Jamie Zoellner

Obesity and Sugar‐sweetened Beverages in African‐American Preschool Children: A Longitudinal Study

A representative sample of 365 low‐income African‐American preschool children aged 3–5 years was studied to determine the association between sugar‐sweetened beverage consumption (soda, fruit drinks, and both combined) and overweight and obesity. Children were examined at a dental clinic in 2002–2003 and again after 2 years. Dietary information was collected using the Block Kids Food Frequency Questionnaire. A BMI score was computed from recorded height and weight. Overweight and obesity were defined by national reference age‐sex specific BMI: those with an age‐sex specific BMI ≥85th, but <95th percentile as overweight and those with BMI ≥95th age‐sex specific percentile as obese. The prevalence of overweight was 12.9% in baseline, and increased to 18.7% after 2 years. The prevalence of obesity increased from 10.3 to 20.4% during the same period. Baseline intake of soda and all sugar‐sweetened beverages were positively associated with baseline BMI z‐scores. After adjusting for covariates, additional intake of fruit drinks and all sugar‐sweetened beverages at baseline showed significantly higher odds of incidence of overweight over 2 years. Among a longitudinal cohort of African‐American preschool children, high consumption of sugar‐sweetened beverages was significantly associated with an increased risk for obesity.

Health Literacy is associated with Healthy Eating Index Scores and Sugar-Sweetened Beverage Intake: Findings from the Rural Lower Mississippi Delta

BACKGROUND Although health literacy has been a public health priority area for more than a decade, the relationship between health literacy and dietary quality has not been thoroughly explored. OBJECTIVE To evaluate health literacy skills in relation to Healthy Eating Index (HEI) scores and sugar-sweetened beverage (SSB) consumption while accounting for demographic variables. DESIGN Cross-sectional survey. PARTICIPANTS/SETTING A community-based proportional sample of adults residing in the rural Lower Mississippi Delta. METHODS Instruments included a validated 158-item regional food frequency questionnaire and the Newest Vital Sign (scores range 0 to 6) to assess health literacy. STATISTICAL ANALYSES PERFORMED Descriptive statistics, analysis of variance, and multivariate linear regression. RESULTS Of 376 participants, the majority were African American (67.6%), without a college degree (71.5%), and household income level <

Understanding the internal and external validity of health literacy interventions: a systematic literature review using the RE-AIM framework.

20,000/year (55.0%). Most participants (73.9%) scored in the two lowest health literacy categories. The multivariate linear regression model to predict total HEI scores was significant (R(2)=0.24; F=18.8; P<0.01), such that every 1-point increase in health literacy was associated with a 1.21-point increase in HEI scores, while controlling for all other variables. Other significant predictors of HEI scores included age, sex, and Supplemental Nutrition Assistance Program participation. Health literacy also significantly predicted SSB consumption (R(2)=0.15; F=6.3; P<0.01) while accounting for demographic variables. Every 1 point in health literacy scores was associated with 34 fewer kilocalories per day from SSBs. Age was the only significant covariate in the SSB model. CONCLUSIONS Although health literacy has been linked to numerous poor health outcomes, to our knowledge this is the first investigation to establish a relationship between health literacy and HEI scores and SSB consumption. Our study suggests that understanding the causes and consequences of limited health literacy is an important factor in promoting compliance to the Dietary Guidelines for Americans.

Exploring the Theory of Planned Behavior to Explain Sugar-sweetened Beverage Consumption

We conducted a systematic literature review, using the RE-AIM framework, with the goal of determining what information is available to inform research to practice translation of health promotion interventions developed to address health literacy. Thirty-one articles reflecting 25 trials published between 2000 and 2010 met inclusion criteria. Two researchers coded each article, using a validated RE-AIM (reach, effectiveness/efficacy, adoption, implementation, maintenance) data extraction tool, and group meetings were used to gain consensus on discrepancies. Across all studies (14 randomized controlled trials, 11 quasi-experimental; 24 clinic-based, 1 community-based), the mean level of reporting RE-AIM indicators varied by dimension (reach = 69%; efficacy/ effectiveness = 58%; adoption = 36%; implementation = 35%; maintenance = 11%). Among participants enrolled in the 25 interventions, approximately 38% were identified as low health literate. Only eight of the studies examined health literacy status as a moderator of intervention effectiveness. This review suggests that the current research on health promotion for participants with low health literacy provides insufficient information to conclude whether interventions for health literacy can attract the target population, achieve an effect that is sustainable, or be generalized outside of clinical settings. Recommendations for enhancing the design and reporting of these trials are provided.

Assessing the Internal and External Validity of Mobile Health Physical Activity Promotion Interventions: A Systematic Literature Review Using the RE-AIM Framework

OBJECTIVE To describe sugar-sweetened beverage (SSB) consumption and to establish psychometric properties and utility of a Theory of Planned Behavior (TPB) instrument for SSB consumption. METHODS This cross-sectional survey included 119 southwest Virginia participants. Most of the respondents were female (66%), white (89%), and had at least a high school education (79%), and their average age was 41.4 ± 13.5 years. A validated beverage questionnaire was used to measure SSB. Eleven TPB constructs were assessed with a 56-item instrument. Analyses included descriptive statistics, 1-way ANOVA, Cronbach α, and multiple regression. RESULTS Sugar-sweetened beverage intake averaged 457 ± 430 kcal/d. The TPB model provided a moderate explanation of SSB intake (R(2) = 0.38; F = 13.10, P < .01). Behavioral intentions had the strongest relationships with SSB consumption, followed by attitudes, perceived behavioral control, and subjective norms. The 6 belief constructs did not predict significant variance in the models. CONCLUSIONS AND IMPLICATIONS Future efforts to comprehensively develop and implement interventions guided by the TPB hold promise for reducing SSB intake.

Qualitative Application of the Theory of Planned Behavior to Understand Beverage Consumption Behaviors among Adults

Background Mobile health (mHealth) interventions are effective in promoting physical activity (PA); however, the degree to which external validity indicators are reported is unclear. Objective The purpose of this systematic review was to use the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to determine the extent to which mHealth intervention research for promoting PA reports on factors that inform generalizability across settings and populations and to provide recommendations for investigators planning to conduct this type of research. Methods Twenty articles reflecting 15 trials published between 2000 and 2012 were identified through a systematic review process (ie, queries of three online databases and reference lists of eligible articles) and met inclusion criteria (ie, implementation of mobile technologies, target physical activity, and provide original data). Two researchers coded each article using a validated RE-AIM data extraction tool (reach, efficacy/effectiveness, adoption, implementation, maintenance). Two members of the study team independently abstracted information from each article (inter-rater reliability >90%) and group meetings were used to gain consensus on discrepancies. Results The majority of studies were randomized controlled trials (n=14). The average reporting across RE-AIM indicators varied by dimension (reach=53.3%, 2.67/5; effectiveness/efficacy=60.0%, 2.4/4; adoption=11.1%, 0.7/6; implementation=24.4%, 0.7/3; maintenance=0%, 0/3). While most studies described changes in the primary outcome (effectiveness), few addressed the representativeness of participants (reach) or settings (adoption) and few reported on issues related to maintenance and degree of implementation fidelity. Conclusions This review suggests that more focus is needed on research designs that highlight and report on both internal and external validity indicators. Specific recommendations are provided to encourage future mHealth interventionists and investigators to report on representativeness, settings, delivery agents for planned interventions, the extent to which protocol is delivered as intended, and maintenance of effects at the individual or organizational level.

H.U.B city steps: methods and early findings from a community-based participatory research trial to reduce blood pressure among african americans

Despite strong scientific data indicating associations among sugar-sweetened beverages (SSB) and numerous adverse health outcomes, little is known about culturally specific beliefs and potential individual-level behavioral strategies to reduce SSB intake. The primary objective of this formative study targeting adults residing in rural southwest Virginia was to apply the Theory of Planned Behavior to investigate culturally specific attitudes, subjective norms, and perceived behavioral control constructs related to the consumption of SSB, water, and artificially sweetened beverages. Using a homogenous sampling strategy, eight focus groups were conducted with 54 adult participants who exceeded recommendations of <1 cup of SSB/day. An experienced moderator and co-moderator utilized a semi-structured script, grounded in the Theory of Planned Behavior, to execute the focus group. All focus groups were audiotaped and transcribed verbatim. Three researchers independently coded meaning units to the major themes and subsequently met to gain consensus in coding. Important beverage-specific themes emerged for attitudes, subjective norms, perceived behavioral control, and intentions. Across all beverages, the most notable themes included taste (n=161 meaning units), availability/convenience (n=95 meaning units), habit/addiction (n=57 meaning units), and cost (n=28 meaning units). Health consequences associated with beverages and water-quality issues also surfaced, as well as normative beliefs, including the influence of doctors and peers. The identified themes and subthemes provide critical insight into understanding culturally relevant context and beliefs associated with beverage consumption behaviors and helps inform the development and evaluation of future intervention efforts targeting SSB consumption in the health disparate region of southwest Virginia.

Talking Health, A pragmatic randomized-controlled health literacy trial targeting sugar-sweetened beverage consumption among adults: Rationale, design & methods

BackgroundCommunity-based participatory research (CBPR) has been recognized as an important approach to develop and execute health interventions among marginalized populations, and a key strategy to translate research into practice to help reduce health disparities. Despite growing interest in the CBPR approach, CBPR initiatives rarely use experimental or other rigorous research designs to evaluate health outcomes. This behavioral study describes the conceptual frameworks, methods, and early findings related to the reach, adoption, implementation, and effectiveness on primary blood pressure outcomes.MethodsThe CBPR, social support, and motivational interviewing frameworks are applied to test treatment effects of a two-phased CBPR walking intervention, including a 6-month active intervention quasi experimental phase and 12-month maintenance randomized controlled trial phase to test dose effects of motivational interviewing. A community advisory board helped develop and execute the culturally-appropriate intervention components which included social support walking groups led by peer coaches, pedometer diary self-monitoring, monthly diet and physical activity education sessions, and individualized motivational interviewing sessions. Although the study is on-going, three month data is available and reported. Analyses include descriptive statistics and paired t tests.ResultsOf 269 enrolled participants, most were African American (94%) females (85%) with a mean age of 43.8 (SD = 12.1) years. Across the 3 months, 90% of all possible pedometer diaries were submitted. Attendance at the monthly education sessions was approximately 33%. At the 3-month follow-up 227 (84%) participants were retained. From baseline to 3-months, systolic BP [126.0 (SD = 19.1) to 120.3 (SD = 17.9) mmHg; p < 0.001] and diastolic BP [83. 2 (SD = 12.3) to 80.2 (SD = 11.6) mmHg; p < 0.001] were significantly reduced.ConclusionsThis CBPR study highlights implementation factors and signifies the communitys active participation in the development and execution of this study. Reach and representativeness of enrolled participants are discussed. Adherence to pedometer diary self-monitoring was better than education session participation. Significant decreases in the primary blood pressure outcomes demonstrate early effectiveness. Importantly, future analyses will evaluate long-term effectiveness of this CBPR behavioral intervention on health outcomes, and help inform the translational capabilities of CBPR efforts.

Engaging the Dan River Region to Reduce Obesity Application of the Comprehensive Participatory Planning and Evaluation Process

High consumption of sugar-sweetened beverages (SSB) contributes to a wide range of poor health outcomes. Further, few US adults drink less than the recommended ≤8 oz per day; and individuals with low socioeconomic, low health literacy status, and in rural areas are even less likely to meet recommendations. Unfortunately, few SSB behavioral interventions exist targeting adults, and none focus on low health literacy in rural areas. Talking Health, a type 1 effectiveness-implementation hybrid trial targeting adults in rural southwest Virginia, was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). The primary aim of this pragmatic randomized-controlled trial was to determine the effectiveness of a scalable 6-month intervention aimed at decreasing SSB consumption (SIPsmartER) when compared to a matched contact physical activity promotion control group (MoveMore). SIPsmartER was developed based upon the Theory of Planned Behavior and uses health literacy strategies to improve comprehension of the intervention content among participants. MoveMore is based on a research-tested intervention that was adapted to address all theory of planned behavior constructs and health literacy principles. Secondary aims include additional health outcomes (e.g., physical activity, weight) and reach, adoption, implementation, and maintenance indicators. This paper highlights the opportunities and considerations for developing health behavior trials that aim to determine intervention effectiveness, provide all study participants an opportunity to benefit from research participation, and collect key information on reach and the potential for organizational adoption, implementation, and maintenance with the longer-term goal of speeding translation into practice settings.

Exploring Community Gardens in a Health Disparate Population: Findings from a Mixed Methods Pilot Study

Despite ongoing recommendations to engage health-disparate populations in the initiation and execution of community-based research, few studies report on the process of community engagement. The action-oriented Comprehensive Participatory Planning and Evaluation (CPPE) process is designed to guide community health planning and evaluation. This article describes how the CPPE process was utilized within a community-based participatory research initiative aimed at addressing obesity in the health-disparate Dan River Region. Encouraging community engagement in formulating research agendas and promoting ownership of health solutions will be key to improving obesity risk factors among Dan River Region residents and similar vulnerable communities.