Mi Vida Saludable: Content Validity and Reliability of The Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW) for Cancer Survivors.

The purpose of this study is to conduct validity and reliability testing of a new instrument, the Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW), which is for women who identify as Latina and are breast cancer survivors. PSEDPALW measures preferences and self-efficacy for four behaviors: physical activity (PA), fruit and vegetable (FV) intake, dietary fat (DF) intake, and added sugar (AS) intake (eight scales in total). Validity testing was conducted through an expert panel review and a cognitive interviewing focus group (n = 4). Reliability was tested via internal consistency reliability (n = 118) and test-retest reliability (n = 30). Validity testing was used to refine PSEDPALW. Reliability testing was conducted on three versions with 104, 47, and 41 items. PA scales had acceptable Cronbach's α (>0.70) but low ICC (NS). FV and DF scales had acceptable Cronbach's α (>0.70), with preferences for the shorter (47- and 41-item) versions (Cronbach's α < 0.70), and all scales had moderate ICC (p < 0.05, except the FV scale on the 104-item version (p = 0.07)). The AS preferences scale had Cronbach's α < 0.70, with self-efficacy > 0.70 for all versions and ICC moderate for all versions (p ≤ 0.01). PSEDPALW may be useful to assess diet and physical activity preferences and self-efficacy in theory-based diet and physical activity interventions in women who identify as Latina and are breast cancer survivors.

Ultra-processed foods and the development of obesity in adults.

Ultra-processed foods (UPF) are ubiquitous in the modern-day food supply and widely consumed. High consumption of these foods has been suggested to contribute to the development of obesity in adults. The purpose of this review is to present and evaluate current literature on the relationship between UPF consumption and adult obesity. Cross-sectional studies (n = 9) among different populations worldwide show a positive association between UPF consumption and obesity. Longitudinal studies (n = 7) further demonstrate a positive association between UPF consumption and development of obesity, suggesting a potential causal influence of UPF consumption on obesity risk. However, only one randomized controlled trial has tested the causality of this association. The study included in this review found greater energy intake and weight gain with consumption of a high UPF diet compared to a high unprocessed food diet. The potential mechanisms by which UPF increase the risk of obesity include increased energy intake due to increased sugar consumption, decreased fiber consumption, and decreased protein density; however, more research is needed. Overall, the evidence identified in the current review consistently support a positive relation between high UPF consumption and obesity. While there is a need for more experimental research to establish causality and elucidate the mechanisms, the sum of the evidence supports a need for research on treatment modalities that include reductions in UPF consumption for the management of adult obesity.

Position of the Society for Nutrition Education and Behavior: Nutrition Educator Competencies for Promoting Healthy Individuals, Communities, and Food Systems: Rationale and Application.

It is the position of the Society for Nutrition Education and Behavior that to improve the health of individuals, communities, and food systems, it is essential that nutrition educators meet each of 6 content competencies (basic food and nutrition knowledge, nutrition across the life cycle, food science, physical activity, food and nutrition policy, and agricultural production and food systems) and 4 process competencies (behavior and education theory; nutrition education program design, implementation and evaluation; written, oral, and social media communication; and nutrition education research methods). These competencies reflect the breadth of the nutrition education field and are grounded in peer-reviewed research. The rationale and evidence base for these competencies are presented. They are designed for educational institutions to plan curricula and programs; public, private, and nonprofit organizations for training; individuals for professional development; and policymakers and advocates to inform strong, comprehensive nutrition education policy.

Teachers' Resources to Support School Lunch: Professional Development Is Warranted.

In the United States, many children who come from low-income backgrounds and experience food insecurity do not take and eat school lunch, despite it being a nutritious meal. Teachers could play a role in encouraging students' consumption of school lunch; however, teachers in America are traditionally uninvolved in the lunch period. The purpose of this research was to understand the resources kindergarten through twelfth grade (K-12) teachers need to encourage students to take and eat school lunch. Two data collection workshops and semi-structured follow-up interviews were conducted with K-12 teachers. The workshops and interviews were recorded, transcribed, and analyzed for salient themes. Ten teachers participated in the workshops and six teachers participated in the follow-up interviews. In general, teachers believe school meals are essential for students' focus and behavior in the classroom. However, to encourage students to take and eat school lunch, teachers need support and resources. From the workshops and interviews, three themes emerged: (1) improvements in the food quality; (2) school community support; and (3) professional development. The data suggests professional development is the greatest resource teachers need, as professional development can enhance teachers' motivation to advocate for better food quality and engage school community support. Greater teacher involvement in school lunch could lay the groundwork for future healthier generations.

Qualitative Study of Participation Facilitators and Barriers for Emergency School Meals and Pandemic Electronic Benefits (P-EBT) in an Urban Setting during COVID-19.

During the COVID-19 pandemic, significantly fewer of New York City's (NYC's) 1.1 million public school children participated in emergency grab-and-go meals-heightening the risk of inadequate nutrition security for many of NYC's most vulnerable residents. This study sought to examine student families' facilitators and barriers to participation in the grab-and-go meal service and their experiences with pandemic-electronic benefit transfer (P-EBT) funds, a cash benefit distributed when schools were closed. We recruited 126 parents of children in NYC public schools who had participated in the grab-and-go service. Using opened-ended questions, we interviewed 101 parents in 25 1-h online focus groups. We identified four main themes which broadly impacted school meal participation: communication, logistics, meal appeal, and personal circumstances. Key facilitating subthemes included clear communication, ease of accessing sites, and high variety. Key sub-themes negatively impacting participation included limited communication and low meal variety. Accurate, timely communication; easily accessible distribution locations; and convenient distribution times could have increased participation and satisfaction. For P-EBT, parents welcomed the funds and used them readily, but some experienced difficulties obtaining payments. The simultaneous inclusion of community-based research in the evaluation of emergency feeding programs could improve future outcomes for school meal participation and electronic benefits.

Comparison of Missing School Meals among Public Schools: How Did New York State Do during COVID-19?

BACKGROUND: The COVID-19 pandemic created barriers to participation in school meals. As a result, many students may have missed out on school meals. The objectives of this study are (1) to compare the number of school meals served by New York State public schools during the first spring and summer of the COVID-19 pandemic to the number served before the COVID-19 pandemic, and (2) to determine relationships between the number of meals served and the levels of school district need and urbanicity. METHODS: This study is a secondary analysis of administrative data. The percentage change in the number of school breakfasts and lunches served was calculated for each month and by school district need level and urbanicity level. RESULTS: The number of school meals served decreased during the first spring of the pandemic compared to the spring of the previous school year (-43% in April, -51% in May), while the number of school meals served increased during the first summer of the pandemic compared to the summer of the previous school year (+92% in July, +288% in August). CONCLUSIONS: Waivers may provide flexibility to increase participation in school meals, especially during the summer.

Teachers' Experiences Implementing a School Wellness Initiative in Anchorage, AK: A Qualitative Study.

BACKGROUND: Teachers are uniquely poised to support students' healthy eating habits and physical activity. However, research is needed to examine the successes and challenges teachers face when implementing a school wellness initiative. The purpose of this study was to examine teachers' experiences implementing and managing a pilot school wellness initiative where students had longer lunch and recess, and more physical activity throughout the day. STATISTICAL ANALYSIS: Using a grounded theory approach, transcripts were analyzed qualitatively using principles of content analysis to identify themes and domains. Application of the codes and interrater reliability were conducted with a trained research assistant. METHODS: Focus groups were conducted to understand the challenging and successful experiences of teachers as they implemented and managed a school wellness initiative. The participants were teachers (N = 39) from six purposively selected elementary schools participating in a school wellness initiative. Focus groups were conducted in-person at participating schools. RESULTS: Teachers observed calmer students who ate more lunch with longer lunch periods. In addition, teachers observed improved focus in the classroom and fewer behavior issues with more physical activity opportunities. Successful strategies included reversing lunch and recess and implementing physical activity into daily lessons. However, some teachers had difficulty managing the extra time in the cafeteria and scheduling physical activity throughout the day, particularly in schools where administrators were not as supportive of the initiative. In the schools with greater administrative buy-in and support, teachers had easier, more positive experiences implementing the wellness initiative. CONCLUSIONS: School wellness initiatives in which teachers play a large role have the potential to support teachers and students. This study found that teachers value student health and understand students need to be nourished to learn, but teachers' experiences suggest they need support and buy-in from their administrators to be successful.

Wellness in the Schools: A Lunch Intervention Increases Fruit and Vegetable Consumption.

Wellness in the Schools (WITS) is a national non-profit organization partnering with public schools to provide healthy, scratch cooked, less processed meals (called an Alternative Menu), and active recess. This study examined the effects of WITS programming on school lunch consumption, including fruit and vegetable intake, in second and third grade students in New York City public schools serving a high proportion of students from low-income households. The intervention was evaluated with a quasi-experimental, controlled design with 14 elementary schools (7 that had initiated WITS programming in fall 2015 and were designated as intervention schools, and 7 matched Control schools). School lunch consumption was assessed by anonymous observation using the System of Observational Cafeteria Assessment of Foods Eaten (SOCAFE) tool in the fall of 2015 (Time 0, early intervention) and the spring of 2016 (Time 1) and 2017 (Time 2). There were no baseline data. Data were also collected on the types of entrées served in the months of October, January, and April during the two school years of the study. Across time points, and relative to students in the Control schools, students in WITS schools ate more fruits and vegetables (units = cups): Time 0: Control 0.18 vs. WITS 0.28; Time 1: Control 0.25 vs. WITS 0.31; and Time 2: Control 0.19 vs. WITS 0.27; p < 0.001. They also had more fruits and vegetables (cups) on their trays, which included more vegetables from the salad bar. However, students in the WITS schools ate fewer entrées (grain and protein) and drank less milk than students in the Control schools. Compared to the Control schools, WITS schools offered more homestyle entrées and fewer finger foods and sandwich entrees, i.e., less processed food. Students in WITS schools who received the Alternative menu and all of the WITS programming at all data collection time points selected and consumed more fruits and vegetables. Replication studies with randomized designs and true baseline data are needed to confirm these findings and to identify avenues for strengthening the effects of the program on other school lunch components.

Protocol for a family-centered behavioral intervention to reduce early childhood caries: the MySmileBuddy program efficacy trial.

BACKGROUND: Although largely preventable through diet management and topical fluoride use, early childhood caries (ECC) often progresses to severity that necessitates surgical repair. Yet repair often fails to mitigate caries progression. Needed is an effective behavioral intervention to address underlying behavioral causes. METHODS: This randomized controlled trial will evaluate the efficacy of a behaviorally focused, family-centered intervention, the MySmileBuddy Program (MSB Program), to reduce ECC progression in high-risk preschoolers in New York City. Recruitment will target 858 children ages 24-71 months with ECC and their parents from primary care medical and dental clinics. The study aims to assess the MSB Program's efficacy to: (1) decrease ECC progression measured 12-months post-randomization; and (2) enhance adoption of a low cariogenic diet and twice-daily fluoridated toothpaste use compared to control group. Potential causal pathways (mediators and moderators) will be explored. The MSB Program equips community health workers (CHWs) with an app that facilitates multilevel risk assessment and provides motivational interviewing-based counseling to inform parents about the caries process, develop personalized goals, and create family-level action plans to achieve targeted behaviors. Social support from CHWs (4 interactions during the 6-month intervention, supplemented by up to 4 in-person/remote contacts throughout the 12-month study period, based on need) is bolstered by automated text messages. Participants will be randomized to a Control Group (paper-based educational handout plus toothbrushes and fluoridated toothpaste for the child) or Intervention Group (MSB Program, two tooth-brushing observations with feedback and instruction, and toothbrushes and toothpaste for the entire family). All children will receive visual ICDAS dental examinations and parents will complete study measures at baseline and 12-months. An incentive up to $150 plus round-trip transit cards ($5.50 value) will be provided. DISCUSSION: This study hypothesizes that the MSB Program can reduce ECC progression in a high-risk population. Sufficient incentives and a focus on establishing rapport between participants and CHWs are anticipated to mitigate recruitment and retention challenges. If successful, this study will advance the long-term goal of reducing pediatric oral health disparities by demonstrating the efficacy of an acceptable and feasible intervention that shifts attention from dental repair to behavioral risk mitigation. TRIAL REGISTRATION: Trial registration was completed on 4/13/2021 through the U.S. National Library of Medicine ClinicalTrials.gov website (Identifier: NCT04845594).

Experiential Features of Culinary Nutrition Education That Drive Behavior Change: Frameworks for Research and Practice.

Evidence of the benefits of culinary nutrition education is growing in the literature. Culinary nutrition education programs are naturally experiential, social, skills-based, and effective in improving nutrition-related beliefs, knowledge, and behaviors. In this article, we explore a set of motivational experiences in culinary nutrition education that have been identified as "drivers" of behavior change. These drivers emerged from 20 years of implementation and evaluation of hands-on cooking programs across the life span in more than 30 states within the United States. From these drivers, we developed a framework to guide both new and existing programs that can be best designed to motivate behavior change. These frameworks add value to the work of culinary nutrition educators and will inform and support future culinary nutrition education programs. In future research, health educators implementing skills-based health promotion programs in diverse settings can test the application of this framework to determine its relevance in broader areas.

A Cooking-Based Intervention Promotes Gluten-Free Diet Adherence and Quality of Life for Adults with Celiac Disease.

Current treatment for celiac disease (CD) requires a life-long gluten-free diet (GFD).1 Among the top challenges are eating outside the home2 and over-reliance on processed foods, which are often high-fat, low-fiber, and high-sugar.3 Home cooking is a GFD management strategy that addresses both. Research not specific to CD suggests a variety of positive outcomes related to home cooking: healthier dietary pattern, positive self-management behaviors (eg, improved glycosylated hemoglobin and cholesterol levels), increased willingness to integrate complex dietary changes, and improved quality of life (QOL).4-6 In this study we assessed the feasibility and acceptability of a cooking-based nutrition education intervention to promote GFD adherence and QOL among adults with CD.

Defining Food Education Standards through Consensus: The Pilot Light Food Education Summit.

BACKGROUND: Consistent with the Whole School, Whole Community, Whole Child Approach, food education encompasses nutritional status, culture, community, environment, and society. Unifying standards are needed to support food education integration in K-12 curricula. Pilot Light, a Chicago-based nonprofit, sought to generate such standards. This study reports a formative evaluation research process that led to the development of Food Education Standards (FES). METHODS: Nine FES were drafted within the context of the National Health Education Standards. The 2-day Pilot Light Food Education Summit convened 26 experts and community members to review draft FES. A facilitated, consensus-building process generated refined FES and K-12 competencies. Drawing on Summit outcomes and expert feedback, a team of teachers subsequently drafted final FES. Summit participants completed pre- and post-Summit surveys to assess changes in food education priorities. RESULTS: The initial 9 FES were refined to 7. Comparison data indicated shifts in endorsed priorities for food education, moving from prioritizing specific knowledge, such as "categorizing food into food groups," toward "students having a conscious decision-making process around food." CONCLUSIONS: Developed with input from experts across multidisciplinary fields, the evidence-based Pilot Light FES can be feasibly implemented in multiple subjects across all school types and community socio-demographic levels.

In Defense of Food Curriculum: A Mixed Methods Outcome Evaluation in Afterschool.

Background. Highly processed foods are inexpensive and abundant in our food supply, nutritionally poor, and disproportionately marketed to minority youth. This study is part of a curriculum development project to develop, implement, and evaluate the In Defense of Food (IDOF) curriculum designed to increase intake of whole/minimally processed foods and decrease intake of highly processed foods in youth. Aims. This pilot outcome evaluation was undertaken to assess initial effectiveness and to provide an in-depth understanding of changes in behavioral outcomes and psychosocial mediators. Methods. We used an explanatory mixed method approach, including a single-arm pretest-posttest of intervention effect, followed by a food rules assessment and in-depth interviews to describe participant responses to the intervention in more detail. The study was conducted in three afterschool classrooms in urban low-income neighborhoods with 32 multiethnic middle-school youth, receiving 10 weekly 2-hour sessions. Results. Two weeks postintervention, there was a large positive significant increase in whole/minimally processed food intake (p < .01; d = 0.59) and a small decrease in consumption of highly-processed foods (p = ns; d = 0.06), compared with baseline. Significant increases in psychosocial mediators: Self-efficacy and positive outcomes expectations were seen; others were not significant but changed in the desired direction. Qualitative assessments suggest that the intervention promoted skill building, but environmental barriers made these difficult to use. Discussion. The IDOF curriculum may be most effective for promoting consumption of fruits and vegetables, rather than decreasing intake of highly processed foods. In addition, in this young age-group, short actionable food rules may support self-regulation and behavior change. Conclusion. Among adolescent students in low-income urban neighborhoods, the IDOF afterschool curriculum may help promote self-efficacy and positive outcome expectancies and increase fruit and vegetable intake. Focusing on food processing and using "Food Rules" may be promising to elicit behavior change in youth; however, greater supports are needed to overcome social and environmental barriers.

Cafeteria noise exposure and fruit and vegetable consumption at school lunch: A cross-sectional study of elementary students.

Presently in the U.S., few children meet the recommendation for daily consumption of fruits and vegetables (FV). School feeding programs have shown promise for increasing FV consumption among young children. However, several aspects of the school cafeteria environment have not been examined regarding their relationship with FV consumption. The purpose of this study was to examine the relationship between noise, selected environmental factors previously explored in the literature (i.e., recess/lunch order, the amount of time allocated for lunch, the presence of a salad bar, and number of FV items offered) and 2nd and 3rd grade students' FV consumption during lunch. A digital photography method was used to assess FV consumption among students across 40 days from 20 schools and environmental exposures, including the noise or sound pressure level of the cafeteria, were assessed during lunch. On average, students in this study consumed 0.35 (SD = 0.31) cups of fruit and 0.24 (SD = 0.29) cups of vegetables. The average noise level in cafeterias was 79.7 (SD = 4.1) Leq DbA (range 70 DbA - 84 DbA). Combined FV consumption was negatively associated with noise exposure (B = -0.017; SE = 0.004; P < 0.001) in hierarchical linear models. Among young children eating in cafeterias, increased noise levels may decrease consumption of fruits and vegetables at the school lunch meal. We hypothesize that increased noise can work in two ways to decrease FV consumption: increased socializing (i.e., talking) and/or decreased hedonic enjoyment of the school lunch meal, however future research is needed to examine these mechanisms and provide causal evidence of this effect.

School Lunch Environmental Factors Impacting Fruit and Vegetable Consumption.

OBJECTIVE: Assess impact of school lunch environmental factors on fruit and vegetable (F&V) consumption in second and third grade students. DESIGN: Cross-sectional observations in 1 school year. PARTICIPANTS: Students from 14 elementary schools in 4 New York City boroughs (n = 877 student-tray observations). MAIN OUTCOME MEASURE(S): Dependent variables were F&V consumption collected by visual observation. Independent variables included school lunch environmental factors, and individual-level and school-level demographics. ANALYSIS: Hierarchical linear modeling was used with F&V consumption as the outcome variable, and relevant independent variables included in each model. RESULTS: Slicing or precutting of fruits and having lunch after recess were positively associated (P < .05) with .163- and .080-cup higher fruit consumption across all students, respectively. Preplating of vegetables on lunch trays, having 2 or more vegetable options, and having lunch after recess were positively associated (P < .05) with .024-, .009-, and .007-cup higher vegetable consumption across all students, respectively. CONCLUSIONS AND IMPLICATIONS: Although there was a small increase in intake, results of the study support that some school lunch environmental factors affect children's F&V consumption, with some factors leading to more impactful increases than others. Slicing of fruits seems most promising in leading to greater fruit consumption and should be further tested.

Validation of a Questionnaire to Measure Fruits and Vegetables Selected and Consumed at School Lunch among Second- and Third-Grade Students.

BACKGROUND: Interventions designed to encourage fruit and vegetable (F/V) consumption within schools are increasingly common. Thus, there is a need for valid, practical dietary assessment instruments to evaluate their effectiveness. OBJECTIVE: The aim of this study was to examine the validity of a group-administered, paper-and-pencil questionnaire to assess F/V selection and consumption at school lunch relative to digital photography. DESIGN: This was a five-phase, method-comparison study in which the questionnaire was iteratively modified between each phase. PARTICIPANTS/SETTING: The study examined sets of questionnaires and photographs of lunch trays (n=1,213) collected on 44 days between May 2015 and June 2016 among second-grade students from three New York City schools (phases 1 to 4) and second- and third-grade students from 20 schools across eight states (phase 5). MAIN OUTCOME MEASURES: Outcomes assessed were selection, amount eaten, preference, and intention to consume F/V. STATISTICAL ANALYSES PERFORMED: Validity was assessed by percent agreement (categorized as "match, omission, or intrusion" for items on or off tray and "match, overestimation, or underestimation" for amount eaten), Spearman correlation coefficients, and intraclass correlation coefficients (ICC). RESULTS: The total match rate for items on tray was substantial (phases 1 to 5: 83%, 84%, 92%, 93%, and 89%), with items more frequently intruded than omitted. For amounts eaten, the total match rates were moderate, but generally improved throughout the study (phases 1 to 5: 65%, 64%, 83%, 83%, and 76%), with overestimations more frequent than underestimations. There was good correspondence between methods in the estimates of amount eaten in a quantitative, cup equivalent amount (fruit ICC=0.61; vegetables ICC=0.64). Significant differences (α=.05) were not observed between second- and third-grade students, respectively, in the match rate for fruits (86% and 89%) or vegetable (89% and 86%) items on tray or fruit (69% and 73%) and vegetables (74% and 76%) amount eaten. Excellent correlations were observed between amount eaten and preference for fruit (r=0.91) and vegetables (r=0.93). CONCLUSIONS: The questionnaire offers a feasible, valid instrument for assessing F/V selection and consumption among elementary students in schools participating in the National School Lunch Program. Additional research is recommended to test the instrument's sensitivity and to reproduce these findings using an alternative reference method, such as direct observations.

Why and How Schools Make Nutrition Education Programs "Work".

BACKGROUND: There are many potential health benefits to having nutrition education programs offered by expert outside sources in schools. However, little is known about why and how schools initiate, implement, and institutionalize them. Gaining this understanding may allow the impact and reach of nutrition and other health education programs in schools to be extended. METHODS: A total of 22 school community members from 21 purposefully selected New York City public elementary schools were interviewed using a semistructured interview protocol about their schools' experiences initiating, implementing, and institutionalizing nutrition education programs. Interviews were audiotaped and transcribed. Chronological narratives were written detailing each school's experience and passages highlighting key aspects of each school's experience were identified. These passages (N = 266) were sorted into domains and themes which were regrouped, resorted, and adjusted until all researchers agreed the domains and themes represented the collective experiences of the schools. RESULTS: The interviews elicited 4 broad domains of action: building motivation, choosing programs, developing capacity, and legitimizing nutrition education. Within each domain, themes reflecting specific actions and thoughts emerged. CONCLUSIONS: The identified domains of action and their themes highlight specific, practical actions that school health advocates can use to initiate, implement, and institutionalize nutrition education programs in schools.

¡Cocinar Para Su Salud! Development of a Culturally Based Nutrition Education Curriculum for Hispanic Breast Cancer Survivors Using a Theory-Driven Procedural Model.

We developed a theory-based dietary change curriculum for Hispanic breast cancer survivors with the goal of testing the effects of the intervention on change in dietary intake of fruits/vegetables and fat in a randomized, clinical trial. Social cognitive theory and the transtheoretical model were used as theoretical frameworks to structure curriculum components using the Nutrition Education DESIGN Procedure. Formative assessments were conducted to identify facilitators and barriers common to Hispanic women and test the degree of difficulty and appropriateness of program materials. Focus groups provided valuable insight and informed preimplementation modifications to the dietary program. The result was a systematically planned, evidence-based, culturally tailored dietary intervention for Hispanic breast cancer survivors, ¡Cocinar Para Su Salud! (Cook for Your Health!). The methodology described here may serve as a framework for the development of future dietary interventions among diverse and minority populations. Short- and long-term study results will be reported elsewhere.

Associations among measures of energy balance related behaviors and psychosocial determinants in urban upper elementary school children.

BACKGROUND: Childhood obesity prevention is a pressing issue. Understanding the relationships among eating and physical activity behaviors and potential psychosocial determinants of behavior will help us design more effective interventions. This study aimed to examine such relationships in a large sample of urban elementary school children. METHODS: Fifth grade students in 20 recruited New York City public schools completed a validated questionnaire on six "do more" (fruits and vegetables and physical activity) and "do less" (sweetened beverages, processed packaged snacks, fast food and sedentary behavior) energy balance related behaviors (EBRBs) and psychosocial determinants of behavior from social cognitive and self-determination theories. Correlations among behaviors and hierarchical linear model analyses of the relationship between psychosocial determinants and behaviors were conducted for those with complete data (n = 952). RESULTS: The "do more" and the "do less" behaviors were significantly correlated within categories (p < 0.01). "Do more" food-related behaviors were correlated with physical activity but so were sports drinks, while the "do less" food-related behaviors tended to be correlated to sedentary behavior (p < 0.01). "Do more" behaviors were associated with self-efficacy and habit strength, and "do less" behaviors with outcome expectations, self-efficacy, habit strength, and behavioral intention. CONCLUSIONS: Interventions can address the healthy and less healthy clusters of behaviors together, focusing on strategies to enhance their self-efficacy and habit strength for the "do more" behaviors and outcome expectations to motivate intention to choose fewer "do less" behaviors, along with enhancing self-efficacy and habit. Research can examine these determinants as potential mediators of change in intervention.