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.

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

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

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

Obesity among children is a public health concern. Preschool-­‐aged children, especially those from low-­‐income families, are no exception to the obesity epidemic. During the RD Parent Empowerment Program, parents of Head Start children in Johnson City, TN completed a structured education program over the course of 4 workshops related to healthy habits of families. The goal was to empower parents to shop smart, cook healthy, and eat right. The Family Nutrition and Physical Activity (FNPA) screening tool was used as an assessment tool to evaluate behavior change over the course of the program. Improvement in overall FNPA score was seen at the conclusion of the program. Individual assessment of breakfast consumption, family meal patterns, fruit and vegetable intake, beverage choices, and restriction occurred. Participation in the RD Parent Empowerment Program resulted in maintaining healthy behaviors or improved behaviors for many participants. A larger sample may provide more conclusive results.

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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College students are among the highest consumers of sweetened beverages, drinking more than 25% of their daily calorie needs from sweetened drinks. They also tend to be low consumers of milk. This is important, as high consumption of sweetened drinks and low consumption of nutrient-dense drinks is associated with obesity, dental caries and bone disease. Point-of-purchase (POP) marketing and nutrition education programs are thought to be effective in changing food selection behaviors of college students. Therefore, we conducted a 2-week intervention that combined POP marketing and nutrition education aiming to 1. decrease sweetened beverage consumption 2. increase milk/milk equivalent consumption and 3. increase knowledge of beverages and health among University of Massachusetts students. To determine effectiveness of the campaign, college students enrolled at UMass Amherst with a meal plan of > six meals/week were recruited via email for survey participation prior to (n=1547) and 14 days after (n=1387) the intervention. We compared self-reported beverage consumption and nutrition knowledge for pre- versus post-intervention and exposed versus unexposed (post-intervention) survey respondents with Chi-square tests. Using both approaches to assess campaign effectiveness, we found that exposed participants were less likely to drink regular soda at least once per week (p =0.001, p = 0.044), more likely to identify fruit juice is not a source of calcium/vitamin D (p<0.001, p = 0.011) and more likely to identify that there is a link between artificial sweeteners and hunger (p<0.001, p<0.001). We found that POP marketing was effective in decreasing soda consumption and increasing nutrition knowledge about calcium/vitamin D and artificial sweeteners in our study. These results suggest that similar POP marketing campaigns may be useful in college settings to improve beverage choices and knowledge. Successful campaigns that impact long-term behavior may also improve long-term health outcomes for college students by decreasing sweetened beverage intake.

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