The δ13C Value of Fingerstick Blood Is a Valid, Reliable, and Sensitive Biomarker of Sugar-Sweetened Beverage Intake in Children and Adolescents.

Background: Reliance on self-reported dietary intake methods is a commonly cited research limitation, and dietary misreporting is a particular problem in children and adolescents. Objective indicators of dietary intake, such as dietary biomarkers, are needed to overcome this research limitation. The added sugar (AS) biomarker δ13C, which measures the relative abundance of 13C to 12C, has demonstrated preliminary validity in adults. Objective: The purpose of this investigation was to determine the comparative validity, test-retest reliability, and sensitivity of the δ13C biomarker to detect AS and sugar-sweetened beverage (SSB) intake using fingerstick blood samples in children and adolescents. Methods: Children (aged 6-11 y, n = 126, 56% male, mean ± SD age: 9 ± 2 y) and adolescents (aged 12-18 y, n = 200, 44% male, mean ± SD age: 15 ± 2 y) completed 4 testing sessions within a 3-wk period. Participants' height, weight, demographic characteristics, and health history were determined at the first session; 24-h recalls were obtained at each visit and fingerstick blood samples were collected at visits 1 and 3. Samples were analyzed for δ13C value using natural abundance stable isotope mass spectrometry. δ13C value was compared with dietary outcomes in the full sample, and in child and adolescent subgroups. t Tests and correlational analyses were used to assess biomarker validity and reliability, whereas logistic regression and area under the receiver-operator characteristic curve (AUC) were used to evaluate sensitivity. Results: Reported mean ± SD AS consumption was 82.2 ± 35.8 g/d and 329 ± 143 kcal/d, and SSB consumption was 222 ± 243 mL/d and 98 ± 103 kcal/d. Mean δ13C value was -19.65 ± 0.69‰, and was lower in children than in adolescents (-19.80 ± 0.67‰ compared with -19.56 ± 0.67‰, P = 0.002). δ13C values were similar across sessions (visit 1: -19.66 ± 0.68‰; visit 3: -19.64 ± 0.68‰; r = 0.99, P < 0.001) and were associated (P < 0.001) with intake of total AS (grams, kilocalories: r = 0.29) and SSB (milliliters, kilocalories: r = 0.35). The biomarker was able to better discriminate between high and low SSB consumers than high and low AS consumers, as demonstrated by the AUC (0.75 and 0.62, respectively). Conclusions: The δ13C biomarker is a promising, minimally invasive, objective biomarker of SSB intake in children and adolescents. Further evaluation using controlled feeding designs is warranted. Registered at clinicaltrials.gov as NCT02455388.

The Hydration Equation: Update on Water Balance and Cognitive Performance.

To become aware of the most practical measures of hydration status.To describe sources of water input and output and the basics of water balance.To understand how hydration status may impact daily cognitive performance. CONDENSED VERSION AND BOTTOM LINE: Water is a crucial nutrient and euhydration is necessary for optimal daily functioning. Water balance is precisely regulated within the body and many methods exist for assessing hydration status. Cognitive performance measures an individual's attentiveness, critical thinking skills, and memory. Traditionally a 2% or more body water deficit was thought to produce cognitive performance decrements; however, recent literature suggests that even mild dehydration - a body water loss of 1-2% - can impair cognitive performance. Counseling clients about their health and wellbeing should include conveying the importance of water for normal body functioning, as well as its effects on physical and cognitive performance.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report.

BACKGROUND: There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles. CASE PRESENTATION: The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year. CONCLUSIONS: This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework.

BACKGROUND: Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking. OBJECTIVE: To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults. METHODS: MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions). RESULTS: Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC. CONCLUSION: International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

The prevalence of subclinical eating disorders among male cyclists.

Disordered eating behaviors are typically seen as a problem in females and there are little data assessing their prevalence in males. The objective of the present cross-sectional investigation was to identify subclinical disordered eating patterns and dietary characteristics among competitive male cyclists. A nutritional questionnaire, the Eating Attitudes Test-26 (EAT-26), and Survey of Eating Disorders Among Cyclists, were completed by male cyclists (n=61) and noncyclists (n=63). Male cyclists scored significantly higher on the EAT-26 compared to the male control group (P<0.001). Of the 12 cyclists who showed the greatest tendency toward disordered eating (EAT-26 >20), only five self-reported having an eating disorder. Approximately half the cyclists believed eating disorders were somewhat common in the sport (28 of 60). The nutritional questionnaire revealed that male cyclists may not consume adequate nutrients to sustain their metabolic needs. Thus, the results of this study suggest that male cyclists may not know how to identify disordered eating habits and may be at an amplified risk for eating disorders and nutritional deficits. Further research should utilize various measures to address the prevalence of disordered eating in a larger sample size and quantify energy balance.

Evaluation of the Relative Validity and Test-Retest Reliability of a 15-Item Beverage Intake Questionnaire in Children and Adolescents.

BACKGROUND: Added sugar intake, in the form of sugar-sweetened beverages (SSBs), may contribute to weight gain and obesity development in children and adolescents. A valid and reliable brief beverage intake assessment tool for children and adolescents could facilitate research in this area. OBJECTIVE: The purpose of this investigation was to evaluate the relative validity and test-retest reliability of a 15-item beverage intake questionnaire (BEVQ) for assessing usual beverage intake in children and adolescents. DESIGN: This cross-sectional investigation included four study visits within a 2- to 3-week time period. PARTICIPANTS/SETTING: Participants (333 enrolled; 98% completion rate) were children aged 6 to 11 years and adolescents aged 12 to18 years recruited from the New River Valley, VA, region from January 2014 to September 2015. Study visits included assessment of height/weight, health history, and four 24-hour dietary recalls (24HRs). The BEVQ was completed at two visits (BEVQ 1, BEVQ 2). MAIN OUTCOME MEASURES: To evaluate relative validity, BEVQ 1 was compared with habitual beverage intake determined by the averaged 24HR. To evaluate test-retest reliability, BEVQ 1 was compared with BEVQ 2. STATISTICAL ANALYSES PERFORMED: Analyses included descriptive statistics, independent sample t tests, χ2 tests, one-way analysis of variance, paired sample t tests, and correlational analyses. RESULTS: In the full sample, self-reported water and total SSB intake were not different between BEVQ 1 and 24HR (mean differences 0±1 fl oz and 0±1 fl oz, respectively; both P values >0.05). Reported intake across all beverage categories was significantly correlated between BEVQ 1 and BEVQ 2 (P<0.001). In children (n=126), reported intake of milk and energy (in kilocalories) for total beverages was not different (all P values >0.05) between BEVQ 1 and 24HR (mean differences: whole milk=3±4 kcal, reduced-fat milk=9±5 kcal, and fat-free milk=7±6 kcal, which is 7±15 total beverage kilocalories). In adolescents (n=200), water and SSB kilocalories were not different (both P values >0.05) between BEVQ 1 and 24HR (mean differences: -1±1 fl oz and 12±9 kcal, respectively). CONCLUSIONS: A 15-item BEVQ provides results that are similar relative to multiple 24HRs for determining habitual milk and total beverage intake in children, and water and SSB intake in adolescents. The 15-item BEVQ is a reliable indicator of habitual beverage intake in both children and adolescents. Future studies could explore whether adjustments to BEVQ beverage categories, portion size, and format could improve the tool's ability to measure beverage intake in young populations.

Beverage Choices of Adolescents and Their Parents Using the Theory of Planned Behavior: A Mixed Methods Analysis.

BACKGROUND: Added sugar intake in the form of sugar-sweetened beverages (SSBs) has been considered a contributor to weight gain and cardiometabolic dysfunction in adults and youth. Adolescents are some of the highest consumers of added sugars, taking in ∼16% of their total calories from added sugars with ∼40% of these calories coming from SSBs. Food preferences and self-regulation of dietary intake by youth can be influenced by parents. OBJECTIVE: To evaluate the effectiveness of the Theory of Planned Behavior (TPB) in understanding and predicting adolescents' SSB consumption, identify which constructs are the most important when evaluating SSB consumption in adolescents, and determine whether and how adolescents' beverage choices are influenced by parents' reactions to their beverage choices. DESIGN: Measurements for this cross-sectional study included four record-assisted 24-hour dietary recalls and responses to an SSB-specific TPB questionnaire from 100 adolescents. Consenting parents completed a beverage intake questionnaire, a TPB questionnaire, and the Parent Response to Beverage Choice Questionnaire. RESULTS: The TPB explained 34% of the variance in adolescents' and parents' intention to limit SSBs to <1cup/day. Parents' perceived behavioral control (b=1.35; P=0.002) and adolescents' subjective norms (b=0.57; P=0.001) were the strongest predictors of intention, and intention was the strongest predictor of SSB consumption in both adolescents and parents (b=-37 [P=0.026] and b=-49 [P=0.003], respectively). The TPB explained more variance in parent SSB consumption (R(2)=0.38) than adolescents (R(2)=0.22). Parents did more discouraging of SSBs and encouraging of non-SSBs. Adolescents' intention to limit SSB consumption moderated the relationship between parents' reactions encouraging SSBs and adolescents' predicted SSB consumption (P=0.021). CONCLUSIONS: The TPB explained a small but significant amount of variance in adolescents' SSB consumption. When addressing adolescent SSB intake, people in addition to parents may influence their intentions and SSB consumption.

A systematic literature review and meta-analysis: The Theory of Planned Behavior's application to understand and predict nutrition-related behaviors in youth.

BACKGROUND: Efforts to reduce unhealthy dietary intake behaviors in youth are urgently needed. Theory-based interventions can be effective in promoting behavior change; one promising model is the Theory of Planned Behavior (TPB). PURPOSE: The aim of this study was to determine, using a systematic literature review, how the TPB has been applied to investigate dietary behaviors, and to evaluate which constructs are associated with dietary behavioral intentions and behaviors in youth. METHODS: Publications were identified by searching electronic databases, contacting experts in the field, and examining an evolving Internet-based TPB-specific bibliography. Studies including participants aged 2-18years, all TPB constructs discernible and measured with a description of how the variables were assessed and analyzed, were published in English and peer-reviewed journals, and focused on nutrition-related behaviors in youth were identified. Accompanying a descriptive statistical analysis was the calculation of effect sizes where possible, a two-stage meta-analysis, and a quality assessment using tenants from the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements. RESULTS: Thirty-four articles, including three intervention studies, were reviewed. The TPB was most often used to evaluate healthy eating and sugary snack and beverage consumption. Attitude had the strongest relationship with dietary behavioral intention (mean r=0.52), while intention was the most common predictor of behavior performance (mean r=0.38; both p<0.001). All three interventions revealed beneficial outcomes when using the TPB (e.g. η(2)=0.51 and ds=0.91, 0.89, and 0.79); extending the Theory with implementation intentions may enhance its effectiveness (e.g. η(2)=0.76). CONCLUSIONS: Overall, the TPB may be an effective framework to identify and understand child and adolescent nutrition-related behaviors, allowing for the development of tailored initiatives targeting poor dietary practices in youth. However, support from the literature is primarily from observational studies and a greater effort towards examining these relationships within intervention studies is needed.

The comparative validity of interactive multimedia questionnaires to paper-administered questionnaires for beverage intake and physical activity: pilot study.

BACKGROUND: Brief, valid, and reliable dietary and physical activity assessment tools are needed, and interactive computerized assessments (ie, those with visual cues, pictures, sounds, and voiceovers) can reduce administration and scoring burdens commonly encountered with paper-based assessments. OBJECTIVE: The purpose of this pilot investigation was to evaluate the comparative validity and reliability of interactive multimedia (IMM) versions (ie, IMM-1 and IMM-2) compared to validated paper-administered (PP) versions of the beverage intake questionnaire (BEVQ-15) and Stanford Leisure-Time Activity Categorical Item (L-Cat); a secondary purpose was to evaluate results across two education attainment levels. METHODS: Adults 21 years or older (n=60) were recruited to complete three laboratory sessions, separated by three to seven days in a randomly assigned sequence, with the following assessments-demographic information, two IMM and one paper-based (PP) version of the BEVQ-15 and L-Cat, health literacy, and an IMM usability survey. RESULTS: Responses across beverage categories from the IMM-1 and PP versions (validity; r=.34-.98) and the IMM-1 and IMM-2 administrations (reliability; r=.61-.94) (all P<.001) were significantly correlated. Paired t tests revealed significant differences in sugar-sweetened beverage (SSB) grams and kcal (P=.02 and P=.01, respectively) and total beverage kcal (P=.03), on IMM-1 and IMM-2; however, comparative validity was demonstrated between IMM-2 and the PP version suggesting familiarization with the IMM tool may influence participant responses (mean differences: SSB 63 grams, SEM 87; P=.52; SSB 21 kcal, SEM 33; P=.48; total beverage 65 kcal, SEM 49; P=.19). Overall mean scores between the PP and both IMM versions of the L-Cat were different (both P<.001); however, responses on all versions were correlated (P<.001). Differences between education categories were noted at each L-Cat administration (IMM-1: P=.008; IMM-2: P=.001; PP: P=.002). Major and minor themes from user feedback suggest that the IMM questionnaires were easy to complete, and relevant to participants' typical beverage choices and physical activity habits. CONCLUSIONS: In general, less educated participants consumed more total beverage and SSB energy, and reported less engagement in physical activity. The IMM BEVQ-15 appears to be a valid and reliable measure to assess habitual beverage intake, although software familiarization may increase response accuracy. The IMM-L-Cat can be considered reliable and may have permitted respondents to more freely disclose actual physical activity levels versus the paper-administered tool. Future larger-scale investigations are warranted to confirm these possibilities.