Does the Mexican sugar-sweetened beverage tax have a signaling effect? ENSANUT 2016.

OBJECTIVE: To evaluate the potential signaling effect of the Mexican tax on sugar-sweetened beverages (SSBs) by analyzing the association between awareness of and opinions about its effectiveness with current consumption of taxed SSBs and with a self-reported change in consumption of SSBs since the implementation of the tax. We also examined the association between psychosocial and environmental determinants of SSB consumption with current consumption of taxed SSBs and with a reported change in consumption of SSBs. METHODS: Cross-sectional analyses of survey and food-frequency questionnaire data from the Mexican National Health and Nutrition Survey 2016. Participants were Mexican adults (20-59 years, N = 6,650). Logistic regression was used to evaluate the probability of a person reporting a decrease in SSB consumption, given their awareness of the tax, opinion about its effectiveness, psychosocial (SSB health-related beliefs, self-efficacy, and liking of SSBs) and environmental (availability of potable water) determinants. Multiple linear regression analysis was utilized to examine the association between the aforementioned factors and current consumption of taxed SSBs. RESULTS: Compared with adults not aware, adults who were aware of the SSB tax were more likely (OR = 1.30) to report a decrease in SSB consumption (p = .012). In urban areas, adults aware of the tax drank a significantly lower amount of taxed SSBs (-15.7%; p = .023) than those not aware. Self-efficacy and liking of SSBs were significantly associated with a reported decrease in consumption and with current consumption (p < .001), while health beliefs and availability of potable water were not significantly associated with either reported change in SSB consumption or current consumption of taxed SSBs. CONCLUSIONS: Implementation of an SSB tax accompanied by highly visible campaigns may further influence the impact of taxes on SSBs consumption. Future public health and nutrition education campaigns designed to increase knowledge and enhance motivation should be complemented by programs to assist individuals develop self-efficacy and self-regulation skills.

Brief Report: Mealtime Behaviors of Chinese American Children with Autism Spectrum Disorder.

This study investigated mealtime behaviors of Chinese-American children with autism spectrum disorder (ASD). Thirty-one parents of Chinese-American children with ASD participated in this study and the Brief Autism Mealtime Behavior Inventory (BAMBI) was used. The top problematic mealtime behaviors reported by parents were prefers "crunchy" food (54.2%); not willing to try new foods (48%); and does not remain seated at the table until the meal is finished (46%). This study found that the majority of the Chinese-American children with ASD seldom or never were aggressive (96%) or disruptive during mealtimes (92.3%). Compared to their white counterparts, Chinese-American children with ASD showed slightly lower scores on problematic mealtime behaviors. These findings may provide significant information to practitioners.

Testing an Integrated Model of Program Implementation: the Food, Health & Choices School-Based Childhood Obesity Prevention Intervention Process Evaluation.

Childhood obesity is a complex, worldwide problem. Significant resources are invested in its prevention, and high-quality evaluations of these efforts are important. Conducting trials in school settings is complicated, making process evaluations useful for explaining results. Intervention fidelity has been demonstrated to influence outcomes, but others have suggested that other aspects of implementation, including participant responsiveness, should be examined more systematically. During Food, Health & Choices (FHC), a school-based childhood obesity prevention trial designed to test a curriculum and wellness policy taught by trained FHC instructors to fifth grade students in 20 schools during 2012-2013, we assessed relationships among facilitator behaviors (i.e., fidelity and teacher interest); participant behaviors (i.e., student satisfaction and recall); and program outcomes (i.e., energy balance-related behaviors) using hierarchical linear models, controlling for student, class, and school characteristics. We found positive relationships between student satisfaction and recall and program outcomes, but not fidelity and program outcomes. We also found relationships between teacher interest and fidelity when teachers participated in implementation. Finally, we found a significant interaction between fidelity and satisfaction on behavioral outcomes. These findings suggest that individual students in the same class responded differently to the same intervention. They also suggest the importance of teacher buy-in for successful intervention implementation. Future studies should examine how facilitator and participant behaviors together are related to both outcomes and implementation. Assessing multiple aspects of implementation using models that account for contextual influences on behavioral outcomes is an important step forward for prevention intervention process evaluations.

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.

The Special Supplemental Nutrition Program for Women, Infants, and Children Fresh Start Randomized Controlled Trial: Baseline Participant Characteristics and Reliability of Measures.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Fresh Start (WFS) is a randomized controlled trial of nutrition education to promote farmers' market fruit and vegetable (F/V) purchases and consumption among women enrolled in WIC. OBJECTIVES: To describe the baseline characteristics (demographics and F/V intake [including F/V juice]) of WFS participants, compare the characteristics with those of WIC participants in New Jersey and nationwide, and examine the baseline reliability of study measures. DESIGN: Cross-sectional. PARTICIPANTS/SETTING: Seven hundred forty-four women served by a New Jersey-based WIC agency located in a densely populated, urban area. MAIN OUTCOME MEASURES: Demographic characteristics; newly developed measures of farmers' market-related knowledge, attitudes, and skills; and validated measures of F/V intake. STATISTICAL ANALYSES: Descriptive statistics to characterize the sample. One-sample t and one-sample sign tests to compare the characteristics with reference values. For dietary behaviors, comparisons were with state and national estimates of the frequency and quantity of F/V intake. RESULTS: Participants had a mean age of 28.9±6.8 years and were predominantly Hispanic (59%), US-born (60%), never married (41%), unemployed (62%), receiving assistance other than WIC (70%), and food insecure (55%). Half reported a high school education or less. Higher proportions of WFS participants than WIC participants nationwide were represented among demographic groups at increased risk of inadequate F/V intake. WFS participants consumed more fruit (2.7 cups/day) but less vegetables (1.4 cups/day) than did women nationwide (1.1 and 1.4 cups/day, respectively; P<0.01). Although participants consumed recommended amounts of fruit, their vegetable intake was below recommended levels. All but two of the measures developed for the study had reliability coefficients at or above 0.60. CONCLUSIONS: Intervention is warranted to improve participants' vegetable intake. Registered dietitian nutritionists should be aware of F/V intake differences that may require differential intervention strategies.

Association Between the Built Environment in School Neighborhoods With Physical Activity Among New York City Children, 2012.

INTRODUCTION: The benefits of physical activity for health and well-being are well established, yet built environment characteristics in the school neighborhood may constrain students' ability to engage in physical activity and contribute to the considerable variation in physical activity among students at different schools. METHODS: Baseline data from the Food, Health and Choices obesity prevention trial were used to create multilevel linear models of the relationship between fifth-grade students' (n = 952) physical activity and related psychosocial factors and characteristics of the built environment of the school's neighborhood (park access, public transportation density, total crime, and walkability), controlling for age and body mass index z scores. RESULTS: Total crime was inversely associated with boys' light physical activity duration (ß = -0.189; P = .02) and behavioral intention for physical activity (ß = -0.178; P = .03). Boys' habit strength for physical activity was positively associated with public transportation density (ß = 0.375; P = .02) and negatively associated with total crime (ß = -0.216; P = .01), explaining 67% of between-school variation. Girls' frequency of light physical activity was positively associated with park access (ß = 0.188; P = .04). Built environment characteristics explained 97% of the between-school variation in girls' self-efficacy in walking for exercise. CONCLUSIONS: Characteristics of the built environment surrounding schools were associated with and explain between-school variation in students' physical activity and several theory-based psychosocial factors. Partnerships between public health practitioners, policy makers, and school administrators may be warranted to shape the school neighborhood, specifically to decrease crime rates and increase park access, to encourage physical activity in youth.

Differences in Fruit and Vegetable Intake by Race/Ethnicity and by Hispanic Origin and Nativity Among Women in the Special Supplemental Nutrition Program for Women, Infants, and Children, 2015.

INTRODUCTION: The objective of this exploratory study was to determine whether fruit and vegetable consumption differed by race/ethnicity, by origin and nativity among Hispanics, and by language preference (as an indicator of acculturation) among foreign-born Hispanics. METHODS: We recruited 723 women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and orally administered a questionnaire containing demographic items, validated measures of food security status and social desirability trait, and the Behavioral Risk Factor Surveillance System fruit and vegetable module. Differences in intakes of 100% fruit juice, fruit, cooked or canned beans, and dark green, orange-colored, and other vegetables were assessed by using analysis of covariance with Bonferroni post hoc tests. Analyses were controlled for age, pregnancy status, breastfeeding status, food security status, educational attainment, and social desirability trait. RESULTS: The frequency of vegetable intake differed by race/ethnicity (cooked or canned beans were consumed more often among Hispanic than non-Hispanic black and non-Hispanic white or other participants, orange-colored vegetables were consumed more often among Hispanics than non-Hispanic black participants, and other vegetables were consumed more often among non-Hispanic white or other than among non-Hispanic black and Hispanic participants), origin (other vegetables were consumed more often among Columbian and other Hispanics than Dominican participants) and nativity (orange-colored vegetables were consumed more often among foreign-born than US-born Hispanics). Fruit and vegetable intake did not differ by language preference among foreign-born Hispanics. CONCLUSION: Differences in fruit and vegetable consumption among WIC participants by race/ethnicity and by Hispanic origin and nativity may have implications for WIC nutrition policies and nutrition education efforts.

Mediating Mechanisms of Theory-Based Psychosocial Determinants on Behavioral Changes in a Middle School Obesity Risk Reduction Curriculum Intervention, Choice, Control, and Change.

BACKGROUND: A limited number of school-based intervention studies have explored mediating mechanisms of theory-based psychosocial variables on obesity risk behavior changes. The current study investigated how theory-based psychosocial determinants mediated changes in energy balance-related behaviors (EBRBs) among urban youth. METHODS: A secondary analysis study was conducted using data from a cluster randomized controlled trial. Data from students at 10 middle schools in New York City (n = 1136) were used. The intervention, Choice, Control, and Change curriculum, was based on social cognitive and self-determination theories. Theory-based psychosocial determinants (goal intention, cognitive outcome expectations, affective outcome expectations, self-efficacy, perceived barriers, and autonomous motivation) and EBRBs were measured with self-report questionnaires. Mediation mechanisms were examined using structural equation modeling, Results: Mediating mechanisms for daily sugar-sweetened beverage (SSB) consumption and purposeful stair climbing were identified. Models with best fit indices (root mean square error of approximation = 0.039/0.045, normed fit index = 0.916/0.882; comparative fit index = 0.945/0.932; Tucker-Lewis index = 0.896/0.882, respectively) suggested that goal intention and reduced perceived barriers were significant proximal mediators for reducing SSB consumption among both boys and girls or increasing physical activity by stair climbing among boys. Cognitive outcome expectations, affective outcome expectations, self-efficacy, and autonomous motivation indirectly mediated behavioral changes through goal intention or perceived barriers (p < 0.05 to p < 0.001). The final models explained 25%-27% of behavioral outcome variances. CONCLUSIONS: Theory-based psychosocial determinants targeted in Choice, Control, and Change in fact mediated behavior changes in middle school students. Strategies targeting these mediators might benefit future success of behavioral interventions. Further studies are needed to determine other potential mediators of EBRBs in youth.

Validity and Reliability of Behavior and Theory-Based Psychosocial Determinants Measures, Using Audience Response System Technology in Urban Upper-Elementary Schoolchildren.

OBJECTIVE: To examine the validity and reliability of a questionnaire administered with an audience response system (ARS). DESIGN: Cross-sectional study. SETTING: Two New York City public elementary schools. PARTICIPANTS: Fourth- and fifth-grade students. MAIN OUTCOME MEASURES: A Food, Health, and Choices questionnaire (FHC-Q) assessed energy balance-related behaviors (EBRBs) including intake of fruits and vegetables, sugar-sweetened beverages, processed packaged snacks, and fast food; physical activity; recreational screen time; and associated psychosocial determinants (≥ 3 questions/outcome scale). Previously validated reference instruments were used for relative validation. The ARS format was compared with a paper-and-pencil format. All measures were administered in a classroom setting. ANALYSIS: Pearson correlation coefficients between the reference instruments and the FHC-Q were calculated. Internal consistency reliabilities were evaluated with Cronbach α. Spearman rank correlation, intra-class correlation, and percent agreement were used for test-retest reliability between paper-and-pencil and ARS, and between 2 ARS FHC-Q administrations. RESULTS: Correlations for EBRBs with reference instruments ranged from 0.38 to 0.61 (P < .01). Cronbach α ranged from .77 to .92 for EBRBs and .74 to .90 for psychosocial determinants. Test-retest reliability correlations ranged from 0.36 to 0.87 (P < .001). Agreement for knowledge questions ranged from 69.8% to 84.8%. CONCLUSIONS AND IMPLICATIONS: The ARS FHC-Q has acceptable validity and reliability for collecting data on EBRBs and associated psychosocial determinants for upper-elementary students.

Intraclass Correlation Coefficients for Obesity Indicators and Energy Balance-Related Behaviors Among New York City Public Elementary Schools.

OBJECTIVE: Sample size and statistical power calculation should consider clustering effects when schools are the unit of randomization in intervention studies. The objective of the current study was to investigate how student outcomes are clustered within schools in an obesity prevention trial. METHOD: Baseline data from the Food, Health & Choices project were used. Participants were 9- to 13-year-old students enrolled in 20 New York City public schools (n= 1,387). Body mass index (BMI) was calculated based on measures of height and weight, and body fat percentage was measured with a Tanita® body composition analyzer (Model SC-331s). Energy balance-related behaviors were self-reported with a frequency questionnaire. To examine the cluster effects, intraclass correlation coefficients (ICCs) were calculated as school variance over total variance for outcome variables. School-level covariates, percentage students eligible for free and reduced-price lunch, percentage Black or Hispanic, and English language learners were added in the model to examine ICC changes. RESULTS: The ICCs for obesity indicators are: .026 for BMI-percentile, .031 for BMIz-score, .035 for percentage of overweight students, .037 for body fat percentage, and .041 for absolute BMI. The ICC range for the six energy balance-related behaviors are .008 to .044 for fruit and vegetables, .013 to .055 for physical activity, .031 to .052 for recreational screen time, .013 to .091 for sweetened beverages, .033 to .121 for processed packaged snacks, and .020 to .083 for fast food. When school-level covariates were included in the model, ICC changes varied from -95% to 85%. CONCLUSIONS: This is the first study reporting ICCs for obesity-related anthropometric and behavioral outcomes among New York City public schools. The results of the study may aid sample size estimation for future school-based cluster randomized controlled trials in similar urban setting and population. Additionally, identifying school-level covariates that can reduce cluster effects is important when analyzing data.

Linking implementation process to intervention outcomes in a middle school obesity prevention curriculum, 'Choice, Control and Change'.

This study investigates the link between process evaluation components and the outcomes of a school-based nutrition curriculum intervention, 'Choice, Control and Change'. Ten New York City public middle schools were recruited and randomly assigned into intervention or control condition. The curriculum was to improve sixth to seventh grade students' energy balance related behaviors, based on social cognitive and self-determination theories, and implemented during the 2006-2007 school year (n = 1136). Behaviors and psychosocial variables were measured by self-reported questionnaires. Process components were evaluated with classroom observations, teacher interviews, and a student questionnaire. Using 'Teacher Implementation' (dose delivered) and 'Student Reception' (dose received) process data; intervention group was further categorized into medium- and high-implementation groups. Analysis of covariance revealed that, compared with control group, only high-implementation group showed significant improvement in students' behavior and psychosocial outcomes. Hierarchical linear models showed that 'Teacher Implementation' and 'Student Reception' significantly predicted students' sweetened beverage outcomes (P < 0.05). 'Student Satisfaction' was also greater when these implementation components were higher, and significantly associated with behavior and psychosocial outcomes (P < 0.05). Implementation process influenced the effectiveness of the 'Choice, Control and Change' intervention study. It is important to take into account the process components when interpreting the results of such research.