BACKGROUND: Current efforts to control the obesity epidemic has focused on sugar sweetened beverages (SSB), particularly soda, and less on alcohol intake even though alcohol is also a source of “empty calories”. Few data are available about the association between soda and excessive alcohol consumption and whether people may substitute one form of beverage for the other, essentially “choosing their poison”. METHODS: We used the Behavioral Risk Factor Surveillance System (BRFSS) data from 2017 to examine the relationship between alcohol and soda consumption in adults 18 and older. We first compared the rates of different types of sweetened beverage consumption soda in our population. We then examined the association between the sugar-sweetened beverage and alcohol drinking status using regression models adjusted for potential confounders. Analyses were weighted and adjusted using SAS 9.4 to account for the complex sampling methods. RESULTS: Based on 2017 BRFSS data, we found an inverse relationship between heavy drinking and soda consumption after adjusting for age, sex, race, income, education, marital and insurance status, smoking, diabetes, and hypertension. Compared to those who don’t drink soda, the odds ratio of heavy drinking was 0.75 (95% CI 0.63, 0.90) for those who drink up to one soda/week; 0.66 (0.53, 0.81) for those drinking >1 to <7 sodas/week; 0.73 (0.65, 0.97) for ≥7 to <14 sodas/week; and 0.70 (0.49, 1.02) for ≥14 sodas/week. CONCLUSION: There seems to be an inverse association between soda and alcohol consumption. Public health efforts may want to consider targeting both behaviors concurrently to avoid beverage substitution.

No description available.

The overconsumption of added sugars leads to negative effects on health such as an increased risk for obesity, cardiovascular disease, and diabetes. With approximately 50% of added sugars in the American diet being attributed to sugar-sweetened beverage (SSB) intake, non-nutritive sweeteners (NNS) are recommended as potential replacements. The purpose of this secondary analysis of Talking Health, a 6-month SSB reduction intervention, was to explore 1) changes in NNS consumption patterns between SIPsmartER (n=101) and MoveMore (n=97) interventions, and 2) differences in demographics between three groups of various SSB-NNS consumption change patterns (Group 1: decreased SSB, increased NNS; Group 2: decreased SSB, no change in NNS; Group 3: increased SSB, regardless of NNS). Results showed that the SIPsmartER intervention significantly created more new NNS users than MoveMore after the 6 month intervention. There were significant between group over time differences for intake of aspartame, sucralose, and total NNS, with intake increasing for SIPsmartER participants as compared to MoveMore. However, when exploring demographics between the three SSB-NNS consumption change groups, no differences were found between those who successfully decreased SSB while increasing NNS and the other groups. While diet beverages were the most commonly consumed dietary source of NNS across groups over time, other sources such as tabletop sweeteners, yogurt, and meal replacement products contributed to total NNS intake. Future research is needed to identify those who would benefit most from using NNS as a tool to decrease SSB intake. This will help inform future interventions and provide appropriate strategies to decrease added sugars intake. / Master of Science / The overconsumption of added sugars leads to negative effects on health such as an increased risk for obesity, cardiovascular disease, and diabetes. With approximately 50% of added sugars in the American diet being attributed to sugar-sweetened beverage (SSB) intake, non-nutritive sweeteners (NNS) are recommended as potential replacements. The purpose of this secondary analysis of Talking Health, a 6-month SSB reduction intervention, was to explore 1) changes in NNS consumption patterns between SIPsmartER (n=101) and MoveMore (n=97) interventions, and 2) differences in demographics between three groups of various SSB-NNS consumption change patterns (Group 1: decreased SSB, increased NNS; Group 2: decreased SSB, no change in NNS; Group 3: increased SSB, regardless of NNS). Results showed that the SIPsmartER intervention significantly created more new NNS users than MoveMore after the 6 month intervention. There were significant between group over time differences for intake of aspartame, sucralose, and total NNS, with intake increasing for SIPsmartER participants as compared to MoveMore. However, when exploring demographics between the three SSB-NNS consumption change groups, no differences were found between those who successfully decreased SSB while increasing NNS and the other groups. While diet beverages were the most commonly consumed dietary source of NNS across groups over time, other sources such as tabletop sweeteners, yogurt, and meal replacement products contributed to total NNS intake. Future research is needed to identify those who would benefit most from using NNS as a tool to decrease SSB intake. This will help inform future interventions and provide appropriate strategies to decrease added sugars intake.

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.

Introduction: Weight problems not only affect adults, but youth as well. Excessive sugar-sweetened beverage (SSB) consumption is suggested to be a contributor to youth overweight and obesity and other cardiometabolic risk factors. Parents, although probably not readily admitted by adolescents, are known to influence youth's dietary beliefs and practices. Using theoretical models, like the Theory of Planned Behavior (TPB) that accounts for intention, attitudes, norms, and perceptions of control, to develop interventions can be more effective in changing health-risk behaviors versus those not grounded in theory. Methods: A systematic literature review and meta-analysis on how the TPB has been applied to youth's diet-related behaviors was conducted. Subsequently, a mixed methods investigation of adolescents' (n=100) and parents' (n=66) SSB consumption and exploratory analysis of parents' responses to adolescents' beverage choices was carried out. Results: From 34 articles, attitude was identified as having the strongest relationship with behavioral intention (mean r=0.52), and intention as the most common predictor of youth's diet-related behavior (mean r=0.38, both p<0.001). However, in the mixed methods analysis adolescents' subjective norm was the strongest predictor of intention to limit sugary beverage consumption to less than one cup per day (b=0.57, p=0.001). Intention was the strongest predictor of SSB intake in parents and adolescents (b=-47, p=0.01; b=-37, p≤0.05). The TPB explained more variance in parents' SSB consumption than adolescents' (R²=0.22 versus R²=0.38, both p≤0.001, respectively). At lower levels of intention to limit SSB consumption and higher levels of parental encouragement to consume SSBs, adolescents' predicted SSB intake was highest (p=0.059) suggesting that some adolescents may be influenced by their parent's reactions to their sugary beverage choices while others may not. Conclusions: Intention appears to be a strong construct influencing adolescents' diet-related behaviors, specifically SSB consumption, and this intention may be influenced by parents and other social factors. Future work can tap into adolescents' peer network and role models or authority figures to identify how these groups and individuals influence and moderate the intention to limit sugary beverage consumption. / 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

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.

The number of overweight adults has risen to two-thirds of the population, thus increases in energy intake, particularly from beverages are of great concern. Sugar-sweetened beverage (SSB) intake has increased by 222 calories in recent decades, which contributes a significant source of added sugars to the American diet. It has been reported that water consumers have a lower overall energy intake (~194 kcals) as compared to non-consumers of water therefore substituting water for SSBs may facilitate weight loss and weight management. Evidence also indicates that diet quality follows a socioeconomic gradient, and that the environment has a powerful influence on beverage consumption. Thus, modifying the food environment could be a promising strategy for promoting healthier beverage consumption behavior. A large portion of the US population spends their day at a worksite making the worksite a viable setting for implementing environmental approaches to promote effective behavior change. At this time, it is unclear if a reduction of SSB intake would be a viable dietary weight management intervention strategy. Therefore, our purpose was to determine if water, SSB intake, SSB energy, total beverage intake, and total beverage energy varies with individual and environmental factors among overweight and obese employees from 28 worksites involved in a randomized controlled weight management trial. These findings may contribute to the development of tailored weight management programs aimed to improve beverage consumption patterns. / Master of Science