BACKGROUND: Health-related interventions informed by behavioral theory have been shown to be more effective in changing behaviors as compared to those that are not. The Theory of Planned Behavior (TPB) has been used to successfully predict and explain a variety of health related behaviors, including sugar-sweetened beverage (SSB) intake and physical activity (PA). The TPB assumes that behavioral intentions are the most important determinant of behavior. Intentions are the function of individual's attitudes toward the behavior (these evaluations can be positive or negative), subjective norms (social standards and expectations surrounding the behavior), and perceived behavioral control (perception of the ease with which the behavior can be performed). According to literature, behavioral intentions predict 20% - 40% of the variance in health behaviors with attitudes beings the strongest predictor of diet, and perceived behavioral control being the strongest predictor of physical activity related intentions. Excessive SSB consumption and inadequate PA have been highly associated with the obesity epidemic, and related comorbidities such as cardiovascular disease and type-2 diabetes. Understanding and targeting these behaviors through application of health behavior theories, such as the TPB, is important. PRIMARY AIMS: This research is embedded within a larger 2-arm randomized-control trial, Talking Health, which targets residents in rural southwest Virginia. Guided by the TPB, the overall goal of the Talking Health trial is to determine the effectiveness of a 6-month intervention aimed at decreasing SSB intake (SIPsmartER) compared to a matched contact control aimed at increasing PA (MoveMore). Each condition includes three classes, one teach-back call, and 11 interactive voice response (IVR) calls. The primary aims of this secondary analysis of Talking Health are to 1) determine if single-item TPB indicators are correlated with multi-item TPB scales for SSB and PA; 2) examine how baseline TPB variables predict participation in the SIPsmartER and MoveMore; 3) determine how the IVR TPB variables assessed during IVR calls predict future SSB and PA behaviors reported in a subsequent IVR call; and 4) explore how TPB variables change over the course of the teach back and 11 IVR calls. METHODS: Eligibility requirements included being 18 years of age or older, having reliable access to a telephone, drinking 200 kilocalories of SSB per day, and having no contraindications for moderate-intensity physical activity. The present research utilizes data from the baseline health assessment, class attendance and IVR and teach back calls completion data, as well as data collected in teach-back and 11 IVR calls. Multi-item TPB constructs for both SSB and PA behaviors were assessed at baseline (measured on a 7-point Likert scale). Each IVR call assessed self-reported past week behavior (ounces of SSB or minutes of PA) and four single-item TPB constructs including behavioral intentions, perceived behavioral control, instrumental attitudes, affective attitudes, and subjective norms. Participation was measured as the number out of 15 activities completed by participants (three classes, one teach back call, and 11 IVR calls). Statistical analysis included descriptive statistics, Chi square tests, independent T-tests, Pearson's correlations, Cronbach's α, and sequential multi-step regression models. Multiple data imputations were used to account for missing data. RESULTS: Of the 301 participants, 81% were female and 93% were Caucasian. The mean age of participants was 48.8 ± 13.5. Additionally, 32% of participants completed high school education, 55% earned < $20,000 per year, 32% had a full time or part time job, and 33% were classified as low health literate. Single-item indicators for both SSB-TPB questions (r > 0.60) and PA-TPB questions (r > 0.69) were highly correlated with their multi-item scales. Baseline TPB variables did not predict the participation rates in either SIPsmartER (F=1.763, R2=0.057, P=0.124) or MoveMore (F=0.815, R2=0.028, P=0.541) conditions. Of the nine SIPsmartER IVR regression models, eight were significant, and the SSB-TPB variables predicted about 30% of the variance in SSB behavior. Of the nine MoveMore IVR regression models, all were significant, and the PA-TPB variables predicted about 20% of the variance in SSB behavior. In both conditions, the majority of variance was explained by behavioral intentions and the addition of other TPB variables (perceived behavioral control, instrumental attitudes, affective attitudes, and subjective norms) explained substantially less variance in the behaviors. There were no notable patterns of change in TPB variables over 11 IVR calls for either SIPsmartER or MoveMore participants. DISCUSSION: Our findings show that single-item indicators can be used as reliable measures of the TPB constructs. The TPB model did not show significant predictive value when it comes to participation in SIPsmartER or MoveMore. On the other hand, our findings show that TPB model explained about 30% (SSB) and about 20% (PA) of variance in behavior. Although significant changes in IVR TPB variables were found between the two time points in several instances for both SSB and PA behavior, there were no patterns of change over time. Based on our findings, assessing behavioral intentions as the goal behavior in each IVR call may be the most useful application of the TPB. Other TPB variables can be assessed using single-item indicators. / Master of Science

In the United States, low-income, ethnic/racial minorities and rural populations are at increased risk for poorer health outcomes compared to higher income, non-minorities, and urban populations. Two key determinants that influence rural health disparities are health literacy and social capital. Health literacy can be described as an individual-level factor and defined as, "the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions." Social capital is a concept that accounts for the role of collective social functioning and has been defined as, "the features of social structures, such as levels of interpersonal trust and norms of reciprocity and mutual aid" which act as resources for individuals to facilitate collective action." The overarching goal of this research is to explore factors influencing health disparities, including health literacy, social capital in two rural regions of Virginia. The first study is embedded in Talking Health, a larger 2-arm RCT targeting adults in rural Southwest Virginia and examined participants' perceptions of and satisfaction with components of a behavioral intervention designed using health literacy concepts to decrease sugary beverage intake in rural, low-health literacy participants. The second study is also embedded in the Talking Health trial, yet focused on the maintenance of behavior 12-months after the intervention concluded. Guided by RE-AIM, this study examined the reach, effectiveness and implementation of a 12-month randomized extended care intervention aimed at enhancing long-term maintenance of behavior change and study retention when compared to a control condition. The last study is part of a larger telephone surveillance survey conducted in the Dan River Region located in south central Virginia. This study described current levels of social capital in the Dan River Region and examined the influence of social capital on FV consumption, physical activity, sugary beverage intake and BMI on a sample of rural and urban adults. / Ph. D.

Health literacy (HL) is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low HL has been associated with poorer self-reported health status, inability to manage chronic conditions, and less use of preventive services. More research is needed to explore the relationship between HL and sugar-sweetened beverage (SSB) intake and physical activity (PA). Although numerous HL interventions are evident in the literature, those that test HL as a moderator of effectiveness are lacking. Additionally, it has been recognized that systems-level HL efforts are necessary to lessen the burden of low HL. This dissertation addresses these needs with three unique studies that took place within the rural, medically underserved southwest Virginia region. Study 1 was a secondary analysis that examined the relationship and responsiveness of the Stanford Leisure-Time Activity Categorical Item (L-Cat) and adapted Godin Leisure-Time Exercise Questionnaire (GLTEQ) and determined if baseline HL status moderated intervention effects. There was high agreement L-Cat and adapted GLTEQ for classifying individuals as meeting PA recommendations. Baseline HL status did not moderate change in L-Cat or adapted GLTEQ measures. Study 2 was a secondary analysis that determined if 6-month change in SSB intake predicted 6-month change in body mass index (BMI), weight, and quality of life (QOL), and determined if HL moderated these relationships. The regression models for weight and QOL were not significant. The BMI model was significant. Six-month change in SSB intake, experimental condition, and age were significant predictors for the BMI model. As hypothesized, HL did not moderate relationships in any models. Study 3 details a multilevel mixed-methods needs assessment and collaboratively developed organizational HL improvement plan within the Virginia Department of Health (VDH). Staff responses revealed about half reported doing well across HL domains (written communication, oral communication, self-management and empowerment, supportive systems). However, needs were observed across all domains, with most improvement needed in written communication domain. There were significant correlations between clients' HL status and their perceptions of VDHs' HL practices, indicating potential areas of improvement within VDH. / Ph. D.

Master of Science / Department of Human Nutrition / Tandalayo Kidd / Weiqun Wang / The number of overweight and obese college students in the United States has remained high, which could be related to the comfort food and beverages consumed. Sugar-sweetened beverages and fried potatoes are beverages and comfort food commonly consumed by college students. Furthermore, people’s behavior is affected by their perceptions and goals. Thus, this study aimed to assess the correlations between the perception, goal of body weight, and sugar-sweetened beverages and fried potatoes consumption behaviours of college students. A cross-sectional survey of 371 college students was conducted via a self-reporting questionnaire that included information related to sugar-sweetened beverages and fried potato consumption behavior in the past month. The involved students also described their body weight perception and future goal. Spearman correlation and Chi-square analyses were performed to examine the associations. There were significant associations (p<0.0001) between perception of body weight and goal of body weight, regular soda consumption and other sweetened beverage consumption, regular soda consumption and fried potato consumption, and other sweetened beverage consumption and fried potatoes consumption. In addition, there were significant correlations between goals of body weight and other sweetened beverage consumption (p=0.0370). These findings confirmed that perception of body weight was associated with goal of body weight and provided a significant importance for educational intervention to students on improving awareness of healthy body weight and eating.

Introduction: The consumption of fast food and soft drinks is a risk factor for developing overweight and obesity. This study aimed at assessing if there is association between household socioeconomic level and the consumption of fast food and soft drinks among children. Material and Methods: A cross-sectional assessment of the data from the third round (2009-2010) of the youngest cohort of the Young Lives study in Peru was conducted. Sampling was conducted in three stages: In the first one, the country was divided into equal geographical regions, excluding the 5% of the richest district; in the second stage, 20 sentinel sites were chosen and an area within each sentinel site was selected. Finally, in the third stage, eligible children were selected. Outcomes were the self-reported consumption of fast food and soft drinks (never, sometimes, and always), whereas the exposure was household socioeconomic status (in quintiles). Crude and adjusted models were created between variables of interest using Poisson regression models, with robust variance, to report prevalence ratios (PR) and 95% confidence intervals (95% CI). Results: Data of 1901 children, of which 942 (49.6%) were girls, with a mean age of 7.5 (SD: 0.5) was analyzed. A total of 24.1% (95%CI: 22.2%-26.1%) reported always consuming fast food, whilst this number was 22.4% (20.5%-24.3%) for soft drinks. Compared to the lowest socioeconomic quintile, those who were in higher socioeconomic status had more probability of consuming fast food and soft drinks (Chi-squared for trends <0.001). The highest socioeconomic quintile had a greater probability to always consume fast food (PR=1.42; 95%CI: 1.08-1.88) and soft drinks (PR=1.71; 95%CI: 1.24-2.37). Conclusions: This study shows that there is a significant association between the household socioeconomic level and the consumption of soft drinks and fast food. / Revisión por pares

Background: Sugar sweetened beverages (SSBs) comprise the largest source of added sugars in US adolescents’ diets. SSB consumption is pervasive in US culture and is a critical risk factor for weight gain and obesity in adolescents. This thesis evaluates multi-level factors that influence adolescent SSB consumption. Methods: The first two aims of this thesis utilized data from the cross sectional, internet based Family Life, Activity, Sun, Health and Eating (FLASHE) study to: 1) examine availability of SSBs in multiple settings (home, school, neighborhood) and adolescent SSB consumption, 2) examine the associations between perceptions of parenting practices and adolescent SSB consumption. The third aim used focus group discussions to understand adolescents’ perceptions about SSBs. Results: We found that SSB availability in the home was an important predictor of adolescent SSB consumption, regardless of SSB availability in other settings. Also, parenting practices that facilitate adolescent SSB consumption are associated with higher adolescent SSB consumption, but discussing/negotiating SSB behaviors is not associated with adolescent SSB consumption. Adolescents’ described their attitudes, reinforcements, knowledge, and sources of influence around SSBs which are multifactorial and complex. Conclusions: This thesis identified potential targets for addressing adolescent SSB consumption through availability of SSBs at home, parenting practices, and adolescent perceptions around SSBs. These are important modifiable factors in the adolescents’ sociocultural environment that should be targeted in future dietary interventions to influence adolescent SBB consumption.

Indiana University-Purdue University Indianapolis (IUPUI)

Unhealthy eating habits are one of the main causes of deteriorating health and premature death among Sweden’s population. Foods containing added sugars are common today and they rarely contain the nutrients that are essential for our bodies to stay healthy. Overconsuming sugar can lead to several diseases, including obesity and caries. Obesity in turn increases the risk of suffering from cardiovascular diseases, cancer, stroke, and diabetes type 2. The health effects of sugar are costly to society and a sugar tax on sugar-sweetened beverages is a possible financial instrument to improve public health and at the same time reduce healthcare costs. The cost savings and tax revenue can then be used to finance further implementations of strategies to improve the public health of the citizens of Sweden. The purpose of this essay is to investigate whether it is socio-economically viable to introduce an excise tax on sugar-sweetened beverages in Sweden. The drinks that would be affected by the tax are sodas, juices, energy drinks, sport drinks and ciders. A cost-benefit analysis is the economic method that will be used in this essay to investigate the issue. The possible costs and benefits from the implementation of a tax are identified and valued in monetary terms. In addition to this, a sensitivity analysis is carried out to test how sensitive the project is to differences in estimated costs and benefits. The calculations of costs and benefits are based on secondary data and statistics from previous studies as well as reports and statistics from Swedish authorities. The results of this essay show that the benefits of a tax on sugar-sweetened beverages had exceeded the costs, which is also showed by the cost-benefit ratio which is 1,47 and thus exceeds 1. The sensitivity analysis shows that the results are stable and credible since alternative values of costs and benefits also would lead to cost-benefit ratios exceeding 1. Based on the results, a recommendation is made to introduce an excise tax on sugar-sweetened beverages in Sweden, since the introduction is estimated to be socio-economically viable. / I denna uppsats utförs en kostnads-nyttoanalys för att undersöka om det är samhällsekonomiskt lönsamt att införa en punktskatt på sötad dryck i Sverige. De drycker som skulle påverkas av skatten är läsk, juice, saft, energidryck, sportdryck, cider samt måltidsdryck som är sötade med socker eller naturligt innehåller en hög sockerhalt. Socker har endast negativ påverkan på vår hälsa och överkonsumtion av socker är en orsak till ett flertal sjukdomar som är vanligt förekommande idag, bland annat övervikt och karies. Övervikt ökar i sin tur risken för att drabbas av fetma, hjärt- och kärlsjukdomar, cancer, stroke och diabetes typ 2. Hälsoeffekterna av socker är kostsamma för samhället och en sockerskatt på dryck är ett möjligt styrmedel för att förbättra folkhälsan och samtidigt minska dessa kostnader. Kostnadsbesparingarna kan därefter distribueras till viktiga ändamål, exempelvis för att finansiera ytterligare strategier för en bättre hälsa hos befolkningen. Resultaten i uppsatsen visar att fördelarna av en skatt på sötade drycker hade överstigit kostnaderna, vilket går att se då nyttokostnadskvoten som beräknas uppgår till 1,47 och alltså överstiger 1. Utöver kostnads-nyttoanalysen utförs även en känslighetsanalys för att testa hur känsligt resultatet är för förändringar av värdet för olika parametrar som kommer påverkas av införandet av skatten. Känslighetsanalysen visar att resultatet är stabilt och trovärdigt då även alternativa värden leder till en nyttokostnadskvot som överstiger 1. Resultatet används som grund för en rekommendation om att införa en punktskatt på sötade drycker i Sverige, då införandet är samhällsekonomiskt lönsamt.

Bakgrund: Sockersötade drycker är drycker till vilka sockerarter tillsatts. Dessa drycker konsumeras globalt och många gånger överskrids rekommendationerna om intag av tillsatt socker, vilket kan leda till negativa hälsoeffekter. Sockersötade drycker kan öka risken att drabbas av övervikt, fetma och typ 2-diabetes som i sin tur är riskfaktorer för att utveckla bukspottkörtelcancer. Det finns därför ett ökat intresse att undersöka den potentiellt ökade cancerrisken vid konsumtion av sockersötade drycker. Syfte: Syftet var att undersöka om intag av sockersötade drycker kan öka risken att drabbas av bukspottkörtelcancer. Metod: Arbetet är en litteraturstudie där vetenskapliga artiklar sökts med databasen PubMed. Sökorden var ”sugar-sweetened beverages” och ”pancreas cancer”. Av de artiklar som erhölls inkluderades observationsstudier och kliniska studier. Utifrån ytterligare inklusions- och exklusionskriterier valdes sju studier ut och granskades. Resultat: Resultat från tre av sju studier visar att det inte förekommer något samband mellan konsumtion av sockersötad dryck och risk för bukspottkörtelcancer medan resultat från tre studier påvisar samband. Resultat från en studie visar att det finns samband hos kvinnor men inte hos män. Slutsats: Hälften av studierna visar ett samband mellan konsumtion av sockersötad dryck och en ökad risk att drabbas av bukspottkörtelcancer. För att minska risken kan det således vara fördelaktigt att följa de rekommendationer som finns kring tillsatt socker. / Background: Sugar-sweetened beverages are beverages to which sugars are added. These beverages are consumed globally and many times the recommendations on added sugar are exceeded, which can lead to negative health effects. Sugar-sweetened beverages may increase the risk of overweight, obesity and type 2 diabetes which are risk factors for developing pancreatic cancer. Thus, there is an increased interest to study the potentially increased cancer risk associated with the consumption of sugar-sweetened beverages. Aim: The aim was to examine whether consumption of sugar-sweetened beverages can increase the risk of pancreatic cancer. Method: This work is a literature study using scientific articles searched with the database PubMed. The search terms were “sugar-sweetened beverages” and “pancreas cancer.” Of the articles obtained, observational studies and clinical studies were included. Based on inclusion and exclusion criteria, seven studies were selected and reviewed. Results: Results from three of seven studies show that there is no relationship between consumption of sugar-sweetened beverages and risk of pancreatic cancer, while results from three other studies show that there is a relationship. Results from one study show that there is a relationship in women but not in men. Conclusion: Half of the studies shows that there is a relationship between consumption of sugar-sweetened beverages and increase the risk of pancreatic cancer. To reduce the risk, it can be beneficial to follow the recommendations that exist regarding added sugar.

Objetivos: Estudar a influência que a renda das famílias e os preços dos alimentos exercem sobre a aquisição de alimentos mais saudáveis (frutas e hortaliças, F&H) e menos saudáveis (bebidas adoçadas, BA). Metodologia: Utilizaram-se dados sobre aquisição de alimentos coletados pela Pesquisa de Orçamentos Familiares (POF), realizada entre julho de 2002 e junho de 2003 pelo IBGE em uma amostra probabilística de 48.470 domicílios do país. A influência da renda familiar e do preço de frutas e hortaliças e de bebidas adoçadas sobre seu consumo foi estudada empregando-se técnicas de análise de regressão múltipa para estimação de coeficientes de elasticidade, controlando-se variáveis sócio-demográficas e preço dos demais alimentos. Resultados: Com a diminuição do preço de F&H haveria aumento da participação desses alimentos no total de aquisições: 10 por cento de redução nos preços de F&H aumentaria em 7,9 por cento sua participação no total calórico. Com o aumento da renda familiar também haveria aumento na participação calórica de F&H: 10 por cento de aumento na renda aumentaria em 2,7 por cento a participação de F&H no total calórico. O efeito dos aumentos de renda tendeu a ser menor nos estratos de maior renda. Haveria significativa redução na aquisição de bebidas adoçadas frente a aumentos no seu preço: para cada 10 por cento de aumento nos preços de bebidas adoçadas haveria uma redução de 8,4 por cento no consumo desses produtos. Aumentos na renda familiar também influenciariam o consumo de bebidas adoçadas, mas com efeito oposto e de magnitude inferior à metade do observado com o aumento de preços: para cada 10 por cento de aumento na renda familiar haveria um aumento de 4,1 por cento no consumo de bebidas adoçadas. Conclusões: Políticas de ajuste de preços como a imposição ou isenção de uma taxa podem ser utilizadas como ferramentas na promoção da alimentação saudável no país, seja estimulando o consumo de alimentos saudáveis ou desestimulando o consumo de não saudáveis / Objectives: To study the influence of family income and food prices on the acquisition of items that act as indicators of a healthy (fruits and vegetables, F&V) or an unhealthy (sugar-sweetened beverages, SSB) food intake. Methods: We used data from the Household Budget Survey (HBS) carried out by IBGE between July 2002 and June 2003 in a probabilistic sample of 48,470 Brazilian households. The influence of family income and the price of fruit and vegetables and sugar-sweetened beverages on its consumption was studied employing techniques multiple regression analysis to estimate elasticity coefficients, controlling for demographic variables and price of other foods. Results: Reducing the price of F&V would increase its participation on total food purchases: 10 per cent reduction in prices of F&V would increase by 7.9 per cent its share of total calories. The increase in family income would also increase the proportion of calories from F&V: 10 per cent increase in income would increase by 2.7 per cent the participation of F&V on total calories. The effect of a raise in income tended to be lower in higher income groups. On the other hand, an increase in the price of SSB would result in considerable reduction in its consumption: for every 10 per cent increase in the prices of SSB a reduction of 8.4 per cent in the consumption would be expected. Increases in income also influence the consumption of SSB, but having the opposite effect, and magnitude less than half that observed for the increase in prices: each 10 per cent increase in family income would increase by 4.1 per cent the consumption of SSB. Conclusions: Public policies aiming the adjustment of prices - as the imposition or exemption of a tax - can be used as a tool in promoting healthy eating in Brazil, either encouraging the consumption of healthy foods or discouraging the consumption of unhealthy products