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

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

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

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

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

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

BACKGROUND: Low health literacy and numeracy are significant problems facing the United States. Recent research focuses heavily on the role health literacy and numeracy play in perception of disease risk, health care costs, all-cause mortality, and access to care; however, there has been relativity little emphasis on the relationships between health literacy or numeracy with health promotion behaviors, such as nutrition or physical activity. As our nation continues to face challenges with the high prevalence of obesity and other chronic diseases, it is increasingly important to understand the role that health literacy and numeracy play in nutrition and physical activity behaviors, as well as in the prevalence and control of chronic disease. PRIMARY AIMS: The proposed research is embedded within a larger randomized-control trial, Talking Health, which is a 2-arm behavioral trial targeting residents in eight counties in southwest Virginia with sugar-sweetened beverage (SSB) consumption as the primary outcome. The primary aims of this cross-sectional study, using baseline Talking Health data, are to 1) examine correlations among health literacy and numeracy measures, namely the Newest Vital Sign (NVS), separated by reading (NVS Reading) and math (NVS Math) scores, the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Subjective Numeracy Scale (SNS); 2) explore the relationships between demographic factors and the NVS, REALM, and SNS scores; 3) determine the relationships between the NVS, REALM, and SNS and dietary quality [i.e. Health Eating Index (HEI) scores], physical activity behaviors, and anthropometric and biological variables (body mass index, blood pressure, fasting blood lipids, and fasting blood glucose); and 4) determine if NVS, REALM, and SNS scores predict metabolic syndrome (MetS), while controlling for relevant demographic factors. METHODS: Eligibility requirements for the study include 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 Southwest Virginia. Using previously validated instruments and standardized data collection protocol, a variety of baseline variables was collected on 264 participants. Health literacy was measured using the NVS and REALM and health numeracy was measured using the SNS. Dietary intake was measured via three 24-hour dietary recalls and HEI scores were calculated. Physical activity behaviors were assessed using the Godin Leisure Time Exercise Questionnaire. Weight was measured using a calibrated digital Tanita scale (Model: 310GS), height was measured using a portable research-grade stadiometer, blood pressure measurements were made with an OMRON automated oscillometric device (Model: HEM-907XL), and fasting blood samples were obtained via a finger stick and the CardioChek PA system was used to assess blood glucose, cholesterol, and triglycerides. MetS scores were determined based on an adaptation of the National Cholesterol Education Program guidelines. Statistical analysis included descriptive statistics, simple correlations (Pearson bivariate), one-way ANOVAs, and regression models. RESULTS: Of 264 enrolled participants (mean age 41.1 + 13.5 years; 92.0% Caucasian; 81.8% female; 30.6% > high school education; 42% > $15,000 annual income), 33.7% were classified as having a high probability of low health literacy or possibility of low health literacy as measured by the NVS, 19.7% had less than a high school reading level as measured by the REALM, and 45.4% had low health numeracy as measured by the SNS. Additionally, 78.8% were overweight or obese and 29.0% meet the criteria for metabolic syndrome. Nine of the ten correlations between the NVS Total, NVS Reading, NVS Math, REALM, and SNS were statistically significant (p < .01, two-tailed). NVS scores were found to be significantly different by age (F = 2.36, p = .05), race (F = 4.49, p = .03), education level (F = 20.97, p < .001), and income (F = 13.88, p < .001); while REALM scores were only significantly different by race (F = 3.74, p = .05), education level (F = 21.06, p < .001), and income (F = 6.80, p < .001). SNS scores were significantly different by gender (F = 12.40, p = .001), education level (F = 11.01, p < .001), and income (F = 14.45, p < .001). Only systolic blood pressure, diastolic blood pressure, and strength training activity was found to be significantly different by health literacy and/or numeracy level; however, when controlling for hypertension medication use and/or demographic variables, only the relationship between health literacy (i.e, NVS) and strength training activity remained significant (R2 = 0.09, p = .01). Finally, health literacy and numeracy were not found to be predictive of metabolic syndrome while controlling for demographic variables. DISCUSSION: Although numerous demographic factors were related to baseline health literacy and numeracy levels, anthropometric/biological variables, physical activity behaviors, and diet quality did not differ by health literacy and health numeracy level, with the exception of systolic blood pressure and strength training activity. This research helps to fill the gaps in the literature surrounding the prevalence of health literacy, health numeracy, and health promoting behaviors and chronic disease among rural residents in medically underserved counties in southwest Virginia. While few cross-sectional relationships were found, future research from this RCT should examine if health literacy and health numeracy moderates or mediates intervention changes in anthropometric/biological variables, physical activity behaviors, diet quality, and metabolic syndrome scores. / Master of Science