Secondary Logo

Associations Among Caregiver Feeding Practices and Blood Pressure in African American Adolescents

The Jackson Heart KIDS Study

Burton, E. Thomaseo, PhD, MPH; Wilder, Tanganyika, PhD; Beech, Bettina M., DrPH, MPH; Bruce, Marino A., PhD, MSRC, MDiv

doi: 10.1097/FCH.0000000000000215
Original Articles

Caregiver feeding practices have been linked to youth health outcomes. The present study examined associations among caregiver feeding practices and blood pressure in 212 African American adolescents via the Child Feeding Practices Questionnaire. Results revealed a positive association between caregivers' concern about their child's weight and diastolic blood pressure, which was more acute for older adolescent boys. Caregivers' perceived responsibility for the quality and quantity of food their child receives was also associated with lower diastolic blood pressure in older adolescent boys. Feeding practices are ideal targets of lifestyle intervention, and health care providers should continue to involve caregivers as adolescents approach adulthood.

Department of Pediatrics, The University of Tennessee Health Science Center, Memphis (Dr Burton); Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee (Dr Burton); Department of Biological Sciences, Florida A&M University, Tallahassee, Florida (Dr Wilder); Department of Population Health Science, John D. Bower School of Population Health (Drs Beech and Bruce) and Myrlie Evers-Williams Institute for the Elimination of Health Disparities (Drs Beech and Bruce), The University of Mississippi Medical Center, Jackson; and Center for Research on Men's Health, Vanderbilt University, Nashville, Tennessee (Dr Bruce).

Correspondence: E. Thomaseo Burton, PhD, MPH, Pediatric Obesity Program, The University of Tennessee Health Science Center, 50 N Dunlap St, 452R, Memphis, TN 38103 (

This research was supported by the Center for Research on Men's Health at Vanderbilt University and grants from the Department of Health & Human Services' Office of Minority Health (Prime Award Number 1 CPIMP091054—Beech) and the National Heart, Lung, and Blood Institute (1R25HL126145—Beech; 1K01HL88735—Bruce).

The authors declare no conflict of interest.

FOR DECADES, the prevalence of obesity and hypertension among African Americans has been disproportionately higher than that of other racial or ethnic groups in the United States.1 Evidence suggests that these disparate health patterns may begin to emerge as early as childhood and adolescence.2,3 Excess weight and elevated blood pressure (BP) are particularly salient for African American individuals, families, and communities, given the increased risk for costly and debilitating physical health conditions such as premature stroke, chronic kidney disease, and cardiovascular disease (CVD).4–6

Researchers have established an association between excess weight and BP among children and adolescents from diverse backgrounds.7–10 Interestingly, Rosner and colleagues11 present results indicating interaction between ethnic group and body mass index (BMI). The authors observed that African American youth tend to have higher BPs than their white peers at lower levels of BMI. Although this study found that hypertension was more prevalent among white youth with higher BMIs, these findings highlight the susceptibility of African American youth at all levels of BMI. In fact, when compared with other racial groups, African American adolescents are twice as likely to develop hypertension by early adulthood.12,13 To date, however, relatively few studies have taken a within-group approach to examine this relationship among African American youth.14,15 The confluence of excess weight and elevated BP among African American children and adolescents is especially concerning considering their heightened risk for cardiovascular complications and premature mortality, impaired psychological well-being, and decreased quality of life across the life span.6,16

Excess weight and elevated BP are multifactorial health concerns with biological, behavioral, and environmental underpinnings, and family is a mechanism through which risk can be conferred across generations. Parental caregivers can play a prominent role in child and adolescent health outcomes through heritable traits as well as by establishing behavioral and environmental contexts.17 One particular path that has been identified in the literature is parenting style.18,19 For example, parental feeding practices have been associated with BMI and waist circumference (WC) among African American adolescents.20 Considering that African Americans develop risk factors for hypertension earlier in the life span,21,22 adolescence may be an ideal time to intervene. Lifestyle changes, including modifications to diet and exercise, tend to be first-line recommendations for intervention.4 Although adolescents are in the process of establishing more autonomy in their health behaviors, lifestyle practices and behaviors during this stage of development can be malleable and influenced by parents or guardians. Hence, the impact of caregiver influence on youth lifestyle behaviors and the persistence of these behaviors into young adulthood require further study.

There is a critical need for research to elucidate the individual and collective implications of excess weight and elevated BP for early onset and accelerated progression of cardiometabolic diseases among African American youth. The aim of this study was to examine the associations among caregiver feeding practices and BP in a sample of African American adolescents from the southern United States. We hypothesized that caregiver feeding practices would be associated with their children's level of BP. We also anticipated that age and sex would influence the magnitude of relation among feeding practices and BP.

Back to Top | Article Outline



Participants for the present study were 212 African American youth enrolled in the Jackson Heart KIDS Pilot Study (JHS-KIDS) and their caregivers. This offspring cohort consists of children and grandchildren of individuals enrolled in the Jackson Heart Study (JHS), the largest single-site epidemiologic evaluation of CVD risk among African Americans.23 Based in Jackson, Mississippi, a primary aim of JHS-KIDS was to examine the development of obesity and factors related to metabolic and cardiovascular disease among a cohort of African American adolescents.24

Potential JHS-KIDS participants were recruited through JHS participants who identified youth who might meet eligibility criteria. Potential participants were then screened by telephone to ensure eligibility (ie, 12-19 years of age, English as primary spoken language). Those meeting eligibility requirements were invited to the JHS-KIDS clinic site where they and their accompanying caregiver (ie, parent/grandparent) completed informed consent and assent forms. Adolescent participants had their BP, height, weight, and WC measured while caregivers provided anthropometric data and completed the Child Feeding Questionnaire.25 This study was approved by The University of Mississippi Medical Center Institutional Review Board.

Back to Top | Article Outline


Primary outcomes

Primary outcomes for the present study were systolic (SBP) and diastolic (DBP) blood pressure. Trained study personnel measured resting BP using a Critikon Dinamap–automated random zero sphygmomanometer (Tampa, Florida). The SBP and DBP variables used in the present study represent the average of 3 seated readings with a 1-minute rest period between each reading.

Back to Top | Article Outline

Independent variables

The Child Feeding Questionnaire25 is a self-report measure of caregivers' views and concerns regarding child obesity risk and their use of controlling feeding practices. This 31-item questionnaire comprises 7 subscales, each rated on a corresponding 5-point (0-4) Likert-type scale: (1) perceived responsibility, 3 items measuring caregivers' perceived responsibility for quality and quantity of food served to their child; (2) perceived parent weight, 4 items querying caregivers' perception of their own weight status; (3) perceived child weight, 6 items assessing caregivers' perception of child's weight status; (4) concern about child weight, 3 items measuring caregivers' concerns about child's risk for obesity; (5) restriction, 8 items assessing caregivers' regulation of unhealthy foods (eg, sweets) that may contribute to obesity risk; (6) pressure to eat, 4 items measuring caregivers' insistence that their child eat enough food; and (7) monitoring, 3 items assessing caregivers' oversight and tracking of child's intake of unhealthy foods (eg, high-fat snacks). Because of the focus on caregiver feeding practices, the present study did not use the perceived parent weight or perceived child weight subscales. The remaining subscales demonstrated acceptable internal consistency (Cronbach α values range: 0.71-0.93).

Back to Top | Article Outline

Demographic and anthropometric variables

Basic demographic information was obtained during the caregiver interview and included adolescent participant's age, sex, race/ethnicity, and medical history. Caregiver's relationship to the child participant and highest level of education completed were also collected.

Trained research staff collected adolescents' height and weight in duplicate using a Shorr Height Measuring Board (Olney, Maryland) and Seca 770 Model scale (Hamburg, Germany), respectively. The average of these measures was used to calculate crude BMI, which was transformed to z scores using the lambda-mu-sigma method.26,27 These values were standardized by age and sex using the 2000 Centers for Disease Control and Prevention Growth Charts as reference.28 Waist circumference was measured at the level of the umbilicus with a Tech-Med Model #4414 fiberglass measuring tape (Hauppage, New York). Measurements were taken in triplicate and averaged for precision.

Back to Top | Article Outline

Statistical analyses

The sample was described in total and by sex using means and standard deviations (for continuous variables) and proportions (for categorical variables). T tests and χ2 tests were used to assess variability by sex of independent and dependent variables included in multivariate analyses. Multivariable ordinary least squares regression was used to examine the relationship between caregiver feeding practices and BP outcomes; interaction terms were included to investigate hypothesized moderation effects. Models were conducted for the total sample and stratified by sex. Significance level was set at P < .05 and all tests were 2-sided. All statistical analyses were conducted with StataSE Version 15.

Back to Top | Article Outline


Table 1 reports descriptive characteristics of the sample of African American adolescents and their caregivers. The average age of the adolescents was 15.16 years (SD = 2.19), and there was equal distribution of boys (49.5%) and girls (50.5%) in the sample. Mean SBP and DBP readings were approaching adult prehypertensive levels in this sample of adolescents, and boys had significantly higher SBP (p < .0001) than girls. Mean BMI z scores and WC measures were also approaching levels that correspond with increased risk for cardiometabolic complications among youth.29 There were no mean differences in anthropometric measures by sex.



The preponderance of caregiver respondents were women (86.5%), parents (70.3%), and baccalaureate degree recipients (58.04%). Mean scores on Child Feeding Questionnaire subscales revealed that caregivers perceived themselves moderately responsible for their adolescent's eating decisions and were somewhat concerned about their child's weight. On average, caregivers reported moderate restrictive and monitoring practices and disagreed that they pressure their children to eat more food. When compared with grandparents, parents reported greater perceived responsibility for type and amount of food provided to their child (P < .001). No other mean differences between study variables were noted for parents and grandparents.

Multivariable regression analyses were conducted to explore the associations among child feeding practices, SBP, and DBP (see Table 2). While results revealed no direct effects for SBP, caregivers' report of concern about their child's weight was positively related to DBP (B = 0.32, P < .05). The relationship between caregiver concern and DBP varied by sex as the sex-stratified models produced results indicating that association for girls was similar to the pooled model while the corresponding results for boys were not statistically significant.



Interaction terms were added to the regression models to investigate the degree to which age moderates the relationship between caregiver feeding and BP. Moderation analyses conducted on sex-stratified models revealed that the association between concern for obesity risk and DBP was more acute for older adolescent boys (B = 0.23, P < .05; R2 = 0.20). This finding is illustrated in Figure 1. Similarly, as can be seen in Figure 2, caregiver perception of greater responsibility for providing the appropriate types and amounts of food was associated with lower DBP as adolescent boys got older (B = 0.24, P < .05; R2 = 0.19). Each of these interaction models demonstrated a medium effect size (Cohen f2 = 0.26 and 0.24, respectively).

Figure 1

Figure 1

Figure 2

Figure 2

Back to Top | Article Outline


The rising rate of obesity and CVD risk factors among adolescents is a concerning trend that is even more pronounced among African Americans.6,21 Taken together, the high prevalence and early onset of hypertension in this population indicate a strong need for developmentally and culturally appropriate interventions that may redirect the trajectory of hypertensive disease as adolescents approach adulthood. Modifications to lifestyle behaviors, key targets of early intervention efforts, are strongly influenced by caregivers, who model eating and activity patterns as well as facilitate or impede access to healthy choices.30,31 The present study fills an important gap in the literature by examining associations among caregiver feeding practices and BP outcomes among a sample of African American adolescents.

The study sample comprised adolescents who, on average, presented with elevated BMI, WC, and BP readings, indicating an elevated risk for premature CVD and related diseases. While there were no sex differences for markers of weight status, boys in the sample had higher mean SBP than girls. This finding is consistent with reports using data from the National Health and Nutrition Examination Survey32 and underscores the importance of tailoring health intervention efforts to consider factors such as sex. Our hypothesis that caregiver feeding practices were related to BP outcomes was partially supported. Caregivers who expressed concern about their child's weight were more likely to be parenting a child with higher DBP. This finding held for girls in a sex-stratified model and highlights the moderating role of sex on the relationship between obesity and hypertension. The combination of obesity and hypertension portends heightened cardiometabolic consequences6 and both should be the focus of future prevention and intervention efforts.

Results from the present study indicate that age as well as sex may be important factors in how caregiver feeding practices influence BP outcomes. Specifically, caregiver concern for the risk of obesity and perceived responsibility for their adolescent's intake were associated with lower DBP among older boys. These findings suggest that caregivers of boys approaching adulthood who appreciate the deleterious effects of obesity and who are more cognizant of their role in providing healthy food options may be directly or indirectly influencing DBP. It is important to note that elevated DBP is typically quite amenable to lifestyle changes,33,34 and while elevated SBP is the hallmark indicator of hypertension, long-term elevation of DBP has been linked to isolated systolic hypertension.34 African American adolescent and young adult men are particularly susceptible to elevations in DBP, which highlights the importance of early culturally and developmentally appropriate intervention.35,36

Back to Top | Article Outline


The strengths of the present study include a focus on an offspring cohort of African American adolescents affiliated with the JHS. Obesity, hypertension, and other cardiometabolic conditions are of particular prevalence and concern in the southern region of the United States; however, generalizability of these findings to other geographic regions is limited. The cross-sectional design of this study does not allow for temporal relationships or causal inferences to be established from the results, and the use of self-report questionnaires introduced the possibility of biased or socially desirable responses. However, anthropometric and vital measurements were obtained by trained medical providers in a clinical setting, which adds to the strengths of this study design.

Back to Top | Article Outline


Results from this study suggest that medical providers managing weight and BP concerns among African American adolescents should continue to involve caregivers in the care of these youth, even as they approach adulthood. In addition, intervention strategies should be tailored for sex of the youth. These findings are consistent with recommendations for family-based approaches to implementing healthy lifestyle behaviors.37,38 The physiological and psychosocial sequelae associated with excess weight and elevated BP are relevant across the life span. Early intervention, however, holds promise for improved health and quality-of-life outcomes as individuals age. There is a particular need for more interventional research on implementation and consistent maintenance of healthy lifestyle behaviors among African American youth, and this study supports the important role that caregivers play in adolescent health outcomes.

Back to Top | Article Outline


1. Rosner B, Cook NR, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988-2008. Hypertension. 2013;62(2):247–254.
2. Brady TM, Fivush B, Parekh RS, Flynn JT. Racial differences among children with primary hypertension. Pediatrics. 2010;126(5):931–937.
3. Freedman DS, Goodman A, Contreras OA, DasMahapatra P, Srinivasan SR, Berenson GS. Secular trends in BMI and blood pressure among children and adolescents: the Bogalusa Heart Study. Pediatrics. 2012;130(1):e159–e166.
4. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213–256.
5. Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9(5):474–488.
6. Cheung EL, Bell CS, Samuel JP, Poffenbarger T, Redwine KM, Samuels JA. Race and Obesity in Adolescent Hypertension. Pediatrics. 2017;139(5):e20161433.
7. Chiolero A, Madeleine G, Gabriel A, Burnier M, Paccaud F, Bovet P. Prevalence of elevated blood pressure and association with overweight in children of a rapidly developing country. J Hum Hypertens. 2007;21(2):120–127.
8. Macedo ME, Trigueiros D, de Freitas F. Prevalence of high blood pressure in children and adolescents. Influence of obesity. Rev Port Cardiol. 1997;16(1):27–30, 27–28.
9. Ostchega Y, Carroll M, Prineas RJ, McDowell MA, Louis T, Tilert T. Trends of elevated blood pressure among children and adolescents: data from the National Health and Nutrition Examination Survey1988-2006. Am J Hypertens. 2009;22(1):59–67.
10. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics. 2004;113(3):475.
11. Rosner B, Prineas R, Daniels SR, Loggie J. Blood pressure differences between blacks and whites in relation to body size among US children and adolescents. Am J Epidemiol. 2000;151(10):1007–1019.
12. Berenson GS, Wattigney WA, Webber LS. Epidemiology of hypertension from childhood to young adulthood in black, white, and Hispanic population samples. Public Health Rep. 1996;111(suppl 2):3–6.
13. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK. Trends in blood pressure among children and adolescents. JAMA. 2004;291(17):2107–2113.
14. Bruce MA, Beech BM, Norris KC, Griffith DM, Sims M, Thorpe RJ Jr. Sex, obesity, and blood pressure among African American adolescents: the Jackson Heart KIDS Pilot Study. Am J Hypertens. 2017;30(9):892–898. doi:10.1093/ajh/hpx071.
15. Bruce MA, Beech BM, Griffith DM, Thorpe RJ Jr. Weight status and blood pressure among adolescent African American males: the Jackson Heart KIDS Pilot Study. Ethn Dis. 2015;25(3):305–312.
16. Olive LS. Youth psychological distress and intermediary markers of risk for CVD: the emerging field of pediatric psychocardiology. Atherosclerosis. 2017;261:158–159.
17. Ferrer RL, Palmer R, Burge S. The family contribution to health status: a population-level estimate. Ann Fam Med. 2005;3(2):102–108.
18. Sleddens EF, Gerards SM, Thijs C, de Vries NK, Kremers SP. General parenting, childhood overweight and obesity-inducing behaviors: a review. Int J Pediatr Obes. 2011;6(2-2):e12–e27.
19. Kaur H, Li C, Nazir N, et al Confirmatory factor analysis of the child-feeding questionnaire among parents of adolescents. Appetite. 2006;47(1):36–45.
20. Burton ET, Wilder T, Beech BM, Bruce MA. Caregiver feeding practices and weight status among African American adolescents: the Jackson Heart KIDS Pilot Study. Eat Behav. 2017;27:33–38.
21. Dekkers C, Treiber FA, Kapuku G, Van Den Oord EJ, Snieder H. Growth of left ventricular mass in African American and European American youth. Hypertension. 2002;39(5):943–951.
22. White MS, Addison CC, Jenkins BW, Bland V, Clark A, LaVigne DA. Optimistic bias, risk factors, and development of high blood pressure and obesity among African American adolescents in Mississippi (USA). Int J Environ Res Public Health. 2017;14(2):pii: E209.
23. Taylor HA Jr, Wilson JG, Jones DW, et al Toward resolution of cardiovascular health disparities in African Americans: design and methods of the Jackson Heart Study. Ethn Dis. 2005;15(4 suppl 6):S6-4–17.
24. Beech BM, Bruce MA, Crump ME, Hamilton GE. The Jackson Heart KIDS Pilot Study: theory-informed recruitment in an African American Population [published online ahead of print April 29, 2016]. J Racial Ethn Health Disparities. 2017;4(2):288–296. doi:10.1007/s40615-016-0228-x.
25. Birch LL, Fisher JO, Grimm-Thomas K, Markey CN, Sawyer R, Johnson SL. Confirmatory factor analysis of the Child Feeding Questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite. 2001;36(3):201–210.
26. Vidmar S, Carlin J, Hesketh K, Cole T. Standardizing anthropometric measures in children and adolescents with new functions for egen. Stata J. 2004;4(1):50–55.
27. Flegal KM, Cole TJ. Construction of LMS parameters for the Centers for Disease Control and Prevention 2000 growth charts. Natl Health Stat Rep. 2013(63):1–3.
28. Kuczmarski RJ, Ogden CL, Guo SS, et al 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11. 2002(246):1–190.
29. Savva SC, Tornaritis M, Savva ME, et al Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord. 2000;24(11):1453–1458.
30. Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev. 2004;62(1):39–50.
31. Brown R, Ogden J. Children's eating attitudes and behaviour: a study of the modelling and control theories of parental influence. Health Educ Res. 2004;19(3):261–271.
32. Xi B, Zhang T, Zhang M, et al Trends in elevated blood pressure among US children and adolescents: 1999-2012. Am J Hypertens. 2016;29(2):217–225.
33. Franklin SS, Pio JR, Wong ND, et al Predictors of new-onset diastolic and systolic hypertension: the Framingham Heart Study. Circulation. 2005;111(9):1121–1127.
34. Franklin SS, Larson MG, Khan SA, et al Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation. 2001;103(9):1245–1249.
35. Franklin SS, Jacobs MJ, Wong ND, L'Italien GJ, Lapuerta P. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension. 2001;37(3):869–874.
36. Soto LF, Kikuchi DA, Arcilla RA, Savage DD, Berenson GS. Echocardiographic functions and blood pressure levels in children and young adults from a biracial population: the Bogalusa Heart Study. Am J Med Sci. 1989;297(5):271–279.
37. Kitzmann KM, Beech BM. Family-based interventions for pediatric obesity: methodological and conceptual challenges from family psychology. J Fam Psychol. 2006;20(2):175–189.
38. Quattrin T, Cao Y, Paluch RA, Roemmich JN, Ecker MA, Epstein LH. Cost-effectiveness of family-based obesity treatment. Pediatrics. 2017;140(3):e20162755.

adolescents; blood pressure; feeding; Jackson Heart KIDS Pilot Study; obesity

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved