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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.

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

Obesity is a public health concern and cardiometabolic consequences are severe when obesity develops during youth and continues into adulthood. Treatment prior to adulthood confers health benefits, but adolescent obesity rates have continually increased, reaching 20.6% in 2013-2014. Quality and quantity of dietary intake contribute to the development of obesity, but limitations of self-reported dietary intake are evident in overweight or obese adolescents, who frequently misreport nutrients of concern. Added sugar, sodium, and protein intake may indicate diet quality in this population. The 2015-2020 Dietary Guidelines recommend decreasing consumption of added sugars, sodium, and processed protein due to their known contributions to overweight and obesity. Objective dietary intake assessment measures are necessary for investigating the association between dietary intake and health outcomes. Added sugar, sodium, and protein intake could be assessed objectively with a panel of urinary biomarkers. Prior research indicates the potential of these urinary biomarkers to reflect dietary intake, but to date, no controlled feeding study has been conducted in adolescents. Using a controlled feeding design, the current study aims to evaluate the validity of urinary sucrose, fructose, sodium, and nitrogen as objective indicators of dietary intake. It is hypothesized that urinary sucrose and fructose will reflect dietary added sugar intake, while urinary sodium and nitrogen will correspond to dietary sodium and protein intake, respectively, in a healthy adolescent population. These biomarkers, if valid, could be used in clinical and epidemiological research to improve understanding of the associations between dietary intake and health outcomes. / Master of Science

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

An estimated 20.5% of adolescents ages 12 – 19 years were obese (≥95th percentile of BMI-for-age) in 2011 – 2014. Consumption of added sugars (AS) has been linked with adverse effects on weight and cardiovascular disease risk factors. Approximately 16% of adolescents’ calories come from AS, of which sugar-sweetened beverages (SSB) are a major contributor. However, the relationship between AS/SSB intake and obesity is controversial, partly due to limitations in self-reported dietary data. Objective dietary intake biomarkers may circumvent this problem. The δ13C biomarker for AS intake is based upon the fact that C4 plants– major source for sugar production in the United States – have elevated δ¹³C values compared to C3 plants, which includes most fruits and vegetables. The δ¹³C value of blood, which is influenced by diet, has been established as a valid, reliable, and sensitive biomarker, but when compared to selfreported AS intake. This investigation evaluated the sensitivity and reliability of the δ13C biomarker, assessed with fingerstick blood samples, in adolescents using a controlled feeding, crossover design. Fingerstick δ¹³C values significantly changed by -0.05‰ and +0.03‰ after subjects completed the 5% and 25% AS diets, respectively (F(1, 30) = 18.828, p < 0.001). High reliability was found between two consecutive fingerstick δ¹³C values on the low (ICC = 0.996) and high (ICC = 0.997) AS diets. Thus, fingerstick δ¹³C may be a sensitive and reliable indicator of AS intake in adolescents. Future investigations should develop an equation to estimate AS intake based on fingerstick δ¹³C / Master of Science

<p>  </p> <p>The prevalence of obesity and type 2 diabetes has increased worldwide over the last decades. Sugar-sweetened beverages are especially problematic in the development of obesity and type 2 diabetes. Although the proportion of Americans consuming SSB regularly has been steadily declining, added sugar intake still remains above recommendations by the Dietary Guidelines for Americans and World Health Organization. However, alternatives to SSB exist on the market. For many years, the primary alternatives to SSB were low-calorie sweetened beverages, with sweetness replacers such as aspartame or sucralose. In recent years, options that are less sweet or unsweetened (instead of alternatively sweetened) have become increasingly available. These less-sweet beverages are available in similar packaging and at similar cost as SSB. Thus, these less-sweet beverages may be ideal options to reduce added sugar in the diet. However, few studies have tested switching consumers from SSB to less-sweet beverages (rather than low-calorie sweetened beverages or plain water), and thus the acceptability and implications of this dietary change are minimally documented. In this work, we tested less sweet soda-like beverages and unsweetened sparkling waters for potential to replace SSB. First, we showed that small reductions in sweetness in cola-flavored sodas are noticeable to individuals, meaning that any switch from SSB to less-sweet options will likely need to be overt to the consumer. Next, we conducted a 12-week intervention with adolescents, which showed that replacing SSBs with unsweetened sparkling waters leads to increased liking of less-sweet sodas and shifts in the ideal level of sweetness towards lower sugar concentrations. Building on these results, our final study shows that even just 2 weeks is enough time to induce these changes in acceptance of less sweetness in sodas, if a consumer prefers the higher concentrations of sugar at the beginning of the intervention (a “sweet liker”). Future studies are needed to evaluate how replacing SSB with less sweet options, leading to shifts in sweetness preference, might influence overall diet and risks for diet-related chronic diseases.</p>