Improving Maternal Cardiovascular Health in Underserved Populations: a Narrative Review of Behavioral Intervention Trials Targeting Postpartum Weight Retention.

PURPOSE OF REVIEW: Racial/ethnic minority and socioeconomically disadvantaged individuals experience greater postpartum weight retention, which has been linked to the development of cardiovascular disease. This article reviews recent literature on behavioral interventions targeting postpartum weight retention in these populations. RECENT FINDINGS: Seven randomized controlled trials published since 2010 were selected for this review. Four were successful in reducing or preventing postpartum weight retention. Recruitment primarily occurred in low-income urban areas. All interventions reported using the Social Cognitive Theory and targeted mostly individual-level behavior change focused on diet and physical activity. Four were technology-based, and most implemented strategies to increase cultural relevance of the intervention. Opportunities for future interventions include expand target population to enroll individuals starting in pregnancy and address rural populations; incorporate empirically tested retention strategies; increase focus on psychosocial factors, particularly chronic stress; utilize multilevel approaches; continue to leverage technology; and maximize efforts to increase cultural relevancy.

Applying the socio-ecological model to understand factors associated with sugar-sweetened beverage behaviours among rural Appalachian adolescents.

OBJECTIVE: The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents' sugar-sweetened beverage (SSB) intake. DESIGN: This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake - step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver's SSB behaviours, caregiver's SSB rules) and step 4: environmental (i.e., home SSB availability) level variables. SETTING: Eight middle schools across four rural southwest Virginia counties in Appalachia. PARTICIPANTS: Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd 0·5) years). RESULTS: Mean SSB intake was 36·3 (sd 42·5) fluid ounces or 433·4 (sd 493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent's SSB consumption: behavioural intention (P < 0·05), affective attitude (P < 0·05), perceived behavioural control (P < 0·05), health literacy (P < 0·001), caregiver behaviours (P < 0·05), caregiver rules (P < 0·05) and home availability (P < 0·001). CONCLUSIONS: SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents.

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.

Retention and engagement of rural caregivers of adolescents in a short message service intervention to reduce sugar-sweetened beverage intake.

Objective: This study investigates a 6-month short message service (SMS) intervention to reduce adolescent sugar-sweetened beverage (SSB) intake. The objectives are to describe caregiver retention and SMS engagement as well as explore differences by caregiver characteristics. Methods: Caregivers completed a baseline survey then messages were sent two times per week. Message types included the following: SSB intake assessments, educational information, infographic URLs, and strategies. Engagement was measured through interaction with these messages and included: assessment completion, reminders needed, number of strategies chosen, and URLs clicked. Results: Caregivers (n = 357) had an average baseline SSB intake of 23.9 (SD = 26.8) oz/day. Of those, 89% were retained. Caregivers with a greater income and education were retained at a higher rate. Average engagement included: 4.1 (SD = 1.3) of 5 assessments completed with few reminders needed [4.1 (SD = 3.7) of 14 possible], 3.2 (SD = 1.1) of 4 strategies selected, and 1.2 (SD = 1.6) of 5 URLs clicked. Overall, average engagement was relatively high, even where disparities were found. Demographic characteristics that were statistically related to lower engagement included younger age, lower income, lower educational attainment, single caregivers, lower health literacy. Furthermore, caregivers with a reduced intention to change SSB behaviors completed fewer assessments and needed more reminders. Higher baseline SSB intake was associated with lower engagement across all indicators except URL clicks. Conclusions: Results can be used to develop targeted retention and engagement strategies (e.g., just-in-time and/or adaptive interventions) in rural SMS interventions for identified demographic subsets. Trial registration: Clincialtrials.gov: NCT03740113.

Social jet lag and eating styles in young adults.

Social jet lag refers to circadian misalignment that occurs when people shift their sleep schedules from weekdays to weekends. Social jet lag is linked with numerous negative health outcomes, with emerging research connecting social jet lag to increased consumption of unhealthy foods. Existing research has not yet examined the associations between social jet lag and eating styles (e.g., emotional eating). Emotional eating and loss of control over eating are problematic eating styles which may lead to overeating and weight gain. Conversely, intuitive eating is associated with positive health outcomes such as lower risk of obesity. The present study examined social jet lag and eating styles in a young adult sample, as emerging adulthood is an important developmental time period for establishing healthy sleep and eating habits. Results of the current study indicated that in a sample of 372 American undergraduate participants, social jet lag significantly predicted lower intuitive eating (ß = -.129, p = .012) and greater emotional eating (ß = .12, p = .022) when controlling for age, sex, and chronotype. It was marginally predictive of loss of control over eating (ß = .102, p = .050). Sleep quantity on weekdays (not weekends) also significantly predicted intuitive eating (p = .017) and loss of control over eating (p = .044), and sleep quality significantly predicted intuitive eating (p < .001), emotional eating (p < .001), and loss of control over eating (p < .001). These findings extend our understanding of the relationship between social jet lag and eating styles in college students. Addressing social jet lag in this population is an important consideration for their cardiometabolic health and for reducing weight fluctuations.

Exploring differences in adolescent BMI and obesity-related behaviors by urban, suburban, and rural status.

Data from the nationally representative 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study was examined to identify differences in adolescent Body Mass Index (BMI) and obesity-related behaviors by rurality status (i.e., urban, suburban, rural) while accounting for relevant demographics (i.e., sex, race/ethnicity, household income). This secondary, cross-sectional analysis included 1,353 adolescents. Analyses included descriptive statistics, one-way analysis of variance, Chi-squared tests, and multiple linear regression models (reported significance level p < 0.05). Rurality was not associated with BMI when controlling for demographics. However, relative to rural adolescents, suburban adolescents had significantly higher junk food, sugar-sweetened beverages (SSB), sugary food (all ß=+0.2, p ≤ 0.001), and fruit/vegetable intake (ß=+0.1, p ≤ 0.05). Compared to Non-Hispanic White adolescents, Non-Hispanic Black adolescents had significantly higher BMI (ß=+4.4, p ≤ 0.05), total sedentary time (ß=+4.1, p ≤ 0.001), junk food, SSB, and sugary food intake (all ß=+0.2, p ≤ 0.05). Relative to their lower-income household counterparts, adolescents from higher-income households had significantly lower BMI (ß = -9.7, p ≤ 0.001), junk food (ß = -0.2, p ≤ 0.05), and SSB intake (ß = -0.5, p ≤ 0.001). Contrary to literature, rurality was not a significant predictor of adolescent BMI. While suburban status was significantly associated with several diet-related risk factors, it was not in the direction anticipated. Being non-Hispanic Black and from a low-income household had the greatest influence on adolescent BMI. Findings highlight the importance of using a three-category classification for rurality.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia.

OBJECTIVE: To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents. DESIGN: Cross-sectional. SETTING: Southwestern Virginia, US, part of Central Appalachia. PARTICIPANTS: Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits. MAIN OUTCOME MEASURES: Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants. ANALYSIS: Descriptive statistics, 1-way ANOVA, and stepwise regression. RESULTS: On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (ß = -0.41; P < 0.05), receiving SNAP benefits (ß = 14.19; P ≤ 0.01), behavioral intentions (ß = -5.48; P ≤ 0.001), affective attitudes (ß = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (ß = 1.92; P ≤ 0.001), and home availability (ß = 7.43; P ≤ 0.01) were significantly associated with SSB intake. CONCLUSIONS AND IMPLICATIONS: Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

Comparing two different family-based childhood obesity treatment programmes in a medically underserved region: Effectiveness, engagement and implementation outcomes from a randomized controlled trial.

BACKGROUND: Access to evidence- and family-based childhood obesity (FBCO) treatment interventions is a challenge, especially in underserved regions where childhood obesity disparities persist. OBJECTIVE: Compare two 6-month FBCO treatment interventions, iChoose (high intensity, parent-child dyads) and Family Connections (low intensity, parents only), in one underserved US region. METHODS: This unblinded, RCT reports on effectiveness and implementation outcomes. Eligibility included children ages 5-12 with BMI ≥85th percentile. Analyses included descriptive statistics and intention-to-treat Heckman treatment effect models. RESULTS: Enrolled children (n = 139, mean age 10.1 ± 1.7 years, 30% with overweight, 70% with obesity, 45% black, 63% Medicaid) were randomly assigned to iChoose (n = 70) or Family Connections (n = 69). Retention rates were 63% for iChoose and 84% for Family Connection. Among children, 6-month BMI z-score changes were not statistically significant within iChoose [BMI z-score 0.03 (95% CI = -0.13, 0.19)] or Family Connections [BMI z-score 0.00 (95% CI = -0.16, 0.16)]. Likewise, parents' BMI changes were not statistically significant. No adverse events were reported. Both programmes were delivered with high fidelity (77%-100%). Engagement in core components was 25%-36% for iChoose and 52%-61% for Family Connections. Implementation costs per child with improved BMI z-score were $2841 for iChoose and $955 for Family Connections. CONCLUSIONS: Neither intervention yielded significant improvements in child BMI z-score or parent BMI, yet both were delivered with high fidelity. Relative to iChoose, descriptive data indicated higher retention, better engagement, and lower costs for Family Connections-suggesting that a lower intensity and parent-focused programme may better fit the intended audience's context.

Understanding Teach-Back and Teach-To-Goal Strategies Embedded in Support Calls for a Health Literacy-Sensitive Childhood Obesity Treatment Trial.

BACKGROUND: Low caregiver health literacy (HL) is related to increased obesity risk for their children. Teach-Back and Teach-to-Goal (TB/TTG) are strategies that may improve comprehension of key concepts for people who have low HL but have yet to be examined in the context of childhood obesity treatment. OBJECTIVE: This study evaluated TB/TTG strategies integrated within support calls delivered to caregivers as part of a 3-month childhood obesity intervention. METHODS: Ninety-four caregivers (60% Black, 42% high school education or less, 53% with income ≤$29,999, and 34% low HL) with overweight/obese children age 8 to 12 years enrolled in a childhood obesity intervention. Caregiver HL was assessed at baseline using the Newest Vital Sign and caregivers were dichotomized to low and adequate HL groups for analyses. Caregivers received 6 bi-weekly support calls that alternated with in-person, family sessions. Call completion rates, comprehension of key content (correct responses on TB/TTG questions), and satisfaction with support calls were evaluated. Qualitative information on call satisfaction was gathered at the 3-month time point. KEY RESULTS: Average completion rate across all calls was 62% with a mean call time of 26 minutes (no significant difference between HL groups). Caregivers had an average score of 0.90 out of 1 when evaluating overall call comprehension by scoring TB/TTG performance. Content comprehension in calls 1, 3, and 4 was significantly higher among caregivers with adequate HL relative to low HL (p < .1). Caregivers from both HL groups felt satisfied with calls [9.1 (2.0)/10-point scale] and agreed that calls helped them learn class material better [8.1 (2.7)]. Qualitatively, caregivers provided 81 (75%) positive responses (e.g., good content) and 27 (25%) negative responses (e.g., too lengthy) regarding the support calls. CONCLUSIONS: Support calls using TB/TTG strategies were feasible, well received, and should be considered for incorporation into childhood obesity interventions. [HLRP: Health Literacy Research and Practice. 2021;5(3):e208-e217.] Plain Language Summary: This study evaluated support calls that used Teach-Back and Teach-to-Goal health literacy strategies as part of a childhood obesity treatment trial. Support calls were well accepted and facilitated comprehension of the key learning objectives in caregivers, regardless of health literacy level. These strategies should be considered for incorporation into childhood obesity treatment interventions to increase uptake of main concepts.

Low Health Literacy Is Associated With Energy-Balance-Related Behaviors, Quality of Life, and BMI Among Rural Appalachian Middle School Students: A Cross-Sectional Study.

BACKGROUND: Many studies document associations between low health literacy (HL) and poor health behaviors and outcomes. Yet, HL is understudied among adolescents, particularly from underserved, rural communities. We targeted rural adolescents in this cross-sectional study and explored relationships between HL and (1) energy-balance-related health behaviors and (2) body mass index (BMI) and quality of life (QOL). METHODS: Surveys were administered to 7th graders across 8 middle schools in rural Appalachia. HL was assessed using the Newest Vital Sign. Energy-balance-related behaviors and QOL were assessed using validated instruments. Height and weight were objectively measured. Analyses were conducted using the Hodges-Lehmann nonparametric median difference test. RESULTS: Of the 854 adolescent students (mean age = 12; 55% female), 47% had limited HL. Relative to students with higher HL, students with lower HL reported significantly lower frequency of health-promoting behaviors (water, fruit and vegetable intake, physical activity, sleep), higher frequency of risky health behaviors (sugar-sweetened beverages, junk food, screen time), and had higher BMI percentiles and lower QOL (all p < .05). CONCLUSIONS: Low HL is associated with energy-balance-related behaviors, BMI, and QOL among rural, Appalachian adolescents. Findings underscore the relevance of HL among rural middle school students and highlight implications for school health.

Assets and Challenges to Recruiting and Engaging Families in a Childhood Obesity Treatment Research Trial: Insights From Academic Partners, Community Partners, and Study Participants.

Background: There is need for the childhood obesity treatment literature to identify effective recruitment and engagement strategies for rural communities that are more likely to lack supportive infrastructure for healthy lifestyles and clinical research relative to their urban counterparts. This community case study examines recruitment and engagement strategies from a comparative effectiveness research (CER) trial of two family-based childhood obesity (FBCO) treatment interventions conducted in a medically underserved, rural region. Guided by a Community Based Participatory Research (CBPR) and systems-based approach, the primary aim was to analyze interviews from academic partners, community partners, and parent study participants for recruitment and engagement assets, challenges, and lessons learned. Methods: Over the 3-year lifespan of the study, researchers conducted 288 interviews with Community Advisory Board members (n = 14), Parent Advisory Team members (n = 7), and study participants (n = 100). Using an inductive-deductive approach, interviews were broadly coded for recruitment and engagement assets, challenges, and recommendations; analyzed for descriptive sub-coding; and organized into stakeholder/organization and participant level themes. Codes were analyzed aggregately across time and examined for differences among stakeholders and parent study participants. Results: Adherence to CBPR principles and development of strong community partnerships facilitated recruitment and engagement; however, variability in recruitment and engagement success impacted partner confidence, threatened outcome validity, and required additional resources. Specifically, assets and challenges emerged around eight key needs. Three were at the stakeholder/organization level: (1) readiness of stakeholders to conduct CBPR research, (2) development of sustainable referral protocols, and (3) development of participant engagement systems. The remaining five were at the participant level: (1) comfort and trust with research, (2) awareness and understanding of the study, (3) intervention accessibility, (4) intervention acceptability, and (5) target population readiness. Future recommendations included conducting readiness assessments and awareness campaigns, piloting and evaluating recruitment and engagement strategies, identifying participant barriers to engagement and finding a priori solutions, and fostering stakeholder leadership to develop sustainable protocols. Conclusion: Collective findings from multiple perspectives demonstrate the need for multi-leveled approaches focusing on infrastructure supports and strategies to improve stakeholder and participant awareness of, and capacity for, recruiting and engaging medically underserved, rural families in a FBCO CER trial.

Consumption of Added Sugars by Rural Residents of Southwest Virginia.

Introduction: Nationally, rural residents have high consumption of added sugars, yet the top sources have not been explored. Characterizing added-sugar intake in high sugar-sweetened beverage (SSB) consumers in rural areas is an important step to help inform interventions and policies. Purpose: The objective of this study was to explore the top food and beverage sources of added sugar and to examine variations by sociodemographic characteristics. Methods: This cross-sectional study analyzed data from a randomized-controlled trial to reduce SSB in eight rural Appalachian counties. Data were obtained from baseline demographic surveys and three 24-hour dietary recalls. Dietary analyses included deriving AS grams and percentage of total energy intake from added sugar from individual food categories. Results: This study had 301 participants, of which 93% were White (non-Hispanic), 81% were female, 49% were aged 35 to 54 years, 43% had an income of ≤$14,000, 33% had low health literacy, and 32% had < college education. Males and those with an income of ≤$14,000 had significantly higher consumption of added sugar. Added sugar contributed to 21% of total energy intake. The top source of added sugar was soda. SSB contributed to 66% of added sugar and 14% of total energy intake. Within SSB, soda contributed to 40% of added sugar, and 8% of total energy intake. Cola and citrus flavored drinks were the main varieties consumed. Implications: Study findings can be used to adapt evidence-based interventions to reflect commonly consumed food and beverages and help inform food- and beverage-based dietary guidelines and policies specific to rural populations.

Using a Socioecological Approach to Identify Factors Associated with Adolescent Sugar-Sweetened Beverage Intake.

BACKGROUND: Adolescents are among the highest consumers of sugar-sweetened beverages (SSBs) in the United States. More research is needed to understand the relationship of multiple levels of influence on adolescent SSB intake across the socioecological model in a nationally representative sample. OBJECTIVE: This secondary analysis of cross-sectional data aims to explain variance in adolescent SSB intake by exploring the associations of adolescent demographic (ie, age, race/ethnicity, and parent socioeconomic status), intrapersonal (ie, behavioral intention, self-efficacy, and media perception), interpersonal (ie, social norms and perceived parenting practices), and home availability variables. DESIGN: This study included 1,560 adolescents who participated in the 2014 National Cancer Institute-sponsored cross-sectional Family, Life, Activity, Sun, Health, and Eating study. Descriptive statistics, analyses of variance, and stepwise multiple linear regression models were used to explore factors associated with SSB intake. In the stepwise regression, a 4-step model was analyzed with each subsequent step adding variables from different socioecological model levels. RESULTS: The final step that included 14 variables individually associated with SSB intake significantly predicted 16.5% of the variance in SSB intake. Four variables were associated with higher SSB intake in the final step when controlling for all other variables: male sex (ß=.066), non-Hispanic black vs non-Hispanic white (ß=.123), adolescent's report of having parents allow them to have SSBs on a bad day (ß=.150), and home SSB availability (ß=.263). Race/ethnicity other than Hispanic and/or non-Hispanic black vs non-Hispanic white was associated with lower intake (ß= -.092). CONCLUSIONS: When considering potential targets for multilevel behavioral interventions aimed at reducing adolescent SSB intake, emphasis on reducing SSB availability at home may be especially important. Furthermore, although adolescence is a period of increasing independence, parent influence on adolescent's health behaviors may also be a key intervention target. Home and parental SSB factors may be more important than targeting intrapersonal factors and social norms among adolescents.

Freeze-Dried Watermelon Supplementation Has Modest Effects on Bone and Lipid Parameters of Ovariectomized Mice.

This study investigated the effects of two doses of freeze-dried watermelon (WM) on bone and lipid parameters in ovariectomized (OVX) mice, a model of post-menopausal osteoporosis. Three-month-old C57BL/6 female mice (n=46) were sham-operated (SHAM) or OVX and randomly assigned to the control or WM diets for 12 weeks: SHAM-control, OVX-control, OVX+1%, or 10% (wt/wt) freeze-dried WM. All diets were isocaloric and isonitrogenous, and had the same calcium and phosphorus concentrations. Freeze-dried WM supplementation was not able to prevent the decrease in whole body, tibial, and lumbar bone mineral density due to estrogen deficiency. Micro-computed tomography analyses showed that WM was also not able to modulate changes in tibial trabecular and cortical bone microarchitecture due to ovariectomy. However, the lumbar trabecular micro-architecture analyses revealed that the WM-10% group had a similar connectivity density, trabecular number, trabecular separation, and structure model index as the SHAM group. Supplementation with 10% WM reduced plasma cholesterol and total liver lipids to the level of the SHAM group but was still similar to that of the OVX-control group. Supplementation with 10% WM increased liver catalase (CAT) mRNA levels but had no effects on mRNA levels of glutathione peroxidase (GPX) and the pro-inflammatory cytokine interleukin-6. There were no differences in plasma activity of the antioxidant enzymes GPX and CAT between all treatment groups. Our findings demonstrate some positive effects of watermelon for modulating lipids and attenuating lumbar vertebral bone loss arising from ovarian hormone deficiency.

Development and Pilot Testing of Text Messages to Help Reduce Sugar-Sweetened Beverage Intake Among Rural Caregivers and Adolescents: Mixed Methods Study.

BACKGROUND: A high consumption of sugar-sweetened beverages (SSBs) poses significant health concerns, particularly for rural adults and adolescents. A manner in which the health of both caregivers and adolescents can be improved is by developing innovative strategies that target caregivers as the agents of change. Sending text messages through mobile phones has been cited as an effective way to improve behavioral outcomes, although little research has been conducted in rural areas, particularly focusing on SSB intake. OBJECTIVE: By targeting rural caregivers, this 2-phase study aimed to (1) understand caregivers' perceptions and language preferences for SSB-related text messages to inform and refine message development and delivery and (2) evaluate the acceptability of text messages for SSB intake behavior change and examine short-term effects on SSB intake behavior. METHODS: A convergent mixed methods design was used to systematically develop and pilot-test text messages with caregivers in Southwest Virginia. In phase 1, 5 focus groups that included a card-sorting activity were conducted to explore advantages/disadvantages, language preferences (ie, tone of voice, audience, and phrase preferences), and perceived use of text messages. In phase 2, caregivers participated in a 5-week text message pilot trial that included weekly educational and personalized strategy messages and SSB intake assessments at baseline and follow-up. Before the focus groups and after completing the pilot trial, caregivers also completed a pre-post survey that assessed SSB intake, SSB home availability, and caregivers' SSB-related practices. Caregivers also completed individual follow-up telephone interviews following the pilot trial. RESULTS: In phase 1, caregivers (N=33) reported that text messages were convenient, accessible, and easy to read. In addition, they preferred messages with empathetic and authoritative tones that provided useful strategies and stayed away from using absolute words (eg, always and never). In the phase 2 pilot trial (N=30), 87% of caregivers completed baseline and 77% completed follow-up assessment, suggesting a high utilization rate. Other ways in which caregivers reported benefiting from the text messages included sharing messages with family members and friends (80%), making mental notes (57%), and looking back at messages as reminders (50%). Caregivers reported significant improvements in home environment, parenting practices, and rulemaking around SSB (P=.003, P=.02, and P=.04, respectively). In addition, the frequency of SSB intake among caregivers and adolescents significantly decreased (P=.003 and P=.005, respectively). CONCLUSIONS: Spending time in the formative phases of text message development helped understand the unique perspectives and language preferences of the target population. Furthermore, delivering an intervention through text messages has the potential to improve caregiver behaviors and reduce SSB intake among rural caregivers and adolescents. Findings from this study were used to develop a larger bank of text messages, which would be used in a future study, testing the effectiveness of a text message intervention targeting SSB intake-related caregiver behaviors.

A comparative effectiveness trial of two family-based childhood obesity treatment programs in a medically underserved region: Rationale, design & methods.

While there is a large body of literature documenting the efficacy of family-based childhood obesity (FBCO) treatment interventions, there is little evidence that these interventions have been systematically translated into regular practice - particularly in health disparate regions. To address this research-practice gap, this project was guided by a community advisory board (CAB) and the RE-AIM planning and evaluation framework within a systems-based and community-based participatory research approach. Families with overweight or obese children between 5 and 12 years old, in the medically-underserved Dan River Region, were randomly assigned to one of two FBCO treatment programs (iChoose vs. Family Connections) delivered by local Parks & Recreation staff. Both programs have previously demonstrated clinically meaningful child BMI z-score reductions, but vary in intensity, structure, and implementation demands. Two clinical CAB partners embedded recruitment methods into their regional healthcare organization, using procedures representative to what could be used if either program was taken to scale. The primary effectiveness outcome is child BMI z-scores at 6-months, with additional assessments at 3-months and at 12-months. Secondary goals are to determine: (1) reach into the intended audience; (2) effectiveness on secondary child and parent outcomes; (3) intervention adoption by organizations and staff; (4) fidelity, cost, and capacity for intervention implementation; and (5) maintenance of individual-level changes and organizational-level sustainability. This research addresses literature gaps related to the features within clinical and community settings that could improve both child weight status and the translation of FBCO interventions into typical practice in medically-underserved communities. IDENTIFIERS: Clincialtrials.gov: NCT03245775.

Kids SIPsmartER, a cluster randomized controlled trial and multi-level intervention to improve sugar-sweetened beverages behaviors among Appalachian middle-school students: Rationale, design & methods.

The intake of sugar-sweetened beverages (SSB) is disproportionately high in Appalachia, including among adolescents whose intake is more than double the national average and more than four times the recommended daily amount. Unfortunately, there is insufficient evidence for effective strategies targeting SSB behaviors among Appalachian youth in real-world settings, including rural schools. Kids SIPsmartER is a 6-month, school-based, behavior and health literacy program aimed at improving SSB behaviors among middle school students. The program also integrates a two-way short message service (SMS) strategy to engage caregivers in SSB role modeling and supporting home SSB environment changes. Kids SIPsmartER is grounded by the Theory of Planned Behavior and health literacy, media literacy, numeracy, and public health literacy concepts. Guided by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), this type 1 hybrid design and cluster randomized controlled trial targets 12 Appalachian middle schools in southwest Virginia. The primary aim evaluates changes in SSB behaviors at 7-months among 7th grade students at schools receiving Kids SIPsmartER, as compared to control schools. Secondary outcomes include other changes in students (e.g., BMI, quality of life, theory-related variables) and caregivers (e.g., SSB behaviors, home SSB environment), and 19-month maintenance of these outcomes. Reach is assessed, along with mixed-methods strategies (e.g., interviews, surveys, observation) to determine how teachers implement Kids SIPsmartER and the potential for institutionalization within schools. This paper discusses the rationale for implementing and evaluating a type 1 hybrid design and multi-level intervention addressing pervasive SSB behaviors in Appalachia. Clincialtrials.gov: NCT03740113.