Adolescents' awareness and use of menu labels in eating establishments: results from a focus group study.

OBJECTIVE: Menu labelling has been identified as a potential strategy to help individuals make healthier choices when eating out. Although adolescents eat out often, little research involving menu labelling has been conducted with this population. The objectives of the present study were to: (i) gather qualitative information from adolescents regarding use of menu labels when eating out; (ii) gather adolescents' suggestions for optimal ways to design menu labels; and (iii) examine differences between adolescents living in communities of different socio-economic status. DESIGN: Qualitative. Five focus groups of five to ten participants. SETTING: Austin, TX, USA, 2012. SUBJECTS: Forty-one adolescents living in diverse communities recruited using a snowballing technique at public and private recreation centres (twenty-four females; twenty-two African American). RESULTS: Participants reported that menu labelling, in general, does not influence food selections when eating out. Among participants living in low-income communities, food purchases were based on price, taste and familiarity. Among participants living in high-income areas, food purchases were based on quality and ability to satiate (among boys). According to participants, effective ways to present menu labels are by matching calorie levels with physical activity equivalents or through simple graphics. CONCLUSIONS: For adolescents, providing menu labels in their current format may not be an effective strategy to increase healthy food selection. Given that the current menu label format has been set by federal policy in the USA cannot be easily changed, research to determine how this format can be best presented or enhanced so that it can have an impact on all US sub-populations is warranted.

Association of parental social support with energy balance-related behaviors in low-income and ethnically diverse children: a cross-sectional study.

BACKGROUND: Parents play an important role in providing their children with social support for healthy eating and physical activity. However, different types of social support (e.g., instrumental, emotional, modeling, rules) might have different results on children's actual behavior. The purpose of this study was to assess the association of the different types of social support with children's physical activity and eating behaviors, as well as to examine whether these associations differ across racial/ethnic groups. METHODS: We surveyed 1169 low-income, ethnically diverse third graders and their caregivers to assess how children's physical activity and eating behaviors (fruit and vegetable and sugar-sweetened beverage intake) were associated with instrumental social support, emotional social support, modeling, rules and availability of certain foods in the home. We used sequential linear regression to test the association of parental social support with a child's physical activity and eating behaviors, adjusting for covariates, and then stratified to assess the differences in this association between racial/ethnic groups. RESULTS: Parental social support and covariates explained 9-13% of the variance in children's energy balance-related behaviors. Family food culture was significantly associated with fruit and vegetable and sugar-sweetened beverage intake, with availability of sugar-sweetened beverages in the home also associated with sugar-sweetened beverage intake. Instrumental and emotional support for physical activity were significantly associated with the child's physical activity. Results indicate that the association of various types of social support with children's physical activity and eating behaviors differ across racial/ethnic groups. CONCLUSIONS: These results provide considerations for future interventions that aim to enhance parental support to improve children's energy balance-related behaviors.

Socioeconomic inequalities in children's diet: the role of the home food environment.

BACKGROUND: It is well documented in the literature that low socioeconomic status (SES) is associated with lower consumption of healthy foods and that these differences in consumption patterns are influenced by neighborhood food environments. Less understood is the role that SES differences in physical and social aspects of the home food environment play in consumption patterns. METHODS: Using data on 4th grade children from the 2009-2011 Texas School Physical Activity and Nutrition (SPAN) study, we used mixed-effects regression models to test the magnitude of differences in the SPAN Health Eating Index (SHEI) by parental education as an indicator of SES, and the extent to which adjusting for measures of the home food environment, and measures of the neighborhood environment accounted for these SES differences. RESULTS: Small but significant differences in children's SHEI by SES strata exist (-1.33 between highest and lowest SES categories, p<0.01). However, incorporating home food environment and neighborhood environment measures in this model eliminates these differences (-0.7, p=0.145). Home food environment explains a greater portion of the difference. Both social (mealtime structure) and physical aspects (food availability) of the home food environment are strongly associated with consumption of healthy and unhealthy foods. CONCLUSIONS: Our findings suggest that modifiable parent behaviors at home can improve children's eating habits and that the neighborhood may impact diet in ways other than through access to healthy food.

Conceptualizing, implementing, and monitoring a structural health promotion intervention in an organizational setting.

This article presents a framework for developing and carrying out an implementation monitoring plan of a complex structural intervention in an organizational setting and describes seven steps for analyzing and reporting results for fidelity and completeness of implementation. This process is illustrated using the Environmental Interventions in Children's Homes (ENRICH) Wellness Project. ENRICH aimed to promote physical activity and healthful nutrition behaviors among children residing in children's group homes by working collaboratively with organizational staff. A comprehensive implementation monitoring plan was developed based on the particulars of the setting, context, and the program framework and used multiple data sources, criteria for evidence of implementation, and data triangulation to examine evidence for organizational implementation. Eleven of 17 organizations (65%) met the criteria for nutrition implementation whereas 9 of 17 (53%) met the criteria for physical activity implementation. Implementation data can be used descriptively, as described here, and may also be used in future outcome analyses to better understand project outcomes. The framework and evaluation approach are applicable to complex interventions in other organizational settings.

A descriptive study of beverage consumption among an ethnically diverse sample of public school students in Texas.

OBJECTIVE: The purpose of this study was to examine prevalence rates of 5 types of beverage consumption by sociodemographic factors among 4th-, 8th-, and 11th-grade public school students in Texas. METHODS: This study is based on secondary analyses of cross-sectional data from the 2004-2005 School Physical Activity and Nutrition study, a comprehensive surveillance study of energy balance-related behaviors and behavioral antecedents in a state-representative sample of 4th-, 8th-, and 11th-grade public school students in Texas (N = 23,190). Previous-day beverage consumption prevalence estimates were calculated for 5 types of beverages (i.e., fruit-flavored drinks, regular sodas, diet sodas, milk, and 100% fruit juice) by grade level, gender, ethnicity, school-level socioeconomic status, and metropolitan status. Logistic regression estimates of consumption prevalence were obtained for important sociodemographic indicators, including sex, grade, and ethnicity. Adjusted Wald tests were used to derive significance tests for sex differences in consumption, as sex emerged as a key determinant of consumption prevalence and varied systematically by type of beverage. RESULTS: The most commonly consumed beverage by all participants was milk. However, more than 50% of students also reported regular soda and fruit-flavored drink consumption during the previous day. Milk and fruit juice consumption showed a steady decline with grade level, while consumption of regular soda increased with grade level. By 11th grade, the prevalence of any beverage consumption, including milk and juice, was significantly greater among boys. Ethnic differences in sugar-sweetened beverage consumption were most prevalent in 8th and 11th grades, with the highest estimated prevalence of sugar-sweetened beverages (i.e., fruit-flavored drink and regular soda) consumption among African Americans. Differences in beverage consumption by school-level socioeconomic status and metropolitan status were small. CONCLUSIONS: These findings indicate that a large proportion of public elementary students in Texas are consuming sugar-sweetened beverages and that consumption of sugar-sweetened beverages varies by a range of sociodemographic factors. Given the important link between sugar-sweetened beverages and obesity in children, these findings can be used to tailor obesity prevention efforts to specific subpopulations for the promotion of healthier beverage consumption.

Cognitive and home environmental predictors of change in sugar-sweetened beverage consumption among adolescents.

Sugar-sweetened beverage (SSB) consumption may increase risk for unnecessary weight gain. To develop interventions discouraging consumption, more insight is needed about cognitive and environmental predictors related to the decrease in SSB consumption. The present paper aims (1) to describe the relationship between potential cognitive determinants of change (attitudes, subjective norms, perceived behavioural control and intentions) and perceived environmental factors (family food rule and home availability of SSB) with changes in SSB consumption between baseline and 4-month follow-up and (2) to study whether the relationships between the environmental factors and SSB consumption are mediated by the cognitive determinants. Information on possible predictors and SSB intake at baseline and 4-month follow-up was provided by 348 Dutch adolescents (aged 12-13 years) through online questionnaires that were completed at school. Multilevel logistic regression and mediation analyses were used to determine direct and indirect associations between predictors and behaviour. The present results show that a high perceived behavioural control to decrease intake at baseline was associated with a decrease in consumption of SSB between baseline and follow-up (OR = 0.53). Low availability and a stricter family food rule were associated with a decrease in SSB consumption between baseline and follow-up (OR = 2.39, 0.54). The association between availability and decrease in SSB consumption was for 68 % mediated by perceived behavioural control to drink less. In conclusion, interventions to decrease SSB intake should focus on improving attitudes and perceived behavioural control to reduce intake, and on limiting home availability and stimulating stricter family food rules regarding SSB consumption.

Correlates of availability and accessibility of fruits and vegetables in homes of low-income Hispanic families.

Availability and accessibility (AA) has been consistently shown across studies as the most important correlate of fruits and vegetables (FV) intake. However, there is little data on factors that influence AA of FV, especially in Hispanic families. The objective of this cross-sectional study was to examine the association between parental factors, child's preferences for FV and AA of FV in homes of low-income Hispanic families with children 5-12 years old. A convenience sample of 184 parents of low socioeconomic status recruited through public elementary schools completed a self-administered questionnaire about demographics, language spoken at home and food insecurity (FI). Parental factors and child's preferences were measured using a 16-item questionnaire, which was developed specifically for the study. AA of FV was measured using a validated nine-item index. Hierarchical multiple regression analysis indicated that language spoken at home, parental practices that promote consumption of FV, parental role modeling and perceived benefits of fast food had significant and independent associations with AA of FV at home. Intervention programs should take into consideration the language spoken at home and target at improving parental factors in order to improve AA of FV.

Examining the Role of Income Inequality and Neighborhood Walkability on Obesity and Physical Activity among Low-Income Hispanic Adults.

Obesity is a major public health issue affecting rising medical costs and contributing to morbidity and premature mortality. We aimed to identify factors that may play a role in obesity and physical activity at the individual and environmental/neighborhood levels. We analyzed data from an adult sample who were parents of students enrolled in a school-based health and wellness program. The sample was restricted to those who were Hispanic and whose children were on free/reduced lunch (n = 377). Dependent variables: body mass index (BMI); neighborhood walkability. Walk Score® was used to assess neighborhood walkability. Overall, 46% of participants were obese and 31% were overweight. The median age of respondents was 34 years, and the majority were female (88%) and married (59%). Participants who resided in a census tract with a higher relative income inequality (high, OR 2.54, 90% CI 1.154-5.601; moderate-high OR 2.527, 90% CI 1.324-4.821) and those who were unmarried (OR 1.807, 90% CI 1.119-2.917) were more likely to be obese versus normal weight. Overweight individuals that resided in areas that were walkable versus car-dependent averaged more days engaging in walking for at least 30-min (p <.05). Identifying individual and neighborhood factors associated with obesity can inform more targeted approaches to combat obesity at multiple ecological levels. The importance of understanding how neighborhood characteristics influence health-related and behavioral outcomes is further reinforced with the current findings. Identifying effective strategies to engage communities and organizations in creating, implementing, adopting, evaluating, and sustaining policy and/or environmental interventions will be needed to combat the obesity epidemic.

Health by Design: Interweaving Health Promotion into Environments and Settings.

The important influence of the environmental context on health and health behavior-which includes place, settings, and the multiple environments within place and settings-has directed health promotion planners from a focus solely on changing individuals, toward a focus on harnessing and changing context for individual and community health promotion. Health promotion planning frameworks such as Intervention Mapping provide helpful guidance in addressing various facets of the environmental context in health intervention design, including the environmental factors that influence a given health condition or behavior, environmental agents that can influence a population's health, and environmental change methods. In further exploring how to harness the environmental context for health promotion, we examine in this paper the concept of interweaving of health promotion into context, defined as weaving or blending together health promotion strategies, practices, programs, and policies to fit within, complement, and build from existing settings and environments. Health promotion interweaving stems from current perspectives in health intervention planning, improvement science and complex systems thinking by guiding practitioners from a conceptualization of context as a backdrop to intervention, to one that recognizes context as integral to the intervention design and to the potential to directly influence health outcomes. In exploring the general approach of health promotion interweaving, we examine selected theoretical and practice-based interweaving concepts in relation to four key environments (the policy environment, the information environment, the social/cultural/organizational environment, and the physical environment), followed by evidence-based and practice-based examples of health promotion interweaving from the literature. Interweaving of health promotion into context is a common practice for health planners in designing health promotion interventions, yet one which merits further intentionality as a specific health promotion planning design approach.

Preventing obesity: a life cycle perspective.

Traditional approaches to treating overweight and obese adults by focusing on individual weight loss have not been effective in stemming the tide of obesity in the population. Recent research has identified critical factors that, as they accumulate and interact over an individual's life span, may put a person at risk for obesity. These factors include rapid weight gain in infancy and childhood, early puberty, and excessive weight gain in pregnancy. Based on this research, a life cycle perspective can be used to develop comprehensive interventions that address the multiple determinants of obesity. Because obesity tracks across generations, it is essential to adopt effective obesity prevention measures now to prevent even higher rates of obesity in future generations. Dietetics professionals can reduce individual risks by providing nutritional services that support appropriate weight gain in childhood and pregnancy. We can also advocate for policies in communities, schools, and worksites that support breastfeeding, ensure access to health-promoting foods, and provide opportunities to be physically active.

Assessing environmental assets for health promotion program planning: a practical framework for health promotion practitioners.

Conducting a health needs assessment is an important if not essential first step for health promotion planning. This paper explores how health needs assessments may be further strengthened for health promotion planning via an assessment of environmental assets rooted in the multiple environments (policy, information, social and physical environments) that shape health and behavior. Guided by a behavioral-ecological perspective- one that seeks to identify environmental assets that can influence health behavior, and an implementation science perspective- one that seeks to interweave health promotion strategies into existing environmental assets, we present a basic framework for assessing environmental assets and review examples from the literature to illustrate the incorporation of environmental assets into health program design. Health promotion practitioners and researchers implicitly identify and apply environmental assets in the design and implementation of health promotion interventions;this paper provides foundation for greater intentionality in assessing environmental assets for health promotion planning.

Predicting adolescent risk behaviors based on an ecological framework and assets.

OBJECTIVES: To examine the relationship between an aggregate risk score (smoking, drinking, and number of sex partners) and measures of youth assets in a sample of 3439 youth aged 14-18 years. METHODS: Linear regression models for African American and white males and females predicted an aggregate risk score. RESULTS: After adjustments, the youth asset most predictive of risk was self/peer values regarding risk behaviors. Perceived school support was also predictive. CONCLUSIONS: Taking an ecological approach to the measurement of adolescent health behaviors contributes to our understanding of these risk behaviors.

Racial and ethnic differences in the home food environment explain disparities in dietary practices of middle school children in Texas.

OBJECTIVE: To examine racial and ethnic differences among middle school children in the home food environment (HFE) and the extent to which associations of healthy and unhealthy eating with the HFE differ by race and ethnicity. DESIGN: Cross-sectional secondary analyses of baseline data from Coordinated Approach to Child Health Middle School, a school-based intervention targeting obesity and obesogenic behaviors among middle school children in Austin, TX. PARTICIPANTS: A total of 2,502 children (mean age, 13.9 years; 58% Hispanic, 28% white, and 14% black). VARIABLES MEASURED: Availability and accessibility of healthy foods, and parental support of healthy eating, and family meals. Consumption of both healthy and unhealthy foods was examined. ANALYSIS: Differences across racial and ethnic groups in aspects of HFE were estimated using linear regression. Models also examined racial and ethnic differences in consumption of healthy and unhealthy foods. If adjusting for HFE, such differences were accounted for. RESULTS: White children had significantly better HFEs than Hispanic and black children with greater availability and accessibility of healthy foods (P < .001). Adjusting for a healthy HFE reduced disparities in consumption of healthy foods but not in consumption of unhealthy foods. CONCLUSIONS AND IMPLICATIONS: Improved HFE may increase healthy eating among ethnic minorities but is unlikely to reduce unhealthy eating.

Psychosocial factors and theory in physical activity studies in minorities.

OBJECTIVES: To summarize the effectiveness of interventions targeting psychosocial factors to increase physical activity (PA) among ethnic minority adults and explore theory use in PA interventions. METHODS: Studies (N = 11) were identified through a systematic review and targeted African American/Hispanic adults, specific psychosocial factors, and PA. Data were extracted using a standard code sheet and the Theory Coding Scheme. RESULTS: Social support was the most common psychosocial factor reported, followed by motivational readiness, and self-efficacy, as being associated with increased PA. Only 7 studies explicitly reported using a theoretical framework. CONCLUSIONS: Future efforts should explore theory use in PA interventions and how integration of theoretical constructs, including psychosocial factors, increases PA.

Using community insight to understand physical activity adoption in overweight and obese African American and Hispanic women: a qualitative study.

Ecologic models suggest that multiple levels of influencing factors are important for determining physical activity participation and include individual, social, and environmental factors. The purpose of this qualitative study was to use an ecologic framework to gain a deeper understanding of the underlying behavioral mechanisms that influence physical activity adoption among ethnic minority women. Eighteen African American and Hispanic women completed a 1-hour in-depth interview. Verbatim interview transcripts were analyzed for emergent themes using a constant comparison approach. Women were middle-aged (age M = 43.9 ± 7.3 years), obese (body mass index M = 35.0 ± 8.9 kg/m(2)), and of high socioeconomic status (88.9% completed some college or more, 41.2% reported income >$82,600/year). Participants discussed individual factors, including the need for confidence, motivation and time, and emphasized the importance of environmental factors, including their physical neighborhood environments and safety of and accessibility to physical activity resources. Women talked about caretaking for others and social support and how these influenced physical activity behavior. The findings from this study highlight the multilevel, interactive complexities that influence physical activity, emphasizing the need for a more sophisticated, ecologic approach for increasing physical activity adoption and maintenance among ethnic minority women. Community insight gleaned from this study may be used to better understand determinants of physical activity and develop multilevel solutions and programs guided by an ecologic framework to increase physical activity in ethnic minority women.

Individual, social and environmental correlates of physical activity in overweight and obese African American and Hispanic women: A structural equation model analysis.

OBJECTIVE: Ecologic frameworks account for multilevel factors related to physical activity (PA) and may be used to develop effective interventions for women. The purpose of this study was to examine the influence of individual, social and environmental factors on PA among African American and Hispanic women using structural equation modeling. METHOD: Overweight and obese women (N=164, 65.9% African American) completed a 7-day accelerometer protocol, a physical assessment, and questionnaires on body image, self-efficacy, motivational readiness, social support, home environment for physical activity and perceived environment. Trained assessors evaluated each participant's neighborhood and collected objective measures of physical activity resources and the pedestrian environment. Assessments were completed between 2006 and 2008. RESULTS: Structural model fit was acceptable (RMSEA=.030). Body composition and image was negatively associated with PA, and motivational readiness had an indirect effect on PA through body composition and image. PA resources and the pedestrian environment operated through the perceived environment to positively influence neighborhood cohesion, which was positively associated with body composition and image. CONCLUSION: PA is more heavily influenced by intrapersonal factors related to weight. Improving intrapersonal factors related to weight and perceptions of the environment may lead to increased PA in African American and Hispanic women.

Clarifying concepts about macronutrients' effects on satiation and satiety.

It seems that many people, including dietetics professionals and other nutrition experts, are unclear about some of the fundamental yet complex concepts behind the influence of dietary macronutrients (ie, protein, carbohydrate, and fat) on appetite regulation. Recent research has begun to unravel some of the more complicated physiological processes of appetite control and regulation generated by hormones such as leptin, ghrelin, and the gut hormone peptide YY3-35. Although the processes by which the macronutrients in our foods influence appetite regulation have been a topic of study for decades, they remain confusing and are often misunderstood. The objective of this article is to define the terminology commonly used to discuss the macronutrients' roles in appetite regulation and to discuss the interrelated concepts and roles of taste, palatability, and energy density.

Factors of fruit and vegetable intake by race, gender, and age among young adolescents.

OBJECTIVE: To explore demographic differences in individual, social, and environmental factors potentially related to fruit and vegetable intake. DESIGN: Self-report questionnaires administered to a convenience sample of middle school students during regular classes. PARTICIPANTS: Black and white adolescents, 11 to 15 years of age (N = 736). VARIABLES MEASURED: Measures included self-efficacy, family dinner frequency, normative beliefs, outcome expectations, modeling, availability, preferences, snack choice, and demographics. ANALYSIS: Chi-square, general linear models, and Poisson and linear regressions as appropriate. RESULTS: Black participants reported greater social influences than did white participants, whereas white adolescents reported greater family environmental influences on fruit and vegetable intake. The oldest adolescents reported lower self-efficacy, peer modeling, family dinner frequency, and fruit and vegetable preferences compared with younger adolescents. White participants and females reported a higher preference for vegetables than did black participants and males. Regression models for self-efficacy and snack choice explained 41% and 34% of the variance, respectively. Preferences for vegetables and parental modeling were the strongest correlates of self-efficacy. Self-efficacy was the strongest correlate of snack choice. CONCLUSIONS AND IMPLICATIONS: Decreases in several factors with age highlight the importance of intervention for this age group. Future research is needed for a better understanding of the formation and modification of self-efficacy and snack choice.

Effects of a structural intervention and implementation on physical activity among youth in residential children's homes.

This study reports the effects of a structural intervention, ENRICH (Environmental Interventions in Children's Homes) which targeted the physical and social environment within residential children's homes (RCHs) to increase physical activity (PA) among residents (n=799). Participating RCHs (n=29) were randomized to Early (n=17) or Delayed (n=12) groups from 2004 to 2006 and 2006 to 2008, respectively. Children's PA was measured at three time periods (2004, 2006, 2008). Intent-to-treat analysis revealed no intervention impact on PA. Subsequent analyses used process evaluation data to group organizations into high and low PA-promoting RCHs to compare PA level, controlling for assignment to condition. Organizations with high PA-promoting environments were found to have more active youth. Utility of a comprehensive implementation monitoring plan and the need for formative assessment of organizational capacity is discussed.

Measurement properties of psychosocial and environmental measures associated with fruit and vegetable intake among middle school adolescents.

OBJECTIVE: To assess the measurement properties of several scales modified or created to assess factors related to fruit and vegetable intake within a young adolescent population. DESIGN: Cross-sectional with data collected via self-report. SETTING: Data were collected in regularly scheduled classes in the school setting. PARTICIPANTS: African American and Caucasian middle school students (ages 11-15 years). VARIABLES MEASURED: Self-efficacy, modeling, outcome expectations, normative beliefs, parental food management practices, and influences on food choice. ANALYSIS: Pearson correlations, factor analysis, and Cronbach α. RESULTS: Subscales with adequate to good internal consistencies (0.65-0.88) were established. Fruit and vegetable intake was significantly correlated with self-efficacy, parent and peer modeling, family and peer normative beliefs, and social and health outcome expectations. Fruit and vegetable intake was not significantly correlated with permissive eating, food self-preparation, or the 3 subscales measuring influences on food choice (social influence, avoiding weight-gain food, and appeal and access). CONCLUSIONS AND IMPLICATIONS: These measures, most originally developed for children and adults and modified for this study, demonstrated adequate measurement properties for an adolescent sample.