Pamela Koch

Adolescents Demonstrate Improvement in Obesity Risk Behaviors after Completion of Choice, Control & Change, a Curriculum Addressing Personal Agency and Autonomous Motivation

BACKGROUND The rapid increase of obesity and diabetes risk beginning in youth, particularly those from disadvantaged communities, calls for prevention efforts. OBJECTIVE To examine the impact of a curriculum intervention, Choice, Control & Change, on the adoption of the energy balance-related behaviors of decreasing sweetened drinks, packaged snacks, fast food, and leisure screen time, and increasing water, fruits and vegetables, and physical activity, and on potential psychosocial mediators of the behaviors. DESIGN Ten middle schools were randomly assigned within matched pairs to either intervention or comparison/delayed control conditions during the 2006-2007 school year. SUBJECTS/SETTING Students were from low-income New York City neighborhoods; 562 were in the intervention condition, and 574 in the comparison condition. INTERVENTION Students received the 24 Choice, Control & Change lessons that used science inquiry investigations to enhance motivation for action, and social cognitive and self-determination theories to increase personal agency and autonomous motivation to take action. MAIN OUTCOME MEASURES Self-report instruments to measure energy balance-related behaviors targeted by the curriculum and potential psychosocial mediators of the behaviors. STATISTICAL ANALYSES Analysis of covariance with group (intervention/control) as a fixed factor and pretest as covariate. RESULTS Students in intervention schools compared to the delayed intervention controls reported consumption of considerably fewer sweetened drinks and packaged snacks, smaller sizes of fast food, increased intentional walking for exercise, and decreased leisure screen time, but showed no increases in their intakes of water, fruits, and vegetables. They showed substantial increases in positive outcome expectations about the behaviors, self-efficacy, goal intentions, competence, and autonomy. CONCLUSIONS The Choice, Control & Change curriculum was effective in improving many of the specifically targeted behaviors related to reducing obesity risk, indicating that combining inquiry-based science education and behavioral theory is a promising approach.

Variables of the Theory of Planned Behavior are associated with family meal frequency among adolescents.

OBJECTIVE To examine associations between Theory of Planned Behavior variables and the family meal frequency. METHODS Fifth-through seventh-grade students (n = 236) completed a self-administered questionnaire in their classrooms. The relationships between Theory of Planned Behavior variables (intention, attitudes, subjective norms, and perceived behavioral control) and family meal frequency were examined with Spearman correlations and multiple logistic regression analysis. RESULTS Positive intention, positive subjective norm of family eating together, and lower perceived difficulty of making time increased the odds of adolescents having family dinners at least 5 d/wk compared with adolescents having family dinners 2 days or fewer per week. Positive intention and lower perceived difficulty for making time increased odds of having family breakfasts at least 5 d/wk. CONCLUSIONS AND IMPLICATIONS To increase family meal frequency, nutrition educators are encouraged to focus on increasing intention, creating positive norms about the family meal, and reducing perceived barriers caused by time conflicts.

¡Cocinar Para Su Salud!: Randomized controlled trial of a culturally-based dietary intervention among Hispanic breast cancer survivors

BACKGROUND There is a need for culturally relevant nutrition programs targeted to underserved cancer survivors. OBJECTIVE Our aim was to examine the effect of a culturally based approach to dietary change on increasing fruit/vegetable (F/V) intake and decreasing fat intake among Hispanic breast cancer survivors. DESIGN Participants were randomized to Intervention and Control groups. Diet recalls, detailed interviews, fasting blood, and anthropometric measures were collected at baseline, 3, 6, and 12 months. PARTICIPANTS/SETTING Hispanic women (n=70) with stage 0 to III breast cancer who completed adjuvant treatment and lived in New York City were randomized between April 2011 and March 2012. INTERVENTION The Intervention group (n=34) participated in ¡Cocinar Para Su Salud!, a culturally based nine-session (24 hours over 12 weeks) intervention including nutrition education, cooking classes, and food-shopping field trips. The Control group (n=36) received written dietary recommendations for breast cancer survivors. MAIN OUTCOME MEASURES Change at 6 months in daily F/V servings and percent calories from total fat were the main outcome measures. STATISTICAL ANALYSES Linear regression models adjusted for stratification factors and estimated marginal means were used to compare changes in diet from baseline to 3 and 6 months. RESULTS Baseline characteristics were the following: mean age 56.6 years (standard deviation 9.7 years), mean time since diagnosis 3.4 years (standard deviation 2.7 years), mean body mass index (calculated as kg/m²) 30.9 (standard deviation 6.0), 62.9% with annual household income ≤

Social networks and social support for healthy eating among Latina breast cancer survivors: implications for social and behavioral interventions

15,000, mean daily servings of all F/V was 5.3 (targeted F/V 3.7 servings excluding legumes/juices/starchy vegetables/fried foods), and 27.7% of daily calories from fat. More than 60% in the Intervention group attended seven or more of nine classes, with overall study retention of 87% retention at 6 months. At month 6, the Intervention group compared with Control group reported an increase in mean servings of F/V from baseline (all F/V: +2.0 vs -0.1; P=0.005; targeted F/V: +2.7 vs +0.5; P=0.002) and a nonsignificant decrease in percent calories from fat (-7.5% vs -4.4%; P=0.23) and weight (-2.5 kg vs +3.8 kg; P=0.22). CONCLUSIONS ¡Cocinar Para Su Salud! was effective at increasing short-term F/V intake in a diverse population of Hispanic breast cancer survivors.

Intraclass Correlation Coefficients for Obesity Indicators and Energy Balance–Related Behaviors Among New York City Public Elementary Schools

PurposeLittle is known about Latina breast cancer survivors’ social networks or their perceived social support to achieve and maintain a healthy diet. This paper describes the social networks and perceived support for healthy eating in a sample of breast cancer survivors of predominantly Dominican descent living in New York City.MethodsSpanish-speaking Latina breast cancer survivors enrolled in a randomized controlled trial of a culturally tailored dietary intervention. Social networks were assessed using Cohen’s Social Network Index and a modified General Social Survey Social Networks Module that included assessments of shared health promoting behaviors. Perceived social support from family and friends for healthy, food-related behaviors was assessed.ResultsParticipants’ networks consisted predominantly of family and friends. Family members were more likely than other individuals to be identified as close network members. Participants were more likely to share food-related activities than exercise activities with close network members. Perceived social support for healthy eating was high, although perceived support from spouses and children was higher than support from friends. Despite high levels of perceived support, family was also identified as a barrier to eating healthy foods by nearly half of women.ConclusionsAlthough friends are part of Latina breast cancer survivors’ social networks, spouses and children may provide greater support for healthy eating than friends.Implications for Cancer SurvivorsInvolving family members in dietary interventions for Latina breast cancer survivors may tap into positive sources of support for women, which could facilitate uptake and maintenance of healthy eating behaviors.

Long-term diet and biomarker changes after a short-term intervention among Hispanic breast cancer survivors: The ¡Cocinar Para Su Salud! randomized controlled trial

Objective. Sample size and statistical power calculation should consider clustering effects when schools are the unit of randomization in intervention studies. The objective of the current study was to investigate how student outcomes are clustered within schools in an obesity prevention trial. Method. Baseline data from the Food, Health & Choices project were used. Participants were 9- to 13-year-old students enrolled in 20 New York City public schools (n = 1,387). Body mass index (BMI) was calculated based on measures of height and weight, and body fat percentage was measured with a Tanita® body composition analyzer (Model SC-331s). Energy balance–related behaviors were self-reported with a frequency questionnaire. To examine the cluster effects, intraclass correlation coefficients (ICCs) were calculated as school variance over total variance for outcome variables. School-level covariates, percentage students eligible for free and reduced-price lunch, percentage Black or Hispanic, and English language learners were added in the model to examine ICC changes. Results. The ICCs for obesity indicators are: .026 for BMI-percentile, .031 for BMI z-score, .035 for percentage of overweight students, .037 for body fat percentage, and .041 for absolute BMI. The ICC range for the six energy balance–related behaviors are .008 to .044 for fruit and vegetables, .013 to .055 for physical activity, .031 to .052 for recreational screen time, .013 to .091 for sweetened beverages, .033 to .121 for processed packaged snacks, and .020 to .083 for fast food. When school-level covariates were included in the model, ICC changes varied from −95% to 85%. Conclusions. This is the first study reporting ICCs for obesity-related anthropometric and behavioral outcomes among New York City public schools. The results of the study may aid sample size estimation for future school-based cluster randomized controlled trials in similar urban setting and population. Additionally, identifying school-level covariates that can reduce cluster effects is important when analyzing data.

Cost-effectiveness of a Nutrition Education Curriculum Intervention in Elementary Schools

Background: Among Hispanic breast cancer survivors, we examined the long-term effects of a short-term culturally based dietary intervention on increasing fruits/vegetables (F/V), decreasing fat, and changing biomarkers associated with breast cancer recurrence risk. Methods: Spanish-speaking women (n = 70) with a history of stage 0–III breast cancer who completed treatment were randomized to ¡Cocinar Para Su Salud! (n = 34), a culturally based 9-session program (24 hours over 12 weeks, including nutrition education, cooking classes, and food-shopping field trips), or a control group (n = 36, written dietary recommendations for breast cancer survivors). Diet recalls, fasting blood, and anthropometric measures were collected at baseline, 6, and 12 months. We report changes between groups at 12 months in dietary intake and biomarkers using 2-sample Wilcoxon t tests and generalized estimating equation (GEE) models. Results: At 12 months, the intervention group compared with the control group reported higher increases in mean daily F/V servings (total: +2.0 vs. −0.4; P < 0.01), and nonsignificant decreases in the percentage of calories from fat (−2.2% vs. −1.1%; P = 0.69) and weight (−2.6 kg vs. −1.5 kg; P = 0.56). Compared with controls, participants in the intervention group had higher increases in plasma lutein (+20.4% vs. −11.5%; P < 0.01), and borderline significant increases in global DNA methylation (+0.8% vs. −0.5%; P = 0.06). Conclusions: The short-term ¡Cocinar Para Su Salud! program was effective at increasing long-term F/V intake in Hispanic breast cancer survivors and changed biomarkers associated with breast cancer recurrence risk. Impact: It is possible for short-term behavioral interventions to have long-term effects on behaviors and biomarkers in minority cancer patient populations. Results can inform future study designs. Cancer Epidemiol Biomarkers Prev; 25(11); 1491–502. ©2016 AACR.

¡Cocinar Para Su Salud! Development of a Culturally Based Nutrition Education Curriculum for Hispanic Breast Cancer Survivors Using a Theory-Driven Procedural Model

Objective To estimate the long‐term cost‐effectiveness of an obesity prevention nutrition education curriculum (Food, Health, & Choices) as delivered to all New York City fifth‐grade public school students over 1 year. Methods This study is a standard cost‐effectiveness analysis from a societal perspective, with a 3% discount rate and a no‐intervention comparator, as recommended by the US Panel on Cost‐effectiveness in Health and Medicine. Costs of implementation, administration, and future obesity‐related medical costs were included. Effectiveness was based on a cluster‐randomized, controlled trial in 20 public schools during the 2012–2013 school year and linked to published estimates of childhood‐to‐adulthood body mass index trajectories using a decision analytic model. Results The Food, Health, & Choices intervention was estimated to cost

Mediating Mechanisms of Theory-Based Psychosocial Determinants on Behavioral Changes in a Middle School Obesity Risk Reduction Curriculum Intervention, Choice, Control, and Change

8,537,900 and result in 289 fewer males and 350 fewer females becoming obese (0.8% of New York City fifth‐grade public school students), saving 1,599 quality‐adjusted life‐years (QALYs) and

Testing an Integrated Model of Program Implementation: the Food , Health & Choices School-Based Childhood Obesity Prevention Intervention Process Evaluation

8,098,600 in direct medical costs. Food, Health, & Choices is predicted to be cost‐effective at