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Objective:The objective of the current study was to identify factors across the socio-ecological model (SEM) associated with adolescents’ sugar-sweetened beverage (SSB) intake.Design:This cross-sectional study surveyed adolescents using previously validated instruments. Analyses included descriptive statistics, ANOVA tests and stepwise nonlinear regression models (i.e., two-part models) adjusted to be cluster robust. Guided by SEM, a four-step model was used to identify factors associated with adolescent SSB intake – step 1: demographics (i.e., age, gender), step 2: intrapersonal (i.e., theory of planned behaviour (attitudes, subjective norms, perceived behavioural control, behavioural intentions), health literacy, media literacy, public health literacy), step 3: interpersonal (i.e., caregiver’s SSB behaviours, caregiver’s SSB rules) and step 4: environmental (i.e., home SSB availability) level variables.Setting:Eight middle schools across four rural southwest Virginia counties in Appalachia.Participants:Seven hundred ninety seventh grade students (55·4 % female, 44·6 % males, mean age 12 (sd0·5) years).Results:Mean SSB intake was 36·3 (sd42·5) fluid ounces or 433·4 (sd493·6) calories per day. In the final step of the regression model, seven variables significantly explained adolescent’s SSB consumption: behavioural intention (P< 0·05), affective attitude (P< 0·05), perceived behavioural control (P< 0·05), health literacy (P< 0·001), caregiver behaviours (P< 0·05), caregiver rules (P< 0·05) and home availability (P< 0·001).Conclusions:SSB intake among adolescents in rural Appalachia was nearly three times above national mean. Home environment was the strongest predictor of adolescent SSB intake, followed by caregiver rules, caregiver behaviours and health literacy. Future interventions targeting these factors may provide the greatest opportunity to improve adolescent SSB intake.

Objective:The aim of the study was to identify components of the COM-B (capability, opportunity, motivation and behaviour) model that influences behaviour to modify dietary patterns in 40–55-year-olds living in the UK, in order to influence the risk of cognitive decline in later life.Design:This is a qualitative study using the COM-B model and theoretical domains framework (TDF) to explore beliefs to adopting the Mediterranean-DASH Intervention for Neurodegenerative delay (MIND) diet.Setting:Northern Ireland.Participants:Twenty-five participants were recruited onto the study to take part in either a focus group or an interview. Participants were men and women aged between 40 and 55 years. Participants were recruited via email, Facebook and face to face.Results:Content analysis revealed that the main perceived barriers to the adoption of the MIND diet were time, work environment, taste preference and convenience. The main perceived facilitators reported were improved health, memory, planning and organisation, and access to good quality food.Conclusions:This study provides insight into the personal, social and environmental factors that participants report as barriers and facilitators to the adoption of the MIND diet among middle-aged adults living in the UK. More barriers to healthy dietary change were found than facilitators. Future interventions that increase capability, opportunity and motivation may be beneficial. The results from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.

Objectives: To collect and summarise all current data from observational studies, generating evidence of the association between health literacy (HL) and the dietary intake of sugar, salt and fat, to analyse intervention studies on the promotion of an appropriate dietary intake of the above-mentioned nutrients and to ascertain whether HL moderates the efficacy of such intervention. Design: A systematic literature search of analytical observational studies on the association between HL and dietary intake of sugar, salt and fat was performed in Medline and Scopus databases. Intervention studies on the promotion of healthy nutrition that concerned the intake of sugar, salt and fat were also assessed. Results: Of the eight observational studies included in this review, five investigated dietary intake of sugar, one focused on salt, one assessed sugar and salt and one analysed the fat intake. The results of the five studies assessing sugar were mixed: three found an association between low levels of HL and a high sugar intake, one found this association only for boys and two found no evidence of any association. The two studies assessing salt and the one assessing fat found no evidence of any association with HL. One intervention study on the sugar intake concluded that HL was not a significant moderator of the intervention’s effectiveness. Conclusion: No evidence of any association between HL and salt and fat intake emerged, while for sugar, the results are mixed. More work is needed to better understand the moderating effects of HL on the outcomes of health promotion interventions.

Objective:The aim of this study was to investigate the association of the number of hours of nutrition education and teachers’ qualifications with nutrition knowledge and dietary behaviour in students.Design:In this representative cross-sectional study, socio-demographic data, anthropometric measurements, socio-economic status (SES), physical fitness, nutrition knowledge and eating habits were assessed. Differences between groups were tested byχ2andttests. Multiple linear and logistic regression modelling was used to examine the relationship between demographic characteristics, lifestyle and dietary behaviours, nutrition knowledge, nutrition-trained teachers and number of nutrition lessons.Setting:Sixteen secondary schools in urban (n6) and rural regions (n10) of Tyrol, Western Austria.Participants:Students (n513) aged 14·2 (sd0·7) years.Results:Higher nutrition knowledge was significantly associated with attending rural school (P= 0·001), having no migration background (P< 0·001), (very) good physical activity behaviour (P= 0·040), non-trained teacher (P= 0·006) but higher number of hours of nutrition education (P= 0·013). Regression models showed that higher nutrition knowledge was independently associated with lower intake of meat and iced tea and higher intake of vegetables and plant-based oils. A higher amount of nutrition education (h/week) was significantly associated with higher intake of dark (wholegrain) bread, lower intake of meat and of energy drinks sweetened with sweeteners.Conclusions:Our results suggest that more hours in nutrition education result in higher nutrition knowledge and greater nutrition literacy, which may lead to health-promoting dietary habits. School-based nutrition education can be seen as preventive measure to increase nutritional competences in adolescents independent of their SES.

Objective:Job-related chronic stress has been discussed as a risk factor for weight change and metabolic disorders. The current study was conducted to understand the situations in which stress-induced eating occurs among office workers and how workers perceive stress to influence their daily eating practices and weight change.Design:In-depth, one-on-one interviews were conducted with office workers.Setting:Metropolitan areas in South Korea.Participants:Twenty-two office workers from thirteen companies participated in the study.Results:Most participants mentioned that they often felt work-related stress and reported various levels of perceived stress, as measured with open-ended questions. The main sources of work stress were (i) the nature of job characteristics, (ii) performance evaluations and (iii) relationships within the organisation. Participants linked stress with increased food consumption and cravings for sweet, savoury and greasy foods. Many participants emphasised the links between multiple health behaviours and stress. Not only dietary choices but also alcohol consumption, sleeping difficulty and insufficient physical activity were related to coping with work stress and demands. Finally, most participants who perceived work stress believed that their weight gain in adulthood was triggered by work stress.Conclusions:It is necessary to consider promoting behavioural modifications to support weight management and providing a means for stress management and the minimisation of stress-inducing working environments for workers to maintain or achieve a healthy weight and to prevent chronic disease incidence.

Objective:Women in South Asia, including Nepal, have some of the poorest nutritional indicators globally, leading to poor maternal and child health outcomes. Nepal also suffers from high levels of household food insecurity, and newly married women are at high risk. Intra-household relationships may mediate the relationship between food insecurity and women’s nutrition in Nepal for newly married women. Our aim is to understand how newly married, preconception, women’s food consumption changes when she enters her husband’s home, compared with her natal home. We also explore whether relationship quality with husbands and mothers-in-law mediates the association between food insecurity and eating less high-quality food, using structural equation modelling.Design:Cross-sectional survey data.Setting:Rural Nepal in 2018.Participants:Data were collected from 200 newly married, preconception women.Results:Women had poor diet quality, and most ate fewer high-quality foods important for pregnancy in their marital, compared with natal, home. Higher quality relationships with mothers-in-laws mediated the association between food insecurity and a woman eating fewer high-quality foods in her marital, compared with natal, home. Relationship quality with husbands was not associated with changes in food consumption.Conclusions:Preconception, newly married women in Nepal are eating less high-quality foods important for women’s health during the preconception period – a key period for avoiding adverse maternal and infant health outcomes. Relationships with mothers-in-law are key to women’s access to high-quality food, suggesting that interventions aiming to improve maternal and child nutrition should target all household members.

Objective:Low- and middle-income countries (LMIC) are increasingly experiencing the double burden of malnutrition. Studies to identify ‘double-duty’ actions that address both undernutrition and overweight in sub-Saharan Africa are needed. We aimed to identify acceptable behaviours to achieve more optimal feeding and physical activity practices among both under- and overweight children in Rwanda, a sub-Saharan LMIC with one of the largest recent increases in child overweight.Design:We used the Trials of Improved Practices (TIPs) method. During three household visits over 1·5 weeks, we used structured interviews and unstructured observations to collect data on infant and young child feeding practices and caregivers’ experiences with testing recommended practices.Setting:An urban district and a rural district in Rwanda.Participants:Caregivers with an under- or overweight child from 6 to 59 months of age (n 136).Results:We identified twenty-five specific recommended practices that caregivers of both under- and overweight children agreed to try. The most frequently recommended practices were related to dietary diversity, food quantity, and hygiene and food handling. The most commonly cited reason for trying a new practice was its benefits to the child’s health and growth. Financial constraints and limited food availability were common barriers. Nearly all caregivers said they were willing to continue the practices and recommend them to others.Conclusions:These practices show potential for addressing the double burden as part of a broader intervention. Still, further research is needed to determine whether caregivers can maintain the behaviours and their direct impact on both under- and overweight.

Objective:To explore the perceptions of soldiers participating in a US Army Office of The Surgeon General’s worksite health promotion programme (WHPP) on the local food environment within their campus-style workplace.Design:Focus groups were conducted to evaluate the perceived effectiveness of the WHPP implementation. Further exploration of focus group data through thematic analysis focused on perceived contributions of the military campus-style food environment to soldiers’ nutrition behaviours.Setting:Three US Army installations located in the continental USA.Participants:Active duty soldiers (n 366) participating in one of the fifty-eight focus groups.Results:Soldiers shared a common belief of self-discipline and personal responsibility as the foothold to nutrition behaviour change. Soldiers described aspects of the military campus-style food environment as factors impeding achievement of optimal nutrition. Collectively, soldiers perceived the proximity and density of fast-food restaurants, lack of healthy alternatives on the installation and the cost of healthy food as inhibitors to choosing healthy foods. Overwhelmingly, soldiers also perceived time constraints as a factor contributing to unhealthy food choices.Conclusions:Although nutrition behaviour is individually driven, soldiers perceived the military campus-style food environment inhibits healthy decision making. Nutrition programming in military WHPP must integrate food environment changes to improve soldiers’ nutrition behaviour outcomes. Applicable to the military, food choice behaviour studies suggest environmental changes must be appealing to young adults. Considerations for environmental changes should include an increased portion size for healthy options, broadened use of soldiers’ daily food allowances on local produce and increased availability of grab-and-go options.

Objective:To examine if increased intake of locally available nutrient-dense foods among pregnant women improved the quality of their dietary intake and if use of the Theory of Planned Behaviour could explain changes in their dietary behaviour.Design:We used data from a randomised controlled trial where the intervention group received nutrition education and dietary counselling. We promoted the use of recipes that utilised powders to enhance dietary diversity. We examined how the intervention achieved changes in dietary intakes and used mixed effects logistic regression models with random effects at village level to explore changes over time of the outcomes, adjusted for selected explanatory variables.Setting:The study was conducted in twenty villages in rural Malawi.Participants:Data from 257 pregnant women who were enrolled during late first trimester and followed until birth.Results:The intervention achieved improvements in the Dietary Diversity Score (DDS) and the Six Food Group Pyramid (SFG) score, especially in intakes of micronutrient-rich foods. A third of the women in the intervention group attained optimal DDS, whereas about 50 % attained optimal SFG. The theorised behaviour mediators (i.e. nutrition attitudes, nutrition behaviour control and subjective norm) that had improved were also significantly associated with high DDS.Conclusions:Improved dietary intakes were achieved through promoting the use of locally available nutrient-dense foods. Attainment of high DDS was a consequence of the women’s belief in the effectiveness of the proposed nutrition recommendations. We identified critical personal and environmental constraints related to dietary intakes during pregnancy in a low-resource setting.

ObjectiveThe purpose of the current study was to examine associations of individual and aggregated screen-based behaviours, and total sitting time, with healthy and unhealthy dietary intakes among adolescents.DesignCross-sectional study of adolescents. Participants self-reported durations of television viewing, computer use, playing electronic games (e-games), total sitting time, daily servings of fruits and vegetables, and frequency of consumption of sugar-sweetened beverages (SSB), diet beverages, fast foods and discretionary snacks. Logistic regression models were conducted to identify associations of screen-based behaviours, total screen time and total sitting time with dietary intakes.SettingVictoria, Australia.SubjectsAdolescents (n 939) in School Year 11 (mean age 16·8 years).ResultsThe results showed that watching television (≥2 h/d) was positively associated with consuming SSB and diet beverages each week and consuming discretionary snacks at least once daily, whereas computer use (≥2 h/d) was inversely associated with daily fruit and vegetable intake and positively associated with weekly fast-food consumption. Playing e-games (any) was inversely associated with daily vegetable intake and positively associated with weekly SSB consumption. Total screen (≥2 h/d) and sitting (h/d) times were inversely associated with daily fruit and vegetable consumption, with total screen time also positively associated with daily discretionary snack consumption and weekly consumption of SSB and fast foods.ConclusionsIndividual and aggregated screen-based behaviours, as well as total sitting time, are associated with a number of indicators of healthy and unhealthy dietary intake. Future research should explore whether reducing recreational screen time improves adolescents’ diets.

ObjectiveThe present study aimed to investigate disordered eating (DE) among Sami compared with non-Sami residing in northern Norway.DesignIn a cross-sectional design, stratified by sex and ethnicity, associations were tested between DE (Eating Disturbance Scale; EDS-5) and age, education level, BMI category, anxiety and depression, physical activity and consumption of snacks.SettingThe SAMINOR 2 Clinical Survey (2012–2014) based on the population of ten municipalities in northern Norway.SubjectsAdults aged 40–69 years; 1811 Sami (844 male, 967 female) compared with 2578 non-Sami (1180 male, 1398 female) individuals.ResultsNo overall significant ethnic difference in DE was identified, although comfort eating was reported more often by Sami individuals (P=0·01). Regardless of ethnicity and sex, symptoms of anxiety and depression were associated with DE (PP=0·01). DE was associated (OR, 95% CI) with low physical activity in men in general and in non-Sami women (Sami men: 2·4, 1·4, 4·0; non-Sami men: 2·2, 1·4, 3·6; non-Sami women: 1·8, 1·2, 2·9) and so was the consumption of snacks (Sami men: 2·6, 1·3, 5·0; non-Sami men: 1·9, 1·1, 3·1; non-Sami women: 2·1, 1·3, 3·4).ConclusionsThere were no significant differences regarding overall DE comparing Sami with non-Sami, although Sami more often reported comfort eating. There were significant sex and ethnic differences related to DE and physical activity, snacking and education level.

ObjectiveTo develop and validate a questionnaire to measure food-related and activity-related practices of child-care staff, based on existing, validated parenting practices questionnaires.DesignA selection of items from the Comprehensive Feeding Practices Questionnaire (CFPQ) and the Preschooler Physical Activity Parenting Practices (PPAPP) questionnaire was made to include items most suitable for the child-care setting. The converted questionnaire was pre-tested among child-care staff during cognitive interviews and pilot-tested among a larger sample of child-care staff. Factor analyses with Varimax rotation and internal consistencies were used to examine the scales. Spearman correlations, t tests and ANOVA were used to examine associations between the scales and staff’s background characteristics (e.g. years of experience, gender).SettingChild-care centres in the Netherlands.SubjectsThe qualitative pre-test included ten child-care staff members. The quantitative pilot test included 178 child-care staff members.ResultsThe new questionnaire, the Child-care Food and Activity Practices Questionnaire (CFAPQ), consists of sixty-three items (forty food-related and twenty-three activity-related items), divided over twelve scales (seven food-related and five activity-related scales). The CFAPQ scales are to a large extent similar to the original CFPQ and PPAPP scales. The CFAPQ scales show sufficient internal consistency with Cronbach’s α ranging between 0·53 and 0·96, and average corrected item–total correlations within acceptable ranges (0·30–0·89). Several of the scales were significantly associated with child-care staff’s background characteristics.ConclusionsScale psychometrics of the CFAPQ indicate it is a valid questionnaire that assesses child-care staff’s practices related to both food and activities.

ObjectiveTo identify barriers to fruit and vegetable intake for Indigenous Australian children and quantify factors related to these barriers, to help understand why children do not meet recommendations for fruit and vegetable intake.DesignWe examined factors related to carer-reported barriers using multilevel Poisson models (robust variance); a key informant focus group guided our interpretation of findings.SettingEleven diverse sites across Australia.SubjectsAustralian Indigenous children and their carers (N1230) participating in the Longitudinal Study of Indigenous Children.ResultsAlmost half (45 %;n555/1230) of carers reported barriers to their children’s fruit and vegetable intake. Dislike of fruit and vegetables was the most common barrier, reported by 32·9 % of carers; however, we identified few factors associated with dislike. Carers were more than ten times less likely to report barriers to accessing fruit and vegetables if they lived large citiesv. very remote areas. Within urban and inner regional areas, child and carer well-being, financial security, suitable housing and community cohesion promoted access to fruit and vegetables.ConclusionsIn this national Indigenous Australian sample, almost half of carers faced barriers to providing their children with a healthy diet. Both remote/outer regional carers and disadvantaged urban/inner regional carers faced problems accessing fruit and vegetables for their children. Where vegetables were accessible, children’s dislike was a substantial barrier. Nutrition promotion must address the broader family, community, environmental and cultural contexts that impact nutrition, and should draw on the strengths of Indigenous families and communities.