Elizabeth Anderson Steeves

Limiting variety in non-nutrient-dense, energy-dense foods during a lifestyle intervention: a randomized controlled trial

BACKGROUND Dietary variety is a factor that influences consumption but has received little attention in obesity treatment. OBJECTIVE This study examined the effect of limiting the variety of different non-nutrient-dense, energy-dense foods (NND-EDFs) (i.e., chips, ice cream, cookies) on dietary intake and weight loss during an 18-mo lifestyle intervention. DESIGN Two hundred two adults aged 51.3 ± 9.5 y with a BMI (in kg/m2) of 34.9 ± 4.3 (57.8% women, 92.2% white) were randomly assigned to 1 of 2 interventions: Lifestyle (1200-1500 kcal/d, ≤30% of energy as fat; n = 101) or Lifestyle + limited variety (LV) (limit variety of NND-EDFs, i.e., 2 choices; n = 101). Both interventions involved 48 group sessions. Dietary intake, NND-EDF hedonics, NND-EDF variety in the home, and weight were assessed at 0, 6, 12, and 18 mo. RESULTS Intent-to-treat analyses showed that the Lifestyle+LV group consumed less variety (P < 0.01) and energy daily (P < 0.05) from NND-EDFs than did the Lifestyle group at 6, 12, and 18 mo. The Lifestyle+LV group consumed less total energy daily (P < 0.05) at 6 mo than did the Lifestyle group. The Lifestyle+LV group reported less (P < 0.05) NND-EDF variety in the home at 6 and 18 mo than did the Lifestyle group. The hedonics of one chosen NND-EDF decreased more (P < 0.05) in the Lifestyle+LV group. Despite these effects, no difference in percentage weight loss occurred at 18 mo (Lifestyle+LV: -9.9 ± 7.6%; Lifestyle: -9.6 ± 9.2%). CONCLUSIONS Limitations in dietary variety decreased intakes in the targeted area but did not affect weight loss. Limiting variety in more areas may be needed to improve weight loss and weight-loss maintenance. This trial was registered at clinicaltrials.gov as NCT01096719.

The Effects of an Energy Density Prescription on Diet Quality and Weight Loss: A Pilot Randomized Controlled Trial

Dietary goals specific for lowering energy density (ED) may promote a nutrient-dense diet and weight loss. This pilot study examined the effects of ED-based diet prescriptions on diet quality and weight loss during a 3-month behavior-based obesity intervention conducted in a research setting. Forty-four adults with overweight/obesity (age 52.1±7.6 years, body mass index [BMI; calculated as kg/m(2)] 34.8±4.8, 81.8% women, and 93.2% white) were recruited between December 2009 and March 2010 and randomly assigned to: Low ED (consume ≥10 foods ≤1.0 kcal/g dietary ED and ≤2 foods ≥3.0 kcal/g dietary ED per day (n=15); Low-Energy, Low-Fat (1,200 to 1,500 kcal/day, ≤30% energy from fat (n=15); or Low-ED, Low-Energy, Low-Fat (n=14). Participants received 12 weekly group sessions led by a research interventionist. Dietary intake (measured by 3-day food records), self-reported physical activity, and weight were measured at baseline and 3 months. Intent-to-treat analyses showed all conditions reduced dietary ED and energy intake (P<0.001). Low-ED and Low-ED, Low-Energy, Low-Fat interventions increased fruit consumption (P<0.05). All conditions increased self-reported physical activity (P<0.001), with no difference between conditions. Although participants in all conditions lost weight (P<0.001), those in the Low-ED condition lost more (P<0.05) than those in the Low-ED, Low-Energy, Low-Fat condition (Low-ED -20.5±7.0 lb, Low-Energy, Low-Fat -16.9±10.1 lb, and Low-ED, Low-Energy, Low-Fat -12.5± 6.5 lb). A diet prescription that lowered ED increased fruit intake and enhanced weight loss compared with other weight loss prescriptions.

Reducing TV Watching During Adult Obesity Treatment: Two Pilot Randomized Controlled Trials☆

The more time adults spend being sedentary, the greater the risk of obesity. The effect of reducing television (TV) watching, a prominent sedentary behavior, on weight loss has not been tested in an adult standard behavioral obesity intervention, and the mechanisms by which reducing TV watching influences energy balance behaviors are not well understood. Two, 8-week, pilot, randomized controlled trials were conducted examining the effect of a reduced TV watching prescription on energy balance behaviors and weight loss within an adult standard behavioral obesity intervention. In the first study, participants (n=24) were randomized into one of two conditions: (a) reduce energy intake and increase moderate to vigorous physical activity (MVPA) (INCREASE PA); or (b) reduce energy intake and decrease TV watching (DECREASE TV). As findings from the first pilot study did not show an increase in MVPA in the DECREASE TV group, the second study was designed to examine the effect of adding a reduced TV prescription to a standard intervention to optimize outcomes. In Pilot Study 2, participants (n=28) were randomized to INCREASE PA or to INCREASE PA+DECREASE TV. Outcomes included objectively measured TV watching and MVPA, self-reported light physical activity (LPA-Pilot Study 2 only), self-reported dietary intake while watching TV, and weight. Conditions with TV watching prescriptions significantly reduced TV watching. Both studies showed medium to large effect sizes for conditions with TV watching prescriptions to show greater reductions in dietary intake while watching TV. Pilot Study 1 found a trend for an increase in MVPA in INCREASE PA and Pilot Study 2 found significant increases in MVPA in both conditions. Pilot Study 2 found a significant increase in LPA in the INCREASE PA+DECREASE TV. Results indicate adding a TV watching prescription to a standard obesity intervention did not enhance increases in MVPA, but may assist with reducing dietary intake while TV watching and increasing LPA. Future research should examine the effect of reducing TV watching during obesity treatment over a longer time frame in a larger sample.

Daily self-weighing within a lifestyle intervention: impact on disordered eating symptoms.

OBJECTIVE To determine whether daily self-weighing (DSW) is associated with disordered eating (DE) symptoms within an adult lifestyle intervention (LI), and to examine changes in DE symptoms during the 18-month trial. METHOD One-hundred and seventy-eight adults (53% female, 90% White, 52.0 ± 8.6 years, BMI = 35.0 ± 4.4 kg/m2) were enrolled in a randomized trial testing 2 dietary prescriptions within a LI (standard vs. limited dietary variety). Both arms were taught DSW and had the same contact schedule and calorie and activity goals. Frequency of weighing and DE were assessed at 0, 6, 12, and 18 months. Analyses controlled for treatment arm. RESULTS At baseline, 16.3% of participants reported weighing ≥ daily compared with 83.7%, 72.3%, and 68.2% at 6, 12, and 18 months, respectively. There was no relationship between change in frequency of self-weighing and change in DE symptoms at any time point. Further, there were no significant differences between those who weighed ≥ daily versus < daily on DE composite scores at baseline or 6 months; at 12 and 18 months participants who weighed ≥ daily reported lower DE scores compared with those who weighed < daily (p = .008 and .043 at 12 and 18 months, respectively). Participants who weighed ≥ daily achieved better weight losses than those weighing < daily at 12 and 18 months (p = .003 and <.001). There was a significant reduction over time in DE symptoms (p < .0001) and a reduction in odds of meeting criteria for Binge Eating Disorder (BED; ps < .001). CONCLUSIONS Daily self-weighing did not appear to be related to increased disordered eating behavior and was associated with better weight loss outcomes.

Monitoring capabilities of the Omron HJ-720ITC pedometer.

Abstract Purpose: The purpose of our study was to examine the monitoring capabilities of the Omron HJ-720ITC pedometer and determine the feasibility of using it in physical activity interventions. Methods: Using data from an 8-week lifestyle-intervention study, we tested the capabilities of the pedometer for recording physical activity data. Data from a total of 28 subjects were used in our analysis. The total number of patient steps per day was recorded over the duration of an intervention, as well as “aerobic steps per day” (ie, those taken at a cadence of > 60 steps per minute for ≥ 10 consecutive minutes). Daily wear time was computed in order to ascertain participant compliance in wearing the pedometer. In addition, aerobic steps per minute were computed, providing an assessment of activity intensity during continuous walking bouts. Results: Total steps per day and aerobic steps per day increased from baseline assessment to Week 8. Participants exceeded 100 steps/minute for 89% of their aerobic minutes, suggesting that they were in the moderate-intensity range (3–6 metabolic equivalent tasks) when performing continuous bouts of walking (> 10 minutes). Conclusion: The new pedometer is a reasonably priced, wearable activity monitor that is feasible for use in clinical and research settings.

Development and Implementation: B’More Healthy Communities for Kid’s Store and Wholesaler Intervention

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B’More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community’s access to healthy food. The objective of this article is to describe the development and implementation of BHCK’s corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

The Impact of a Multi-Level Multi-Component Childhood Obesity Prevention Intervention on Healthy Food Availability, Sales, and Purchasing in a Low-Income Urban Area

The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

Breakfast Consumption Frequency and Its Relationships to Overall Diet Quality, Using Healthy Eating Index 2010, and Body Mass Index among Adolescents in a Low-Income Urban Setting

ABSTRACT The aim of this study was to describe the relationship of breakfast frequency to diet quality and BMI among low-income, predominantly African American adolescents aged 9–15 (n = 239). Mean frequency of breakfast consumption was 5.0 ± 0.15 times per week. A significant, positive relationship was seen between HEI scores and frequency of breakfast consumption (p = .01). Dairy (p = .02) and whole grains (p < .01) HEI component scores were significantly related to breakfast frequency. No relationship was seen between breakfast frequency and BMI. Research with more rigorous designs should be conducted to assess the potential effects of breakfast consumption on diet quality in this population.

A Youth-Leader Program in Baltimore City Recreation Centers: Lessons Learned and Applications:

Peer-led interventions may be an effective means of addressing the childhood obesity epidemic; however, few studies have looked at the long-term sustainability of such programs. As part of a multilevel obesity prevention intervention, B’More Healthy Communities for Kids, 16 Baltimore college students were trained as youth-leaders (YLs) to deliver a skill-based nutrition curriculum to low-income African American children (10-14 years old). In April 2015, formative research was used to inform sustainability of the YL program in recreation centers. In-depth interviews were conducted with recreation center directors (n = 4) and the YLs (n = 16). Two focus groups were conducted with YLs (n = 7) and community youth-advocates (n = 10). Barriers to this program included difficulties with transportation, time constraints, and recruiting youth. Lessons learned indicated that improving trainings and incentives to youth were identified as essential strategies to foster continuity of the youth-led program and capacity building. High school students living close to the centers were identified as potential candidates to lead the program. Based on our findings, the initial intervention will be expanded into a sustainable model for implementation, using a train-the-trainer approach to empower community youth to be change agents of the food environment and role models.

Food in My Neighborhood: Exploring the Food Environment through Photovoice with Urban, African American Youth

ABSTRACT This study adapted Photovoice methodology for younger participants to better understand the perceptions of urban African American youth on their food environments and diets. Youth (n = 17, ages 10–13 years) photographed and described, using novel narrative-based activities, the myriad places they regularly acquired “junk food” from environments saturated with such but differed in their assessments of the availability and desirability of more nutritious alternative foods. Youth often discussed specific foods as well as peers and adults in their lives as either entirely “healthy” or “unhealthy.” This concrete thinking should be considered when designing messaging strategies to improve diets in similar populations. Overall, Photovoice is an engaging and effective method to engage youth in efforts to improve food environments and diets.