An explanation for the accuracy of sensor-based measures of energy intake: Amount of food consumed matters more than dietary composition.

Understanding and intervening on eating behavior often necessitates measurement of energy intake (EI); however, commonly utilized and widely accepted methods vary in accuracy and place significant burden on users (e.g., food diaries), or are costly to implement (e.g., doubly labeled water). Thus, researchers have sought to leverage inexpensive and low-burden technologies such as wearable sensors for EI estimation. Paradoxically, one such methodology that estimates EI via smartwatch-based bite counting has demonstrated high accuracy in laboratory and free-living studies, despite only measuring the amount, not the composition, of food consumed. This secondary analysis sought to further explore this phenomenon by evaluating the degree to which EI can be explained by a sensor-based estimate of the amount consumed versus the energy density (ED) of the food consumed. Data were collected from 82 adults in free-living conditions (51.2% female, 31.7% racial and/or ethnic minority; Mage = 33.5, SD = 14.7) who wore a bite counter device on their wrist and used smartphone app to implement the Remote Food Photography Method (RFPM) to assess EI and ED for two weeks. Bite-based estimates of EI were generated via a previously validated algorithm. At a per-meal level, linear mixed effect models indicated that bite-based EI estimates accounted for 23.4% of the variance in RFPM-measured EI, while ED and presence of a beverage accounted for only 0.2% and 0.1% of the variance, respectively. For full days of intake, bite-based EI estimates and ED accounted for 41.5% and 0.2% of the variance, respectively. These results help to explain the viability of sensor-based EI estimation even in the absence of information about dietary composition.

The role of parents in behavioral treatment for adolescent obesity: design and rationale for the TEENS+ randomized clinical trial.

BACKGROUND: There is an urgent need for innovative approaches to adolescent obesity treatment, particularly among individuals from racially and ethnically marginalized backgrounds, who face increased risk of obesity and its associated morbidity and mortality. There is a particular dearth of research on the long-term efficacy of adolescent obesity treatments. Further, research and clinical practice guidelines consistently recommend parents' inclusion in their adolescents' obesity treatment, yet the most effective strategy to engage parents in adolescent obesity treatment remains unclear. Towards that end, this investigation will conduct a fully-powered, randomized clinical trial to examine the efficacy of two distinct approaches to involving parents in their adolescents' obesity treatment. METHODS: Participants will be 210 12-16 year old adolescents (body mass index [BMI]≥85th percentile) and parents (BMI≥25 kg/m2) with overweight or obesity. Dyads will be randomized to one of two 4-month treatments: 1) TEENS+Parents as Coaches (PAC), engaging parents as helpers in their child's weight management via parent skills training based on authoritative parenting, or 2) TEENS+Parent Weight Loss (PWL), engaging parents in their own behavioral weight management. All adolescents will participate in the TEENS+ protocol, which includes nutrition education with dietary goals, supervised physical activity, and behavioral support, and integrates motivational interviewing to enhance treatment engagement. Assessments of anthropometrics, dietary intake, physical activity, parenting and home environment variables will be completed at 0, 2, 4, 8, and 12 months with the primary endpoint at 12-month follow-up. DISCUSSION: Results of this investigation have the potential to significantly advance science in this area and ultimately inform clinical practice guidelines related to the role of parents in adolescent obesity treatment. TRIAL REGISTRATION: Clinicaltrials.gov NCT03851796. Registered: February 22, 2019.

Randomized controlled trial to enhance children's sleep, eating, and weight.

BACKGROUND: The present study assessed the efficacy of a behavioral intervention to enhance children's sleep and reduce caloric intake and body mass index (BMI) change. METHODS: Seventy-eight children 8-11 years old who slept 9.5 h/night or less were randomized to the sleep intervention or to no treatment control. The primary outcome was 2-month change in the actigraph-estimated sleep period; changes in reported caloric intake, percent calories from fat, and BMI/BMI z-score (BMIz) were assessed. RESULTS: Children randomized to intervention enhanced their sleep period by 40 ± 7 min/night relative to control (p < 0.001), and were more likely to increase their sleep period by 30 min/night or more (52% versus 15%, p = 0.003). No differences were observed for reported dietary intake or BMI/BMIz. However, in post-hoc analyses collapsing across groups, those who increased sleep by 30 min/night or more had lower BMI (-0.31 kg/m2, p = 0.01) and BMIz (-0.07, p = 0.03) and reported fewer percent calories from fat at 2 months (-2.2%, p = 0.04). CONCLUSIONS: A brief behavioral intervention can enhance children's sleep, but did not result in changes in caloric intake or weight status. Enhancing sleep by 30 min/night or more may be beneficial for weight regulation. IMPACT: A brief behavioral intervention improved children's nocturnal sleep relative to no treatment control. Given the many benefits of a good night's sleep across domains of functioning, findings have significant implications for children's health and wellbeing. There were no differences between groups on eating behaviors or BMI. However, across groups, children who increased their sleep period by at least 30 min/night, reported reduced intake from fat and evidenced lower BMI at 2 months. Thus, a brief intervention can improve sleep and may have potential benefits for weight regulation.

Design and rationale for evaluating the impact of salad bars on elementary school students' fruit, vegetable, and energy intake: a wait list control, cluster randomized controlled trial.

BACKGROUND: Most children do not consume the recommended amount of fruit and vegetable (FV) servings. Changing the school food environment can be a cost-efficient, effective approach to improving children's dietary quality. There is great popular support for school salad bars as a means to increase children's FV intake within the National School Lunch Program (NSLP), yet empirical research is limited. Further, although FV consumption can facilitate healthy weight management if these foods replace high calorie items, there is a need to enhance understanding of salad bars' influence on children's diet quality and energy intake within the NSLP. This is particularly important to investigate in schools in communities characterized by high poverty, as students they serve are particularly likely to rely on school meals. METHODS: This report describes the design and rationale of a federally-funded investigation that uses validated methods to evaluate school salad bars. This district plans to install salad bars into 141 elementary schools over 5-years, facilitating the conduct of a waitlist control, cluster randomized controlled trial. Specifically, 12 pairs of matched schools will be randomly selected: half receiving a salad bar (Intervention) and half serving pre-portioned FVs only, standard under the NSLP (Control). Thus, groups will have different FV presentation methods; however, all schools will operate under a policy requiring students to take at least one FV serving. Schools will be matched on Title I status and percent of racial/ethnic minoritized students. Intake will be objectively assessed at lunch in each school pair, prior to (baseline), and 4-6 weeks after salad bars are installed (post), yielding ~ 14,160 lunch observations throughout the study duration. Cafeteria sales and NSLP participation data will be obtained to determine how salad bars impact revenues. Finally, implementation factors and cafeteria personnel's perspectives will be assessed, to identify barriers and facilitators to salad bars use and inform sustainability efforts. Proposed methods and current status of this investigation due to COVID-19 are described. DISCUSSION: Results will have great potential to inform school nutrition policies and programs designed to improve dietary quality and reduce obesity. TRIAL REGISTRATION: Retrospectively registered (10/28/22) in clinicaltrials.gov (NCT05605483).

Consistent Morning Exercise May Be Beneficial for Individuals With Obesity.

This review explores the hypothesis that a consistent exercise time, especially consistent morning exercise, improves exercise adherence and weight management for individuals with overweight or obesity. We discuss data supporting this premise, identify limitations of current research, and outline directions for future research on exercise timing to more robustly evaluate our thesis.

Validating an automated image identification process of a passive image-assisted dietary assessment method: proof of concept.

OBJECTIVE: To validate an automated food image identification system, DietCam, which has not been validated, in identifying foods with different shapes and complexities from passively taken digital images. DESIGN: Participants wore Sony SmartEyeglass that automatically took three images per second, while two meals containing four foods, representing regular- (i.e., cookies) and irregular-shaped (i.e., chips) foods and single (i.e., grapes) and complex (i.e., chicken and rice) foods, were consumed. Non-blurry images from the meals' first 5 min were coded by human raters and compared with DietCam results. Comparisons produced four outcomes: true positive (rater/DietCam reports yes for food), false positive (rater reports no food; DietCam reports food), true negative (rater/DietCam reports no food) or false negative (rater reports food; DietCam reports no food). SETTING: Laboratory meal. PARTICIPANTS: Thirty men and women (25·1 ± 6·6 years, 22·7 ± 1·6 kg/m2, 46·7 % White). RESULTS: Identification accuracy was 81·2 and 79·7 % in meals A and B, respectively (food and non-food images) and 78·7 and 77·5 % in meals A and B, respectively (food images only). For food images only, no effect of food shape or complexity was found. When different types of images, such as 100 % food in the image and on the plate, <100 % food in the image and on the plate and food not on the plate, were analysed separately, images with food on the plate had a slightly higher accuracy. CONCLUSIONS: DietCam shows promise in automated food image identification, and DietCam is most accurate when images show food on the plate.

Examining the pattern of new foods and beverages consumed during obesity treatment to inform strategies for self-monitoring intake.

Maintaining dietary self-monitoring during obesity treatment may improve outcomes. As dietary variety is associated with energy intake, understanding the pattern of when new foods and beverages are consumed may assist with identifying when self-monitoring should occur. This study examined dietary variety (total number of differing foods and beverages consumed) from the first 40 days of self-monitoring records reporting ≥ 3 eating occasions and >600 kcal/day from 60 adults (55.9 ±â€¯9.1 yrs, 35.1 ±â€¯5.3 kg/m2, 80.0% female, 95.0% white) participating in a smartphone-based, lifestyle intervention. Dietary variety was coded using an ingredient-based approach. Additionally, new flavors of previously consumed items, and modified and non-modified items contributed to variety. Total number of different foods and beverages consumed over 40 coded days (cumulative variety [cv40]); number of days to reach 50%, 75%, and 100% of cv40; cv40 by eating occasions; and mean number of new items consumed on weekdays and weekend days were calculated. CV40 was 145.4 ±â€¯33.5. Number of coded days to consume 50%, 75%, and 100% of cv40 was 12.7, 25.1, and 40.0, respectively. Dinner was greater (p < 0.0001) in cv40 (58.6 ±â€¯18.5 different items) than other eating occasions, and lunch was greater (p < 0.0001) (38.8 ±â€¯10.7 different items) than breakfast and snack. Weekend days had a greater mean number of new items consumed than weekdays, (3.8 ±â€¯1.0 items vs. 3.6 ±â€¯0.9 items, p = 0.035). Variety of items consumed during obesity treatment is high, and to capture the majority of differing items consumed, at least 4 weeks of detailed recording is needed. After this, to capture new foods and beverages consumed, self-monitoring dinners, lunch, and weekend days may be helpful.

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.

Impact of food craving and calorie intake on body mass index (BMI) changes during an 18-month behavioral weight loss trial.

The purpose of this study was to explore relations between food craving, caloric intake, and body mass index (BMI) changes over the course of an 18-month weight loss trial. Two-hundred two obese adults (mean BMI = 34.9 kg/m2; mean age = 51.30 years, 92.2% White; 57.8% female) who participated in a behavioral weight loss trial completed measures of food craving, caloric intake, and BMI at baseline, 6 and 18 months. From baseline to 6 months, higher initial food cravings were associated with more gradual and less steep reductions in BMI. Additionally, the relation between changes in food craving and BMI changes varied by levels of change in caloric intake, such that BMI change and change in food cravings were positively associated at low levels of change in caloric intake, but were unrelated at average and high levels of change in caloric intake. Similarly, from baseline to 6 months and from 6 to 18 months, the relation between changes in food craving and BMI changes also varied by initial levels of caloric intake. Explicit clinical targeting of food craving management may be beneficial for individuals beginning weight loss programs, especially for those who report higher levels of food craving at baseline. Baseline caloric intake and change in calorie intake over time may serve as moderators of the relation between food cravings and BMI.

Effect of Adding Online Social Support Tools to an Adult Walking Program: A Pilot Randomized Controlled Trial.

This pilot study examined the efficacy of providing access to online social support tools on adults' step counts during a technology-mediated walking intervention. Sixty-three insufficiently active adults were randomized to a 12-week walking intervention with (SUPPORT) or without (NO SUPPORT) access to online social support tools. Both groups received a pedometer, step goals, and access to relevant websites. The SUPPORT group also received access to online social support tools. A mixed-factor analysis of variance was conducted to examine within- and between-group differences in measures of daily steps, psychosocial indicators, and health. Both groups significantly (p < .05) increased their daily steps over time from baseline by 1,401 (SUPPORT) and 2,461 (NO SUPPORT), with no significant differences between groups. Psychosocial and health improvements were no greater for SUPPORT versus NO SUPPORT. The SUPPORT group's use of the online social support tools was low. Results suggest that giving adults access to online social support tools during a technology-mediated walking program did not lead to an enhanced increase in daily steps versus an identical program without these tools; however, the low use of these tools may have weakened their effect. Future studies should examine SUPPORT versus NO SUPPORT among groups with preexisting social ties.

Psycho-Physiological Effects of Television Viewing During Exercise.

We propose that enjoyment is an important factor in the adoption and long-term maintenance of exercise. Television (TV) viewing is believed to be a highly enjoyed leisure-time activity, combining it with exercise may make for a more enjoyable exercise experience. The objective of this study was to examine the effects of television (TV) viewing on psychological and physiological variables during a moderate-intensity exercise bout. Twenty-eight insufficiently active (<150 minutes per week of moderate intensity PA and/or 75 minutes of vigorous PA) adults (Age: M = 47.4 ± 7.6 years) participated in this study. Each participant performed three separate 30-minute walking bouts on a motorized treadmill. During each bout, participants watched a program they selected (30-minute scripted show) (self-selected TV condition), a British Broadcasting Corporation (BBC) nature program (standardized TV condition), or no TV program (no TV condition). Participants were unable to select the nature program as their self-selected program, as it was not a 30-minute scripted program. A Polar Heart Rate (HR) monitor and validated surveys on affect and enjoyment were used. Participants reported greater enjoyment of exercise for both self-selected and standardized TV conditions (97.1 ± 15.2 and 92.7 ± 15.2), compared to the No TV condition (77.5 ± 13.4, p < 0.001). The two TV conditions resulted in similar levels of focus on TV viewing (self-selected TV: 81.2 ± 19.7; standardized TV: 79.1 ± 14.2, p > 0.05) and dissociation from walking (self-selected TV: 38.1 ± 6.7 and standardized TV: 33.2 ± 3.9); they also resulted in more dissociation than the no TV condition (TV: 72.6 ± 5.6, p = 0.002). The findings indicate that TV viewing, regardless of whether the programming is self-selected or standardized, associates with greater enjoyment of exercise.

Dietary intake patterns and diet quality in a nationally representative sample of women with and without severe headache or migraine.

OBJECTIVE/BACKGROUND: The role of diet in migraine is not well understood. We sought to characterize usual dietary intake patterns and diet quality in a nationally representative sample of women with and without severe headache or migraine. We also examined whether the relationship between migraine and diet differs by weight status. METHODS: In this analysis, women with migraine or severe headache status was determined by questionnaire for 3069 women, ages 20-50 years, who participated in the National Health and Nutrition Examination Study, 1999-2004. Women who experienced severe headaches or migraines were classified as migraine for the purposes of this analysis. Dietary intake patterns (micro- and macronutrient intake and eating frequency) and diet quality, measured by the Healthy Eating Index, 2005, were determined using one 24-hour dietary recall. RESULTS: Dietary intake patterns did not significantly differ between women with and without migraine. Normal weight women with migraine had significantly lower diet quality (Healthy Eating Index, 2005 total scores) than women without migraine (52.5 ± 0.9 vs. 45.9 ± 1.0; P < .0001). CONCLUSIONS: Whereas findings suggest no differences in dietary intake patterns among women with and without migraine, dietary quality differs by migraine status in normal weight women. Prospective analyses are needed to establish how diet relates to migraine onset, characteristics, and clinical features in individuals of varying weight status.

Acute Changes in Sleep Duration on Eating Behaviors and Appetite-Regulating Hormones in Overweight/Obese Adults.

There is considerable interest in the role of sleep in weight regulation, yet few studies have examined this relationship in overweight/obese (OW/OB) adults. Using a within-subject, counterbalanced design, 12 OW/OB women were studied in lab with two nights of short (5 hr time in bed [TIB]) and two nights of long (9 hr TIB) sleep. Hunger, consumption at a buffet, and fasting hormone levels were obtained. Significant polysomnographic differences occurred between conditions in total sleep time and sleep architecture (ps < .001). Percent energy from protein at the buffet increased following short sleep. No differences were observed for total energy intake or measured hormones. Further research is needed to determine how lengthening sleep impacts weight regulation in OW/OB adults.

Impact of fruit juice and beverage portion size on snack intake in preschoolers.

It has been recommended that beverages other than 100% fruit juice, such as water, be served at meals and snacks for preschool-aged children to reduce excessive energy intake. Using a 2 × 2 × 2 design (between-subjects factor of order and within-subjects factors of beverage type and size), 26 children (3.9 ± 0.6 years of age, 50% female, 73% white, and 88.5% non-Hispanic or Latino) completed four, 20-min snack sessions consisting of 200 g of applesauce, 60 g of graham crackers, and either 6 oz. (approximately 180 g) or 12 oz. (approximately 360 g) of 100% berry fruit juice or water, to examine the influence of 100% fruit juice and the portion size of the provided fruit juice, on beverage, food, and overall snack intake. Mixed-factor analyses of covariance revealed a significant (p < 0.05) beverage type and size interaction for amount of beverage consumed, with the 12 oz. juice condition consuming the greatest amount of beverage (226.6 ± 116.4 g), and for energy consumed from food, with the 12 oz. water condition consuming more than the 12 oz. juice condition (117.7 ± 69.1 kcal vs. 88.5 ± 64.1 kcal). A main effect of beverage type was found on overall snack energy intake, with more overall energy consumed when juice was provided (175.4 ± 50.0 kcal vs. 104.8 ± 62.8 kcal, p < 0.001). Providing preschool-aged children with a larger size of beverage at a snack increased beverage and/or food intake, and serving 100% juice led to greater overall snack energy intake. Future research should examine the role of 100% fruit juice, and beverage portion size, in contributing to excessive daily energy intake in preschool-aged children.

Position of the Academy of Nutrition and Dietetics: Medical Nutrition Therapy Behavioral Interventions Provided by Dietitians for Adults With Overweight or Obesity, 2024.

Providing interventions that facilitate improvement of dietary intake and other health behaviors can improve nutrition-related outcomes in adults with overweight or obesity. Medical nutrition therapy (MNT) behavioral interventions require expertise from registered dietitian nutritionists or international equivalents (dietitians), which no other health care provider can provide for adults with obesity. Current evidence supports the role of MNT behavioral interventions for adults with overweight or obesity as an effective treatment option, when appropriate for and desired by the client. This Academy of Nutrition and Dietetics Position Paper describes potential benefits and concerns regarding dietitian-provided MNT behavioral interventions for adults with overweight and obesity and informs dietitians about implications for practice. This Position Paper is supported by a systematic review examining effectiveness of MNT interventions provided by dietitians and by an evidence-based practice guideline. It is the position of the Academy of Nutrition and Dietetics that MNT behavioral interventions for adults (aged 18 years and older) with overweight or obesity should be a treatment option, when appropriate and desired by the client, to improve cardiometabolic, quality of life, and anthropometric outcomes. Dietitians providing MNT recognize the complex contributors to overweight and obesity, and thus individualize interventions, based on a shared decision-making process, and deliver interventions in an inclusive, compassionate, and client-centered manner. Interventions should include collaboration with an interprofessional team when needed. Dietitians strive to increase health equity and reduce health disparities by advocating and providing opportunities for increased access to effective nutrition care services. This position remains in effect until December 31, 2031.

Behavioral Intervention that Extends Sleep Duration Leads to Greater Self-Control in School-Aged Children.

OBJECTIVE: Short sleep and evening phase preference associate with impaired self-control, yet few studies have assessed the efficacy of sleep extension for improving this behavioral domain. Thus, this secondary analysis of a behavioral sleep intervention measured whether an intervention that enhanced children's sleep also affected self-control. Differences by chronotype were also explored. METHODS: Sixty-seven children (8-11 yr), who reportedly slept <9.5 hr/d, were randomized to either a control or sleep intervention condition (i.e., 4-session behavioral intervention to enhance sleep by 1-1.5 hr/night). Chronotype was assessed using the Child Chronotype Questionnaire at baseline, and self-control was assessed using the Self-Control Rating Scale (SCRS, a caregiver report) at baseline and 8 weeks postrandomization. Total sleep time (TST) was measured using wrist actigraphy for 1 week at both baseline and 8 weeks postrandomization. Partial correlations and mixed-model ANOVAs were used for statistical analyses, with age as a covariate. RESULTS: At baseline, children with shorter TST (r = -0.29, p = 0.02) and an evening preference (r = 0.26, p = 0.049) were perceived as having lower self-control by their caregivers. Significant condition*time interaction effects were found for TST (p < 0.001) and SCRS score (p = 0.046): From baseline to follow-up, children randomized to the sleep intervention exhibited a significant increase in TST and were perceived as having greater self-control by their caregiver; children randomized to the control condition exhibited no change in TST or in SCRS score. The condition*chronotype*time interaction effect was not significant. CONCLUSION: A brief sleep intervention that enhanced TST also resulted in enhanced caregiver reported self-control in school-age children. Results add to the growing evidence for the importance of sleep health in children.

School Nutrition Personnel Perceptions of School Salad Bars before and after COVID-19.

Many schools have salad bars as a means to increase students' fruit and vegetable intake. School nutrition programs experienced drastic changes to the school food environment due to COVID-19. The aim of the current study was to understand cafeteria personnel's experiences related to salad bar implementation before the COVID-19 pandemic and in the current school environment to inform efforts to enhance salad bar sustainability. Seven elementary schools (N = 30 personnel) installed salad bars prior to COVID-19; three of these schools (n = 13 personnel) re-opened salad bars after COVID-19. Cafeteria personnel completed surveys assessing their experiences with salad bars at both time points. Satisfaction with salad bar implementation and training was high pre- and post-COVID-19. Most agreed that salad bars increased students' fruit and vegetable intake, yet had concerns about cleanliness and waste. Perceived job difficulty increased post-COVID-19 (p = 0.01), and satisfaction with student salad bar training decreased (p = 0.001). Additional staff support and greater student training were needed post-COVID-19. Overall, salad bars were viewed favorably; however, more challenges and lower satisfaction were reported following COVID-19. Increasing support for cafeteria personnel is needed for salad bar sustainability and improving the school food environment.

Study design and rationale for TEENS+REACH: Evaluating ripple effects of a family-based lifestyle intervention to untreated family members.

Background: Understanding the effects of family-based lifestyle intervention beyond the treated adolescent is important, given that obesity is a familial disease and there are likely bidirectional relations between an adolescent's treatment success and broader household changes. However, it is unknown if recommended household-wide changes are adopted or if untreated family members experience weight-related benefits. Methods: TEENS + REACH leverages our ongoing randomized clinical trial of TEENS+, a family-based lifestyle intervention for adolescents with obesity, to determine: 1) if household-wide changes to the shared home environment are implemented, 2) if ripple effects to untreated family members are observed, and 3) whether these changes are predictive of adolescents' weight management success. TEENS + REACH will expand trial assessments to include comprehensive assessments of the shared home feeding, weight, and physical activity environment of the target adolescents. Specifically, we will enroll untreated children (8-17yrs) and caregivers living in the same household as the target parent/adolescent dyad (N = 60 families). At 0, 2, 4 (primary endpoint), and 8-months, the target parent/adolescent dyad and other untreated children and caregivers in the home will complete anthropometric assessments. Discussion: Results will determine the familial reach of TEENS+ and reveal potential mediators of treatment response, which can inform future efforts to optimize family-based lifestyle interventions. Trial registration: TEENS + REACH was retrospectively registered in Clinicaltrials.gov March 22, 2023 (NCT05780970) as an observational study ancillary to the TEENS + clinical trial, registered February 22, 2019 (NCT03851796).

Translating the Recommended Multicomponent Intervention for Childhood Overweight and Obesity into Practice: Implementation Challenges.

A multicomponent, family-based intervention with ≥ 26 contact hours is recommended for the treatment of childhood overweight and obesity. This intervention utilizes behavioral strategies to improve diet, physical activity, and sedentary behaviors. The evidence-based recommendations for this treatment have predominantly come from randomized trials in which the intervention is implemented by research-trained staff in academic research settings, with the intervention delivered to fairly homogeneous samples that are limited in being inclusive of those experiencing health disparities. Thus, there are challenges in implementing the recommended intervention into practice. In particular, there are implementation challenges related to providers, contact time, and settings that impact all children. Specifically, the structure of the intervention may diminish its ability to be delivered by many types of providers in different settings, limiting overall accessibility. There are implementation challenges affecting children who experience health disparities, as it is not clear how efficacious the recommended intervention is for African American or Latinx children, or children from households with low income. Several strategies to reduce identified implementation challenges, such as reducing contact time and intensity of the dietary intervention, are discussed. However, use of these strategies may reduce the effect size of the weight improvements commonly seen with the recommended intervention. Suggestions for future research regarding implementation, specifically using study designs that enhance the ability to create cost-efficient and adaptive interventions that can generalize to many different children and families, are provided.

Transcranial Magnetic Stimulation for Reducing the Relative Reinforcing Value of Food in Adult Patients With Obesity Pursuing Metabolic and Bariatric Surgery: Protocol for a Pilot, Within-Participants, Sham-Controlled Trial.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the most effective and durable obesity treatment. However, there is heterogeneity in weight outcomes, which is partially attributed to variability in appetite and eating regulation. Patients with a strong desire to eat in response to the reward of palatable foods are more likely to overeat and experience suboptimal outcomes. This subgroup, classified as at risk, may benefit from repetitive transcranial magnetic stimulation (rTMS), a noninvasive brain stimulation technique that shows promise for reducing cravings and consumption of addictive drugs and food; no study has evaluated how rTMS affects the reinforcing value of food and brain reward processing in the context of MBS. OBJECTIVE: The goal of the Transcranial Magnetic Stimulation to Reduce the Relative Reinforcing Value of Food (RESTRAIN) study is to perform an initial rTMS test on the relative reinforcing value (RRV) of food (the reinforcing value of palatable food compared with money) among adult patients who are pursuing MBS and report high food reinforcement. Using a within-participants sham-controlled crossover design, we will compare the active and sham rTMS conditions on pre- to posttest changes in the RRV of food (primary objective) and the neural modulation of reward, measured via electroencephalography (EEG; secondary objective). We hypothesize that participants will show larger decreases in food reinforcement and increases in brain reward processing after active versus sham rTMS. METHODS: Participants (n=10) will attend 2 study sessions separated by a washout period. They will be randomized to active rTMS on 1 day and sham rTMS on the other day using a counterbalanced schedule. For both sessions, participants will arrive fasted in the morning and consume a standardized breakfast before being assessed on the RRV of food and reward tasks via EEG before and after rTMS of the left dorsolateral prefrontal cortex. RESULTS: Recruitment and data collection began in December 2022. As of October 2023, overall, 52 patients have been screened; 36 (69%) screened eligible, and 17 (47%) were enrolled. Of these 17 patients, 3 (18%) were excluded before rTMS, 5 (29%) withdrew, 4 (24%) are in the process of completing the protocol, and 5 (29%) completed the protocol. CONCLUSIONS: The RESTRAIN study is the first to test whether rTMS can target neural reward circuits to reduce behavioral (RRV) and neural (EEG) measures of food reward in patients who are pursuing MBS. If successful, the results would provide a rationale for a fully powered trial to examine whether rTMS-related changes in food reinforcement translate into healthier eating patterns and improved MBS outcomes. If the results do not support our hypotheses, we will continue this line of research to evaluate whether additional rTMS sessions and pulses as well as different stimulation locations produce clinically meaningful changes in food reinforcement. TRIAL REGISTRATION: ClinicalTrials.gov NCT05522803; https://clinicaltrials.gov/study/NCT05522803. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50714.