Effect of the Smart Moms intervention on targeted mediators of change in child sugar-sweetened beverage intake.

OBJECTIVE: Few parent-targeted interventions have examined the mechanisms of action by which the intervention changes child behavior. The purpose of this study was to test the theoretical and behavioral mediators of the Smart Moms intervention on changes in child sugar-sweetened beverage and juice (SSB/juice) consumption. STUDY DESIGN: This is a secondary mediation analysis of data from a 6-month randomized controlled trial (N = 51 mother-child dyads) of a mobile phone-based program to reduce child SSB/juice intake compared with a waitlist control group. METHODS: Linear mixed models compared changes in intervention targets from baseline to 3 months between treatment groups. Intervention targets that changed significantly between groups were tested in a multiple mediation model to evaluate their significance as mediators of change in child SSB/juice at 6 months. RESULTS: Maternal beverage consumption but no other behavioral or theoretical intervention targets mediated the effect of the intervention on the reduction in child SSB/juice at 6 months. There were few mediators of the intervention on child SSB/juice change. CONCLUSION: Greater longitudinal research is needed to understand predictors of child dietary changes to inform future intervention efforts. In addition, a greater focus on the measurement of theoretical constructs in family-based child obesity prevention research is needed.

A mHealth randomized controlled trial to reduce sugar-sweetened beverage intake in preschool-aged children.

BACKGROUND: Sugar-sweetened beverages and maternal weight are strong drivers of child obesity, but few studies have targeted these risk factors as an obesity prevention strategy in children. OBJECTIVE: The objective of this study was to test the efficacy of a smartphone-delivered intervention to reduce parent-provided sugar-sweetened beverage and juice (SSB/juice) consumption among children ages 3-5 and maternal weight. METHODS: Mothers with overweight or obesity, who had a child ages 3-5 that consumed at least 12 fl. oz./day of SSB/juice (N = 51 dyads) were randomized to the Smart Moms group that received one group session, lessons on a mobile website, and text messages, or to a waitlist control group. Mothers self-monitored their children's beverages in addition to their own beverages, high-calorie foods, and weight. Assessments at baseline, 3, and 6 months included dietary recalls to measure SSB/juice intake and objectively measured maternal weight. RESULTS: Using linear mixed models controlling for baseline values, child age and race, there was a greater reduction in child SSB/juice in Smart Moms compared with control at 6 months (-9.7 oz./day vs. 1.7 oz./day, p < .01). Mothers in Smart Moms lost 2.4 kg at 6 months compared with a 0.9-kg gain in the control group (p < .01). CONCLUSIONS: An intervention delivered using mHealth technologies can target mothers to change child dietary behaviours and improve maternal weight, which suggests a novel approach to family-based obesity prevention.

Impact of lymphedema and arm symptoms on quality of life in breast cancer survivors.

Lymphedema is one of many arm problems reported by breast cancer survivors. Understanding the impact of lymphedema on quality of life requires consideration that arm symptoms may occur with or without lymphedema. It was hypothesized that specific arm symptoms and pain, related or unrelated to lymphedema, would be more associated with quality of life outcomes than arm swelling. The relation of arm swelling and of arm symptoms and associated severity with a range of quality of life outcomes following breast cancer treatment was assessed in a diverse sample of 295 women, 141 of whom had a clinical diagnosis of lymphedema. Arm swelling (as defined by interlimb volume or circumference differences) and lymphedema severity (defined by Common Toxicity Criteria) were less correlated with quality of life than total number of arm symptoms and specific individual symptoms. Pain in the affected arm correlated with poor quality of life outcomes, regardless of arm swelling. When evaluating the impact of lymphedema on quality of life, arm swelling may not be as important as the total number and specific types of arm symptoms present, as these may be more informative about quality of life outcomes in survivors of breast cancer with and without lymphedema.

Does the type of CIA policy significantly affect bar and restaurant employment in Minnesota cities?

Clean indoor air (CIA) policies that include free-standing bars and restaurants have been adopted by communities to protect employees in all workplaces from exposure to environmental tobacco smoke, most notably employees working in restaurants and free-standing bars. However, due to the perception of negative economic effects on alcohol-licensed hospitality businesses, partial CIA policies (those that provide an exemption for free-standing bars) have been proposed as a means to reduce the risk of economic effects of comprehensive CIA policies applied to all worksites. Bar and restaurant employment per capita were used to determine if partial CIA policies produced differential economic effects compared to comprehensive CIA policies. Ten cities in the state of Minnesota were studied from 2003-2006. Economic data were drawn from monthly employment in bars and restaurants, and a pooled time-series was completed to evaluate three types of local CIA policies: Comprehensive, partial, or none beyond the state law. Communities with a comprehensive CIA policy had a decrease of 9 employees per 10,000 residents compared with communities with partial CIA policies (p = 0.10). Communities with any type of CIA policy (partial or comprehensive) had an increase of 3 employees per 10,000 residents compared to communities without any CIA policies (p = 0.36). There were no significant differential economic effects by CIA policy type in Minnesota cities. These findings support the adoption of comprehensive CIA policies to provide all employees protection from environmental tobacco smoke exposure.

The relationship between local clean indoor air policies and smoking behaviours in Minnesota youth.

BACKGROUND: While clean indoor air (CIA) policies are intended to reduce exposure to second-hand smoke in the workplace, restrictions in public workplaces have the potential to discourage youth smoking. There is growing evidence from cross-sectional and ecological studies, but limited evidence from longitudinal studies that this is so. OBJECTIVE: To evaluate the association between local CIA policies and smoking behaviours among Minnesota youth over time. DESIGN, SETTING AND SUBJECTS: A cohort of 4233 Minnesota youths, ages 11 to 16 at baseline, was interviewed via telephone for 6 years (2000-2006). Individual, family and community level variables were collected from participants every 6 months. A generalised estimating equation (GEE) logistic regression was used to assess the relationship between CIA policies and past-month smoking in youth over time. The analysis was controlled for potential confounders at individual and community levels. RESULTS: There was not significant association between CIA policies and youth smoking behaviours in the multivariate analyses. At the individual level, parental smoking significantly increased the odds of smoking nearly 40% and close friend smoking increased the odds of past-month smoking by nearly 100% for each close friend. Banning smoking in the home was significantly associated with a 12% reduction in the odds of past-month smoking. CONCLUSION: After accounting for other community and individual level factors known to be associated with youth smoking, there was no significant association between CIA policies and past-month smoking for youth over time.

Process evaluation results from a school- and community-linked intervention: the Trial of Activity for Adolescent Girls (TAAG).

Process evaluation is a component of intervention research that evaluates whether interventions are delivered and received as intended. Here, we describe the process evaluation results for the Trial of Activity for Adolescent Girls (TAAG) intervention. The intervention consisted of four synergistic components designed to provide supportive school- and community-linked environments to prevent the decline in physical activity in adolescent girls. Process evaluation results indicate that the intervention components were delivered from intervention staff to teachers with high fidelity (84-97%) to the protocol and with lower fidelity (range: 18-93%) from teachers to students. Physical activity programs for girls, a unique feature of the TAAG intervention, increased from a mean of 10 programs per school to a mean of 16 and 15 in years 1 and 2, respectively, in intervention schools, with no change in control schools. These findings suggest that a multicomponent school- and community-based physical activity intervention can be delivered with fidelity and result in a middle school environment that supports physical activity for girls.

Intraclass correlation for measures from a middle school nutrition intervention study: estimates, correlates, and applications.

This article presents the first estimates of school-level intraclass correlation for dietary measures based on data from the Teens Eating for Energy and Nutrition at School study. This study involves 3,878 seventh graders from 16 middle schools from Minneapolis-St. Paul, Minnesota. The sample was 66.8% White, 11.2% Black, and 7.0% Asian; 48.8% of the sample was female. Typical fruit and vegetable intake was assessed with a modified version of the Behavior Risk Factor Surveillance System questionnaire. Twenty-four-hour dietary recalls were conducted by nutritionists using the Minnesota Nutrition Data System. Mixed-model regression methods were used to estimate variance components for school and residual error, both before and after adjustment for demographic factors. School-level intraclass correlations were large enough, if ignored, to substantially inflate the Type I error rate in an analysis of treatment effects. The authors show how to use the estimates to determine sample size requirements for future studies.

Stability in consumption of fruit, vegetables, and sugary foods in a cohort from age 14 to age 21.

BACKGROUND: Eating behavior is an etiologic factor in the development of lifestyle-related diseases. Knowledge about the stability of eating behavior during the transition from adolescence to early adulthood has implication for dietary interventions for children and young adolescents. METHOD: Dietary data were collected by means of a short food frequency questionnaire as part of a Norwegian longitudinal cohort study on health behavior, lifestyle, and self-reported health of adolescents. Of 885 14-year-old baseline participants, 521 21-year-olds participated and 40% completed all surveys at each time point. RESULTS: Mean weekly frequency of consumption of fruit and vegetables decreased by 1-2.5 times per week between ages 14 and 21, whereas that of sugar-containing soft drinks increased by almost 1 time per week between ages 15 and 16. Tracking of consumption patterns into young adulthood was seen for all four foods (P < 0.05 for differences in means between the tracking groups). The proportions of individuals remaining in the same tracking categories at the major transition stages were 50-70%. Yet, some changed in the opposite direction of the observed trends. CONCLUSIONS: Despite the overall changes in mean weekly frequency of consumption and prevalence of daily consumers, relative ranking by frequency at age 14 indicated some stability of eating behavior into young adulthood.

Effects of the CATCH physical education intervention: teacher type and lesson location.

BACKGROUND: Substantial differences exist in how and where physical education (PE) is conducted in elementary schools throughout the United States. Few effectiveness studies of large-scale interventions to improve PE have been reported. DESIGN: Multicenter randomized trial. SETTING/ PARTICIPANTS: The Child and Adolescent Trial for Cardiovascular Health (CATCH) was implemented in PE classes in 96 schools (56 intervention, 40 control) in four study centers: California, Louisiana, Minnesota, and Texas. INTERVENTION: The 2.5-year PE intervention consisted of professional development sessions, curricula, and follow-up consultations. MAIN OUTCOME MEASURES: Intervention effects on student physical activity and lesson context in PE were examined by teacher type (PE specialists and classroom teachers) and lesson location (indoors and outdoors). RESULTS: Differential effects by teacher type and lesson location were evidenced for both physical activity and lesson context. Observations of 2016 lessons showed that intervention schools provided more moderate-to-vigorous physical activity (p=0.002) and vigorous physical activity (p=0.02) than controls. Classroom teachers improved physical activity relatively more than PE specialists, but PE specialists still provided longer lessons and more physical activity. Classroom teachers increased lesson length (p=0.02) and time for physical fitness (p=0.03). CONCLUSIONS: The intervention improved PE of both specialists' and classroom teachers' lessons. States and districts should ensure that the most qualified staff teaches PE. Interventions need to be tailored to meet local needs and conditions, including teacher type and location of lessons.

Reliability and validity of the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist: a self-report instrument to measure fat and sodium intake by middle school students.

OBJECTIVE: To develop a scoring algorithm and evaluate the reliability and validity of scores from the Child and Adolescent Trial for Cardiovascular Health (CATCH) Food Checklist (CFC) as measures of total fat, saturated fat, and sodium intake in middle school students. DESIGN: Randomized, controlled trial in which participants were assigned to 1 of 3 study protocols that varied the order of CFC and 24-hour dietary recall administration. Criterion outcomes were percent energy from total fat, percent energy from saturated fat, and sodium intake in milligrams. SUBJECTS/SETTING: A multiethnic sample (33% ethnic and racial minorities) of 365 seventh-grade students from 8 schools in 4 states. STATISTICAL ANALYSES: Multivariable regression models were used to calibrate the effects of individual food checklist items; bootstrap estimates were used for cross-validation; and kappa statistics, Pearson correlations, t tests, and effect sizes were employed to assess reliability and validity. RESULTS: The median same-day test-retest reliability kappa for the 40 individual CFC food items was 0.85. With respect to item validity, the median kappa statistic comparing student choices to those identified by staff dietitians was 0.54. Test-retest reliability coefficients ranged from 0.84 to 0.89 for CFC total nutrient scores. Correlations between CFC scores and 24-hour recall values were 0.36 for total fat, 0.36 for saturated fat, and 0.34 for sodium; CFC scores were consistent with hypothesized gender differences in nutrient intake. APPLICATIONS/CONCLUSIONS: The CFC is a reliable and valid tool for measuring fat, saturated fat, and sodium intake in middle school students. Its brevity and ease of administration make the CFC a cost-effective way to measure middle school students' previous day's intake of selected nutrients in school surveys and intervention studies.

A practical, theory-based approach to establishing school nutrition advisory councils.

This article describes a process for establishing school nutrition advisory councils (SNACs) as an integral part of a school environment approach to promoting the nutritional health of students. The application of social cognitive theory as the conceptual framework for SNACs is discussed and the steps for establishing councils, including describing the school food environment, recruiting council members and convening the council, are reviewed. Actions taken by SNACs to positively affect the school nutrition environment are also described. SNACs are 1 component of the Teens Eating for Energy and Nutrition at School (TEENS) study, a group randomized, school-based intervention trial conducted in 16 middle schools in the Minneapolis-St Paul, Minn, metropolitan area. TEENS seeks to promote healthful dietary behaviors among young adolescents to reduce future cancer risk. Primary outcome measures include increasing fruit and vegetable intake and decreasing fat consumption. SNACs were established in the intervention schools to assess the overall school food environment and to advance school-level policy that promotes a healthful food environment.

Perceptions of the family mealtime environment and adolescent mealtime behavior: do adults and adolescents agree?

The family mealtime environment has great potential to affect the eating behaviors of youth in the family. It is difficult to determine the important elements of a healthy mealtime environment because a valid assessment of the family environment is so difficult to obtain.The objective of this study is to examine the level of agreement between adult and adolescent perceptions of the family mealtime environment and adolescent mealtime behavior.A telephone survey was used to query adult and adolescent family members about how they perceive the family mealtime environment and the adolescent's mealtime behavior. A convenience sample of 282 adult/adolescent pairs from four schools in the Minneapolis/St. Paul area completed the telephone surveys. Frequencies of responses and the associations between the adult and adolescent responses are presented. Pearson correlations and regression were used to examine the level of association between adult and adolescent responses. Mixed-model regression was used for the continuous variables, and mixed-model logistic regression was used for the dichotomous variables. This study showed very little concordance between adolescent and adult responses. Only one question regarding arguments about eating during mealtime showed concordance. Adults and adolescents living in the same household seem to have different perceptions of the family mealtime environment and adolescent eating patterns. Researchers need to be aware of and concerned with the validity of the use of self-report for descriptions of family mealtime. They also need to be aware of the difference in adult and adolescent perceptions and consider these differences when designing messages for the family.

Conducting nutrition education research in junior high schools: approaches and challenges.

This article describes some of the approaches used and challenges encountered conducting nutrition education research in junior high schools. The Teens Eating for Energy and Nutrition at School (TEENS) study recruited 16 schools and over 3800 seventh graders to participate in an intervention to increase students' intakes of fruits, vegetables, and lower fat foods for the purpose of reducing their future risk of cancer. The TEENS intervention included a classroom curriculum as well as a school environment and family component. This article describes some of the issues faced in the design and implementation of the study including recruiting schools and teens, maximizing the number of students within each intervention school exposed to all components of the intervention, and implementing elements of nutrition education in a classroom setting. The methods used to meet these challenges and the success of the methods attempted are described.

How do children's eating patterns and food choices change over time? Results from a cohort study.

PURPOSE: The purpose of this study was to investigate the change in eating patterns and food choices in a cohort of students as they moved from the third to the eighth grade. DESIGN: Dietary behaviors and food choices were abstracted from 24-hour recalls and compared across grade levels. SETTING: The setting for the study was elementary and junior high schools. SUBJECTS: The subjects were a cohort of 291 students from Minnesota. MEASURES: Individual 24-hour dietary recalls from a cohort of students were collected in the third, fifth and eighth grades. RESULTS: As students moved from elementary to junior high and middle school, their consumption of breakfast, fruits, vegetables, and milk decreased. Soft drink consumption increased. In the third grade, nearly 99% of the cohort reported eating breakfast; by the eighth grade, 85% reported eating breakfast. Fruit consumption fell by 41% between the third and the eighth grades while vegetable consumption fell by 25%. The proportion of beverage coming from soft drinks more than tripled between the third and the eighth grades with concomitant reductions in milk and fruit juice consumption. CONCLUSIONS: Family, school, and community-wide efforts are needed to promote healthful eating patterns and food choices among adolescents. Our research indicates that nutrition education is needed in the elementary and middle school years. In addition, we need to work on improving teens' social and physical environments to encourage and facilitate their choice of healthy foods.

The Minnesota DARE PLUS Project: creating community partnerships to prevent drug use and violence.

The research community has criticized Drug Abuse Resistance Education (D.A.R.E.) because the extant literature indicates a lack of evidence that the elementary school program prevents drug use. Yet D.A.R.E. continues to be the most widely implemented drug use prevention program in the United States and has considerable community support. To date, the junior high D.A.R.E. program has not been evaluated. The Minnesota DARE PLUS Project is a randomized trial of 24 schools and communities. During 1999-2001, students in eight schools will receive the junior high D.A.R.E. curriculum in 7th grade; eight schools also will receive the curriculum as well as additional parent involvement, peer leadership, and community components in the 7th and 8th grades; and eight schools will serve as controls. This article describes the background and conceptualization, the curriculum and additional intervention components, and the evaluation methods of the DARE PLUS Project.

Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health.

OBJECTIVE: To assess differences through grade 8 in diet, physical activity, and related health indicators of students who participated in the Child and Adolescent Trial for Cardiovascular Health (CATCH) school and family intervention from grades 3 through 5. DESIGN: Follow-up of the 4-center, randomized, controlled field trial with 56 intervention and 40 control elementary schools. PARTICIPANTS: We studied 3714 (73%) of the initial CATCH cohort of 5106 students from ethnically diverse backgrounds in California, Louisiana, Minnesota, and Texas at grades 6, 7, and 8. RESULTS: Self-reported daily energy intake from fat at baseline was virtually identical in the control (32.7%) and intervention (32.6%) groups. At grade 5, the intake for controls remained at 32.2%, while the intake for the intervention group declined to 30.3% (P<.001). At grade 8, the between-group differential was maintained (31.6% vs 30.6%, P = .01). Intervention students maintained significantly higher self-reported daily vigorous activity than control students (P = .001), although the difference declined from 13.6 minutes in grade 5 to 11.2, 10.8, and 8.8 minutes in grades 6, 7, and 8, respectively. Significant differences in favor of the intervention students also persisted at grade 8 for dietary knowledge and dietary intentions, but not for social support for physical activity. No impact on smoking behavior or stages of contemplating smoking was detected at grade 8. No significant differences were noted among physiologic indicators of body mass index, blood pressure, or serum lipid and cholesterol levels. CONCLUSION: The original CATCH results demonstrated that school-level interventions could modify school lunch and school physical education programs as well as influence student behaviors. This 3-year follow-up without further intervention suggests that the behavioral changes initiated during the elementary school years persisted to early adolescence for self-reported dietary and physical activity behaviors.

Distribution of and factors associated with serum homocysteine levels in children: Child and Adolescent Trial for Cardiovascular Health.

CONTEXT: Although evidence suggests that homocysteine is a risk factor for cardiovascular disease in adults, little information exists on homocysteine levels in children. OBJECTIVES: To describe the distribution of serum homocysteine concentrations among children and to examine the association between homocysteine levels and several characteristics, including serum levels of folic acid and vitamins B12 and B6. DESIGN: Cross-sectional analysis. SETTING: School-based cohort from California, Louisiana, Minnesota, and Texas. PARTICIPANTS: A total of 3524 US schoolchildren, aged 13 and 14 years, from the Child and Adolescent Trial for Cardiovascular Health (completed in 1994). Measurement was conducted in 1997. MAIN OUTCOME MEASURE: Nonfasting serum total homocysteine concentration. RESULTS: The distribution of homocysteine values ranged from 0.1 to 25.7 micromol/L (median, 4.9 micromol/L). Geometric mean homocysteine concentration was significantly higher in boys (5.22 micromol/L) than girls (4.84 micromol/L); blacks (5.51 micromol/L) than whites (4.96 micromol/L) or Hispanics (4.93 micromol/L); nonusers of multivitamins (5.09 micromol/L) than users (4.82 micromol/L); and smokers (5.19 micromol/L) than nonsmokers (5.00 micromol/ L). Serum homocysteine was significantly inversely correlated with serum levels of folic acid (r= -0.36; P = .001), vitamin B12 (r = -0.21; P = .001), and vitamin B6 (r = -0.18; P = .001). Serum homocysteine was not significantly associated with serum lipid levels or family history of cardiovascular disease and was only weakly related to body mass index and systolic blood pressure. After multivariate adjustment, homocysteine remained independently associated with sex, race, serum folic acid and vitamin B12 levels, and systolic blood pressure. CONCLUSIONS: The distribution of homocysteine levels in children is substantially lower than that observed for adults; however, a small percentage of children are still potentially at elevated risk for future cardiovascular disease. Serum folic acid may be an important determinant of homocysteine levels in children.

Comparison of 3 methods for counting fruits and vegetables for fourth-grade students in the Minnesota 5 A Day Power Plus Program.

OBJECTIVE: To compare fruit and vegetable servings calculated from 24-hour dietary recall data using 3 methods: a counting scheme developed for the 5 A Day for Better Health study, a method developed by the University of Minnesota Cancer Prevention Research Unit to quantify total consumption of fruits and vegetables, and a counting scheme based on the US Food and Drug Administration's Reference Amounts. The counting methods differ by food items counted and by serving sizes for those items. SUBJECTS/SETTING: Record-assisted 24-hour dietary recalls were collected from 617 randomly selected fourth-grade students (317 girls, 300 boys) from 23 schools in St Paul, Minn, participating in the Minnesota 5 A Day Power Plus Program. DESIGN: The dietary recalls were analyzed using the Minnesota Nutrition Data System (version 2.6/8a/23). Total servings of fruits and vegetables, servings of vegetables, servings of fruits plus juices, servings of fruit juice, and servings of fruit excluding juice were tallied using each counting method. STATISTICAL ANALYSES: A mixed-model Poisson regression analysis was conducted to compare numbers of servings calculated using the 3 methods. RESULTS: Counts of daily total fruits and vegetables averaged 3.9 servings with the 5 A Day method, 4.1 servings using US Food and Drug Administration Reference Amounts, and 5.1 servings with the Minnesota Cancer Prevention Research Unit method (P < .0001). APPLICATIONS: Because the different counting methods yield different tallies of fruit and vegetable intake, it is important for researchers and practitioners interested in fruit and vegetable consumption to be clear about their uses of the data before choosing a counting scheme.