No description available.

Introduction: Beverages influence diet quality, however, beverage intake among youth with obesity is not well-described in literature. Dietary pattern analysis can identify how beverages cluster together and enable exploration of population characteristics. Objectives: 1) Assess the frequency of children and youth with obesity who fail thresholds of: no sugar-sweet beverages (SSB), <1 serving/week of SSB, ≥2 servings/day of milk and factors influencing the likelihood of failing to meet these cut-offs. 2) Derive patterns of beverage intake and examine related social and behavioural factors and health outcomes at entry into Canadian pediatric weight management programs. Methods: Beverage intake of youth (2–17 years) enrolled in the CANPWR study (n=1425) was reported at baseline visits from 2013-2017. Beverage thresholds identified weekly SSB consumers and approximated Canadian recommendations. The relationship of sociodemographic (income, guardian education, race, household status) and behaviours (eating habits, physical activity, screen time) to the likelihood of failing cut-offs was explored using multivariable logistic regression. Beverage patterns were derived using Principal Component Analysis. Related sociodemographic, behavioural and health outcomes (lipid profile, fasting glucose, HbA1c, liver enzymes) were evaluated with multiple linear regression. Results: Nearly 80% of youth consumed ≥1 serving/week of SSB. This was more common in males, lower educated families and was related to eating habits and higher screen time. Two-thirds failed to drink ≥2 servings milk/day and were more likely female, demonstrated favourable eating habits and lower screen time. Five beverage patterns were identified: 1) SSB, 2) 1% Milk, 3) 2% Milk, 4) Alternatives, 5) Sports Drinks/Flavoured Milks. Patterns were related to social and lifestyle determinants; the only related health outcome was HDL. Conclusion: Many children and youth with obesity consumed SSB weekly. Fewer drank milk twice daily. Beverage intake was predicted by sex, socioeconomic status and other behaviours, however most beverage patterns were unrelated to health outcomes. / Thesis / Master of Science (MSc) / Beverage intake can influence diet and health outcomes in population-based studies. However, patterns of beverage consumption are not well-described among youth with obesity. This study examined beverage intake and relationships with sociodemographic information, behaviours and health outcomes among youth (2-17 years) at time of entry into Canadian pediatric weight management programs (n=1425). In contrast to current recommendations, 80% of youth consumed ≥1 serving/week of sugar-sweetened beverages and 66% consumed 2 servings/day of milk. Additionally, five distinct patterns of beverage intake were identified using dietary pattern analysis. Social factors (age, sex, socioeconomic status) and behaviours (screen time, eating habits) were related to the risk of failing to meet recommendations and to beverage patterns. Identifying sociodemographic characteristics and behaviours of youth with obesity who fail to meet beverage intakes thresholds and adhere to certain patterns of consumption may provide insight for clinicians to guide youth to improved health in weight management settings.

Attention on beverage intake, specifically sugar-sweetened beverages (SSB), has increased in recent years (1). Energy-containing beverages do not provide the same satiety as solid foods, and intake of solid food is not spontaneously reduced when energy-containing beverages are consumed (2,3). This may contribute to positive energy balance (1). Conversely, a reduction in energy intake occurs by replacing SSB with water and may facilitate weight loss (4,5). A valid, reliable and sensitive assessment tool for quantifying beverage consumption and determining its influence on weight status could help advance research on this topic. Three studies were conducted to develop the BEVQ, a self-administered quantitative beverage intake questionnaire. First study (n=105): the 19-item BEVQ's validity was examined by comparing participant's beverage intake to the "gold standard" of dietary intake assessment, food intake records; reliability was assessed by comparing two BEVQ's, administered two weeks apart. The BEVQ demonstrated acceptable validity (R2=0.53, water g; 0.46, 0.61 total beverage g, kcal; 0.49, 0.59 SSB g, kcal) as well as reliability (all correlations P<0.001) (6). Second study (n=1,596): the BEVQ underwent exploratory factor analyses (EFA) to identify the potential to reduce items. Three beverage items, which contributed <10% to total beverage intake g, kcal, were eliminated; EFA identified beer and light beer as a combined category. The refinement led to the 15-item BEVQ, which produced a lower readability score of 4.8 and shorter administration time (~2 min) (7). Third study (n=70): the ability of the BEVQ-15 to detect changes in beverage intake was evaluated by increasing participant water and fruit juice consumption and evaluating BEVQ-15 outcomes before and after the feeding period. Increases in water, juice and total beverage (g) were detected during the intervention period (P<0.001) (8). This rapid, valid, reliable and sensitive beverage intake assessment tool may determine the habitual intake of SSB and other beverages, and evaluate the effectiveness of clinical and public health interventions which aim to address national SSB recommendations. Future work is needed to evaluate the validity and reliability of the BEVQ-15 in children, as well as develop cost-effective noninvasive biomarkers that can objectively estimate intake of specific foods/dietary components (9). / Ph. D.

Children and adolescents consume sugar-sweetened beverages (SSBs) excessively, which is associated with childhood obesity, dental caries, and increased risk for cardiovascular disease and type 2 diabetes. Interventions spanning the socio-ecological model (i.e., intrapersonal, interpersonal, environmental, policy) have been shown to reduce SSB consumption under controlled conditions. However, not much is known about their potential to work under "real-world" conditions. This information can ensure that effective programs reach populations that could most benefit, such as children and adolescents in Central Appalachia, who consume three to four times more SSBs than their American peers. Central Appalachia is a rural, geographically isolated region where attempts to reduce SSBs are challenged by limited resources, skepticism toward health programs/providers, and pervasive cultural norms around SSBs. This dissertation describes three studies (2014-2016) that address these challenges by testing multi-level interventions that prioritize cultural acceptability and feasibility. The first study was a systematic review of child and adolescent SSB studies using the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, maintenance) framework to evaluate whether studies reported elements necessary for replicability, such as resources needed for delivery or factors that might prevent participation. The review revealed that available evidence does not provide this information, and recommended that future studies prioritize evaluating and reporting these elements. The second and third studies describe methods to test implementation of Kids SIPsmartER, a theory-based program targeting various socio-ecological levels, in an Appalachian Virginia county. The second study engaged a group on local middle school youth (n=9) in adapting the program, which targeted universal theoretical constructs, to ensure that it was culturally acceptable and demonstrated potential to generate community-wide changes. The third study used a randomized controlled design to determine whether Kids SIPsmartER was feasible as a school-based program. This study tested the program's potential reduce SSBs, as well as whether it was accepted, in demand, and able to be practically implemented within schools, the most common gathering place for rural adolescents. Taken together, these studies provide the foundation for larger, more controlled studies that prioritize both efficacy and replicability, in order to reduce the disproportionate burden of SSBs and associated diseases across Central Appalachia. / Ph. D.

Currently, 17.1% of 2-19 year olds are obese. While obesity is a multifactorial disease, energy imbalance is commonly cited as a primary etiology. Excess consumption of added sugar (AS) from corn and cane sweeteners has been implicated as a leading contributor to weight gain in youth and adults. Children and adolescents are among the highest consumers of AS, which account for 16% of their total daily calories (~318 calories/d), which is above American Heart Association, World Health Organization, and Dietary Guidelines for Americans recommendations. Although a strong temporal relationship has been established between weight gain and increased consumption of corn and cane sweeteners, a causal relationship is difficult to determine due to the inherent limitations of self-report dietary assessments (i.e., measurement errors such as underreporting). Further, obtaining accurate dietary intake data from children and adolescents is challenging due to the high dietary variability observed in this population. To overcome the limitations of self-report dietary assessments, the Institute of Medicine has recognized the need to develop and validate objective biomarkers of dietary intake.One such biomarker is the delta (δ) 13C biomarker; preliminary studies suggest that the δ13C biomarker is a valid, objective indicator of AS intake in adults and holds promise for children and adolescents. Establishing δ13C as a valid, reliable and sensitive means for assessing habitual AS intake in children and adolescents provides valuable objective dietary information with the potential to address a pressing public health concern, which is the relationship between AS intake and health. / Master of Science

The objective of this thesis was to examine the demographic characteristics and the drink-related determinants of alcohol use among U.S. military personnel. The data were obtained from The 1985 Worldwide Survey of Alcohol and Nonmedical Drug Use among Military Personnel which included 17,328 active duty military personnel. Analysis of Variance and Pearson r were used to examine the zero-order relationships among all independent and dependent variables in the study. Multiple Regression and Path Analysis were used to reveal the relationships between demographic and drink-related variables in predicting alcohol use. Findings from bivariate analyses explored the zero-order relationships between alcohol use and demographic attributes as well as drink-related determinants. It was found that the following characteristics were more frequently associated with military personnel who used alcohol: male, black, younger, not living with a spouse, in lower military ranks and with lower educational attainment. Furthermore, personnel who were strongly influenced by their drinking peers, considered the positive personal benefits of alcohol use, had favorable attitudes toward alcohol use, and encountered more serious problem situations were found to exhibit higher levels of alcohol use. Findings from multiple regressions and path analyses indicated that personal benefit was the most important determinant in predicting alcohol use. lt was found that the effects of problem situations on alcohol use were largely mediated by personal benefit. Moreover, peer influence not only directly affected alcohol use, but also mediated the effect of age on alcohol use. Surprisingly, it was found that normative definition toward alcohol use was not a good predictor of alcohol use. Both direct and mediating effects of normative definition on alcohol use were weak and negligible. Based on the findings of the study, implications for academic research on alcohol use were also discussed in the thesis. / Master of Science

BACKGROUND: Understanding the reach and representativeness of participants enrolled in behavioral trials, including nutrition and physical activity trials, helps inform the generalizability of study findings and potential public health impacts. Exploring the reach and representativeness of trials that target low socioeconomic and low health literate participants in rural and medically underserved areas, such as southwest Virginia (SWVA), is especially important. The proposed research is part of Talking Health, a six-month, pragmatic randomized-control trial aimed at decreasing sugar-sweetened beverage (SSB) consumption (SIPsmartER) as compared to matched contact control targeting improving physical activity (MoveMore). This community-based trial targets an 8-county region in SWVA. OBJECTIVES: Guided by the reach dimension of the RE-AIM framework, the primary objectives of this study were to determine if eligible and enrolled participants in the Talking Health trial were representative of: 1) eligible, but declined participants, and 2) the broader targeted 8-county region based on 2010 US county level census data. We hypothesized that eligible and enrolled participants would be represented in terms of age, race, ethnicity, educational attainment, income, and health literacy when compared to eligible and declined participants, as well as to the broader US census data. We also hypothesized that males would be underrepresented. METHODS: Eligibility requirements for the study included being 18 years of age or older, having reliable access to a telephone, drinking 200 kilocalories of SSB per day, and being a resident of SWVA. A variety of recruitment strategies were used such as active recruitment at health departments, free clinics, and local businesses with help from Virginia Cooperative Extension agents along with passive methods such as flyers, newspaper ads, and word of mouth. The eligibility screener included basic demographic information such as gender, age, race, marital status, occupation, income, educational attainment, number of children in household, and insurance provider. The screener also had three validated subjective health literacy questions. Statistical analysis included descriptive statistics, independent sample t-tests, Chi-square tests, and One Way ANOVA tests to examine the representativeness of enrolled participants. RESULTS: In total, 1,056 participants were screened, 620 were eligible (58.7%), and 301 (48.5%) enrolled. On average, demographic data for enrolled participants included: 93% Caucasian; 81.4% female; income of $23,173±$17,144; 32% high school (HS) education; and health literacy score 4.5±2.2(3=High, 15=Low). Among eligible participants, when comparing enrolled vs. declined participants there were significant differences (p<0.05) in educational attainment [enrolled=32% HS, declined=48% HS], health literacy scores [enrolled=4.5(2.2), declined=5.0(3.1)], gender [enrolled=81% female, declined=73% female], age [enrolled=41.8(13.4) years, declined=38.3(13.6) years], and race [enrolled=93% white, declined=88% white]. However there were no significant differences in ethnicity and income. When compared to average US Census data across the eight counties, enrolled participants had a higher educational attainment [enrolled sample=68%HS, Census=58%HS], higher proportion of females [enrolled sample=81%, Census=48%], and lower mean income [enrolled sample= $23,173, Census=$36,675]. There were no meaningful differences in terms of race and ethnicity between the enrolled sample and Census data. DISCUSSION: Contrary to our hypothesis, eligible and enrolled participants differed from non-enrolled participants in terms of age, race, education, and health literacy. Our enrolled sample was slightly older, predominately Caucasian, with higher educational attainment and higher health literacy. However, as hypothesized, there were no significant differences for ethnicity and income status, and men were underrepresented. When the study sample was compared to US Census data, the sample was well represented in terms of age, race, and ethnicity; however, enrolled participants had a much lower average annual income and a higher educational attainment. Men were also underrepresented when compared to the census data. There was no census data to compare health literacy status, which limits information regarding the representativeness of the enrolled sample. Importantly, this study has revealed the representativeness of individuals enrolled in this behavioral trial, helps inform the generalizability of study findings, and identifies future research for community-based studies targeting rural and medically underserved areas in SWVA. For example, future behavioral interventions need concerted recruitment strategies to target males, individuals with lower health literacy status, and individuals with less than a high school degree. Exploring and addressing barriers for study enrollment among these sub-groups is also important. / Master of Science

Around 46.2 million Americans living in rural areas are disproportionately burdened by health disparities. Likewise, obesity and obesity-associated diseases (e.g., diabetes, cardiovascular disease) are much higher for rural residents when compared to their urban counterparts. There is a high need to understand and address the nutritional determinants of these health inequities among adults and adolescents. One area of concern in rural dietary habits pertains to added sugars and more specifically, sugar-sweetened beverages (SSB). Excessive added sugars and SSB intake have been strongly linked to many of the nutrition and chronic disease disparities impacting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these in both adults and adolescents. There is an opportunity to better understand added sugars and SSB patterns in rural populations to inform the development of culturally relevant, multi-level interventions that address high consumption. Study #1 is a cross-sectional study that explores top food and beverage sources of added sugars in the diet of adults (n = 301) living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of adolescents (n = 1,560) from the Family Life, Activity, Sun, Health and Eating (FLASHE) study sponsored by the National Cancer Institute, to explore factors across the levels of the socioecological model associated with adolescent SSB intake. Study #3 utilizes focus groups and a pilot trial to understand language preferences, acceptability and use of SMS aimed at caregivers to reduce SSB intake in both caregivers and adolescents living in rural areas of Southwest Virginia (n = 33). Collectively, these three studies offer recommendations and culturally relevant strategies for future large-scale trials aimed at reducing SSB intake among adolescents and caregivers in rural communities and ultimately reducing rural health disparities. / Doctor of Philosophy / Rural populations in the United States are at higher risk for being diagnosed with and dying from preventable and obesity-associated diseases like heart disease and cancer. Excessive added sugars and sugary drink (i.e. sodas, sweet tea/coffee, energy drinks, sweetened fruit drinks, sports drinks) intake have been strongly linked to many of the chronic diseases afflicting rural residents. Moreover, studies conducted in rural populations have found high consumptions of these, in both adults and adolescents. There is a great need to better understand added sugars and sugary drink patterns in rural populations so that we can develop programs to reduce consumption that are also culturally well received. Study #1 in this dissertation explores top food and beverage sources of added sugars in the diet of 301 adults living in rural areas of Southwest Virginia. Study #2 uses a nationally representative sample of 1,560 adolescents to explain why adolescent SSB intake might be higher. Study #3 aims to understand language preferences, acceptability and use of a text message program to reduce sugary drink intake in both caregivers and adolescents living in rural areas of Southwest Virginia. Collectively, these three studies offer recommendations and culturally relevant strategies for future large scale trials aimed at reducing sugary drink intake among adolescents and caregivers in rural communities and ultimately improving rural health.

Background: Low health literacy and increased sugar-sweetened beverage (SSB) consumption are two broad public health concerns facing the United States. For example, it is estimated that 90 million Americans have insufficient literacy skills (IOMC, 2004) and low health literacy is associated with poorer health outcomes (Berkman et. al., 2011). Furthermore, SSBs contribute about 80% of added sugars in the diet (Nielsen & Popkin, 2004) and have been associated with poor health outcomes, including obesity, type II diabetes, bone fractures, dental caries, and coronary heart disease. Despite these findings, there is limited research related to how to effectively decrease SSB intake among adults. Additionally, there have been few studies investigating health literacy interventions that target health behaviors in community settings (Allen et.al, 2011). Objective: As guided by the Theory of Planned Behavior (TPB) and constructs of health literacy, this 5-week, 2-arm randomized controlled pilot trial, used mixed methods to examine the effects of an intervention to decrease SSB (SipSmartER), as compared to a matched-contact control condition targeting physical activity (Move More). The primary aims of this pilot project were to evaluate participant's feedback through process and summative evaluation as well as evaulate intervention content and/or delivery through process evaluation by staff tracking for quality improvements. Secondary aims included the assessment of changes in theorized mediating variables and health behaviors among participants. Methods: Twenty-five participants (mean age = 42±14 years, mean BMI = 34.3±7.5 kg/m₂, 19 females, 12 African Americans, 9 (high school education) residing in Roanoke, VA were randomized to either SipSmartER (n=14) or Move More (n=11) to begin the 5-week intervention. Inclusion criteria consisted of participants being 18 years of age or older, English speaking, consuming greater than 200 kcal/day of SSB, and being without medical conditions in which physical activity would be contraindicated. Both 5-week interventions included two interactive small group sessions (Weeks 1 & 5) and three support telephone calls (Weeks 2, 3 & 4). Pre-post data was obtained using previously validated instruments including Beverage Intake Questionnaire (Bev-Q), Theory of Planned Behavior constructs addressing SSB and physical activity, media literacy, subjective numeracy, Stanford Leisure-Time Activity Categorical Item (L-CAT), and quality of life. Descriptive statistics, ANOVA, and regression models were used in data analysis. Results: Although SSB consumption decreased more among the SipSmartER participants (-257±622.6 kcal/day) than Move More (-200±404.6 kcal/day) there were no significant group by time differences. However, among all participants, changes in TPB constructs significantly predicted changes in SSB (R²=0.592; F=2.485; p=0.080) and physical activity behaviors (R2=0.621; F=2.813; p=0.056). Participant and staff feedback were very positive, ranging from 4.2-5.0 on a 5-point likert scale that included questions about intervention organization, flow, effectiveness, engagement, and enjoyment. Favorite themes that emerged with SipSmartER participants when asking about small group sessions included, realizing how much sugar is found in SSBs, understanding the health risks associated with drinking too much sugar, realizing how much sugar was being consumed during the day, and learning about better alternatives. Conclusion: Findings suggest promise for the piloted intervention to reduce SSB consumption through targeted TPB and health literacy strategies. This pilot study has allowed further refinement and execution of a larger trial that includes a larger sample and longer study duration (i.e. 6-months) and follow-up period (i.e. 18-months). / Master of Science

BACKGROUND: Turmeric is a root with curcumin and non-curcumin derivatives that serve as antioxidants, which reduce the risk of oxidative stress-induced chronic disease. The provision of health information has shown to increase the acceptability of functional foods that impart unfamiliar flavors. PURPOSE: The purpose of this study was to evaluate the acceptability and sensory qualities of a functional beverage with fresh turmeric, and the impact of information related to the beverage's health benefits on acceptability. This study also investigated personal and psychological factors associated with food acceptance. METHODS: Antioxidant capacity (ferrous equivalents) and polyphenolic content were evaluated in a fruit-based beverage containing 0g, 7g, 14g, and 22g of fresh turmeric. Sixty-one individuals were recruited to participate in a sensory evaluation of two fruit-based beverages with and without fresh turmeric. Thirty-one participants were given health information related to the beverage and 30 participants received no health information. The degree of liking was measured on a hedonic scale and sensory attributes were measured using a Just About Right (JAR) scale. Food choice motives and demographic characteristics were measured using a Food Choice Questionnaire and demographics questionnaire. RESULTS: The development of a functional beverage with 14 grams of turmeric was considered significantly more acceptable with the provision of health information and resulted in a significant increase in antioxidant capacity and polyphenolic content. There was a significant difference in acceptability scores of the functional beverage across antioxidant interest groups and health motivation groups. / Master of Science / Turmeric is a root composed of antioxidants, which reduce the risk of certain diseases. The provision of health information has shown to positively impact the overall liking of functional foods containing unfamiliar flavors. The purpose of this study was to evaluate the overall liking and sensory qualities of a functional beverage with fresh turmeric, and the impact of information related to the beverage’s health benefits on acceptability. This study also investigated personal and psychological factors associated with food acceptance. Antioxidant capacity and polyphenolic content were evaluated in a fruit-based beverage containing 0g, 7g, 14g, and 22g of fresh turmeric. Sixty-one individuals were recruited to participate in a sensory evaluation of two fruit-based beverages with and without fresh turmeric. Thirty-one participants were given health information related to the beverage and 30 participants received no health information. The degree of liking was measured on hedonic scale and sensory attributes were measured using a Just About Right (JAR) scale. Food choice motives and demographic characteristics were measured using a Food Choice Questionnaire and demographics questionnaire. The functional beverage with 14 grams of turmeric was considered significantly more acceptable with the provision of health information and resulted in a significant increase in antioxidant capacity and polyphenolic content. There was a significant difference in acceptability scores of the functional beverage across antioxidant interest groups and health motivation groups.