Karen Weber Cullen

Eating Patterns, Dietary Quality and Obesity

Obesity among children has reached epidemic proportions. Today, an estimated one in four children in the United States is overweight, while 11% are obese. Children who are overweight tend to remain so up to 20 years of age; in general, they have a 1.5- to twofold higher risk for becoming overweight as adults. The prevalence of overweight has increased approximately twofold in the 20-year period from 1974 to 1994, with the largest increases observed among 19- to 24-year-olds. The annual increases in weight and obesity that occurred from 1983 to 1994 were 50% higher than those from 1973 to 1982. Overweight youth are 2.4 times as likely to have a high serum total cholesterol level, and 43.5 times as likely to have three cardiovascular risk factors. Although the total energy intake of children has remained the same, and the macronutrient density of the diet has changed, the percentage of energy from fat has decreased, while that from carbohydrates and protein has increased. Children have been consuming lower amounts of fats/oils, vegetables/soups, breads/grains, mixed meats, desserts, candy, and eggs, and increasing amounts of fruits/fruit juices, beverages, poultry, snacks, condiments, and cheese. Changes in specific eating patterns may explain the increase in adiposity among children; e.g., increases have occurred in the number of meals eaten at restaurants, food availability, portion sizes, snacking and meal-skipping. Successful prevention and treatment of obesity in childhood could reduce the adult incidence of cardiovascular disease. Because substantial weight loss is difficult to maintain, the prevention of obesity by promoting healthier lifestyles should be one of our highest priorities in the new millennium.

Availability, Accessibility, and Preferences for Fruit, 100% Fruit Juice, and Vegetables Influence Children's Dietary Behavior

The relationships among home fruit (F), 100% fruit juice (J), and vegetable (V) availability and accessibility separately, as reported by 225 fourth- through sixth-grade children and their parents (n = 88), separately, and FJV preferences to child-reported FJV consumption were assessed. For girls, child-reported FJV availability and accessibility accounted for 35% of the variability in FJV consumption. Child-reported availability and parent-reported accessibility were significantly correlated with child FJV consumption in a combined model. For children with high FJV preferences, FJV availability was the only significant predictor, whereas both avail-ability and accessibility were significantly related to consumption for children with low FJV preferences. Interventions targeting child dietary behaviors may need to tailor to the home environment, separately by gender. Extra efforts are necessary by parents to enhance accessibility among children who do not like FJV.

Squire's Quest! Dietary Outcome Evaluation of a Multimedia Game

BACKGROUND Fruit, juice, and vegetable (FJV) consumption among children is low. Innovative programs are needed to enable children to increase FJV intake. Psychoeducational multimedia permits the delivery of interventions as designed and capitalizes on known behavior change principles. DESIGN Elementary school was the unit of recruitment, assignment, and analysis. Twenty-six elementary schools were pair matched on size and percentage of free or reduced-price lunch, and randomly assigned to treatment or control groups. Data were collected just before and just after the program. SETTING/PARTICIPANTS All fourth-grade students in participating elementary schools were invited to participate. Data were collected on 1578 students. MAIN OUTCOME Servings of fruit, 100% juice, and vegetables consumed. INTERVENTION Squires Quest! is a ten-session, psychoeducational, multimedia game delivered over 5 weeks, with each session lasting about 25 minutes. Based on social cognitive theory, educational activities attempted to increase preferences for FJV through multiple exposures and associating fun with their consumption, increase asking behaviors for FJV at home and while eating out, and increase skills in FJV preparation through making virtual recipes. MEASURES Four days of dietary intake were assessed before and after the intervention. Assessment was made by the Food Intake Recording Software System (FIRSSt), which conducts a multiple pass, 24-hour dietary intake interview directly with the children. RESULTS Children participating in Squires Quest! increased their FJV consumption by 1.0 servings more than the children not receiving the program. CONCLUSIONS Psychoeducational multimedia games have the potential to substantially change dietary behavior. More research is warranted.

Using goal setting as a strategy for dietary behavior change

Recent reviews have noted that behavioral theory-based nutrition education programs are more successful at achieving food behavior change than knowledge-based programs and that a clear understanding of the mechanisms of behavior change procedures enable dietetics professionals to more effectively promote change. Successful dietary behavior change programs target 1 or more of the personal, behavioral, or environmental factors that influence the behavior of interest and apply theory-based strategies to influence or change those factors. Goal setting is a strategy that is frequently used to help people change. A 4-step goal-setting process has been identified: recognizing a need for change; establishing a goal; adopting a goal-directed activity and self-monitoring it; and self-rewarding goal attainment. The applications of goal setting in dietary interventions for adults and children are reviewed here. Because interventions using goal setting appear to promote dietary change, dietitians should consider incorporating the goal-setting strategies to enhance the behavior change process in nutrition education programs.

Effect of a La Carte and Snack Bar Foods at School on Children's Lunchtime Intake of Fruits and Vegetables

OBJECTIVES To compare lunch fruit, juice, and vegetable (FJV) intake of fourth-grade students who receive only National School Lunch Program meals and fifth-grade students who also have access to a school snack bar and to compare FJV intake by meal source among fifth-grade students. DESIGN Cross-sectional study: students completed FJV preference questionnaires and 5 days of lunch food records in classrooms. SUBJECTS/SETTING 312 fourth- and 282 fifth-grade students in south Texas. MAIN OUTCOME MEASURES Mean FJV consumption. STATISTICAL ANALYSES PERFORMED Descriptive statistics, correlation analyses, analysis of variance, analysis of covariance. RESULTS Fourth-grade students (n = 312) consumed significantly more fruits, juices, and vegetables (0.80 serving) than fifth-grade students (n = 282) (0.60 serving). Students whose parents reported a high school education or less consumed more regular and total vegetables than students whose parents reported some college or higher education. There were no interaction effects among gender, grade, ethnic, or family education groups. Fifth-grade students who ate only snack bar meals consumed significantly less total fruits, juices, and vegetables (0.40 serving) than fifth-grade students who ate school lunch meals (0.82 serving). Controlling for FJV preferences did not change the main effect for grade level in the FJV consumption models. APPLICATIONS/CONCLUSIONS FJV consumption during school lunch is low. School foodservice staff should identify FJV items that middle school students prefer and increase availability of those items in middle school cafeterias and snack bars.

School-Based Obesity Prevention: A Blueprint for Taming the Epidemic.

OBJECTIVE To review the literature on school-based obesity prevention programs to identify what can be done to minimize the increasing levels of obesity. METHODS Twenty articles reporting school-based dietary or physical activity change programs were identified that used BMI or skinfolds as part of the evaluation. RESULTS Seven studies obtained change in BMI and differed from those not finding change in 3 ways: program implementers were not classroom teachers; intervention targeted middle or high schools; and inactivity reduction was promoted. CONCLUSIONS An 8-step research strategy was delineated to develop and evaluate programs with a maximum chance of taming the obesity epidemic.

The Food Intake Recording Software System is Valid Among Fourth-grade Children

OBJECTIVES To assess the validity of the Food Intake Recording Software System (FIRSSt) against observation of school lunch and a 24-hour dietary recall (24hDR); and to test the effects of sequencing, observation and a hair sample as a bogus pipeline on accuracy of dietary report. DESIGN Six-group design systematically varying sequence of self-report (FIRSSt vs 24hDR), observation of school lunch and hair sample as a bogus pipeline manipulation, with random assignment of participants. SUBJECTS/SETTING 138 fourth-grade students in 2 elementary schools. MAIN OUTCOME MEASURES Accuracy of reported food consumption was measured in terms of matches, intrusions, and omissions among the FIRSSt, 24hDR, and as observed at school lunch. Students also completed self-report of performance with FIRSSt. STATISTICAL ANALYSIS PERFORMED t tests, Pearson correlations, analysis of variance, factor analysis. RESULTS When compared with school lunch observation for one meal, FIRSSt attained 46% match, 24% intrusion and 30% omission rates, while a dietitian-conducted 24hDR obtained 59% match, 17% intrusion, and 24% omission rates. FIRSSt attained 60% match, 15% intrusion, and 24% omission rates against 24hDR for all meals in the previous day. There was no evidence of sequence of assessment affecting accuracy indicators, but there was a weak effect of school lunch observation on percent intrusions. Obtaining a hair sample reduced the omission rate for FIRSSt vs 24hDR and increased the match rate for 24hDR vs observation, thereby enhancing this as a bogus pipeline procedure. Children generally enjoyed completing FIRSSt. Hispanic children were more likely to report problems using FIRSSt. APPLICATIONS/CONCLUSIONS FIRSSt is somewhat less accurate than a dietitian-conducted 24hDR. However, this lower-cost procedure provides a promising method for assessing diet among children. Observation of consumption at school lunch may be reactive and artificially increase agreement. Obtaining a hair sample as a bogus pipeline may be a valuable technique for enhancing the accuracy of dietary assessment among children.

Relative Reliability and Validity of the Block Kids Questionnaire among Youth Aged 10 to 17 Years

This cross-sectional study tested the reliability and validity of the Block Kids Questionnaire to assess diet during the past 7 days. Within a 7-day period, 10- to 17-year-old children and adolescents completed two 24-hour dietary recalls by telephone, followed by the Block Kids Questionnaire at the end of the week. Test-retest reliability was assessed using intraclass correlations for 18 participants who completed a second Block Kids Questionnaire 1 month later. Validity of the Block Kids Questionnaire compared to the 24-hour dietary recall was assessed for the whole sample and by age group using paired t tests and Pearson correlation coefficients adjusted for attenuation and energy intake. Participants were 83 children and adolescents (57% Hispanic, 21% African-American, and 23% white; 53% were female subjects, mean age 13 years). The Block Kids Questionnaire mean daily consumption values were higher for percent energy from carbohydrate, and servings of fruit, 100% fruit juice, and vegetables, and lower for all other categories compared to the 24-hour dietary recall. All reliability intraclass correlations were >0.30, except percent energy from protein and fruit/vegetable servings. Significant differences in the means between the two dietary assessment methods were noted for most nutrients/food groups. The adjusted correlation coefficients ranged from 0.69 for percent energy from carbohydrate to -0.03 for grain servings, with 60% of the food group servings <0.18. Overall, the majority of the correlation coefficients for children aged >12 years were higher than those aged < or =12 years. These results suggest that the Block Kids Questionnaire has validity for some nutrients, but not most food groups assessed, and appears more useful for adolescents.

Socioenvironmental influences on children's fruit, juice and vegetable consumption as reported by parents: reliability and validity of measures.

OBJECTIVE To pilot test theory-based questionnaires to measure socioenvironmental influences on childrens fruit, juice and vegetable (FJV) consumption as reported by parents. DESIGN Cross-sectional. SETTING Parents of fourth to sixth grade students completed socioenvironmental questionnaires. The students completed food records (FRs) for 2 days in the classroom. SUBJECTS Interviews were completed by 109 parents (17% African-American, 32% Hispanic-American and 51 Euro-American). RESULTS Student mean daily FJV intake was 2.1 servings. Principal components analyses revealed subscales measuring positive and negative parenting practices; self-efficacy for modelling and planning/encouraging FJV consumption, and making FJV available; encouraging, consequences and discouraging food socialization practices; negative home, cost and canned/frozen food barriers; meal planning; child shopping; mother food preparation; and child lunch and dinner FJV preparation practices. Internal consistencies were adequate to high. Negative parent practices and negative home FJV barriers were significantly negatively correlated with child FJV consumption variables. Planning/encouraging self-efficacy was positively associated with fruit consumption, and child dinner FJV preparation was significantly negatively correlated with child juice consumption. CONCLUSIONS These questionnaires may provide important insights about the relationship between parent-reported socioenvironmental influences and childrens FJV consumption. Future work should test these questionnaires with larger groups of parents and youths, with more reliable estimates of usual FJV intake, e.g. 7-day food records, to obtain a detailed understanding of how parents influence what children eat. Tests of models of relationships among these variables are warranted, but should control for possible confounding variables, e.g. socioeconomic status, gender of the child, etc.

Distance to food stores & adolescent male fruit and vegetable consumption: mediation effects

BackgroundThe physical environments in which adolescents reside and their access to food stores may influence their consumption of fruit and vegetables. This association could either be direct or mediated via psychosocial variables or home availability of fruit and vegetables. A greater understanding of these associations would aide the design of new interventions. The purpose of this study was to examine associations between distance to food stores and restaurants and fruit and vegetable consumption and the possible mediating role of psychosocial variables and home availability.MethodsFruit and vegetable consumption of 204 Boy Scouts was assessed by a food frequency questionnaire in 2003. Participant addresses were geo-coded and distance to different types of food stores and restaurants calculated. Fruit and vegetable preferences, home availability and self-efficacy were measured. Regression models were run with backward deletion of non-significant environmental and psychosocial variables. Mediation tests were performed.ResultsResiding further away from a small food store (SFS) (convenience store and drug store) was associated with increased fruit and juice and low fat vegetable consumption. Residing closer to a fast food restaurant was associated with increased high fat vegetable and fruit and juice consumption. Vegetable preferences partially mediated (26%) the relationship between low fat vegetable consumption and distance to the nearest SFS.ConclusionDistance to SFS and fast food restaurants were associated with fruit and vegetable consumption among male adolescents. Vegetable preferences partially mediated the distance to low fat vegetable relationship. More research is needed to elucidate how environmental variables impact childrens dietary intake.