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Several school-based interventions aimed at increasing fruit and vegetables (FV) intake among children have demonstrated success in short-term interventions. The Fit Game is a school-based intervention aimed at encouraging children to consume increasing amounts of FV during a game, which is a narrative. Just as children are being encouraged to eat FV at school, so is it equally important for them to eat FV at home. Parents strongly influence the amount of FV children consume at home. The aim of this thesis is to examine associations between factors that influence consumption of fruits and vegetables at and away from school among children who are participating in a schoolbased intervention, which has been shown to increase fruit and vegetable consumption at school. Associations between factors of the home environment and FV intake of children at and away from school are also explored. The study population was 37 parent-child pairs who participated in the Fit Game intervention conducted at one elementary school in 2013 (n = 252). This study showed that there was an increase in FV intake of children at school during the period they played the Fit Game; however there was no change in fruit and vegetable intake away from school during that same period of time. In addition, though parents and children’s intake of FV were correlated, parents did not change their FV intake during the period of time their child participated in the Fit Game at school. There was no significance between children’s intake and the factors in the home environment including family meals, FV accessibility and availability as well as parental knowledge. This study used rigorous methods to assess dietary intake. It is, however, important that this study is replicated with a larger sample that is more diverse.

The current study evaluated the development and acceptability of a social marketing campaign to improve emerging adults’ fruit and vegetable (FV) intake. A social marketing campaign was developed through focus groups with 24 college students. Materials were implemented in two dining locations at Virginia Commonwealth University. Sales of carrots, apples, and chips were collected in three phases: baseline, implementation of the campaign, and washout. In addition, surveys were collected from 303 diners across all phases and locations. Results indicated an increase in carrot sales, decrease in sales of chips sold with a meal, and mixed findings regarding sales of apples and chips sold alone. Intercept surveys indicated the marketing materials were perceived positively, and clearly understood. Statistical analysis of self-report measures revealed that perceptions of one’s health status and autonomy were associated with fruit and vegetable (FV) intake and overall nutrition knowledge. The implementation of a social marketing campaign to encourage FV intake appeared to influence sales of both healthy and non-healthy food items. It is vital for future campaigns and policies to highlight autonomy for health behavior decision-making.

Doctor of Philosophy / Department of Food, Nutrition, Dietetics and Health / Tandalayo Kidd / Objective: The purpose of this study is to promote healthy dietary and physical activity (PA) behaviors in adolescents using a six-module nutrition education resource—Wise Eating (WE)—which was designed specifically for the adolescent population based on the concept and principles of Intuitive Eating (IE).  Study Design: Repeated measures study with pre-assessment and post-assessment. Outcome Measures and Analysis: This study assessed participating adolescents’ breakfast intake, fruit and vegetable (FV) consumption, and PA behaviors; perceptions of IE factors; and perceptions of the Theory of Planned Behavior (TPB) variables. Independent samples t-tests and one-way ANOVAs were used to determine differences in demographic variables and differences between the control and the intervention group. Paired t-tests were performed to compare the behavioral and perception changes from the pre-assessment to the post-assessment. Multiple linear regressions were performed to examine the relationship between TPB variables and FV consumption and PA participation intent and behaviors. Results: The total number of participants at the pre- and the post-assessment was 154 and 148, respectively. Participant’s gender and grade level were evenly distributed. Hispanic was identified as the predominant ethnic population at both the pre- and the post-assessment. At post-assessment, participants in the intervention group significantly increased their breakfast intake frequency, FV consumption frequency, and PA participation frequency (P < .05). Sixth graders had significantly higher breakfast intake frequency, FV consumption frequency, and PA participation frequency when compared with 7th and 8th graders (P < .05). The TPB variables significantly predicted FV consumption and PA intent and behaviors at both the pre- and the post-assessment, and the perceived behavioral control served as the most consistent predictor. For the intervention group, the IE total and Factor 1—Unconditional Permission to Eat scores were significantly increased at the post-assessment when compared with the control group (P .001). Conclusions: These findings tested the effectiveness of WE education modules and further emphasized the need for more interventions on IE to improve dietary and PA behaviors change in the adolescent population.

Patterns of fruit and vegetable consumption begin in childhood and persist into adulthood. Educating parents regarding appropriate dietary requirements for preschoolers is critical to supporting their appropriate growth and development. The purpose of this study was to determine whether a parent health report (including information about the child's fruit and vegetable consumption and recommendations regarding how to increase fruit and vegetable consumption) resulted in a greater fruit and vegetable intake in preschoolers and kindergarteners. Results from both the open trial and the randomized-controlled trial suggest that the parent health report may be a beneficial tool to increase vegetable consumption in preschoolers and kindergarteners. Increases in vegetable consumption can lead to the establishment of lifelong habits of healthy vegetable intake and decrease risk for chronic diseases in the future.

At present, the process of parental modelling of eating behaviours and attitudes has received limited research interest. While often mentioned as a possible factor in relation to child feeding and the development of eating behaviours, only a few studies have explicitly researched parental modelling. The main aims of this thesis were to develop a new measure to assess modelling multidimensionally and to explore the relationships between parental modelling of eating behaviours with a variety of parent and child factors. Initially, a parental self-report measure (the Parental Modelling of Eating Behaviours Scale; PARM) was developed, validated and piloted as part of a series of studies exploring the associations between modelling and a range of self-reported parental and child factors. To provide further validation for the PARM, an observational coding scheme was developed, based on the newly developed modelling measure, and this was utilised in two further studies which looked at self-reported and observed parent and child factors. The key findings from this thesis suggest a number of beneficial relationships. For example, maternal modelling was positively correlated with healthy food intake in both mothers and their children. In addition, both maternal and paternal modelling were associated with children s increased enjoyment of food and lower levels of food fussiness. Observations of maternal modelling were also found to be positively related to other observed adaptive, non-directive feeding practices, such as encouragement to eat. However, less positive relationships were also identified, with modelling being related to parents mental health symptoms and to unhealthy food intake in both mothers and their children. In conclusion, this thesis has identified three distinct facets of modelling and highlighted factors which might be linked to parental role modelling around eating behaviours. While much of the research within this thesis is exploratory, and the findings require replication, they would suggest that parental modelling has the potential to positively influence children s eating behaviours. However, parents should also be made aware of the potential detrimental effect that modelling less adaptive eating behaviours may have on their children s food intake, particularly those eating behaviours that parents may be unaware of modelling.

Breast and prostate cancer incidence and mortality have been steadily decreasing. Reasons for these reductions may be related to increased rates of cancer screening and other factors such as improvements in diet, including consumption of fruits and vegetables. We wanted to determine if individuals who get screened for breast and prostate cancer are more or less likely to consume adequate servings of fruit and vegetables. A cross-sectional study using the BRFSS survey was conducted. Individuals included in this study (n=26,222), were asked about their breast or prostate cancer screening history. They were also asked about their servings per day of fruit and vegetables. Statistical analyses were conducted using the SAS 9.2 software program. Logistic regression analyses were conducted on the variables and potential confounders. Over 40% of individuals who did not screen for breast and prostate cancer were in the 50-59 years of age category. A trend was seen with younger age groups being less likely to consume 3 or more daily servings of fruit and vegetables than their older counterparts. Another trend was seen in education levels. Individuals with lower education were less likely to consume at least 3 daily servings of fruit and vegetables. There was a statistically significant association between cancer screening and servings of fruit and vegetables per day. Individuals who were screened for either breast or prostate cancer were 52% more likely to consume 3 or more servings of fruit and vegetables than those who did not screen for either breast or prostate cancer (OR=1.52, 95% CI: 1.29-1.79). Further research needs to be conducted related to how other health behaviors may be related to cancer screening adherence and fruit/vegetable intake.

Introdução: O consumo adequado de frutas, verduras e legumes (FVL) durante a gestação apresenta impacto positivo sobre a saúde da mulher e da criança. Os fatores ambientais associados ao comportamento alimentar vêm recebendo destaque no âmbito da saúde pública por afetar diretamente a saúde dos indivíduos. Entretanto, desconhecemos a existência de estudos que investigaram a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes. Objetivo: Verificar a reprodutibilidade de um questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes (manuscrito 1) e avaliar a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2). Metodologia: O estudo de reprodutibilidade (manuscrito 1) foi conduzido em 2010 entre 48 gestantes usuárias do serviço público de saúde de Ribeirão Preto, SP. O questionário é composto por 12 questões de múltipla escolha que incluem a percepção do ambiente alimentar e para o consumo de frutas e hortaliças. Para verificação da reprodutibilidade, o questionário foi aplicado em duplicata, com intervalo entre 15 e 45 dias. A concordância entre as respostas foi avaliada por meio do teste de Kappa ponderado ou Kappa. A relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2) foi avaliada empregando-se os dados de um estudo transversal, conduzido em 2012, entre 282 gestantes adultas. O consumo de FVL foi avaliado por meio de um questionário de freqüência alimentar (QFA) , e dois recordatórios de 24 horas. O Multiple Source Method foi utilizado para estimar o consumo usual de FVL. A percepção do ambiente alimentar foi avaliada mediante a aplicação de questionário estruturado. Para a investigação da relação entre a as variáveis da percepção do ambiente alimentar e consumo adequado de FVL (400g/dia), modelos de regressão logística [OR (95% IC)] foram empregados ajustados por escolaridade, idade e classe econômica das gestantes. Resultados: No manuscrito 1, verificou-se a reprodutibilidade do questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes. Concordância forte (Kappa entre 0,6 e 0,79) para: número de refeições ao dia, hábito de se alimentar no local de trabalho, distância entre a residência e local de aquisição de FVL e qualidade de FVL no local de aquisição. Concordância moderada (Kappa entre 0,4 e 0,59): hábito de se alimentar fora do domicílio, em restaurantes do tipo self-service ou por quilo, em lanchonetes, se adquire alimentos em mercearias, lojas de conveniência ou padaria, motivo da escolha do local para aquisição de FVL, variedade de FVL no local de aquisição e apoio familiar para ter uma alimentação saudável. Concordância fraca (Kappa entre 0,2-0,39): freqüência em que faz refeições na casa de amigos/ parentes, freqüência em que adquire alimentos em supermercados e varejão ou feira livre e percepção em relação ao preço de FVL. As questões que obtiveram concordância fraca foram reformuladas previamente a sua utilização. No manuscrito 2 observou-se que 35% das mulheres estudadas reportaram o Resumo consumo adequado de frutas e hortaliças durante a gestação, não encontrando uma associação direta entre a percepção do ambiente alimentar e o consumo adequado de frutas e hortaliças entre elas. Entretanto, as gestantes que relataram ter o hábito de fazer quatro ou mais refeições ao dia apresentaram maior chance de consumir a quantidade adequada de furtas e hortaliças quando comparadas àquelas que relataram menor número de refeições ao dia [OR 2.01 (95% IC 1.03, 3.91) p 0.04]. Da mesma forma, as mulheres que referiram o hábito de comprar FVL em varejão ou feira livre apresentaram maior chance de atingir a recomendação de frutas e hortaliças, independente de idade, escolaridade e classe socioeconômica [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusão: O questionário sobre a percepção do ambiente alimentar e para o consumo de FVL apresentou boa precisão entre gestantes. Não houve associação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças entre as gestantes estudadas. / Introduction: The adequate intake of fruits and vegetables (FV) during pregnancy has a positive impact on the health of women and children. Environmental factors associated with eating behavior have received attention in the context of public health by directly affecting individuals health. However, unaware of the existence of studies that investigated the relationship between self perceived food environment and fruit and vegetable intake in pregnant women. Objective: To evaluate the reliability of a self perceived questionnaerie about the food environment and for the consumption of fruit and vegetable in pregnant women (manuscript 1). To evaluate the relationship between self perceived food environment and the adequate consumption of fruits and vegetables in pregnant women (manuscript 2). Methods: The study was conducted in 2010 among 48 pregnant women attended by the public health service of Ribeirão Preto, SP. The questionnaire consists of 12 multiple choice questions which include the perception of the food environment and consumption of FV. To investigate the reproducibility of the questionnaire, it was administered twice, between 15 and 45 days apart. The agreement between the responses was assessed using the Kappa or Kappa weighted (manuscript 1). A cross-sectional study was conducted in 2012 among 282 adult pregnant women. Fruit and vegetable intake during pregnancy was assessed by a food frequency questionnaire, and 2 dietary recalls. The Multiple Source Method approach was applied to estimate usual FV intake. Self perceived food environment was assessed by a structured questionnaire. For the present analysis, we examined the association of self perceived food environment and the adequate intake of fruit and vegetable (400g/daily) in logistic regression models [OR (95% CI)], adjusted by maternal age, socioeconomic class, and educational level (manuscript 2). Results: Manuscript 1 describes the reliability of a self perceived questionnaire about the food environment and for the consumption of fruits and vegetables in pregnant women. There was strong agreement (Kappa: 0,6 to 0,79) for: meals per day, habit of eating at work, distance between the residence and places to purchase fruit and vegetable, quality of fruit and vegetable at the purchase place. Moderate agreement (Kappa 0,4 to 0,59): habit of eating out of home, habit of eating in self service restaurant, habit of eating in fast food restaurant, purchase food at grocery stores, convenience stores or bakery, variety of fruits and vegetables available and family support for healthy eating. Weak agreement (Kappa 0,2 to 0,39): habit of eating in friends or family house, purchase food at supermarket or FV specialized food market and perception of FV price. All the questions that had weak agreement were reformulated prior to use it. The manuscript 2 showed that 35% of the women intervied reported adequate intake of FV during pregnancy, with no association between self perceived food environment and adequate FV intake. However, a higher meal frequency was associated with a better chance of daily adequate intake of fruit and vegetable [OR 2.01 (95% CI 1.03, 3.91) p 0.04]. Moreover, the habit of buying fruit and vegetable in Abstract specialized food market was associated with the daily intake of 400g of fruit and vegetable [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusion: The questionnaire of the perceived food environment and for the consumption of fruits and vegetables showed good precision among pregnant women. No association between self-perceived food environment and the adequate intake of FV among pregnant women was found.

Introdução: O consumo adequado de frutas, verduras e legumes (FVL) durante a gestação apresenta impacto positivo sobre a saúde da mulher e da criança. Os fatores ambientais associados ao comportamento alimentar vêm recebendo destaque no âmbito da saúde pública por afetar diretamente a saúde dos indivíduos. Entretanto, desconhecemos a existência de estudos que investigaram a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes. Objetivo: Verificar a reprodutibilidade de um questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes (manuscrito 1) e avaliar a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2). Metodologia: O estudo de reprodutibilidade (manuscrito 1) foi conduzido em 2010 entre 48 gestantes usuárias do serviço público de saúde de Ribeirão Preto, SP. O questionário é composto por 12 questões de múltipla escolha que incluem a percepção do ambiente alimentar e para o consumo de frutas e hortaliças. Para verificação da reprodutibilidade, o questionário foi aplicado em duplicata, com intervalo entre 15 e 45 dias. A concordância entre as respostas foi avaliada por meio do teste de Kappa ponderado ou Kappa. A relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2) foi avaliada empregando-se os dados de um estudo transversal, conduzido em 2012, entre 282 gestantes adultas. O consumo de FVL foi avaliado por meio de um questionário de freqüência alimentar (QFA) , e dois recordatórios de 24 horas. O Multiple Source Method foi utilizado para estimar o consumo usual de FVL. A percepção do ambiente alimentar foi avaliada mediante a aplicação de questionário estruturado. Para a investigação da relação entre a as variáveis da percepção do ambiente alimentar e consumo adequado de FVL (400g/dia), modelos de regressão logística [OR (95% IC)] foram empregados ajustados por escolaridade, idade e classe econômica das gestantes. Resultados: No manuscrito 1, verificou-se a reprodutibilidade do questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes. Concordância forte (Kappa entre 0,6 e 0,79) para: número de refeições ao dia, hábito de se alimentar no local de trabalho, distância entre a residência e local de aquisição de FVL e qualidade de FVL no local de aquisição. Concordância moderada (Kappa entre 0,4 e 0,59): hábito de se alimentar fora do domicílio, em restaurantes do tipo self-service ou por quilo, em lanchonetes, se adquire alimentos em mercearias, lojas de conveniência ou padaria, motivo da escolha do local para aquisição de FVL, variedade de FVL no local de aquisição e apoio familiar para ter uma alimentação saudável. Concordância fraca (Kappa entre 0,2-0,39): freqüência em que faz refeições na casa de amigos/ parentes, freqüência em que adquire alimentos em supermercados e varejão ou feira livre e percepção em relação ao preço de FVL. As questões que obtiveram concordância fraca foram reformuladas previamente a sua utilização. No manuscrito 2 observou-se que 35% das mulheres estudadas reportaram o Resumo consumo adequado de frutas e hortaliças durante a gestação, não encontrando uma associação direta entre a percepção do ambiente alimentar e o consumo adequado de frutas e hortaliças entre elas. Entretanto, as gestantes que relataram ter o hábito de fazer quatro ou mais refeições ao dia apresentaram maior chance de consumir a quantidade adequada de furtas e hortaliças quando comparadas àquelas que relataram menor número de refeições ao dia [OR 2.01 (95% IC 1.03, 3.91) p 0.04]. Da mesma forma, as mulheres que referiram o hábito de comprar FVL em varejão ou feira livre apresentaram maior chance de atingir a recomendação de frutas e hortaliças, independente de idade, escolaridade e classe socioeconômica [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusão: O questionário sobre a percepção do ambiente alimentar e para o consumo de FVL apresentou boa precisão entre gestantes. Não houve associação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças entre as gestantes estudadas. / Introduction: The adequate intake of fruits and vegetables (FV) during pregnancy has a positive impact on the health of women and children. Environmental factors associated with eating behavior have received attention in the context of public health by directly affecting individuals health. However, unaware of the existence of studies that investigated the relationship between self perceived food environment and fruit and vegetable intake in pregnant women. Objective: To evaluate the reliability of a self perceived questionnaerie about the food environment and for the consumption of fruit and vegetable in pregnant women (manuscript 1). To evaluate the relationship between self perceived food environment and the adequate consumption of fruits and vegetables in pregnant women (manuscript 2). Methods: The study was conducted in 2010 among 48 pregnant women attended by the public health service of Ribeirão Preto, SP. The questionnaire consists of 12 multiple choice questions which include the perception of the food environment and consumption of FV. To investigate the reproducibility of the questionnaire, it was administered twice, between 15 and 45 days apart. The agreement between the responses was assessed using the Kappa or Kappa weighted (manuscript 1). A cross-sectional study was conducted in 2012 among 282 adult pregnant women. Fruit and vegetable intake during pregnancy was assessed by a food frequency questionnaire, and 2 dietary recalls. The Multiple Source Method approach was applied to estimate usual FV intake. Self perceived food environment was assessed by a structured questionnaire. For the present analysis, we examined the association of self perceived food environment and the adequate intake of fruit and vegetable (400g/daily) in logistic regression models [OR (95% CI)], adjusted by maternal age, socioeconomic class, and educational level (manuscript 2). Results: Manuscript 1 describes the reliability of a self perceived questionnaire about the food environment and for the consumption of fruits and vegetables in pregnant women. There was strong agreement (Kappa: 0,6 to 0,79) for: meals per day, habit of eating at work, distance between the residence and places to purchase fruit and vegetable, quality of fruit and vegetable at the purchase place. Moderate agreement (Kappa 0,4 to 0,59): habit of eating out of home, habit of eating in self service restaurant, habit of eating in fast food restaurant, purchase food at grocery stores, convenience stores or bakery, variety of fruits and vegetables available and family support for healthy eating. Weak agreement (Kappa 0,2 to 0,39): habit of eating in friends or family house, purchase food at supermarket or FV specialized food market and perception of FV price. All the questions that had weak agreement were reformulated prior to use it. The manuscript 2 showed that 35% of the women intervied reported adequate intake of FV during pregnancy, with no association between self perceived food environment and adequate FV intake. However, a higher meal frequency was associated with a better chance of daily adequate intake of fruit and vegetable [OR 2.01 (95% CI 1.03, 3.91) p 0.04]. Moreover, the habit of buying fruit and vegetable in Abstract specialized food market was associated with the daily intake of 400g of fruit and vegetable [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusion: The questionnaire of the perceived food environment and for the consumption of fruits and vegetables showed good precision among pregnant women. No association between self-perceived food environment and the adequate intake of FV among pregnant women was found.

This study was designed to compare the fatty acid and fruit and vegetable intake of people with and without periodontal disease. Periodontal disease affects approximately 15 percent of the developed world population. Participants filled out a food frequency questionnaire (FFQ) for both fruit and vegetable and fat intake. A sample of whole blood (EDTA) was collected to determine the fatty acid profile of participants’ red blood cell (RBC) membrane. This analytical procedure determines the average fatty acid intake of the participant over the previous 90 to 120 days. Participants were classified as case (n=10, patients diagnosed with periodontal disease) or control group (n=10, patients without periodontal disease). Our hypothesis was that the case group would have higher fat intake and lower fruit and vegetable intake, with lower levels of omega-3 fatty acids and higher levels of omega-6 fatty acids in the RBC membrane. FFQ results indicated that case participants consumed significantly higher amounts of total fat (109.02 vs. 94.46g/d; p= .05), saturated fat (35.102 vs. 28.242g/d; p= .033) and their diets had a higher percentage of total dietary fat (38.73% vs. 34.99%; p=.044). FFQ for fruit and vegetable intake showed no significance between the case and control groups (4.41 vs. 4.56 servings/d; p=.871). For the most part, there were no significant differences between the percent composition of the individual fatty acids isolated from the RBC membrane or in ratios of omega-3 to omega-6 fatty acid groups as determined by RBC fatty acid analysis. Results indicated a numerically lower intake of omega-3 fatty acids in the case than in the control group. Likewise, there was a numerically higher intake of omega-6 fatty acids in the case group. These numbers demonstrate a trend towards the hypothesis being correct and patients with periodontal disease consuming more omega-6 fatty acids and less omega-3 fatty acids.