INTRODUCTION: Research has strongly linked increased consumption of sugar-sweetened beverages (SSBs) to obesity/overweight in youth. AIM: This study aims to: (1) examine SSB consumption rates in high school students nationwide, (2) explore association between SSB consumption and adiposity (overweight/obesity), (3) examine gender, racial/ethnic, and physical activity (PA) status differences in SSB consumption. METHODS: The Youth Risk Behavior Survey (YRBS)-2015 was employed in this study. Weighted percentages were used to examine differences in SSB consumption and adiposity prevalence by gender, race and PA status. Multivariate logistic regression was used to determine association between SSB consumption and adiposity. Adjusted and unadjusted odds ratios and 95% CIs were calculated. RESULTS: Overall, 20% of students drank sodas daily ≥ 1 times a day and about 14% drank sports drinks daily. More male students consumed both sodas and sports drinks than female students. Soda consumption was largest in the group with zero days PA (25%) and consumption of sports drinks was highest in the daily PA category (24%) than the other categories. Multivariate logistic regression revealed higher odds of obesity among male students as compared to female students (OR=1.7, 95% CI=1.4, 2.1) and among Hispanic students as compared to white students (OR=1.5, 95% CI=1.2, 1.8), after adjusting for all other covariates. Students who engaged in daily PA had lower odds of obesity than those who had no PA (OR=0.6, 95% CI=0.5, 0.8). There was no significant difference in the odds of obesity between those who consumed SSBs and those who did not. DISCUSSION: This study provides insight into SSB consumption trends in US adolescents by socio- demographic factors and PA status, as well as its association with adiposity. Male gender, certain racial minorities and lack of physical activity can potentially be responsible for greater SSB consumption. Sports drinks consumption is high even in physically active youth. Lack of association between SSB intake and adiposity may be due to the limited SSBs included.

Background: In the U.S., Hispanics have among the highest rates of overweight and obesity when compared to other racial/ethnic groups placing them at a greater risk for obesity-related disease. Identifying intervention strategies to reduce caloric intake and/or improve cardiometabolic health in Hispanics is critical to reducing morbidity and mortality among this large and growing population. Evidence exists to support diet-specific behavioral interventions, including beverage modifications, in reducing obesity-related health risks. However, the acceptability and feasibility of a beverage intervention in obese Hispanic adults has not been robustly evaluated. Methods: The objective of this pilot study is to assess the feasibility and acceptability of a randomized, controlled beverage intervention in 50 obese Hispanic adults ages 18-64 over 8-weeks. Eligible participants were obese (30-50.0 kg/m(2)), between the ages 18-64, self-identified as Hispanic, and were able to speak, read, and write in either English and/or Spanish. Study recruitment was completed August 2017. Upon the completion of baseline assessments, participants will be randomized to either Mediterranean lemonade, Green Tea, or flavored water control. After completing a 2-week washout period, participants will be asked to consume 32 oz. per day of study beverage for 6-weeks while avoiding all other sources of tea, lemonade, citrus, juice, and other sweetened beverages; water is permissible. Primary outcomes will be recruitment, retention, and acceptability of the intervention strategies. Our study will also evaluate participant-reported tolerance and as an exploratory aim, assess safety/toxicity-related to renal and/or liver function. Fasting blood samples will be collected at baseline and 8-weeks to assess the primary efficacy outcomes: total cholesterol, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Secondary outcomes include fasting glucose, hemoglobin A1c (HbA1c), and high-sensitivity C-reactive protein (hs-CRP). Discussion: This pilot study will provide important feasibility, safety, and early efficacy data necessary to design a larger, adequately-powered randomized controlled trial.

The former finance minister stated in his budget speech in 2016 that sugar tax would come into force in South Africa from 1 April 2017. The treasury's reason for implementing sugar taxation is to reduce the health problems caused by sugar. It is nothing new to use fiscal measures to recover both taxes and to prevent health problems but it was not yet possible to reach a definite conclusion about the impact of sugar tax on the consumption of sugary drinks and the prevalence of obesity. The reason for this is that there is evidence that the implementation of food tax in different countries has shown different results in terms of public health issues and tax benefits. In South Africa, the implementation of sugar tax can either reduce the prevalence of obesity and thereby have a positive effect on the economy or its implementation may adversely affect the economy. If treasury does not implement sugar tax the economy can also be adversely affected by the prevalence of obesity. This dissertation deals with the effects of non-communicable diseases and sugar tax on the South African economy. The focus is on how sugar tax is being implemented internationally and how South Africa intends to implement sugar tax. / Die voormalige minister van finansies het in sy begrotingstoespraak in 2016 vermeld dat suikerbelasting vanaf 1 April 2017 in Suid-Afrika in werking gaan tree. Die tesourie se rede vir die implementering van suikerbelasting is om, in samewerking met die Departement van Gesondheid, die gesondheidsprobleme wat deur suiker veroorsaak word te verminder. Dit is niks nuuts om fiskale maatstawwe te gebruik om beide belasting in te vorder en gesondheidsprobleme te voorkom nie, maar dit was nog nie moontlik om tot ’n definitiewe gevolgtrekking te kom oor die impak van suikerbelasting op die verbruik van suikerversoete drankies en die voorkoms van vetsug nie. Die rede hiervoor is dat daar bewyse is dat die implementering van voedselbelasting in verskillende lande verskillende resultate getoon het in terme van openbare gesondheidskwessies en belastingvoordele. In Suid-Afrika kan die implementering van suikerbelasting óf die voorkoms van vetsug verminder en sodoende die ekonomie bevoordeel óf die implementering daarvan kan die ekonomie negatief beïnvloed. Indien die tesourie nie suikerbelasting implementeer nie kan die ekonomie as gevolg van die voorkoms van vetsug negatief beïnvloed word. Die kern van hierdie skripsie handel oor die gevolge van nieoordraagbare siektes en suikerbelasting op die Suid-Afrikaanse ekonomie. Daar word spesifiek gefokus op hoe suikerbelasting internasionaal geïmplementeer word en hoe Suid-Afrika beoog om suikerbelasting te implementeer. / Mini Dissertation (LLM)--University of Pretoria, 2017. / Mercantile Law / LLM / Unrestricted

Background: Low health literacy is a significant problem affecting our country.  While the associations between low health literacy and poorer health outcomes have been well documented (Berkman et al., 2011), the literature lacks evidence of effective strategies to address health literacy in the context of health behaviors such as diet and physical activity (PA). Likewise, few interventions have reported on how health literacy status influences performance and engagement in the intervention. Two potential intervention strategies include the teach back method or teach to goal approach and interactive voice response (IVR) technology. These strategies hold promise as a means of improving health literacy and reaching vulnerable, low health literate populations, but these strategies have not been widely explored in the literature (Paasche-Orlow et al., 2005; Baker et al., 2011; Schillinger et al., 2009; Bennett et al., 2012; Piette et al., 1999). Primary Aims: This research was embedded in a larger trial, Talking Health, which is a 6-month, 2 group randomized controlled trial to determine the effects of a health behavior intervention on reducing sugar-sweetened beverage (SSB) consumption in Southwest Virginians. The primary aims of this study were to examine the associations between health literacy status and 1) number of rounds of teach back needed to reinforce key concepts, 2) proportion of correct answers on the first round of teach back, 3) level of intervention engagement (i.e., completion rates for teach back call, IVR calls, and small group classes), and 4) perceptions of the intervention components. Methods: The data reported represent the first 3 cohorts of the Talking Health trial including participants in Lee, Giles, and Pulaski Counties. Eligibility requirements included being 18 years or older, English speaking, consuming at least 200 calories per day from SSB, able to participate in moderate intensity PA, and having reliable access to a telephone. Data were collected at baseline and at the 6-month follow-up assessment. Health literacy was assessed using the validated Newest Vital Sign. Participants were randomized to a behavioral intervention aimed at decreasing SSB consumption (SipSmartER) or to a matched-contact control group targeting PA (Move More). Both groups participated in 3 small group education sessions, received a live teach back call, and 11 supportive IVR calls. Participants completed a summative evaluation at the 6-month follow-up, which captured their perceptions of the intervention components. ANOVAs were used to measure differences in outcomes by health literacy status, randomized condition, and interactions. Results: Of the 125 enrolled participants, 92.0% were Caucasian, 76.8% were female, 29.6% had d high school education, 64.0% had <$25,000 annual household income, and 32.8% had low health literacy skills. Eighty-five participants (68.0%) completed the teach back call. The overall model when looking at the degree to which health literacy status and randomized condition predicted the number of rounds of teach back needed to reinforce key concepts was significant (F= 8.323, p < 0.001). Out of 3 possible teach back attempts, participants in the low health literacy category required a significantly higher number of teach back attempts as compared to those with high health literacy (F= 16.769, p <0.001), and participants randomized to Move More required a significantly higher number of teach back attempts compared to SipSmartER participants (F=7.296, p= 0.008). Similarly, the overall model when looking at the degree to which health literacy status and randomized condition predicted the proportion correct on the first round of teach back was significant (F= 9.836, p<0.001), such that those with higher health literacy status  (F= 19.176, p< 0.001) and those randomized to SipSmartER condition answered a significantly higher proportion of questions correct (F= 9.783, p= 0.002). Intervention engagement including completion of the small group education sessions, the live teach back call, and the IVR calls did not vary significantly across randomized condition or literacy levels. Low health literate participants had a significantly higher overall perceived satisfaction with the IVR, as compared to high health literate participants (F= 5.849, p= 0.020). However, perceptions of other intervention components (e.g., small group sessions, teach back call, personal action plans, drink diaries/exercise logs,) were similar among participants with low and high health literacy status and across randomized conditions.   Conclusion: These data confirm the importance for multiple teach back opportunities and additional exposure to health information to ensure participant comprehension of key intervention content"in particular for those with lower health literacy. This research also supports that IVR is an effective approach to reaching vulnerable, low health literate populations. Future research should investigate the efficacy and cost-effectiveness of utilizing teach back methods delivered using automated technologies. Future research also is needed to determine how teach back performance are related to other study factors such as retention, engagement, and health outcomes. / Master of Science

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.

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: 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

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.