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Determinants of dietary behavior among youth: an umbrella review
International Journal of Behavioral Nutrition and Physical Activityvolume 12, Article number: 7 (2015)
The literature on determinants of dietary behavior among youth is extensive and unwieldy. We conducted an umbrella review or review-of-reviews to present a comprehensive overview of the current knowledge.
Therefore, we included systematic reviews identified in four databases (i.e. PubMed, PsycINFO, The Cochrane Library and Web of Science) that summarized determinants of observable child and adolescent dietary behaviors. Data extraction included a judgment of the importance of determinants, strength of evidence and evaluation of the methodological quality of the eligible reviews.
In total, 17 reviews were considered eligible. Whereas social-cognitive determinants were addressed most intensively towards the end of the 20th century, environmental determinants (particularly social and physical environmental) have been studied most extensively during the past decade, thereby representing a paradigm shift.
With regard to environmental determinants, mixed findings were reported. Sedentary behavior and intention were found to be significant determinants of a wide range of dietary behaviors in most reviews with limited suggestive evidence due to the cross-sectional study designs. Other potential determinants such as automaticity, self-regulation and subjective norm have been studied in relatively few studies, but results are promising.
The multitude of studies conducted on potential determinants of dietary behavior provides quite convincing evidence of the importance of several determinants (i.e. quite some variables were significantly related to dietary behavior). However, because of the often used weak research designs in the studies covered in the available reviews, the evidence for true determinants is suggestive at best.
Dietary behaviors have been found to track from childhood into adulthood . Unhealthy food habits in childhood, therefore, can have a tremendous health impact later in life. Given the high prevalence of nutrition-related disease and mortality in Western countries , it is necessary to develop effective behavioral interventions to improve diet quality. But which factors determine a person’s dietary behavior? Interventions to improve health-related behaviors should be tailored to the most important and changeable determinants of these behaviors, preferably applying behavior change theories . To facilitate improvement of relevant, effective programs and policies promoting healthy eating targeting dietary behavior it is important to identify the various factors that may influence children’s and adolescents’ food consumption.
Socio-cognitive models of (health) behavior and behavior change, such as the Theory of Planned Behavior , Social-Cognitive Theory , and the Health Belief Model  have been applied frequently in development of nutrition education interventions. In very general terms -and not paying attention to the richness of and also differences between these models- these theories regard nutrition behavior to be determined by beliefs and conscious decisions, rational considerations of pros and cons of the behavior, perceived social influences, and assessment of personal efficacy and control. In additional fields of research, the physiological and affective influences on dietary behaviors have been studied, providing evidence for such basic factors as hunger and satiety, sensory perceptions, and perceived palatability of foods  as important drivers of food choice and dietary behaviors. And somewhat more recently, the so-called food environment that defines the availability and accessibility (i.e. physical environment), affordability (i.e. economic environment), social appropriateness or support (social-cultural environment), as well as rules, regulations and policies (i.e. political environment) regarding food choice and dietary behaviors has been studied in relation to food intake and dietary behaviors, as informed by (social) ecological behavior models [8-12]. Kremers and colleagues  proposed to integrate these insights in their Environmental Research framework for weight Gain prevention (EnRG; Figure 1). EnRG is a dual-process model and regards dietary behavior and physical (in) activity to be the result of direct ‘automatic’ responses to environmental cues (e.g. meal patterns and routines) as well as of more rational decision making based on cognitions such as intentions and beliefs. Furthermore, EnRG includes mediating pathways between environment and cognitions as well as potential moderators of the impact of these determinants such as habit strength and self-regulation skills.
The purpose of this study was to get a comprehensive and systematic overview of the scientific literature on correlates (referred to as potential determinants) and determinants of dietary behavior among children and adolescent (referred to as youth) to facilitate the improvement of effective healthy eating promoting interventions and identify gaps for future research initiatives. Because the scientific literature on this topic is unwieldy and has been documented in a number of systematic reviews in recent years, we aimed to conduct a review-of-reviews to provide a more comprehensive overview. We were interested in the association of all determinants that are potentially modifiable (social-cognitive, environmental, sensory and automatic processes) with observable dietary behavior (actual consumption behaviors like fruit consumption, beverage intake, snacking) among youth. By conducting a review-of-reviews, the so-called umbrella review, we aimed to (a) explore which determinant-behavior relationships have been studied so far, and (b) assess the importance and strength of evidence of potential determinants. The EnRG framework served to categorize the findings. Parallel to this umbrella review, a separate review-of-reviews of studies among adults was conducted by the same team with the same methodology . Some parts of these two reviews -especially the description of the methodology- are therefore very similar.
Search strategy and eligibility criteria
To identify all relevant systematic reviews, we conducted systematic searches in the bibliographic databases PubMed, PsycINFO (via CSA Illumina), The Cochrane Library (via Wiley) and Web of Science for articles published between January 1, 1990 and May 1, 2014. The search terms included controlled terms, e.g. MeSH in PubMed, Thesaurus in PsycINFO, as well as free text terms (only in The Cochrane Library). Search terms expressing ‘food and dietary behavior’ were used in combination with search terms comprising ‘determinants’, ‘study design: (systematic) review’, ‘study population: humans’ and ‘time span (January 1, 1990 to May 1, 2014)’. The PubMed search strategy can be found in Table 1. The search strategies used in the other databases were based on the PubMed strategy.
Studies were included if they met the following criteria: (i) systematic reviews on observable food and dietary behavior (i.e. consumption behaviors like fruit intake and snacking consumption, not purchasing behavior); (ii) studies describing potential behavioral determinants; (iii) study design: (systematic) review; (iv) study population: humans and (v) time span: January 1, 1990 to May 1, 2014. We excluded: (i) studies that were not written in English; (ii) studies in which dietary behavior was not an outcome of the study; (iii); studies about dietary behaviors in disease management and treatment; (iv) studies that focused on specific population groups (e.g. chronically ill, pregnant women, cancer survivors); (v) studies not published as peer reviewed systematic reviews in scientific journals, e.g. theses, dissertations, book chapters, non-peer reviewed papers, conference proceedings, reviews of case studies and qualitative studies, design and position papers, umbrella reviews; (vi) reviews of studies on not directly observable dietary behavior (e.g. nutrient or energy intake, appetite); (vii) reviews of studies on non-modifiable determinants (e.g. physiological, neurological or genetic factors); (viii) reviews of studies on the effect of interventions (but reviews of experimental manipulation of single determinants were included); (ix) reviews not conducted systematically (search strategy including keywords and databases used not identified, and/or with too little information of the included studies presented). The current umbrella review focuses on youth (<18 years). A second umbrella review using the same methodology about determinants of dietary behavior in adults is published elsewhere .
Figure 2 summarizes the manuscript selection process. In total, 17714 citations were obtained using PubMed (n = 13156), PsycINFO (n = 961), The Cochrane Library (n = 920), and Web of Science (n = 2677). The subsequent screening of the citations was performed by multiple reviewers (all citations were screened by ES and WK; some were screened by LB, SK, and EV). All titles of the citations were independently screened for relevance by two reviewers (ES and WK). Any disagreement was resolved by including the citation into the abstract screening process. Subsequently, abstracts of the remaining 1031 citations were retrieved for further screening. Another 729 citations were removed, resulting in 292 articles for full-text assessment for eligibility. In case of doubt, potential inclusion was discussed with a third reviewer (SK). Studies that did not meet the inclusion criteria (n = 257) were removed. Figure 2 displays the reasons for exclusion. Additionally, duplicates (n = 10) were removed. Thereafter, the reference lists of all review papers selected for inclusion (n = 25) were scanned for further relevant references. This reference tracking technique resulted in one additional review article appropriate for inclusion. In total, 26 reviews were considered eligible. However, of these reviews, 9 were only focused on determinants of adult dietary behavior (references reported in the umbrella review about determinants of dietary behavior in adults of Sleddens et al. ). Five reviews assessed dietary behavior of both youth and adults [15-19]. Therefore, 17 reviews were considered eligible for our umbrella review on determinants of youth dietary behavior [15-31].
Data extraction including rating of methodological quality
Four authors (ES, WK, LK, and LB) extracted data from the selected reviews. The extracted data included search range applied, total number of studies included in the reviews and number of studies included in the reviews that are eligible for the current umbrella review, total number of participants of included studies in the reviews and number of participants of the included studies that are eligible for the current umbrella review, and age and continent of included eligible studies. For a description of the results, correlate and outcome measures were extracted, as well as overall results of the reviews and overall limitations and recommendations of reviews. Additionally, the methodological quality of the reviews was evaluated using quality criteria adapted from De Vet, De Ridder, & De Wit  and based on the Quality Assessment Tool for Reviews . In total, a review was scored on eight criteria (with a total quality scoring ranging from 0–8) (see Table 2); 0 when the criteria was not applicable for the included review; 1 when the criteria was applicable for the included review. Disagreement between the reviewers on individual items were identified and solved during a consensus meeting. The quality of the reviews could be labeled as weak (quality scores ranging from 0 to 3), moderate (quality scores ranging from 4 to 6) or strong (quality scores ranging from 7 to 8). Furthermore, we judged the importance of included determinants in the reviews and judged its strength of evidence. The importance of a determinant refers to the statistical significance of a potential determinant and/or effect size estimate in relation to a particular type of dietary behavior. It refers to the amount of reviews (or eligible studies within the reviews) that did or did not find statistically significant results. For a particular determinant to receive the highest ranking (highest level of importance), all eligible studies in each review should have found a significant relationship and/or reported a (non)-significant effect size larger than 0.30. The strength of evidence represents the consistency between study findings and designs of the studies. Longitudinal observational studies and -where relevant- experimental studies of sufficient size, duration and quality showing consistent effects were given prominence as the highest ranking study designs. For this judgment we applied two coding schemes, see Tables 3 and 4 respectively. The criteria for grading evidence were adapted from those of the World Cancer Research Fund . The data extraction method is similar to the study of Sleddens et al. .
Description of reviews
Quality assessment ratings are presented in Table 2. One review received a quality rating of 2 (weak). The other reviews were rated as moderate (n = 9) or strong (n = 7). In all reviews, the inclusion and exclusion criteria were clearly stated and the review did integrate findings beyond describing or listing findings of primary studies. Clearly defined search strategies were absent in more than half of the reviews (9 out of 17 reviews), as usually a flow chart of the data screening process was missing.
Table 5 provides an overview of the characteristics of the included reviews. In three reviews [22-24] all included studies were eligible for our current study. Most of the studies included in the reviews used a cross-sectional study design. Six studies did not provide any information about sample sizes [15,16,19,21,24,29]. The remaining reviews included a total sample size of 695 to 570,403. The target groups of the eligible studies ranged in ages between the different reviews, although the focus was on primary school-aged children and adolescents. Most of the studies included in the reviews were conducted in North-America, followed by Europe.
Findings of the reviews
Table 6 provides an overview of the correlates and outcomes (i.e. observable dietary behaviors) included in the reviews, and the overall findings, limitations and recommendations reported by the authors of these reviews. In the following two paragraphs we give an overview of the determinant-behavior relationships that have been studied so far, and give an overview of the importance and strength of evidence of potential determinants.
Determinant-behavior relationship: correlate and outcome measures
Potential determinants of a range of dietary behavior outcomes among youth were explored, and many studies included multiple dietary behavior outcomes.
Thirteen reviews explored associations between environmental factors and dietary behavior [16,18,20,21,23-31]. Within the environmental determinants, the social-cultural environment was most often studied (n = 12) [16,18,20,21,23-30]. Thereafter, the physical environmental determinants (n = 9) [16,21,23-26,29-31], the economic/financial environmental determinants (n = 4) [16,21,29,30], and the political environment (n = 1) . Three reviews explored the associations between social-cognitive determinants and dietary behavior [15,24,27]. These social-cognitive determinants included attitude, self-efficacy/perceived behavioral control, and intention in the study of McClain et al.  and Rasmussen et al. , subjective norm in the study of Rasmussen et al. , and self-regulation in the study of Adriaanse et al. . Two of these reviews also examined the influence between sensory determinants and dietary behavior [24,27]. One review addressed the relation between habit strength and dietary behavior . And finally, three reviews looked at sedentary behavior in relation to dietary behavior [19,22,27].
In total, four reviews solely explored associations between determinants and fruit and/or vegetable consumption: self-regulation ; physical, social-cultural and economic environmental determinants ; physical and social-cultural determinants ; and social-cultural, political, and social-cognitive determinants, sensory processes, and sedentary behavior . Additionally, one review solely explored associations between habit strength and sugar-sweetened beverage intake , and one review solely explored association between physical and social-cultural environmental determinants and breakfast consumption . The other 11 reviews explored determinants of a variety of healthful and unhealthful dietary behaviors (e.g. snacks, fruit and vegetables, soft drinks, milk, breakfast) [18-24,28-31]. Dietary behaviors most often included as outcomes in the included reviews were fruit and/or vegetable consumption (n = 14) [15,16,18-24,27-29,31], followed by sugar-sweetened beverage consumption (n = 10) [17,18,20-24,28-30], snack consumption (n = 9) [18,19,21-24,28,29,31] and breakfast consumption (n = 7) [18,20,22,23,25,28,30] (see Table 5).
The importance and strength of evidence of potential determinants
With regard to the importance of a determinant and its strength of evidence (Table 6), most determinant-behavior relationships were coded with a zero, indicating that the findings are mixed. The following categories of determinants were found to be significantly related to dietary behavior and/or reported a (non)-significant effect size larger than 0.30 in all identified eligible studies of the included reviews assessing these categories of determinants (++ in Table 3): some aspects of social-cognitive determinants (such as attitude, self-regulation, intention and self-efficacy) and dietary behavior [15,24,27]; habit strength and sugar-sweetened beverage intake ; sensory processes and snacking ; and sedentary behavior and sugar-sweetened beverage and breakfast consumption . The following categories of determinants were found to be significantly related to dietary behavior and/or reported a (non)-significant effect size larger than 0.30 in more than 75% of the identified reviews assessing these categories of determinants (+ in Table 3): the physical environment and fruit intake ; the social-cultural environment and fruit and vegetable intake [16,18,21,24,27-29] and sugar-sweetened beverage consumption [18,20,21,23,24,28-30]; intention, sensory processes, and knowledge for fruit and vegetable intake [24,27]; and sedentary behavior and fruit intake , fruit and vegetable intake and snack intake [19,22]. The evidence is mostly limited (limited, suggestive: Ls), predominantly due to the abundance of studies with cross-sectional designs so that causal or predictive relations could not be established. Systematic review on the influence of political environments, self-regulation, subjective norm and automaticity were mostly lacking in the included reviews.
The multitude of studies conducted on determinants of dietary behavior among youth provides mixed and sometimes quite convincing evidence regarding associations between potential determinants and a range of dietary behaviors. However, because of the general use of cross-sectional designs in the studies covered in the available reviews, the evidence for true determinants is suggestive at best.
In particular, environmental determinants (mainly the social-cultural environment) and social-cognitive determinants have been studied quite extensively for their association with different dietary behaviors, with somewhat mixed results. The included reviews suggest that in the past decade, environmental determinants have been studied most extensively. This is an important finding in itself, suggesting a paradigm shift in the field, i.e. from a focus on social-cognitive determinants to environmental factors. This shift towards more consideration of the social-ecological approach was also seen in our umbrella review on determinants of dietary behavior in adults . Other potential determinants of dietary behavior, such as automaticity, self-regulation, and subjective norm, have been studied in relatively few studies, but study results are promising. With regard to the outcomes investigated, most reviews explored relations of potential determinants with fruit and/or vegetable intake.
In the reviewed papers we found evidence that the social-cultural environment, such as the familial influence (e.g. [21,24,27,28]) is a significant correlate of fruit and vegetable intake and snack consumption in youth in more than 75% of the available studies (see Table 7). Parents, as gatekeepers of the home food supply, can influence children’s eating behavior either through the use of specific food parenting practices (i.e. context-specific acts of parenting on child eating including encouraging of food variety and controlling a child’s intake of unhealthy products) or through the indirect influence of general parenting . Social-cognitive determinants have been studied often, but the evidence regarding their importance is limited (i.e. suggestive at best). Intention, a proximal indicator of actual behavior, was found to be a significant determinant of fruit and vegetable intake, snack intake, and sugar-sweetened beverage intake [24,27]. Socio-cognitive theories such as the Theory of Planned Behavior  are indicated to have limited value in predicting the translation of intention into action. This limitation is addressed in reviews on the constructs of habit  and implementation intentions . The review on implementation intentions showed considerable support for the effect of implementation intentions on increasing fruit and vegetable intake (medium effect size) among youth. However, the effect of implementation intentions on the reduction of unhealthy eating patterns was less convincing. Habit strength was one of the factors to be significantly related to sugar-sweetened beverage intake with moderate to strong effect sizes in all identified eligible studies of the review of Gardner et al. . Automatic processes, including habit strength appears to reduce the utility of cognitive factors for the prediction or association with dietary behavior . Additionally, screen time was found to be consistently associated with dietary behavior [19,22,27]. The included reviews provide evidence that the amount of screen time was significantly related to dietary behavior; screen time was positively associated with snack and sugar-sweetened beverage intake [19-22] and inversely associated with fruit and vegetable intake [19-27]. An important mechanism linking screen time to unhealthy dietary behavior is exposure to marketing of unhealthy foods and beverages through screens [35,36]. The food and beverages depicted in these advertisements are predominantly unhealthy foods high in fat, salt and sugar [35,37]. Sedentary activities and unhealthy dietary behavior have repeatedly been found to cluster [38-40] and may also share similar environmental cues causing these behaviors to co-occur. Sedentary behavior offers a context for the consumption of energy-dense food products, disrupting the habituation to food cues.
Systematic reviews on the influence of political environments, self-regulation, subjective norm and habitual behavior were mostly lacking in the included reviews. In addition, some types or categories of potential determinants were not covered in the present umbrella review because we did not come across systematic reviews of such determinants. For instance, although we found two systematic reviews on sensory determinants of dietary behavior [24,27], most of the reviews were excluded as they did not comply to the quality standards of systematic reviews that we used as an inclusion criteria, e.g. . This does not necessarily imply that such factors as taste and preferences are not important, but just that these have not been covered well at present in systematic reviews. Furthermore, it should be noted that lack of evidence for the importance of a possible determinant is not the same as evidence that the determinant is not important; since lack of well-designed studies is often the main reason for lack of evidence. We need to try to distinguish between well-researched determinants and still no evidence for importance, and determinants that have just not been studied (well enough) to make meaningful conclusions.
Limitations and methodological issues
Several limitations should be taken into consideration in reviewing these findings. These include the cross-sectional nature of many studies relying on self-report measures; heterogeneity of conceptualization, measurement, samples and analyses used, making it difficult to compare results between studies; inability to conduct a meta-analysis; lack of validity and reliability of dietary intake and correlate measures; and categorization of determinants into more global categories thereby losing important information. Additionally, the systematic reviews included a wide age range, i.e. respondents from birth to 18 years. During childhood many developmental transitions take place that may imply differential importance of distinct behavioral determinants. For instance, parents are highly responsible as gatekeepers of the home food supply for their children’s dietary intake behavior. However, parental influence decreases with advancing age of the child as the child is increasingly exposed to other environments (e.g. school environment, peer influences).
In addition to the quality of the research design, the fact that some determinants have not been extensively studied yet, studies of some types of determinants have not been reviewed systematically, and the lack of robust results from this umbrella review may also be explained by the fact that groups or types of determinants are often studied in relative isolation. For instance, studies in which different categories of determinants - e.g. sensory determinants, self-regulation, and political environmental factors - were studied with integrative approaches are largely lacking. Such studies would allow for exploration and testing of mediating and moderating pathways between these determinants in influencing dietary behavior. Already some studies combining environmental and social-cognitive determinants have been reported in recent years and do support such mediating and moderating pathways, e.g. [42-45].
This is the first umbrella review that provides an overview of reviewed research regarding a broad range of potential determinants of dietary behavior in youth. Umbrella reviews in itself are, however, also prone to bias in various ways. Differences in reviewing methodology and reporting were apparent, as well as differences in for example categorizations of the determinants. By nature, umbrella reviews lead to loss of detail. In addition, some individual studies are included in multiple reviews which may have led to an overrepresentation of single studies in our results. Finally, we excluded reviews that primarily addressed biological determinants or papers with summative outcomes such as caloric intake, and we also did not include reviews that focused on qualitative data.
Conclusions and recommendations
The evidence gathered in our umbrella review suggests that intention and sedentary behavior have the strongest evidence base as determinants of healthy and unhealthy dietary behavior in youth. The influence of distinct determinants may, however, be stronger in interaction with other influences. We would advocate for studies that address combined, mediating and interactive influences on dietary behavior . Such studies are advocated to include behaviors that have been found to cluster with dietary behavior, such as sedentary behavior. Other recommendations include the need for better designed studies, beyond mere cross-sectional research, −i.e. more longitudinal and experimental or intervention research, and research using natural experiments-, larger samples among specific age groups, and more valid and reliable measures (dietary behavior and correlates). Our results underline the importance of embracing theories and factors additional to determinants derived from socio-cognitive theories that are often used to inform interventions to promote healthy dietary behaviors. Theories that are promising of further research for determinants of dietary behavior research include habit theory and (social-) ecological models of health behavior.
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This research was funded by The Netherlands Organization for Health Research and Development, project number 115100008. The authors would like to thank Professor C. de Graaf for his cooperation on this project.
The authors declare that they have no competing interests.
ES, WK, SK and JB conceptualized the study. EV and PK performed the literature search; ES, WK, EV, LB and SK were involved in the screening process; ES, WK, LK and LB extracted data. ES drafted the manuscript. All authors reviewed draft versions of the manuscript and provided critical feedback. All authors have made a significant contribution to this manuscript, and all authors read and approved the final manuscript.