Differences in dietary acceptability, restraint, disinhibition, and hunger among African American participants randomized to either a vegan or omnivorous soul food diet

The Nutritious Eating with Soul study was a 24-month, randomized behavioral nutrition intervention among African American adults. This present study, which is a secondary analysis of the NEW Soul study, examined changes in dietary acceptability, restraint, disinhibition, and hunger. Participants (n = 159; 79% female, 74% with ≥ college degree, mean age 48.4 y) were randomized to either a soul food vegan (n = 77) or soul food omnivorous (n = 82) diet and participated in a two-year behavioral nutrition intervention. Questionnaires assessing dietary acceptability (Food Acceptability Questionnaire; FAQ) and dietary restraint, disinhibition, and hunger (Three-Factor Eating Questionnaire; TFEQ) were completed at baseline, 3, 6, 12, and 24 months. Mixed models were specified with main effects (group and time) and interaction effects (group by time) to estimate mean differences in FAQ and TFEQ scores using intent-to-treat analysis. After adjusting for employment, education, food security status, sex, and age, there were no differences in any of the FAQ items, total FAQ score, dietary restraint, disinhibition, and hunger at any timepoint except for one item of the FAQ at 12 months. Participants in the vegan group reported a greater increase in satisfaction after eating a meal than the omnivorous group (mean difference 0.80 ± 0.32, 95% CI 0.18, 1.42; P = 0.01). This is one of the first studies to examine differences in dietary acceptability, hunger, and other eating factors among African American adults randomized to either a vegan or omnivorous soul food diet. The findings highlight that plant-based eating styles are equally acceptable to omnivorous eating patterns and have similar changes in hunger, restraint, and disinhibition. These results suggest that plant-based eating styles can be an acceptable dietary pattern to recommend for cardiovascular disease prevention and may result in greater post-meal satisfaction.

Community Health Worker Implementation and Cost Analysis of a Plant-Based Nutrition Program

OBJECTIVE

This study describes program implementation through a research-restaurant partnership and assesses participant satisfaction, program costs, and percent body weight changes.

METHODS

Participants (n = 60) in a virtual synchronous (n = 43) or virtual asynchronous (n = 17) 12-week plant-based nutrition program received restaurant vouchers. Class satisfaction data were collected weekly. Assessments were completed at baseline, 3 months, and 9 months, along with interviews (n = 13) between 3 and 9 months. The costing approach estimated costs per participant. Interviews were coded using a content analysis and constant comparative method.

RESULTS

Participants rated the intervention favorably. Program costs were $198.63/participant, and participants' willingness to pay postintervention was $101.50 ± $63.90. Participants shared satisfaction with course content, the restaurant partnership, and suggestions for future delivery. No changes in participants' percent body weight were observed between 3 and 9 months (P = 0.98), indicating maintenance of 3-month weight loss.

CONCLUSIONS AND IMPLICATIONS

A research-restaurant partnership successfully implemented a nutrition program and generated positive feedback. With the lifting of coronavirus disease 2019 pandemic restrictions, future research can now test alternative implementation methods (in person vs online) in other restaurants.

"It's Gonna Be Okay"-A Qualitative Exploration of the COVID-19 Pandemic's Effects on African American Participants During a Dietary Intervention Study

BACKGROUND

African American adults are at increased risk for chronic diseases. Limited research exists regarding how the COVID-19 pandemic affected African American adults in behavioral interventions.

OBJECTIVE

This study assessed how the early months of the COVID-19 pandemic, before vaccine availability and widespread testing, affected stress, nutrition, and exercise behaviors of African American adults participating in a dietary intervention study.

DESIGN

This was a qualitative interview study conducted with participants from both diet groups as part of the ongoing Nutritious Eating with Soul (NEW Soul) study. NEW Soul is a 2-year, randomized dietary intervention study with participants randomized to follow a vegan (intervention) or low-fat omnivorous diet (control), with both diets focused on soul food.

PARTICIPANTS/SETTING

Participants (n = 20) came from 2 cohorts of the larger intervention study in South Carolina and were purposefully recruited based on high and low attendance at intervention sessions. Participants in the first cohort were near the end of the intervention, and participants in the second cohort were near the mid-point. The interviews were conducted from June to July 2020.

MAIN OUTCOME MEASURES

Outcomes included participants' experiences related to stress, nutrition, and exercise behaviors during the early months of the COVID-19 pandemic.

ANALYSIS

Interviews were recorded and transcribed verbatim. Interview transcripts were coded by two coders using NVivo software. Interviews were coded through content analysis using a constant comparative method.

RESULTS

Participants discussed the following 3 themes in relation to health behaviors: increased stress, change in routines, and advice to follow health goals.

CONCLUSIONS

Findings provide perspectives for designing interventions for African American adults establishing new routines to overcome setbacks and changes in routines created by the COVID-19 pandemic.

COVID-19 Pandemic Associations on Mental and Physical Health in African Americans Participating in a Behavioral Intervention

The COVID-19 pandemic has had disproportionate effects on communities of color, with higher death rates among African Americans (AA). The purpose of this study was to assess associations in African Americans' mental and physical health with the COVID-19 pandemic. Data for this study came from a larger nutrition intervention of AAs in the Southeastern United States, the Nutritious Eating with Soul study. Data collected before and after March 15, 2020 (the day when local South Carolina schools and businesses closed), were analyzed to assess the association of the pandemic on participants' stress, control of healthy eating, physical activity, and body mass index. Repeated measures analysis of covariance using full maximum likelihood estimation to handle missing data was used. At the onset of the COVID-19 pandemic, 150 participants were enrolled in the study (48.2 ± 10.6 years old, 79% female, 75% with college degree or higher). Participants' reporting of stress did not show statistically significant change over time. Cognitive control increased 1.43 points (F = 20.60, p < 0.0001) and body mass index increased 0.72 kg/m2 (F = 10.68, p = 0.001). Future longitudinal studies should investigate how the COVID-19 pandemic continues to present challenges to understanding and improving health among African Americans. The study is registered at www.clinicaltrials.gov NCT03354377.

NEW Soul in the neighborhood-reach and effectiveness of a dissemination and implementation feasibility study

Dissemination and implementation (D&I) studies of dietary interventions for African Americans are limited. Restaurants may be an innovative setting to deliver dietary interventions. Purpose: Assess weight loss, self-efficacy for healthy eating, diet quality, and quality of life in African Americans in two groups: virtual synchronous and virtual asynchronous. Guided by RE-AIM, the Nutritious Eating with Soul @ Rare Variety Café Feasibility study included nutrition education, accountability partners for support, and cooking demonstrations led by a community health worker and was delivered across two cohorts in a non-randomized design. The intervention was conducted over 12 consecutive weekly classes. Due to the COVID-19 pandemic, intervention delivery was online. African Americans between 18-65 years old with overweight/obesity, not currently following a plant-based diet or taking medications to control diabetes, and living in a southeastern city were recruited. Participants completed in-person weight assessments and online surveys at baseline and post-intervention. Linear mixed models analyzed changes in outcomes and differences in 3-month outcomes between groups. All models controlled for age and sex. Regarding Reach, 199 participants expressed interest, and 60 enrolled. Among the full sample, participants decreased body weight -2.6 ± 0.5 kg (p < .0001) and increased self-efficacy 1.6 ± 0.7 points (p = .03). No differences in 3-month outcomes between groups were observed. This D&I feasibility study successfully recruited participants during the COVID-19 pandemic and produced significant results. The successful online intervention delivery compared to in-person suggests the potential for greater D&I in vegan soul food restaurants. As restrictions are loosened, future studies will test in-person delivery.

A 12-Week Randomized Intervention Comparing the Healthy US, Mediterranean, and Vegetarian Dietary Patterns of the US Dietary Guidelines for Changes in Body Weight, Hemoglobin A1c, Blood Pressure, and Dietary Quality among African American Adults

BACKGROUND

The US Dietary Guidelines (USDG) form the basis of nutrition guidelines, but the research informing the 3 USDG dietary patterns (Healthy US-Style [H-US], Mediterranean [Med], and vegetarian [Veg]) has been drawn largely from observational studies among White populations.

OBJECTIVES

The Dietary Guidelines 3 Diets study was a 3-arm, 12-wk randomly assigned intervention among African American (AA) adults at risk of type 2 diabetes mellitus that tested the 3 USDG dietary patterns.

METHODS

The AAs (ages 18-65 y, BMI 25-49.9 kg/m2, and BMI was measured in kg/m2) with ≥3 type 2 diabetes mellitus risk factors were recruited. Weight, HbA1c, blood pressure, and dietary quality (healthy eating index [HEI]) were collected at baseline and 12 wk. In addition, participants attended weekly online classes that were designed using material from the USDG/MyPlate. Repeated measures, mixed models with maximum likelihood estimation, and robust computation of standard errors were tested.

RESULTS

Of the 227 participants screened, 63 were eligible (83% female; age 48.0 ± 10.6 y, BMI 35.9 ± 0.8 kg/m2) and randomly assigned to the Healthy US-Style Eating Pattern (H-US) (n = 21, 81% completion), healthy Mediterranean-style eating pattern (Med) (n = 22, 86% completion), or healthy vegetarian eating pattern (Veg) (n = 20, 70% completion) groups. Within-group, but not between groups, weight loss was significant (-2.4 ± 0.7 kg H-US, -2.6 ± 0.7 kg Med, -2.4 ± 0.8 kg Veg; P = 0.97 between group). There was also no significant difference between groups for changes in HbA1c (0.03 ± 0.05% H-US, -0.10 ± 0.05% Med, 0.07 ± 0.06% Veg; P = 0.10), systolic BP (-5.5 ± 2.7 mmHg H-US, -3.2 ± 2.5 mmHg Med, -2.4 ± 2.9 mmHg Veg; P = 0.70), diastolic blood pressure (-5.2 ± 1.8 mmHg H-US, -2.0 ± 1.7 mmHg Med, -3.4 ± 1.9 mmHg Veg; P = 0.41), or HEI (7.1 ± 3.2 H-US, 15.2 ± 3.1 Med, 4.6 ± 3.4 Veg; P = 0.06). Post hoc analyses showed that the Med group had significantly greater improvements in HEI compared to the Veg group (difference = -10.6 ± 4.6; 95% CI: -19.7, -1.4; P = 0.02).

CONCLUSIONS

The present study demonstrates that all 3 USDG dietary patterns lead to significant weight loss among AA adults. However, none of the outcomes were significantly different between groups. This trial was registered at clinicaltrials.gov as NCT04981847.

Effect of a Plant-Based vs Omnivorous Soul Food Diet on Weight and Lipid Levels Among African American Adults: A Randomized Clinical Trial

IMPORTANCE

More African American individuals die from cardiovascular disease (CVD) than any other chronic disease condition. Despite this disparity, African American individuals are underrepresented in nutrition and CVD interventions.

OBJECTIVE

To compare the effects of an entirely plant-based (vegan) or low-fat omnivorous (omni) diet on change in body weight and lipids during a 2-year intervention.

DESIGN, SETTING, AND PARTICIPANTS

The Nutritious Eating With Soul (NEW Soul) study was a 2-year, randomized clinical trial conducted in 2 cohorts (2018-2020 and 2019-2021) that took place in a university teaching kitchen in Columbia, South Carolina (before March 2020), and via online videoconference sessions (after March 2020). Participants included African American adults aged 18 to 65 years with overweight or obesity (body mass index of 25.0-49.9) and without type 2 diabetes, uncontrolled thyroid disease, recent weight loss, or pregnancy. Data assessors and statisticians were blinded to study condition. Data analysis was performed from March to June 2022.

INTERVENTIONS

The intervention included weekly nutrition classes for 6 months biweekly classes for 6 months, and monthly classes for 12 months. Dietary interventions either emphasized no animal product intake (vegan) or a low-fat omnivorous diet (omni). Both dietary patterns emphasized soul food cuisine (traditional African American southern foodways).

MAIN OUTCOMES AND MEASURES

Primary outcomes included change in body weight and lipid measures at 12 months.

RESULTS

There were 568 participants who completed an online screening questionnaire; 409 were excluded and 159 were randomized (77 to the vegan group and 82 to the omni group). Of the 159 participants (mean [SD] age, 48.4 [10.6] years; 126 female [79%]) who began the study, the main outcome of body weight was obtained for 121 participants (76%) at 12 months. There were no differences in outcomes between groups, including 12-month changes in weight (mean, -2.39 kg [95% CI, -3.48 to -1.30 kg] for the vegan group vs -2.03 kg [95% CI, -3.07 to -1.00 kg] for the omni group; P = .64), total cholesterol (-1.05 mg/dL [95% CI, -9.60 to 7.50 mg/dL] for the vegan group vs 1.66 mg/dL [95% CI, -7.20 to 10.50 mg/dL] for the omni group; P = .67), or low-density lipoprotein cholesterol (mean, -2.56 mg/dL [95% CI, -9.52 to 4.40 mg/dL] for the vegan group vs -0.79 mg/dL [95% CI, -7.98 to 6.40 mg/dL] for the omni group; P = .73). Weight loss at 12 months among cohort 1, whose weight was assessed in 2019 before the COVID-19 pandemic, was significantly greater than that for cohort 2, whose weight was assessed summer 2020 during COVID-19 (-3.45 kg [95% CI, -4.67 to -2.22 kg] vs -1.24 kg [95% CI, -2.24 to -0.25 kg]; P = .01).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial examining weight loss and CVD risk factor reduction among African American adults, there were no differences between the groups, and the magnitude of changes overall was small.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03354377.

Dietary Inflammatory Index and sleep quality and duration among pregnant women with overweight or obesity

STUDY OBJECTIVES

Sleep disturbances, which can worsen during pregnancy, have been linked to inflammatory processes. This study tested the hypothesis that more pro-inflammatory diets during pregnancy are associated with a decrease in sleep quality and shorter sleep duration.

METHODS

The Health in Pregnancy and Postpartum study promoted a healthy lifestyle in pregnant women with pre-pregnancy overweight or obesity (n = 207). Data from <16 weeks and 32 weeks gestation were used. Sleep was measured using BodyMedia's SenseWear® armband. Diet was assessed using two 24-hr dietary recalls. Energy-density Dietary Inflammatory Index (E-DIITM) scores were calculated from micro and macronutrients. Linear mixed-effects models estimated the impact of the E-DII score on sleep parameters.

RESULTS

Women with more pro-inflammatory diets, compared to those with more anti-inflammatory diets, were more likely to be nulliparous (51% vs. 25%, p = 0.03), frequent consumers of fast food (29% vs. 10% consuming on 4-6 days during the previous week, p = 0.01), ever-smokers (21% vs. 6%, p = 0.02), and younger (mean age 29.2 vs. 31.3 years, p = 0.02). For every one-unit increase (i.e., more pro-inflammatory) in the E-DII score, sleep latency increased by 0.69 min (p < 0.01). Among European Americans only, every one-unit higher E-DII was associated with a 2.92-min longer wake-after-sleep-onset (p = 0.02).

CONCLUSION

An E-DII score that is 5 points lower (i.e., more anti-inflammatory) would equate to about 105 min of additional sleep per week among European American women. Anti-inflammatory diets may help to counteract detriments in sleep during pregnancy, especially among European American women. Additional work is needed among African American women.

CLINICAL TRIALS IDENTIFIER

Name: Promoting Health in Pregnancy and Postpartum (HIPP); URL: https://clinicaltrials.gov/ct2/show/NCT02260518; Registration Identifier: NCT02260518.

Effects of a behavioral intervention on physical activity, diet, and health-related quality of life in pregnant women with elevated weight: results of the HIPP randomized controlled trial

BACKGROUND

Physical activity (PA), diet, and health-related quality of life (HRQOL) are related to maternal and infant health, but interventions to improve these outcomes are needed in diverse pregnant women with elevated weight.

METHODS

Health In Pregnancy and Postpartum (HIPP) was a randomized controlled trial. Women who were pregnant (N=219, 44% African American, 56% white) with overweight or obesity but otherwise healthy were randomized to a behavioral intervention grounded in Social Cognitive Theory (n=112) or to standard care (n=107). The intervention group received an in-depth counseling session, a private Facebook group, and 10 content-based counseling calls with accompanying behavioral podcasts followed by weekly or biweekly counseling calls until delivery. The standard care group received monthly mailings and 10 podcasts focused on healthy pregnancy. PA (SenseWear armband), diet (ASA24), and HRQOL (SF-12) measures were obtained from blinded assessors at baseline (<16 weeks) and late pregnancy (32 weeks). Mixed model repeated measures regression models tested treatment (Group x Time) and within-group effects. We hypothesized that intervention participants would have higher levels of PA, a better-quality diet, and higher HRQOL than standard care participants. Exploratory analyses examined whether changes in outcomes over time differed according to whether participants had recommended, excessive, or inadequate weight gain.

RESULTS

Treatment effects favored intervention participants for vegetable intake (d=0.40, p<0.05) and % whole grains (d=0.60, p<0.01). HRQOL mental component improved in both groups, but less in intervention than standard care participants (d=-0.33, p<0.05). Time effects demonstrated that total PA, steps/day, and HRQOL physical component declined significantly in both groups. Within-group effects showed that diet quality significantly improved in intervention participants. Moderate-intensity PA declined significantly in standard care participants, whereas light-intensity PA declined and sedentary behavior increased significantly in intervention participants. Finally, exploratory analyses showed that total PA and light PA increased whereas sedentary behavior decreased among those meeting guidelines for weight gain, with opposite patterns seen among those with excessive or inadequate weight gain.

CONCLUSIONS

The intervention improved several dietary outcomes but had modest impacts on PA and HRQOL, underscoring the challenge of behavior change during pregnancy.

TRIAL REGISTRATION

This trial was registered in ClinicalTrials.gov on 10/09/2014. NCT02260518.

"They Eat What They Eat, I Eat What I Eat": Examining the Perspectives and Experiences of African Americans Who Adopt Plant-Based Diets

Adopting a plant-rich or plant-based diet is one of the major recommendations for addressing obesity, overweight, and related health conditions in the United States. Currently, research on African Americans' food choices in the context of plant-based diets is limited. The primary aim of this study was to understand food-related experiences and perceptions of African Americans who were participating in the Nutritious Eating with Soul (NEW Soul) study, a culturally tailored dietary intervention focused on increasing the consumption of plant-based foods. The roles of gender and ethnicity were also examined to identify how eating patterns were chosen or maintained. Twenty-one African American adults in South Carolina, who were randomly assigned to either a vegan diet (n = 11) or a low-fat omnivorous diet (n = 10) in the NEW Soul study, completed one-on-one, qualitative interviews. Emerging themes included awareness, being in control, and identity. The study revealed that access to social support and coping strategies for addressing negative comments about plant-based food choices may be important components to include in future nutrition interventions focused on African Americans.

Meal timing, distribution of macronutrients, and inflammation among African-American women: A cross-sectional study

Chronic low-grade inflammation is an underlying risk factor for numerous chronic diseases, including cancer. Eating earlier in the day has been associated with a reduction in levels of inflammatory markers and inflammation-related health outcomes (e.g., obesity, metabolic disorders). This cross-sectional study of 249 obese African-American women examined the effect of various mealtime-related factors associated with macronutrient consumption in relation to chronic inflammation and Breast Imaging Reporting and Data System (BI-RAD) readings. During 2011 and 2013, a single 24-hour dietary recall was administered, blood samples were assayed for c-reactive protein (CRP) and interleukin-6 (IL-6), and BI-RAD ratings were assessed to determine the influence of mealtime on chronic inflammation and breast cancer risk score. Multiple linear and logistic regression models were used to assess these relationships. Higher carbohydrate consumption at breakfast was associated with a significantly lower CRP vs. higher carbohydrate consumption at dinner (6.99, vs. 9.56 mg/L, respectively, p = .03). Additionally, every 1-unit increase in percent energy consumed after 5PM resulted in a BI-RAD reading indicating a possibly suspicious abnormality (OR: 1.053, 95% CI: 1.003-1.105), suggesting an increase in breast cancer risk. Timing of energy and macronutrient intake may have important implications for reducing the risk of diseases associated with chronic inflammation.

Beyond Calorie Tracking: A Pilot Trial of a Remotely Delivered Behavioral Weight Loss Intervention Using an Ad Libitum Plant-Based Diet (Preprint)

Background

Many traditional lifestyle interventions use calorie prescriptions, but most individuals have difficulty sustaining calorie tracking and thus weight loss. In contrast, whole food plant-based diets (WFPBDs) have previously shown significant weight loss without this issue. However, most WFPBD interventions are face-to-face and time-intensive, and do not leverage gold standard behavioral strategies for health behavior change.

Objective

This open pilot trial was the first to evaluate the feasibility of a fully featured, remotely delivered behavioral weight loss intervention using an ad libitum WFPBD.

Methods

Over 12 weeks, participants (N=15) with overweight or obesity received a newly designed program that integrated behavioral weight loss and a WFPBD prescription via weekly web-based modules and brief phone coaching calls. Assessments were performed at baseline, midtreatment (6 weeks), and after treatment (12 weeks).

Results

The intervention was rated as highly acceptable (mean 4.40 out of 5, SE 0.18), and attrition was low (6.7%). In all, intention-to-treat analyses revealed that 69% (10.4/15) of the participants lost 5% of their weight (mean –5.89, SE 0.68 kg). Predefined benchmarks for quality of life were met.

Conclusions

A pilot digital behavioral weight loss intervention with a non–energy-restricted WFPBD was feasible, and the mean acceptability was high. Minimal contact time (80-150 minutes of study interventionist time per participant over 12 weeks) led to clinically relevant weight loss and dietary adherence for most participants (10.4/15, 69% and 11.8/15, 79%, respectively), and quality of life improvements (reliable change indices >1.53). We hope that this work will serve as a springboard for future larger scale randomized controlled studies evaluating the efficacy of such programs for weight loss, dietary change, and quality of life.

Trial Registration

ClinicalTrials.gov NCT04892030; https://clinicaltrials.gov/ct2/show/NCT04892030

Examining demographic characteristics and food access indicators from the location of vegan soul food restaurants in the south

Objective: There have been a number of soul food restaurants serving exclusively vegan meals opening up across the country to appeal to African Americans and others interested in eating healthier soul foods. This study determined the number of restaurants serving vegan soul foods in the South and identified the locations of these restaurants in order to understand the characteristics of the surrounding communities that they serve.Design: Two reviewers identified restaurants using standardized search criteria for menu items in the 16 states (and the District of Columbia) that are categorized as being in the South from the Census Bureau. Mean percentage of African Americans, poverty rates, and obesity rates by county where restaurants were located were collected via census data. Restaurants were classified as being in or out of a food desert zone using the United States Department of Agriculture's (USDA) food atlas map (0.5- and 1.0-mile radius). T-tests were conducted to test for differences in the census data between the restaurants that were considered to be in and out of a food desert zone.Results: Overall, 45 restaurants met the inclusion criteria. Counties where restaurants were located had a mean African American population of 36.5 ± 18.5%, mean poverty rate of 15.5 ± 3.85% and mean obesity rate of 26.8 ± 4.8%. More than one third (n = 18, 40.0%) of the restaurants were considered to be in a food desert zone. There were no significant differences in the mean population, obesity, and poverty rates between restaurants classified in a food desert zone and restaurants not located in a food desert zone.Conclusion: A significant number of restaurants were classified in food desert zones, implying their potential to provide healthier meals by serving vegan soul foods to residents in the surrounding neighborhoods. Future work should assess how these restaurants might influence healthier eating habits in their communities.

The IMAGINE Intervention: Impacting Physical Activity, Body Fat, Body Mass Index, and Dietary Inflammatory Index

Background

Many behavior-change interventions focused on nutrition and physical activity (PA) have been implemented to prevent disease and promote optimal health.

Purpose

This study examined changes in PA with Energy-adjusted Dietary Inflammatory Index (E-DII™) and chronic disease risk factors in participants of a multicomponent intervention.

Methods

Data from the Inflammation Management Intervention (IMAGINE) were used. Participants self-selected into the intervention or control group. At baseline and 12 weeks (post-intervention), participants completed three unannounced 24-hour dietary recalls (24HR), anthropometric measures (height, weight), and a dual x-ray absorptiometry scan. PA was measured using Sensewear^® armbands. E-DII scores were calculated from the 24HR. Descriptive statistics and t-tests summarized variables and multiple regression assessed relationships between PA and body mass index (BMI), total body fat percent, and E-DII scores.

Results

Intervention participants increased moderate-to-vigorous PA (MVPA) and lowered BMI, total body fat, and E-DII scores compared to controls. Every 10-minute increase in post-intervention MVPA was associated with 1.6 kg/m² lower BMI (p<0.01) and 2.4% lower body fat percent (p<0.01) among control participants, after adjusting for covariates. Every 10-minute increase in post-intervention MVPA was associated with 0.3 lower (i.e., less inflammatory) post-intervention E-DII (p=0.01) scores among intervention participants, after adjusting for covariates.

Conclusion

Participants who changed dietary intake changed PA. While changes were in expected directions, this intervention's emphasis on dietary behaviors compared to PA may have attenuated the relationship between PA and study outcomes.

Associations between Fasting Duration, Timing of First and Last Meal, and Cardiometabolic Endpoints in the National Health and Nutrition Examination Survey

Background: Research indicates potential cardiometabolic benefits of energy consumption earlier in the day. This study examined the association between fasting duration, timing of first and last meals, and cardiometabolic endpoints using data from the National Health and Nutrition Examination Survey (NHANES). Methods: Cross-sectional data from NHANES (2005–2016) were utilized. Diet was obtained from one to two 24-h dietary recalls to characterize nighttime fasting duration and timing of first and last meal. Blood samples were obtained for characterization of C-reactive protein (CRP); glycosylated hemoglobin (HbA1c %); insulin; glucose; and high-density lipoprotein (HDL), low-density lipoprotein (LDL), and total cholesterol. Survey design procedures for adjusted linear and logistic regression were performed. Results: Every one-hour increase in nighttime fasting duration was associated with a significantly higher insulin and CRP, and lower HDL. Every one-hour increase in timing of the last meal of the day was statistically significantly associated with higher HbA1c and lower LDL. Every one-hour increase in first mealtime was associated with higher CRP (β = 0.044, p = 0.0106), insulin (β = 0.429, p < 0.01), and glucose (β = 0.662, p < 0.01), and lower HDL (β = −0.377, p < 0.01). Conclusion: In this large public health dataset, evidence for the beneficial effect of starting energy consumption earlier in the day on cardiometabolic endpoints was observed.

The Roles of Campus Ministry Leaders: Guiding Students through the Transition to Adulthood

Despite historic existence of campus ministries at universities, little is known about the roles of campus ministry leaders. This research explored campus ministry leaders' engagement with students through interviews (n = 19). Analysis indicated interviewees' work includes building relationships with students, navigating the secular context of a public university, and tensions with others in campus ministry. Interviewees reported emotional strain resulting from extensive caring labor. Focused support for campus ministers would benefit both leaders and students.

Associations of maternal stress and/or depressive symptoms with diet quality during pregnancy: a narrative review

BACKGROUND

Pregnancy can be a stressful time for many women; however, it is unclear if higher stress and depressive symptoms are associated with poorer diet quality during pregnancy.

OBJECTIVE

The aims for this narrative review were to (1) synthesize findings of original, peer-reviewed studies that examined associations of stress and/or depressive symptoms with diet quality during pregnancy; (2) review the measurement tools used to assess stress, depressive symptoms, and diet quality; (3) identify current gaps in the extant literature; and (4) offer recommendations for future research.

METHODS

A search strategy was used to identify peer-reviewed manuscripts published between January 1997 and October 2018, using the following databases: PubMed, CINAHL Complete, PsycINFO, Academic Search Complete, and Psychology & Behavioral Sciences Collection. The search was updated December 2019. Two reviewers independently assessed title, abstract, and full-text of the studies that met the inclusion criteria. Data were extracted and a quality assessment was conducted.

RESULTS

Twenty-seven observational studies were identified in this review (21 cross-sectional and 6 longitudinal). In 22 studies, higher stress and/or depressive symptoms were associated with poorer diet quality or unhealthy dietary patterns; 5 studies found no association. Findings are mixed and inconclusive regarding the relationship among stress, depressive symptoms, and food groups related to diet quality and frequency of fast-food consumption.

CONCLUSIONS

The current data suggest stress and depressive symptoms may be a barrier to proper diet quality during pregnancy; however, variability in the assessment tools, timing of assessments, and use of covariates likely contribute to the inconsistency in study findings. Gaps in the literature include limited use of longitudinal study designs, limited use of comprehensive diet-quality indices, underrepresentation of minority women, and lack of multilevel theoretical frameworks. Studies should address these factors to better assess associations of stress and/or depressive symptoms with diet quality during pregnancy.

Stress and Depressive Symptoms Are Not Associated with Overall Diet Quality, But Are Associated with Aspects of Diet Quality in Pregnant Women in South Carolina

BACKGROUND

Poor mental health may hinder diet quality in pregnancy.

OBJECTIVE

This study 1) examined whether stress and depressive symptoms are associated with diet quality (via Healthy Eating Index [HEI] 2015 total scores and dietary intake of food groups/nutrients that align with HEI-2015 components) and 2) tested race as a moderator in the relationship between mental health and diet quality.

DESIGN

This was a cross-sectional analysis of baseline data from a randomized controlled trial collected January 2015 through January 2019 in Columbia, South Carolina. Trained staff administered demographic and psychosocial questionnaires and conducted anthropometric measures. Participants completed two 24-hour dietary recalls, which were self-administered (one on-site, one at home).

PARTICIPANTS

The Health in Pregnancy and Postpartum study was a randomized controlled trial targeting excessive gestational weight gain among pregnant women with overweight/obesity (N = 228).

MAIN OUTCOME MEASURES

The HEI-2015 total scores and food groups/nutrients that align with HEI-2015 were calculated.

STATISTICAL ANALYSES PERFORMED

Multiple linear regression models were used to estimate the relationship between mental health and HEI-2015 total scores and dietary intake of food groups or nutrients that align with HEI-2015 components. Multiplicative interaction terms of stress or depressive symptoms with race were used to determine moderation.

RESULTS

Participants' diet quality was suboptimal (M = 52.0 ± 11.7; range, 27-85). Stress was negatively associated with HEI-2015 total scores (crude but not adjusted model). Stress scores were positively associated with consumption of dairy, refined grains, and added sugars and negatively associated with total protein foods. Depressive symptoms were positively associated with consumption of dairy, refined grains, and saturated fats. Race was not a moderator.

CONCLUSIONS

Diet quality was poor overall, but stress and depressive symptoms were not associated with HEI-2015 total scores in adjusted models. Excluding dairy, stress and depressive symptoms were associated with the consumption of food groups or nutrients related to worse diet quality. These relationships should be examined longitudinally to help establish causality and inform future interventions.

Effective recruitment strategies for African-American men and women: the Nutritious Eating with Soul study

Previous studies have found it challenging to recruit African-American (AA) participants into health education research studies. The goal of this article is to describe the recruitment methods used for the Nutritious Eating with Soul (NEW Soul) study, a 2-year randomized behavioral health education intervention, conducted in two cohorts, with emphasis on methods used for reaching men. Participants indicated how they learned about the study on an online screening questionnaire from a list of the recruitment strategies we employed. Due to limited recruitment of men in Cohort 1, recruitment strategies for Cohort 2 focused on reaching men. Across the two cohorts, a total of 568 (23% men) participants completed the online screener and 159 (21% men) completed all baseline assessments and enrolled in the study. The most effective methods for completing screening questionnaires were radio ads, referrals from friends and family, TV interviews, social media posts and community events. Men were primarily recruited via radio ads, whereas women were more often recruited through TV and social media. Radio was an effective way to recruit AA adults into nutrition interventions, particularly men. In addition, low-cost methods, such as personal referrals, social media posts and community events were also effective strategies.

Healthy Food Density is Not Associated With Diet Quality Among Pregnant Women With Overweight/Obesity in South Carolina

OBJECTIVE

Examine the association and moderating effect of residential location (urban/rural) on the relationship between neighborhood healthy food density and diet quality.

DESIGN

Cross-sectional analysis of baseline data from the Health in Pregnancy and Postpartum study, a randomized trial designed to prevent excessive gestational weight gain.

PARTICIPANTS

Pregnant women in South Carolina with prepregnancy overweight/obesity (n = 228).

MAIN OUTCOME MEASURES

Healthy Eating Index-2015 (HEI) was used to measure diet quality from 2 24-hour dietary recalls. The HEI total scores and 11 binary HEI components (those that met the standard for maximum component score vs those that did not) were calculated as dependent variables.

ANALYSIS

Multiple linear and logistic regression models were used to examine the association between healthy food density and HEI total scores and meeting the standards for maximum component scores. Healthy food density × residential location tested for moderation. P < 0.05 indicated significance.

RESULTS

Participants' diet quality was suboptimal (mean, 52.0; SD, 11.7; range, 27-85). Healthy food density was not significantly related to HEI total scores or components, and residential location was not a moderator.

CONCLUSIONS AND IMPLICATIONS

Diet quality was suboptimal, and there was no relationship between healthy food density and diet quality among Health in Pregnancy and Postpartum study participants. These data support examining behavioral factors that could influence diet quality.

Healthy Eating and Physical Activity Interventions in Faith-Based Settings: A Systematic Review Using the Reach, Effectiveness/Efficacy, Adoption, Implementation, Maintenance Framework

CONTEXT

Faith-based health interventions may improve obesity-related health behaviors, including healthy eating and physical activity. However, the generalizability of results and comprehensiveness of reporting for critical design elements sufficient for large-scale implementation and broad public health impact are unclear. This review assesses the degree to which faith-based healthy eating and physical activity programs report intervention elements using the reach, effectiveness/efficacy, adoption, implementation, maintenance framework.

EVIDENCE ACQUISITION

A systematic literature search was initiated in June 2017, and updated searches concluded in December 2019. Articles were included if they (1) were published in an English language peer-reviewed journal, (2) were conducted in the U.S., (3) were interventions, (4) included individual-level healthy eating or physical activity behavioral outcomes, (5) were conducted within an organizational setting, and (6) were faith-based. Intervention elements were extracted, and comprehensiveness of reporting for intervention elements was assessed according to reach, effectiveness/efficacy, adoption, implementation, maintenance domains.

EVIDENCE SYNTHESIS

A total of 38 interventions (46 articles) met the inclusion criteria. Most were conducted at the individual/interpersonal level (66%); few included additional elements of policy or environmental change (34%). Most interventions showed favorable changes in at least 1 health behavior outcome. No intervention addressed all reach, effectiveness/efficacy, adoption, implementation, maintenance indicators. The mean level of reporting was low for all reach, effectiveness/efficacy, adoption, implementation, maintenance dimensions (reach: 2.3 of 5 [SD=1.0] indicators, efficacy/effectiveness: 2.3 of 4 [SD=0.8] indicators, adoption: 3.7 of 6 [SD=1.4] indicators, implementation: 1.3 of 3 [SD=0.6] indicators, maintenance: 0.3 of 3 [SD=0.5] indicators).

CONCLUSIONS

Studies reporting outcomes of faith-based interventions to improve healthy eating/physical activity behaviors lack the information necessary to understand the potential for broad dissemination and implementation in community settings. Future studies should report on the considerations for the translation and dissemination of evidence-based programs to expand public health impact.

The role of self-efficacy and information processing in weight loss during an mHealth behavioral intervention

Self-efficacy (SE) and information processing (IP) may be important constructs to target when designing mHealth interventions for weight loss. The goal of this study was to examine the relationship between SE and IP with weight loss at six-months as part of the Dietary Interventions Examining Tracking with mobile study, a six-month randomized trial with content delivered remotely via twice-weekly podcasts. Participants were randomized to self-monitor their diet with either a mobile app (n = 42) or wearable Bite Counter device (n = 39). SE was assessed using the Weight Efficacy Life-Style Questionnaire and the IP variables assessed included user control, cognitive load, novelty, elaboration. Regression analysis examined the relationship between weight loss, SE change & IP at six months. Results indicate that elaboration was the strongest predictor of weight loss (ß =−0.423, P = 0.011) among all SE & IP variables and that for every point increase in elaboration, participants lost 0.34 kg body weight.

Church Leaders' Views of Obesity Prevention Efforts for Children and Youth

OBJECTIVE

To examine church leaders' views on the role of faith-based organizations in promoting healthy eating and physical activity in children.

DESIGN

Qualitative research using semi-structured in-depth interviews.

SETTING

South Carolina.

PARTICIPANTS

Leaders (n = 26) from United Methodist churches (n = 20).

PHENOMENON OF INTEREST

Perceptions of health promotion efforts for children in faith-based settings, including primary health concerns, perceived opportunities, partnerships, and the relationship of these efforts to the overall church mission.

ANALYSIS

Interviews were transcribed verbatim and coded using a constant comparative method.

RESULTS

Five themes emerged related to (1) multiple concerns about health issues facing children; (2) existing church structures influencing health behaviors; (3) potential partnerships to address children's health; (4) importance of role models; and (5) the need for a tailored approach.

CONCLUSIONS AND IMPLICATIONS

Church leaders viewed childhood health behaviors as an important area of concern for the church and identified links between physical and spiritual health. They identified multiple existing and potential organizational and community structures as important in improving healthy eating and physical activity. Faith-based organizations can play an important role in developing and delivering health programming for children but desired assistance through partnerships with subject matter experts.

Turn up the healthy eating and activity time (HEAT): Physical activity outcomes from a 4-year non-randomized controlled trial in summer day camps

Summer day camps (SDCs) serve over 14 million children in the U.S. and are well-positioned to help children accumulate the guideline of 60 min per day (60 min/d) of moderate-to-vigorous physical activity (MVPA). The purpose of this study was to evaluate a multi-component intervention to increase the percentage of children meeting 60 min/d of MVPA. Twenty SDCs serving 3524 children (7.9 yrs., 46.2% girls, 66.1% non-Hispanic Black) participated in a 4-summer non-randomized two-group intervention. Children's accelerometer-derived MVPA was collected using accelerometers worn on the non-dominant wrist. SDCs were assigned to either 2 summers of intervention (n = 10, no intervention summer 2015, intervention summer 2016 and 2017) or 1 summer of intervention (n = 10, no intervention summer 2015 and 2016, intervention summer 2017). The final summer (July 2018) was a no intervention follow-up. Multilevel mixed effects regression models estimated changes in percent of children meeting 60 min/d of MVPA. Across all summers and SDCs, children accumulated an average of 89.2 min/day (±22.5) of MVPA. The likelihood of meeting the 60 min/d MVPA guideline was not different during intervention versus baseline summers for boys or girls (p > 0.05). Girls and boys were 3.5 (95CI = 1.5, 8.1) and 3.7 (95CI = 1.6, 8.4) times more likely to meet the 60 min/d guideline during intervention summers versus follow-up, respectively. The intervention was not successful at increasing the percentage of children meeting the 60 min/d MVPA guideline. However, children attending SDCs accumulated substantial amounts of MVPA thus efforts should focus on making SDCs an accessible setting for all children.

Defining Adherence to Mobile Dietary Self-Monitoring and Assessing Tracking Over Time: Tracking at Least Two Eating Occasions per Day Is Best Marker of Adherence within Two Different Mobile Health Randomized Weight Loss Interventions

BACKGROUND

Mobile dietary self-monitoring methods allow for objective assessment of adherence to self-monitoring; however, the best way to define self-monitoring adherence is not known.

OBJECTIVE

The objective was to identify the best criteria for defining adherence to dietary self-monitoring with mobile devices when predicting weight loss.

DESIGN

This was a secondary data analysis from two 6-month randomized trials: Dietary Intervention to Enhance Tracking with Mobile Devices (n=42 calorie tracking app or n=39 wearable Bite Counter device) and Self-Monitoring Assessment in Real Time (n=20 kcal tracking app or n=23 photo meal app).

PARTICIPANTS/SETTING

Adults (n=124; mean body mass index=34.7±5.6) participated in one of two remotely delivered weight-loss interventions at a southeastern university between 2015 and 2017.

INTERVENTION

All participants received the same behavioral weight loss information via twice-weekly podcasts. Participants were randomly assigned to a specific diet tracking method.

MAIN OUTCOME MEASURES

Seven methods of tracking adherence to self-monitoring (eg, number of days tracked, and number of eating occasions tracked) were examined, as was weight loss at 6 months.

STATISTICAL ANALYSES PERFORMED

Linear regression models estimated the strength of association (R²) between each method of tracking adherence and weight loss, adjusting for age and sex.

RESULTS

Among all study completers combined (N=91), adherence defined as the overall number of days participants tracked at least two eating occasions explained the most variance in weight loss at 6 months (R²=0.27; P<0.001). Self-monitoring declined over time; all examined adherence methods had fewer than half the sample still tracking after Week 10.

CONCLUSIONS

Using the total number of days at least two eating occasions are tracked using a mobile self-monitoring method may be the best way to assess self-monitoring adherence during weight loss interventions. This study shows that self-monitoring rates decline quickly and elucidates potential times for early interventions to stop the reductions in self-monitoring.

The effects of meal-timing on self-rated hunger and dietary inflammatory potential among a sample of college students

College is an important time for young adults to establish healthy eating habits since students are at risk for gaining weight during the college years. An emerging area of research is examining the effect of meal-timing, which involves the timing of food intake throughout the day, in an effort to improve satiety and bodyweight. The purpose of this study was to examine the use of meal-timing among a sample of college students and to assess what aspects from an intervention could help them to adhere to meal-timing long term. Participants were randomly assigned to either a daytime group (≤30% total kcals after 5 pm) or a nighttime group (≥50% total kcals after 5 pm). After completing the intervention, almost half of participants (49%) reported they could adhere to meal-timing long-term. Having more resources that support meal-timing are needed to help students potentially achieve a healthy weight and prevent chronic diseases.

Impact of a 12-month Inflammation Management Intervention on the Dietary Inflammatory Index, inflammation, and lipids

BACKGROUND AND AIMS

The objective of this study was to assess the feasibility (ability to recruit participants and develop the 12-month intervention), acceptability (retention of participants in the intervention), and impact on systemic inflammation and Dietary Inflammatory Index (DII®) scores over a 12-month DII-based intervention.

METHODS

Adults were recruited to participate in a self-selection trial (intervention: n = 61, in-person classes; control: n = 34, newsletters). Classes included participatory cooking and dietary recommendations focused on consuming a plant-based diet rich in anti-inflammatory foods (spices, vegetables, etc.). Changes in markers of inflammation, lipids, and DII were analyzed using general linear models with repeated measurements.

RESULTS

At 3 months, intervention participants had significantly lower DII scores (-2.66 ± 2.44) compared to controls (-0.38 ± 2.56) (p < 0.01); but not at 12 months (P = 0.10). The only biomarker to approach a significant group effect or group-by-time interaction was CRP (P = 0.11 for the group-by-time interaction). CRP decreased by -0.65 mg/L (95%CI = 0.10-1.20, P = 0.02) at 12 months in the intervention group; no significant decrease was seen for the control group. With both groups combined at 3 months, those with the greatest decrease/improvement in DII score (tertile 1) compared with those whose scores increased (tertile 3) had greater reductions in CRP (-1.09 vs. +0.52 mg/L, P = 0.04), total cholesterol (-9.38 vs. +12.02 mg/dL, P = 0.01), and LDL cholesterol (-11.99 vs. +7.16 mg/dL, P = 0.01).

CONCLUSIONS

Although the intervention group had reductions in DII and CRP, main inflammation and lipid outcomes did not differ between groups. Overall, those participants with the largest reduction in DII scores had the largest reductions in CRP and LDL and total cholesterol. Future interventions may need to have more components in place to support maintenance and continued reductions in the DII. CLINICALTRIALS.

GOV IDENTIFIER

NCT02382458.

Children's Obesogenic Behaviors During Summer Versus School: A Within-Person Comparison

BACKGROUND

Evidence consistently shows children in the United States gain 3 to 5 times more weight during summer vacation (∼2.5 months) compared to the 9-month school year. The purpose of this study is to examine within-child differences in 4 obesogenic behaviors (physical activity [PA], sedentary/screen-time, diet, and sleep) during school versus summer.

METHODS

We used a repeated-measures within-subjects design. Children (N = 30 mean age = 8.2 years; 57% female; 37% overweight/obese; 100% African American) wore accelerometers on the nondominant wrist for 24 hr/d over 9 consecutive days during school and summer of 2016 to capture PA, sedentary time, and sleep. Parents completed a daily diary to report bed/wake times, diet, and screen-time of their child each day. Mixed-effect models compared summer and school behaviors.

RESULTS

Children spent more time sedentary (69% vs 67% of wake wear time), less time in light PA (25% vs 23% of wake wear time), had higher screen-time (242 vs 123 minutes/day), slept longer (428 vs 413 minutes/night), and consumed more sugar-based foods (6 days vs 2.5 days/week) and fruit (7 days vs 4.7 days/week) during summer compared to school (p < .05).

CONCLUSION

Initial evidence suggests children are displaying multiple unfavorable obesogenic behaviors during summer compared to school that may contribute to accelerated weight gain during summer.

The Electronic Community Park Audit Tool (eCPAT): Exploring the Use of Mobile Technology for Youth Empowerment and Advocacy for Healthy Community Policy, Systems, and Environmental Change

Empowering and engaging youth in advocacy and participatory action research (PAR) for healthy community environments is an emerging approach to reducing the childhood obesity epidemic. Technology is a promising strategy for engaging youth in such efforts. The Community Park Audit Tool (CPAT) is user-friendly tool for evaluating the ability of parks to promote youth physical activity. Recently an electronic version of the tool (eCPAT) was developed and validated. The purpose of this study was to explore the use of eCPAT mobile technology on youth empowerment and advocacy. This study examined tool usability, youths' technology access, use, and readiness for PAR efforts, effectiveness of mobile technology on youth empowerment and advocacy, interaction effects between tool format and regular technology use, and tool format preferences. Youth ages 11-18 years were recruited and randomized into one of three study conditions: Control (no audit), paper (CPAT), and mobile technology (eCPAT). Intervention youth completed two park audits using assigned format. A subsample of youth in the Control group completed both CPAT and eCPAT audits for comparison. Independent samples t-tests and MANCOVAs explored differences in post-project levels of tool usability and empowerment and advocacy scores between groups. Multivariate linear regression analysis explored the interaction between Control, Paper, or eCPAT group membership and mean technology use in predicting empowerment and advocacy. Youth (n = 124) completed pre and post surveys. The majority of youth had access to technology (smartphone 77.4%, tablet/iPad 67.7%). Youth used mobile technology at least once a day to use apps (M = 7.8, SD = 3.2), browse the web (M = 6.3, SD = 3.3), and search for information (M = 6.3, SD = 3.5). Youth were also ready and willing to use technology for PAR (M = 3.42-3.59). No main or interaction effects were found for post-project levels of youth empowerment or advocacy. However, the eCPAT tool had high usability scores, was better liked, and was preferred by youth over paper-pencil methods. Mobile technologies are ubiquitous and a preferred strategy among youth for engagement in community change. Future studies should explore mobile technology as a potential strategy for engaging youth in ongoing PAR efforts to achieve successful engagement and advocacy in community healthy environmental change.

Baseline markers of inflammation, lipids, glucose, and Dietary Inflammatory Index scores do not differ between adults willing to participate in an intensive inflammation reduction intervention and those who do not

BACKGROUND:

Chronic inflammation is associated with numerous chronic diseases and can be managed with diet.

AIM:

The purpose of this study was to examine differences in baseline characteristics and plasma inflammation levels between two groups of participants that participated in an intensive, lifestyle intervention or a remotely delivered intervention. This work also assessed the association between Dietary Inflammatory Index (DII)^® scores and participants' inflammatory and metabolic biomarkers at baseline.

METHOD:

Ninety-five participants (61 intervention, 34 control) chose to enroll in either a 12-month intervention consisting of a face-to-face nutrition, physical activity, and stress management intervention or a remotely-delivered intervention (control group) focusing on general cancer prevention. The intervention group met at the University of South Carolina for classes and the control group had materials emailed to them. A quantile regression was used to compare participants' high-sensitivity C-reactive protein and interleukin-6 levels. Multiple linear regression was used to determine the association between DII scores and biomarkers.

RESULTS:

There were significant differences in age, body mass index, body fat percentage, and blood pressure between groups, but there were no differences in levels of inflammatory biomarkers. Values of interleukin-6 at the 90th percentile of its distribution were 8.31 pg/ml higher among those in DII quartile 4 compared with quartile 1 ( p = 0.02). All other outcomes were not significant.

CONCLUSION:

Given similar levels of inflammatory biomarkers, participants opting for the control group would also have benefited from a more intensive lifestyle intervention focusing on reducing inflammation.

Economic evaluation of a group randomized controlled trial on healthy eating and physical activity in afterschool programs

Limited information is available on the cost-effectiveness of interventions to achieve healthy eating and physical activity policies in afterschool programs (ASPs). The objective of this study is to present the costs associated with a comprehensive intervention in ASPs. Intervention delivery inputs (IDIs) associated with a group randomized delayed treatment controlled trial involving 20 ASPs serving >1700 children (5-12yrs) were catalogued prospectively across 2-years (2014-2015). IDIs, analyzed 2015, were expressed as increases in per-child per-week enrollment fees based on a 34-week school year in US$. Total IDIs for year-1 were $15,058 (+$0.58/child/week enrollment fee). In year-2, total costs were $13,828 (+$0.52/child/week) for the delayed group and $7916 (+$0.30/child/week) for the immediate group, respectively. Site leader and staff hourly wages represented 11-17% and 45-46% of initial training costs; travel and trainer wages represented 31-42% and 50-58% of booster costs. Overall, a 1% increase in boys and girls, separately, accumulating 30 mins/d of moderate-to-vigorous physical activity ranged from $0.05 to $0.26/child/week, while a one-day increase in serving a fruit/vegetable or water, or not serving sugar-added foods/beverages ranged from $0.16 to $0.87/child/week. Costs associated with implementing the intervention were minimal. Additional efforts to reduce costs and improve intervention effectiveness are necessary.

Erratum: The Dietary Intervention to Enhance Tracking with Mobile Devices (DIET Mobile) Study: A 6-Month Randomized Weight Loss Trial

OBJECTIVE:

To examine the use of two different mobile dietary self-monitoring methods for weight loss.

METHODS:

Adults with overweight (n = 81; mean BMI 34.7 ± 5.6 kg/m²) were randomized to self-monitor their diet with a mobile app (App, n = 42) or wearable Bite Counter device (Bite, n = 39). Both groups received the same behavioral weight loss information via twice-weekly podcasts. Weight, physical activity (International Physical Activity Questionnaire), and energy intake (two dietary recalls) were assessed at 0, 3, and 6 months.

RESULTS:

At 6 months, 75% of participants completed the trial. The App group lost significantly more weight (−6.8 ± 0.8 kg) than the Bite group (−3.0 ± 0.8 kg; group × time interaction: P < 0.001). Changes in energy intake (kcal/d) (−621 ± 157 App, −456 ± 167 Bite; P = 0.47) or number of days diet was tracked (90.7 ± 9.1 App, 68.4 ± 9.8 Bite; P = 0.09) did not differ between groups, but the Bite group had significant increases in physical activity metabolic equivalents (+2015.4 ± 684.6 min/wk; P = 0.02) compared to little change in the App group (−136.5 ± 630.6; P = 0.02). Total weight loss was significantly correlated with number of podcasts downloaded (r = −0.33, P < 0.01) and number of days diet was tracked (r = −0.33, P < 0.01).

CONCLUSIONS:

While frequency of diet tracking was similar between the App and Bite groups, there was greater weight loss observed in the App group.

Byte by Bite: Use of a mobile Bite Counter and weekly behavioral challenges to promote weight loss

The goal of this study was to examine the usability and feasibility of the mobile Bite Counter (a watch-like device that detects when a user consumes food or beverage) and the impact of weekly behavioral challenges on diet and physical activity outcomes. Overweight (mean BMI 31.1±4.9 kg/m²) adults (n=12) were recruited to participate in a four-week study to test both the usability and feasibility of using the device as part of a behavioral weight loss intervention. Participants were instructed to self-monitor number of bites/day using the Bite Counter, attend weekly group sessions, and listen to weekly podcasts. Participants were given weekly challenges: use a daily bite limit goal (wk1), turn off Bite Counter when fruits/vegetables are consumed (wk2), self-monitor kilocalories vs. bites (wk3), and receive a 10 bites/day bonus for every 30 minutes of exercise (wk4). Participants lost a mean of -1.2±1.3 kg. Only the wk3 challenge produced significant differences in kcal change (wk3 1302±120 kcal/day vs. baseline 2042±302 kcal/d, P<0.05). Bite Counter use was significantly correlated with weight loss (r= -0.58, P<0.05). Future studies should examine the use of the Bite Counter and impact of behavioral challenges over a longer period of time in a controlled study.

The Dietary Intervention to Enhance Tracking with Mobile Devices (DIET Mobile) Study: A 6-Month Randomized Weight Loss Trial

OBJECTIVE

To examine the use of two different mobile dietary self-monitoring methods for weight loss.

METHODS

Adults with overweight (n = 81; mean BMI 34.7 ± 5.6 kg/m² ) were randomized to self-monitor their diet with a mobile app (App, n = 42) or wearable Bite Counter device (Bite, n = 39). Both groups received the same behavioral weight loss information via twice-weekly podcasts. Weight, physical activity (International Physical Activity Questionnaire), and energy intake (two dietary recalls) were assessed at 0, 3, and 6 months.

RESULTS

At 6 months, 75% of participants completed the trial. The App group lost significantly more weight (-6.8 ± 0.8 kg) than the Bite group (-3.0 ± 0.8 kg; group × time interaction: P < 0.001). Changes in energy intake (kcal/d) (-621 ± 157 App, -456 ± 167 Bite; P = 0.47) or number of days diet was tracked (90.7 ± 9.1 App, 68.4 ± 9.8 Bite; P = 0.09) did not differ between groups, but the Bite group had significant increases in physical activity metabolic equivalents (+2015.4 ± 684.6 min/wk; P = 0.02) compared to little change in the App group (-136.5 ± 630.6; P = 0.02). Total weight loss was significantly correlated with number of podcasts downloaded (r = -0.33, P < 0.01) and number of days diet was tracked (r = -0.33, P < 0.01).

CONCLUSIONS

While frequency of diet tracking was similar between the App and Bite groups, there was greater weight loss observed in the App group.

Understanding differences between summer vs. school obesogenic behaviors of children: the structured days hypothesis

Background

Although the scientific community has acknowledged modest improvements can be made to weight status and obesogenic behaviors (i.e., physical activity, sedentary/screen time, diet, and sleep) during the school year, studies suggests improvements are erased as elementary-age children are released to summer vacation. Emerging evidence shows children return to school after summer vacation displaying accelerated weight gain compared to the weight gained occurring during the school year. Understanding how summer days differ from when children are in school is, therefore, essential.

Discussion

There is limited evidence on the etiology of accelerated weight gain during summer, with few studies comparing obesogenic behaviors on the same children during school and summer. For many children, summer days may be analogous to weekend days throughout the school year. Weekend days are often limited in consistent and formal structure, and thus differ from school days where segmented, pre-planned, restrictive, and compulsory components exist that shape obesogenic behaviors. The authors hypothesize that obesogenic behaviors are beneficially regulated when children are exposed to a structured day (i.e., school weekday) compared to what commonly occurs during summer. This is referred to as the ‘Structured Days Hypothesis’ (SDH). To illustrate how the SDH operates, this study examines empirical data that compares weekend day (less-structured) versus weekday (structured) obesogenic behaviors in U.S. elementary school-aged children. From 190 studies, 155 (~80%) demonstrate elementary-aged children’s obesogenic behaviors are more unfavorable during weekend days compared to weekdays.

Conclusion

In light of the SDH, consistent evidence demonstrates the structured environment of weekdays may help to protect children by regulating obesogenic behaviors, most likely through compulsory physical activity opportunities, restricting caloric intake, reducing screen time occasions, and regulating sleep schedules. Summer is emerging as the critical period where childhood obesity prevention efforts need to be focused. The SDH can help researchers understand the drivers of obesogenic behaviors during summer and lead to innovative intervention development.

Children's Moderate to Vigorous Physical Activity Attending Summer Day Camps

INTRODUCTION

National physical activity standards call for all children to accumulate 60 minutes/day of moderate to vigorous physical activity (MVPA). The contribution of summer day camps toward meeting this benchmark is largely unknown. The purpose of this study was to provide estimates of children's MVPA during summer day camps.

METHODS

Children (n=1,061, 78% enrollment; mean age, 7.8 years; 46% female; 65% African American; 48% normal weight) from 20 summer day camps wore ActiGraph GT3x+ accelerometers on the wrist during camp hours for up to 4 non-consecutive days over the summer of 2015 (July). Accumulated MVPA at the 25th, 50th, and 75th percentile of the distribution was estimated using random-effects quantile regression. All models were estimated separately for boys and girls and controlled for wear time. Minutes of MVPA were dichotomized to ≥60 minutes/day of MVPA or <60 minutes/day to estimate percentage of boys and girls meeting the 60 minutes/day guideline. All data were analyzed in spring 2016.

RESULTS

Across the 20 summer day camps, boys (n=569) and girls (n=492) accumulated a median of 96 and 82 minutes/day of MVPA, respectively. The percentage of children meeting 60 minutes/day of MVPA was 80% (range, 41%-94%) for boys and 73% (range, 30%-97%) for girls.

CONCLUSIONS

Summer day camps are a setting where a large portion of boys and girls meet daily physical activity guidelines. Public health practitioners should focus efforts on making summer day camps accessible for children in the U.S.

Choosing between responsive-design websites versus mobile apps for your mobile behavioral intervention: presenting four case studies

Both mobile apps and responsive-design websites (web apps) can be used to deliver mobile health (mHealth) interventions, but it can be difficult to discern which to use in research. The goal of this paper is to present four case studies from behavioral interventions that developed either a mobile app or a web app for research and present an information table to help researchers determine which mobile option would work best for them. Four behavioral intervention case studies (two developed a mobile app, and two developed a web app) presented include time, cost, and expertise. Considerations for adopting a mobile app or a web app-such as time, cost, access to programmers, data collection, security needs, and intervention components- are presented. Future studies will likely integrate both mobile app and web app modalities. The considerations presented here can help guide researchers on which platforms to choose prior to starting an mHealth intervention.

Trading pounds for points: Engagement and weight loss in a mobile health intervention

Objective

The objective of this study was to describe participant engagement and examine predictors of weight loss and points earned through the point-based incentive system of the Social Pounds Off Digitally (POD) app.

Materials and methods

Overweight and obese adults with Android smartphones/tablets (body mass index 25-49.9 kg/m²; N = 24) were recruited for a 3-month weight loss intervention. Participants completed a survey assessing demographics and personality and had their weight measured. Participants received the content of the intervention via podcasts and used the Social POD app to self-monitor diet, physical activity, and weight. The Social POD app contained: tracking features; in-app notifications to track; pre-set goals for tracking; newsfeed for updates on others' goal attainment; ability to earn and track points for usage (exchanged for study-provided prizes); and a message screen. Analyses examined relationships between percent weight loss, personality characteristics, and total points earned.

Results

A total of 4843 points were earned (mean = 202 ± 105 points/participant). Most participants earned all three prizes (62.5%), followed by two prizes (21%), no prizes (12.5%), and one prize (4%). Total points earned significantly predicted percent weight loss (B = -0.02, p = .01), and higher conscientiousness significantly predicted greater total points earned (B = 10.27, p = .01), but other personality characteristics assessed did not.

Conclusion

A mobile app yielded moderately high participant engagement, as demonstrated by points earned. Earning points was significantly associated with percent weight loss, and conscientiousness was significantly associated with total points earned. Future research should examine whether point systems impact health behavior and weight loss when rewards are discontinued.

Clinical trial registration number

NCT02344836.

First year physical activity findings from turn up the HEAT (Healthy Eating and Activity Time) in summer day camps

BACKGROUND

Summer day camps (SDCs) serve 14 million children yearly in the U.S. and aim to provide participating children with 60 minutes of moderate-to-vigorous physical activity (MVPA). This study evaluated an intervention designed to increase the percent of children meeting this MVPA guideline.

DESIGN

Two-group, pre-post quasi-experimental.

SETTING/PARTICIPANTS

Twenty SDCs serving 1,830 children aged 5-12 years were assigned to MVPA intervention (n = 10) or healthy eating attention control (n = 10).

INTERVENTION

The STEPs (Strategies to Enhance Practice) intervention is a capacity-building approach grounded in the Theory of Expanded, Extended and Enhanced Opportunities. Camp leaders and staff receive training to expand (e.g., introduction of activity breaks/active field trips), extend (e.g., schedule minimum of 3 hours/day for PA opportunities), and enhance (e.g., maximize MVPA children accumulate during schedule activity) activity opportunities. Camps in the comparison condition received support for improving the types of foods/beverages served.

MAIN OUTCOME MEASURES

Percent of children accumulating the 60min/d MVPA guideline at baseline (summer 2015) and post-test (summer 2016) measured via wrist-accelerometry.

RESULTS

Multilevel logistic regression conducted fall 2016 indicated boys and girls attending intervention SDCs were 2.04 (95CI = 1.10,3.78) and 3.84 (95CI = 2.02,7.33) times more likely to meet the 60min/d guideline compared to boys and girls attending control SDCs, respectively. This corresponded to increases of +10.6% (78-89%) and +12.6% (69-82%) in the percentage of boys and girls meeting the guideline in intervention SDCs, respectively. Boys in comparison SDCs increased by +1.6% (81-83%) and girls decreased by -5.5% (76-71%). Process data indicated intervention SDCs successfully extended and enhanced PA opportunities, but were unable to expand PA opportunities, compared to control SDCs.

CONCLUSIONS

Although substantial proportions of children met the MVPA guideline at baseline, no SDCs ensured all children met the guideline. This intervention demonstrated that, with support, SDCs can help all children in attendance to accumulate their daily recommended 60min MVPA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02161809.

Is a Picture Worth a Thousand Words? Few Evidence-Based Features of Dietary Interventions Included in Photo Diet Tracking Mobile Apps for Weight Loss

BACKGROUND

Apps using digital photos to track dietary intake and provide feedback are common, but currently there has been no research examining what evidence-based strategies are included in these apps.

METHODS

A content analysis of mobile apps for photo diet tracking was conducted, including whether effective techniques for interventions promoting behavior change, including self-regulation, for healthy eating (HE) are targeted. An initial search of app stores yielded 34 apps (n = 8 Android and Apple; n = 11 Android; n = 15 Apple). One app was removed (unable to download), and other apps (n = 4) were unable to be rated (no longer available). Remaining apps (n = 29) were downloaded, reviewed, and coded by 2 independent reviewers to determine the number of known effective self-regulation and other behavior change techniques included. The raters met to compare their coding of the apps, calculate interrater agreement, resolve any discrepancies, and come to a consensus.

RESULTS

Six apps (21%) did not utilize any of the behavior change techniques examined. Three apps (10%) provided feedback to users via crowdsourcing or collective feedback from other users and professionals, 7 apps (24%) used crowdsourcing or collective feedback, 1 app (3%) used professionals, and 18 apps (62%) did not provide any dietary feedback to users.

CONCLUSION

Few photo diet-tracking apps include evidence-based strategies to improve dietary intake. Use of photos to self-monitor dietary intake and receive feedback has the potential to reduce user burden for self-monitoring, yet photo diet tracking apps need to incorporate known effective behavior strategies for HE, including self-regulation.

Crowdsourcing for self-monitoring: Using the Traffic Light Diet and crowdsourcing to provide dietary feedback

Background

Smartphone photography and crowdsourcing feedback could reduce participant burden for dietary self-monitoring.

Objectives

To assess if untrained individuals can accurately crowdsource diet quality ratings of food photos using the Traffic Light Diet (TLD) approach.

Methods

Participants were recruited via Amazon Mechanical Turk and read a one-page description on the TLD. The study examined the participant accuracy score (total number of correctly categorized foods as red, yellow, or green per person), the food accuracy score (accuracy by which each food was categorized), and if the accuracy of ratings increased when more users were included in the crowdsourcing. For each of a range of possible crowd sizes (n = 15, n = 30, etc.), 10,000 bootstrap samples were drawn and a 95% confidence interval (CI) for accuracy constructed using the 2.5th and 97.5th percentiles.

Results

Participants (n = 75; body mass index 28.0 ± 7.5; age 36 ± 11; 59% attempting weight loss) rated 10 foods as red, yellow, or green. Raters demonstrated high red/yellow/green accuracy (>75%) examining all foods. Mean accuracy score per participant was 77.6 ± 14.0%. Individual photos were rated accurately the majority of the time (range = 50%–100%). There was little variation in the 95% CI for each of the five different crowd sizes, indicating that large numbers of individuals may not be needed to accurately crowdsource foods.

Conclusions

Nutrition-novice users can be trained easily to rate foods using the TLD. Since feedback from crowdsourcing relies on the agreement of the majority, this method holds promise as a low-burden approach to providing diet-quality feedback.

Social networks for improving healthy weight loss behaviors for overweight and obese adults: A randomized clinical trial of the social pounds off digitally (Social POD) mobile app

OBJECTIVE

To test the efficacy of a weight loss mobile app based on recommender systems and developed by experts in health promotion and computer science to target social support and self-monitoring of diet, physical activity (PA), and weight (Social POD app), compared to a commercially available diet and PA tracking app (standard).

MATERIALS AND METHODS

Overweight adults [N=51] were recruited and randomly assigned to either the experimental group [n=26; theory-based podcasts (TBP)+Social POD app] or the comparison group (n=25; TBP+standard app). The Social POD app issued notifications to encourage users to self-monitor and send theory-based messages to support users who had not self-monitored in the previous 48h. Independent samples t-test were used to examine group differences in kilograms lost and change in BMI. Analysis of covariance was used to analyze secondary outcomes while controlling for baseline values.

RESULTS

Participant attrition was 12% (n=3 experimental and n=3 comparison). Experimental group participants lost significantly more weight (-5.3kg, CI: -7.5, -3.0) than comparison group (-2.23kg, CI: -3.6, -1.0; d=0.8, r=0.4, p=0.02) and had a greater reduction in BMI (p=0.02). While there were significant differences in positive outcome expectations between groups (p=0.04) other secondary outcomes (e.g., caloric intake and social support) were not significant.

DISCUSSION

Use of the Social POD app resulted in significantly greater weight loss than use of a commercially available tracking app. This mobile health intervention has the potential to be widely disseminated to reduce the risk of chronic disease associated with overweight and obesity.

The Fast-Casual Conundrum: Fast-Casual Restaurant Entrées Are Higher in Calories than Fast Food

BACKGROUND

Frequently eating fast food has been associated with consuming a diet high in calories, and there is a public perception that fast-casual restaurants (eg, Chipotle) are healthier than traditional fast food (eg, McDonald's). However, research has not examined whether fast-food entrées and fast-casual entrées differ in calorie content.

OBJECTIVE

The purpose of this study was to determine whether the caloric content of entrées at fast-food restaurants differed from that found at fast-casual restaurants.

DESIGN

This study was a cross-sectional analysis of secondary data. Calorie information from 2014 for lunch and dinner entrées for fast-food and fast-casual restaurants was downloaded from the MenuStat database.

OUTCOME MEASURES

Mean calories per entrée between fast-food restaurants and fast-casual restaurants and the proportion of restaurant entrées that fell into different calorie ranges were assessed.

STATISTICAL ANALYSES PERFORMED

A t test was conducted to test the hypothesis that there was no difference between the average calories per entrée at fast-food and fast-casual restaurants. To examine the difference in distribution of entrées in different calorie ranges between fast-food and fast-casual restaurants, χ(2) tests were used.

RESULTS

There were 34 fast-food and 28 fast-casual restaurants included in the analysis (n=3,193 entrées). Fast-casual entrées had significantly more calories per entrée (760±301 kcal) than fast-food entrées (561±268; P<0.0001). A greater proportion of fast-casual entrées compared with fast-food entrées exceeded the median of 640 kcal per entrée (P<0.0001).

CONCLUSIONS

Although fast-casual entrées contained more calories than fast-food entrées in the study sample, future studies should compare actual purchasing patterns from these restaurants to determine whether the energy content or nutrient density of full meals (ie, entrées with sides and drinks) differs between fast-casual restaurants and fast-food restaurants. Calorie-conscious consumers should consider the calorie content of entrée items before purchase, regardless of restaurant type.

Perspective: Randomized Controlled Trials Are Not a Panacea for Diet-Related Research

Research into the role of diet in health faces a number of methodologic challenges in the choice of study design, measurement methods, and analytic options. Heavier reliance on randomized controlled trial (RCT) designs is suggested as a way to solve these challenges. We present and discuss 7 inherent and practical considerations with special relevance to RCTs designed to study diet: 1) the need for narrow focus; 2) the choice of subjects and exposures; 3) blinding of the intervention; 4) perceived asymmetry of treatment in relation to need; 5) temporal relations between dietary exposures and putative outcomes; 6) strict adherence to the intervention protocol, despite potential clinical counter-indications; and 7) the need to maintain methodologic rigor, including measuring diet carefully and frequently. Alternatives, including observational studies and adaptive intervention designs, are presented and discussed. Given high noise-to-signal ratios interjected by using inaccurate assessment methods in studies with weak or inappropriate study designs (including RCTs), it is conceivable and indeed likely that effects of diet are underestimated. No matter which designs are used, studies will require continued improvement in the assessment of dietary intake. As technology continues to improve, there is potential for enhanced accuracy and reduced user burden of dietary assessments that are applicable to a wide variety of study designs, including RCTs.