. So you cannot just take the food and throw it in the garbage
when so many people are starving for food. Because that’s how we grew up. So, the same thing
we are just passing on to the next generation”.
Mothers who pressured also (13/16) reported that it was a culturally-learned behavior. “I
think it’s a social mentality that has been handed from our parents. Like, you are blessed with so
much food. So don’t waste your food; there are children who are not getting this much…….. I
think this is very common, not only among Indians, basically among Asians. It’s inherent for all
the mothers.” The majority of the mothers (12/16) who used pressuring, however, expressed
frustration that it was not effective at getting their children to eat healthfully or to eat sufficient
amounts. “It’s a struggle. It’s a struggle. It’s hard. I don’t know what else to say. It’s hard
because, it takes so much time and effort to get them to finish their food……and it always feels
like, daily nagging kind a thing……..Finish your food, finish your food.” Due to the perceived
ineffectiveness of pressuring, almost all mothers (14/16) who used pressuring used other

55

controlling behaviors as well, such as rewarding children with sweets and using TV to control
children’s food intake.

Rewarding with food. Nearly half of all mothers interviewed (13/27) reported
rewarding their children with food to encourage them to finish a meal or consume a specific food
such as fruit or vegetables. Sweets, desserts, and snack foods were frequent rewards.
Yet, almost all mothers (24/27) cited undesirable outcomes from using food as a reward
for specific eating behaviors. Mothers said that when children are offered food rewards for
finishing a meal, they become more interested in the reward than the meal itself. They were also
concerned that rewarding children with treats could encourage a habit of eating certain foods
only when a food reward is provided. One mother said “I think it’s not a good habit because the
kid expects that if I’m finishing this, I am going to get ice cream. So, it becomes a ritual. Like, I
know that mama is going give me ice cream every time I finish my lunch. So she is not interested
in the lunch. “So where’s my ice cream?” I don’t think that’s a good thing to do.” Over half of
the mothers interviewed (14/27) also indicated that rewarding children for any behavior will
negatively affect their development as it creates an expectation of material rewards for behavior
and discourages an attitude of responsibility and obligation in children.
Despite their negative views on rewarding, all mothers (13/27) who used food rewards
believed that it was easy and effective strategy to get children to finish their food and consume
healthy foods, especially Indian dishes. Interestingly, most of these mothers (9/13) also reported
using pressuring behaviors to encourage eating. One mother summarized, “I think you…
somehow get your way, but not make the child feel like they’re being pressurized into eating

56

something. They feel like okay, (if) I finished it, then I get my reward. At the same time, you’re
introducing (them) to more food, new food. And then they get into the habit of finishing it.”

Eating while watching TV. Another negative behavior employed by mothers was to
allow children to eat while watching TV, as well as serving food or feeding them by hand in
front of the TV. Despite knowledge of the ill effects of TV watching on children’s food
consumption, the majority of mothers (14/27) admitted to using this tactic. “If I want him to
drink milk or, eat some good food, I prefer him watching TV and eat it. Because he doesn’t
concentrate on what he is eating, and that way at least he’s getting some good stuff.” Most
mothers (8/14) using TV as a feeding strategy felt that they had lost control of their children
watching TV during eating because the children were habituated to it from a very young age. “It
is difficult, because it’s kind of become involuntary for children to switch on the TV. Or, take the
plate and go in front of the TV and watch…Without watching something they cannot eat.”
All mothers (27) clearly understood that TV was a distraction to children while eating.
Mothers explained that children unconsciously overeat because they do not pay attention to what
and how much they were eating when focusing on TV. They also stated that children did not pay
attention to their consumption of Indian dishes, which they might normally resist, while
watching TV. As a result, mothers intentionally used this inattention to “sneak in” desired
Indian foods.
Mothers had a very good understanding of the harmful effects of eating while watching
TV, particularly that it might lead to overeating, and therefore expressed resignation over
practicing this behavior. “As a mother I don’t prefer it. But sometimes if I have to give her some
fruits … if I turn on the TV, she’ll eat the fruits and vegetables. Otherwise, she won’t eat. Or

57

she’ll drink the milk. I’m not very happy, but, I think she’s eating (that way).” Mothers,
however, reported the use of TV to force children’s food consumption because they felt that
there was no other method that was as easy and effective for getting children to eat “healthy
foods” that they would normally resist. One mother expressed her resignation by saying, “I
would say it’s a wrong choice to put the TV on and feed them. That’s wrong. But I just can’t
find another way to feed them.”

Discussion
Although literature suggests differences in feeding behaviors among ethnic groups
(Sherry et al., 2004; Ventura, Gromis, & Lohse, 2010), there is little emphasis on the role that
culture plays in influencing these behaviors. In this study, the in-depth open-ended inquiry
allowed for the emergence of the cultural influences on child feeding behaviors. In particular,
the study found that cultural beliefs related to religion, ethnic identity, and traditional foods are
strong determinants of both positive and negative feeding behaviors among immigrant Asian
Indians.
First, the analysis showed the role that religious beliefs play in the practice of the
negative feeding behaviors of pressuring children to eat. Food, for example, is revered in Asian
culture and it is common to invoke a respect for those who do not have enough food (Yunus,
2005), even when individuals have not personally experienced food insecurity. In addition,
Asian Indian Hindus consider food a gift from Annapurna Devi, mother goddess worshiped for
nourishment (Arundhati, 2001), and they therefore treat it with utmost respect. Due to such
religious beliefs, discarding leftover food is often regarded as unacceptable. In this study Asian
Indian mothers were motivated to engage in negative feeding behaviors, such as extreme

58

pressuring, by these underlying cultural beliefs. It is possible that such beliefs of Asian Indian
mothers may be responsible for high prevalence of controlling behaviors reported in previous
studies as well (Hackett & Hackett, 1994; Hinton, 2010).
Asian Indian mothers’ use of pressure to induce children to eat is of concern because it
may disrupt children’s ability to regulate their energy intake and increase risk of weight
problems (Birch, Fisher, & Davison, 2003; Fisher & Birch, 1999; Farrow & Blissett, 2006;
Galloway et al., 2006). There is little research on the outcomes of controlling child feeding
behaviors on Asian children. Hinton (2010) showed that Asian Indian mothers’ use of external
control may impair children’s regulation of energy intake. Eating disorders in South Asian girls’
have been associated with their perceptions of their mothers’ being over controlling (McCourt &
Waller, 1995).
Second, our results found their ethnic identity was a major motivator for mothers in the
practice of positive behavior of having family meals. This motivator is consistent with findings
reported in the literature. First generation Asian Indians often strive to retain their cultural
identity and transmit this to their children even many years after immigrating to a Western
country, (Dasgupta, 1998; Patel, Power, & Bhavnagri, 1996). One of the identifying values
Asian Indian immigrants retain is their preference for traditional Indian foods, even after
significant adaptation to a Western environment (Wakil, Siddique, & Wakil, 1981). Our study
found that consumption of Indian dishes during family meals was one way for Asian Indian
mothers to remain connected to Indian culture, which they now perceived to be foreign to their
children. This characteristic of Asian Indian mothers in our study is also consistent with their
low acculturation scores and hence a higher tendency to hold on to their cultural values.

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In addition to the cultural and religious beliefs that influence pressuring and family
meals, we saw feeding behaviors were influenced by an underlying belief that traditional Indian
dishes are healthy. Mothers frequently emphasized the nutritional value of traditional Indian
foods and this became an important motivation to practice both positive as well as negative
feeding behaviors. Research shows that feeding behaviors are usually associated with a mother’s
desire to improve children’s nutrition outcomes (Sherry et al., 2004; Campbell, Crawford, &
Hesketh, 2007). This was true for Asian Indian mothers in our study as well. However, the
combination of multiple beliefs such as nutritional value of traditional food, traditional food as a
part of cultural identity, and religious reverence for traditional food, contributed to the
widespread practice of controlling behaviors.
Mothers appeared unsuccessful in identifying positive alternative feeding strategies to
pressuring to achieve their goals in feeding their children. Mothers did not believe pressuring
was very effective, and so in addition to it used one or even two negative controlling behaviors,
often with resignation.
First, mothers used food rewards as a short term solution to feed Indian foods to children.
This finding is consistent with the literature which indicates that food rewards are often used
because they are practical solution to avoid children’s food fussiness, even though mothers in
this and other work recognized it as inappropriate (Campbell, Crawford, & Hesketh, 2007).
These behaviors continued over time increase children’s preference for the rewarded food while
decreasing the preference for, and consumption of promoted food (Birch et al., 1987; Birch et al.
1982; Newman & Taylor, 1992). It’s possible such behaviors of Asian Indian mothers could
lead to resistance by children to eating Indian dishes leading to even more controlling feeding
behaviors.

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Second, the mothers in our study had developed a new, and to their belief, effective
strategy of using TV to control their children’s food intake. While direct control such as
pressuring to eat, rewarding with food, and restricting children consumption of certain foods are
commonly studied feeding practices (Rhee, 2008), this type of control using TV to circumvent
children’s resistance to certain foods has not been reported previously in the literature. Ogden,
Reynolds, and Smith (2006) has used the term “covert control” to refer to forms of food control
that cannot be detected by the child. Covert control is a more subtle and less direct approach to
managing child's diet by doing things such as avoiding unhealthy restaurants or not bringing
unhealthy foods into the house (Brown et al., 2008). In contrast to direct or overt control (e.g.
pressuring to eat), covert control has been associated with healthier eating in children (Wardle et
al., 2003; Ogden, Reynolds, & Smith., 2006; Brown et al., 2008). By contrast, discreetly
controlling children’s food intake using TV found in this study is a form of covert control which
would be expected to have damaging outcomes on children’s health . Mothers in this study were
using TV viewing to distract children’s attention from their food consumption, hoping to develop
a preference for foods they were “sneaking” into their children. Lack of attention to eating by
engaging simultaneously in other activities such as TV viewing promotes overconsumption of
foods, (Francis & Birch, 2006; Bellissimo et al., 2007; Temple et al., 2007). This newly reported
use of a covert control to manipulate children’s intake for an intended healthy outcome may
introduce another health concern of overweight.

Implications for Research and Practice
Our research points to the need for nutrition professionals to become cross-culturally
sensitive and competent in order to work effectively with immigrant populations. It invites

61

researchers to take an inquisitive approach to understand and work within the values, beliefs, and
practices of people from other cultures so that culturally sensitive nutrition education could be
developed.
In this population of Asian Indian mothers, nutrition education should focus on a
comprehensive approach encompassing cultural values, traditional foods, and ethnic identity
issues along with nutrition outcomes. Mothers’ beliefs of the nutritional value of traditional
Indian foods and their concern with development of ethnic identity could be used as positive
motivators to maintaining and promoting positive behaviors such as family meals than focusing
on nutrition benefits alone.
Addressing negative behavior such as pressuring to eat, deep-rooted within cultural and
religious beliefs, is challenging and requires developing alternative feeding strategies that
acknowledge and respect such beliefs rather than ignore them. For example, encouraging
mothers to not overfill children’s plate and serve small portions may help prevent food wastage
and reduce the frequency and intensity of pressuring behavior, while preserving cultural values.
Finally, nutrition educators may focus on mothers’ motivations in practicing negative
controlling behaviors. Asian Indian mothers recognized the long term undesirable consequences
of these behaviors, helping mothers understand their controlling behaviors could undermine the
very nutrition and cultural outcomes they desire for their children may lead to receptivity to more
alternate and more positive behaviors that preserve these important goals they have in feeding
and raising their children.

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Table 2-1. Demographic Information of Participants
Demographic Characteristics
Age (years)

34.70 ± 3.440

Years in US

9.74 ± 6.85 (1-38)

Education
Masters/PhD/Professional degree
4 years degree/Bachelor’s degree

13 (48%)
14 (52%)

Employment Status
Homemaker
Graduate student
Employed part-time
Employed full-time
Household Income ($)
$20,000 – $40,000
$40,000 – $60,000
$60,000 – $80,000
>$80,000

11 (41%)
4 (15%)
2 (7%)
10 (37%)
(n=25)
4 (16%)
2 (8%)
6 (24%)
13 (52%)

BMI (Kg/m2)
Low (BMI<18)
Normal (18 ≤ BMI < 25)
Overweight (25 ≤ BMI < 30)
Obese (BMI ≥ 30)

1 (3.7%)
9 (33.3%)
12 (44.4%)
5 (18.5%)

Average acculturation score (1-5)

2.035 (range 1.619 – 2.857)

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CHAPTER THREE:
DEVELOPING AND TESTING NUTRITION MESSGES FOR ASIAN INDIAN
MOTHERS

Abstract
Asian Americans born in the US are twice as likely to be overweight compared to those born
elsewhere and newly migrating. The prevalence of childhood overweight for Asian Indians will
increase as more Asian Indian children are born in the US. Childhood obesity prevention efforts
often focus on parent behaviors that influence children’s dietary intake and weight status.
Research shows that Asian Indian mothers may need nutrition education materials developed
specifically for this group. The aim of this study was to develop and test nutrition messages for
Asian Indian mothers addressing eight parental feeding behaviors likely to influence children’s
diet and weight status. Based on our previous research, nine nutrition education messages were
adapted from those developed by the United States Department of Agriculture and 29 new
messages were developed. These messages were tested using cognitive interviews with ten
Asian Indian mothers. Mothers were receptive to 31 messages, with minor revisions made to
five messages to improve clarity and increase acceptability. Two messages that received strong
negative responses were deemed inappropriate for this population. Nutrition professionals
working with Asian Indian families may use the final messages in education materials to help
mothers develop healthy child feeding practices.
Key words: feeding behaviors, nutrition messages, Asian Indian, testing.

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Introduction
While the rates of childhood obesity have reached epidemic levels for the major ethnic
groups in the US (Ogden et al., 2010), high rates have also been reported among Asian American
children (Popkin & Udry, 1998; Thorpe et al., 2004). Asian Indian, a sub-group of Asian
American, is a rapidly growing immigrant population in the US (US Bureau of Census, 2010). It
is estimated that the proportion of overweight Asian Indian children will rise as more Asian
Indian children are born and raised in the Westernized culture (Lauderdale & Rathouz, 2000),
indicating a need to target obesity prevention efforts to this group.
Several factors have been suggested to contribute to the increase in childhood obesity.
Research shows that parents significantly influence children’s eating habits and weight status
(Patrick et al., 2005; Rhee, 2008; Ventura & Birch, 2008). While creating a positive mealtime
environment by having regular family meals and modeling healthy eating improves dietary
intake in children (Rhee, 2008), allowing children to watch TV while eating negatively affects
children’s self regulation of energy intake (Francis & Birch, 2006). Making healthy food
available and accessible at home can have a significant effect on children’s preference for and
consumption of such food (Francis & Birch, 2006). Controlling feeding practices, such as
pressuring children to eat, rewarding children with food, and restricting children’s consumption
of certain foods can also override children’s ability to self-regulate energy intake leading to
eating problems and overweight status (Rhee, 2008). Given the significant impact on children’s
eating and weight status (Rhee, 2008; Ventura & Birch, 2008), these feeding behaviors have
become a focus for interventions targeted toward parents to promote healthy eating and to
prevent obesity in their children (McGarvey et al., 2004; Golan & Weizman 2001; Golan &
Crow, 2004; Lindsay, 2006).

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Recently, the United States Department of Agriculture (USDA) and Food and Nutrition
Service (FNS) developed and tested nutrition messages to be used in Federal nutrition education
programs to address low-income mothers’ feeding behaviors (United States Department of
Agriculture [USDA], 2008). These messages were developed based on focus group discussions
with low-income Caucasian, African American, and Mexican American mothers; it is possible
they may need to be adapted for use with Asian Indian mothers.
Our previous research has shown that Asian Indian mothers not only use controlling
feeding practices extensively, but they also let children watch TV while eating as a means to
control children’s food intake (unpublished data). Some of these controlling feeding behaviors
are not addressed by the USDA messages. Furthermore, Asian Indian mothers’ practice of
certain feeding behaviors is strongly driven by unique cultural beliefs. Our findings suggest that
Asian Indian mothers lack appropriate and effective feeding strategies and may benefit from
nutrition messages that are culturally sensitive and specifically targeted toward this group.
The aim of this study was to develop and test culturally appropriate nutrition education
messages for Asian Indian mothers. The goal of these nutrition messages is to help Asian Indian
mothers identify and practice feeding behaviors that are conducive to healthy eating, and
therefore overweight prevention, in their children. This article describes the process of
developing nutrition messages, provides results of testing the messages, and discusses the
implications for nutrition educators working with Asian Indian mothers.

Methods
A three-step approach was used to develop and test nutrition messages for Asian Indian
mothers.

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Step 1
A formative assessment was conducted using a qualitative approach to identify the
factors that influence Asian Indian mothers’ practice of 8 feeding behaviors – family meals, TV
viewing and eating, parental modeling, availability of foods at home, accessibility of foods at
home, restricting children’s consumption of certain food, rewarding children with food, and
pressuring children to eat (unpublished data). Using the Theory of Planned Behavior (Ajzen,
1991) we identified beliefs, barriers, and facilitators likely to influence Asian Indian mothers’
practice of each feeding behavior.
Step 2
Based on our previous research, we determined that nine messages developed by the
USDA with minor modifications were appropriate for testing with Asian Indian mothers as these
messages reflected beliefs, barriers, and facilitators of Asian Indian mothers. USDA messages
frequently used the word “veggies”, but Asian Indian mothers preferred the word “vegetables”
which was substituted in these messages. Twenty nine new messages were created to address
behavioral beliefs, barriers, and facilitators unique to Asian Indian mothers as well as their
feeding behaviors not addressed by the USDA. This resulted in a total of 38 messages for eight
feeding behaviors. Similar to the USDA messages, the new messages developed for Asian Indian
mothers consisted of two types: 1) core messages and 2) supporting messages. For each feeding
behavior, core messages incorporated Asian Indian mothers’ behavioral beliefs (belief about an
outcome of a behavior) pertaining to a given feeding behavior and provided a recommendation
for an appropriate action. In this way, the core message asked the audience to take an
appropriate action for a given feeding behavior and provided the incentives or reasons (benefits
cited by the mothers during formative assessment) linked to the action. The supporting content

67

provided information to ease the barriers and enhance self-efficacy of Asian Indian mothers in
practicing a given feeding behavior.
The reading level of the messages was determined using the simple measure of
gobbledegook (SMOG) formula (McLaughlin, 1969). The average readability score of the
th

messages ranged from 5 to 6

th

grade reading level. After the draft messages were created, they

underwent review by experts in the field of health behavior change, nutrition education, and
health communication, and revisions were made.
Step 3
Individual interviews were conducted to determine how Asian Indian mothers understand
and respond to the nutrition messages. Prior to interviews, informed written consent was
obtained from participants and they also completed a demographic questionnaire and the SuinnLew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn et al., 1987) to measure their
acculturation level.
Interviews were conducted with ten Asian Indian immigrant mothers of children ages 510 years using cognitive response testing (Carbone, Campbell, Honess-Morreale, 2002). A semistructured interview guide was used to test the following aspects of the messages –
comprehensibility, agreement with the information, and feasibility of acting on the message. A
concurrent verbal probing technique (Carbone, Campbell, Honess-Morreale, 2002) was used: the
participant was shown one message at a time and concurrently asked questions pertaining to that
message to capture her responses. The participant was asked to comprehend the meaning of the
message by summarizing the message in her own words. Next, she was asked to express words
and phrases that would make the message clearer and easier to understand. The participant was
then asked how much she agreed with and trusted the information. Finally, feasibility was
68

determined by asking the participant if it would be easy or hard for her to follow the
recommendations provided in the message. When testing different ideas in core messages for a
given feeding behavior, participants were asked to rank the messages based on their preferences.
The interviews lasted an average of fifty minutes. The sample size was determined by
saturation of responses, i.e. the point at which no new responses were obtained. Response
saturation was obtained after conducting 8 interviews; however, 2 additional interviews were
conducted to ensure saturation had been reached.
The interviews were audio-recorded and notes were taken during the interview. The
audio recordings of participants’ responses and written notes were qualitatively analyzed to
identify common themes and similar responses for each of the three aspects of a given message.
Based on the responses from cognitive interviews, the messages were left unchanged, revised to
address the issues of ambiguities and disagreements, or deemed inappropriate for this target
group.
This study was approved by the Institutional Review Board at Michigan State University.
Participants were provided with a $20 gift card as reimbursement for their participation.

Results
The average acculturation score was 2.05 (from a possible score of 1 to 5) and ranged
from 1.38 to 2.85, reflecting a high Asian identification of the participants. The mean age of
participants was 35.8 years (range 29 to 42 years) and the average number of years they had
lived in the US was 10 years (range 2 to 39 years). Participants were highly educated, with 60%
having a graduate or a professional degree and 40% having a bachelor’s degree. About 40% of
the participants were employed full time and 30% were homemakers. Others were either

69

employed part time (10%) or were students (20%). Annual household income was higher than
$60,000 for 90% of the participants.
The 38 tested messages are presented for each feeding behavior categorized into three
groups: mealtime environment (Table 3-1), availability and accessibility of healthy food at home
(Table 3-2), and controlling child-feeding behaviors (Table 3-3). Core messages (C) are listed
first, followed by supporting messages (S). Out of 38 total messages, 31 messages (6 from
USDA) received consistent positive reactions (one message received mixed responses) and were
retained without any modifications. We determined five messages (1 from USDA) needed minor
revisions to address the issues of ambiguity and agreement. These revisions were made based on
comments provided by the mothers. Two messages (both from USDA) were deemed
inappropriate due to poor acceptability of these messages with this target audience.

Mealtime Environment

Family meals (Fm). Although, all core messages addressing the importance of family
meals were well accepted (Table 3-1), the message “when you eat together, your kids can see
and get to know the foods your family enjoys” (FmC1) was most preferred among all core
messages. The mothers liked the idea of exposing children and making them familiar with
family foods incorporated in this message. The first two supporting messages (FmS1 and FmS2)
were well received by mothers. However, they felt that the supporting message “Family meals
are possible when everybody is in it together” (FmS3) was ambiguous. They needed more
information on how “kids can be great help” in making family meals possible. This message
was revised by adding tasks mothers suggested were safe for children to perform and would get

70

them involved in making family meals. The mothers felt that the message “Do some tasks a day
before” (FmS4) lacked clarity since it did not specifically mention that the recommendation
applies to meal preparation. Revisions were made to clarify this message as well.

TV viewing while eating (Tv). All core and supporting messages about not letting
children watch TV while eating (Table 3-1) received strong and consistent positive reactions
from the mothers. When asked about their preference for core messages, the message “Your
kids will pay attention to what and how much they eat” (TvC1) was preferred by most mothers
over the message that stressed kids will like the taste of food (TvC2).

Parental modeling of healthy eating (Mo). Although all three core messages for
modeling healthy eating behaviors (Table 3-1) were well accepted, the message “Want your kids
to eat new foods?” (MoC1) suggesting parental modeling to encourage children to eat new foods
was most preferred among the three core messages. The supporting message (MoS1) suggesting
the effects of making negative comments and showing dislike for a particular food on children
was very appealing since almost every mother had experienced instances where parents’ negative
comments about a food had adversely influenced children’s liking for that food. Although all
supporting messages (MoS1, MoS2, and MoS3) were well received by mothers, the message
suggesting that ‘if food likes and dislikes are counter balanced by both parents, parental
modeling could still be practiced’ (MoS3) was ambiguous to some mothers. The mothers were
initially unsure to who the message was referring (e.g. child or mother). This was clarified with a
revision.

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Availability and Accessibility of Food at Home

Availability of healthy food at home (Av). Although mothers agreed with both core
messages recommending making healthy food available at home (Table 3-2), they liked and
preferred the first message that phrased the outcome as a question: “Want your kids to eat
healthy foods?” (AvC1) versus directly stating the outcome: “When kids are home, they will
choose and eat from what’s available” (AvC2). Core message 3 (AvC3) was also well accepted
by mothers. The mothers felt that the availability of “unhealthy” or “junk” food at home was a
major barrier to children’s consumption of healthy food. However, some mothers expressed
reluctance to completely avoid bringing less healthy food home. They noted that despite the
presence of healthy food, children were more likely to prefer and choose the less healthy foods
that were available. Therefore, these mothers reported a lower preference for the latter message
‘Keep lots of healthy foods…when kids are home, they choose and eat from what’s available’
(AvC2). This section does not contain supporting messages addressing this barrier since
availability of less healthy food was also strongly related to restricting children’s consumption of
such foods. This issue was addressed in the section pertaining to restriction of foods.

Accessibility of healthy food at home (Ac). While both core messages (AcC1 and
AcC2) addressing accessibility of fruits and vegetables (Table 3-2) were well accepted, mothers
had a stronger preference for “Keep fruits and vegetable where your kids can see them” (AcC2).
However, they also felt that fruits and vegetables could be kept in places other than the
refrigerator such as the table or kitchen counter, where children can easily see them. This
message was revised accordingly. The supporting message “Kids love to dip fresh vegetables in

72

low-fat ranch dressing (AcS1) received mixed responses. Some mothers agreed with the
message, while others didn’t find the use of dip appropriate to their family. The message was
retained without any modification for those to whom it was suited. A few mothers shared strong
opinions about not keeping fruits and vegetables in cut form in response to the message “Store
cut fruits and vegetables in sealed plastic bags…..” (AcS2). These mothers felt that when fruits
and vegetables are cut they start losing freshness and important nutrients.

Controlling Child-Feeding Behaviors

Restricting consumption of certain foods (Re). In previous interviews, Asian Indian
mothers described alternatives to restricting children’s consumption of certain foods. They were
divided in their beliefs – some mothers preferred to not buy foods they considered unhealthy
(ReC1), while others felt it was appropriate to have small amounts of these foods at home for
children to consume them in limited amounts (ReC2). When testing both these ideas in two
different messages (Table 3-3), the mothers showed a strong preference for either one or the
other message. This suggested that both the messages be kept as a part of nutrition education.
The supporting messages suggesting availability of healthy snacks for children to choose from
(ReS1) and buying healthier versions of snacks (ReS2), intended to address the barrier of
availability of unhealthy food, were also well accepted by all mothers.

Offering food rewards for finishing meal (Rw). The core messages about not using
food as a reward for encouraging children to finish their meal (Table 3-3) were well received by
the mothers, with higher preference given to the message “Reward with praise, not food”

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(RwC1) versus the message “Reward your kids with things other than food” (RwC2). Some
mothers who were already rewarding their children with sweets for eating or finishing other
foods felt that it would be hard for them to follow these recommendations. However, when
testing the supporting content that provided ideas of using alternatives to food rewards, the
mothers felt that it was feasible for them to follow the recommendations and were motivated to
try the ideas provided in supporting messages (RwS1 and RwS2).

Pressuring to eat (Pr). The core messages addressing pressuring to eat tested the
concept of “division of responsibility” (Table 3-3) – offering a variety of healthy food choices
and letting children choose ‘what’ and ‘how much’ to eat, in two different messages (PrC1 and
PrC2), both adapted from the USDA messages. Most mothers showed a strong and consistent
disagreement with the idea of offering variety and allowing children to choose what and how
much to eat. The mothers expressed concern that they did not trust their children to eat enough if
they were allowed to decide how much to eat. The mothers strongly felt that it was their
responsibility to decide how much their child would eat. The mothers also felt that it was not
always possible for them to provide a variety of foods to their children for each meal. Even
when a variety of foods were offered, the mothers felt that children should eat at least a small
amount from all the varieties. As a result of lack of receptivity to this concept, these messages
were deemed inappropriate for Asian Indian mothers.
One of the supporting messages tested the idea of ‘letting children serve themselves in
small amounts’ (PrS2) (taken from USDA) and “allowing for a second helping” tied to the
concept of “helping children learn not to waste food”. This message was intended to reduce the
pressuring behaviors of mothers by advising them to serve small portions of food. The mothers

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connected very well to this message. Our previous work found that wasting food is a major
concern of Asian Indian mothers when feeding their children resulting in pressuring children to
eat; this may have resulted in the receptivity to smaller portions as a way to address the concern
on wastage. Although the mothers were receptive to the idea of controlling portion size to avoid
food wastage, some mothers disagreed with letting children serve themselves (PrS2). Asian
Indian foods are mostly in the form of curry. Mothers felt that the children will make a mess if
allowed to serve themselves. Some mothers also expressed fear of children hurting themselves if
the food was too hot. This message was revised accordingly.

Discussion
This study developed core and supporting messages for Asian Indian mothers related to
eight key feeding behaviors. Our study addressed some feeding behaviors that were not included
in the USDA messages. For example, watching TV while eating and rewarding with food were
brought up in focus groups conducted by the USDA (USDA, 2008; White et al., 2011).
However, messages were not developed to address these issues. Given the extent of TV viewing
while eating in Asian Indian children and its harmful effects on children’s energy regulation and
weight problems (Francis & Birch, 2006), five messages related to TV watching and eating were
developed specifically for Asian Indian mothers. Although addressed by the USDA (White et
al., 2011), all messages related to family meals were specifically developed for Asian Indian
mothers considering their distinct beliefs about the benefits of family meals and meal
preparations related to Asian Indian foods (unpublished data).
Nine out of 38 messages pertaining to food availability, food accessibility, parental
modeling, and pressuring children to eat were adapted from the USDA messages. The majority

75

of these messages used or adapted from the USDA were well accepted by Asian Indian mothers.
Acceptance of these messages by low-income mothers of different ethnic groups as well as high
income Asian Indian mothers indicates that despite cultural differences, common beliefs and
opinions exist regarding child feeding. However, there were differences in the views by these
Asian Indian mothers about a few messages that were driven by strong cultural beliefs. For
example, USDA’s message to control portion size suggests letting children serve themselves.
While, this message was well accepted by low-income mothers (White et al, 2011), Asian Indian
mothers did not agree with letting their children serve themselves due to the fear of children
making a mess during mealtime. Previous research has shown that Asian parents continue to
spoon feed their children until they are old enough to eat neatly and efficiently by themselves to
prevent messy mealtimes and cleaning up after meals (Yunus, 2005). Another message aimed at
enhancing children’s likelihood to choose fruits and vegetables that are accessible by serving
them with low-fat ranch dressing (AcS1) was well accepted by low income mothers (USDA,
2008). However, our study found that half the mothers shared positive responses about this
message since they liked the idea of providing “low-fat” ranch, which was perceived to be
healthy. The half of the mothers disagreed with message since they considered salad dressings
and dips as traditional American foods and did not feel a need to have these foods in their homes.
Asian Indian mothers may currently not be receptive to introducing western foods into their
traditional Indian diet due to low acculturation. However, dietary patterns of immigrants change
with acculturation resulting in incorporation of more western foods (Satia-Abouta, 2003). Such
information could thus be helpful to mothers who are likely to incorporate American foods in
their diet to do so in a healthy manner.

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A few mothers did not believe in cutting fruits and vegetables in advance to preserve
freshness and important nutrients. Although these issues emerged with very few mothers, it is
still a barrier nutrition educators should consider with this population. Alternatively, educators
could provide Asian Indian mothers with additional information on how to safely store cut fruits
and vegetables for few days in a refrigerator without losing nutrients. To help mothers
encourage children’s consumption of fruits and vegetables, the mothers could also be advised to
provide fruits and vegetables that do not require cutting (e.g. banana, grapes, plums, baby carrots
etc.) accessible to children.
Similar to the responses obtained from low-income mothers (White et al, 2011), Asian
Indian mothers showed strong and consistent disagreement with the messages that incorporated
the concept of ‘division of responsibility’. Several researchers suggest using this concept in
nutrition education and interventions targeted at mothers to help them reduce mother-child
conflicts over eating while giving some control to both parents and children (Satter, 1987; Dietz
& Stern 1999; Sherry et al., 2004). However, responses from this study, and the study conducted
by White et al. (2011) suggest that mothers may not be receptive to this idea as presented.
Another explanation of this concept is needed before mothers understand the application of this
concept. Alternatively, strategies may be used to reduce controlling feeding practices. One
concept, used in this study and well received by the mothers, is to link mothers’ behavior (e.g.
serving small portion of food) to their cultural beliefs (helping children avoid food wastage) as
the main purpose of behavior.

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Conclusions and Implications for Practitioners
Testing of these messages demonstrated that the majority of the messages are culturally
appropriate for Asian Indian mothers in terms of language, informational content, and feasibility
of acting on the message. Other messages were revised to be suitable; only a few messages were
so poorly received that they would not be acceptable in nutrition education for this group. Our
final set of messages may be incorporated into nutrition education materials for Asian Indian
population to encourage Asian Indian mothers to practice feeding behaviors that are conducive to
healthy eating and overweight prevention in their children.
Since there are very limited health and nutrition interventions for the Asian Indian
population, integrating these messages into existing programs is challenging. Identifying
potential communication channels that allow reaching a large number of Asian Indian mothers is
crucial for disseminating these messages. Common sites often targeted and considered by Asian
Indian mothers include schools and physician’s offices. Targeting such venues located in areas
with high density of Asian Indian populations could be useful in delivering nutrition education.
Other channels unique to this group, such as Asian Indian organizations and clubs, religious
centers, Asian Indian grocery stores, and websites for Asian Indians were also identified during
interviews with mothers. Several religious, cultural and social events and gatherings for parents
and children organized by these organizations draw together a large number of Asian Indians and
could be appropriate settings to provide nutrition information.

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Table 3-1. Nutrition Messages Related to Mealtime Environment
Message
a
number

Message

Participants’
response

Behavior Fm: Family Meals
FmC1

When you eat together, your kids can see and get to know the
foods your family enjoys.

Well accepted

FmC2

Eat together. Your kids will learn to eat the foods your family
enjoys.

Well accepted

FmC3

Family meals are a great time to talk to your child about health
and nutrition.

Well accepted

FmS1

You may not be able to eat together every day. Try to eat
dinner together on weekdays or breakfast and lunch during
weekends.
Involve kids in making meals. Allow your kids to wash fruits
and vegetables, mix ingredients, and open packages. Kids like
to eat foods they help prepare.

Well accepted

FmS3

Original: Family meals are possible when everybody is in it
together. Your spouse and kids can be a great help.
Revised: Sometimes family meals are possible when your
spouse and kids help. Kids can help with some tasks like
setting the table, picking up dishes, and tossing salad.

Needed
b
Revision

FmS4

Original: Do some tasks a day before. Wash and cut
vegetables. Have roti dough ready in fridge. Soak lentils the
night before or use a slow cooker.
Revised: Save some time during making a meal by doing some
tasks a day before. Have roti dough ready in fridge. Soak
lentils the night before or use a slow cooker.
Behavior Tv: TV Viewing and Eating

Needed
Revision

TvC1

Turn off the TV! Your kids will pay more attention to what
and how much they eat.
Turn off the TV! When your kids focus on food, they learn to
like the taste of food.
Set rules of not watching TV during mealtime or snack time in
your family when the kids are young. This way, it does not
become a habit.
Be good role models. Avoid watching TV during mealtime or
snack time.

Well accepted

Kids like to watch TV while eating when they are eating alone.
Try to eat meals and snacks with your kids.

Well accepted

FmS2

TvC2
TvS1

TvS2
TvS3

79

Well accepted

Well accepted
Well accepted

Well accepted

Table 3-1 (cont’d)
Behavior Mo: Parental Modeling of Healthy Eating
MoC1

Want your kids to eat new foods? Eat them yourself and your
kids will want to try them too.

MoC2

Kids learn from watching you. Make sure you and your spouse Well accepted
eat fruits and vegetables and your kids will too. [Adapted from
c
USDA]

MoC3

When you enjoy a particular food, it shows your child that it is
okay to try the food.

Well accepted

MoS1

Showing your dislike or making negative comments about a
food in front of your child, teaches the child that the food is not
good.

Well accepted

MoS2

It's normal for kids to be picky eaters. Help them increase the
type of fruits and vegetables they like by being a good role
model. [Adapted from USDA]

Well accepted

MoS3

Original: Do not like a specific fruit or vegetable? Your kids
could still have a good role model if your spouse enjoys that
food.
Revised: If one parent does not like a specific fruit or
vegetable, your kids could still have a good role model when
the other parent enjoys that food.

Needed
Revision

a

Well accepted

The first two alphabets of message number represent the feeding behavior. The third alphabet
represents core (C) or supporting (S) message, followed by a number to distinguish more than
one message within the same section.
b
Revisions made to the original message based on the responses from the participants to address
ambiguity and disagreements.
c
Already existing USDA message (White et al, 2011) that reflected beliefs, barriers, or
facilitators reported by Asian Indian mothers in the previous formative assessment has been
modified by either adding new sentences or words to the part of the message.

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Table 3-2. Nutrition Messages Related to Food Availability and Accessibility at Home
Message
a
number

Message

Participants’
response
b

Behavior Av: Making Healthy Food Available at Home
AvC1

Want your kids to eat healthy foods? Make sure you bring
fruits and vegetables home.

Well accepted

AvC2

Keep lots of healthy foods at home. When your kids are at
home, they will choose and eat from what's available.

Well accepted

AvC3

Let your kids be “produce pickers”. Allow them to pick fruits
and vegetables at the store. They will love to eat the foods
c
they picked. [Adapted from USDA]

Well accepted

Behavior Ac: Making Healthy Food Accessible
AcC1

Want your kids to reach for a healthy snack? Make sure they
can see cut fruits and vegetables when they open the
refrigerator. [Adapted from USDA]

Well accepted

AcC2

Original: Keep fruits and vegetables where your kids can see
them. Keep cut fruits and vegetables in clear plastic bags or
boxes on a low shelf in the fridge.
Revised: Keep cut fruits and vegetables where your kids can
see them. Keep them in clear plastic bags or boxes on a low
shelf in the fridge, or in a bowl on a table or kitchen counter.
When your kids come home hungry, have healthy foods such
as fruits and vegetables ready-to-eat. [Adapted from USDA]

Needed
d
Revision

AcC3
AcS1

AcS2

Well accepted

Kids love to dip fresh vegetables in low-fat ranch dressing.
Well accepted
Store cut vegetables near their favorite dip on a low shelf in the
fridge. [Adapted from USDA].
Store cut fruits and vegetables in sealed plastic bags or airtight Well accepted
plastic boxes to keep them fresh.

a

The first two alphabets of message number represent the feeding behavior. The third alphabet
represents core (C) or supporting (S) message, followed by a number to distinguish more than
one message within the same section.
b
This section does not contain supporting message as the barriers in this section are addressed in
‘Behavior Re: Restricting children’s consumption of certain foods’ due to a strong relationship
between availability of food and restriction of food”.
c
Already existing USDA message (White et al, 2011) that reflected beliefs, barriers, or
facilitators reported by Asian Indian mothers in the previous formative assessment has been
modified by either adding new sentences or words to the part of the message.
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Table 3-2 (cont’d)
d

Revisions made to the original message based on the responses from the participants to address
ambiguity and disagreements.

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Table 3-3. Nutrition Messages Related to Controlling Child Feeding Behaviors
Message
a
number

Message

Participants’
response

Behavior Re: Restricting Consumption of Certain Food
ReC1

Having junk foods that the kids are not allowed to eat makes
the food more tempting. Instead, make healthy snacks
available for your kids.

Well accepted

ReC2

Concerned about children eating too much unhealthy food?
Try to buy such foods in small amounts only.

Well accepted

ReS1

Stack your pantry with healthy snacks such as cereal bars,
nuts, and dry fruits for the kids to choose from.

Well accepted

ReS2

Buy healthier snacks such as baked instead of fried chips or
oatmeal instead of chocolate chip cookies.

Well accepted

Behavior Rw: Rewarding with Food
RwC1

Reward with praise, not food. Teach your child all foods are Well accepted
good by praising them for trying new foods.

RwC2

Reward your kids with things other than food. When you
promise a sweet or dessert for finishing the food, your child
thinks that sweets or desserts are better than other foods.

Well accepted

RwS1

Let your kids earn points or stickers towards something they
value instead of offering sweets or desserts.

Well accepted

RwS2

Instead of dessert, offer to do activities with your child such as
reading a story book, doing a coloring activity, or letting your
child choose a special outing.

Well accepted

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Table 3-3 (cont’d)
Behavior Pr: Pressuring to Eat
PrC1

PrC2

PrS1

PrS2

Patience works better than pressure. Offer choices and a
variety of healthy foods. Let your kids choose what to eat.
Kids enjoy a food when eating is their own choice. [Adapted
b
from USDA]
Patience works better than pressure. Offer choices and a
variety of healthy foods. Let your kids choose how much to
eat. Kids will eat the right amount when eating is their own
choice. [Adapted from USDA]
Sometimes new foods take time. Kids do not always like
new foods right away. Offer one new food at a time. Offer
new food many times. Tell them to taste at first and be patient
with them. [Adapted from USDA]
Original: Help your kids learn not to waste food. Let your
kids serve themselves at mealtime. Teach them to take small
amounts at first. Tell them they can have more if they are still
hungry. [Adapted from USDA]
Revised: Help your kids learn not to waste food. Serve
them small amounts at first. Tell them they can have more if
they are still hungry. [Adapted from USDA]

a

Inappropriate

Inappropriate

Well accepted

Needed
c
Revision

The first two alphabets of message number represent the feeding behavior. The third alphabet
represents core (C) or supporting (S) message, followed by a number to distinguish more than
one message within the same section.
b
Already existing USDA message (White et al, 2011) that reflected beliefs, barriers, or
facilitators reported by Asian Indian mothers in the previous formative assessment has been
modified by either adding new sentences or words to the part of the message.
c
Revisions made to the original message based on the responses from the participants to address
ambiguity and disagreements.

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CHAPTER FOUR:

CONTRIBUTIONS, RECOMMENDATIONS, LIMITATIONS, AND CONCLUSIONS

Contributions
This study was conducted in two stages to achieve the following objectives: 1) Assess the
underlying factors that influence Asian Indian mothers’ practice of child feeding behaviors using
the Theory of Planned Behavior. 2) Develop and test culturally appropriate nutrition messages
for Asian Indian mothers to promote feeding behaviors conducive to healthy eating and obesity
prevention in children.
The findings from stage one provided a thorough understanding of how Asian Indian
mothers feed their children by assessing their beliefs about expected outcomes, barriers, and
facilitators in practicing feeding behaviors (Chapter 2). This research addresses the gap in
existing literature about the type of child feeding behaviors used by Asian Indian mothers and
the motivations that drive these behaviors. The study highlights the role of unique beliefs and
values integral to Asian Indian culture that influenced the practice of child feeding behaviors.
Such information is valuable when designing effective nutrition education for Asian Indian
population. Furthermore, it explains why certain controlling feeding behaviors were frequently
practiced to encourage healthy eating in children despite the known adverse nutritional outcomes
and how that could be addressed in education programs.
Elucidating the depth and detailed information needed to understand the Asian Indian
mothers’ practice of feeding behaviors was possible due to the qualitative nature of the study.
Qualitative methodology was chosen as a suitable approach for this research as it allows target
audiences’ beliefs, values, attitudes, knowledge related to the behaviors to emerge, such that we
85

might develop appropriate education, which was ideal given the second objective of this study.
In addition, the use of projective technique provided the respondents an opportunity to explain
and share their experiences, attitudes, and perceptions. This provided a greater depth of
understanding about why certain opinions were held and behaviors performed.
Formative research is critical for developing understandable and persuasive health
messages (Fishbein & Cappella, 2006; Jemmott et al., 1995; Kreuter & Haughton, 2006; Myrick,
1998; Witte, Meyer, & Martell, 2001). Formative research conducted using the Theory of
Planned Behavior provided an excellent framework for developing nutrition messages which
were culturally appropriate and well received by Asian Indian mothers. The Theory of Planned
Behavior has a tremendous potential of informing behavior change interventions (Armitage &
Conner, 2002; Hardeman et al., 2002; Rutter, 2000). For this research, it helped identify existing
messages developed by the USDA that could be used with Asian Indian mothers and also guided
the development of new messages most needed by Asian Indian mothers.
Finally, testing of message was a vital step of this research to gauge the target audience’s
reactions and responses to the developed messages, and draw valid conclusions about its
effectiveness prior to its implementation in educational programs (Chapter 3). Testing of the
nutrition messages for Asian Indian mothers not only allowed us to understand how these
messages were received by the target but also allowed revision to some of the messages so that
they were best accepted by the target audience. It also helped identify certain cultural beliefs
related to food freshness and dietary acculturation that needed to be addressed while using
messages in nutrition education.

86

Recommendations for Future Research
The feeding behaviors assessed in this dissertation have shown to be associated with
children’s eating habits and weight status (Rhee, 2008). However, these findings come from
research studying primarily Caucasians, African Americans, and Mexican Americans.
Quantitative research with larger sample size is needed to understand the associations between
feeding behaviors and children’s eating and weight outcomes in Asian Indians. Research has
shown ethnic disparities in use of controlling feeding practices (Faith et al., 2003; Ventura,
Gromis, & Lohse, 2010). Future research should focus on understanding what kind of controlling
feeding practices (grounded in cultural beliefs) are used by Asian Indian mothers and how those
affect children’s attitude toward foods and their self-regulation of energy intake. This study
would be a guiding framework for developing assessment tools to conduct future quantitative
studies with Asian Indian population.
Controlling feeding practices have been linked to maternal concern of child’s weight
(May et al., 2007; Crouch, O’Dea, & Battisti, 2007). Almost all the mothers in this study
perceived their child as “normal weight” (results not reported), and mothers were well aware that
unhealthy eating could lead to obesity and associated health problems (results not reported).
However, this study did not assess Asian Indian mothers concerns of children’s current and
future weight nor did it measure children’s current weight. As research has reported a mismatch
between childhood overweight and maternal concern (Kaiser et al., 1999; Jain et al., 2001),
future studies should assess Asian Indian mothers concern of child’s weight and its relationship
to child’s actual weight and child feeding practices adopted by these mothers.
Robinson et al. (2001) noted that parental report of overweight, a risk factor found to
predict future overweight in their children (Whitaker et al., 1997), was associated with exerting

87

significantly less control over their children's intake. Due to the qualitative nature and small
sample size of this study, it was not possible to determine associations between mothers’ weight
and feeding practices. The majority of the mothers in this study were classified as overweight
(18.5%) or obese (44.4%). Therefore, it becomes important to not only determine the prevalence
of obesity of Asian Indian mothers in the US, but also to understand if mothers’ weight status
influences their practice of feeding behaviors and children’s weight.
Finally, the goal of nutrition messages is to help Asian Indian mothers adopt and practice
appropriate feeding behaviors. Future studies should assess the effects of nutrition messages
(developed and tested in this study) on Asian Indian mothers’ behavioral change or adoption of
feeding behaviors and how it affects children’s eating habits.

Strengths and Limitations
One of the greatest strength of this study was the use of projective technique to conduct
in-depth interviews. When the participants were asked to reflect upon the pictures and stories of
a hypothetical character of Asian Indian mother, they readily associated themselves with the
character and were able to answer in a non-threatening manner. Likewise, the interviewer being
an Asian Indian herself also increased the trust level of participants to share their views about
Indian cultural beliefs associated with their feeding behaviors.
There were several limitations to this study. Asian Indian mothers in this study were
highly educated and had a high annual household income suggesting that they belonged to a high
socio-economic status (SES). Although the demographic characteristics of Asian Indian mothers
in this study were consistent with those reported by the US Bureau of Census 2000, this could be
a potential limitation of the study. Since the release of last data by the US bureau of Census,

88

migration influx of Asian Indians in the last 12 years could have resulted in changes in the
demographic characteristics. The findings of this study should be applied with caution to Asian
Indian families belonging to a different SES.
This study looked at the child feeding behaviors of first generation Asian Indian mothers,
which explains the low acculturation score as the mothers may not have assimilated or integrated
into ‘western culture’. Most Asian Indian mothers in this study identified themselves as
“bicultural” in behavioral competency and as “Indian” in cultural values. This is consistent with
results from previous literature explaining that the behavioral aspects of a new culture are
acquired more rapidly than the values of a new culture by immigrant population (Inman, 1999).
In addition, Asian Indians tend to retain their cultural values even many years after their
immigration (Dasgupta, 1998). However, this is a limitation since it is not known if behavioral
and cultural beliefs about child feeding in second or third generation Asian Indian mothers
concur with the beliefs of first generation Asian Indian mothers. Future research should focus on
second and third generation Asian Indian mothers to identify difference and similarities in
behavioral and cultural beliefs related to child feeding.
Due to the scope of this research, it focused on children in a limited age group (5-10
years, or elementary school aged). Although children in this age group develop some degree of
independence in terms of eating, parents are still the primary people responsible for feeding their
children. Furthermore, a set pattern of eating habit is also fairly well established by this age. Our
findings revealed that mothers were using TV to control children’s food intake when they were
younger suggesting that Asian Indian mothers struggle with feeding their children using
appropriate strategies when children are very young. This could be considered as a potential
limitation of this study. Further research is needed to examine the feeding behaviors of Asian

89

Indian mothers with young children so that interventions can be made available to mothers
before their struggle with child feeding begins.
Use of triangulation methods in qualitative study could improve the validity and
reliability of research or evaluations of findings (Mathison, 1988). One of the limitations of this
study is that it used one method (mono-method bias) for data collection. Examining parent-child
interaction during meal using observations could have provided additional information such as
the extent of pressure used by the mothers and child’s response to it.

Conclusions
This is the first study to assess a variety of child feeding behaviors of Asian Indian
mothers. The findings from stage 1 of this study clearly indicated a need to develop and
implement culturally appropriate nutrition education interventions for Asian Indian families to
promote healthy eating in children. Although, this study has certain limitations, it provides
important information, which will help develop and conduct future quantitative research with
Asian Indian population in the context of child feeding. Finally, messages developed in this
study will contribute to obesity prevention efforts in Asian Indian children when used in nutrition
interventions.

90

APPENDICES

91

Appendix A: Interview Guide for Research Stage 1
Interviewer:
Before I begin the interview I would like you to know that there are no right or wrong answers to
any questions. I am interested in your thoughts about the household activities related to feeding
your family.
Activity # 1 – Cards
Expected outcomes of feeding behaviors
Interviewer:
I have a stack of 8 cards with pictures on it. The cards show different household activities related
to feeding your family. We will go through all the cards one at a time and I will ask you
questions related to each card.
Tell me what do you think is happening in the picture?
When and where do you see this happening?
What do you think about this activity?
Probes: What makes it important for a mother to do this?
Does it make any difference to what the child eats? How?
Controlling feeding behaviors – Probes: What might make a mother do this? Does it make any
difference to what the child eats? How
Is this is a good thing to do? Why would you say so?
Perceived behavioral control
Interviewer:
Would it be hard or easy for a mother to do this?
Feeding styles: is it easy or hard for a mother to not do this?
Probes: What makes it easy or hard for her to do this? What would make it easier for her to do
this?
Activity # 2 - Stories
Perceived behavioral control
Interviewer:
Now I will read you short stories about Arti. After I read each one, I will ask you some
questions. I would like to remind you that there are no right or wrong answers to this. I am
interested in your thoughts.
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Arti is a mother of two children, Anu who is 8 years old and Sonu who is 6 years old. She lives
in Michigan and works full time.
Family meals
After Arti comes home from work its already dinner-time. She has a lot to do before and after
dinner. Arti would like to have her family sit together and have dinner.
TV watching during meals
When the kids sit for dinner they like to watch their favorite show on TV while they are eating.
Arti is not sure if this is a good idea.
Food availability
Arti is shopping for foods. Her kids like cookies and sweets but she also wants them to eat more
fruits and vegetables and she also want something that she can cook very fast for meals.
Food accessibility
Arti is not sure that keeping healthy foods easy to reach and ready-to-eat for children will help
children eat them more. She thinks that if her children want those foods, they will ask for help.
For her 8 year old, she thinks that her child is old enough to get it on her own.
Parental modeling
Arti and her kids are having a meal. Arti has heard that she should set a good eating example for
her children but she doesn’t like fruits and vegetable and she thinks that it doesn’t matter to her
children what she eats.
Pressure
Arti and her children are having a meal. Arti wants her children to eat enough food. When she
serves food, she wants her children to eat all the food in the plate. Her children always leave food
on the plate after meal.
Food rewards
Arti and her children are having a meal. Arti wants her children to eat meals that she has cooked.
But her children won’t eat them and instead they ask for dessert first.
Restriction
Arti has bought some foods like cakes and cookies for her family. Her kids like them a lot but
she doesn’t want her kids to eat too much of these foods. Her kids are asking for it.
Questions: What do you think Arti would do in this situation? Why do you say so?
What advice would you give to Arti about the situation? Why?
Activity # 3 – Stories
Evaluation of behavioral belief

93

Interviewer:
Now I will read two stories. One is about “Gupta” family and the other one is about “Mathur”
family. After I read them I will ask you some questions on eating habits of children and health
outcomes (Read the stories twice for each part if needed).
Story 1
Gupta family includes Mr & Mrs. Gupta and their children (6 and 8 years old). The whole
family sits down for dinner every day. Their meal most of the times includes vegetables, fruits,
fruit juice, milk and whole grain foods. The mother always keeps fruits, milk and other healthy
foods handy for her children to eat.
Story 2
Mathur family includes Mr. & Mrs. Mathur and their children (6 and 8 years old). Most of the
times they have chips, pop, cookies and other food items at home. The mother tells the children
not to eat too much of these foods, but the children do not always listen to her.
Questions: What would be the eating habits of the children from Gupta & Mathur family like?
Probes: Would eating habits of the children from Gupta & Mathur family be different? How?
What do you think about the health of children from Gupta & Mathur family?
Probes: Would the health of the children in Gupta family be different from the children in
Mathur family? How? Would their health be different when they grow up, how? Have you heard
about any health conditions due to unhealthy eating habits? How do you see the role of parents in
Gupta & Mathur family to prevent these health conditions in the future?
Subjective Norm
Questions
Has anyone given you advice/information about eating and feeding children related to the
household activities we just discussed? What do they tell you?
Probes: Doctor, family, relatives, and friends.
What do you think about their advice?
Probe: Do you usually follow the advice? Why or why not?
**If you were to receive information on how to feed children and improve their eating habits,
where would you like to get that information from?
Probes: doctor, local organizations, religious centers, and schools.

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Appendix B: Demographic Form
Please provide the following information
1. Age ____________(years)
2. Age when arrived in the US _______________ (years)
3. Have you lived in a country other than India or US? (This does not include trip or visit to
India or other country)
**Answer the following question if the answer in Q3 is yes
Yes**
Specify which country_______________?
No
For how long you lived there_______________?
4. What is your race? (Check all that apply)
Asian/Asian American
Caucasian
African American
American Indian
Other ____________________
5. What is your ethnicity
Hispanic or Latino (please check yes or no)
Yes
No
6. Which one best describes your religious affiliation?
Hindu
Muslim
Christian
Jain
Sikh
Not religious
Other ________________ (please specify)
7. What languages do you speak at home ______________?
8. What state of India are you from __________________?
9. What is your marital status?
Married
Not married/separated/divorced
10. Mark the highest level of your formal education and specify the country you got your
education
Have not completed high school ______________
95

Received high school diploma or GED___________
Some college or technical school_________________
4-year degree/Bachelor’s degree______________
Masters/Ph.D./Professional degree______________
11. Mark the highest level of your spouse’s formal education and specify the country he got his
education
Have not completed high school____________
Received high school diploma or GED__________
Some college or technical school_________________
4-year degree/Bachelor’s degree________________
Masters/Ph.D./Professional degree_______________
12. Which one best describes your employment status?
Student
Homemaker
Not employed
Employed part time
Employed full time
Retired
Other
13. Which one best describes your spouse’s employment status?
Student
Homemaker
Not employed
Employed part time
Employed full time
Retired
Other
14. What is your annual household income?
Less than $20,000
$20,000 – $40,000
$40,000 – $60,000
$60,000 – $80,000
$80,000 – $100,000
$More than $100,000
15. Type of housing
Own house
Rental house
University apartments
Other apartments
Other (specify) _________________

96

16. Please provide information on all children ages 5-10 years in the household.
Age
(Years)

Gender
(Male/Female)

Height
(Inches)

Weight
(Lbs)

I think my child is ________?
(Select one)
Underweight
Normal weight
Overweight
Underweight
Normal weight
Overweight
Underweight
Normal weight
Overweight
Underweight
Normal weight
Overweight

17. Please provide the following information on all the other members in the household
Age (years)

Gender (male or female)

Relationship

1.
2.
3.
4.
5.

18. Do you have a family history of any of the following health conditions?
Heart disease
Blood pressure
Cancer
Diabetes
Other (specify)________________
19. Your Height ____________ and Weight_________lbs
20. Does your child have food allergies?
Yes
No
97

Appendix C: Interview Picture Cards for Stage 1

Figure 2-1. Family meal (For interpretation of the references to color in this and all other
figures, the reader is referred to the electronic version of this dissertation)

Figure 2-2. Parental modeling

Figure 2-3. Making healthy foods available
98

Figure 2-4. Making healthy foods accessible

Figure 2-5. TV viewing and eating

“Clean
your
Plate”

Figure 2-6. Pressuring children to eat
99

Figure 2-7. Offering food rewards

Figure 2-8. Restricting children’s consumption of certain foods

100

Appendix D: Suinn-Lew Asian Self-identity Acculturation Scale (SL-ASIA)
INSTRUCTIONS: The following questions are to collect information about your past
background as well as more recent behaviors related to your cultural identity. Choose the one
answer which best describes you.
1.

What language can you speak?
1.
2.
3.
4.
5.

2.

What language do you prefer?
1.
2.
3.
4.
5.

3.

Indian
Asian
Asian American
Indian-American
American

Which identification does (did) your mother use?
1.
2.
3.
4.
5.

5.

Indian only (for example, Hindi, Marathi, Gujarati, Tamil, etc.)
Mostly Indian, some English
Indian and English about equally well (bilingual)
Mostly English, some Indian
Only English

How do you identify yourself?
1.
2.
3.
4.
5.

4.

Indian only (for example, Hindi, Marathi, Gujarati, Tamil, etc.)
Mostly Indian, some English
Indian and English about equally well (bilingual)
Mostly English, some Indian
Only English

Indian
Asian
Asian American
Indian-American
American

Which identification does (did) your father use?
1.
2.
3.
4.
5.

Indian
Asian
Asian American
Indian-American
American

101

6.

What was the ethnic origin of the friends and peers you had, as a child up to age 6?
1.
2.
3.
4.
5.

7.

What was the ethnic origin of the friends and peers you had, as a child from 6 to 18?
1.
2.
3.
4.
5.

8.

Almost exclusively Indians, Indian-Americans
Mostly Indians, Indian-Americans
About equally Indian groups and Anglo groups
Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups
Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

What is your music preference?
1.
2.
3.
4.
5.

11.

Almost exclusively Indians, Indian-Americans
Mostly Indians, Indian-Americans
About equally Indian groups and Anglo groups
Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups
Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

If you could pick, whom would you prefer to associate within the community?
1.
2.
3.
4.
5.

10.

Almost exclusively Indians, Indian-Americans
Mostly Indians, Indian-Americans
About equally Indian groups and Anglo groups
Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups
Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

Whom do you now associate within the community?
1.
2.
3.
4.
5.

9.

Almost exclusively Indians, Indian-Americans
Mostly Indians, Indian-Americans
About equally Indian groups and Anglo groups
Mostly Anglos, Blacks, Hispanics, or other non-Indian ethnic groups
Almost exclusively Anglos, Blacks, Hispanics, or other non-Indian ethnic groups

Only Indian music (for example, Hindi, Marathi, Gujarati, Tamil, etc.)
Mostly Indian
Equally Indian and English
Mostly English
English only

What is your movie preference?

102

1.
2.
3.
4.
5.
12.

Indian-language movies only
Indian-language movies mostly
Equally Indian/English English-language movies
Mostly English-language movies only
English-language movies only

What generation are you? (circle the generation that best applies to you)
1.
1st Generation = I was born in India or country other than U.S.
2.
2nd Generation = I was born in U.S., either parent was born in India or country
other than U.S.
3.
3rd Generation = I was born in U.S., both parents were born in U.S, and all
grandparents born in India or country other than U.S.
4.
4th Generation = I was born in U.S., both parents were born in U.S, and at least
one grandparent born in India or country other than U.S. and one grandparent born in
U.S.
5.
5th Generation = I was born in U.S., both parents were born in U.S., and all
grandparents also born in U.S.
6.
Don't know what generation best fits since I lack some information.

13.

Where were you raised?
1.
2.
3.
4.
5.

14.

What contact have you had with India?
1.
2.
3.
4.
5.

15.

Raised one year or more in India
Lived for less than one year in India
Occasional visits to India
Occasional communications (letters, phone calls, etc.) with people in India
No exposure or communications with people in India

What is your food preference at home?
1.
2.
3.
4.
5.

16.

In India only
Mostly in India, some in U.S.
Equally in India and U.S.
Mostly in U.S., some in India
In U.S. only

Exclusively Indian food
Mostly Indian food, some American
About equally Indian and American
Mostly American food
Exclusively American food

What is your food preference in restaurants?
103

1.
2.
3.
4.
5.
17.

Do you
1.
2.
3.
4.
5.

18.

Exclusively Indian food
Mostly Indian food, some American
About equally Indian and American
Mostly American food
Exclusively American food

Write only an Indian language?
Write an Indian language better than English?
Write both Indian and English equally well?
Write English better than an Indian language?
Write only English?

Do you
1.
2.
3.
4.
5.

Read only an Indian language?
Read an Indian language better than English?
Read both Indian and English equally well?
Read English better than an Indian language?
Read only English?

19. If you consider yourself a member of the Indian group (Indian, Indian-American, etc.,
whatever term you prefer), how much pride do you have in this group?
1.
2.
3.
4.
5.
20.

How would you rate yourself?
1.
2.
3.
4.
5.

21.

Extremely proud
Moderately proud
Little pride
No pride but do not feel negative toward group
No pride but do feel negative toward group

Very Indian
Mostly Indian
Bicultural
Mostly Westernized
Very Westernized

Do you participate in Indian occasions, holidays, traditions, etc.?
1.
2.
3.
4.

Nearly all
Most of them
Some of them
A few of them
104

5.

None at all

22. Rate yourself on how much you believe in Indian values (e.g., about marriage, families,
education, work):
1
(do not
believe)
23.

3

4

5
(strongly believe
in Indian values)

Rate your self on how much you believe in American (Western) values:

1
(do not
believe)
24.

2

2

3

4

5
(strongly believe
in Indian values)

Rate yourself on how well you fit when with other Indians:

1
2
(do not fit)

3

4

5
(fit very well)

25. Rate yourself on how well you fit when with other Americans who are non-Indians
(Westerners):

1
2
(do not fit)

3

4

5
(fit very well)

26. There are many different ways in which people think of themselves. Which ONE of the
following most closely describes how you view yourself?
1. I consider myself basically an Indian person. Even though I live and work in America, I
still view myself basically as an Indian person.
2. I consider myself basically as an American. Even though I have an Indian background
and characteristics, I still view myself basically as an American.
3. I consider myself as an Indian-American, although deep down I always know I am an
Indian.
4. I consider myself as an Indian-American, although deep down, I view myself as an
American first.
5. I consider myself as an Indian-American. I have both Indian and American
characteristics, and I view myself as a blend of both.

105

Appendix E: Coding structure
Table 2-2: Coding Structure and Code Definitions
Theme

Code

Definition

Rule of application

Feeding
behavior
(FB)
(For this
code also
include
intentions or
mothers’
advice to
other
mothers
about
performing/n
ot
performing
specific
feeding
behavior)
Family meal

FB

Comments or
description
of mothers’
actual
performance
or intentions
to perform a
FB

References given to:
Mothers’
comments/description
of how a particular FB
is performed at her or
others’ home or her
intentions to practice a
particular FB in future
(e.g. giving advice to
other mothers)

FBP1

Mothers’
comments/des
cription of
how meals
(lunch, school
lunches,
dinner,
breakfast,
snacks) are set
up at home
(or outside)

References given to
description of:
1. Family meals: meals
(lunch, dinner,
breakfast, snacks)
eaten at home or
outside together as a
family
2. Meals (lunch, dinner,
breakfast, snacks)
eaten individually at
home or outside
(school, office, etc.)
3. Planning and
preparation of above
mentioned meals,
timings of meals,
foods eaten or offered
during meals etc.

106

Example

“We all eat meals at
different times these
days. My daughter
comes from school
at 4:00 she eats her
dinner. And then
my husband comes
sometimes late,
sometimes early.
And, I don’t wait for
him for dinner.”

Table 2-2 (cont’d)
TV viewing
and eating

FBN1

Mothers’
comments or
description of
feeding
child/ren,
child/ren
eating in front
of TV, or
rules for
watching TV
while eating

Modeling of
eating
behaviors

FBP2

Mothers’
comments or
description of
people’s
behavior of
eating foods
in front of the
children to set
an example
Mothers’
behavior of
involving
children in
food
preparation
Mothers’
comments/des
cription of
foods
available at
home

Availability
FBP3
of healthy
foods at home

References given to:
1. Child/ren’s habits or
behavior of eating
snacks or meals
while watching TV
2. Mothers’ behavior
of letting/not letting
the child eat or
feeding the child in
front of TV
3. Rules for watching
TV while eating
References given to:
1. Persons (mother,
father, sibling, peers
etc.) behavior of
eating healthy or
non-healthy foods
and setting an
example for children
2. Mothers’ behaviors
of involving
children in food
preparation

“Most of his snacks
that he eats, he does
this, he sits and
watches his
cartoons, and he’s
having a snack.”

References to:
Mothers’ behavior of
purchasing/bringing
foods at home and
making them available
to children
Examples to look for:
What foods are made
available, how the foods
are made available (e.g.
frequency of grocery
shopping, preparing list,
mother’s or family
members’ food choices
etc.), etc.

“I go grocery
shopping, uh, and
then I have the fruit
and vegetables in
the fridge.”

107

“I don’t like
broccoli, I never
ever used to eat
broccoli at all. And
now that I want my
son to eat, I eat it.”

Table 2-2 (cont’d)
Accessibility
of foods

FBP4

Mothers’
comments/des
cription of
keeping the
foods
accessible to
children

References given to:
Mothers’ behavior of
keeping the foods in
manner;
1. That is easy for the
children to reach or
see, and ready to be
eaten
2. Not accessible to
children
Example to look for:
Cutting, peeling,
chopping, washing the
fruits, cleaning, putting
in bowl/table etc.

“Something like a
watermelon or
grapes, I, I make
sure it’s cut. Uh,
grapes I make sure
it’s washed, and
then keep.”

Pressure/forci
ng/encouragi
ng children to
eat

FBN2

Mothers’
comments or
description of
behaviors
such as
forcing,
threatening or
pressuring the
child to eat or
finish the
meal

References given to:
1. Mothers’ behavior
or strategies used to
force, threaten, or
pressure the child to
eat or finish the
meal.
2. Child’s reaction and
responses to this
behavior
Examples to look for:
Power struggle between
the mother and child,
depriving privileges, tell
the child to eat specific
foods from the plate
(e.g. vegetables), spoon
feed the child, etc.

“My thing is I force,
and I…do this,
clean your plate.”

108

Table 2-2 (cont’d)
Offering food
rewards

FBN3

Restricting
certain foods

FBN4

Importance
of Feeding
Behaviors
for Eating
habits

ImpE

Mothers’
behavior of
offering or
giving
food/not
offering food
rewards to
children for
finishing
meals or
chores
Comments or
description of
mothers’
behavior of
restricting/not
restricting
children’s
consumption
of certain
foods

Mothers’
perception of
advantages/d
isadvantages
of practicing
positive &
negative FBs
for short
term and
long term
eating habits
of children

References given to:
Mothers’ behavior of
giving or offering or not
offering food rewards to
children for finishing
meals or doing chores

“When the kid is not
ready to go to
school, you give the
2 M&M’s which
will, help them to do
that chore.”

References given to:
1. Mothers’ behavior of
restricting/not
restricting foods;
1. Foods that are
restricted to children
2. Manner and
situations in which
the foods are
restricted
Examples to look for:
Rules & timing when
the foods are restricted,
Manner of food
restriction (e.g. hiding),
religious restrictions etc.
2. Child’s reaction and
responses to this
behavior
References given to:
Advantages/disadvant
ages of practicing
positive & negative
FBs for short-term
and long-term eating
habits of children

“But sometimes, if
they open the fridge
and they see it, they
might get tempted.
But still we have the
rules that, it should
be only on
Saturdays.”

109

Table 2-2 (cont’d)
Family meal

TV viewing
and eating

ImpEP1

ImpEN1

Mothers
thoughts on
benefits of
family meals
for the family
and children’s
eating habits

Mothers’
thoughts on
the harmful
effects of
watching TV
while eating
on children’s
eating habits

References given to:
1. Benefits/lack of
benefits of family
meals for the
family members
2. Benefits/lack of
benefits of family
meals for
children’s eating
habits
Examples to look for:
Family conversation,
family bonding,
spending time with
family etc.
Examples to look for:
Opportunities for
modeling healthy eating
habits, monitoring
child’s food intake,
children eating
homemade/nutritious
foods, etc.
References given to:
Detrimental effects of
watching TV while
eating in relation to
child’s eating habits
Examples to look for:
Control over portion
size, lack of awareness
in eating etc.

110

“He tells me about
his day, his friends
in his school. So
it’s a special
bonding time for
me.”
“When I’m sitting
with him and eating
my meal with him
that I make sure he,
he’s not just
drinking juice or, or
water all the time,
and ignoring his
food.”

“He probably eats
less, I would think,
because he’s
distracted by
watching TV.”

Table 2-2 (cont’d)
Modeling of
eating
behaviors

ImpEP2

Mothers’
thought on
favorable or
unfavorable
effects of
modeling of
eating
behaviors by
parents,
siblings, and
peers on
children’s
eating habits

Availability
ImpEP3
of healthy
foods at home

Mothers
thoughts on
influence of
any foods
available at
home,
involving
children in
grocery
shopping on
children’s
food
consumption

Accessibility
of foods

Mothers’
thoughts on
influence of
foods that are
easy to
reach/ready to
eat on
children’s
eating habits

ImpEP4

References given to:
The favorable or
unfavorable effect of
modeling of eating
behaviors (healthy/nonhealthy) by parents,
siblings, and peers on
children’s eating habits
Favorable or
unfavorable effects of
involving kids in meal
preparation
Examples to look for:
Children’s likeliness to
eat modeled foods,
children
requesting/asking for
foods eaten by peers etc.
References given to:
1. Advantages or
disadvantages of
availability/presence
of any food items at
home for children’s
food choices or food
intake
2. Advantages/disadva
ntages of involving
kids in grocery
shopping

References given to:
Children’s likeliness to
eat the foods that are
prepared or placed in a
manner that is visible,
easy to reach/ready to
eat
Examples to look for:
Children’s likeliness to
eat accessible foods
from the fridge, pantry,
etc.
111

“Yeah, I think so,
because we have to
be role models for
our children. We
cannot say
something and then
not do it. So if we
eat healthy, the kids
may learn to eat the
same food and…”

“ If you have, all
the, like the fruits
and vegetables, if
you have it ready in
your house, then,
you know, it’s
easier to offer that
to your child. If you
don’t have, have
that in the house,
then it’s like, okay, I
don’t have this, but I
Have chips; do you
want chips?”
“Like for example
fruits, like you
know if I cut it and
put it in the, uh,
table, definitely she
eats.”

Table 2-2 (cont’d)
Pressure/forci
ng children to
eat

ImpEN2

Offering food
rewards

ImpEN3

Restricting
certain foods

ImpEN4

Mothers
comments/des
cription of
Advantages or
disadvantages
of forcing the
child to clean
the
plate/finish
the meal

References given to:
Benefits or
disadvantages (perceived
by mothers), related to
child’s eating habit, of
forcing the child to clean
the plate/finish the meal
Examples to look for:
Amount eaten, proper
nutrition, child throwing
up, create dislike for the
food, weight of child,
etc.
Advantages or References given to:
disadvantages Benefits or
, perceived by disadvantages, related to
mothers, of
child’s eating habits, of
rewarding
offering food rewards to
children with children
foods
Examples to look for:
Children habituated to
food rewards, rewarded
foods become comfort
food, etc.
Advantages or
disadvantages
, perceived by
mothers, of
restricting
children from
consuming
certain foods
at home and
outside

References given to:
Benefits or
disadvantages, related to
child’s eating habits, of
restricting children from
consuming certain foods
at home and outside
Examples to look for:
Control overeating of
certain foods, weight
concerns, children eating
when outside parental
control, etc.

112

“So to make sure
that they’re getting
enough nutrition
and enough of
everything that’s
there on the plate,
it’s important for
them the mother to
make sure that they
finish what’s on the
plate.”

“I feel like it
becomes a comfort
food. Where, if he
gets stressed out,
then you’re gonna
reach out for that as
a reward to yourself,
saying I’ve had a
bad day, so I can
treat myself with
that.”
“Because I think
sugar, it, we should
limit it, the dessert.
It’s not like you can
eat all, how much
quantity you want to
eat…”

Table 2-2 (cont’d)
Importance
of Eating
Habits for
Health

ImpH

Mothers’
opinion about
advantages/di
sadvantages
of children’s
current eating
habits for
children’s
short-term
and long-term
health

Healthy and
balanced
foods/diet

Hlt

Healthy
Foods

HltF

Mothers’
opinions
about
healthy foods
and balanced
diet
Mothers
opinions and
perceptions
about healthy
foods and
healthy diet

References given to:
Advantages/disadvantag
es of children’s current
eating habits for shortterm and long-term
health of children
Examples to look for:
Health in general, eating
habits later in life,
disease prevention (e.g.
diabetes, heart disease,
and cancer), prevention
of overweight, healthy
teeth, bones, skin, etc.

“They will grow up
to, you know, kind
of obese and, will,
plus, they do not
appreciate any
healthy habits. And,
you know, kind of
slows them down in
everything that they
do…”

References given by
mothers about or
mothers’ own idea,
conception and
classification of
Examples to look for:
• Foods that are healthy
or not healthy (e.g.
junk foods, fast foods
etc.)

“So, I think, I don’t
know whether there
are studies or
something like that,
but I feel like, more
you eat frozen or
pre—you know,
preservatives in
foods, you know,
this is not healthy
for you.”

113

Table 2-2 (cont’d)
Balanced diet

HltB

Mothers
opinions and
perceptions
about
balanced
meals

Physical
activity

ActP

Mothers
opinions
about
physical
activity

Perceived
Behavioral
Control Barriers

PbcB

Mothers’
perception of
things/situati
ons that pose
a barrier to
the
performance
of positive
FBs and
facilitate/pro
mote the
performance
of negative
FBs

Mothers’ references
about healthy and
balanced meals/diet
Examples to look for:
• Inclusion of fruits and
vegetables in diet
• Inclusion of nonhealthy food items in
diet
• Inclusion of nonhealthy foods along
with healthy food
items to make a
balanced diet
Mothers’ references
about;
• The importance of
physical activity for
health
• Family members
performance of
physical activity
• Lack of physical
activity in children –
video games,
computer, etc.
References given to:
Situations or things
that make it difficult
for the mothers to
perform positive FBs
and things or
situations that make it
easy to perform
negative FBs

114

“Like pop and all,
we don’t encourage
her to ask, but once
in a while when she
goes for a party or
something, then she
has it, which is okay
for us. Like, you
know, it’s just once
in a while. Yeah, so
kind of, you have to
balance.”

To get them more
involved in different
physical activities.
Like, my son, we
have him in…
tennis, swimming,
you name it.
Everything that I
can control, I’ve
done it.

Table 2-2 (cont’d)
Family meal

PbcBP1

Mothers’
perception of
things or
situations that
pose a barrier
to having
family meals

References given to:
Situations or things that
make it difficult for the
mother to cook and have
a family sit together for
meal
Examples to look for:
Work schedule of
parents, children,
presence of younger
child/ren requiring
special attention or
hampering mother’s
meal time etc.

TV viewing
and eating

PbcBN1

Mothers’
perception of
things or
situations that
facilitate them
to feed/ let the
child eat
while
watching TV

Modeling of
eating
behaviors

PbcBP2

Mothers’
perception of
things or
situations that
pose a barrier
for
mother/father
to model
healthy eating
behaviors

Reference given to:
Situations or things that
make it easy for the
mother to feed/let the
child eat while watching
TV
Examples to look for:
Child’s habits, ease of
feeding children, child
and mother’s schedule,
etc.
References given to:
Situations or things that
make it difficult for the
mother/father to eat and
enjoy healthy foods in
front of children
Examples to look for:
Dislikes of
mother/father, support
from spouse, peer
influence, etc.

115

But… she (mother)
has to put some
efforts though.
Yeah. Especially in
my home, each one
eats different food.
The kid, the food
has to be mashed,
and, the food has to
be hidden. And…
and the kid doesn’t
sit till the end of the
meal, so when I take
my meal, I have to
come on in. So
what I do is… I give
the meal to the kid,
feed it. After I feed
them…… Then I sit
for my meal with
my husband
Because, you know,
then you can get all
your other stuff
done. So it’s
definitely easy.

“It was very tough.
Because I still don’t
like it and I have to
eat it, so it’s really
tough.”

Table 2-2 (cont’d)
Availability
of foods at
home

PbcBP3

Mothers’
perception of
things or
situations that
pose a barrier
to
purchase/brin
g healthy
foods at home
and make
children to eat
those foods

References given to:
Things or situations that
make it difficult to;
1. Purchase/bring
healthy foods at
home
2. Make children eat
foods brought at
home
Examples to look for:
Weather, cost of foods,
likes and dislike of
parents and children,
etc.

Accessibility
of foods

PbcBP4

Mothers’
References given to:
perception of Things or situations that
make it difficult for;
things or
situations that 1. Mother to make
poses a barrier
healthy foods easy
in making
to reach (e.g.
healthy foods
cutting, cleaning,
easy to reach
peeling F/V) and
and ready to
ready to eat
eat
2. Children to eat
accessible foods
Examples to look for:
Likes/dislikes of
children, etc.

116

Bringing it is not
hard part, but
feeding them is a
hard part. So, I like
to try, you know,
new things with my
kids, you know, eat
pear, or try papaya,
and they hate
papaya actually.
So, feeding them is
a hard part.
Sometimes they
don’t like to try new
foods.
“I read this thing
like, if you keep the
foods cut, there’s an
oxidation process,
because you cut it
with knife. And,
when oxidation
happens, it can ruin
the taste of food
and, you know, it
also, you know,
makes some
chemicals which is
not, you know, good
for you. So I never,
you know, cut fruits
and put them in
shelf.”

Table 2-2 (cont’d)
Pressure/forci
ng children to
eat

PbcBN2

Offering food
rewards

PbcBN3

Situations or
things that
persuade a
mother to
force the child
to eat

References given to:
Characteristics/behavior
of the child in relation
to eating,
religious/cultural
reasons, or other
situations perceived by
the mother that causes a
mother to force the child
to eat/finish the meal
Examples to look for:
Picky eater, appetite,
food dislike of child,
food wastage, playful
mood of the child,
cultural reasons
(respecting food), etc.
Situations that References given to:
persuade a
Characteristics of the
mother to
child, or other situations
offer food
perceived by the mother
rewards to
that causes a mother to
children
reward the child with
food
Examples to look for:
Getting the child eat
main meal, getting
chores done from
children, weight of the
child, etc.

117

“And she says my
tummy is full
mama, if it’s rice.
Then after 10
minutes, I see her
opening the fridge
and eating cereal.
So, that kind of a
thing.”

“Yeah, it’s good,
because kids are
excited, and they
feel recognized for
what they have
done.”

Table 2-2 (cont’d)
Restricting
certain foods

PbcBN4

Things or
situations that
persuade a
mother to
restrict
children’s
consumption
of certain
foods at home
and outside

References given to:
Characteristics of the
child (personality),
religious/cultural
reasons, or other
things/situations
perceived by the mother
that causes a mother to
restrict children’s
consumption of certain
foods at home and
outside
Examples to look for:
Religious restrictions,
availability to (exposure
to) foods at home and
outside, timings (e.g.
right before meal) etc.

Perceived
Behavioral
Control –
Facilitators

PbcF

Mothers’
perception of
things/situati
ons that
facilitates the
performance
of positive
FBs and
provide a
alternative to
the
performance
of negative
FBs

References given to:
Situations or things
that make it easy for
the mothers to
perform positive FBs
& things or situations
that make it difficult to
perform negative FBs

118

“I… especially
scream at her.
Suppose I’m
making elaborate
dinner, waiting that
I’ll serve them at
5:00 or 6:00. And
then she opens the
fridge and tries to
eat her cereal, or
nuggets. I’ll literally
scream at her,
saying, you know
you stop it because,
I worked hard to
prepare the food…”
“They’ll question
their parent how
come I’m not
allowed to eat a
chicken sandwich,
how come I’m not
allowed to eat, uh,
sausage or bacon, or
whatever, and they
give ‘em this thing
about religion, you
know.”

Table 2-2 (cont’d)
Family meal

PbcFP1

Mothers’
perception of
things that
facilitate
having family
meals

TV viewing
and eating

PbcFN1

Mothers’
perception of
things or
situations that
allow to avoid
TV viewing
while eating
or feeding the
child

Modeling of
eating
behaviors

PbcFP2

Mothers’
perception of
things or
situations that
facilitate the
mother/father
to model
healthy eating
behaviors

References to:
Situations or things that
make it easy for the
mother to cook and have
a family sit together for
meal
Examples to look for:
Pre-planning and
preparations, schedule,
assistance from family
members etc.
Reference given to:
Situations or things that
allow the mothers to
avoid TV viewing while
eating or feeding the
child
Examples to look for:
Mealtime rules, video
recording the favorite
show etc.

References given to:
Situations or things that
make it easy for the
mother/father to eat and
enjoy healthy foods in
front of children
Examples to look for:
Diet (vegetarianism) or
likes of mother/father,
etc.

119

“Depends on how
much a spouse helps
out in the house and
stuff.”

“She (mother)
should say the TV,
once you are done
with the food, they
can watch the TV.
She has to make the
dinnertime little
early, so, and she
has to insist that
after dinner she has
to… mm, they can
see TV. So that
way they can finish
their dinner and then
see the TV.”
“I think because I’m
vegetarian, so we’ve
never had meat in
our house, so our
main diet is
vegetables and
fruits. So, I don’t
think anything has
changed, after my,
my son was born or
anything, it just
continued the same,
and he’s eating what
we are eating.”

Table 2-2 (cont’d)
Availability
PbcFP3
of healthy
foods at home

Mothers’
perception of
things or
situations that
facilitate
purchasing/bri
nging healthy
foods at home
and getting
children to eat
those foods

References given to:
Things or situations that
make it easy to;
1.Purchase/bring
healthy foods at
home
2.Make children eat
foods brought at
home
Examples to look for:
Likes and dislike of
parents and children,
sneaking vegetables,
etc.

Accessibility
of foods

Mothers’
perception of
things or
situations that
facilitate
making
healthy foods
easily
accessible to
children

References given to:
Things or situations that
make it easy for the
mother to make healthy
foods easy to reach (e.g.
cutting, cleaning,
peeling F/V) and ready
to eat

PbcFP4

120

“Like the, I’ll go
through Meijer’s
and Kroger’s paper
before I go and buy
anything. and if, if
it’s a time crunch
thing where I can’t
go—like let’s say
Kroger has milk on
sale, but, Meyer’s
has everything else,
has more, whoever
has the most stuff
that I want, I go
there.”
“Yeah, again that’s,
that’s easy to. It’s
just the way I
arrange my fridge,
and moment I come,
I cut and chop and
wash everything and
keep it in the fridge,
so that’s not extra
efforts to do. It was
part of my routine
even before then, so,
it’s easy”

Table 2-2 (cont’d)
Pressure/forci
ng children to
eat

PbcFN2

Things or
situations that
allow the
mother to
avoid forcing
the child to
eat

References given to:
Things or situations that
provide a mother with
an alternative to forcing
the child to eat
Mothers’ behavior of
feeding the child using
strategies other than
forcing, threatening, or
pressuring.
Examples to look for:
Sneaking vegetables,
menu planning,
appropriate portion size,
praise the child or food,
offer food choices,
making the food
interesting, reasoning
with the child (e.g.
nutrition talk) etc.

Offering food
rewards

PbcFN3

Things or
situations that
allow the
mother to
avoid offering
food rewards
to children

References given to:
Characteristics of the
child, things/situations
that provide a mother
with an alternative to
offering food rewards to
the child
Examples to look for:
Offering non-food
rewards, child interested
in other rewards, etc.

121

“We just give her a
little bit. She wants
more of something,
and we give her a
little bit, and I
always tell her you
can take more, there
is plenty more. So
you can have
seconds. And if she
needs it, she asks for
it, and we serve her
more.”
“Or even if she
doesn’t like it,
because she’s so
enthusiastic because
we are eating it, and
then we, we praise
her, oh wow, you
really liked it? And
she’s like yeah. So,
I think it’s probably
in the flow of the
dinner, that she
actually finishes
everything on her
plate.”
“I think rewards
should be more…
you know, praise,
appreciation, or
maybe some good
stickers, or maybe
some, you know, a
small trip to
somewhere. But not
with food.”

Table 2-2 (cont’d)
Restricting
certain foods

PbcFN4

Things or
situations that
allow the
mother to
avoid
restricting
children’s
consumption
of certain
foods at home
and outside

Responsibilit
y

Res

Parent
Responsibilit
y

ResP

Mothers
comments or
description
of
responsibility
of developing
eating habits
in children
Mothers
comments or
description of
parent
responsibility
of developing
eating habits
in children

School
Responsibilit
y

ResS

Mothers
comments or
description of
role and
responsibility
of school in
developing
children’s
eating habits

References given to:
Things or situations that
provide a mother with
an alternative to restrict
children’s consumption
of certain foods at home
and outside
Examples to look for:
Not purchasing the
foods, purchasing
healthier options of junk
foods, etc.

“First of all, if she
doesn’t, like these
foods, she should
not buy them.”

References given to:
The role and
responsibility of parents
in developing
(healthy/non-healthy)
eating habits in children

“Definitely a very
important role,
because, they are
the one who provide
the food, and,
setting an example,
and getting the kids
to have a healthy
food habit.”
“When she went,
she told me mom I
want baby carrots,
how, because the
school which told
her, which told her.
Where did you eat
baby carrots? And
maybe friends
house. But she told
mama I had in
school, with the
Ranch dip. So,
that’s also affects”

References given to:
Role and responsibility
of school and influence
of school food
environment in
developing children’s
food choices, food
attitudes, and eating
habits

122

Table 2-2 (cont’d)
Health
condition

ConH

Advice or
information
on feeding
children

InfS

Compliance
with
Information

infC

Mothers
References given to:
comments or 1. Health conditions of
description
self and others
of health
(family members
conditions of
and relatives) as a
self and
result of genetics
others
(family history) and
eating habits
2. Changes in attitudes
of mother as a result
of these health
conditions in their
eating habits
3. Changes in mothers
FB as a result of
these health
conditions
Mothers’
References given to:
comments/des The information about
cription of
feeding (food, nutrition,
information & recipes, etc.) children
sources of
and sources from where
information
the information is
about feeding obtained (irrespective of
children
the accuracy of
information)
Examples
• Friends
• Relatives
• Doctors
• Internet sources
• Other
Mothers’
compliance
with the
information
they obtain
about feeding
their children

References given to:
Mothers’ comments and
description of whether
and how much they
comply with the
information obtained
from others about
feeding their children

123

“Um, I purchase
bread, and I always
go for wheat bread.
I don’t like white,
because, uh,
especially my
husband has a BP,
so the doctor has
said no white food.
So now I’m trying
to using less of
potatoes too,
because it has lot of
carbs. You don’t
have to eat lot of
white.”
“… mostly Indian,
so, you know, my
parents like,
especially when
they were growing
up, my daughter,
when she was like
kid and all that, at
certain age I should
give her this, I
shouldn’t give her
that. All those
information came
from my parents,
not from any other
sources.”
“You know, that’s
its not possible to
just copy
everything, because,
one says something,
another one says.
So you just have to
go into a general,
uh, you know, uh,
on a general view,
okay, this is good.”

Table 2-2 (cont’d)
Validity of
Information

InfV

Mothers
comments
about the
validity and
suitability of
the
information
on feeing
children

References given to:
The validity and
suitability of the
information they already
received or would like
to receive about feeding
children
Examples to look for:
• Research based
information
• Cultural
appropriateness

Potential
sources of
Educational
messages

InfP

Mothers’
comments/des
cription of
potential
sources where
the mothers
would like to
receive
information
on feeding
children

References given to:
Potential sources where
the mothers think are
appropriate to obtain the
information and the
reasons why these
places are appropriate

Intrinsic
motivation
factors

IntM

Intrinsic
motivational
factors that
influence the
attitude of
mothers
toward
feeding
behaviors

Mothers
comments/description
of intrinsic factors that
shape their feeding
behaviors
Examples to look for:
1. Indian cultural
values and attitude
regarding food and
parenting
2. Mothers own
experiences as a
child, and with other
children in family

124

“The researchers
can do a great job in
saying that you have
to go by this family.
Then, even if the
parents were in
doubt to whether
should they follow
it, or maybe I can do
it, they might be
convinced with that
saying that okay,
this helped so many
people”
“I think rather than
all these places,
your child’s
pediatric, you know.
That would be the
first place, because,
you know, we do
follow through, like
as a mother, like
whenever I go for a
visit, whatever
information I get, I
just follow through
that very seriously.”
Rule of exclusion:
this does not include
likes and dislikes of
mother

Table 2-2 (cont’d)
Indian Foods IndF

Gender
differences

GenD

Comments/de
scription of
mothers’ or
children’s
attitude
toward Indian
foods

Mothers’ or children’s’
attitude toward Indian
foods
Examples to look for:
1. General outlook of
Indian foods in
terms of nutrition
and culture
2. Kids eating/not
eating, likes/dislikes
of Indian foods
3. Mothers’ wanting
children to eat
Indian foods
4. Indian foods for
family lunch

Differences in
children’s
eating habits,
behaviors, or
attitude due to
gender

References given to:
Comments or
description of
differences in children’s
eating habits, food
behaviors, or attitude
toward foods due to
gender

125

“In our country dal
is definitely because
that’s a main source
of proteins for us.
Especially for the
vegetarians. And
they are so healthy.
So I think you
should have dhal
things. That’s
important.”
“Yeah. Believe it or
not, my daughter is
now 10. I used to
feed her, till she was
9, she was my only
child and she used
never used to eat
any Indian food.
Like I used to get so
scared that she’s not
eating any healthy
food.”

Appendix F: Additional Themes from Stage 1
Table 2-3: Themes for Availability, Accessibility and Restricting Consumption of Certain Foods
Theoretical
concepts
Behavior

Behavioral belief

Barriers
Facilitators

Behavior

Behavioral belief
Barriers

Facilitators

Themes for family meals
Themes for making healthy foods available
Some bought only healthy foods (fruit, vegetables, and meat if the
family is non-vegetarian); do not buy any “junk foods”.
Some bought healthy as well as “junk foods” in moderation or in
limited quantities.
Do not prefer frozen foods, canned foods, and cut fruits and
vegetables.
Conveniently allows mother to cook and offer foods available at
home.
Provides exposure and familiarizes children to new and variety of
foods.
Makes children more likely to eat foods.
Availability of unhealthy foods distracts children from eating
healthy foods.
Easy availability of variety and quality of healthy foods at grocery
store.
Easy accessibility to grocery stores.
Themes for making healthy foods accessible
Strategies to make foods accessible include
o Manner: washing grapes, cutting fruits
o Location: front section of the fridge, in front of the kids, in a
bowl on the table
Fruits not kept accessible but are cut and provided immediately
when children ask or when the mother feels like.
Children are asked to grab the foods from the fridge when they
want.
Children are more likely to eat foods when are accessible.
Easy for mothers to offer if the foods are ready-to-eat.
Children are distracted by the availability of unhealthy foods.
Picky eaters do not reach for healthy accessible foods.
Children are not allowed to get foods from the refrigerator due to
the fear of causing a mess.
Cutting fruits and vegetables causes loss of freshness and appeal.
Buying pre-cut fruits from the store, help from the spouse, and
making a routine of cutting fruits immediately after they are brought
home.
Themes for Restricting children’s consumption of certain foods

126

Table 2-3 (cont’d)
Behavior

Behavioral belief

Barriers

Facilitators

Some mothers do not restrict children‘s consumption of junk foods
and children allowed to eat in limited quantities and at specific
times.
Some mothers restrict children’s consumption of junk foods in a
very firm, strict and non-yielding manner.
Food restriction strategies used:
o Not bringing unhealthy foods at home
o If available at home, hiding the foods or keeping then out of
child’s reach
o Letting children eat them at specific times and not all times
Ensure that children do not eat unhealthy food.
Control portion size of “junk foods”.
Control consumption of sugar and fat as it leads to obesity, tooth
decay, stomach problems such as constipation.
Availability and accessibility of unhealthy food at home tempts
children for such food.
Children have high preference and liking for “junk foods”.
Buying healthy versions of snack foods such as oatmeal instead of
chocolate chip cookies, or baked instead of fried chips.

127

Table 2-4: Themes for Evaluation of Behavioral Beliefs and Subjective Norm

Theoretical
concepts
Beliefs about
nutrition and
health

Normative belief

Motivation to
comply

Themes for family meals
Themes for making healthy foods available
Long-term health conditions resulting from unhealthy eating habits
include: obesity, diabetes, high blood pressure, high cholesterol,
heart diseases, cancer.
Healthy eating habits can reduce the genetic risk of health
conditions such as diabetes and heart disease.
Eating more fruits and vegetables can prevent chronic diseases such
as cancer.
Short-term health conditions resulting from unhealthy eating habits
include – lack of stamina and strength, attention span, falling sick
frequently, infections, dental health, stomach problems such as
constipation, and weak eyesight.
Mothers received information from doctors, pediatricians or
dietician. Most mother also mentioned having pediatrician, doctors,
or dieticians being Indian origin. Some of these doctors were also
their friends.
Most mothers also went to the internet for information such as
healthy recipes for kids, blogs of other mothers on the internet about
feeding their children.
Family members (parents and in-laws) provided information on how
to feed vegetables to the kids, share their experience about child
feeding, what foods to feed to children, prepare food in a manner
child likes.
Mothers discussed with their friends about child feeding, shared tips
about feeding healthy foods to kids and recipes.
Advice from parents (especially mother) considered valuable.
Advice from the doctors, nutritionists, and pediatrician was taken
very seriously by the mothers and followed upon.
In some cases advice from the friends was taken and followed upon
if it worked for the child.

128

Appendix G: Interview Guide for Research Stage 2
Interviewer:
Before I begin the interview I would like you to know that there is no right or wrong answers to
any questions. I am interested in your thoughts about nutrition messages related to feeding your
child and family.
For this interview, I will show you some messages. We will go through each message one at a
time and I will ask you questioned related to each message. Your thoughts will help us improve
these messages.
(The mothers will be shown each message and then asked the below questions for each message)
Questions:
Comprehensibility
What do you think this message is asking you to do?
What does this term mean “____”?
What are the things in this message that are confusing/unclear to you?
How can we make these things clear?
What other word or phrase would you suggest to make it clear?
Probe: Can you tell me in your own words what does this message mean?
Credibility and agreement
Tell me how do you feel about the information provided in the message?
How much do you agree with/believe the information?
Probes: What do you think about the accuracy of the information? Do you believe mothers like
you will get the benefits if they do what is asked in this message? Why/Why not? Do you think
this information is meant for you? How
Feasibility
How is this information useful to you?
Does this seem possible for you to do? How?
Probes: Do you think you can use this information in feeding your children? How? Do you see
yourself following these recommendations? How (or why not)?

129

Appendix H: Frequency Sheets for Message Development

Table 3-4. Frequency Sheet for Family Meals

Behavioral
Belief
Opportunity to
model

Frequenc
y
11

Exposure and
introduction to
new and variety
of foods

6

Monitor child’s
food
consumption
(type and
amount

5

Opportunity for
parents to talk
about health
and nutrition

4

Overall,
children
motivated to
eat healthy
foods

Barriers

3

130

Facilitators

Frequency

Help from
spouse in
cooking and
cleaning

10

9

Cooking some
foods in
morning, on
weekends, or
day before

10

7

Following easy
and simple
recipes

8

3

Help from
children in
setting up
table, cleaning
etc.
Cutting
vegetables on
weekends or
night before

5

Soaking or
boiling lentils
in advance
Having readymade roties

Full time work
commitments
resulting in to
tiredness, lack
of time, too
much
responsibility of
cooking on one
person
Time conflicts:
Children eating
at different time,
graduate student
commitment,
father coming
late
Presence of
younger child at
home require
separate
feeding, food
arguments, and
disagreements
Elaborate
preparation of
Indian meals
require more
time

Frequenc
y
13

5

9

4

Table 3-4 (cont’d)
Preparing roti
dough in
advance
Using frozen
pre-cut
vegetables

131

4

3

Table 3-5. Frequency Sheet for Parental Modeling
Behavioral
Frequency Barriers
Belief
Children copy
21
Food dislike
both healthy
and eating
and nonhabits of
healthy eating
parents
habits of
parents
Children are
8
Child's dislike
motivated and
of food
encouraged to
try and eat new
foods
Gives a sense
4
Lack of
of familiarity
support from
and safety
spouse
toward food
and makes
food more
acceptable
Parents
3
Religious
negative
restrictions
comments
about foods
makes children
not eat those
foods
Modeling as a
2
strategy to
expose to and
encourage
eating of new
foods

Frequency Facilitators

132

6

4

Parents like for
fruits and
vegetables, and
openness to try
new fruits and
vegetables
Not showing
dislike and eating
a few bites in
front of children

Frequency
8

7

2

Balance of likes
and dislike
between parents

5

3

Cooking or
preparing foods
that taste better

5

Vegetarianism
and health
consciousness

5

Table 3-6. Frequency Sheet for Food Availability
Behavioral
Belief
Conveniently
allows mother
to cook and
offer foods

Frequency

Barriers

Frequency

14

Picky eater
child does
not like the
foods

4

Provides
exposure and
familiarizes
children to new
and variety of
foods

8

2

Availability of
unhealthy
foods makes
children more
likely to eat
those foods

10

Presence of
unhealthy
foods at
home causes
distraction to
eating
healthy foods
Spouse
bringing
unhealthy
foods that
causes
distraction
Dislike of
parents for
certain foods

Weather
conditions
makes
shopping
difficult and
affects
availability of
quality foods
133

Facilitators

Frequency

Easy
availability of
variety and
quality foods
at grocery
store
Easy
accessibility of
grocery store

7

2

Foods not very
expensive

5

3

Involving
children in
grocery
shopping
exposes
children to
variety of
foods, letting
them pick
fruits and
veggies makes
them more
likely to eat
those foods
Substituting
expensive
fruits with
cheaper ones

5

3

4

2

Table 3-6 (cont’d)
Some fruits
are expensive

134

3

Shopping
based on
ongoing sales
or deals
Buying
colorful,
attractive, and
clean fruits
Preparing food
in interesting
and creative
manner

2

2

2

Table 3-7. Frequency Sheet for Food Accessibility
Behavioral
Frequency
Belief
Makes
20
children more
likely to eat
and makes
them
independent in
their decision
Easily offer
4
the foods
when the child
is hungry
without losing
time and
patience
Does not
5
make any
difference as it
depends on
the taste of the
child

Barriers

Frequency

Facilitators

Frequency

Children
distracted by
the presence of
unhealthy
foods at home

12

Routine for the
mother to cut
fruits and
veggies after
grocery
shopping

4

Children do not
reach for
healthy options
because they
do not like it

8

Buying pre-cut
fruits from
grocery store

3

Children will
not pick
healthy foods,
they have to be
told to eat
healthy foods
Children not
allowed to
access the
refrigerator to
avoid mess
Some fruits are
cumbersome to
cut and spoil if
not eaten soon
Fruits cut for a
long time lose
freshness and
appeal
Lack of time,
help, and
motivation to
cut fruits

11

Help from
spouse in
cutting fruits

3

7

Dip is helpful

2

135

3

8

3

Table 3-8. Frequency Sheet for TV Viewing while Eating
Behavioral
Belief
TV causes
distraction
resulting in
overeating

Frequency Barriers
16

No control over
what and how
much they are
eating

5

Do not realize
what foods
they are eating

9

Do not savor
and relish the
taste of foods

6

TV distraction
slows down
foods
consumption
resulting in
under eating

14

Tooth decay
and improper
chewing of
foods
No interaction
with family
members

4

2

Frequency Facilitators

Allows mother
to feed any food
in more
quantity
without child's
knowledge
Habit of
watching TV is
an uncontrolled
phenomenon
for children
Snack time or
meal time is the
only time for
children to
watch TV
Meal time only
time for the
parents to watch
TV

Letting child
watch TV
allows the
mother to
complete chores
& have some
time to herself
Peer modeling

Lack of family
interaction

136

12

12

Parents having
meals with
children, and
conversation
during mealfamily meals
Mealtime rules Let children
watch TV before
of after meal

Frequency
4

4

8

Recording
favorite show

2

6

Arrangement of
the house such
that does not
permit TV
viewing during
mealtime (e.g.
TV not viewable
from dining
table)

3

4

4

2

Table 3-9. Frequency Sheet for Pressuring Children to Eat
Behavioral
Belief
Ensures
children eat
vegetables,
enough of all
foods, and get
good nutrition
Develops good
health as a
result of above

Frequency Barriers

Frequency Facilitators

Frequency

10

Food is scared
and it is
culturally
inappropriate to
waste food

18

14

3

Inculcating
8
cultural values
of not wasting
food and
teaching good
manners of
eating
Children do not 10
like home
cooked or
Indian foods and
prefer other
foods (e.g. fast
foods)
Children eat
5
enough and not
become hungry
after a while

Give appropriate 3
portion size

Not letting
children snack
before mealtime

3

Children do not 4
know they are
hungry and need
to eat more
Playing is
4
priority for
children

Introduce new
foods slowly
and in small
amounts
Allow the child
to become
familiar with the
food by letting
them taste
several times

3

Child learns to
know his
appetite

5

Ensures that
child eats
enough and
does not get
hungry after a
while
Encourages
overeating

4

Child develops
aversion to
forced foods
and does not
eat when
outside
parental
control

4

3

137

Giving small
portions and
allow for second
helping

Offering variety 4
and letting child
decide, offer one
foods that the
child likes

2

Table 3-9 (cont’d)
Child may
choke or throw
up

4

Praising the
child for trying
and giving
rationales
Reducing the
amount of spice
in food
preparation
Twisting child's
favorite food by
adding veggies

138

6

2

2

Table 3-10. Frequency Sheet for Using Food as Rewards
Behavioral
Belief
Children
become
habituated to
rewarded foods

Children will
be more
interested in
rewarded food
and not the
main meal
Rewarded
foods fall into
the category of
unhealthy
foods and can
result in
unhealthy
eating habits
and overweight
Increased
liking for
rewarded food
Children are
encouraged to
eat healthy
foods, finish
main meal,
develop good
eating habits
In general,
results in
expectant
nature of child
in general

Frequency Barriers

Frequency Facilitators

Frequency

11

Helps children
eat the main
meal without
forcing

6

4

9

Helps the
mother get
things done
without
working hard

3

Providing
alternative
rewards such as
reading story
books, buying
books, coloring
activity
Taking children
out to games,
playground,
park, zoo, picnic

4

Helps child
gain weight

2

Praising the
child, show love,
and affection

3

3

Children feel
recognized and
appreciated

3

Stickers or
points

2

Letting children
watch TV or
play with toys or
computer

4

6

2

139

5

Table 3-11. Frequency Sheet for Restricting Consumption of Certain Food
Behavioral
Belief
Control the
portion size of
unhealthy
foods

Frequency

Barriers

Frequency

Facilitators

Frequency

9

7

Buying limited
quantities of
junk foods and
in
predetermined
portion size

12

Ensure that
children do
not eat
unhealthy
foods at all
Prevent
consumption
of fat and
sugar and
thereby other
health
problems
including
overweight
Prevent
consumption
of junk foods
before meal
time
Children resist
more if they
are restricted
(including
religious
restrictions)

3

Availability
and
accessibility
of unhealthy
foods tempts
children for
such foods at
home
Children have
strong liking
for junk foods

3

Not buying junk
foods at all

12

Religious
restrictions

2

Setting a snack
time routine and
when the child
is allowed to eat
snacks

4

16

2

Buying healthier 3
versions of
snack foods

3

140

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