A Proposed Cost-Benefit Analysis of Adult EFNEP Utilizing Biomarkers of Chronic Disease Risk.

OBJECTIVE: To assess whether the adult Expanded Food and Nutrition Education Program (EFNEP) is a cost-effective intervention that generates sustained improvement in biomarkers of chronic disease risk. DESIGN: A longitudinal quasi-experimental design with 2 parallel arms (untreated comparison vs EFNEP) and 4 waves of data collection (pretest, posttest, 6 months, and 12 months after completion). SETTING: Eligible adult EFNEP community settings in Colorado, Florida, Maryland, and Washington. PARTICIPANTS: Free-living adults (n = 500) aged 18-50 years, with income ≤ 185% of the Federal Poverty Line. INTERVENTION(S): Adult EFNEP delivered using an evidence-based curriculum, Eating Smart • Being Active. MAIN OUTCOME MEASURE(S): Chronic disease biomarkers (body mass index, blood pressure, and HbA1c), food and physical activity behaviors, dietary intake, health status, and demographics will be measured using objective biometric indicators, the Adult EFNEP Questionnaire, a 24-hour dietary recall, a health questionnaire, and demographic forms. ANALYSIS: Linear mixed models will be used to assess whether adult EFNEP has a significant (P < 0.01) impact on 3 chronic disease biomarkers. The program's estimated impact on chronic disease biomarkers will be incorporated into a cost-benefit analysis framework to assess the economic value generated by adult EFNEP through chronic disease risk reduction.

Parents Report Positive Changes in Parental Feeding Practices 12 Months After Intervention.

OBJECTIVE: Determine self-reported parental feeding behavior changes and perspectives on parental feeding intervention at 12-month follow-up. METHODS: Telephone focus groups using a 2 × 2 design (English/Spanish × in-class or online) with Expanded Food and Nutrition Education Program participants (n = 37) with children 2-8 years and high exposure to the Food, Feeding, and Your Family intervention (7 lessons). Researchers (n = 3) independently identified themes. RESULTS: Parental behavior changes that (1) positively influenced children's diets, (2) involved children in food-related activities, (3) eased stressful situations around food, (4) led to healthier food choices, and (5) saved money when food shopping. Commonly implemented practices included establishing structured mealtime routines, introducing new foods multiple times, and encouraging children's eating competence. Online participants noted materials were easily accessible via text messages. CONCLUSIONS AND IMPLICATIONS: Incorporating parental feeding content (in-class or online) into nutrition education interventions, such as the Expanded Food and Nutrition Education Program, supports developing positive parental feeding behaviors in families with low income.

Using Mobile Technology for Family-Based Prevention in Families with Low Incomes: Lessons from a Randomized Controlled Trial of a Childhood Obesity Prevention Program.

Researchers are increasingly using web-based technologies to deliver family-based, prevention programming. Few studies have examined the success of such approaches for families with low incomes. The purpose of this study was to describe the level of in-class and online engagement in a childhood obesity prevention program for parents with low incomes, to examine the demographic correlates of parent engagement, and to examine dosage effects on parental feeding outcomes as a function of online exposure. All participants attended in-class nutrition education classes (Eating Smart · Being Active) as part of the Expanded Food and Nutrition Education Program (EFNEP) in Colorado and Washington State (classes were offered in English and Spanish). Participants in this analysis were 168 parents from a larger cluster randomized controlled trial who had been randomly assigned to also receive a newly developed, mobile-based version of an efficacious, feeding-focused, childhood obesity prevention program. Results showed that despite high levels of in-person attendance (70%), participants only accessed 47% of the videos (online content). Older parents and parents of girls showed higher levels of in-person attendance; currently employed parents showed lower levels. Online engagement varied as a function of ethnicity and acculturation: non-Hispanic parents accessed the most videos, low-acculturated Hispanic parents accessed the second most, and highly acculturated Hispanic parents accessed the least. In contrast, low-acculturated Hispanic parents showed the highest in-person attendance. For all but one outcome, significant online program effects were found only for parents who accessed at least half of the videos. Implications for mobile-based, family-based prevention programs for parents with low incomes are considered.ClinicalTrials.gov Identifier: NCT03170700; Registration Date: March 08, 2017.

Short-Term Efficacy of a Childhood Obesity Prevention Program Designed to Pair Feeding Content With Nutrition Education.

Background: Family-based programs show considerable promise in preventing overweight and obesity in young children. However, dissemination is difficult because significant participant and staff involvement is required. This study examined the short-term efficacy of adding parental feeding content to a widely-used nutrition education curriculum for families in low-resourced communities comparing the influence of two delivery methods (in-class and online) on parents' feeding knowledge, practices, and styles. Methods: In this cluster randomized controlled trial, parents of 2- to 8-year-old children enrolled in the EFNEP (Expanded Food and Nutrition Education Program) in Colorado and Washington were randomly assigned to: in-class nutrition education only, in-class nutrition education with in-class feeding content, or in-class nutrition education with online feeding content. Data from the 382 participants who completed both pretest and posttest assessments are reported in this study. Results: Multilevel analyses showed empirical support for the influence of the program on parents' feeding knowledge, practices, and styles. Online and in-class methods were equally effective in delivering feeding content in low-resourced communities. Consistent effects were seen across the two delivery methods for encouraging children to try new foods (p < 0.05), use of child-centered feeding practices (i.e., greater responsiveness, p < 0.05), child involvement in food preparation (p < 0.05), and understanding the number of presentations often necessary for child acceptance of a new food (p < 0.001). Location and language differences were seen across some constructs. Conclusions: This study demonstrates the efficacy of in-class and online approaches to feeding highlighting the program's positive effects on promoting healthy feeding behaviors for parents of children in low-resourced families. ClinicalTrials.gov Identifier: NCT03170700.

Development of Reliable and Valid Questions to Assess Food Resource Management Behaviors in Adults With Limited Income.

OBJECTIVE: Develop reliable, valid questions to assess changes in food resource management (FRM) behaviors in adults with limited incomes. DESIGN: Questionnaire development using a mixed-methods approach: content validity (subject matter and curricula), face validity, temporal reliability (test-retest), sensitivity to change, and exploratory factor analysis (EFA). SETTING: Community settings in 12 states. PARTICIPANTS: Convenience samples of English-speaking Expanded Food and Nutrition Education Program (EFNEP) or EFNEP-eligible adults: 105 (cognitive interviews), 181 (test-retest), 185 (sensitivity), and 389 (EFA) adults. VARIABLES MEASURED: Behaviors related to FRM skills: planning, shopping, and budgeting. ANALYSIS: Consistency and agreement in cognitive interviews and temporal reliability; sensitivity at posttest (paired t tests, Wilcoxon signed-rank tests); internal consistency of scales identified in EFA (Cronbach α). P < 0.5. RESULTS: All questions had acceptable temporal reliability ranges for the intraclass correlation coefficient (0.48-0.74) and Spearman rank-order correlation (0.48-0.73). All questions were sensitive to change at posttest (P < 0.001). Planning and saving scales, revealed by EFA, demonstrated internal consistency (> 0.80 Cronbach α). CONCLUSIONS AND IMPLICATIONS: The 9 FRM behavior questions have acceptable temporal reliability and content and face validity and can be used nationally by EFNEP to assess participants' self-reported behavior changes. Other nutrition programs with similar audiences and content could use these questions to measure changes in FRM behaviors.

Implementation Science Strategies Promote Fidelity in the Food, Feeding, and Your Family Study.

OBJECTIVE: Use of implementation science strategies to promote fidelity in the Food, Feeding, and Your Family study. DESIGN: Cluster randomized controlled trial with 3 conditions: control, in-class, or online, delivered in English or Spanish. Observations of 20% of classes. SETTING: Expanded Food and Nutrition Education Program (EFNEP) in 2 states. PARTICIPANTS: EFNEP peer educators (n = 11). INTERVENTION: Parental feeding content incorporated into EFNEP lessons (in-class) or through text with links to videos/activities (online). Extensive educator training, scripted curriculum, frequent feedback. ANALYSIS: Assessment of fidelity compliance. Qualitative analysis of verbatim educator interviews and classroom observer comments. RESULTS: During 128 class observations (40-45 per condition), peer educators followed scripted lesson plan 78% to 89% of the time. There was no evidence of cross-contamination of parental feeding content in control and only minor sharing in online conditions. Variations with fidelity were primarily tied to the EFNEP curriculum, not the parent feeding content. Educators (n = 7) expressed favorable opinions about the Food, Feeding, and Your Family study, thought it provided valuable information, and appreciated support from EFNEP leadership. CONCLUSIONS AND IMPLICATIONS: Incorporating implementation science strategies can help ensure successful adherence to research protocols. With proper training and support, EFNEP peer educators can deliver an evidence-based curriculum as part of a complex research study.

Pairing Feeding Content With a Nutrition Education Curriculum: A Comparison of Online and In-Class Delivery.

OBJECTIVE: To develop a childhood obesity prevention program, Food, Feeding and Your Family (FFYF), which encourages eating self-regulation in young children. This article describes the research methods for FFYF. Activities that will be used to guide the development of the program are illustrated in a logic model. DESIGN: A randomized control trial will be conducted with participant groups randomized into 1 of 3 conditions: (1) in-class delivery of feeding content and nutrition education, (2) online delivery of feeding content and in-class delivery of nutrition education, and (3) nutrition education only. Assessments will be collected at baseline, program completion, and 6 and 12 months after completion of the program. SETTING: Study will be conducted through the Expanded Food and Nutrition Education Program in Colorado and Washington State. PARTICIPANTS: Parents with 2- to 8-year-old children will be recruited from affiliated community agencies, 540 participants across both states. INTERVENTIONS: FFYF derives content from an empirically validated parental feeding program, Strategies for Effective Eating Development, and will be administered with Eating Smart • Being Active, an evidence-based, nutrition education curriculum. MAIN OUTCOME MEASURES: Parents will report on feeding practices, child eating behaviors, feeding styles, and acculturation. ANALYSIS: Because of the nested nature of the data, multilevel analyses will be used: time points, within parents, and within groups.

Development and Testing of the Healthy Food Pantry Assessment Tool.

OBJECTIVE: To develop and test an observational survey that quantifies food pantry environments (FPE). DESIGN: Best practices in FPE were identified through key informant interviews. The tool was pilot-tested, including a content review, and then field-tested for reliability. SETTING: Key informant phone interviews (n = 41); pilot and field test visits occurred at 45 pantries from multiple states. SUBJECTS: Food bank/pantry staff and nutrition educators were recruited for interviews through purposive and snowball sampling. Pilot and field test survey users (n = 65) were food pantry representatives and matched community partners who both rated the FPE using the tool. VARIABLES MEASURED: Pearson correlation was used to determine test-retest and interrater reliability. ANALYSIS: Qualitative data were coded for healthy FPE strategies. Quantitative data were calculated using descriptive statistics (significant at P < .05). RESULTS: Qualitative data were coded for observable FPE characteristics. Reliability scores were substantial to nearly perfect for 48 of 61 survey items (79%) for test-retest and 49 of 61 (80%) for interrater reliability (Pearson r = .6-1.0). CONCLUSIONS AND IMPLICATIONS: The Healthy Food Pantry Assessment Tool is research-tested and can be used to evaluate and quantify the healthfulness of FPE.

Psychosocial factors influencing the frequency of fast-food consumption among urban and rural Costa Rican adolescents.

OBJECTIVE: The aim of this study was to identify psychosocial factors that influence fast-food consumption in urban and rural Costa Rican adolescents. METHODS: A self-administered questionnaire designed for the study asked about sociodemographic information, frequency of fast-food consumption, meaning of "fast food," location of purchase, and psychosocial correlates. Five psychosocial factors were extracted by using principal components analysis with Varimax rotation method and eigenvalues. Descriptive statistics and a hierarchical linear regression model were used to predict the frequency of fast-food consumption. RESULTS: Responses from 400 adolescents (ages 12-17 y) reveal that daily consumption of fast food was 1.8 times more frequently mentioned by rural adolescents compared with urban youth. Urban and rural differences were found in the way adolescents classified fast foods (rural adolescents included more traditional foods like chips, sandwiches, and Casado-a dish consisting of rice, black beans, plantains, salad, and a meat), and in purchasing locations (rural adolescents identified neighborhood convenience stores as fast-food restaurants). Living in rural areas, convenience and availability of foods, and the presence of external loci of control were predictors of a higher frequency of fast-food consumption, whereas health awareness predicted a lower frequency. CONCLUSIONS: The development of interventions to reduce fast-food consumption in Costa Rican adolescents should consider not only convenience, but also the availability of these foods where adolescents are more exposed, particularly in rural areas. Interventions such as improving the convenience of healthy fast foods available in school canteens and neighborhood stores, policies to increase the price of unhealthy fast food, and activities to provide adolescents with the skills to increase self-efficacy and reduce the effect of external loci of control are recommended.

Changes in dietary intake and food sources of saturated and cis and trans unsaturated fatty acids in Costa Rican adolescents: 1996 versus 2006.

OBJECTIVE: To identify how dietary intake and food sources of saturated (SFA) and cis (PUFA) and trans (TFA) unsaturated fatty acids in the diet of Costa Rican adolescents changed from 1996 to 2006--a period with several public health nutrition changes. METHODS: Cross-sectional comparisons used data from measured food records of 133 adolescents (ages 12-17 y) surveyed in 1996 and a similar group of adolescents surveyed in 2006. Values obtained in 1996 and 2006 were compared with the current World Health Organization guidelines for chronic disease prevention. RESULTS: Adolescents surveyed in 2006 reported a significantly higher mean daily energy intake from linoleic acid (LA) and alpha-linolenic acid (ALA) (0.9% and 7.8%, respectively) compared with the 1996 cohort, whereas SFA and TFA were significantly lower (9.5% and 1.3%, respectively). Food sources of fat also changed. In 2006, 2% of SFA in the diet came from palm shortening (compared with 34% in 1996); 39% of TFA came from ruminant-derived foods (in 1996, soybean oil was the main contributor of TFA, 34%), and bakery products (mainly pre-packaged cookies) provided 25% of the source of TFA, compared with only 11% in 1996. Dietary fatty intake of Costa Rican adolescents in 2006 is closer to WHO guidelines compared with 1996. CONCLUSIONS: After public health initiatives that changed fatty acid profile of most foods, intakes of TFA, SFA, and food sources of fatty acids in adolescents' diets improved. Public health nutrition efforts should continue to strengthen diets that are low in SFA and TFA and higher in ALA content among Costa Rican adolescents.