Application of the Theory of Planned Behaviour to inform development of a Dissemination and Implementation science training for nutrition practitioners.

OBJECTIVE: To determine nutrition practitioners' attitudes, behavioural control and normative beliefs to best inform the development and formulation of a nutrition-specific Dissemination and Implementation (D&I) science training. DESIGN: A cross-sectional survey aimed to assess Theory of Planned Behaviour (TPB) constructs and intention to use D&I science. A validated TPB questionnaire assessed constructs including perceived behavioural control, subjective, injunctive and descriptive normative beliefs, attitudes and intention to use D&I science. For analysis, Spearman's ρ, Kruskal-Wallis and Steel-Dwass tests were conducted for quantitative variables. SETTING: Online, 26-item Qualtrics survey. PARTICIPANTS: Cross-sectional sample of members (n 70) affiliated with the Society for Nutrition Education and Behaviour listserv. RESULTS: The major finding from this study was a significant positive correlation between perceived behavioural control score and intention (r = 0·315, P = 0·0119). CONCLUSIONS: D&I training interventions could formulate learning and teaching strategies to target perceived behavioural control (self-efficacy, knowledge and ability) to enhance intention. For example, application and experience-based learning techniques trainings could be strategies to increase knowledge and abilities.

Implementation of Diabetes Education and Support in Appalachia.

Limited research on diabetes education and support implementation in Appalachia, which is a critical knowledge gap considering barriers to care, and high prevalence rates. The aim was to understand what each facility is providing regarding diabetes education and services within West Virginia. This study reports cognitive interview qualitative findings from a multi-methods study. Individuals were recruited through an online search to identify clinics, organizations, and hospital staff that provided diabetes education in the state of West Virginia. Eligible participants were individuals who facilitated and managed diabetes education and support in counties of West Virginia. The interviews followed an 11-item interview guide, approved, and reviewed by a practicing Registered Dietitian and Certified Diabetes Care Education Specialist in West Virginia. All qualitative data from the interviews were hand-coded using grounded theory, by two researchers. 15 participating organizations from the state of West Virginia were included and described three phenomena: Diabetes Education Implementation (differences in: evaluation measures, modality, delivery format, topical areas); Barriers to Care (staffing, lack of training, evaluation, loss of research partnerships and funding); and Facilitators to Care (community-based involvement, interdisciplinary collaboration, capacity building (trainings). There are concerns with program drift and "risky" adaptations such as inconsistent evaluative measures, lack of training for program facilitators, variety of delivery formats, and content material. Findings recommend more alignment in program delivery to better implementation. Further studies should assess patient experiences with implemented diabetes education programs in West Virginia to further support the current research findings.

Relationships of Maternal Employment and Work Impact with Weight-Related Behaviors and Home Environments of Mothers and Their School-Age Children.

The prevalence of obesity continues to rise. Preventing obesity, especially childhood obesity, is critically important. Parents, especially mothers, play a vital role in preventing childhood obesity. Numerous factors, such as maternal employment, may influence maternal weight-related practices and home environment characteristics that affect the risk of childhood obesity. Given the prevalence of both childhood obesity and maternal employment, this study was conducted to examine how weight-related maternal, child, and household behaviors as well as home environment characteristics differ by maternal employment hours and extends existing research by examining work impact on behaviors and home characteristics. U.S. mothers (n = 527) with at least one school-age child (6 to 11 years), who were between the ages of 25 and 54 years and the main food gatekeeper in the household completed an online survey. ANOVA comparisons of non-working, part-time employed, and full-time employed mothers revealed few differences in any of the variables studied. Cluster analysis of the 336 employed mothers based on six work impact scale scores found three unique clusters characterized as Enthusiastic Earners, Indifferent Earners, and Strained Earners. Few differences in sociodemographic and job characteristics occurred among clusters and the differences noted had small effect sizes. Clusters did not differ by maternal BMI or perceived child weight status. However, the clusters differed in numerous weight-related behaviors and home environment characteristics. Future research should aim to determine the direction of the associations of work impact with weight-related behaviors and home environments as well as identify potential strategies for overcoming the negative effects of employment on weight-related behaviors and environments and weight status as well as clarify other factors that may affect maternal work impact, such as time management, reasons for employment, and stress.

Diet quality and eating behaviors of college-attending young adults with food addiction.

BACKGROUND: College students are heavily influenced by their food environment and are an important population in which to study food addiction. This mixed-methods study aimed to examine diet quality and eating behaviors of college students with food addiction. METHODS: Students attending a large university in November 2021 were invited to complete an online survey that measured food addiction, eating styles, eating disorder symptoms, diet quality, and anticipated feelings after eating. Kruskal-Wallis H determined differences between those with and without food addiction in mean scores of quantitative variables. Participants who met the symptom threshold for the presence of food addiction were invited to participate in an interview that elicited more information. Quantitative data was analyzed using JMP Pro Version 16.0 and qualitative data was thematically analyzed using NVIVO Pro Software Version 12.0. RESULTS: Respondents (n = 1645) had a 21.9 % prevalence of food addiction. Individuals with mild food addiction had the highest scores in cognitive restraint. Those with severe food addiction had the highest scores in uncontrolled eating, emotional eating, and eating disorder symptoms. Individuals with food addiction showed significantly higher negative expectancies for healthy and junk food, lower intake of vegetables, higher intakes of added sugars and saturated fat. Interview participants had problems with sweets and carbohydrates most often and described eating until physically ill, eating in response to negative emotions, dissociation while eating, and strong negative feelings after eating. CONCLUSION: Findings contribute to the understanding of the behaviors, emotions, and perceptions surrounding food by this population, providing potential behaviors and cognitions to target for treatment.

Food Security is Associated with Higher Diet Quality Among Children of the US-Affiliated Pacific Region.

BACKGROUND: The prevalence of food insecurity and its relationship to diet quality are factors impacting the health of persons living across the United States-affiliated Pacific region (USAP). OBJECTIVES: The aim of this study was to describe characterize the relationship between household food security status and diet quality of 2- to 8-y-old children across jurisdictions in the USAP. METHODS: Baseline data from 2- to 8-y-olds (n = 3099) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, an obesity prevention study conducted in communities across Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawaii, and a concomitant prevalence study in communities across the Freely Associated States (FAS) (the Federated States of Micronesia: Kosrae, Pohnpei, Chuuk, Yap; Republic of Marshall Islands; Republic of Palau) were collected in 2012. Caregivers self-reported sociodemographic data and food insecurity. Assisted by their caregiver, children completed two dietary records on nonconsecutive, randomly assigned days. The Healthy Eating Index 2005 (HEI-2005) was used to assess the diet quality. Data were summarized overall and by jurisdiction. Differences in HEI-2005 and HEI component scores among jurisdictions and by household food security status were tested using 1-factor ANOVA. RESULTS: Half or more of participants from American Samoa, Guam, CNMI, and FAS reported household food insecurity (n = 295, 59.7%; n = 292, 49.9%; n = 267, 54.6%; n = 572, 69.0%, respectively). HEI-2005 scores varied by jurisdiction (P < 0.001) and were significantly lower among FAS participants (54.7 ± 1.2) than among all other jurisdictions (P < 0.05). Total diet quality scores did not differ by food security status (59.9 ± 0.8 food secure compared with 58.3 ± 1.1 food insecure, P = 0.07); however, most diet quality adequacy component scores were significantly higher and moderation component scores significantly lower among participants in food secure households than those in food insecure households. CONCLUSIONS: Significant differences in children's diet quality and household food security existed across USAP jurisdictions.

Early life influences on the development of food addiction in college attending young adults.

PURPOSE: There is little investigation into the causes of food addiction. The aim of this study was to determine the impact of early life influences on the development of food addiction in college-attending young adults aged 18-29. METHODS: This study utilized a sequential explanatory mixed-methods research design. College-attending young adults were invited to complete an online survey measuring Adverse Childhood Experiences (ACEs), food addiction, depression, anxiety, stress, and demographic information. Correlations between food addiction and the other variables were analyzed and significant variables were placed into a nominal logistic regression model to predict the development of food addiction. Participants who met the criteria for food addiction were invited to participate in interviews to examine their childhood eating environment and when their symptoms emerged. Interviews were transcribed and thematically analyzed. Quantitative analysis was conducted using JMP Pro Version 16.0 and qualitative analysis was conducted using NVIVO Software Version 12.0. RESULTS: Survey respondents (n = 1645) had an overall 21.9% prevalence of food addiction. Significant correlations were observed between food addiction and ACEs, depression, anxiety, stress, and sex (p < .01 for all). Depression was the only significant predictor of the development of food addiction (OR = 3.33 95% CI 2.19, 5.05). The most common eating environment described by interview participants (n = 36) was an emphasis on diet culture, ideal body image, and restrictive environments. Symptoms frequently emerged after transitioning into college and having the ability to make their own food choices. CONCLUSION: These results show the impact of early life eating environments and young adulthood mental health on the development of food addiction. These findings contribute to the understanding of underlying causes of food addiction. LEVEL OF EVIDENCE: Level V, Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

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.

Impact of resilience on college student mental health during COVID-19.

OBJECTIVE: The aim of this study was to investigate how the COVID-19 pandemic impacted college student mental health and alcohol use and to determine how resilience could alleviate negative outcomes. PARTICIPANTS: Students attending an Appalachian university during spring 2020 were surveyed shortly after on-campus activities stopped. METHODS: Survey items included resilience, demographics, self-rated health, and depression symptoms, anxiety symptoms, and alcohol use before and since COVID-19. RESULTS: There was a significant increase in prevalence of severe depression, severe anxiety, and high stress, and a significant decrease in prevalence high risk for problem drinking before and since COVID-19. Four separate standard least squares regression models were conducted with each of the dependent variables. Self-rated health was the strongest predictor for changes in depression, anxiety, and stress in each of the models, displaying a negative relationship. CONCLUSIONS: Universities should prepare students using resilience training and provide employment and other resources to mitigate effects of stressful situations.

Examining gender and the longitudinal effect of weight conscious drinking dimensions on body mass index among a college freshman cohort.

Objective: This study aims to: (1) examine gender differences for weight conscious drinking among college students accounting for the broader phenomenon (e.g. including the Alcohol Effects dimension); and (2) longitudinally examine the effect of weight conscious drinking behaviors on body mass index (BMI). Participants: United States freshmen students from eight participating universities (N= 1,149). Methods: Structural equation modeling was used to model the effect of gender on weight conscious drinking dimensions at 7-month follow-up. Results: Findings suggest a significant effect of gender on Alcohol Effects (ß = -.15, SE = .05, p = .005) at 7-month follow-up among college freshmen. Weight conscious drinking dimensions predicted no significant change in BMI at 7-month follow-up among college freshmen. Conclusion: Findings contribute to weight conscious drinking theory and provide campus weight conscious drinking prevention initiatives with evidence to tailor their programming to address female tendencies to engage in compensatory strategies to enhance the psychoactive effects of alcohol.

Struggling with the basics: food and housing insecurity among college students across twenty-two colleges and universities.

OBJECTIVES: To quantify the number and type of students failing to secure basic needs. PARTICIPANTS: Students attending 22 postsecondary schools in the United States in Fall 2019. METHODS: The Adult Food Security Module and part of the #RealCollege Survey were used to measure food and housing insecurity, respectively. Logistic and linear regression models were used to assess the relationship between selected factors and basic needs insecurities. RESULTS: Participants (n = 22,153) were classified as 44.1% and 52.3% food insecure and housing insecure, respectively. Homeless students or those who experienced childhood food insecurity were at the greatest odds of college food insecurity. Year in school was the largest contributor to being housing insecure, with PhD or EdD students being 1,157% more likely to experience housing insecurity compared to freshmen. CONCLUSIONS: High prevalence of basic needs insecurities remain. Current campus initiatives may be insufficient, calling for a more holistic approach at the campus, state, and national levels.

Impact of a Brief Culinary Medicine Elective on Medical Students' Nutrition Knowledge, Self-efficacy, and Attitudes.

The aim of this study was to determine how a brief culinary medicine curriculum impacted medical students' nutrition knowledge, attitudes, and self-efficacy and to evaluate which parts of the curriculum students found to be most helpful. This preliminary intervention study enrolled participants in a 2-week culinary medicine elective course and measured pre- and post-elective. Students attending an Appalachian medical school (n = 16) participated in this study. Participants were surveyed on their nutrition knowledge, self-efficacy in providing nutrition advice, and attitudes towards use of nutrition in practice pre- and post-elective. Participants also completed elective evaluations following the course. Changes in mean outcome scores were measured pre- and post-elective using signed Wilcoxon tests. Alpha was set at .05. Frequencies of responses were calculated to determine which course components were ranked highest in their efficacy. Nutrition knowledge and self-efficacy increased significantly from pre- to post-elective (p < .0001 and p < .0001, respectively). Students valued the hands-on and culinary components of the course most. Results indicate that a brief culinary medicine curriculum can effectively improve medical students' knowledge and self-efficacy of nutrition counseling and that students prefer hands-on and applied learning when learning about nutrition.

HomeStyles-2 for SNAP-Ed families with children in middle childhood: Cluster randomized trial protocol.

BACKGROUND: Childhood obesity prevention efforts are needed in the United States, especially for families with low income. The purpose of this study is to determine whether HomeStyles-2, a nutrition education and childhood obesity prevention program for families with children in middle childhood (ages 6 to 11 years), motivates parents to re-shape their home environments and weight-related lifestyle practices to be more supportive of meeting national nutrition and physical activity recommendations and weight status of their children more so than those in the control condition. METHODS: A research-practice partnership with Florida's Supplemental Nutrition Assistance Program-Education (SNAP-Ed) program was formed to conduct a cluster randomized trial to evaluate the HomeStyles-2 intervention. SNAP-Ed-eligible individuals who are parents/caregivers of children aged 6-11 living in the study catchment area will be invited to enroll in the study and participate in a six-lesson series using the HomeStyles-2 program or an attention control program. The primary outcome measures related to parent weight-related behaviors will be assessed on the individual level. Linear mixed models with a hierarchical design will be used to assess outcomes of interest. DISCUSSION: This study has the potential to demonstrate the effectiveness of a new curriculum implemented in a federal nutrition education program. Because of the COVID-19 pandemic, adjustments were made to the intervention design to allow for virtual delivery of the intervention through SNAP-Ed. This unanticipated change will offer much-needed research on the effectiveness of virtual nutrition education, which may help to expand SNAP-Ed's reach across the country. TRIAL REGISTRATION: NCT05019339.

Impact of COVID-19 on college student diet quality and physical activity.

Background: The COVID-19 pandemic can cause in increase in stress experienced by college students and consequently, potentially adversely affect their health behaviours. Aims: The aim of this study was to investigate how COVID-19 impacted college-attending young adults diet quality and physical activity. Methods: Students attending an Appalachian university in spring 2020 participated in this cross-sectional study. Participants were surveyed on their eating habits, diet quality, and physical activity before and since COVID-19. Frequencies of responses were analyzed and Bowker's test was used to determine differences in responses before and since COVID-19. Alpha was set at 0.05. Results: Almost one third (32.6%) of students reported eating somewhat more since COVID-19 and 67.9% of these students stated it was due to boredom. Students showed a significant increase in frequency of eating and in consumption of almost every food group. The number of students engaging in low physical activity increased from 27.8% to 51.9% and the number of students engaging in high physical activity decreased from 59.5% to 34.0% (p < .0001) and many switched to the use of at-home workouts. Conclusion: Results indicate the effects of campus closure on college student's lifestyles and the risk of developing health problems due to the COVID-19 pandemic, potentially inhibiting their academic progress and well-being.

Life of a vegetarian college student: Health, lifestyle, and environmental perceptions.

Objective To examine health behavior and environmental perception differences among vegetarian and nonvegetarian students. Participants: First-year university students (n = 1078) from eight United States universities. Methods: Data were obtained from base 2015 and followup 2016 assessments. Vegetarians and nonvegetarians were compared for anthropometrics, lifestyle behaviors, and campus environmental perceptions (CEPS). Results: Vegetarians had smaller waist circumference, lower systolic blood pressure, higher fruit and vegetable consumption, lower percentage of energy obtained from fat, and higher perceived stress. Vegetarians expressed a lower rating of perceptions of health policies on campus. Conclusion: A clear difference in indicators of physical health does not appear, however, vegetarian students show positive dietary patterns which can promote positive health outcomes. Further, vegetarians had lower perceptions of health policies on campus. Results can be used by administrators to ensure policies are in place to support health of students as currently vegetarian students see limitations in the environmental health policies.

"My Entire World Stopped": College Students' Psychosocial and Academic Frustrations during the COVID-19 Pandemic.

The COVID-19 pandemic disrupted normalcy for college attending young adults which resulted in a loss of the campus environment and classroom setting. This change in setting may interfere with a student's personal and academic wellbeing. This study used an online survey to evaluate college students' academic and psychosocial frustrations during the COVID-19 pandemic. Data were collected from March-April 2020 at a land-grant university in the Appalachian region. Data were available from 2643 undergraduate and graduate students. There was a 65.8% and 15.7% increase in the number of students who reported their learning and health as fair, poor, or very poor after the COVID-19 pandemic, respectively. Qualitative responses were coded and 8 themes and 24 subthemes emerged. College students expressed frustrations regarding technology, classwork, research, family, social, emotional, behavioral, and financial aspects of life. These results can be used by higher education administration, faculty, and staff when planning for online courses. Ensuring that student frustrations and barriers to success are recognized and considered may help prevent students departing from higher education during this time.

Dyadic Analysis of a Self-report Physical Activity Measure for Adult-Youth Dyads.

Adult physical activity levels influence youth physical activity levels, but the nature of this relationship is still unknown. Most research focusing on this topic has been conducted with accelerometers, which are ideal since self-report physical activity measures can be biased. However, self-report measures for physical activity are useful to include in studies to gather information at low-cost. The purpose of this study was to further develop a self-report adult-youth dyad measure of physical activity. This study was conducted using secondary data analysis of the physical activity measures used in an intervention on behavioral nutrition (iCook 4-H). Participants were a sample of 214 adults (M = 39.0, SD = 8.0 years) and youth (M = 9.4, SD = 0.7 years) pairs. Accelerometer data was collected for a subset of youth (n = 122). There was dependency between the adult-youth physical activity data, and a dyadic confirmatory factor analysis model showed good fit to the data and achieved metric invariance, a measure to determine if the same construct was being measured in both youth and adults. Invariance was confirmed across matched versus unmatched sex pairs and some evidence of invariance with youth accelerometer data. Based on study findings, when using self-report measures of physical activity, researchers should measure both members of the adult-youth dyad to get more accurate measurements. Further validation of these findings is needed using an objective physical activity measure, like accelerometers, with all participants and more diverse samples.

Newly Food-Insecure College Students in Appalachia During the COVID-19 Pandemic.

OBJECTIVE: This study investigated if the coronavirus disease (COVID-19) pandemic influenced college student food insecurity and factors that might contribute to a student becoming newly food insecure. DESIGN: A convenience sample was assessed using a cross-sectional survey. SETTING: Online. PARTICIPANTS: College students (n = 2,018) enrolled at a land-grant institution in Appalachia. MAIN OUTCOME MEASURE(S): Food insecurity was assessed using the Hunger Vital Sign with reference before COVID-19 and since COVID-19. Demographic and pandemic-specific questions and their associations with food insecurity status were assessed. ANALYSIS: Students were categorized as food secure (food secure before and since COVID-19 or food insecure in the year before COVID-19 but not food insecure since COVID-19), consistently food insecure (food insecure before and since COVID-19), and newly food insecure (food secure before but food insecure since COVID-19). Multivariate logistic regression was used to investigate the relationship between new food insecurity and contributing factors. RESULTS: Of respondents, 68.4% were food secure, 16.5% were consistently food insecure, and 15.1% were newly food insecure. Loss of employment, increased grocery expenditure, anxiety, and a perceived threat posed by COVID-19 were significant indicators of students being newly food insecure. CONCLUSIONS AND IMPLICATIONS: More students were facing food insecurity as a result of the COVID-19 pandemic. Continued advocacy for sustainable solutions to college food insecurity is needed.

HomeStyles-2: Randomized controlled trial protocol for a web-based obesity prevention program for families with children in middle childhood.

BACKGROUND: Parents are children's primary role models, are food and physical activity gatekeepers, and create the home structure/lifestyle environment. Thus, parents strongly influence children's weight-related behaviors and have the opportunity to cultivate a "culture of health" within the home. Yet, there is a dearth of evidence-based obesity prevention intervention programs, especially for families with children aged 6-11 years, commonly called middle childhood. METHODS: The aim of the HomeStyles-2 online learning mode RCT is to determine whether this novel, age-appropriate, family intervention enables and motivates parents to shape home environments and weight-related lifestyle practices (i.e.,diet, exercise, sleep) to be more supportive of optimal health and reduced obesity risk in middle childhood youth more than those in the control condition. The RCT will include the experimental group and an attention control group. The participants will be parents with school-age children who are systematically randomly assigned by computer to study condition. The HomeStyles intervention is predicated on the social cognitive theory and a social ecological framework. The RCT will collect sociodemographic characteristics of the participant, child, and partner/spouse; child and parent health status; parent weight-related cognitions; weight-related behaviors of the parent and child; and weight-related characteristics of the home environment. Deliverables Enrollment for this study will begin in 2022. DISCUSSION: This paper describes these aspects of the HomeStyles-2 intervention: rationale; sample eligibility criteria and recruitment; study design; experimental group intervention theoretical and philosophical underpinnings, structure, content, and development process; attention control intervention; survey instrument development and components; outcome measures; and planned analyses. TRIAL REGISTRATION: ClinicalTrials.gov, Protocol #NCT04802291, Registered March 14, 2021.

The Application of Systems Science in Nutrition-Related Behaviors and Outcomes Implementation Research: A Scoping Review.

Use of systems science can improve the dissemination and implementation (D&I) process. However, little is known about use of systems science in nutrition D&I research. The purpose of this article is to synthesize the ways in which systems science methodology is applied in nutrition D&I research. Scoping review methodology involved searching 6 academic databases for full-text, peer-reviewed, English articles published between 1970 and 2020 that employed systems science within nutrition D&I research. Data extraction included intervention type, population, study aim, methods, theoretical approach, outcomes, and results. Descriptive statistics and qualitative thematic analysis followed. Thirty-four retained articles qualitatively identified benefits (successful planning and organization of complex interventions) and challenges (limited resources, trainings, and lack of knowledge) to utilizing systems science in nutrition D&I research. Future research should work toward building knowledge capacity among nutrition practitioners by increasing available trainings and resources to enhance the utilization of systems science in nutrition D&I research.

Feasibility and Acceptability of Guided Imagery to Sequentially Address Multiple Health Behaviors During Pregnancy.

INTRODUCTION: Pregnancy presents health challenges related to well-being, physical activity, dietary regulation, and body image. There is evidence to support the use of guided imagery to address these concerns during pregnancy. The purpose of this study was to analyze the use and short-term outcomes of a multiple-behavior guided imagery intervention delivered through a mobile health (mHealth) application for pregnant women. METHODS: A single-arm, 5-week feasibility trial was conducted, and participants were instructed to listen to an audio file every day for 35 days on an mHealth application. Measurements included ongoing assessments of the participants' use of the guided imagery audio files and pre- and post-test measures of depression, anxiety, stress, physical activity, food cravings, and body image. Postintervention qualitative interviews were conducted to assess whether participants would continue to use guided imagery. RESULTS: Fifty-eight participants (mean age, 28.5 years) were enrolled from January to June of 2018. Cloud analytics data showed an average of 4.96 audio downloads per week with the Sleep and Relaxation file being the most widely used (mean weekly usage, 5.67) and reported favorite during follow-up interviews. Paired-sample t tests from pre- to post-test showed significant reductions in depression, anxiety, and stress, increased physical activity, and sedentary behavior along with some changes in body image. DISCUSSION: Future scalable guided imagery interventions are justified to test for efficacy. Guided imagery may also be delivered in person by health care providers or by using widely available technologies.