Reducing dietary intake of added sugars could affect the nutritional adequacy of vitamin A in adolescents: the Costa Rica case.

BACKGROUND: In countries where sugar fortification with vitamin A is mandatory, strategies to reduce the prevalence of overweight/obesity in adolescents that involve lowering added sugar intake could lead to vitamin A inadequate intakes, since vitamin A-fortified sugar for home consumption contributes to a high proportion of this vitamin intake in the adolescent diet. METHODS: The study employed a hierarchical linear model to perform a mediation analysis on a cross-sectional sample of adolescents (13-18 years old) in the province of San José, Costa Rica. RESULTS: Lowering the total energy intake derived from added sugars to less than 10% significantly increases the prevalence of vitamin A inadequate intake in adolescents by 12.1% (from 29.6% to 41.7%). This is explained by the mediation model in which, the reduced adequacy of vitamin A intake is mediated by a reduction in total energy intake derived from added sugars fortified with vitamin A. CONCLUSIONS: The vitamin A fortification of sugar for household consumption should be reassessed according to the current epidemiological profile in Costa Rica to promote strategies that reduce the prevalence of overweight/obesity in adolescents by lowering the consumption of added sugars without affecting vitamin A intake.

How providing a low-cost water filter pitcher led Latino parents to reduce sugar-sweetened beverages and increase their water intake: explanatory qualitative results from the Water Up!@Home intervention trial.

OBJECTIVE: This study sought to explain results of the Water Up!@Home randomised controlled trial where low-income parents were randomised to receive an educational intervention +a low-cost water filter pitcher or only the filter. Parents in both groups had reported statistically significant reductions in sugar-sweetened beverages (SSB) and increases in water intake post-intervention. DESIGN: Qualitative explanatory in-depth interviews analysed thematically and deductively. SETTING: Washington, DC metropolitan area, USA. PARTICIPANTS: Low-income Latino parents of infants/toddlers who had participated in the Water Up! @Home randomised controlled trial. RESULTS: The filter-stimulated water consumption in both groups by (1) increasing parents' perception of water safety; (2) acting as a cue to action to drink water; (3) improving the flavour of water (which was linked to perceptions of safety) and (4) increasing the perception that this option was more economical than purchasing bottled water. Safe and palatable drinking water was more accessible and freely available in their homes; participants felt they did not need to ration their water consumption as before. Only intervention participants were able to describe a reduction in SSB intake and described strategies, skills and knowledge gained to reduce SSB intake. Among the comparison group, there was no thematic consensus about changes in SSB or any strategies or skills to reduce SSB intake. CONCLUSIONS: A low-cost water filter facilitated water consumption, which actively (or passively for comparison group) displaced SSB consumption. The findings have implications for understanding and addressing the role of water security on SSB consumption.

Implementation of a regulatory food policy to reduce availability of energy-dense foods in Costa Rican high schools.

OBJECTIVE: To assess the extent to which mandatory Guidelines to improve the school food environment were being implemented in Costa Rican high schools and to explore the perspectives of key policy actors towards the Guidelines. DESIGN: Semi-structured interviews and site observations. Interviews were recorded, transcribed verbatim and imported to NVivo 12 for analysis. Inductive and deductive themes were identified, and elements of the RE-AIM framework and the social process framework were used when classifying these themes. SETTING: Sixteen public high schools in San José, Costa Rica. PARTICIPANTS: High school principal and kiosk concessionaires. RESULTS: Products that did not adhere to the Guidelines were still widely available in schools, and amongst the most prevalent challenges to implementation that emerged from our interviews, were a lack of understanding of the policy content, a lack of monitoring and accountability, and competing values amongst actors which affected their views on the role that the school must have in offering a healthy food environment. CONCLUSION: Most products offered in high schools did not meet the criteria required by the mandatory Guidelines, and several contextual factors were found to influence implementation. Strengthening the implementation of the Costa Rican Guidelines will require further actions at the governmental and school levels.

Gender-based eating norms, the family environment and food intake among Costa Rican adolescents.

OBJECTIVE: To examine the association between family environment variables (parenting styles, family meal atmosphere), gender-based stereotypes and food intake in Latin American adolescents. DESIGN: Structural equation modelling applied to cross-sectional data, 2017. SETTING: Urban and rural sites of San José, Costa Rica. PARTICIPANTS: n 813; 13-18 years old. RESULTS: Data suggest direct associations between gender-based stereotypes and intake of fruits and vegetables (FV) (ß = 0·20, P < 0·05), unhealthy foods (fast food (FF)) (ß = -0·24, P < 0·01) and ultra-processed foods (ß = -0·15, P < 0·05) among urban girls; intake of legumes among rural girls (ß = 0·16, P < 0·05) and intake of sugar-sweetened beverages (SSB) among rural boys (ß = 0·22, P < 0·05). Family meal atmosphere was associated with legume intake (ß = 0·19, P <·05) among rural girls. Authoritative parenting style was associated with FV intake (ß = 0·23, P < 0·05) among urban boys and FF intake (ß = 0·17, P < 0·05) among urban girls. Authoritarian parenting style was associated with FV consumption (ß = 0·19, P < 0·05) among rural boys, and with SSB and FF consumption (ß = 0·21, P < 0·05; ß = 0·14, P < 0·05, respectively) among urban girls. CONCLUSIONS: Findings are the first to describe the complex family environment and gender-based stereotypes within the context of a Latin American country. They emphasise the need for culturally relevant measurements to characterise the sociocultural context in which parent-adolescent dyads socialise and influence food consumption.

Modelling Longitudinal Directional Associations Between Self-regulation, Physical Activity, and Habit: Results from a Cross-lagged Panel Model.

BACKGROUND: The directionality of associations between self-regulatory variables, behavior, and automaticity is seldomly tested. In this study, we aimed to examine a volitional, self-regulatory sequence of variables proposed in the Health Action Process Approach framework (intention → action plans → action control → behavior) and its relationship with the construct of automaticity of the physical activity habit. METHODS: Longitudinal data was collected from high school students (N = 203, Mage = 15.39 (SD = 1.43), 52% women) at three measurement points. First, a confirmatory factor analysis measurement model was used to examine the study variables across measurement points. Next, a cross-lagged panel model was used to test directionality between variables. RESULTS: After adequate fit of the measurement model was confirmed, a mechanism integrating self-regulation with behavior and automaticity was examined. The hypothesized directionality between variables was verified overall by cross-lagged analysis. However, for the intention-action plan association, the inverse relationship was found: plans were associated with subsequent intentions, but intentions did not predict plans. Moreover, automaticity was not associated with subsequent physical activity behavior. CONCLUSIONS: In general, our findings supported the hypothesized longitudinal direction of the associations, confirming that self-regulation may lead to behavior performance and automaticity. Unexpected findings and implications for intervention and future research are discussed.

Intersectionality between parenting styles, area of residence and gender on food group consumption among Costa Rican adolescents.

Little is known about how parenting styles can influence the adolescent's consumption of sugar-sweetened beverages (SSB), fruits and vegetables (FV) and beans in Latin America. This study uses hierarchical moderated regression models to examine such association by area of residence, sex of the parent and of the adolescent in Costa Rica. Results showed that fathers' authoritarian style was significantly associated with lower intake of sugar-sweetened beverages (SSB) among boys (b = -0.163, p = 0.050), but not girls (b = 0.097, p = 0.114) while mother's authoritarian style was associated with lower SSB intake among girls (b = -0.138, p = 0.031), but not boys (b = 0.159, p = 0.059). Fathers' authoritative style was associated with higher consumption of fruits and vegetables (FV) among boys in rural areas (b=0.440, p= 0.017), but this association was not significant for girls (b=-0.033, p= 0.800) in rural areas or for either gender in urban areas. Parenting styles of the mothers' and fathers' were not significantly associated with Costa Rican adolescent bean consumption, in general or for any of the subgroups. Findings suggest an intersectionality in the effects of parentchild interactions by child and parent sex, cultural and geographic context, and the eating behaviors examined.

Changes in Dietary Intake of Major Nutrients and Food Sources among Costa Rican Adolescents in the Last 20 Years.

BACKGROUND: Adolescence offers a window of opportunity to prevent adult obesity and noncommunicable disease risk factors. With the rising prevalence of adolescent obesity over the last 20 y, identifying any changes in dietary risk factors is crucial. OBJECTIVES: We aimed to assess the dietary intake of major nutrients and their food sources in Costa Rican adolescents from 1996 to 2017. METHODS: Means from 3-d food records from adolescents (ages 13-18 y) living in San José (the province with the highest concentration of adolescents in Costa Rica) were obtained in 1996 (n = 276), 2006 (n = 133), and 2017 (n = 818). Differences in consumption of major nutrients and selected food groups by sex and survey period were tested using age- and area-adjusted ANOVAs. RESULTS: In 2017, adolescents consumed significantly (P < 0.05) less saturated and trans fats [saturated: -3.2% of total energy (TE); trans: -1.4% TE], vegetables (-24 g/d), beans (-42 g/d), and white rice (22 g/d) than in 1996. The 2017 adolescents also reported significantly higher consumption of unsaturated fatty acids (MUFAs: up from 8.2% to 15.3% TE; PUFAs: up from 5.5% to 9.5% TE; P < 0.05), sugary drinks (+134 g/d), pastries/desserts (+55 g/d), other refined starchy foods (+36 g/d), and snacks/fast foods (+26 g/d) than their 1996 counterparts. In 1996 and 2006, the main source of calories was white rice, whereas in 2017, it was sugary drinks (12% TE and 15% TE, respectively; P < 0.05). The intake ratio of beans to white rice was significantly higher in 1996 (1:1.6) than in 2017 (1:3.5). CONCLUSIONS: The changes in the intake of major nutrients and food sources of Costa Rican adolescents present new public health challenges for cardiometabolic risk prevention. Costa Rica should prioritize the design of comprehensive strategies that target added sugar intake while simultaneously increasing access to and promotion of healthful items.

How Latina mothers navigate a 'food swamp' to feed their children: a photovoice approach.

OBJECTIVE: To understand how mothers who recently migrated from Central America to the USA feed their children in a neighbourhood saturated with unhealthful food choices ('food swamp') and to formulate a mother-driven plan of action to facilitate their acquisition of foods. Design/Setting/Subjects We purposively sampled mothers with children (<10 years old) who were recent immigrants/refugees from Central America and lived in a 'food swamp' neighbourhood. We used the photovoice approach to elicit textual data from thirty in-depth interviews, a participatory workshop, and visual data from photographs. Analyses were guided by the Social Ecological Framework and Social Cognitive Theory to identify barriers, facilitators and strategies that support parents in feeding their children. RESULTS: Mothers valued foods that they considered to be 'traditional' and 'healthful'. They navigated their food retail environment looking for these foods (of good quality and well-priced). Food values were reinforced by pre-migration food customs and culture, health professionals' advice and, in some cases, by the desire to avoid conflict with their children. The neighbourhood food environment could directly influence children's food preferences and often created conflict between what the child wanted to eat and the foods that mothers valued. Mothers in this 'food swamp' wanted to be engaged in addressing the selection of foods offered in schools and in neighbourhood food venues to reflect their own food values. CONCLUSIONS: These mothers' feeding choices were influenced directly by their food values, and indirectly by the neighbourhood and school food environments via their children's preferences.

Progress towards elimination of trans-fatty acids in foods commonly consumed in four Latin American cities.

OBJECTIVE: To assess progress towards the elimination of trans-fatty acids (TFA) in foods after the 2008 Pan American Health Organization (PAHO) recommendation of virtual elimination of TFA in Latin America. DESIGN: A descriptive, comparative analysis of foods that were likely to contain TFA and were commonly consumed in four cities in Latin America. SETTING: San José (Costa Rica), Mexico City (Mexico), Rio de Janeiro (Brazil), Buenos Aires (Argentina). SUBJECTS: Foods from each city were sampled in 2011; TFA content was analysed using GC. TFA of selected foods was also monitored in 2016. RESULTS: In 2011-2016, there was a significant decrease in the content of TFA in the sampled foods across all sites, particularly in Buenos Aires (from 12·6-34·8 % range in 2011-2012 to nearly 0 % in 2015-2016). All sample products met the recommended levels of TFA content set by the PAHO. TFA were replaced with a mixture of saturated and unsaturated fats. CONCLUSIONS: Our results indicate a virtual elimination of TFA from major food sources in the cities studied. This could be due to a combination of factors, including recommendations by national and global public health authorities, voluntary and/or mandatory food reformulation made by the food industry.

Influence of sensory and cultural perceptions of white rice, brown rice and beans by Costa Rican adults in their dietary choices.

Little is known about the distinct perceptions towards rice and beans that may shape the consumption of these main staple foods among Costa Ricans. We aimed to identify barriers and motivators that could change the current staple into a healthier one, and assess the sensory perceptions of these foods in this population. Focus group discussions and sensory tastings of 8 traditional white or brown rice and beans preparations were conducted in 98 Costa Ricans, aged 40-65 years. Traditional habits and family support emerged as the two main drivers for current consumption. Consuming similar amounts of rice and beans, as well as unfamiliarity with brown rice, are habits engrained in the Costa Rican culture, and are reinforced in the family and community environment. Suggested strategies for consuming more brown rice and more beans included introducing them during childhood, disseminating information of their health benefits that take into account the importance of tradition, lowering the cost, increasing availability, engaging women as agents of change and for brown rice masking the perceived unpleasant sensory characteristics by incorporating them into mixed dishes. Plain brown rice received the lowest mean hedonic liking scores. The preparations rated highest for pleasant were the beans: rice 1:1 ratio regardless of the type of rice. This study identified novel strategies to motivate Costa Rican adults to adapt their food choices into healthier ones within their cultural and sensory acceptability.

Exploring Differences in Dietary Diversity and Micronutrient Adequacy between Costa Rican and Mexican Adolescents.

Diet diversity becomes especially relevant during adolescence to satisfy the adequate micronutrient intake. Diet diversity (DD) and micronutrient probability of adequacy (PA) were studied in 818 Costa Rican (CR) and 1202 Mexican (MX) adolescents aged 13-18 years. DD was compared using the Minimum Dietary Diversity (MDD) score. Receiver-operating characteristic (ROC) curves were employed to identify the optimal MDD for each sample from the respective countries. The mean MDD for the overall CR sample was 4.17 ± 1.43 points, and for the MX sample, the mean MDD was 4.68 ± 1.48 points. The proportion of adolescents with a DD was significantly higher in Costa Rica than in Mexico (66.5% vs. 55.6%; p < 0.0001). Also, DD was higher in rural Costa Rican adolescents, while no difference was found in the MX adolescents by area of residence. CR adolescents reported significantly higher PA than MX participants for 6 of the 11 micronutrients assessed. The calcium PA in MX adolescents was significantly higher than in the CR sample (MX: 0.84 vs. CR: 0.03; p < 0.0001), while low PA was obtained for iron in both countries (CR: 0.01 vs. MX: 0.07; p < 0.0001). In Costa Rica and Mexico, nutritional interventions and assessing the compliance of food-fortifying programs are needed to improve the PA of diverse micronutrients.

A Landscape of Micronutrient Dietary Intake by 15- to 65-Years-Old Urban Population in 8 Latin American Countries: Results From the Latin American Study of Health and Nutrition.

BACKGROUND: Latin American countries have shifted from traditional diets rich in micronutrients to a Westernized diet rich in high energy-dense foods and low in micronutrients. OBJECTIVE: This study aimed to determine the prevalence of adequate micronutrient intakes in urban populations of 8 Latin American countries. METHOD: Micronutrient dietary intake data were collected from September 2014 to August 2015 from 9216 men and women aged 15.0 to 65.0 years living in urban populations of 8 Latin American countries. Dietary intake was collected using two 24-hour recalls on nonconsecutive days. Micronutrient adequacy of intake was calculated using the Estimated Average Requirement cut-off method. RESULTS: In general terms, the prevalence of inadequate intake of thiamine, riboflavin, niacin, folate, cobalamin, iron, phosphorus, copper, and selenium ranged from 0.4% to 9.9%. In contrast, the prevalence of inadequacy of pyridoxine, zinc, vitamin C, and vitamin A ranged from 15.7% to 51.5%. The nutrients with a critical prevalence of inadequacy were magnesium (80.5%), calcium (85.7%), and vitamin D (98.2%). The highest prevalence of inadequate intakes was observed in the low educational level, participants with overweight/obesity, in men, and varies according to socioeconomic status. CONCLUSIONS: There is an urgent need to define direct regional actions and strategies in Latin America aimed at improving micronutrient adequacy, either through staple food fortification programs, agronomic biofortification, or food policies that facilitate economic access to micronutrient-rich foods.

Plain language titleDescription of the Vitamin and Mineral Consumption Status in Urban Cities of Latin America: Results of the Latin American Health and Nutrition Study.Plain language summaryVitamins and minerals are essential for maintaining good health. However, traditional Latin American diets are changing to include foods that have a lot of sugar and fat but fewer vitamins and minerals. This study was designed to analyze the consumption of these nutrients in urban cities of 8 Latin American countries. We collected food consumption information from September 2014 to August 2015 from 9216 men and women between 15 and 65 years old using a method called 24-hour recall. To find out if participants were consuming the necessary daily amounts of vitamins and minerals, intakes were compared with the daily recommended amounts suggested by the Institutes of Medicine of the United States. We found that Latin American urban populations consume fewer vitamins and minerals than recommended. In some cases, few people do not consume the required amounts of vitamins and minerals, but in other cases, many do not. For example, few do not consume enough thiamine, riboflavin, niacin, folate, cobalamin, iron, phosphorus, copper, and selenium. However an intermediate number of people do not consume enough pyridoxine and zinc, a high number consume little vitamin C and vitamin A, and many people consume very little magnesium, calcium, and vitamin D. We found that the people who consume fewer vitamins and minerals are mostly males, overweight/obese, have lower education and varies according to their financial resources. A deficient intake of vitamins and minerals showed up in most age groups, from adolescence to adulthood. To improve vitamins and minerals intake, it is important that some foods that are frequently eaten are fortified or that the price of foods that are high in vitamins and minerals is lowered.

Energy imbalance gap was associated with body mass index and sex in Latin American adolescents-results from the ELANS study.

Introduction: Energy imbalance gap (EIG) is defined as the average daily difference between energy intake (EI) and energy expenditure (EE). This study aimed to examine the associations between EIG and sociodemographic and anthropometric variables in the adolescent population of eight Latin America countries. Methods: A total of 680 adolescents aged 15 to 18 were included in this study. The estimation of EI was based on two non-consecutive 24-h dietary recalls. EE was predicted from Schofield equations using physical activity level obtained through the long version of the International Physical Activity Questionnaire. Sociodemographic data and anthropometric measurements were also obtained. A descriptive analysis and multilevel linear regression models were used to examine associations between variables. Results: The mean EI, EE, and EIG were 2091.3 kcal, 2067.8 kcal, and 23.5 kcal, respectively. Argentina had the highest EI and EIG, whereas Chile had the lowest EI and EIG. Males had a higher EI (2262.4 kcal) and EE (2172.2 kcal) than females (1930.1 kcal and 2084.5 kcal), respectively (p < 0.05). Overweight subjects had a lower EIG than did underweight and normal-weight subjects (p < 0.05). Subjects with low socioeconomic status (SES) had a lower EE (2047.0 kcal) than those with a high SES (2164.2 kcal) (p < 0.05). Conclusion: Sex and BMI were associated with EIG in adolescents from Latin America.

Exploring the FAO Minimum Dietary Diversity Indicator as a Suitable Proxy of Micronutrient Adequacy in Men and Women Across Reproductive and Non-reproductive Ages in 8 Latin American Countries.

BACKGROUND: Women's Dietary Diversity Score (WDDS) is an indicator of dietary diversity, a key component of diet quality in women of reproductive age (WRA). Limited information is available regarding its applicability in other population groups. OBJECTIVE: To examine the ability of the Minimum Dietary Diversity for Women (MDD-W) of 5-food groups cutoff to predict micronutrient adequacy in men and women 15 to 65 years old from 8 Latin American countries. METHODS: We used a 24-hour recall from 9216 participants in the Latin American Study on Nutrition and Health (ELANS) to determine Dietary Diversity Score (DDS) based on the consumption of 10 food groups. The Mean Probability of Adequacy (MPA) was associated with DDS for the overall sample, for men, WRA, and women of nonreproductive age (WNRA). Sensitivity and specificity analyses were performed to determine if the 5-food groups cutoff point for MDD can be used to correctly identify men, WRA, and WNRA with adequate micronutrient adequacy (MPA ≥ 0.70). RESULTS: We found a mean DDS of 4.78 ± 1.33 and an MPA of 0.64 ± 0.16, with 59% of participants showing a diverse diet (DDS ≥ 5). The 5-food groups-cutoff point showed a better balance between sensitivity and specificity predicting an MPA ≥0.70 in men, WRA, and WNRA. MPA was significantly associated with DDS in WRA and for men and WNRA, as well. CONCLUSION: The 5-food group MDD, originally intended to be used in WRA, performed equally well in predicting MPA ≥0.70 in men, WRA, and WNRA, and can be used as a proxy of micronutrient adequacy in Latin American population.

Plain language titleAssessment of the FAO Minimum Dietary Diversity Index to Estimate Micronutrients Intake in Urban Cities of 8 Latin America CountriesPlain language summaryThe Women's Dietary Diversity Score (WDDS) proposed by the Food and Agriculture Organization is an indicator that measures the variety of foods consumed by women of reproductive age (WRA), and it has been reported in several studies that the more diverse the diet, the greater the probability of meeting micronutrients requirements. This indicator has not been validated in other population, but few studies have been conducted in the Latin American region. So, we aimed to investigate whether the Minimum Dietary Diversity for Women (MDD-W) established for WRA could also predict sufficient micronutrient intake in men and women aged 15 to 65 years in the Latin American population. To accomplish this objective, we used data from the Latin American Study of Nutrition and Health (Estudio Latino Americano de Nutrición y Salud­ELANS) that collected dietary data from 24-h recalls from 9216 participants and analyzed the association between DDS and the Mean Probability of Adequacy (MPA). Additionally, we determined if the MDD cutoff point could correctly identify individuals with appropriate vitamin and mineral intake. We found that the overall mean DDS was 4.78 ± 1.33, the MPA was 0.64 ± 0.16, and approximately 59% of participants had a diverse diet. The MDD of 5-food groups cutoff point was demonstrated to be useful in predicting sufficient micronutrient intake for men, WRA, and women over 50 years. Respondents with a DDS ≥5 had higher micronutrient adequacy. These findings suggest that DDS can serve as a proxy for assessing micronutrient adequacy in urban populations beyond WRA. The effect of promoting diverse diets on micronutrient adequacy as part of intervention programs can be captured by the DDS in urban Latin American populations.

Socio-demographic, behavioral, and health correlates of nutrition transition dietary indicators in San Juan, Puerto Rico.

OBJECTIVE: To identify socio-demographic, behavioral, and health-related correlates of food preferences in Puerto Rico that will help determine Caribbean-region populations vulnerable to nutrition transition. METHODS: Data from a cross-sectional study of a representative sample of 858 adults residing in the San Juan Metropolitan Area of Puerto Rico were analyzed. Multivariable ordinal logistic regressions were used to model the frequency of consumption of 1) fruits and vegetables, 2) tubers/starchy root vegetables, 3) fried foods, and 4) Western-style fast foods as a function of socio-demographic, behavioral, and health-related characteristics. RESULTS: Higher frequency of consumption of fruits and vegetables was associated with being physically active and older and having a medium to high level of education, whereas intake of tubers was associated with being older, having a low income, not using government insurance, and having elevated levels of triglycerides. Frequency of consumption of fast food was associated with younger age, higher income, 12-15 years of formal education, and a higher body mass index (BMI), whereas frequency of consumption of fried food was associated with being younger and male, not being a smoker, and having elevated levels of fasting blood glucose. CONCLUSIONS: The results indicate a nutrition transition in Puerto Rico with health consequences for the Caribbean region. The characteristics of this nutrition transition seem to be determined by income, education, and age, but may also be dictated by access to various food groups. These results set the stage for needed investigation of environmental and individual-level factors that could shape patterns in food consumption.

Exploratory Analysis of Social Networks Linked to the Provision of Beverages in Costa Rican Schools.

Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders' leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment.

Use of a Water Filter at Home Reduces Sugary Drink Consumption among Parents and Infants/Toddlers in a Predominantly Hispanic Community: Results from the Water Up!@ Home Intervention Trial.

BACKGROUND: Water is recommended as an alternative for sugar-sweetened beverages (SSBs). Low-income, minority groups in the United States continue to exhibit high SSB and low water consumption, and are more likely to exceed 100% fruit juice recommendations. OBJECTIVE: To test the effects of a home-based intervention designed to replace SSBs with tap water and reduce excess juice consumption among parents and their infants/toddlers. DESIGN: Randomized controlled trial. PARTICIPANTS: Parents (n = 92) of infants/toddlers who participated in three Early Head Start home-visiting programs that serve predominantly Hispanic, low-income communities during 2019-2021. INTERVENTION: The 12-week intervention (Water Up!@Home) simultaneously addressed physical barriers to tap water consumption (via a water filter) and sociocultural barriers to replacing SSBs and juice with water (via a curriculum). Comparison group received a water filter only. We hypothesized that the intervention would lead to a reduction of 6 fl oz/d in SSB and juice consumption. MAIN OUTCOMES: Parent-reported self and infant/toddler SSBs, water (filtered, tap, or bottled), and 100% fruit juice consumption. STATISTICAL ANALYSES: Analysis of covariance to compare changes in consumption between experimental groups was performed. We also conducted t tests to assess changes within groups. RESULTS: Participants in both groups reported significant reductions in SSBs from baseline (parents: intervention [-11.2 fl oz/d; P < 0.01]; comparison [-8.0 fl oz/d; P < 0.01]; children: intervention [-1.50 fl oz/d; P = 0.03]; comparison [-1.56 fl oz/d; P = 0.02]), increased water consumption (parents in both groups [+5.6 fl oz/d]; children: intervention [+3.61 fl oz/d; P = 0.01], comparison [+2.24 fl oz/d; P = 0.05]), mostly from filtered tap water. Differences between groups were not statistically significant. Intervention participants reported significant reductions in 100% fruit juice vs comparison (parents: -3.6 fl oz/d vs -1.0 fl oz/d; P < 0.01; children: -0.73 fl oz/d vs +0.48 fl oz/d; P = .03). CONCLUSIONS: The intervention effectively reduced 100% fruit juice consumption. Water security should be examined as a contributor to SSB consumption in this population.

Role of Residence Area on Diet Diversity and Micronutrient Intake Adequacy in Urban and Rural Costa Rican Adolescents.

Dietary diversity might be essential to meet nutritional demands during adolescence. Diet diversity among 818 urban and rural Costa Rican adolescents aged 13−18 years was studied using the Minimum Dietary Diversity Score for Women. The Nutrient Adequacy Ratio (NAR) was calculated for 11 nutrients to estimate the nutrient adequacy of the diet. A NAR < 0.7 was considered inadequate for micronutrient intake. The optimal Diet Diversity Score (DDS) cut-off point for this study was 4, established using receiver-operating characteristic curves. The mean DDS for the overall sample was 4.17 ± 1.43, although DDS was significantly higher in adolescents from rural vs. urban areas (4.33 ± 1.43 vs. 4.00 ± 1.42, p-value = 0.001). The odds of having a diverse diet were 62% higher in rural vs. urban adolescents. Overall, 80−95% of adolescents reached a NAR ≥ 0.70 for 8 nutrients except for calcium, zinc, and vitamin A. The residence area plays a key role in adolescent dietary diversity. Although overall DDS was low, foods that make up the rural adolescent diet were nutritionally dense enough to satisfy the EAR for most micronutrients. A high DDS is not necessarily required for the diet to meet most micronutrient demands in adolescence. Improved dietary adequacy of vitamin A, zinc, and calcium is required due to the importance of these micronutrients in maintaining optimal health.

Dietary Intake and Sources of Added Sugars in Various Food Environments in Costa Rican Adolescents.

Consumption of added sugars, especially from sugar-sweetened beverages (SSBs), has been associated with several negative health outcomes during adolescence. This study aimed to identify dietary intake and food sources of added sugars in the home, school, and neighborhood environments of Costa Rican adolescents. Dietary intake of added sugars was determined using 3-day food records in a cross-sectional study of 818 adolescents aged 12 to 19 and enrolled in rural and urban schools in the province of San José. On average, 90% of adolescents consumed more than 10% of their total energy intake from added sugars. Furthermore, 74.0% of added sugars were provided at home, 17.4% at school, and 8.6% in the neighborhood. Added sugars were primarily provided by frescos (29.4%), fruit-flavored still drinks (22.9%), and sugar-sweetened carbonated beverages (12.3%), for a total contribution of 64.6%. Our findings suggest that Costa Rican adolescents have a plethora of added sugar sources in all food environments where they socialize. However, it is relevant for public health to consider the home and school environments as fundamental units of interventions aimed at reducing added sugars in the adolescent diet. Frescos prepared at home and school and fruit-flavored still drinks must be the focus of these interventions.

Association between Fathers' and Mothers' Parenting Styles and the Risk of Overweight/Obesity among Adolescents in San José Province, Costa Rica.

Parenting styles are a risk factor for adolescents overweight/obesity worldwide, but this association is not well understood in the context of Latin America. This study examines the association between the parenting styles of mothers and fathers and the risk of overweight/obesity among Costa Rican adolescents. Data are cross-sectional from a sample of adolescents (13-18 years old) enrolled in ten urban and eight rural schools (n = 18) in the province of San José, Costa Rica, in 2017. Hierarchical logistic regression analyses were performed to assess the likelihood of adolescents being overweight according to the mothers' and fathers' parenting styles. A significant association was found between the risk of adolescent overweight/obesity and the paternal authoritarian style only in rural areas (B = 0.622, SE = 0.317, Wald = 3.864, ExpB = 1.863, p = 0.04), and between said risk and the paternal permissive style only in male adolescents (B = 0.901, SE = 0.435, Wald = 4.286, ExpB = 2.461, p = 0.038). For maternal parenting styles, no associations reached significant levels once logistic regression models were adjusted for the fathers' parenting styles. These findings underscore the importance of further studying the role of fathers' paternal parenting styles on Latin American adolescent weight outcomes. Expanding our understanding of the parenting styles of fathers has important implications for the design and implementation of culturally- and gender-appropriate family interventions.