Indonesian Adolescents' Perceptions of Front-of-Package Labels on Packaged Food and Drinks

Background

Unhealthy snacking among Indonesian adolescents is common and contributes to rising rates of overweight and obesity. With the growing availability and marketing of ultraprocessed snacks, front-of-package labels (FOPLs) have emerged as a promising tool to help adolescents make healthier snack purchases.

Objectives

This study aims to explore Indonesian adolescents' drivers of snack purchase, perceptions of different FOPLs, and views on design features that could influence the impact of FOPLs.

Methods

We employed a mixed-method design, incorporating both focus group discussions (FDGs) and an online survey. Eight FDGs were conducted with 46 participants aged 12-18, of different socioeconomic status from Jakarta metropolitan areas. Three FOPLs, a warning label, traffic light label (TLL), and "healthier choice" label, were tested both independently and as part of snack packages. The Pan American Health Organization nutrient profile and the UK nutrient profile were used for the warning label and TLL, respectively. Participants completed a demographics questionnaire, then an online assessment and discussion that encompassed food purchasing decisions, reactions to each of the FOPLs, comparison of FOPLs, and comparing alternative label designs for each FOPL type. Thematic analysis and the Likert scale were used for quantitative and qualitative analysis, respectively.

Results

Although adolescents preferred the TLL, finding them informative, attractive, and believable, the information conveyed by the TLL was not well understood, particularly by participants with low socioeconomic status. In contrast, although warning labels were less well-liked, they were better understood, grabbed their attention, and were perceived as most likely to discourage them from buying unhealthy foods. The healthier choice label was perceived as least likely to discourage purchases of unhealthy foods.

Conclusions

Although TLLs are best liked among Indonesian adolescents, warning labels are perceived as most likely to help adolescents identify unhealthy foods and discourage their purchases.

As Much As I Can - Utilizing Immersive Theatre to Reduce HIV-Related Stigma and Discrimination Toward Black Sexual Minority Men

BACKGROUND

Despite advances in biomedical HIV prevention modalities such as pre-exposure prophylaxis to prevent the transmission of HIV, racial/ethnic and sexual/gender minority populations are disproportionately impacted by HIV epidemic. Alarming rates of HIV have persisted among Black gay and bisexual men, particularly in Southern states.

METHODS

Utilizing data from the ViiV ACCELERATE! initiative, we explored the impact of As Much As I Can, an immersive theatre production, on HIV-related stigma behaviors. A self-administered post-performance survey was conducted with a cohort (n = 322) of randomly selected audience members.

RESULTS

Overall, the results showed participants had a highly favorable experience, rating the performance with a mean score of 9.77/10. Respondents indicated they intended to change behaviors to promote HIV prevention education and to reduce stigma and discrimination including: (1) Say something if I hear stigmatizing language against people living with HIV (75.4%), (2) Say something if I hear anti-gay language (69.7%) and (3) Tell others about HIV prevention options (e.g., PrEP, PEP, condoms (64.1%). The findings show there is an association between HIV-related behavior intention and linkage to HIV care. Respondents who reported they were more likely to say something about HIV stigma were almost three times (O.R. 2.77; 95% C.I. 0.98-7.8) more likely to indicate they would follow up with a healthcare professional.

CONCLUSIONS

This study suggests that immersive theatre is an effective method for communicating HIV prevention education and reducing HIV-related structural stigma and discrimination that increases HIV vulnerability for Black sexual minority men.

A Mixed Methods, Quasi-Experimental Evaluation Exploring the Impact of a Secondary School Universal Free School Meals Intervention Pilot

Food insecurity amongst households with children is a growing concern globally. The impacts in children include poor mental health and reduced educational attainment. Providing universal free school meals is one potential way of addressing these impacts. This paper reports findings on the impact of a universal free school meals pilot in two English secondary schools. We adopted a mixed-methods, quasi-experimental design. The intervention schools were one mainstream school (n = 414) and one school for students with special educational needs (n = 105). Two other schools were used as comparators (n = 619; n = 117). The data collection comprised a cross sectional student survey during the pilot (n = 404); qualitative interviews with students (n = 28), parents (n = 20) and school staff (n = 12); and student observations of lunchtimes (n = 57). Qualitative data were analysed using thematic analysis, and descriptive analyses and logistic regressions were conducted on the quantitative data. Self-reports of food insecurity were high at both intervention (26.6%) and comparator schools (25.8%). No effects of the intervention were seen in the quantitative findings on either hunger or food insecurity. Qualitative findings indicated that students, families and staff perceived positive impact on a range of outcomes including food insecurity, hunger, school performance, family stress and a reduction in stigma associated with means-tested free school meals. Our research provides promising evidence in support of universal free school meals in secondary schools as a strategy for addressing growing food insecurity. Future research should robustly test the impact of universal free school meals in a larger sample of secondary schools, using before and after measures as well as a comparator group.

Measuring adherence, acceptability and likability of an artificial-intelligence-based, gamified phone application to improve the quality of dietary choices of adolescents in Ghana and Vietnam: Protocol of a randomized controlled pilot test

Unhealthy diets are a critical global concern while dietary measure methods are time consuming and expensive. There is limited evidence that phone-based interventions can improve nutrition data collection and dietary quality, especially for adolescents in developing countries. We developed an artificial-intelligence-based phone application called Food Recognition Assistance and Nudging Insights (FRANI) to address these problems. FRANI can recognize foods in images, track food consumption, display statistics and use gamified nudges to give positive feedback on healthy food choice. This study protocol describes the design of new pilot studies aimed at measuring the feasibility (acceptability, adherence, and usability) of FRANI and its effects on the quality of food choice of adolescents in Ghana and Vietnam. In each country, 36 adolescents (12-18 years) will be randomly allocated into two groups: The intervention group with the full version of FRANI and the control group with the functionality limited to image recognition and dietary assessment. Participants in both groups will have their food choices tracked for four weeks. The control groups will then switch to the full version of FRANI and both groups will be tracked for a further 2 weeks to assess acceptability, adherence, and usability. Analysis of outcomes will be by intent to treat and differences in outcomes between intervention and control group will use Poisson and odds ratio regression models, accounting for repeated measures at individual levels. If deemed feasible, acceptable and usable, FRANI will address gaps in the literature and advance the nutrition field by potentially improving the quality of food choices of adolescent girls in developing countries. This pilot study will also provide insights on the design of a large randomized controlled trial. The functioning and dissemination of FRANI can be an important step towards highly scalable nutrition data collection and healthier food choices for a population at risk of malnutrition. The study protocol and the methods and materials were approved by the Institutional Review Board (IRB) of the IFPRI on April 29th, 2020 (registration number #00007490), the Thai Nguyen National Hospital on April 14th, 2020 (protocol code 274/ĐĐĐ-BVTWTN) and the University of Ghana on August 10th, 2020 (Federalwide Assurance FWA 00001824; NMIMR-IRB CPN 078-19/20). The study protocol was registered in the International Standard Randomized Controlled Trial Number (ISRCTN 10681553; https://doi.org/10.1186/ISRCTN10681553) on November 12, 2021.

Validity test of the theory of planned behavior in college students’ withdrawal from smartphone dependence

Smartphone usage has brought great convenience to our daily life. However, the detrimental consequences of smartphone dependence also require special attention. Based on the theory of planned behavior (TPB), this study designed a questionnaire to investigate college students’ withdrawal from smartphone dependence. The reliability and validity of the questionnaire were tested. The results showed that the reliability of the questionnaire was good (α = 0.84–0.94). The principal component analysis was conducted, contribution rates of these factors were moderately high (62.06%–82.35%). The validity was verified through confirmatory factor analysis. All the model fit indices were higher than the acceptable standard, which indicated the construct validity of the TPB questionnaire is good. The results of the multi-group structural equation model revealed that the model provided excellent fit to the data in each demographic group. The results of structural equation model presented that, in most demographic groups, students’ attitude, subjective norm, and perceived behavioral control of withdrawal from smartphone dependence positively influenced their behavioral intention. Furthermore, subjective norm was the most effective predictors in each group. However, part of the paths from intention to behavior failed to reach the significant level, and their coefficients are relatively small. This reveals the gap between college students’ withdrawal intention and their actual behavior, and there may be other factors influence the relationship between the two variables.

Strategies and interventions for healthy adolescent growth, nutrition, and development

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Gender Differences in Nutritional Quality and Consumption of Lunches Brought from Home to School

Gender difference in the lunches brought from home to school and the amount consumed by elementary and intermediate school students were examined using data collected from 12 schools in Texas. The amount and nutritional quality of food items brought and consumed was evaluated, by comparing the results to the 2012 school meal standards, and Dietary Reference Intakes (DRIs). Almost all lunches brought from home contained grain and meat/meat alternatives, and the amount brought and consumed exceeded the NSLP standards. The majority of students did not bring fruits, vegetables, and whole grain foods, but those who brought consumed most of what they brought. Among elementary school students, only 9% of boys and 14% of girls brought vegetables and the amount brought and consumed did not meet the standards. Although carbohydrate and protein consumption were adequate for boys and girls, the intakes of micronutrients and fiber did not meet the requirements across both genders at both school levels. Overall, lunches brought from home were not well balanced and did not meet NSLP standards and DRIs. It is imperative to identify strategies to improve the nutritional quality of lunches brought from home considering gender difference in food choice and educating parents and children on what is a healthy well-balanced lunch.

Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania

Background: Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.

Underweight and Associated Factors Among Teenage Adolescent Girls in Resource-poor Settings: A Cross-sectional Study

Background and Purpose

Understanding the undernutrition status of teenage adolescent girls living in urban slums and its associated factors is meaningful to formulate customized health strategies. This study aimed to determine the prevalence of being underweight and associated factors among teenage adolescent girls in urban slums.

Materials and Methods

In this cross-sectional study, we enrolled a total of 418 teenage adolescent girls from five of 210 urban slums of Varanasi district, Uttar Pradesh, India employing two-stage probability sampling for the selection of households and subjects, between September 2016 and July 2017. The study of underwight subjects was assessed with BMI for age using standard criteria. Factors associated with being underweight were determined by multivariable logistic regression analysis.

Results

Of 418 study subjects, 49.76% (208/418) were underweight. Results revealed that sociodemographic factors such as teenage adolescent girls who were from SC/ST (schedule caste/schedule tribe) caste/ethnicity (adjusted odds ratio (AOR)=2.02, 95%CI: 1.00–4.23), subjects whose father’s education level was primary or lower (AOR=1.87, 95%CI: 1.12–3.11), and number of people in the family >4 (AOR=2.18, 95%CI: 1.18–4.03) were associated with being underweight. Likewise, dietary behavior-related factors such as vegetarian (AOR=2.21, 95%CI: 1.25–3.92), and <3 meals per day (AOR=2.36, 95%CI: 1.40–3.98) than their counterparts were associated with being underweight. In addition, teenage adolescent girls from food-insecure households (AOR=3.33, 95%CI: 2.01–5.51) were more likely to be underweight than those from food-secure households.

Conclusion

The higher burden of underweight among teenage adolescent girls in Indian urban slums needs to be addressed through specific public health interventions such as by improving education, providing education regarding dietary behavior, and having access to sufficient, safe, and nutritious foods.

Qualitative evaluation of a social media campaign to improve healthy food habits among urban adolescent females in Indonesia

OBJECTIVE

The current study focuses on how adolescent girls in urban Indonesia accept technology in a social media (SM) campaign to promote healthy eating habits.

DESIGN

The study was a qualitative evaluation of the online campaign. In-depth interviews using semi-structured interview guidelines and focus group discussions were used to collect data. Data were analysed using a general inductive approach to provide simple and straightforward answers to our study questions.

SETTINGS

The study was conducted in two urban areas in Indonesia: Jakarta and Jogjakarta.

PARTICIPANTS

Adolescent girls aged 16-19 years.

RESULTS

The SM campaign was perceived as beneficial for increasing participants' knowledge. The campaign helped increase participants' awareness of healthy diets and the health risks of unhealthy diets as well as increase their motivation to change their behaviour and avoid foods containing salt, sugar and excess fat. The participants perceived information from the online campaign as complete and trustworthy. Instagram was cited as the easiest platform to use, while the website was cited as having the most complete information. YouTube provided the best viewing experience but was considered a data-heavy platform. The barriers to change were perceptions of taste, limited choices for healthy but affordable ingredients and family-related factors.

CONCLUSIONS

The online nutrition campaign was well accepted by Indonesian urban adolescent females and motivated them to act to protect their health. Future nutrition-related SM campaigns aimed at this demographic should focus on platforms with the greatest benefit and ease of use.

Factors Influencing British Adolescents' Intake of Whole Grains: A Pilot Feasibility Study Using SenseCam Assisted Interviews

High whole grain intake is beneficial for health. However, adolescents consume low levels of whole grain and the understanding of the underpinning reasons for this is poor. Using a visual, participatory method, we carried out a pilot feasibility study to elicit in-depth accounts of young people's whole grain consumption that were sensitive to their dietary, familial and social context. Furthermore, we explored barriers and suggested facilitators to whole grain intake and assessed the feasibility of using SenseCam to engage adolescents in research. Eight British adolescents (aged 11 to 16 years) wore a SenseCam device which auto-captured images every twenty seconds for three consecutive days. Participants then completed traditional 24-hour dietary recalls followed by in-depth interviews based on day three SenseCam images. Interview data were subjected to thematic analysis. Findings revealed that low adolescent whole grain intake was often due to difficulty in identifying whole grain products and their health benefits; and because of poor availability in and outside of the home. The images also captured the influence of parents and online media on adolescent daily life and choices. Low motivation to consume whole grains, a common explanation for poor diet quality, was rarely mentioned. Participants proposed that adolescent whole grain consumption could be increased by raising awareness through online media, improved sensory appeal, increased availability and variety, and tailoring of products for young people. SenseCam was effective in engaging young people in dietary research and capturing data relevant to dietary choices, which is useful for future research.

Elementary school teachers’ behavioral intentions for healthy nutrition

Purpose

The purpose of this paper is to examine the effects of elementary school teachers’ psychological factors on their behavioral intentions for healthy nutrition in their daily life within an extended version of the theory of planned behavior (TPB).

Design/methodology/approach

The design of the study is correlation study.

Findings

Constructs in the proposal model formed accounted for of variance of intentions and behaviors successfully. Considering the entire proposed model, while personal norm is the most influential factor on intention, self-identity is the most consistent effects on teachers’ behavior. However, among the constructs of TPB, perceived behavioral control is the strongest influence on both intention and behavior.

Originality/value

In the literature, factors affecting healthy behaviors by using TPB focused on mainly children (8–10 year old) and adolescents (11–16 year old) all over the world. However, in some countries, several studies were conducted on adults (e.g. Astrøsm and Rise, 2001; Brouwer and Mosack, 2015), to the best of our knowledge, while there is no study conducted on adults including teachers in Turkey. In addition, recently, two meta-analysis studies were published: Riebl et al. (2015) and Mcdermott et al. (2015). These studies suggested that future studies related to healthy nutrition in the scope of TPB should be continued to investigate.

Cross-cultural validity of the theory of planned behavior for predicting healthy food choice in secondary school students of Inner Mongolia

AIMS

Unhealthy eating behavior is a serious health concern among secondary school students in Inner Mongolia. To predict their healthy food choices and devise methods of correcting unhealthy choices, we sought to confirm the cross-cultural validity of the theory of planned behavior among Inner Mongolian students.

MATERIALS AND METHODS

A cross-sectional study, conducted between November and December 2014. Overall, 3047 students were enrolled. We devised a questionnaire based on the theory of planned behavior to measure its components (intentions, attitudes, subjective norms, and perceived behavioral control) in relation to healthy food choices; we also assessed their current engagement in healthy food choices.

RESULTS

A principal component analysis revealed high contribution rates for the components (69.32%-88.77%). A confirmatory factor analysis indicated that the components of the questionnaire had adequate model fit (goodness of fit index=0.997, adjusted goodness of fit index=0.984, comparative fit index=0.998, and root mean square error of approximation=0.049). Notably, data from participants within the suburbs did not support the theory of planned behavior construction. Several paths did not predict the hypothesis variables. However, attitudes toward healthy food choices strongly predicted behavioral intention (path coefficients 0.49-0.77, p<0.01), regardless of demographic characteristics.

CONCLUSION

Our results support that the theory of planned behavior can apply to secondary school students in urban areas. Furthermore, attitudes towards healthy food choices were the best predictor of behavioral intentions to engage in such choices in Inner Mongolian students.

Understanding fruit and vegetable consumption in children and adolescents. The contributions of affect, self-concept and habit strength

Affective processes and the role of automaticity are increasingly recognised as critical in determining food choice. This study investigated the association of affective attitude, self-identity and habit with fruit and vegetable (FV) intentions and intake in children. Previous studies have not fully explored their implications for children of different age groups and have not considered their independent contribution as part of a coherent model of behaviour that also controls for other psychosocial and environmental determinants of intake. Data was collected through face-to-face interviews with 362 children, 9-15 years old. Children were asked to report on measures of affective attitude, cognitive attitude, self-concept, social norms and facilitating factors following Triandis' Theory of Interpersonal Behaviour (TIB). Three stage least squares was used to estimate the independent association of affective attitude and self-concept with intentions and of intentions and habit with intake. Self-concept had the most prominent role in explaining intentions irrespective of age for both fruit and vegetables. The importance of affective attitude varied by age and with fruit and vegetables, with greater importance for vegetables and for children aged 11-13 years. Cognitive attitude was more relevant than affective attitude for 14 to 15 year-olds' fruit intentions. Intake was more strongly associated with habit than intentions, with stronger associations for 14 to 15 year-olds. The current findings support the importance of self-concept for FV motivations and provide further evidence on the importance of habit to FV intake in young and older children and adolescents. Results also support a targeted usefulness of affective attitude for fruit and vegetable intentions. The discussion considers potential ways in which these constructs can be incorporated into interventions to increase FV intake in children.

Actitud de los consumidores frente a los productos cárnicos con un menor contenido en sodio

Food choice and food purchase are complex phenomena influenced not only by the sensorial char acteristics of the product and its price, but also by other factors such as consumer attitudes towards the product. In this study the model of planned behavior of Ajzen was used to measure consumer attitudes towards low salt meat products. A 48-item questionnaire was completed in by 112 consumers representing different sociodemographic levels. The results obtained showed that the beliefs were not completely unitary and only health- and taste-related beliefs significantly improved attitude prediction. Perceived control was the most important aspect in explaining the behavioral intention of the consumers despite its relatively low consistency. Attitude and the subjective norm also had a significant effect on intention. Sociodemographic parameters clearly divided the consumers in several components of the model, the sex of the individuals being the most important aspect. The predictive ability of the model was clearly different depending on whether separation of the consumers by sex and indirect measures of attitude and subjective norm were taken into account. The model of planned behavior proved to be effective in predicting consumers' behavioral intention. However, there are some aspects of this model such as the biased measurement of attitude and consistency of perceived control which need further improvement.

Predicting Intended and Self-perceived Sugar Restriction among Tanzanian Students using the Theory of Planned Behavior

This study examines the applicability and sufficiency of the Theory of Planned Behavior (TPB) in predicting intention and self-perceived behavior with respect to avoiding between-meal intake of sugared snacks and drinks. One thousand one hundred and twenty-three Tanzanian students (mean age 26.4 years) completed self-administered questionnaires designed to measure the components of the TPB during May–July, 1999. Self-perceived sugar consumption was obtained in a subsample of respondents ( n = 228) four weeks later. The TPB provided a significant prediction of intention ( R2= 0.44), with attitude (= 0.25), subjective norms (= 0.28) and perceived behavioral control (= 0.35) significant, and subsequent behavior ( R2 = 0.15, with intention (= 0.25) and perceived behavioral control (= 0.18) significant. Frequency of past behavior explained a significant, albeit small, amount of additional variance in intention (1 percent) and behavior (4 percent). The results indicate that the TPB is applicable to the prediction of food choice-related intention and behavior among young adult students living in a non-occidental setting.

Allowing and Using Foods of Low Nutritional Value in Elementary School Classrooms: The Implications of Teachers' Beliefs

OBJECTIVE

To investigate elementary teachers' behavior toward allowing and using foods with low nutritional value in the classroom.

DESIGN/SETTING

A survey guided by the Theory of Planned Behavior was administered in fall, 2012 in 10 schools.

PARTICIPANTS

Elementary public school teachers in grades pre-kindergarten through 6.

MAIN OUTCOME MEASURES

Teachers' behavior and beliefs regarding allowing and using foods with low nutritional value in the classroom and Theory of Planned Behavior determinants.

ANALYSIS

Pairwise correlation coefficients and multivariate linear regression to assess relationships between theory determinants and descriptive statistics.

RESULTS

All 3 determinants, Attitude Toward the Behavior (t = 4.04; P < .01), Subjective Norms (t = 3.78; P < .01), and Perceived Behavioral Control (t = 5.19; p < .01), were statistically significant predictors of behavior. The majority of teachers (94%) allowed foods of low nutritional value for celebrations at least some of the time, and 75% stated that they had control over what foods they allow.

CONCLUSIONS AND IMPLICATIONS

Discussions among teachers and school health professionals should ensue to improve nutritional content of foods allowed in classrooms. School policies can be developed and evaluated for effectiveness to have a positive impact on childhood obesity and school nutrition environments.

A systematic literature review and meta-analysis: The Theory of Planned Behavior's application to understand and predict nutrition-related behaviors in youth

BACKGROUND

Efforts to reduce unhealthy dietary intake behaviors in youth are urgently needed. Theory-based interventions can be effective in promoting behavior change; one promising model is the Theory of Planned Behavior (TPB).

PURPOSE

The aim of this study was to determine, using a systematic literature review, how the TPB has been applied to investigate dietary behaviors, and to evaluate which constructs are associated with dietary behavioral intentions and behaviors in youth.

METHODS

Publications were identified by searching electronic databases, contacting experts in the field, and examining an evolving Internet-based TPB-specific bibliography. Studies including participants aged 2-18years, all TPB constructs discernible and measured with a description of how the variables were assessed and analyzed, were published in English and peer-reviewed journals, and focused on nutrition-related behaviors in youth were identified. Accompanying a descriptive statistical analysis was the calculation of effect sizes where possible, a two-stage meta-analysis, and a quality assessment using tenants from the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements.

RESULTS

Thirty-four articles, including three intervention studies, were reviewed. The TPB was most often used to evaluate healthy eating and sugary snack and beverage consumption. Attitude had the strongest relationship with dietary behavioral intention (mean r=0.52), while intention was the most common predictor of behavior performance (mean r=0.38; both p<0.001). All three interventions revealed beneficial outcomes when using the TPB (e.g. η(2)=0.51 and ds=0.91, 0.89, and 0.79); extending the Theory with implementation intentions may enhance its effectiveness (e.g. η(2)=0.76).

CONCLUSIONS

Overall, the TPB may be an effective framework to identify and understand child and adolescent nutrition-related behaviors, allowing for the development of tailored initiatives targeting poor dietary practices in youth. However, support from the literature is primarily from observational studies and a greater effort towards examining these relationships within intervention studies is needed.

Shorter lunch breaks lead secondary-school students to make less healthy dietary choices: multilevel analysis of cross-sectional national survey data

OBJECTIVE

At the time of the study a number of schools within Wales had shortened the amount of time they allow for lunch break. The study investigated the association between length of lunch break and the dietary choices of students in secondary schools.

DESIGN

Student-level data, collected through anonymised questionnaires, included reported dietary choices and correlates of these; data on school approaches to food were collected through postal surveys. Multilevel analysis was used to study the independent association between lunch-break length and student dietary choice.

SETTING

Data were collected from secondary schools in Wales that were part of the 2005/2006 Health Behaviour in School-aged Children (HBSC) study.

SUBJECTS

The final sample for analysis included data from 6693 students aged 11-16 years and 289 teachers from sixty-four secondary schools in Wales.

RESULTS

Once controlling for many individual-level and school-level factors, the length of time allowed for lunch across the range for schools included in the study (minimum =25 min, maximum =62.5 min) was associated with higher odds of students eating fruit for lunch (2.20; 95% CI 1.18, 4.11) and fruit and vegetables on a daily basis (2.15; 95% CI 1.33, 3.47) but lower odds of eating unhealthy foods on a daily basis (0.44; 95% CI 0.24, 0.80).

CONCLUSIONS

Shorter lunch breaks are associated with less healthy dietary choices by students. Schools should consider the impact that lunch-break length has on student dietary choice as well as on other behaviours. Policy makers should work with schools in encouraging them to maintain lunch breaks of a length that allow pupils to make healthy choices.

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.

Developing and applying a socio-ecological model to the promotion of healthy eating in the school

OBJECTIVE

To develop and apply a socio-ecological model (SEM) for healthy eating in school students, to better understand the association between factors at different levels of the SEM and pupils' dietary choices.

DESIGN

Student-level data, collected through anonymised questionnaires, included reported dietary choices and correlates to these; data on school approaches to food were collected through postal surveys. We used multilevel analysis to study the association of each level of the SEM on student dietary choice while controlling for factors found at other levels.

SETTING

Data were collected from secondary schools in Wales that were a part of the 2005/2006 Health Behaviour in School-aged Children (HBSC) study.

SUBJECTS

The final sample for analysis included data from 6693 students aged 11-16 years and 289 teachers from sixty-four secondary schools in Wales.

RESULTS

Student interpersonal factors, an individual's social environment, had a greater association with the dietary choices students made for lunch than student intrapersonal characteristics, those that reside within the person, which were found to have a greater association with the dietary choices made outside school. School organisational factors, such as rules and policies, had a greater association with whether students ate unhealthy foods, whereas the community nature of the school had a greater association with the choosing of healthy foods.

CONCLUSIONS

Using the SEM and multilevel analysis allowed us to study how factors were associated with the choice of different foods at different times of the day by students. Interventions can use an SEM to target specific correlates and change health outcomes in the school.

Does socio-economic status moderate the associations between psychosocial predictors and fruit intake in schoolchildren? The Pro Children study

This study tested whether socio-economic status (SES) moderated the association between the psychosocial constructs included in the attitude-social influence-self-efficacy (ASE) model and fruit intake in Norwegian schoolchildren. The sample consisted of 962 Norwegian sixth graders, mean age 11.3 years. They were split into three SES groups, and multi-group structural equation modeling (MSEM) was used. Children in the highest SES group reported eating fruit more frequently and reported more positive ASE variables than children in the lower SES groups. This was particularly true for social environmental factors, home availability of fruit and intention to eat fruit. MSEM showed that the relationships specified in the adapted ASE model were moderated by SES, as we did not find support for equal model structure across the three samples. Model modification for each SES group separately showed that the relation between home availability and fruit intake was not significant for the medium and low SES groups, and the relation between self-efficacy and intention to eat fruit was not significant for the medium SES group. Future interventions aiming at increasing fruit intake in children need to be sensitive to such SES-related differences and should in particular affect factors that may impede fruit intake in the lower SES groups.

Effect of nutrition intervention using a general nutrition course for promoting fruit and vegetable consumption among college students

OBJECTIVE

To evaluate the effectiveness of implementing nutrition intervention using a general nutrition class to promote consumption of fruits and vegetables in college students.

DESIGN

3-day food records were collected, verified, and analyzed before and after the intervention.

SETTING

A midwestern university.

PARTICIPANTS

80 college students, ages 18 to 24, participated in the study.

INTERVENTION

The intervention focused on nutrition knowledge related to prevention of chronic diseases, healthful dietary choices increasing fruit and vegetable consumption, dietary feedback, and interactive hands-on activities.

MAIN OUTCOME MEASURES

Consumption of: total vegetable, fresh vegetable, starchy vegetable, french fries, vegetable juice, total fruit, fresh fruit, canned fruit, and fruit juice.

ANALYSIS

Dependent t test was used to analyze the differences in pre- and posttest. Analysis of variance was used to determine differences in dietary changes between groups.

RESULTS

Participants significantly increased consumption of not only total fruits and vegetables (P < .005), but also fresh fruits and vegetables (P < .005). Intake of french fries decreased significantly (P < .05). Females responded better to the intervention than males in increasing vegetable consumption (P < .05).

CONCLUSIONS AND IMPLICATIONS

Class-based nutrition intervention focusing on prevention of chronic diseases is a cost-effective approach to increasing fruit and vegetable consumption among college students.

Predictors of intention to eat 2.5 cups of vegetables among ninth-grade students attending public high schools in eastern North Carolina

OBJECTIVE

To identify beliefs about eating 2.5 cups of vegetables and to assess how well these beliefs predict intention to eat them.

DESIGN

A survey based on the Theory of Planned Behavior.

SETTING

Two public high schools in 2 counties in eastern North Carolina.

PARTICIPANTS

157 ninth-grade students (mean age = 14.71 years [SD = 0.82]).

ANALYSIS

Regression analysis was performed to assess how well the variables of the Theory of Planned Behavior predicted behavioral intention to eat 2.5 cups of vegetables.

FINDINGS

Attitude, subjective norms, and perceived behavioral control predicted 77.2% of variance of intention to eat 2.5 cups of vegetables (F [3, 154] = 178.05, P < .001). Attitude was the strongest predictor (beta = 0.434, P < .001), followed by subjective norms (beta = 0.372, P < .001) and perceived behavioral control (beta = 0.159, P < .021).

CONCLUSIONS AND IMPLICATIONS

Factors such as impact of parents and peers, availability of vegetables at home and in school, and making sure that vegetables offered to teens are tasty are important in increasing their intention to eat the recommended amount of vegetables. These factors could help education campaigns targeted toward teens be more successful.

Sensory characterisation and consumer acceptability of small calibre fermented sausages with 50% substitution of NaCl by mixtures of KCl and potassium lactate

The effect of six mixtures with 50% molar substitution of KCl (0-50%) and potassium lactate (0-50%) as NaCl substitutes in small calibre fermented sausages on some sensory parameters and on the acceptability was studied. Also, the relationship between sensory profile and consumer acceptability using external preference mapping was investigated. The results showed that as the K-lactate substitution increased, pH, sweetness, crumbliness and pastiness also increased, and piquantness, hardness, cohesiveness, ripened flavour, acid taste and saltiness decreased. However, the treatments prepared with a high level of salt substitution by KCl showed scores of sensory attributes similar to those of the control. Consumer segmentation showed differences in acceptability between genders, place of residence, educational level and age group. Consumers rejected fermented sausages with high K-lactate substitution but not those with a high KCl substitution. External preference mapping split consumers up into four clusters with different preference patterns. According to these results and from a sensory point of view, it is possible to achieve a reduction of 50% of NaCl in small calibre fermented sausages and to obtain a product acceptable to most consumers.

The role of implicit attitudes towards food and physical activity in the treatment of youth obesity

This study investigated whether implicit and self-reported food and exercise attitudes changed during a residential six month treatment period in youngsters with obesity (n=19). Moreover, it was examined whether this attitudinal change explained their decrease in overweight during the program and at a one year follow up. Two Extrinsic Affective Simon Tasks (EAST) were conducted to investigate implicit attitudes towards exercise and food, respectively. Self-reported attitudes were assessed using a questionnaire. The results revealed that the obese youngsters lost weight during the treatment, that was not regained at follow up. Mean self-reported and implicit attitudes did not change markedly. Moreover, changes in self-reported attitudes were not predictive for decrease in overweight during and after the treatment. In contrast, some small effects were found for the change in implicit attitudes towards food and exercise. Several possible explanations are discussed.

Applying the Theory of Planned Behavior to healthy eating behaviors in urban Native American youth

Background

To investigate the efficacy of the Theory of Planned Behavior (TPB) to predict healthy eating behavior in a group of urban Native American youth.

Methods

Native American boys and girls (n = 139), ages 9–18 years old, were given a self-administered survey to assess eating behavior using the TBP constructs (intention, attitude, subjective norm, barriers, self-efficacy, and perceived behavioral control). Youth were also measured for height and weight and body mass index (BMI) was calculated. Bivariate correlations and stepwise regression analyses of TBP model were performed with SPSS software.

Results

No association was found between intention and healthy eating behavior. However, independently healthy eating behavior was correlated with barriers (0.46), attitude (0.44), perceived behavioral control (0.35), and subjective norm (0.34). The most predictive barriers to eating healthy included the availability and taste of foods. Boys' eating behavior was most predicted by subjective norm, while girls' eating behavior was most predicted by barriers.

Conclusion

Lack of association between intention and healthy eating behavior suggests that factors other than intentions may drive healthy eating behaviors in urban Native American youth. Results indicate that programs promoting healthy eating to youth might focus on collaborating with families to make healthy foods more appealing to youth.

Why do adolescents eat what they eat? Personal and social environmental predictors of fruit, snack and breakfast consumption among 12-14-year-old Dutch students

OBJECTIVE

The aim of the study was to investigate the relative importance of personal and social environmental predictors of the consumption of fruit, high-fat snacks and breakfast.

DESIGN

A school-based cross-sectional survey. Data were collected through written questionnaires.

SETTING

Students from eight schools in the southern part of The Netherlands.

SUBJECTS

Six hundred and one students from preparatory secondary vocational education schools.

RESULTS

About a quarter of the variation in actual behaviours and intentions to change the behaviours could be explained. Stepwise multiple regression analysis revealed that, for all three behaviours, higher intention to change was especially associated with a more positive attitude and subjective norm, and higher intentions to increase fruit intake with more positive self-efficacy expectations. With regard to actual consumption, a more positive attitude towards eating fruit was the only significant correlate of a higher consumption of fruit. A more positive attitude towards eating high-fat snacks, perceived lower intake of the mother, and higher food availability and accessibility were associated with consumption of high-fat snacks, and a more positive attitude to breakfast more frequently was associated with more frequent breakfast consumption.

CONCLUSION

The results indicate that adolescents' attitudes are the most important determinants of different health-related eating behaviours and intentions to change. Interventions promoting a healthy diet for adolescents should include creative strategies to achieve positive associations with healthy dietary changes.

Intention to consume seafood—the importance of habit

The role of habit strength and past behaviour were studied in order to gain a better understanding of seafood consumption behaviour. A sample of Norwegian adults (N=1579) responded to a self-administered questionnaire about seafood consumption habits, past frequency of seafood consumption, and attitude towards and intention to eat seafood. Structural equation modelling revealed that past behaviour and habit, rather than attitudes, were found to explain differences in intention, indicating that forming intention does not necessarily have to be reasoned. The results also indicated that when a strong habit is present, the expression of an intention might be guided by the salience of past behaviour rather than by attitudes. The findings of this study might thus have consequences for dietary interventions.

A review of family and social determinants of children's eating patterns and diet quality

With the growing problem of childhood obesity, recent research has begun to focus on family and social influences on children's eating patterns. Research has demonstrated that children's eating patterns are strongly influenced by characteristics of both the physical and social environment. With regard to the physical environment, children are more likely to eat foods that are available and easily accessible, and they tend to eat greater quantities when larger portions are provided. Additionally, characteristics of the social environment, including various socioeconomic and sociocultural factors such as parents' education, time constraints, and ethnicity influence the types of foods children eat. Mealtime structure is also an important factor related to children's eating patterns. Mealtime structure includes social and physical characteristics of mealtimes including whether families eat together, TV-viewing during meals, and the source of foods (e.g., restaurants, schools). Parents also play a direct role in children's eating patterns through their behaviors, attitudes, and feeding styles. Interventions aimed at improving children's nutrition need to address the variety of social and physical factors that influence children's eating patterns.

A school-based intervention to promote dietary change

PURPOSE

This study examined the effect of 2 school-based interventions on adolescents' consumption and knowledge of fish with the hypothesis that home economics education would enhance the effect of modifications in the school canteen. The school lunch intervention (SL) focused on changes in the school canteen, and the school lunch + home economics intervention (SL + HE) in addition consisted of changes in the home economics syllabus. Pupils in the 8th grade (n = 228) from 3 schools in Göteborg, Sweden, participated (control, n = 83; SL group, n = 58; SL + HE group, n = 87).

METHODS

A controlled design was used in which behavior and knowledge were assessed before and after the intervention. In contrast to much previous research of this type, measurement of behavior was based primarily on direct observation as opposed to self-reported intakes. Behavior (fish consumption) was measured individually by structured observations in the school canteen 5 times (once a week) when fish was served. Nutritional knowledge was measured by means of 10 items in a questionnaire. To analyze changes in behavior, a nonparametric statistical method assessing systematic change in paired ordered categoric variables was used.

RESULTS

At follow-up evaluation, consumption had increased significantly in the SL + HE group, a change that also differed from the control group. In addition, significant positive changes in knowledge were observed in both intervention groups, but not in controls.

CONCLUSIONS

The results suggest that dietary change was achieved by modifying conditions in the school canteen together with changing the home economics syllabus. This study shows the importance of the school in the promotion of dietary change among adolescents.

A prospective study of food variety seeking in childhood, adolescence and early adult life

This prospective study of food variety seeking among children was conducted between 1982 and 1999, with a follow-up in 2001-2002. Two- to three-year-old children were given a free choice of lunch foods in a nursery canteen. Their food choices were recorded and used to calculate early variety seeking scores, globally and by food group (vegetables, animal products, dairy products, starchy foods and combined dishes). The same subjects (n=339) were contacted in 2001-2002, when they were: 17-22 (n=89), 13-16 (n=68), 8-12 (n=99) and 4-7 years of age (n=83). Follow-up variety seeking, globally and by food group, and food neophobia were evaluated using questionnaire instruments. Variety seeking at follow-up increased with early variety seeking and to a lesser extent with age, and decreased with food neophobia. Early and follow-up variety seeking scores were highly related for dairy products and vegetables. Follow-up variety seeking for animal products was higher for boys and increased with age for boys, but not for girls. For each food group, variety seeking at follow-up was related to food neophobia. This study suggests that the acquisition of food repertoire may be influenced by food exposure and food choice behaviours before the age of 4.

Applying the theory of planned behavior to women's behavioral attitudes on and consumption of soy products

OBJECTIVE

To identify variables that significantly predict the intention and behavior concerning soy consumption applying the Theory of Planned Behavior and to determine the role of race on women's perspectives and consumption behaviors concerning soy.

DESIGN

Cross-sectional survey, with self-administered questionnaires.

SETTING

City park service programs, community organizations, black cultural classes, and university offices.

PARTICIPANTS

A convenience sample of 205 black (n = 103) and white (n = 102) women.

VARIABLES MEASURED

Women's behavioral attitudes, subjective norms, perceived behavioral control, intention, and behavior related to soy consumption.

ANALYSIS

Correlation and stepwise regression analysis.

RESULTS

All variables in the Theory of Planned Behavior showed significant correlations with behavioral intention, with behavioral attitudes exhibiting the strongest correlation (r = .57, P < .01). Stepwise multiple regression analyses revealed that behavioral attitude toward taste and subjective norms accounted for 47.7% of the variance in behavioral intention. Behavioral attitude toward taste explained 48.6% of the variability in behavior. There was no difference between races for consumption or Theory of Planned Behavior variables.

CONCLUSIONS AND IMPLICATIONS

A negative attitude toward the taste of soy was the major predictor for low soy consumption. However, future studies should be undertaken to verify this relationship once more women become aware of and have tasted soy.

Beliefs and attitudes towards the consumption of sugar-free products in a sample of Italian adolescents

OBJECTIVE

The objective of this study was to investigate beliefs and attitudes towards sugar-free products in a sample of Italian teenagers.

DESIGN

A total of 10 secondary public schools in the county of Rome were randomly selected. The probability of being extracted was set proportional to the number of students. A random sample of teenagers was selected from the schools for participating in a food consumption survey.

SUBJECTS

The sample included 233 adolescents, aged 15-21 y. A total of 224 adolescents agreed to participate in the study aimed at assessing beliefs and attitudes.

INTERVENTIONS

Two questionnaires were completed at the first day of the last period of the 4-day food survey. The first questionnaire contained questions on attitudes and beliefs toward a healthy diet. The second questionnaire, aimed at assessing adolescents' attitudes towards the consumption of sugar-free products, was based in part on the social-psychological model of the Theory of Planned Behaviour.

RESULTS

In general, the adolescents of this sample seemed to be quite uncertain in their responses. On average, they did not express an emphatic point of view with regard to the act of eating sugar-free products. The results of the assessment of relationships between the variables of the theoretical model revealed the lack of causal links among beliefs, attitudes, intention and consumption of sugar-free products. Perceived behavioural control was not a significant predictor of intention.

CONCLUSIONS

The target of further studies aimed at investigating attitudes towards sugar-free products should be tailored according to the quantity of consumption of such products in order to represent a sample of frequent and high consumers of sugar-free products.

SPONSORSHIP

European Commission Quality of Life and Management of Living Resources Fifth framework Programme. QLRT-1999-00155.