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

INTRODUCTION: Dental caries erosion are both multifactorial diseases. One common factor for both diseases is acid attack on dental enamel. Some beverages contain both erosive acids and cariogenic carbohydrates, thus, promoting both types of disease. Previous literature has examined beverages as single source exposures, despite the fact that beverage consumption is a complex process that contains several beverage. A few studies have examined the patterns of beverage consumption and dental caries in both children and adults. These studies found a significant positive relationship between sugar sweetened beverages consumption and caries. These studies did not differentiate between regular and diet soda, so the relationship between diet/low calorie sweetener drinks and dental caries is not established. In contrast with caries, the association between beverage consumption patterns and erosion has not been studied before. OBJECTIVES: Examine the effect of diet drinks on dental caries and erosion among a representative sample of US children and adults. METHODS: All analyses conducted using cluster analysis to account for the complexity of beverage consumption and to better understand the effect of different consumption patterns on the dentition. NHANES data was used to be able to generalize the results to the US population. RESULTS: In children, we managed to define 6 different clusters including: water, milk, juice drinks, 100% juice, soda, and diet drinks. None of the clusters demonstrated statistically significant associations with dental caries. While individuals with high soda consumption had the highest caries risk, diet drinks had no effect on dental caries. On the other hand, adults were grouped into 4 distinct clusters: water, soda, diet drinks, and coffee/tea. The diet drinks cluster was not associated with higher DMFT score, while high soda consumption demonstrated increased DMFT. In contrast, high diet drinks consumption increased the risk for erosion, although this relationship was not statistically significant. CONCLUSION: This dissertation showed that diet drinks are not associated with dental disease. While we can not recommend consuming these drinks based on this one cross sectional study, we believe that more studies should be conducted so that we can draw a final conclusion regarding oral disease and diet drinks. / 2022-10-24T00:00:00Z

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Poor diet, sedentary behaviors, sugar‐sweetened beverages (SSB) and alcohol intake seem to co‐exist in complex ways that are not well understood. The aim of this study was to provide an understanding of the extent to which unhealthy behaviors cluster in eight Latin America countries. A secondary aim was to identify socio‐demographic characteristics associated with these behaviors by country. Data from adolescents and adults from the “Latin American Health and Nutrition Study” was used and the prevalence of screen‐time, occupational and transportation–sedentary time, socializing with friends, poor diet, SSB and alcohol intake, alone and in combination, were identified. The eight Latin America (LA) countries added to analyses were: Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela. Logistic regression was used to estimate associations between ≥2 behaviors clustering, socio‐demographics and weight status. Among 9218 individuals, the most prevalent behaviors were transportation and occupation–sedentary time, SSB and alcohol intake. Younger, female, married/living with a partner, low and middle‐income and obese individuals had higher chances for these clustering behaviors. These results provide a multi-country level of understanding of the extent to which behaviors co‐occur in the LA population. / University of San Francisco / Revisión por pares

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High sugar-sweetened beverage (SSB) intake and poor vitamin D status have both been associated with increased risk of elevated systolic blood pressure (SBP) in previous research. However, these associations have never been investigated in the same study population, leaving the question of a possible interaction uninvestigated. One potential mechanism for an interaction is that SSB intake may increase serum uric acid (UA) and UA may interfere with utilization of vitamin D. This study examined these relationships in a sample of men and women (n=2,875) aged 20-74 using data collected in the 2003-2006 NHANES survey. No statistically significant association was found between SSB intake and risk of elevated SBP (defined as SBP>120mmHg) in whole group analysis. In subgroup analysis by gender, women (n=1,550) showed a 68% (OR: 1.68, 95% CI: 1.12-2.50, p-value 0.011) increased risk of elevated SBP in the highest SSB intake quartile (mean intake of 3.27 servings/day) compared to the lowest (mean intake of 0.03 servings/day) after adjustment for age, race, BMI, alcohol use, physical activity, and smoking, but no association was found in men (n=1,325). A statistically significant association was found between 25(OH)D and SBP, with a 30% decrease in risk of elevated SBP (OR: 0.70, 95% CI: 0.55-0.90, p-value 0.005) for those in the highest serum 25(OH)D group (>75nmol/L) compared to the lowest (<50nmol/L) in the fully adjusted model. However, no association was found between SSB intake and serum UA. Assessing potential effect modification between SSB and vitamin D in their impact on blood pressure using a multiplicative term and stratified analysis did not provided evidence of an interaction effect.

Over the past several decades, the prevalence of overweight and obesity has increased to 68% of American adults1. During this same time period, there has been an increase in sugar-sweetened beverage consumption. This increase in added sugar consumption, particularly from sugar-sweetened beverages, has been theorized as a possible contributor to the obesity epidemic2,3,4. Sugar-sweetened beverages are the number one source of added sugars in the American diet and organizations such as the American Heart Association have addressed this issue of added sugar consumption due to its association with negative health outcomes5. A variety of demographic factors have been linked to increased added sugar consumption6. Health literacy is another variable which may influence beverage consumption patterns, specifically sugar-sweetened beverage consumption. To date only one study has investigated this association, and the authors reported an inverse relationship between health literacy scores and sugar-sweetened beverage consumption7. Therefore, the purpose of this investigation was to determine what demographic variables serve as predictors of consumption of sugar-sweetened beverages, water, milk, and total beverage calories. This could allow for appropriate interventions to be developed targeting healthier beverage consumption patterns in specific sub-populations. / Master of Science

In the United States, low-income, ethnic/racial minorities and rural populations are at increased risk for poorer health outcomes compared to higher income, non-minorities, and urban populations. Two key determinants that influence rural health disparities are health literacy and social capital. Health literacy can be described as an individual-level factor and defined as, "the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions." Social capital is a concept that accounts for the role of collective social functioning and has been defined as, "the features of social structures, such as levels of interpersonal trust and norms of reciprocity and mutual aid" which act as resources for individuals to facilitate collective action." The overarching goal of this research is to explore factors influencing health disparities, including health literacy, social capital in two rural regions of Virginia. The first study is embedded in Talking Health, a larger 2-arm RCT targeting adults in rural Southwest Virginia and examined participants' perceptions of and satisfaction with components of a behavioral intervention designed using health literacy concepts to decrease sugary beverage intake in rural, low-health literacy participants. The second study is also embedded in the Talking Health trial, yet focused on the maintenance of behavior 12-months after the intervention concluded. Guided by RE-AIM, this study examined the reach, effectiveness and implementation of a 12-month randomized extended care intervention aimed at enhancing long-term maintenance of behavior change and study retention when compared to a control condition. The last study is part of a larger telephone surveillance survey conducted in the Dan River Region located in south central Virginia. This study described current levels of social capital in the Dan River Region and examined the influence of social capital on FV consumption, physical activity, sugary beverage intake and BMI on a sample of rural and urban adults. / Ph. D.

The prevalence of children and adolescents who are considered overweight or obese has grown drastically in the United States. Childhood overweight and obesity is associated with serious long-term health consequences, including an increased risk for cardiovascular disease, type 2 diabetes, strokes, and different types of cancers. Added sugar intake (AS), in the form of sugar-sweetened beverages (SSB), may contribute to weight gain and obesity development in children and adolescents. Due to the negative health implications of SSB consumption, a valid and reliable brief beverage intake assessment tool is needed for children and adolescents to advance research in this area. The BEVQ-15 food frequency questionnaire has been validated as a tool to assess habitual beverage intake in adults. By validating this tool in youth, there will be a rapid, feasibly administered method to assess beverage intake in children and adolescents. The purpose of this investigation was to determine the comparative validity and test-retest reliability of the BEVQ-15 for assessing usual beverage intake in children and adolescents. Participants (n=326) completed four laboratory sessions, which included providing demographic information, assessment of height/weight, and four record-assisted 24 hour dietary recalls (24HR) from January 2014-September 2015. The BEVQ was completed at 2 sessions (BEVQ1, BEVQ2). Validity was assessed by comparing beverage intake from dietary recalls (24HR) to the BEVQ1; reliability was assessed by comparing BEVQ responses at two sessions (BEVQ1, BEVQ2). Data analysis included descriptive statistics, paired sample t-tests, independent sample t-tests, and chi-squared test, and one-way ANOVA tests. Comparisons of validity and reliability were also made within two subsets; children (aged 6-11) and adolescents (aged 12-18). In the full sample, self-reported water and total sugar-sweetened beverage intake (in fl oz and kcal) were not different between BEVQ1 and 24HR. Responses between BEVQ1 and BEVQ2 were not different in intake (fl oz) or energy (kcal) for water, milk, and total sugar-sweetened beverages. In children, milk and energy (kcal) for total beverages were not different between BEVQ1 and 24HR. No differences were reported between BEVQ1 and BEVQ2 across beverage categories. In adolescents, water and energy (kcal) for total-sugar sweetened beverages were not different between BEVQ1 and 24HR. No differences were reported between BEVQ1 and BEVQ2 with the exception of sweetened juice drinks and total beverages. Overall, these results demonstrate that the BEVQ-15 appears to be a valid and reliable tool to assess habitual water and total SSB intake in children and adolescents. This tool could further epidemiological and clinical research examining the impact of SSB intake, as well as intake of other beverages, on health. / Master of Science