Mediators and moderators of the effects of a school-based intervention on adolescents' fruit and vegetable consumption: the HEIA study

OBJECTIVE

To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status.

DESIGN

Cluster-randomised controlled trial.

SETTING

The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months).

PARTICIPANTS

Adolescents (11-13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375).

RESULTS

At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (β: -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths.

CONCLUSIONS

Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

Supporting families of children with overweight and obesity to live healthy lifestyles: Design and rationale for the Fitline cluster randomized controlled pediatric practice-based trial

BACKGROUND

Over a third of preadolescent children with overweight or obesity. The American Academy of Pediatrics (AAP) recommends pediatric providers help families make changes in eating and activity to improve body mass index (BMI). However, implementation is challenging given limited time and referral sources, and family burden to access in-person weight management programs.

PURPOSE

To describe the design of a National Heart Blood and Lung Institute sponsored cluster randomized controlled pediatric-based trial evaluating the effectiveness of the Fitline pediatric practice-based referral program to reduce BMI and improve diet and physical activity in children with overweight or obesity. Comparison will be made between brief provider intervention plus referral to (1) eight weekly nutritionist-delivered coaching calls with workbook to help families make AAP-recommended lifestyle changes (Fitline-Coaching), vs. (2) the same workbook in eight mailings without coaching (Fitline-Workbook).

METHODS

Twenty practices are pair-matched and randomized to one of the two conditions; 494 parents and their children ages 8-12 with a BMI of ≥85th percentile are being recruited. The primary outcome is child BMI; secondary outcomes are child's diet and physical activity at baseline and 6- and 12-months post-baseline. Cost-effectiveness of the two interventions also will be examined.

CONCLUSION

This is the first randomized controlled trial to examine use of a centrally located telephonic coaching service to support families of children with overweight and obesity in making AAP-recommended lifestyle changes. If effective, the Fitline program will provide an innovative model for widespread dissemination, setting new standards for weight management care in pediatric practice.

TRIAL REGISTRATION

The ClinicalTrials.gov registration number is NCT03143660.

Fruit and Vegetable Lesson Plan Pilot Intervention for Grade 5 Students from Southwestern Ontario

The purpose was to create and assess the impact of food literacy curriculum alongside a centrally procured school snack program among grade five students in Southwestern Ontario, Canada. Grade five students (N = 287) from five intervention and three controls schools participated in an 8-week food delivery program. In addition to the food delivery program, intervention schools received a resource kit and access to 42 multidisciplinary food literacy lesson plans using the produce delivered as part of the food delivery program. Participants completed matched pre- and post-test online surveys to assess fruit and vegetable intake, knowledge, preferences, and attitudes. Descriptive analyses and changes in scores between the intervention and control schools were assessed using one-way ANOVAs, paired samples t-tests, and McNemar’s tests. In total, there were 220 participants that completed both the pre- and post-test surveys. There was a significant improvement in fruit and vegetable intake (p = 0.038), yet no differences in knowledge of the recommended number of food group servings, knowledge of food groups, or fruit and vegetable preferences or attitudes were observed. Integrating nutrition lesson plans within core curricula classes (e.g., math, science, and literacy) can lead to modest increases in fruit and vegetable intake.

Garden-Based Integrated Intervention for Improving Children's Eating Behavior for Vegetables

This study was conducted to develop and verify the effects of a garden-based integrated intervention for improving children’s eating behavior for vegetables. A pre-post-test experimental design was employed. The participants were 202 elementary school students (average age: 11.6 ± 1.5 years). The garden-based integrated intervention program was conducted during regular school hours for a total of 12 weeks. The program, based on a mediator model for improving children’s eating behavior, included gardening, nutritional education, and cooking activities utilizing harvests. In order to examine effects of the program, the mediating factors related to children’s eating behavior were evaluated using pre-post questionnaires. As a result of the program, dietary self-efficacy, outcome expectancies, gardening knowledge, nutrition knowledge, vegetable preference, and vegetable consumption were significantly increased, and food neophobia was significantly decreased. In addition, there were positive correlations between most mediating factors. Thus, the garden-based integrated intervention developed in this study was effective in improving children’s eating behavior for vegetables.

Challenges and Facilitators to Promoting a Healthy Food Environment and Communicating Effectively with Parents to Improve Food Behaviors of School Children

Background Childhood obesity is a major public health concern and families play an important role. Improving strategies to reach parents and directing tailored nutrition education to them is needed. Purpose To investigate the challenges and facilitators to promoting a healthy environment at home and to identify communication preferences to inform intervention strategies for effectively reaching low-income urban minority families. Procedure Semi-structured focus group interviews were conducted with four groups involving 16 low-income urban parents (94% female; 88% Hispanic/Latino, 12% African American) of elementary school children. Interviews were transcribed and analyzed applying Social Cognitive Theory and using in-vivo coding. Main Findings The most common barriers to parents providing healthy foods to their children were accommodating child preferences and familial opposition. Parents showed intentionality to engage in healthy behaviors, and often shared procedural knowledge for reaching health goals. The analyses of desired communication channels yielded major preferences: tailored information, information provided through multiple mediums, appropriate duration/frequency of messages, and presented from a voice of authority. Conclusion and Implication While parents expressed desires to be healthy, the home food environment presented substantial challenges. Multi-media supports such as workshops, flyers, and text messaging may be useful to facilitate the sharing of information to minimize the tensions between intentionality and reaching desired goals to be healthy. Some parents thought that information received through text messaging could be easily shared and would act as a voice of authority to support child behavior change.

Testing a Web-Based Interactive Comic Tool to Decrease Obesity Risk Among Minority Preadolescents: Protocol for a Pilot Randomized Control Trial

Background

Childhood obesity is a public health crisis, particularly in low-income, minority populations in the United States. Innovative and technology-enhanced interventions may be an engaging approach to reach at-risk youth and their parents to improve dietary behaviors and feeding practices. However, such tools are limited, especially ones that are theory-based; co-developed with user-centered approaches; tailored to low-income, minority preadolescents; and include parent-focused content.

Objective

The objectives of this study include assessing the feasibility and acceptability and exploring the potential impact of the Intervention INC (Interactive Nutrition Comics for urban, minority preadolescents) Web-based tool, which is focused on decreasing childhood obesity risk in black/African American and Latino children aged 9 to 12 years.

Methods

Intervention INC is underpinned by the narrative transportation theory, social cognitive theory, and health belief model, and it was co-developed by children and parents from the intended population. The child component consists of a 6-chapter interactive nutrition comic optimized for use on tablet devices, a goal-setting and self-assessment feature, and weekly text/email messages and reminders. The parental component consists of 6 Web-based newsletters, access to the child comic, and weekly text/email messages and reminders. The tool was evaluated using a pilot, single-blind, 2-group randomized controlled study design. Child-parent dyads were randomized to either the experimental or comparison group and assigned to a targeted behavior (increase fruit/vegetable or water intake) based on initial screening questions. Data were collected at 4 time points: baseline (T1), intervention midpoint (T2), intervention endpoint (T3), and 3 months postintervention (T4). Primary measures comprise usage, usability, and feasibility of the Web-based tool. Secondary measures comprise dietary knowledge, preferences, and intake and anthropometric measures (for child) and feeding practices and home food environment (for parent).

Results

Study enrollment was completed in November 2017. A total of 89 child-parent dyads were randomized to either the experimental (n=44) or comparison (n=45) group. Data analysis is currently being conducted.

Conclusions

This study aims to implement and assess an innovative approach to deliver health messages and resources to at-risk minority preadolescents and their parents. If found to be acceptable, engaging, feasible, and a potential approach to improve dietary behaviors, a full-fledged randomized controlled trial will be conducted to assess its efficacy and potential impact.

Trial Registration

ClinicalTrials.gov NCT03165474; https://clinicaltrials.gov/ct2/show/NCT03165474 (Archived by WebCite at http://www.webcitation.org/73122IjgP)

International Registered Report Identifier (IRRID)

RR1-10.2196/10682

Pilot evaluation of HEAL - A natural experiment to promote obesity prevention behaviors among low-income pregnant women

Instituting interventions during the prenatal period is optimal for early obesity prevention in the child. Healthy Eating Active Living (HEAL) is a six-week, multi-component program to promote breastfeeding, healthy dietary habits, cooking skills and physical activity among Medicaid-eligible pregnant-women in Texas. HEAL is integrated into the healthcare system and offered as a standard-of-care for eligible patients.

METHODS

Preliminary evaluation of this natural experiment conducted from March 2015 through October 2016 informs the initial feasibility, acceptability and effects of the program on participant diet, home nutrition environment, physical activity, and breastfeeding self-efficacy and intentions measured using self-report surveys. Analysis of covariance (ANCOVA) was conducted to evaluate pre- and post-intervention changes, controlling for participants' ethnicity, age, and income level. Interaction effects of session attendance on the outcomes were further assessed.

RESULTS

Of the 329 women who enrolled in HEAL, 210 women completed the pre-post assessment (64% retention rate). Pre-to-post intervention, there were significant increases in availability and intake of fruits and vegetables, self-efficacy towards consuming more fruits and vegetables, and cooking frequency and skills (p < 0.05), and decreased frequency of eating heat and serve foods (p < 0.05). Significant improvements in physical activity, duration of breastfeeding, perceived benefits and intentions to breastfeed were also observed (p < 0.05). Higher attendance of HEAL sessions was associated with better outcomes. Process evaluation demonstrated 95% fidelity of program implementation.

CONCLUSION

HEAL operationalizes clinic-community linkages and shows promise in improving behaviors during pregnancy. Future research warrants the use of a stringent study design with a control group to determine program efficacy.

The role of perceived benefits and barriers in colorectal cancer screening in intervention trials among African Americans

The Health Belief Model (HBM) is widely used in health behavior interventions. The lack of diverse samples in the development of this theory warrants additional study on how it performs among minorities. While studies have utilized HBM to address colorectal cancer (CRC) screening, limited information exists confirming how these constructs influence screening. Data from three CRC screening trials were used to examine how perceived benefits/barriers perform among African Americans (AA) and whether they serve as mechanisms of the intervention effects on screening. The data were collected in AA churches (Study 1: N = 103; Study 2: N = 285; Study 3: N = 374) where lay members conducted CRC education to increase screening. Participants perceived benefits from colonoscopy (M = 2.4/3, SD = 0.87) and perceived few barriers (M = 0.63/8, SD = 1.1). Benefits were perceived for the fecal occult blood test (M = 11.4/15, SD = 2.1), and few barriers were reported (M = 11.7/30, SD = 3.4). Benefits more consistently predicted pre-intervention screening relative to barriers. For Study 3, individuals with fewer barriers reported a greater increase in colonoscopy screening at 12-months versus those with higher barriers (OR = 0.595, 95% CI = 0.368-0.964), P = 0.035). Benefits/barriers did not mediate the relationship. Potential measurement limitations, particularly for barriers, were uncovered and further research on how to assess factors preventing AA from screening is needed.

Fresh Fruit and Vegetable Program and Requests for Fruits and Vegetables Outside School Settings

BACKGROUND

Consumption of fruits and vegetables (F/V) among elementary school-aged children remains inadequate, especially among low-income children. The US Department of Agriculture's Fresh Fruit and Vegetable Program (FFVP) provides F/V as snacks to children during the school day, outside of school meals. School-based initiatives are successful in changing behaviors in school settings; however, their influence on behaviors outside of schools needs investigation.

OBJECTIVE

To examine whether FFVP participation is associated with F/V requests at stores, self-efficacy to ask for and choose F/V at home, and F/V consumption.

DESIGN

Cross-sectional study.

PARTICIPANT/SETTING

Fourth graders in six classrooms (n=296) from three urban, low-income school districts in Phoenix, AZ, were surveyed during 2015; one FFVP and one non-FFVP school from each district that were similar in school size, percent free/reduced-price meal eligibility, and race/ethnicity of enrolled students were selected.

MAIN OUTCOME MEASURES

Children's self-reported F/V requests during shopping, their self-efficacy to ask for and choose F/V at home, and F/V consumption on the previous day (non-FFVP school day) were measured using questions adapted from validated surveys.

STATISTICAL ANALYSIS

Multivariable mixed-effect regression models, adjusting for clustering of students within classes and classes within schools were explored.

RESULTS

In models adjusting for individual-level factors (ie, age and sex) only, several significant positive associations were observed between school FFVP participation and healthier F/V outcomes. After additionally adjusting for school-level factors (ie, total enrollment and % Hispanic/Latino students) significant associations were observed between school FFVP participation and more requests for vegetables during shopping (P<0.001), higher scores on self-efficacy to choose vegetables at home (P=0.004), stronger preferences for vegetables (P<0.001), and more frequent consumption of fruit (P=0.006).

CONCLUSIONS

School FFVP participation was associated with more requests for vegetables during shopping and higher self-efficacy to make healthy choices at home, suggesting the influence of the FFVP may extend beyond the school day.

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

BACKGROUND

A limited number of school-based intervention studies have explored mediating mechanisms of theory-based psychosocial variables on obesity risk behavior changes. The current study investigated how theory-based psychosocial determinants mediated changes in energy balance-related behaviors (EBRBs) among urban youth.

METHODS

A secondary analysis study was conducted using data from a cluster randomized controlled trial. Data from students at 10 middle schools in New York City (n = 1136) were used. The intervention, Choice, Control, and Change curriculum, was based on social cognitive and self-determination theories. Theory-based psychosocial determinants (goal intention, cognitive outcome expectations, affective outcome expectations, self-efficacy, perceived barriers, and autonomous motivation) and EBRBs were measured with self-report questionnaires. Mediation mechanisms were examined using structural equation modeling, Results: Mediating mechanisms for daily sugar-sweetened beverage (SSB) consumption and purposeful stair climbing were identified. Models with best fit indices (root mean square error of approximation = 0.039/0.045, normed fit index = 0.916/0.882; comparative fit index = 0.945/0.932; Tucker-Lewis index = 0.896/0.882, respectively) suggested that goal intention and reduced perceived barriers were significant proximal mediators for reducing SSB consumption among both boys and girls or increasing physical activity by stair climbing among boys. Cognitive outcome expectations, affective outcome expectations, self-efficacy, and autonomous motivation indirectly mediated behavioral changes through goal intention or perceived barriers (p < 0.05 to p < 0.001). The final models explained 25%-27% of behavioral outcome variances.

CONCLUSIONS

Theory-based psychosocial determinants targeted in Choice, Control, and Change in fact mediated behavior changes in middle school students. Strategies targeting these mediators might benefit future success of behavioral interventions. Further studies are needed to determine other potential mediators of EBRBs in youth.

Characteristics of the home food environment that mediate immediate and sustained increases in child fruit and vegetable consumption: mediation analysis from the Healthy Habits cluster randomised controlled trial

Background

The home food environment can influence the development of dietary behaviours in children, and interventions that modify characteristics of the home food environment have been shown to increase children’s fruit and vegetable consumption. However to date, interventions to increase children’s fruit and vegetable consumption have generally produced only modest effects. Mediation analysis can help in the design of more efficient and effective interventions by identifying the mechanisms through which interventions have an effect. This study aimed to identify characteristics of the home food environment that mediated immediate and sustained increases in children’s fruit and vegetable consumption following the 4-week Healthy Habits telephone-based parent intervention.

Method

Analysis was conducted using 2-month (immediate) and 12-month (sustained) follow-up data from a cluster randomised control trial of a home food environment intervention to increase the fruit and vegetable consumption of preschool children. Using recursive path analysis, a series of mediation models were created to investigate the direct and indirect effects of immediate and sustained changes to characteristics of the home food environment (fruit and vegetable availability, accessibility, parent intake, parent providing behaviour, role-modelling, mealtime eating practices, child feeding strategies, and pressure to eat), on the change in children’s fruit and vegetable consumption.

Results

Of the 394 participants in the randomised trial, 357 and 329 completed the 2- and 12-month follow-up respectively. The final mediation model suggests that the effect of the intervention on the children’s fruit and vegetable consumption was mediated by parent fruit and vegetable intake and parent provision of these foods at both 2- and 12-month follow-up.

Conclusion

Analysis of data from the Healthy Habits trial suggests that two environmental variables (parental intake and parent providing) mediate the immediate and sustained effect of the intervention, and it is recommended these variables be targeted in subsequent home food environment interventions to bring about immediate and sustained changes in child fruit and vegetable intake.

Trial registration

ACTRN12609000820202.

Preschool children's self-reports of fruit and vegetable knowledge, preference, and messages encouraging consumption

BACKGROUND

Fruit and vegetable consumption (FVC) is associated with a reduced risk of diabetes, obesity, cancer, and cardiovascular disease. Only one third of children aged 4-8years consume the recommended 5 servings a day. Studies involving school-aged children (6-11 years) demonstrate that positive outcome expectancies can mediate FVC. There is a lack of similar studies involving preschool-aged (<5 years) children. The purpose of this study was to assess preschool children's knowledge and preference of fruits and vegetables, messages they recall hearing related to FVC, and how they perceive these messages.

METHODS

Children (N = 192) were individually interviewed with a play-based picture card game followed by a mealtime environment reenactment open-ended interview. Fruit and vegetable messages were operationalized using Social Cognitive Theory (SCT). Descriptive statistics and associations are reported.

RESULTS

Each child recalled an average of 2.27 messages associated with FVC. Positive outcome expectancies, negative outcome expectancies, and prompts were most frequently recalled. Statistically significant differences in knowledge, preference, and messages were observed based on income.

CONCLUSIONS

Children as young as age 4 years understand positive outcome expectancies. Experimental trials are warranted to determine if tailored expectancy messages mediate FVC among preschool children.

Mediators of improved child diet quality following a health promotion intervention: the Melbourne InFANT Program

BACKGROUND

Young children's diets are currently suboptimal. Given that mothers have a critical influence on children' diets, they are typically a target of interventions to improve early childhood nutrition. Understanding the maternal factors which mediate an intervention's effect on young children's diets is important, but has not been well investigated. This research aimed to test whether maternal feeding knowledge, maternal feeding practices, maternal self-efficacy, and maternal dietary intakes acted as mediators of the effect of an intervention to improve child diet quality.

METHODS

The Melbourne Infant Feeding Activity and Nutrition Trial (InFANT) Program was a cluster-randomized controlled trial, conducted from 2008-2010. This novel, low-dose, health promotion intervention was delivered quarterly over 15 months and involved educational activities, promotion of peer discussion, a DVD and written materials. Post-intervention, when children were approximately 18 months of age, child diets were assessed using multiple 24-hour recalls and a purpose-developed index of diet quality, the Obesity Protective Dietary Index. Maternal mediators were assessed using a combination of previously validated and purpose-deigned tools. Mediation analysis was conducted using the test of joint significance and difference of coefficients methods.

RESULTS

Across 62 parents' groups in Melbourne, Australia, 542 parents were recruited. Post- intervention, higher maternal feeding knowledge and lower use of foods as rewards was found to mediate the direct intervention effect on child diet quality. While other aspects of maternal feeding practices, self-efficacy and dietary intakes did not act as mediators, they were associated with child diet quality.

CONCLUSIONS

Mediation analysis of this novel health promotion intervention showed the importance of maternal feeding knowledge and use of foods as rewards in impacting child diet quality. The other maternal factors assessed were appropriate targets but further research on how to impact these in an intervention is important. This evidence of intervention efficacy and mediation provides important insights for planning future interventions.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81847050, registered 23 November 2007.

The PRO GREENS intervention in Finnish schoolchildren - the degree of implementation affects both mediators and the intake of fruits and vegetables

Little is known about the mediating effects of the determinants of fruit and vegetable (FV) intake in school-based interventions that promote FV intake, and few studies have examined the impact of the degree of implementation on the effects of an intervention. The present study examined whether the degree of implementation of an intervention had an effect on children's fruit or vegetable intake and determined possible mediators of this effect. The study is part of the European PRO GREENS intervention study which aimed to develop effective strategies to promote consumption of fruit and vegetables in schoolchildren across Europe. Data from 727 Finnish children aged 11 years were used. The baseline study was conducted in spring 2009 and the follow-up study 12 months later. The intervention was conducted during the school year 2009-2010. The effects were examined using multilevel mediation analyses. A high degree of implementation of the intervention had an effect on children's fruit intake. Knowledge of recommendations for FV intake and liking mediated the association between a high degree of implementation of the intervention and an increase in the frequency of fruit intake. Knowledge of recommendations for FV intake and bringing fruits to school as a snack mediated the association between a low degree of implementation of the intervention and an increase in the frequency of fruit intake. Overall, the model accounted for 34 % of the variance in the change in fruit intake frequency. Knowledge of recommendations acted as a mediator between the degree of implementation of the intervention and the change in vegetable intake frequency. In conclusion, the degree of implementation had an effect on fruit intake, and thus in future intervention studies the actual degree of implementation of interventions should be assessed when considering the effects of interventions.

Psychosocial measures used to assess the effectiveness of school-based nutrition education programs: review and analysis of self-report instruments for children 8 to 12 years old

OBJECTIVE

To identify the psychometric properties of evaluation instruments that measure mediators of dietary behaviors in school-aged children.

DESIGN

Systematic search of scientific databases limited to 1999-2010.

MAIN OUTCOME MEASURES

Psychometric properties related to development and testing of self-report instruments for children 8-12 years old.

ANALYSIS

Systematic search of 189 articles and review of 15 instruments (20 associated articles) meeting the inclusion criteria. Search terms used included children, school, nutrition, diet, nutrition education, and evaluation.

RESULTS

Fourteen studies used a theoretical framework to guide the instrument's development. Knowledge and self-efficacy were the most commonly used psychosocial measures. Twelve instruments focused on specific nutrition-related behaviors. Eight instruments included over 40 items and used age-appropriate response formats. Acceptable reliability properties were most commonly reported for attitude and self-efficacy measures. Although most of the instruments were reviewed by experts (n = 8) and/or pilot-tested (n = 9), only 7 were tested using both rigorous types of validity and with low-income youth.

CONCLUSIONS AND IMPLICATIONS

Results from this review suggest that additional research is needed to develop more robust psychosocial measures for dietary behaviors, for low-income youth audiences.

Energy underreporting in African-American girls: a longitudinal analysis

BACKGROUND

The objective of this study was to determine the longitudinal prevalence and predictors of dietary underreporting in African-American preadolescent girls and the association of baseline dietary underreporting with changes in BMI over a 2-year period as part of the Girls health Enrichment Multi-site Studies (GEMS).

METHODS

Energy was summarized at baseline, 12 months, and 24 months and computed as a 3-day average of 24-hour dietary recalls. Physical activity was assessed by accelerometer, basal metabolic rate was estimated using the World Health Organization's prediction equation, and caloric underreporting was based on the Goldberg equation.

RESULTS

We classified 48% of the girls at baseline as underreporters; with underreporting increasing over time (61% at 12 months; 66% at 24 months). Intervention treatment assignment did not affect the prevalence of underreporting over time. The consistency of underreporting (or not) stayed stable over time. Across all three time points, a higher BMI predicted underreporting. Baseline dietary underreporting and baseline BMI were found to be the major predictors of change in BMI, whereas baseline dietary variables did not predict change in BMI.

CONCLUSIONS

Dietary underreporting was extremely common in this sample of AA preadolescent girls and predictive of change in BMI. Given the magnitude and consistency of dietary underreporting along with the fact that no dietary variables predicted change in BMI, measurement of dietary intake in preadolescents, even with sophisticated measurement methodologies, appears biased. The best use of dietary recalls may not be to estimate dietary intake but rather to determine underreporting.

Efficacy of the I Can Control Asthma and Nutrition Now (ICAN) pilot program on health outcomes in high school students with asthma

Asthma is the most prevalent chronic illness in childhood affecting 7 million youth. Many youth with asthma face another risk factor in obesity. Obesity, in turn, increases disorders such as asthma. Studies have recommended that asthma programs also address weight management in youth. Taking this into consideration, the I Can Control Asthma and Nutrition Now (ICAN) program is an innovative school-based program composed of (1) nutrition and weight management education, (2) asthma education, and (3) monthly reenforcement visits. This pilot study tested the initial effectiveness of the ICAN pilot program on a variety of asthma and nutrition outcomes in 25 urban minority students with asthma. Over the course of the pilot program, significant increases in asthma knowledge, asthma self-efficacy, asthma quality of life, asthma self-care, nutrition knowledge, nutrition self-efficacy, and asthma control were observed. The ICAN program has demonstrated promising preliminary results in improving nutrition and asthma health outcomes with urban minority high school students.

LA Sprouts: a garden-based nutrition intervention pilot program influences motivation and preferences for fruits and vegetables in Latino youth

Garden-based approaches to nutrition education may be effective for improving nutrition habits in adolescents. A quasi-experimental, garden-based intervention for Latino youth (LA Sprouts) was piloted and assessed for its influence on behavior associated with dietary intake and psychosocial factors. Study participants were 104 predominately Latino fourth and fifth grade students in Los Angeles (mean age, 9.8±0.7 years; n=70 control subjects, n=34 LA Sprouts participants); more than half (n=61, 59.8%) were overweight or obese (body mass index ≥85th percentile). LA Sprouts participants received an intervention of weekly 90-minute culturally tailored, interactive classes for 12 consecutive weeks at a community garden during the spring of 2010; control participants received an abbreviated delayed intervention. Questionnaire data were obtained before and after the intervention. Compared with control subjects, LA Sprouts participants had an increased preference for vegetables overall, increased preferences for three target fruits and vegetables, as well as improved perceptions that "vegetables from the garden taste better than vegetables from the store." In the overweight/obese subgroup (n=61), LA Sprouts participants had a 16% greater increase in their preference for vegetables compared with control subjects (P=0.009). Results from this pilot study suggest that a cooking, nutrition, and gardening after-school program in a garden-based setting can improve attitudes and preferences for fruits and vegetables in Latino youth, which may lead to improved nutritional habits and dietary intake and reduced health disparities.

Pilot intervention to increase physical activity among sedentary urban middle school girls: a two-group pretest-posttest quasi-experimental design

The primary purpose of the study was to determine whether girls in one school receiving nurse counseling plus an after-school physical activity club showed greater improvement in physical activity, cardiovascular fitness, and body composition than girls assigned to an attention control condition in another school (N = 69). Linear regressions controlling for baseline measures showed no statistically significant group differences, but the directionality of differences was consistent with greater intervention group improvement for minutes of moderate to vigorous physical activity/hour (t = 0.95, p = .35), cardiovascular fitness (t = 1.26, p = .22), body mass index (BMI; t = -1.47, p = .15), BMI z score (t = -1.19, p = .24), BMI percentile (t = -0.59, p = .56), percentage body fat (t = -0.86, p = .39), and waist circumference (t = -0.19, p = .85). Findings support testing with a larger sample.

Development and evaluation of social cognitive measures related to adolescent dietary behaviors

Background

This study aimed to develop and evaluate the reliability and factorial validity, of social-cognitive measures related to adolescent healthy eating behaviors.

Methods

A questionnaire was developed based on constructs from Bandura’s Social Cognitive Theory and included the following scales: self-efficacy, intentions (proximal goals), situation (perceived environment), social support, behavioral strategies, outcome expectations and expectancies. The questionnaire was administered with a two week test-retest among secondary school students (n = 173, age = 13.72 ± 1.24). Confirmatory factor analysis was employed to examine model-fit for each scale using multiple indices including: chi-square index, comparative-fit index (CFI), goodness-of-fit index (GFI), and the root mean square error of approximation (RMSEA). Reliability properties were also examined (ICC and Cronbach’s alpha).

Results

The reliability and factorial validity of each scale is supported: fit indices suggest each model to be an adequate-to-exact fit to the data; internal consistency was acceptable-to-good (α=0.65−0.79); rank order repeatability was strong (ICC = 0.81−0.89).

Conclusions and implications

Results support the reliability and factorial validity of social cognitive scales relating to healthy eating behaviors among adolescents. As such, the developed scales have utility for identifying potential social cognitive correlates of adolescent dietary behavior, mediators of dietary behavior change and validity testing of theoretical models based on Social Cognitive Theory.

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.

What works in school-based energy balance behaviour interventions and what does not? A systematic review of mediating mechanisms

OBJECTIVE

Obesity prevention requires effective interventions targeting the so-called energy balance-related behaviours (that is, physical activity, sedentary and dietary behaviours). To improve (cost-)effectiveness of these interventions, one needs to know the working mechanisms underlying behavioural change. Mediation analyses evaluates whether an intervention works via hypothesised working mechanisms. Identifying mediators can prompt intervention developers to strengthen effective intervention components and remove/adapt ineffective components. This systematic review aims to identify psychosocial and environmental mediators of energy balance-related behaviours interventions for youth.

METHOD

Studies were identified by a systematic search of electronic databases (PubMed, Embase, PsycINFO, ERIC and SPORTDiscus). Studies were included if they (1) were school-based randomised controlled or quasi-experimental studies; (2) targeted energy balance behaviours; (3) conducted among children and adolescents (4-18 years of age); (4) written in English; and (5) conducted mediation analyses.

RESULTS

A total of 24 studies were included. We found strong evidence for self-efficacy and moderate evidence for intention as mediators of physical activity interventions. Indications were found for attitude, knowledge and habit strength to be mediators of dietary behaviour interventions. The few sedentary behaviour interventions reporting on mediating effects prevented us from forming strong conclusions regarding mediators of sedentary behaviour interventions. The majority of interventions failed to significantly change hypothesised mediators because of ineffective intervention strategies, low power and/or use of insensitive measures.

CONCLUSION

Despite its importance, few studies published results of mediation analysis, and more high-quality research into relevant mediators is necessary. On the basis of the limited number of published studies, self-efficacy and intention appear to be relevant mediators for physical activity interventions. Future intervention developers are advised to provide information on the theoretical base of their intervention including the strategies applied to provide insight into which strategies are effective in changing relevant mediators. In addition, future research is advised to focus on the development, validity, reliability and sensitivity of mediator measures.

Dietary self-monitoring and its impact on weight loss in overweight children

OBJECTIVE

To examine whether dietary self-monitoring is related to weight loss in overweight children and whether perceived social support or dietary self-efficacy affects this relation. Design. Longitudinal, behavioral intervention study.

SUBJECTS

The study population included 153 children, aged 7-12 years, with daily food records from a 20-week weight loss program in San Diego, California, USA, conducted between 1999 and 2002. Methods. Self-monitoring was assessed using two methods: a weekly index as a measure of competency (possible range -7 to +35) and recording sufficiency for total compliance (percentage of days).

RESULTS

Significantly greater decreases in percentage overweight were found for children with recording competency at or above the median (mean change: -13.4% vs. -8.6%; p < 0.001) or who were compliant in recording -50% of the days (mean change: -13.0% vs. ?8.4%; p < 0.001). Using hierarchical linear regression, children who had a higher average weekly monitoring index or recorded sufficiently on more days had significantly greater decreases in percent overweight, after adjusting for age, sex, SES, race/ethnicity and baseline percent overweight (p < 0.001). Perceived social support at baseline and dietary self-efficacy were not related to self-monitoring or change in percent overweight in this sample.

CONCLUSION

As has been demonstrated with adults and adolescents, self-monitoring in children was associated with greater decreases in percent overweight. However, dietary self-efficacy and perceived social support were not related to how frequently or thoroughly they monitored dietary intake.

The Power Play! Campaign's School Idea & Resource Kits improve determinants of fruit and vegetable intake and physical activity among fourth- and fifth-grade children

OBJECTIVE

Examine the effect of the California Children's Power Play! Campaign's School Idea & Resource Kits for fourth/fifth grades on the psychosocial determinants of fruit and vegetable (FV) intake and physical activity (PA).

METHODS

Randomized, controlled trial (n = 31 low-resource public schools; 1,154 children). Ten grade-specific, 50-minute nutrition and PA lessons over an 8-week period. Pre/post surveys measuring knowledge, outcome expectations, and self-efficacy (SE) were analyzed using analysis of covariance, controlling for baseline values; chi-square comparing positive/negative changes, adjusted for cluster design effects.

RESULTS

Intervention children made significant gains for FV knowledge (4 items, P < .05 to P < .001); positive outcome expectations (fifth grade only, P < .001); asking/shopping and eating SE (P = .04 and P < .001); PA knowledge (2 items, P < .01 to P < .001); outcome expectations (P < .05); and support seeking SE (P = .04); but not SE to overcome barriers.

CONCLUSIONS AND IMPLICATIONS

The Power Play! Campaign's School Idea & Resource Kits improved the determinants of FV intake and PA.

Effect of fresh fruit availability at worksites on the fruit and vegetable consumption of low-wage employees

OBJECTIVE

To examine the impact of fresh fruit availability at worksites on the fruit and vegetable consumption and related psychosocial determinants of low-wage employees.

DESIGN

A prospective, randomized block experimental design.

SETTING

Seven apparel manufacturing and 2 food processing worksites.

PARTICIPANTS

A convenience sample of 391 low-wage employees in 6 intervention worksites and 137 low-wage employees in 3 control worksites in Los Angeles, CA.

INTERVENTION

Fresh fruit deliveries with enough for 1 serving per employee, 3 days a week for 12 consecutive weeks. The control worksites did not receive the fruit deliveries.

MAIN OUTCOME MEASURES

Participants' fruit and vegetable consumption, fruit and vegetable purchasing habits, self-efficacy, job satisfaction, and overall health were measured at baseline, weeks 4 and 8, and following the 12-week intervention.

ANALYSIS

Descriptive statistics and growth curve analysis using hierarchical linear modeling were employed to analyze the data.

RESULTS

Participants in the intervention worksites showed a significant increase in fruit, vegetable, and total fruit and vegetable consumption, purchasing of fruit, family purchasing of vegetables, and self-efficacy toward eating 2 servings of fruit each day compared to the control worksites.

CONCLUSIONS AND IMPLICATIONS

Improving access to fruit during the workday can improve fruit and vegetable consumption, purchasing habits, and self-efficacy of low-income employees.

Family influence: key to fruit and vegetable consumption among fourth- and fifth-grade students

OBJECTIVE

To assess social and familial environmental influences on fruit and vegetable (FV) consumption of fourth- and fifth-graders living in a culturally diverse, urban setting.

DESIGN

In 2006, students from 9 fourth- and fifth-grade classrooms from a public school in the Washington-Baltimore Metropolitan Region were recruited as part of the Food Stamp Nutrition Education's initiative to increase FV consumption among school-aged children in low-income schools. This intervention was conducted in partnership with the school.

PARTICIPANTS

Ninety-three fourth- and fifth-grade students and their parents.

MAIN OUTCOME MEASURE

The average daily FV consumption of elementary school students was the dependent variable. Home engagement (eg, student participation in menu planning and food selection at home), parental modeling, school environment, peer influences, and individual characteristics were the independent variables.

ANALYSIS

Multiple regression analysis.

RESULTS

Family and home environment factors explained more than 50% of the variance in students' FV consumption.

CONCLUSIONS AND IMPLICATIONS

Interventions designed to influence school-aged children's FV consumption should target family members and consider incorporating strategies to reach families and promote meal planning activities with the children in their homes.

Exploring the mechanisms of physical activity and dietary behavior change in the program x intervention for adolescents

PURPOSE

The objective of this investigation was to examine the mechanisms of physical activity and dietary behavior change in the Program X intervention.

METHODS

Program X involved a clustered randomized controlled design with six schools (N=124 participants, mean age=14.1+/-0.8 years) randomized to intervention or control conditions for the 6-month study period. Physical activity and fruit and vegetable consumption were assessed using pedometers and questionnaires, respectively. The theoretical framework of the intervention was assessed using structural equation modeling, mediation, and moderation analyses.

RESULTS

The model explained 56% of the variance in physical activity at 6-months, but did not represent a good fit to the data, chi(2)=87.43, df=19, p < .001. The model explaining fruit and vegetable consumption explained 31% of the variance and provided a good fit to the data, chi(2)=12.40, df=10, p=.259. None of the variables satisfied the criteria for mediation or moderation in the physical activity model, but gender moderated the effects of intervention on fruit and vegetable consumption.

CONCLUSIONS

None of the hypothesized mediators were responsible for behavior change in the Program X intervention. Future studies should address the limitations of existing psychosocial scales and continue to explore the mechanisms of behavior change using model testing, mediation, and moderation analyses.

Youth proxy efficacy for fruit and vegetable availability varies by gender and socio-economic status

OBJECTIVE

The current study examined proxy efficacy, which was defined as youth's confidence to influence their parents to provide fruits and vegetables. The overall objective was to examine change in middle-school youth's proxy efficacy over time, and to determine if changes were moderated by gender and socio-economic status.

DESIGN

Longitudinal cohort nested within schools.

SETTING

Eight middle schools located in urban, suburban and rural areas of a mid-western US state.

SUBJECTS

Seven hundred and twelve youth followed across their 6th, 7th and 8th grade years. The sample was 51.8 % female, 30.5 % low socio-economic status and 89.5 % Caucasian, non-Hispanic.

RESULTS

Males and lower socio-economic status youth were significantly lower in proxy efficacy at each assessment year compared with females and high socio-economic youth, respectively.

CONCLUSIONS

Proxy efficacy to influence parents to provide fruits and vegetables may be an important construct to target in future interventions.

Examining elementary school--aged children's self-efficacy and proxy efficacy for fruit and vegetable consumption

Children's self-efficacy for fruit and vegetable consumption (FVC) and proxy efficacy to influence others to make fruit and vegetables (FV) available may influence their FVC. A previous investigation has demonstrated that self-efficacy for fruit consumption, self-efficacy for vegetable consumption, proxy efficacy to influence parents to make FV available, and proxy efficacy to influence after-school staff to make FV available can be measured with four independent but related scales. The purpose of the present investigation is to confirm this factor structure and determine if the scales were invariant across gender, ethnicity, and socioeconomic status (SES) subgroups of children attending after-school programs. Results provide further validity evidence for the four correlated scales. In addition, results confirm measurement invariance across gender, SES, and ethnicity, confirming the unbiased generalizability of the current measure to these demographic groups. Lastly, tests of population heterogeneity reveal no meaningful differences in self- and proxy efficacy among gender, SES, and ethnicity subgroups.

Testing theories of dietary behavior change in youth using the mediating variable model with intervention programs

OBJECTIVE

To review and critique current experimentally-based evidence of theoretical mechanisms of dietary behavior change in youth and provide recommendations on ways to enhance theory evaluation.

METHODS

Interventions that examined mediators of dietary behavior change in youth (age 5-18 years) were identified via electronic database searches and reference scanning. Selected studies were reviewed for quality and content and findings were tabulated.

RESULTS

Seven published interventions were found. All were school-based but differed substantially in dietary outcome, target population, measures, methods of mediation analyses, and theoretical framework. Interventions were relatively unsuccessful in changing mediators. Self-efficacy and outcome expectations were the mechanisms most consistently associated with dietary behavior change. However, only outcome expectancies were identified as mediators in multiple interventions.

CONCLUSIONS AND IMPLICATIONS

Few interventions have assessed the validity of theoretical mechanisms of dietary behavior change in youth. The variability in the design and target populations across studies makes it impossible to draw conclusions regarding the validity of theories and mediators of dietary behavior change in youth. Future intervention trials need to focus on the identification of effective procedures for mediator change and adopt a more rigorous and systematic approach to theory testing. This is likely to result in more effective interventions.

Measurement characteristics of dietary psychosocial scales in a Weight Gain Prevention Study with 8- to 10-year-old African-American girls

Few measurement instruments for children's eating behaviors and beliefs have been specifically validated for African-American children. Validation within this population is important because of potential cultural and ethnic influences. Objectives were to evaluate established and newly developed or adapted dietary psychosocial measures in a sample of 303 preadolescent African-American girls and their caregivers. Acceptable internal consistency (Cronbach's alpha > or = 0.70) was found for measures of girls' self-efficacy for healthy eating, outcome expectancies for healthy eating, positive family support for healthy eating and household availability of low-fat food and fruit, juice and vegetables (FJV). Evidence for concurrent validity was found with significant associations between self-efficacy for healthy eating and lower intake of energy (r = -0.17) and fat grams (r = -0.16). Greater FJV availability was associated with greater FJV intake (r = 0.14) and lower body mass index (BMI) in girls (r = -0.12). Positive family support for healthy eating was associated with higher BMI in girls (r = 0.41). These results contribute to the development of scales to evaluate prevention interventions related to dietary intake in African-American children.

Mediating variables in a transtheoretical model dietary intervention program

This study identified mediators of a Transtheoretical Model (TTM) intervention to increase fruit and vegetable consumption among economically disadvantaged African American adolescents (N = 549). Single-and multiple-mediator models were used to determine whether pros, cons, self-efficacy, and stages of change satisfied four conclusions necessary for establishing mediation of intervention effects on youths' dietary behavior. All four conclusions were satisfied for stages of change and pros in the single-mediator models and for stages in the multiple-mediator model. Stages mediated 31% of the intervention effect, and pros mediated 7% of the intervention effect in the single-mediator models. In the multiple-mediator model, stages accounted for 72% of the intervention effect. Findings add to the limited data on mediating variables in TTM dietary intervention programs. Replication studies are needed before it can be concluded that stages of change and pros are consistent mediators of TTM intervention program effects.

Longitudinal and cross-sectional influences on youth fruit and vegetable consumption

Both cross-sectional and longitudinal research depict a decline in the fruit and vegetable consumption (FVC) of children and youths with age, but identifying developmental changes and their influences with regard to FVC cannot be fully explained with application of only one of these research designs. Reviewed here are results from longitudinal and cross-sectional research, and a proposal is presented for a lifespan development methodology that uses a sequential design strategy to illuminate the multilevel processes that determine FVC. Conclusions from the review were similar for both cross-sectional and longitudinal research, with fruit and vegetable (FV) preferences and FV accessibility/availability being the most consistent influences on FVC. Furthermore, this review illuminates several methodological issues, offering suggestions to strengthen comparisons between studies. Research designs that incorporate longitudinal, cross-sectional, and time-lag data are warranted.

The mediational role of identification in the relationship between experience mode and self-efficacy: Enactive role-playing versus passive observation

Abstract Based on Social Cognitive Theory, this study proposes a new concept-mediated enactive experience to understand game playing effects on self-efficacy in the context of a health promotion role-playing game. An experiment demonstrated that a mediated enactive experience afforded by game playing was more effective than a mediated observational experience provided by game watching in influencing self-efficacy. It was found that identification with the game character partially mediated the relationship between experience mode and self-efficacy.

Design and evaluation of a computer game to promote a healthy diet for young adults

This article reports the development and evaluation of a computer game (RightWay Café) as a special medium to promote a healthy diet for young adults. Structural features of computer games, such as interactive tailoring, role playing, the element of fun, and narrative, were operationalized in the RightWay Café game to afford behavior rehearsal in a safe and entertaining way. Theories such as the health belief model, social cognitive theory, and theory of reasoned action guided the content design of the game to influence mediators of behavior change, including self-efficacy, perceived benefits, perceived barriers, and behavior change intention. A randomized controlled evaluation study with pretest, posttest, and follow-up design demonstrated that this game was effective in teaching nutrition and weight management knowledge and increasing people's self-efficacy and perceived benefits of healthy eating, as well as their intention to be on a healthy diet. Limited long-term effects were also found: participants in the game-playing group had greater self-efficacy than participants in the control group after 1 month. This study validates the computer game-based approach to health promotion for young adults. Limitations and implications are also discussed.

Measuring children's self-efficacy and proxy efficacy related to fruit and vegetable consumption

BACKGROUND

Social cognitive theory describes self-efficacy and proxy efficacy as influences on fruit and vegetable consumption (FVC). Proxy efficacy was defined as a child's confidence in his or her skills and abilities to get others to act in one's interests to provide fruit and vegetable (FV) opportunities. The purpose of this study was to develop a scale assessing children's self-efficacy and proxy efficacy for FVC at after-school programs and at home.

METHODS

Elementary-aged children (n = 184) attending 7 after-school programs completed a self-efficacy questionnaire relevant to FVC. Questionnaire validity was investigated with exploratory factor analysis and mixed-model analysis of covariance. Internal consistency reliability and readability were also assessed.

RESULTS

The questionnaire assessed 4 constructs: self-efficacy expectations for fruit consumption, self-efficacy expectations for vegetable consumption, proxy efficacy to influence parents to make FV available, and proxy efficacy to influence after-school staff to make FV available. Children perceiving FV opportunities in after-school had greater self-efficacy expectations for FVC and greater proxy efficacy to influence after-school staff compared to students who did not perceive FV opportunities. Children attending schools of higher socioeconomic status (SES) and less diversity were more confident they could influence their parents to make FV available than students attending lower SES and less diverse schools. Adequate internal consistency and test-retest reliabilities were established.

CONCLUSIONS

Self-efficacy is a multicomponent construct that can be assessed in children using the reliable and valid instrument evaluated by the current study.

Psychosocial predictors of fruit and vegetable consumption in adults a review of the literature

BACKGROUND

Adequate fruit and vegetable intake has been found to promote health and reduce the risk of several cancers and chronic diseases. Understanding the psychological determinants of fruit and vegetable intake is needed to design effective intervention programs.

METHODS

Papers published in English from 1994 to 2006 that described the relationship between psychosocial predictors and fruit and vegetable intake in adults were reviewed. Studies and their constructs were independently rated based on the direction of significant effects, quality of execution, design suitability, and frequency. Methodology from the Guide to Community Preventive Services was used to systematically review and synthesize findings.

RESULTS

Twenty-five psychosocial constructs spanning 35 studies were reviewed (14 prospective and 21 cross-sectional/descriptive studies). Strong evidence was found for self-efficacy, social support, and knowledge as predictors of adult fruit and vegetable intake. Weaker evidence was found for variables including barriers, intentions, attitudes/beliefs, stages of change, and autonomous motivation.

CONCLUSIONS

The findings underscore the need to design future behavioral interventions that use strong experimental designs with efficacious constructs and to conduct formal mediation analyses to determine the strength of these potential predictors of fruit and vegetable intake.

Prevalence and characteristics of energy underreporting in African-American girls

OBJECTIVE

To determine the frequency and characteristics of energy intake underreporting in African-American preadolescent girls as part of the Girls health Enrichment Multi-site Studies (GEMS).

METHODS AND PROCEDURES

Energy intake was summarized using the Nutrition Data System for Research software and computed as a 3-day average of 24-h dietary recalls. Physical activity was assessed by an accelerometer, basal metabolic rate (BMR) was estimated using the World Health Organization's prediction equation, and underreporting of caloric intake was based on the Goldberg equation.

RESULTS

Using a conservative criterion for determining energy underreporting, we classified 54.8% of the girls as underreporters; 45.2% were classified as plausible reporters. Factors related to underreporting included higher BMI (beta = -0.506, P < or = 0.001), older age (beta = -0.159, P = 0.001), greater unhealthy eating behaviors (beta = -0.118, P = 0.025), and higher self-efficacy for diet (beta = -0.098, P = 0.033).

DISCUSSION

Underreporting of dietary intake, specifically energy, is common in African-American preadolescent girls and can be partially explained by weight status and psychosocial variables. The extent of dietary underreporting in specific and high-risk populations is largely unknown and could be evaluated by routinely including a report of such an index in future research studies.

Healthy youth places: a randomized controlled trial to determine the effectiveness of facilitating adult and youth leaders to promote physical activity and fruit and vegetable consumption in middle schools

The Healthy Youth Places (HYP) intervention targeted increased fruit and vegetable consumption (FV) and physical activity (PA) through building the environmental change skills and efficacy of adults and youth. HYP included group training for adult school site leaders, environmental change skill curriculum, and youth-led FV and PA environment change teams. Sixteen schools were randomized to either implement the HYP program or not. Participants (N =1,582) were assessed on FV and PA and hypothesized HYP program mediators (e.g., proxy efficacy) at the end of sixth grade (baseline), seventh grade (Postintervention Year 1), and eighth grade (Postintervention Year 2). After intervention, HYP schools did not change in FV but did significantly change in PA compared to control schools. Proxy efficacy to influence school PA environments mediated the program effects. Building the skills and efficacy of adults and youth to lead school environmental change may be an effective method to promote youth PA.

Memphis Girls health Enrichment Multi-site Studies (GEMS)

Obesity prevalence is increasing in the U.S., especially among children and minority populations. This report describes the design and baseline data of the ongoing Girls health Enrichment Multi-site Studies (GEMS) trial (Memphis site), which is testing the efficacy of a 2-year family-based intervention to reduce excessive increase in body mass index (BMI). This randomized, controlled trial conducted at community centers in Memphis, Tennessee requires major measurements at baseline and at 12 and 24 months post-randomization. The participants are healthy African-American girls and one parent/caregiver of each girl. Participating girls are of ages 8-10 years, with BMI>or=25th percentile of the CDC 2000 growth charts or with one overweight or obese parent/caregiver (BMI>or=25 kg/m(2)). The active intervention is designed to prevent excessive weight gain by promoting healthy eating habits and increasing physical activity. An alternative intervention (comparison group) promotes general self-esteem and social efficacy. The main outcome measure is the difference between the two treatment groups in the change in BMI at 2 years. Three hundred and three girls have been randomly assigned to receive the test intervention (n=153) or the alternative intervention (n=150). The two groups do not differ in baseline characteristics. At the time of enrollment, the mean age was 9 years, the mean BMI was 22 kg/m(2) (mean BMI percentile=77 th), and 41% were overweight (BMI>/=95th percentile using CDC 2000 growth charts). Participants' intake of fruits and vegetables (1.3 serving/day) and fats (36% kcal), and their participation in moderate-to-vigorous physical activity (20 min/day), did not meet national recommendations. The GEMS obesity prevention intervention targets improved diet and increased physical activity to reduce excessive weight gain in healthy African-American girls of ages 8-10.

Psychosocial mediation of fruit and vegetable consumption in the body and soul effectiveness trial

In this study the authors examined psychosocial variables as mediators for fruit and vegetable (FV) intake in a clustered, randomized effectiveness trial conducted in African American churches. The study sample included 14 churches (8 intervention and 6 control) with 470 participants from the intervention churches and 285 participants from the control churches. The outcome of FV intake and the proposed mediators were measured at baseline and at 6-month follow-up. Structural equation modeling indicated that the intervention had direct effects on social support, self-efficacy, and autonomous motivation; these variables also had direct effects on FV intake. Applying the M. E. Sobel (1982) formula to test significant mediated effects, the authors confirmed that social support and self-efficacy were significant mediators but that autonomous motivation was not. Social support and self-efficacy partially mediated 20.9% of the total effect of the intervention on changes in FV intake. The results support the use of strategies to increase social support and self-efficacy in dietary intervention programs.

Correlates of fruit and vegetable consumption among 11-year-old Belgian-Flemish and Dutch schoolchildren

OBJECTIVE

To determine factors associated with the consumption of fruit and vegetables among 11-year-old schoolchildren in Belgium-Flanders and the Netherlands.

DESIGN

In total, 2468 school children from 98 randomly selected schools participated in a cross-sectional survey.

VARIABLES MEASURED

Frequency of fruit and vegetable intake and potential personal, social and environmental correlates were measured by means of self-administered, school-based, written questionnaires.

ANALYSIS

Hierarchical multiple regression analyses were conducted to assess potential correlates of schoolchildren's fruit and vegetable consumption. Separate analyses were conducted for boys and girls.

RESULTS

Bringing fruit to school, modeling behavior of parents and friends, parents demanding that their child eat fruit, knowledge about recommended intake levels, liking fruit, and self-efficacy to eat fruit were the strongest correlates of fruit intake. For vegetables, gender, parental demand, parents facilitating the consumption of vegetables by cutting them for their child, modeling behavior of parents and friends, and preferences for vegetables emerged as strongest correlates. No substantial differences in significant correlates were found according to gender. The percentage of explained variance was 33.7% for fruit and 28.4% for vegetable intake.

CONCLUSIONS

Interventions need to be focused on personal (taste preferences), social (parental influences), and environmental factors (availability).

Translational research in childhood obesity prevention

This article explores the state of translational research in childhood obesity prevention. Five phases of translational research and emerging findings from basic science that could be useful in the design of obesity prevention programs are described. Few intervention studies have been published, and these are dominated by Phase 3 trials (efficacy), conducted in school settings, with a limited number of studies finding significant effects on Body Mass Index or adiposity. Cost-benefit analyses are lacking. Research is needed to translate basic science findings into novel interventions (Phases 1 and 2) and to translate programs with known behavior change capability into dissemination trials (Phase 5). Translation can be facilitated by enhanced communication between basic science and prevention science researchers, the development of interventions for underused settings, using novel strategies, support by institutions and funding agencies for translation, and the design of interventions with translation in mind.

Comparability and reliability of paper- and computer-based measures of psychosocial constructs for adolescent fruit and vegetable and dietary fat intake

BACKGROUND

This study investigated the comparability and reliability of computer- and paper-based measures of psychosocial constructs related to fruit and vegetable and dietary fat intake among adolescents.

METHODS

An ethnically diverse sample of 76 adolescents was studied (mean age 13 years). Scales measured use of change strategies, self-efficacy, decisional balance, family influences, and peer influences separately for the two dietary outcomes.

RESULTS

Comparability analyses indicated that responses for each of the 12 diet-related scales were not significantly different between the computer- and paper-based surveys. Internal consistencies were generally high (alpha from .61 to .97) with slightly better reliability on the computer- vs paper-based surveys. Test-retest reliabilities were adequate to good for most multiple-item scales (interclass correlation coefficients from .43 to .85 and .48 to .90 for paper and computer formats, respectively).

CONCLUSIONS

Computer- and paper-based measures of psychosocial constructs are appropriate and ready for use in either format for studies of dietary behaviors in young people.

Revisiting "Success": Posttrial analysis of a gender-specific HIV/STD prevention intervention

Alongside the recognized need to foster the development of innovative gender-specific HIV interventions, researchers face the urgent need to further understand how current interventions do or do not work. Few studies build posttrial qualitative analysis into standardized interview assessments in randomized controlled trials in order to bolster an assessment of how interventions work. The current investigation is a posttrial qualitative analysis carried out on a randomly selected subsample (N = 180), representing 50% of women who participated in a 3-arm randomized controlled trial known as Project FIO (The Future Is Ours). FIO was a gender-specific HIV prevention intervention carried out with heterosexually active women in a high seroprevalence area of New York City. Posttrial qualitative results extend an understanding of the success of the trial (e.g., reductions in unsafe sex). Qualitative results reflect how the Modified AIDS Risk Reduction Model operated in the expected direction across experimental groups. Results also highlight women's empowerment narratives, reflecting the salience of bodily and sexual rights aspects of the intervention.

Association of socio-psychological factors with the effects of low protein diet for the prevention of the progression of chronic renal failure

OBJECTIVE

Our objectives were to investigate the therapeutic effects of low protein diet (LPD) for chronic renal failure (CRF) in compliant patients with the diet, and to clarify the relationships to the sociopsychological factors.

PATIENTS AND METHODS

Sixty-five patients (47 men and 18 women) with CRF who followed LPD (0.69 g/kg/day) for more than 3 months were recruited in this study. Compliance with the diet therapy was strictly assessed by the patients' dietary records, subsequent interviews regarding the status of daily dietary intake and estimated protein intakes calculated from urinary nitrogen excretion by 24-hour urine collections. The changes of glomerular filtration rate (GFR), serum creatinine (Cr), blood urea nitrogen (BUN), the reciprocal of serum creatinine (1/Cr), scores of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), scales of Profile of Mood States (POMS), scores of self-efficacy and social support were investigated.

RESULTS

Decline rate of GFR, elevation of Cr and BUN and reduction in 1/Cr were significantly lower in compliant patients than in noncompliant patients (p<0.05). There were no differences in SF36 scores between compliant and noncompliant patients. The POMS scales of depression/dejection were high in female noncompliant patients compared to other groups of patients (p<0.05). Self-efficacy score was higher in compliant patients than in noncompliant patients (p<0.05). Social support scores were significantly higher in male compliant patients than in others (p<0.05), and both emotional support and behavioral support showed interaction with both gender and compliance with diet therapy (p<0.05).

CONCLUSION

LPD therapy is effective in suppressing the progression of CRF when it is well-adhered to. There are no correlations of this diet therapy to health-related QOL. Social support and high self-efficacy for men and high self-efficacy for women are associated with improvement of the compliance with LPD therapy, leading to good therapeutic effects.

Determinants of fruit and vegetable consumption among 6-12-year-old children and effective interventions to increase consumption

PURPOSE

To review the current literature about potential determinants of fruit and vegetable intakes and effective intervention strategies to increase the consumption of fruits and vegetables among 6-12-year-old children.

METHODS

A structured review of literature located in PubMed and Psychinfo electronic literature databases.

RESULTS

Of all determinants, the availability and accessibility of fruit and vegetables and taste preferences were most consistently and most positively related to consumption. There was some evidence that parental fruit and vegetable intakes, knowledge of intake recommendations and skills had a positive association with children's intakes, whereas television viewing, exposure to television advertisement, and having a snack bar at school were associated with lower intakes of fruit and vegetables. Multi-component school-based interventions that combined classroom curriculum, parent and food service components showed the greatest promise for fruit and vegetable promotion among children. School fruit and vegetable subscription programmes, scout-based interventions, and fruit and vegetables education via computer multi-media channels also appear promising.

CONCLUSIONS

Interventions should improve the availability and accessibility of fruit and vegetables to children, and should aim to improve their taste preferences for them. Such interventions should be of a multi-component nature, school-based or use other social channels and may include multi-media channels.

Correlates of fruit and vegetable intake among Norwegian schoolchildren: parental and self-reports

OBJECTIVES

To identify correlates of 6th and 7th graders' (age 10-12 years) fruit and vegetable intake, to investigate parent-child correlations of fruit and vegetable intake, and to compare parents' and children's reports of children's accessibility, skills and preferences with respect to fruit and vegetables.

DESIGN

The results presented are based on the baseline survey of the 'Fruits and Vegetables Make the Marks Project', where 38 schools participated.

SETTING

Fruit and vegetable intake was measured by food frequency questions. Theoretical factors, based on Social Cognitive Theory, potentially correlated to intake were measured, including behavioural skills, accessibility, modelling, intention, preferences, self-efficacy and awareness of 5-a-day recommendations.

SUBJECTS

In total, 1950 (participation rate 85%) 6th and 7th graders and 1647 of their parents participated.

RESULTS

Overall, 34% of the variance in the pupils' reported fruit and vegetable intake was explained by the measured factors. The strongest correlates to fruit and vegetable intake were preferences and accessibility. The correlation between the children's and their parents' fruit and vegetable intake was 0.23. The parents perceived their children's accessibility to be better than what was reported by the children (P<0.01), while the children reported their skills to be better than what was perceived by their parents (P<0.01).

CONCLUSION

The results from this study clearly point to a need for nutrition interventions aimed at parents. An important next step will be to investigate whether the identified correlates predict future fruit and vegetable intake, and whether they mediate any changes in intake in an intervention study.