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Early adolescence is a critical time for health behavior development because agency increases during the transition from childhood to adolescence. This qualitative study sought to identify how early adolescent participants described food-related agency. One-on-one interviews were conducted with 30 early adolescents (10-13 years). Data analysis was guided by Bandura's three modes of agency: personal, proxy, and collective. Results suggest participants' food behaviors were informed by a growing knowledge about nutrition, household food rules, and school food environments. Participants described different modes of agency in four areas - grocery shopping, cooking, consumption decisions, and nutrition information seeking - with varying degrees of agency in each area. Understanding how each of the three modes operate and the interplay between them can information future research aimed at improving the nutrition behaviors of early adolescents.

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Early adolescence (ages 10-14) encompasses a critical transition period in which food and nutrition decisions are shifting in important ways. Food routines are food-based activities that repeat across days, weeks, seasons, or lives. Examining routines can provide insight into how individuals are influenced in food choices. The objective of this study was to describe current influences on and experiences with food routines during early adolescence. In-depth interviews, using a photo-elicitation approach, were conducted with 30 participants (16 females; 14 males) in the United States. Participants took photos that were then used during the interview to describe food-related decisions and influences. Interviews were audio recorded and transcribed verbatim. Analysis was guided by a grounded theory approach to identify emergent themes related to routines and resulted in the development of a conceptual model for early adolescent food routines. Participants identified a wide range of routines and three main themes emerged: family, settings, and meals/foods consumed. Some had highly established routines throughout the week, while others described routines only for certain meals or days. Several participants described increased control or the ability to modify routines around some eating episodes such as snacks, lunches, and weekend breakfasts. Findings revealed how participants viewed eating routines and provided information about food-and nutrition-related behaviors that can inform future research and practice. Early adolescents appear to have complex food routines influenced by structures and different amounts of control.

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BACKGROUND: Choose Health: Food, Fun, and Fitness (CHFFF) is aimed at 3rd to 6th graders, and uses experiential learning, food preparation, active games, goal setting, and a family newsletter to target behaviors shown to decrease childhood obesity and chronic disease risk. This study aimed to evaluate CHFFF as intended in low-income settings. METHODS: A quasi-experimental design with delayed intervention was used. CHFFF participants in 27 after-school and 28 in-school groups in 5 New York counties in 2014 to 2015 completed a self-report survey at initial enrollment, after a no-intervention control period, and after receiving CHFFF. Statistical analyses were based on 561 3rd to 6th graders who completed all 3 surveys and participated in at least 4 of the 6 lessons. RESULTS: Compared to their control period, after receiving CHFFF, youth significantly improved in the following multi-item dietary scores: overall dietary intake (p < .001), vegetable intake (p < .001), fruit intake (p < .01), soda/fast food intake (p < .05) and intent to consume soda/fast food (p < .001). Youth also reported reading Nutrition Facts labels and sharing about healthy eating with their family more often (both p < .001), and greater likelihood of having tried a new food (p < .001). CONCLUSIONS: Results provide evidence for the effectiveness of this curriculum in improving self-reported child diet and related behaviors.

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OBJECTIVE: Assess training needs of nutrition educators incorporating policy, systems, and environmental (PSE) approaches into their obesity prevention efforts, to identify content for online training. METHODS: Conducted a national, online survey of state and local Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program Education professionals engaged in PSE efforts. RESULTS: Respondents (n = 601) rated the importance of 24 training topics related to planning, implementing, and evaluating PSE approaches. Most (21) topics were rated very important or essential, confirming the need for a comprehensive approach. Paired-sample t tests found significant differences (P <0.001) in some training needs between local and state staff (eg, training in evaluation rated higher for state staff). Training needs did not differ by program, region, or length of employment. The top 5 settings for PSE efforts were schools, farmers' markets, food banks/pantries, community gardens, and after-school programs. CONCLUSIONS AND IMPLICATIONS: Results informed the development of an online training for program implementers. Future research will be needed to assess and refine training needs further, which will evolve as nutrition educators gain more experience in PSE approaches.

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BACKGROUND: Racial minority children, particularly from low-income households, are at risk for obesity. Family meals have a protective effect on child nutritional health. However, the current evidence is limited in racial and socioeconomic diversity. The objective of this study was to evaluate the impact of a family meals intervention, Simple Suppers, on improvements in diet and health outcomes from baseline (T0) to post-intervention (T1) in intervention compared to waitlist control participants, and determine retention of change in outcomes among intervention participants at 10-week follow-up (T2). METHODS: Simple Suppers was a 10-week family meals intervention implemented as a 2-group quasi-experimental trial. Ten 90-min lessons were delivered weekly. Data were collected at T0 and T1, and from intervention participants at T2. Participants were racially diverse 4-10 year-old children from low-income households. Setting was a faith-based community center. Main outcomes were daily servings of fruit, vegetables, and sugar-sweetened beverages and diet quality; z-scores for body mass index (BMI), waist circumference, systolic and diastolic blood pressure (BP); weight status categories; food preparation skills; and family meals (frequency of dinner, breakfast, TV viewing during meals, meals in dining area). Generalized linear mixed models (GLMMs) and mixed-effects ordinal regression models were used to assess intervention impact (T0:T1). Paired t-tests examined retention of change among intervention participants (T1:T2). RESULTS: One hundred forty children enrolled and 126 completed T1 (90% retention); 71 of 87 intervention participants completed T2(79% retention). Mean (SD) age was 6.9(1.9) yr, 62% female, 60% Black, and 42% low-income. Intervention vs waitlist controls had higher food preparation skills (p < 0.001) and lower TV viewing during meals (p = 0.04) at T1.There were no group differences in dietary intake or quality or z-scores for BMI, waist circumference, or BP, however intervention versus waitlist controls experienced a greater change toward healthy weight (p = 0.04) At T2, intervention participants demonstrated a retention of improved food preparation skills. CONCLUSIONS: Simple Suppers led to improvements in children's weight status, food preparation skills, and TV viewing during meals, but not diet or z-scores for BMI, waist circumference, or BP. Future research should examine the preventive effects of healthy family mealtime routines in children at greatest risk for obesity. TRIAL REGISTRATION: NCT02923050; Simple Suppers Scale-up (S3); Retrospectively registered on Oct 2016; First participant enrolled on Jan 2015.

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BACKGROUND: World migration shifts emphasize the necessity of framing health behavior in the context of life course. Mexican-born households in the U.S. disproportionally experience food insecurity, a condition associated with poor health. Food assistance programs may not be accessible to immigrants, suggesting food provisioning strategies may play a critical protective role. OBJECTIVE: To explore life course and ecological system influences on food provisioning among low-income, Mexican-born mothers in the U.S. to identify target influences and behaviors for interventions. METHODS: Life Course Perspective and Ecological Systems Theory guided this qualitative study. INCLUSION CRITERIA: 1) woman born in Mexico, 2) ≤10 years in U.S., 3) residing in one of two New York State counties, 4) at least one child ≤5 years old, and 5) <200% of the federal poverty line. Participants completed two semi-structured interviews, including a participant-driven photo elicitation interview, in English or Spanish, and a food insecurity assessment. Thematic content analysis identified emergent themes. RESULTS: Five themes emerged that were related to three key life course concepts: social context in Mexico (food insecurity experiences, agrarian experiences, and traditional foods and flavors), transitions (motherhood), and turning points (health events). All themes related to mothers' overall priority of providing home-cooked meals, and demonstrated life course influences shaping food provisioning values and strategies. CONCLUSION: Considering life course experiences is important to creating effective, multi-level approaches to reduce food insecurity among Mexican-born families in the northeastern U.S. Programs should have a particular emphasis on new or soon-to-be mothers and should include improved access to affordable in-season produce or gardening opportunities, peer-led food provisioning programs, and food and nutrition assistance programs.

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CONTEXT: Women with polycystic ovary syndrome (PCOS) report dissatisfaction with their early medical care. Little is understood about factors that can encourage stronger patient-provider relationships and promote treatment adherence. OBJECTIVE: To compare trust in physicians and beliefs about social support from health care providers between women with and without PCOS. DESIGN: Cross-sectional study with online questionnaire. SETTING: Medical clinic referral or broader community recruitment via advertising and websites. PARTICIPANTS: Three hundred thirty-two US-based women with PCOS or with regular menses (n = 134 and n = 198, respectively). MAIN OUTCOME MEASURES: Trust and social support toward health care providers [primary care physicians (PCPs), specialists, and/or nurse practitioners and physician assistants]. RESULTS: PCOS was associated with greater distrust in the PCP's opinion (P < 0.01) and greater confidence about the PCP's prioritization of general health concerns (P = 0.04) than the comparison group. Patients with PCOS felt that the PCP spent less effort and were less qualified to treat PCOS health concerns than general health concerns (both P < 0.001). No significant associations were observed between PCOS diagnosis and trust in specialists. When examining social support, women with PCOS felt they had more arguments with their health care providers than the comparison group (P = 0.02). CONCLUSION: Women with PCOS reported greater overall distrust in the PCP's opinions and more arguments with their health care providers than women without PCOS. These findings support a need to identify additional areas of improvement in the patient-provider relationship to ensure continuity of care for patients with PCOS who require life-long surveillance.

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OBJECTIVE: Evaluate whether participation in Choose Health: Food, Fun, and Fitness (CHFFF), a hands-on, experiential curriculum aimed at third- to sixth-graders, resulted in improvements in the targeted obesity and chronic disease prevention behaviors. METHODS: The researchers evaluated CHFFF in low-income youth participating in 2 federal programs in New York State during 2013-2015. Food and activity behaviors were assessed using the Expanded Food and Nutrition Education Program third- through fifth- and sixth- through eighth-grade pre-post surveys, along with 2 sets of added CHFFF-specific items completed by subsamples. Educators trained in CHFFF had youth complete the surveys as they delivered the curriculum, primarily in schools and after-school programs. RESULTS: Paired t tests showed significant (P < .01) positive changes before to after CHFFF education for consumption of vegetables, fruits, sweetened drinks, nutrition label reading, and other food and activity behaviors. CONCLUSIONS AND IMPLICATIONS: Results provide practice-based evidence that CHFFF promotes positive behavior change in participating youth.

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STUDY QUESTION: Do health-related knowledge, beliefs and self-efficacy differ between women with and without polycystic ovary syndrome (PCOS)? SUMMARY ANSWER: Women with PCOS felt at greater risk for adverse health outcomes, yet believed a healthy lifestyle was less beneficial to prevent weight gain relative to a comparison group. WHAT IS KNOWN ALREADY: Diet and physical activity are often used to treat PCOS, but there are high attrition rates and less engagement in self-help methods. It is unclear whether there are unique psychosocial considerations in PCOS that should be incorporated into these interventions. STUDY DESIGN, SIZE, DURATION: This cross-sectional study enrolled 475 women with (N = 255) and without PCOS (N = 220). PARTICIPANTS/MATERIALS, SETTING, METHODS: Female participants were recruited through paper and web-based advertisements across the US (mean age: 28.1 ± 5.4 years). Participants were either diagnosed with PCOS by a healthcare professional (PCOS group) or had self-reported regular menstrual cycles (comparison group). A reliable and valid online instrument about health-related knowledge, beliefs and self-efficacy was administered to these participants. MAIN RESULTS AND THE ROLE OF CHANCE: Most women with PCOS had a basic understanding of nutrition (96%), but had misconceptions about diagnostic criteria for PCOS (≥86%). PCOS was associated with greater perceived susceptibility for disease and weight gain and poorer perceived control over these health outcomes (all P < 0.05), in relation to the comparison group. Women with PCOS also perceived fewer benefits of healthy behaviors on weight gain (P = 0.03) with less than half of the PCOS group attempting to follow government diet recommendations (47%). There were no differences in the self-efficacy of dietary behaviors between groups. LIMITATIONS, REASONS FOR CAUTION: It is likely that participant self-selection occurred due to the nature of recruitment in this study and results may have limited generalizability since most participants identified as Caucasian. Additionally, it is unclear whether some results may be clinically meaningful due to small effect sizes. WIDER IMPLICATIONS OF THE FINDINGS: These findings support that behavioral interventions should incorporate the unique psychosocial considerations associated with PCOS to encourage patient participation in lifestyle interventions. STUDY FUNDING/COMPETING INTEREST(S): This manuscript was partially supported by Cornell University Human Ecology Alumni Association and College of Agriculture and Life Sciences Alumni Association. The authors have no competing interests. TRIAL REGISTRATION NUMBER: NCT01859663.

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OBJECTIVE: To apply the Theory of Planned Behaviour to examine the relationship between the constructs of background factors and beliefs towards using policy, systems and environmental (PSE) strategies and reported use of PSE strategies to prevent obesity by a group of professional nutrition educators. DESIGN: Cross-sectional study using self-reported survey. SETTING: Cooperative Extension in New York, USA. SUBJECTS: Nutrition educators (n 58); survey response rate 100 %. RESULTS: Nutrition educators' reported use of PSE strategies to prevent obesity were positively associated with background factors of their community networking and number of staff they managed, their belief of other people's expectations of them to make PSE changes and the belief that their communities were ready to use PSE strategies; and negatively associated with their belief that individual-level factors contributed to obesity. The relationships among these variables were complicated and their use of PSE strategies occurred only when they utilized their professional networks at a moderately high level (above mean of 5·3 on a scale of 1-7), given that their community was also ready to use PSE strategies. CONCLUSIONS: Nutrition educators' use of PSE strategies depends on several internal and external factors. Community networking needs to be emphasized as one of the most significant factors contributing to nutrition educators' work in this area. Organizational and community support should be in place in order to facilitate nutrition educators' effective use of PSE strategies.

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BACKGROUND: Given the ongoing childhood obesity public health crisis and potential protective effect of family meals, there is need for additional family meals research, specifically experimental studies with expanded health outcomes that focus on the at-risk populations in highest need of intervention. Future research, specifically intervention work, would also benefit from an expansion of the target age range to include younger children, who are laying the foundation of their eating patterns and capable of participating in family meal preparations. The purpose of this paper is to address this research gap by presenting the objectives and research methods of a 10-week multi-component family meals intervention study aimed at eliciting positive changes in child diet and weight status. METHODS: This will be a group quasi-experimental trial with staggered cohort design. Data will be collected via direct measure and questionnaires at baseline, intervention completion (or waiting period for controls), and 10-weeks post-intervention. Setting will be faith-based community center. Participants will be 60 underserved families with at least 1, 4-10 year old child will be recruited and enrolled in the intervention (n = 30) or waitlist control group (n = 30). The intervention (Simple Suppers) is a 10-week family meals program designed for underserved families from racial/ethnic diverse backgrounds. The 10, 90-min program lessons will be delivered weekly over the dinner hour. Session components include: a) interactive group discussion of strategies to overcome family meal barriers, plus weekly goal setting for caregivers; b) engagement in age-appropriate food preparation activities for children; and c) group family meal for caregivers and children. Main outcome measures are change in: child diet quality; child standardized body mass index; and frequency of family meals. Regression models will be used to compare response variables results of intervention to control group, controlling for confounders. Analyses will account for clustering by family and cohort. Significance will be set at p < 0.05. DISCUSSION: This is the first experimentally designed family meals intervention that targets underserved families with elementary school age children and includes an examination of health outcomes beyond weight status. Results will provide researchers and practitioners with insight on evidence-based programming to aid in childhood obesity prevention. TRIAL REGISTRATION: NCT02923050 . Registered 03 October 2016. Retrospectively registered.

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OBJECTIVE: Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training. DESIGN: Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models. SETTING: An online course for participants in the USA and abroad. SUBJECTS: Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240). RESULTS: One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05). CONCLUSIONS: Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.

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BACKGROUND: This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6-8, typically children ages 10-14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers. METHODS: Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013-2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery. RESULTS: Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended. CONCLUSIONS: RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

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Funding agencies and professional organizations are increasingly requiring community-based nutrition education programs to be evidence-based. However, few nutrition education interventions have demonstrated efficacy, particularly for interventions that address the outer layers of the socioecological model (ie, organizational, community, and public policy). This article reviews the types of evidence available to assess the likelihood that a given intervention will deliver the desired outcomes and how these types of evidence might be applied to nutrition education, and then suggests an approach for nutrition educators to evaluate the evidence and adapt interventions if necessary.

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OBJECTIVE: To determine the effectiveness of the Expanded Food and Nutrition Education Program (EFNEP) curriculum Eating Smart-Being Active (ESBA). DESIGN AND SETTING: A quantitative, multi-state, nonequivalent comparison group pretest-posttest design was used to compare nutrition-related behavior changes in participants. ESBA was compared to previously used curricula for 3 different time periods in 5 states using the EFNEP evaluation tool. PARTICIPANTS: Adults enrolled in EFNEP who completed their entry and exit paperwork during any of the 3 time points. INTERVENTION: An 8-lesson adult curriculum based on the Dietary Guidelines for Americans and MyPlate. ANALYSIS: Analysis of variance and covariance (with pretests scores and demographic variables as covariates) were used to analyze data with significance at P ≤ .05. RESULTS: ESBA elicited a mean positive behavior change for food resource management (P < .01), food safety (P ≤ .001), nutrition (P < .001), and physical activity level in participating states (P ≤ .01). Compared with previous curricula, ESBA produced better mean outcomes in food resource management, nutrition, physical activity, and intakes of fruit and vegetables. CONCLUSION AND IMPLICATIONS: ESBA is effective at eliciting positive nutrition-related behavior change. The results of this multi-state, practice-based approach suggest that ESBA is effective in multiple settings and has external validity for use in EFNEP and other community nutrition programs.

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OBJECTIVE: To develop and apply a framework exploring the extent of involvement in promoting environmental changes to prevent obesity by a group of nutrition educators (NE). DESIGN: Cross-sectional, mixed methods: qualitative interviews informed framework development; survey applied framework to describe NE's involvement in environmental changes. SETTING: Cooperative Extension in New York State. PARTICIPANTS: Interviewees (n = 7) selected to vary in environmental change activities and rural/urban location. Survey response rate was 100% (n = 58). PHENOMENON OF INTEREST/VARIABLES MEASURED: Dimensions and degree of NE's involvement in promoting environmental change. ANALYSIS: Thematic analysis of qualitative data, triangulated with descriptive analyses of NE's performance of tasks in various settings. RESULTS: NE's promotion of environmental changes was characterized using framework based on settings and tasks, dimensions that emerged from qualitative analysis. NE's actions varied across these dimensions and ranged from low to high intensity of collaboration and leadership for environmental change. Most NE surveyed reported actions limited to providing information and recommendations on healthy eating and physical activity. Few reported intensive engagement in developing, implementing, and evaluating plans to change environments for obesity prevention. CONCLUSIONS AND IMPLICATIONS: Framework identifies the levels of engagement in promoting environmental changes and supports future research and practice of community nutrition professionals by providing a roadmap for assessing their involvement on multiple levels to prevent obesity.

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OBJECTIVE: Assess effectiveness of the Expanded Food and Nutrition Education Program on nutrition behaviors post-education and longitudinally. DESIGN: Switching replications randomized experimental design. Participants randomly assigned to immediate education (IE) or delayed education (DE). Participants in IE received intervention the first 8 weeks, and those in DE the second 8 weeks, with no intervention during alternate periods. Data were collected in 3 repeated measures. PARTICIPANTS: Parents (n = 168 randomized; n = 134 completed) of children in 2 Head Start and 6 low-income schools. INTERVENTION: Eight weekly workshops, based on Eating Right is Basic-Enhanced adapted to incorporate dialogue approach with experiential learning. MAIN OUTCOME MEASURES: Ten-item self-reported behavior checklist on nutrition, food resource management, food safety, and food security; responses on a 5-point scale reporting frequency of behavior. ANALYSIS: Chi-square, analysis of variance, and multiple regression. RESULTS: Groups were demographically similar. Both groups reported improved behaviors pre- to post-education (P < .05). There was no significant difference between groups at Time 1 (T1) or DE control period (T1 vs T2). Changed IE behavior was retained T2 to T3. A multiple regression model of overall change, controlling for T1 score and educator, showed significant improvement (n = 134, ß = 5.72, P < .001). CONCLUSIONS AND IMPLICATIONS: Positive outcomes were supported by this experimental study in a usual program context, with reported behavior changes retained at least 2 months.

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Research identifying associations between parental behaviors and children's food and activity choices and weight suggests that the integration of parenting and nutrition education holds promise for promoting healthful eating and activity in families. However, translational research leading to sustainable interventions lags behind. Development and testing of interventions within actual program contexts is needed to facilitate translation to full-scale implementation. Therefore, the goal of this pilot study was to develop and test an integrated nutrition and parenting education intervention for low-income families within the Expanded Food and Nutrition Education Program in New York State. During a 21-month period, low-income parents of 3- to 11-year-olds were recruited through usual programmatic channels by nutrition program staff to participate in a series of eight workshops delivered to small groups. A validated self-administered questionnaire was used to assess behavior change outcomes among 210 parents who completed the program. Mean scores improved significantly for most behaviors, including adult fruit and vegetable intake; adult and child low-fat dairy and soda intake; and child fast-food intake, activity, and screen time (P<0.001). Many parents reported eating together with children at program entry, leaving little room to improve, but about 20% reported at least a 1-point improvement (on a 5-point scale). The most frequent change was reducing how often children ate fast food and was reported by >50% of parents. Design and testing through practice-based research can facilitate development of interventions that are both feasible and likely to improve eating and activity behaviors among low-income families.

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