Early adolescent food routines: A photo-elicitation study.

Early adolescence (ages 10-14) encompasses a critical transition period in which food and nutrition decisions are shifting in important ways. Food routines are food-based activities that repeat across days, weeks, seasons, or lives. Examining routines can provide insight into how individuals are influenced in food choices. The objective of this study was to describe current influences on and experiences with food routines during early adolescence. In-depth interviews, using a photo-elicitation approach, were conducted with 30 participants (16 females; 14 males) in the United States. Participants took photos that were then used during the interview to describe food-related decisions and influences. Interviews were audio recorded and transcribed verbatim. Analysis was guided by a grounded theory approach to identify emergent themes related to routines and resulted in the development of a conceptual model for early adolescent food routines. Participants identified a wide range of routines and three main themes emerged: family, settings, and meals/foods consumed. Some had highly established routines throughout the week, while others described routines only for certain meals or days. Several participants described increased control or the ability to modify routines around some eating episodes such as snacks, lunches, and weekend breakfasts. Findings revealed how participants viewed eating routines and provided information about food-and nutrition-related behaviors that can inform future research and practice. Early adolescents appear to have complex food routines influenced by structures and different amounts of control.

Personal, proxy, and collective food agency among early adolescents.

Early adolescence is a critical time for health behavior development because agency increases during the transition from childhood to adolescence. This qualitative study sought to identify how early adolescent participants described food-related agency. One-on-one interviews were conducted with 30 early adolescents (10-13 years). Data analysis was guided by Bandura's three modes of agency: personal, proxy, and collective. Results suggest participants' food behaviors were informed by a growing knowledge about nutrition, household food rules, and school food environments. Participants described different modes of agency in four areas - grocery shopping, cooking, consumption decisions, and nutrition information seeking - with varying degrees of agency in each area. Understanding how each of the three modes operate and the interplay between them can information future research aimed at improving the nutrition behaviors of early adolescents.

Child diet and health outcomes of the simple suppers program: a 10-week, 2-group quasi-experimental family meals trial.

BACKGROUND: Racial minority children, particularly from low-income households, are at risk for obesity. Family meals have a protective effect on child nutritional health. However, the current evidence is limited in racial and socioeconomic diversity. The objective of this study was to evaluate the impact of a family meals intervention, Simple Suppers, on improvements in diet and health outcomes from baseline (T0) to post-intervention (T1) in intervention compared to waitlist control participants, and determine retention of change in outcomes among intervention participants at 10-week follow-up (T2). METHODS: Simple Suppers was a 10-week family meals intervention implemented as a 2-group quasi-experimental trial. Ten 90-min lessons were delivered weekly. Data were collected at T0 and T1, and from intervention participants at T2. Participants were racially diverse 4-10 year-old children from low-income households. Setting was a faith-based community center. Main outcomes were daily servings of fruit, vegetables, and sugar-sweetened beverages and diet quality; z-scores for body mass index (BMI), waist circumference, systolic and diastolic blood pressure (BP); weight status categories; food preparation skills; and family meals (frequency of dinner, breakfast, TV viewing during meals, meals in dining area). Generalized linear mixed models (GLMMs) and mixed-effects ordinal regression models were used to assess intervention impact (T0:T1). Paired t-tests examined retention of change among intervention participants (T1:T2). RESULTS: One hundred forty children enrolled and 126 completed T1 (90% retention); 71 of 87 intervention participants completed T2(79% retention). Mean (SD) age was 6.9(1.9) yr, 62% female, 60% Black, and 42% low-income. Intervention vs waitlist controls had higher food preparation skills (p < 0.001) and lower TV viewing during meals (p = 0.04) at T1.There were no group differences in dietary intake or quality or z-scores for BMI, waist circumference, or BP, however intervention versus waitlist controls experienced a greater change toward healthy weight (p = 0.04) At T2, intervention participants demonstrated a retention of improved food preparation skills. CONCLUSIONS: Simple Suppers led to improvements in children's weight status, food preparation skills, and TV viewing during meals, but not diet or z-scores for BMI, waist circumference, or BP. Future research should examine the preventive effects of healthy family mealtime routines in children at greatest risk for obesity. TRIAL REGISTRATION: NCT02923050; Simple Suppers Scale-up (S3); Retrospectively registered on Oct 2016; First participant enrolled on Jan 2015.

Health-related knowledge, beliefs and self-efficacy in women with polycystic ovary syndrome.

STUDY QUESTION: Do health-related knowledge, beliefs and self-efficacy differ between women with and without polycystic ovary syndrome (PCOS)? SUMMARY ANSWER: Women with PCOS felt at greater risk for adverse health outcomes, yet believed a healthy lifestyle was less beneficial to prevent weight gain relative to a comparison group. WHAT IS KNOWN ALREADY: Diet and physical activity are often used to treat PCOS, but there are high attrition rates and less engagement in self-help methods. It is unclear whether there are unique psychosocial considerations in PCOS that should be incorporated into these interventions. STUDY DESIGN, SIZE, DURATION: This cross-sectional study enrolled 475 women with (N = 255) and without PCOS (N = 220). PARTICIPANTS/MATERIALS, SETTING, METHODS: Female participants were recruited through paper and web-based advertisements across the US (mean age: 28.1 ± 5.4 years). Participants were either diagnosed with PCOS by a healthcare professional (PCOS group) or had self-reported regular menstrual cycles (comparison group). A reliable and valid online instrument about health-related knowledge, beliefs and self-efficacy was administered to these participants. MAIN RESULTS AND THE ROLE OF CHANCE: Most women with PCOS had a basic understanding of nutrition (96%), but had misconceptions about diagnostic criteria for PCOS (≥86%). PCOS was associated with greater perceived susceptibility for disease and weight gain and poorer perceived control over these health outcomes (all P < 0.05), in relation to the comparison group. Women with PCOS also perceived fewer benefits of healthy behaviors on weight gain (P = 0.03) with less than half of the PCOS group attempting to follow government diet recommendations (47%). There were no differences in the self-efficacy of dietary behaviors between groups. LIMITATIONS, REASONS FOR CAUTION: It is likely that participant self-selection occurred due to the nature of recruitment in this study and results may have limited generalizability since most participants identified as Caucasian. Additionally, it is unclear whether some results may be clinically meaningful due to small effect sizes. WIDER IMPLICATIONS OF THE FINDINGS: These findings support that behavioral interventions should incorporate the unique psychosocial considerations associated with PCOS to encourage patient participation in lifestyle interventions. STUDY FUNDING/COMPETING INTEREST(S): This manuscript was partially supported by Cornell University Human Ecology Alumni Association and College of Agriculture and Life Sciences Alumni Association. The authors have no competing interests. TRIAL REGISTRATION NUMBER: NCT01859663.

Characteristics associated with the application of an ecological approach to preventing childhood obesity.

OBJECTIVE: Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training. DESIGN: Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models. SETTING: An online course for participants in the USA and abroad. SUBJECTS: Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240). RESULTS: One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05). CONCLUSIONS: Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.

The relationship between community nutritionists' use of policy, systems and environmental strategies to prevent obesity and its determinants depends on networking.

OBJECTIVE: To apply the Theory of Planned Behaviour to examine the relationship between the constructs of background factors and beliefs towards using policy, systems and environmental (PSE) strategies and reported use of PSE strategies to prevent obesity by a group of professional nutrition educators. DESIGN: Cross-sectional study using self-reported survey. SETTING: Cooperative Extension in New York, USA. SUBJECTS: Nutrition educators (n 58); survey response rate 100 %. RESULTS: Nutrition educators' reported use of PSE strategies to prevent obesity were positively associated with background factors of their community networking and number of staff they managed, their belief of other people's expectations of them to make PSE changes and the belief that their communities were ready to use PSE strategies; and negatively associated with their belief that individual-level factors contributed to obesity. The relationships among these variables were complicated and their use of PSE strategies occurred only when they utilized their professional networks at a moderately high level (above mean of 5·3 on a scale of 1-7), given that their community was also ready to use PSE strategies. CONCLUSIONS: Nutrition educators' use of PSE strategies depends on several internal and external factors. Community networking needs to be emphasized as one of the most significant factors contributing to nutrition educators' work in this area. Organizational and community support should be in place in order to facilitate nutrition educators' effective use of PSE strategies.

Methods and design of a 10-week multi-component family meals intervention: a two group quasi-experimental effectiveness trial.

BACKGROUND: Given the ongoing childhood obesity public health crisis and potential protective effect of family meals, there is need for additional family meals research, specifically experimental studies with expanded health outcomes that focus on the at-risk populations in highest need of intervention. Future research, specifically intervention work, would also benefit from an expansion of the target age range to include younger children, who are laying the foundation of their eating patterns and capable of participating in family meal preparations. The purpose of this paper is to address this research gap by presenting the objectives and research methods of a 10-week multi-component family meals intervention study aimed at eliciting positive changes in child diet and weight status. METHODS: This will be a group quasi-experimental trial with staggered cohort design. Data will be collected via direct measure and questionnaires at baseline, intervention completion (or waiting period for controls), and 10-weeks post-intervention. Setting will be faith-based community center. Participants will be 60 underserved families with at least 1, 4-10 year old child will be recruited and enrolled in the intervention (n = 30) or waitlist control group (n = 30). The intervention (Simple Suppers) is a 10-week family meals program designed for underserved families from racial/ethnic diverse backgrounds. The 10, 90-min program lessons will be delivered weekly over the dinner hour. Session components include: a) interactive group discussion of strategies to overcome family meal barriers, plus weekly goal setting for caregivers; b) engagement in age-appropriate food preparation activities for children; and c) group family meal for caregivers and children. Main outcome measures are change in: child diet quality; child standardized body mass index; and frequency of family meals. Regression models will be used to compare response variables results of intervention to control group, controlling for confounders. Analyses will account for clustering by family and cohort. Significance will be set at p < 0.05. DISCUSSION: This is the first experimentally designed family meals intervention that targets underserved families with elementary school age children and includes an examination of health outcomes beyond weight status. Results will provide researchers and practitioners with insight on evidence-based programming to aid in childhood obesity prevention. TRIAL REGISTRATION: NCT02923050 . Registered 03 October 2016. Retrospectively registered.

Shopping for fruits and vegetables. Food and retail qualities of importance to low-income households at the grocery store.

Purchasing fruits and vegetables is an integral part of managing food consumption and dietary quality. This study examined how low-income adults who had primary responsibility for household food purchases considered retail produce decisions. We used a qualitative research approach based on grounded theory and an ecological conceptual framework. Twenty-eight low-income rural, village, and inner city heads of households in upstate New York, USA, were selected by purposive and theoretical sampling and interviewed about fruit and vegetable shopping habits, attitudes toward local food stores, and where and how they would prefer to buy produce. Analyses revealed their concerns were organized around five themes: store venue; internal store environment; product quality; product price; relationships with the stores. An unanticipated finding was the differing social relations that appear to exist between participant consumers, store employees and management, and the store itself as a representation of the larger retail food system. Attitudes toward retail food stores in this study are described as passive or fatalistic indifference, supportive, opportunistic, and confrontational (change agents). These attitudes are related to how shoppers considered retail fruit and vegetable choice, access, and availability. These findings suggest ways to individualize nutrition education and consumer education messages.

Training Needs of Nutrition Educators Engaged in Policy, Systems, and Environmental Approaches.

OBJECTIVE: Assess training needs of nutrition educators incorporating policy, systems, and environmental (PSE) approaches into their obesity prevention efforts, to identify content for online training. METHODS: Conducted a national, online survey of state and local Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program Education professionals engaged in PSE efforts. RESULTS: Respondents (n = 601) rated the importance of 24 training topics related to planning, implementing, and evaluating PSE approaches. Most (21) topics were rated very important or essential, confirming the need for a comprehensive approach. Paired-sample t tests found significant differences (P <0.001) in some training needs between local and state staff (eg, training in evaluation rated higher for state staff). Training needs did not differ by program, region, or length of employment. The top 5 settings for PSE efforts were schools, farmers' markets, food banks/pantries, community gardens, and after-school programs. CONCLUSIONS AND IMPLICATIONS: Results informed the development of an online training for program implementers. Future research will be needed to assess and refine training needs further, which will evolve as nutrition educators gain more experience in PSE approaches.

Trust in Physicians and Medical Experience Beliefs Differ Between Women With and Without Polycystic Ovary Syndrome.

CONTEXT: Women with polycystic ovary syndrome (PCOS) report dissatisfaction with their early medical care. Little is understood about factors that can encourage stronger patient-provider relationships and promote treatment adherence. OBJECTIVE: To compare trust in physicians and beliefs about social support from health care providers between women with and without PCOS. DESIGN: Cross-sectional study with online questionnaire. SETTING: Medical clinic referral or broader community recruitment via advertising and websites. PARTICIPANTS: Three hundred thirty-two US-based women with PCOS or with regular menses (n = 134 and n = 198, respectively). MAIN OUTCOME MEASURES: Trust and social support toward health care providers [primary care physicians (PCPs), specialists, and/or nurse practitioners and physician assistants]. RESULTS: PCOS was associated with greater distrust in the PCP's opinion (P < 0.01) and greater confidence about the PCP's prioritization of general health concerns (P = 0.04) than the comparison group. Patients with PCOS felt that the PCP spent less effort and were less qualified to treat PCOS health concerns than general health concerns (both P < 0.001). No significant associations were observed between PCOS diagnosis and trust in specialists. When examining social support, women with PCOS felt they had more arguments with their health care providers than the comparison group (P = 0.02). CONCLUSION: Women with PCOS reported greater overall distrust in the PCP's opinions and more arguments with their health care providers than women without PCOS. These findings support a need to identify additional areas of improvement in the patient-provider relationship to ensure continuity of care for patients with PCOS who require life-long surveillance.

What Does Evidence-Based Mean for Nutrition Educators? Best Practices for Choosing Nutrition Education Interventions Based on the Strength of the Evidence.

Funding agencies and professional organizations are increasingly requiring community-based nutrition education programs to be evidence-based. However, few nutrition education interventions have demonstrated efficacy, particularly for interventions that address the outer layers of the socioecological model (ie, organizational, community, and public policy). This article reviews the types of evidence available to assess the likelihood that a given intervention will deliver the desired outcomes and how these types of evidence might be applied to nutrition education, and then suggests an approach for nutrition educators to evaluate the evidence and adapt interventions if necessary.

Implementing Smarter Lunchrooms Makeovers in New York state middle schools: an initial process evaluation.

BACKGROUND: This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6-8, typically children ages 10-14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers. METHODS: Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013-2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery. RESULTS: Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended. CONCLUSIONS: RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

Practice-based evidence of effectiveness in an integrated nutrition and parenting education intervention for low-income parents.

Research identifying associations between parental behaviors and children's food and activity choices and weight suggests that the integration of parenting and nutrition education holds promise for promoting healthful eating and activity in families. However, translational research leading to sustainable interventions lags behind. Development and testing of interventions within actual program contexts is needed to facilitate translation to full-scale implementation. Therefore, the goal of this pilot study was to develop and test an integrated nutrition and parenting education intervention for low-income families within the Expanded Food and Nutrition Education Program in New York State. During a 21-month period, low-income parents of 3- to 11-year-olds were recruited through usual programmatic channels by nutrition program staff to participate in a series of eight workshops delivered to small groups. A validated self-administered questionnaire was used to assess behavior change outcomes among 210 parents who completed the program. Mean scores improved significantly for most behaviors, including adult fruit and vegetable intake; adult and child low-fat dairy and soda intake; and child fast-food intake, activity, and screen time (P<0.001). Many parents reported eating together with children at program entry, leaving little room to improve, but about 20% reported at least a 1-point improvement (on a 5-point scale). The most frequent change was reducing how often children ate fast food and was reported by >50% of parents. Design and testing through practice-based research can facilitate development of interventions that are both feasible and likely to improve eating and activity behaviors among low-income families.

A randomized controlled trial of a community-based nutrition education program for low-income parents.

OBJECTIVE: Assess effectiveness of the Expanded Food and Nutrition Education Program on nutrition behaviors post-education and longitudinally. DESIGN: Switching replications randomized experimental design. Participants randomly assigned to immediate education (IE) or delayed education (DE). Participants in IE received intervention the first 8 weeks, and those in DE the second 8 weeks, with no intervention during alternate periods. Data were collected in 3 repeated measures. PARTICIPANTS: Parents (n = 168 randomized; n = 134 completed) of children in 2 Head Start and 6 low-income schools. INTERVENTION: Eight weekly workshops, based on Eating Right is Basic-Enhanced adapted to incorporate dialogue approach with experiential learning. MAIN OUTCOME MEASURES: Ten-item self-reported behavior checklist on nutrition, food resource management, food safety, and food security; responses on a 5-point scale reporting frequency of behavior. ANALYSIS: Chi-square, analysis of variance, and multiple regression. RESULTS: Groups were demographically similar. Both groups reported improved behaviors pre- to post-education (P < .05). There was no significant difference between groups at Time 1 (T1) or DE control period (T1 vs T2). Changed IE behavior was retained T2 to T3. A multiple regression model of overall change, controlling for T1 score and educator, showed significant improvement (n = 134, ß = 5.72, P < .001). CONCLUSIONS AND IMPLICATIONS: Positive outcomes were supported by this experimental study in a usual program context, with reported behavior changes retained at least 2 months.

Developing a measure of behavior change in a program to help low-income parents prevent unhealthful weight gain in children.

OBJECTIVE: To develop and test a brief measure of changes in eating, active play, and parenting practices after an intervention to help parents shape children's choices and home environments. DESIGN: Sequential phases of development and testing: expert panel review, cognitive testing interviews, field testing, test-retest study, and assessment of convergence with detailed previously validated instruments. SETTING AND PARTICIPANTS: Expanded Food and Nutrition Education Program (EFNEP), New York State. Low-income parents of 3- to 11-year-old children; Cooperative Extension nutrition and parenting educators. MAIN OUTCOME MEASURES: Questionnaire reliability, validity, respondent comprehension, and feasibility of use in program contexts. ANALYSIS: Qualitative analysis of item comprehension. Correlational analysis of test-retest reliability and convergent validity. RESULTS: A behavior checklist was developed to assess change in parent-reported family eating, physical activity, and parenting practices addressed by an intervention. The checklist was feasible for use in EFNEP and questions were understood as intended. Test-retest reliability was good (r = 0.83) and scores correlated significantly (range, 0.25 to -0.60; P < .05) with detailed measures of dietary habits, parental modeling, physical activity, and home environment. CONCLUSIONS AND IMPLICATIONS: Development and testing in a program context produced a tool community nutritionists can use to evaluate educational interventions aimed at helping parents promote healthful eating and activity.

Enhancing the intrinsic work motivation of community nutrition educators: how supportive supervision and job design foster autonomy.

Mixed-methods research investigated the work motivation of paraprofessional community nutrition educators (CNEs) delivering a long-running public health nutrition program. In interviews, CNEs (n = 9) emphasized "freedom," supportive supervision, and "making a difference" as key sources of motivation. Community nutrition educator surveys (n = 115) confirmed high levels of autonomy, which was associated with supervisors' delegation and support, CNE decision-making on scheduling and curricula, and job satisfaction. Supervisors (n = 32) rated CNEs' job design as having inherently motivating characteristics comparable to professional jobs. Supervisory strategies can complement job design to create structured, supportive contexts that maintain fidelity, while granting autonomy to paraprofessionals to enhance intrinsic work motivation.

Online course increases nutrition professionals' knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity.

OBJECTIVE: To assess the impact of an online continuing education course on the knowledge, skills, and self-efficacy of nutrition professionals to use an ecological approach to prevent childhood obesity. DESIGN: Quasi-experimental design using intervention and delayed intervention comparison groups with pre/post-course assessments. SETTING: Online continuing education course. PARTICIPANTS: Nutrition and health professionals in an online course (n = 105) and a delayed intervention comparison group (n = 37). INTERVENTION: A 6-week, facilitated online course titled, Preventing Childhood Obesity: An Ecological Approach. MAIN OUTCOME MEASURES: Changes in knowledge, skills, and self-efficacy in using an ecological approach to address childhood obesity. ANALYSIS: Paired and independent sample t tests, factor analysis, regression analysis. RESULTS: In contrast to a comparison group, nutrition and health professionals who participated in a 6-week online course had statistically significant increases (P < .01) in their knowledge, skills, and self-efficacy related to using an ecological approach to prevent childhood obesity. CONCLUSIONS AND IMPLICATIONS: A facilitated online course can be effective at increasing the knowledge, skills, and self-efficacy of community-based nutrition and health professionals in using an ecological approach to prevent childhood obesity in their communities.

Job satisfaction and retention of community nutrition educators: the importance of perceived value of the program, consultative supervision, and work relationships.

OBJECTIVE: To investigate how paraprofessional Community Nutrition Educators' (CNEs') perceptions of work context relate to job satisfaction and intention to leave the position. DESIGN: Cross-sectional statewide survey of program personnel. SETTING: Expanded Food and Nutrition Education Program (EFNEP) sites (n = 32) serving low- income families in New York. PARTICIPANTS: CNEs delivering EFNEP (n = 115). MAIN OUTCOME MEASURES: CNE job satisfaction and intention to leave. ANALYSIS: Multivariate regression analysis predicting work attitudes from perceived work context, CNE personality traits, and characteristics of CNEs, supervisors, and programs. RESULTS: Despite low satisfaction with pay, overall job satisfaction was high and intention to leave was low. Satisfaction was positively related to CNEs' perceptions of program value, work relationships, and having a voice in relevant decisions (adjusted R(2) = 0.60). Intention to leave was negatively related to perceptions of program value and supervision and satisfaction with pay (adjusted R(2) = 0.36), but the latter relationship was found only among more educated CNEs. CONCLUSIONS AND IMPLICATIONS: CNEs' satisfaction and intention to leave were strongly associated with perceptions of program value, work relationships, and consultative management. Intrinsically motivating work, often viewed as the domain of professionals, is critical for the morale and retention of paraprofessional nutrition educators.