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  • Change in an Urban Food Environment: Storefront Sources of Food/Drink Increasing Over Time and Not Limited to Food Stores and Restaurants
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-15
    Sean C. Lucan, Andrew R. Maroko, Achint N. Patel, Ilirjan Gjonbalaj, Courtney Abrams, Stephanie Rettig, Brian Elbel, Clyde B. Schechter

    BackgroundLocal food environments include food stores (eg, supermarkets, grocery stores, bakeries) and restaurants. However, the extent to which other storefront businesses offer food/drink is not well described, nor is the extent to which food/drink availability through a full range of storefront businesses might change over time.ObjectivesThis study aimed to assess food/drink availability from a full range of storefront businesses and the change over time and to consider implications for food-environment research.DesignInvestigators compared direct observations from 2010 and 2015.Participants/settingIncluded were all storefront businesses offering foods/drinks on 153 street segments in the Bronx, NY.Main outcome measuresThe main outcome was change between 2010 and 2015 as determined by matches between businesses. Matches could be strict (businesses with the same name on the same street segment in both years) or lenient (similar businesses on the same street segment in both years). Investigators categorized businesses as general grocers, specialty food stores, restaurants, or other storefront businesses (eg, barber shops/beauty salons, clothing outlets, hardware stores, laundromats, and newsstands).Statistical analyses performedInvestigators quantified change, specifically calculating how often businesses in 2015 were present in 2010 and vice versa.ResultsStrict matches for businesses in 2015 present in 2010 ranged from 29% to 52%, depending on business category; lenient matches ranged from 43% to 72%. Strict matches for businesses in 2010 present in 2015 ranged from 34% to 63%; lenient matches ranged from 72% to 83%. In 2015 compared with 2010, on 22% more of the sampled street segments, 30% more businesses were offering food/drink: 66 vs 46 general grocers, 22 vs 19 specialty food stores, 99 vs 99 restaurants, 98 vs 56 other storefront businesses.ConclusionsOver 5 years, an urban food environment changed substantially, even by lenient standards, particularly among “other storefront businesses” and in the direction of markedly greater food availability (more businesses offering food on more streets). Failure to consider a full range of food/drink sources and change in food/drink sources could result in erroneous food-environment conclusions.

  • Diabetes Self-Management Education and Medical Nutrition Therapy: A Multisite Study Documenting the Efficacy of Registered Dietitian Nutritionist Interventions in the Management of Glycemic Control and Diabetic Dyslipidemia through Retrospective Chart Review
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-13
    Patricia Z. Marincic, Maria V. Salazar, Amie Hardin, Susan Scott, Shirley X. Fan, Philippe R. Gaillard, Christopher Wyatt, Laura Watson, Pamela Green, Pam Glover, Molly Hand

    BackgroundDiabetes self-management education (DSME) and medical nutrition therapy (MNT) improve glycemic control and reduce risk of chronic comorbid disease.ObjectiveDocument outcomes for patients with type 2 diabetes (T2D) completing DSME and MNT through American Diabetes Association–recognized programs.DesignDescriptive, retrospective chart review.Participants/settingFour random samples of 100 records of patients with T2D completing DSME and MNT at each of four regional centers in Alabama, June 2013 to 2014, were chosen for review; after exclusions, 392 records were retained.Outcome measuresWeight, body mass index (BMI), hemoglobin A1c (HbA1c), total cholesterol, low-density lipoprotein, high-density lipoproteins (HDL), triglycerides (TG), and TG-to-HDL ratio.AnalysisMixed-model analysis of variance was used to determine differences between continuous variables. McNemar test was used to assess frequency of patients reaching glycemic targets. Paired t tests were used to determine significance of lipid parameters.ResultsSignificant reductions were observed at end of program and 1 year in weight (2.67±5.54 kg, P<0.001; 2.25±5.45 kg, P=0.001), BMI (0.93±1.91, P<0.001; 0.76±1.93, P=0.001), and HbA1c (1.82%±2.23%, P<0.001; 1.22%±2.15%, P<0.001). Patients managed by diet alone had a mean baseline HbA1c of 6.95% and exhibited a 0.8% reduction in HbA1c (P<0.001) at end of program. Those managed with diet plus drug therapy had a baseline HbA1c of 9% and exhibited a 2.09% reduction in HbA1c (P<0.001). Following DSME and MNT, 62% of patients reached glycemic targets (HcA1c≤7%), as compared with 32% at baseline (P<0.001). Significant reductions in TG were observed from baseline (162±74 mg/dL [4.19±1.91 mmol/L]) to follow-up (109±36 mg/dL [2.82±0.92 mmol/L]) (P<0.001). HDL increased from baseline (45±13 mg/dL [1.16±0.34 mmol/L]) to follow-up (48±11 mg/dL [1.24±0.28 mmol/L]) (P=0.05). The TG-to-HDL ratio improved from a baseline of 4.07±2.41 to 2.48±1.26 at follow-up (P<0.001).ConclusionsReductions were observed in weight, BMI, HbA1c, TG, and TG-to-HDL ratio. Improved patient outcomes were achieved in the clinical setting and support universal coverage to increase patient access to DSME and MNT.

  • The Impact of 1 Year of Healthier School Food Policies on Students’ Diets During and Outside of the School Day
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-10
    Juliana F.W. Cohen, Mary T. Gorski Findling, Lindsay Rosenfeld, Lauren Smith, Eric B. Rimm, Jessica A. Hoffman

    BackgroundIn 2012, Massachusetts implemented both the updated national school meal standards and comprehensive competitive food/beverage standards that closely align with current national requirements for school snacks.ObjectivesThis study examines the impact of these combined standards on school meal and snack food selections, as well as food choices outside of school. In addition, this study examines the impact of these standards on nutrients consumed.DesignThe NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) Study was an observational cohort study conducted among students from spring 2012 to spring 2013.Participants/settingOne hundred sixty students in 12 middle schools and high schools in Massachusetts completed two 24-hour recalls before (spring 2012) and after implementation (spring 2013) of the updated standards.Main outcome measuresChanges in school meals, competitive food, and after-school snack selection, as well as nutrients consumed outside of school were examined.Statistical analyses performedLogistic regression and mixed-model analysis of variance were used to examine food selection and consumption.ResultsAfter implementation, 13.6% more students chose a school meal (70.1% vs 56.5%; P=0.02). There were no differences in competitive food purchases but a significant decrease in the number of after-school unhealthy snacks consumed (0.69 [standard error=0.08] vs 1.02 [standard error=0.10]; P=0.009). During the entire day, students consumed, on average, 22 fewer grams of sugar daily after implementation compared with before implementation (86 g vs 108 g; P=0.002).ConclusionsWith the reduction in the number of unhealthy school snacks, significantly more students selected school meals. Students did not compensate for lack of unhealthy snacks in school by increased consumption of unhealthy snacks outside of school. This provides important new evidence that both national school meal and snack policies may improve daily diet quality and should remain strong.

  • Dietary Intervention to Increase Fruit and Vegetable Consumption in Breastfeeding Women: A Pilot Randomized Trial Measuring Inflammatory Markers in Breast Milk
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-10
    Angela R. Essa, Eva P. Browne, Elizabeth C. Punska, Katelyn Perkins, Emily Boudreau, Hilary Wiggins, Douglas L. Anderton, Lindiwe Sibeko, Susan R. Sturgeon, Kathleen F. Arcaro

    BackgroundDiets rich in fruits and vegetables (F/V) can reduce the inflammatory profile of circulating cytokines and potentially decrease the risk of breast cancer. However, the extent to which a diet rich in F/V alters cytokine levels in breast tissue remains largely unknown. Breast milk provides a means of assessing concentrations of secreted cytokines in the breast microenvironment and is a potential tool for studying the effects of diet on inflammation in breast tissue and breast cancer risk.ObjectiveThe aim of this pilot randomized trial was to test the feasibility of increasing F/V intake in breastfeeding women and of measuring changes in markers of inflammation in breast milk.Design and interventionParticipants randomized to the intervention (n=5) were provided weekly boxes of F/V, along with dietary counseling, to increase consumption of F/V to 8 to 10 daily servings for 12 consecutive weeks. Controls (n=5) were directed to the US Department of Agriculture’s “ChooseMyPlate” diet for pregnancy and breastfeeding.Participants/settingTen breastfeeding women consuming fewer than five servings of F/V per day, as estimated by the National Institutes of Health “All-Day” Fruit and Vegetable Screener (F/V Screener), were recruited through flyers and a lactation consultant between February and May 2016 in the Western Massachusetts area.Main outcome measuresBaseline demographic and F/V intake data were collected during enrollment. At week 1 and week 13 (final) home visits, participants provided milk samples and anthropometric measurements were recorded. Participants completed F/V screeners at baseline and at study end. Adiponectin, leptin, C-reactive protein, and 11 additional cytokines were measured in breast milk collected at weeks 1 and 13.Statistical analysesF/V consumption at baseline and after the final visit, and between controls and intervention groups, was compared with dependent and independent t tests, respectively. Differences between cytokine levels at weeks 1 and 13 were assessed with a mixed-effects repeated-measures model.ResultsAll women in the intervention increased F/V intake and were consuming more servings than controls by week 13; daily serving of F/V at baseline and final visit: controls=1.6 and 2.0, diet=2.6 and 9.9. Most cytokines were detected in the majority of milk samples: 12 were detected in 90% to 100% of samples, one was detected in 75% of samples, and one was detected in 7.5% of samples; coefficients of variation were below 14% for 11 of the cytokines.ConclusionsThese preliminary findings indicate that it is feasible to significantly increase F/V intake in breastfeeding women and provide support for conducting a larger diet intervention study in breastfeeding women, in which longer-term benefits of the intervention are assessed.

  • Grocery Stores Are Not Associated with More Healthful Food for Participants in the Supplemental Nutrition Assistance Program
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-01
    Allison M. Lacko, Barry M. Popkin, Lindsey Smith Taillie

    BackgroundDespite interventions to improve the nutrition of grocery store purchases, also referred to as at-home (AH) foods, by participants in the Supplemental Nutrition Program (SNAP), little is known about what proportion of participants’ intake is from AH foods and how the dietary quality of AH food compares with participants’ away-from-home (AFH) food. Although recent research indicates SNAP participants have dietary quality that is slightly worse than that of income-eligible nonparticipants, it is unknown whether this is attributable to AH or AFH consumption.ObjectiveThe objective of this study is to examine differences in self-reported dietary intake by food source for SNAP participants compared with income-eligible nonparticipants using 2011-2014 data from the National Health and Nutrition Examination Survey (NHANES).DesignThis study included data from the NHANES, a cross-sectional, nationally representative survey of the United States population.Study participantsThis study included 2,523 adults with low incomes (≤130% of the federal poverty level) in NHANES (2011-2014).Main outcome measuresSelf-reported intake of calories, solid fats, added sugars, and servings of nonstarchy vegetables, whole fruits, and whole grains was assessed by food source in SNAP participants and income-eligible nonparticipants.Statistical analysisMultivariate linear regression was used for each outcome, controlling for relevant sociodemographic characteristics. Data were stratified by food source, including grocery stores, sit-down restaurants, and fast food.ResultsSNAP participants had a higher intake of solid fats and added sugar from AH foods than nonparticipants. Added sugar from AH food accounted for 15.3% of total calories consumed by SNAP participants, compared with 11.8% for nonparticipants (P<0.001). SNAP participants consumed fewer calories from sit-down restaurants, but both groups consumed similar amounts of calories from fast food. Consumption of nonstarchy vegetables, whole fruits, and whole grains was low for both groups.ConclusionsSNAP participants had poorer diet quality from consumption of AH food than did nonparticipants. Future research should focus on interventions to improve the healthfulness of grocery store purchases as a mechanism to improve dietary quality of SNAP participants.

  • Food Insecurity Is Associated with Body Dissatisfaction among Children in California
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-01
    Emily A. Altman, Lorrene D. Ritchie, Edward A. Frongillo, Kristine A. Madsen

    BackgroundFood insecurity affects 13 million children in the United States. Body dissatisfaction is also prevalent, affecting up to 46% of children. Both food insecurity and body dissatisfaction are associated with poor health outcomes, and both are associated with body weight and racial/ethnic disparities. The association between food insecurity and body dissatisfaction among children has not been examined.ObjectiveThe purpose of this study was twofold: to examine, in a sample of children in grades 4 through 8, the relationship of child food insecurity with body dissatisfaction and to gain an understanding of the interactive roles of body mass index (BMI), race/ethnicity, and sex in the relationship between food insecurity and body dissatisfaction.DesignThis was a cross-sectional study.Participants/settingThis study examined data obtained from 14,768 children in grades 4 through 8 from 54 public schools in California between 2014 and 2016.Main outcome measuresThe primary outcome of interest was body dissatisfaction (five items converted to a binary indicator), and the exposure of interest was child-reported food insecurity (three items converted to a binary indicator). Subsets of validated questionnaires were used to assess body dissatisfaction and food insecurity.Statistical analyses performedData were analyzed using multivariable logistic regression, and effect modification was examined by BMI category (underweight, normal, overweight, obese), race/ethnicity, and sex.ResultsIn this large and diverse sample, after adjusting for cofounders, children experiencing food insecurity, in all BMI categories and from all racial/ethnic backgrounds, had higher odds of body dissatisfaction than their food-secure counterparts. The strength of the relationship differed by BMI and race/ethnicity, with the strongest associations observed for African-American children (odds ratio=2.32; P<0.001) and children with a normal children (odds ratio=1.76; P<0.001).ConclusionsExperiencing food insecurity was associated with greater body dissatisfaction, with the magnitude of the association modified by BMI and race/ethnicity.

  • Association between Vitamin D Status and Premenstrual Symptoms
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-09-01
    Alicia C. Jarosz, Ahmed El-Sohemy

    BackgroundPremenstrual symptoms are experienced by up to 95% of women, and few treatments are available. Previous studies suggest that 25-hydroxyvitamin D (25(OH)D) may be associated with the severity of premenstrual symptoms, but the findings have been inconclusive.ObjectiveThe objective of this study was to determine whether vitamin D status is associated with the severity of individual premenstrual symptoms.Design/participantsCross-sectional analysis of 998 women aged 20 to 29 years recruited at the University of Toronto campus from 2004 through 2010.Main outcome measuresParticipants provided data on their premenstrual symptoms in a premenstrual symptom questionnaire. Fasting overnight blood samples were collected, and plasma 25(OH)D was measured. Participants with plasma 25(OH)D concentrations <20 ng/mL were considered to have inadequate vitamin D status, and those with ≥20 ng/mL, adequate vitamin D status.Statistical analyses performedMultinomial logistic regressions were used to calculate the odds ratio (OR) and 95% confidence interval for the associations between vitamin D status and the severity of 15 premenstrual symptoms. Adjustments were made for age, body mass index, ethnicity/race, physical activity, hormonal contraceptive use, season of blood draw, use of analgesics, and calcium intake.ResultsCompared with participants with adequate vitamin D status, those with inadequate vitamin D status had an increased risk (odds ratio [OR]; 95% CI) of experiencing the following mild symptoms: confusion (OR=1.72; 95% CI, 1.14 to 2.59) and desire to be alone (OR=1.47; 95% CI; 1.03 to 2.10), as well as the following moderate/severe symptoms: cramps (OR=1.50; 95% CI, 1.02 to 2.21), fatigue (OR=1.51; 95% CI, 1.04 to 2.21), anxiety (OR=1.63; 95% CI, 1.02 to 2.63), confusion (OR=2.23; 95% CI, 1.18 to 4.21), and sexual desire (OR=1.65; 95% CI, 1.09 to 2.51). Vitamin D status was not associated with other premenstrual symptoms (acne, bloating, mood swings, increased appetite, headache, clumsiness, insomnia, depression, or nausea).ConclusionFindings suggest that inadequate vitamin D status may be associated with increased severity of some, but not all, premenstrual symptoms.

  • Planning Well-Balanced Vegetarian Diets in Infants, Children, and Adolescents: The VegPlate Junior
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-31
    Luciana Baroni, Silvia Goggi, Maurizio Battino
  • Recognition of Federal Dietary Guidance Icons Is Associated with Greater Diet Quality
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-23
    Lisa Jahns, Zach Conrad, LuAnn K. Johnson, Susan K. Raatz, Sibylle Kranz

    BackgroundAlthough the purpose of federal dietary guidance is to improve eating habits, few studies have described awareness of guidance and concurrent diet quality.ObjectiveThe objective of the current study was to examine the prevalence of individuals who reported hearing of dietary guidance icons and to describe the association between having heard of the icons and diet quality.DesignThis study was a cross-sectional survey.Participants/settingParticipants (n=23,343) were from the National Health and Nutrition Examination—What We Eat in America survey 2005–2014 cycles.Main outcome measuresAwareness of the Food Guide Pyramid, MyPyramid, or MyPlate icons by sociodemographic characteristics and diet quality were measured using Healthy Eating Index (HEI) scores derived from 24-hour recall data.Statistical analyses performedGlobal Wald tests were used to test for differences in awareness of the icons within sociodemographic groups. Total HEI scores were calculated using the population-ratio method. Z-scores were used to test differences in HEI total scores between those with knowledge of the icons and those who responded negatively.ResultsIn all cycles, those with less than a high school diploma were the least likely to report having heard of the icons (P<0.001). In every wave except 2011 to 2012, participants with low or marginal food security status were less likely to report affirmatively (P<0.001), and Supplemental Nutrition Assistance Program (SNAP) participants and SNAP-eligible nonparticipants were least likely to report having heard of the icons (P<0.001) except for 2005 to 2006. HEI scores were higher among those who had heard of MyPyramid in 2007-2012 (P<0.05) and MyPlate in 2013-2014 (P<0.001) compared with those who had not heard of the icon.ConclusionsRecognition of federal dietary guidance icons was associated with higher diet quality recently, but the cross-sectional nature of the data precludes conclusions of causality. Further research is needed to identify barriers and promoters for translating awareness of the federal dietary guidance icons into healthful food purchasing and food consumption decisions.

  • Improving Diet Quality Is Associated with Decreased Inflammation: Findings from a Pilot Intervention in Postmenopausal Women with Obesity
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-20
    Kristen Arnold, Kellie R. Weinhold, Rebecca Andridge, Kylie Johnson, Tonya S. Orchard

    Background Chronic inflammation is associated with obesity, morbidity, and mortality in postmenopausal women. Objective The objective of this pilot study was to determine preliminary feasibility and efficacy of a dietary intervention to improve diet quality and lower inflammation. Design The study had a single-arm, pre- and posttest design. Participants/setting Fourteen postmenopausal women (body mass index >30 [calculated as kg/m2]) from the greater Columbus, OH, area participated between August 2015 and April 2016. Intervention This was a 12-week individualized dietary intervention targeting lower consumption of added sugars and increased fiber and fatty fish. Main outcome measures Primary outcomes of this analysis were serum tumor necrosis factor α receptor-2 (TNFαR-2), interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP); other outcomes included intake of targeted food components and Healthy Eating Index-2010 (HEI-2010) scores calculated from food frequency questionnaires at baseline, end of intervention (week 12 [WK12]), and 24-week (WK24) follow-up. Statistical analyses performed Repeated measures analysis of variance and partial Pearson correlations, respectively, were used to assess changes in outcomes and associations between dietary variables and inflammatory markers, controlling for percent weight change. Results Mean levels of TNFαR-2 decreased pre- to postintervention (P<0.01) and remained reduced at WK24 (P<0.001). Mean intake of added sugars and n-3-rich fish improved from baseline to WK12 and remained better at WK24 (all P<0.001); mean fiber intake did not change significantly (P=0.66; baseline to WK24). Mean HEI-2010 score increased (P<0.001; baseline to WK12). Change in HEI-2010 score inversely correlated with change in TNFαR-2 (P<0.05; baseline to WK24). Change in added sugars directly correlated with change in TNFαR-2 (P<0.05; baseline to WK24), but inversely correlated with change in hsCRP (P<0.05; baseline to WK12, and WK12 to WK24). All participants lost weight by WK12 (P<0.001). Conclusions These pilot intervention findings suggest that improving diet quality is associated with decreases in TNFαR-2.

  • Ethnography in Nutrition and Dietetics Research: A Systematic Review
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-20
    Ella Ottrey, Jessica Jong, Judi Porter

    Ethnography is a qualitative research approach used to learn about people and their culture. There is a need to explore the application and use of ethnographic methodology in nutrition and dietetics research to inform future research and practice. Our aim was to examine the extent, range, nature, and contribution of ethnographic methodology in nutrition and dietetics research. Eight electronic databases were searched using a defined search strategy until November 2017. No restrictions were placed on language, date, or study design of original research. Two authors independently assessed titles and abstracts, then full-text records, against inclusion criteria. Hand-searching of reviews identified in the database search was undertaken. Quality assessment was conducted using the Critical Appraisal Skills Programme checklist. Data were described narratively. A total of 2,185 records were identified, with 92 studies from public health nutrition (n=72), clinical nutrition (n=13), and foodservice (n=7) practice areas meeting inclusion criteria. Common research areas included infant/child feeding, food choice, diabetes, nutrition in schools and food insecurity. In addition to observation, frequently reported data collection techniques were interview (n=85), focus groups (n=17), and document analysis (n=10). Ethnographic research was most often reported from North America (n=31), Europe (n=16), and Australia/Oceania (n=13). This research approach was shown to inform dietetic research and practice by illuminating sociocultural factors that influence dietary beliefs and practices, practitioner training opportunities, evaluating nutrition education methods, informing programs and interventions, identifying nutrition policy and guideline focus areas, and the need for new approaches and communication strategies. Ethnography can increase understanding of complex food and nutrition–related health issues and their contributing factors across public health nutrition, foodservice, and clinical dietetic practice. It can be used to explain health inequalities, direct policy, and inform more effective intervention design and delivery. Wider uptake of this research approach as a stand-alone or complementary study design will advance efforts to improve health and wellbeing through food and nutrition.

  • Defining Adherence to Dietary Self-Monitoring Using a Mobile App: A Narrative Review
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-13
    Jason E. Payne, Melanie T. Turk, Melissa A. Kalarchian, Christine A. Pellegrini

    Understanding how adherence to dietary self-monitoring with apps has been defined is a first step toward examining the relationship between adherence and weight loss. The purpose of this review was to explore how adherence to dietary self-monitoring has been defined in the empirical literature that addresses weight loss app use by overweight and obese adults. The integrative review method and the preferred reporting items for systematic reviews and meta-analyses guided this review. Scientific databases (n=5) were searched, which yielded 29 studies. Studies were screened, evaluated for data quality, and then analyzed according to the constant comparison method. Most studies were weak to moderate quality. Results indicated that adherence was operationally defined in two ways. Adherence was defined as either adherent or nonadherent based on the completion of recording a minimum amount of calorie intake or a calorie amount within a specific range of calories. Another way that adherence was defined was the frequency of dietary self-monitoring, which included the frequency of dietary intake recording, interaction with apps, and the timing of recording. Some studies defined adherence in both ways. Most included studies lacked diversity in study samples. Until a consensus is reached, it may be prudent to study multiple indicators of adherence to dietary self-monitoring using apps, and their respective relationships with weight loss. Studies are needed that address the type and degree of adherence to dietary self-monitoring with an app that is associated with weight loss in diverse populations.

  • Dietary Assessment with a Wearable Camera among Children: Feasibility and Intercoder Reliability
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-08-13
    Alicia Beltran, Hafza Dadabhoy, Courtney Ryan, Ruchita Dholakia, Wenyan Jia, Janice Baranowski, Mingui Sun, Tom Baranowski

    BackgroundThe eButton, a multisensor device worn on the chest, uses a camera to passively capture images of everything in front of the child throughout the day. These images can be analyzed to provide a passive method of dietary intake assessment.ObjectiveThis study assessed the eButton’s feasibility and intercoder reliability for dietary intake assessment.DesignChildren were recruited in the summer and fall of 2015, in Houston, TX, to wear the eButton to take 2 full days of dietary images, and the child–parent dyad participated in a following-day interview to verify what dietitians recorded from the images.Participants/settingThirty 9- to 13-year-old children participated during days convenient to them.Main outcome measuresTwo dietitians independently manually reviewed the images to identify eating events, foods in those events, and portion sizes.Statistical analyses performedDescriptive statistics of agreements and disagreements were calculated between dietitians and with children; t tests and Bland-Altman plots of differences in total kilocalories were calculated between dietitians and between initial dietitian estimates and those finalized after the verification interviews.ResultsThe dietitians agreed on the identity of 60.5% of the 1,026 foods but disagreed on 28.6% of the foods and on the names for 10.8% of the foods. After the verification interviews, the dietitians agreed with the child–parent dyads on the identity of 77.0% of the 921 foods; the child–parent dyad identified 12.4% of the day’s foods when images were not available or not clear; the child–parent dyad clarified that 5.4% of the foods identified were not consumed by the child; and the child–parent dyad clarified the identity of 5.2% of the foods. A software-based approach (three-dimensional wire mesh) could be used to estimate portion size on 24% of the foods, and professional judgment was required for 67.8%. Mean caloric intakes per day were not statistically significantly different between dietitians but were different between dietitians and child–parent dyads in total and on day 2.ConclusionsAn early test of intercoder reliability of an all-day image method of dietary intake assessment obtained intercoder agreement between the two dietitians processing these images of intraclass correlation coefficient=0.67. A following-day verification interview with the child and parent was necessary to ensure completeness of estimates. Several feasibility problems occurred, which may be remedied with additional participant and dietitian training and further technological development.

  • Monthly Variations in Dietary Intake of Women Participating in the Supplemental Nutrition Assistance Program
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-29
    Namrata Sanjeevi, Jeanne Freeland-Graves

    Background Households participating in the Supplemental Nutrition Assistance Program (SNAP) have been shown to spend the majority of their program benefits within the first 3 days of receipt. Hence, it is important to investigate dietary intakes of SNAP participants based on time since receipt of benefits. Objective The objectives of this study were to investigate the dietary intake of women participating in SNAP over 1 month and to compare diet quality between food secure and food insecure women using two indices. Design A longitudinal design was used to examine monthly dietary intake of women in SNAP. Participants were measured for height and weight. A demographics questionnaire and a food frequency questionnaire (FFQ) based on a reference period of 1 week were administered. The FFQ was completed four times, with an interval of 1 week, so that it reflected the diets of participants during weeks 1, 2, 3, and 4 of benefit receipt. Participants also completed the US adult food security module. The Healthy Eating Index-2010 and the Dietary Guidelines Adherence Index 2015 were used to assess diet quality. Participants/setting A total of 217 women were recruited from low-income housing and neighborhood centers in Central Texas from January to December 2015. Women enrolled in SNAP, aged 18 to 50 years, and of Hispanic, African-American, and white race or ethnicity participated in the study. Fifty-eight women were lost during follow-up. Data from eight participants was excluded due to reporting of implausible caloric intakes, thereby resulting in a final sample of 151. Main outcome measures Food group, nutrient intake, and diet quality were the main outcome measures of the study. Statistical analysis A mixed linear model was conducted using week since receipt of benefits as the independent variable and food group, nutrient intake, and diet quality as the dependent variables. An analysis of variance was conducted to determine differences in diet quality based on food security status for each week of the monthly SNAP cycle. Results A significant decrease in daily intakes of fruits, vegetables, dairy, and diet quality was observed over the month (P<0.05, with Bonferroni adjustment). Food secure women had higher diet quality than those with very low food security (P<0.05, with Bonferroni adjustment). However, a decline in diet quality was observed in all groups of women, classified according to food security status. Conclusions These results show that dietary intake of SNAP participants varies based on time since receipt of benefits.

  • How Does Context Relate to Nutrition Promotion and Mealtime Practice in Early Care and Education Settings? A Qualitative Exploration
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-29
    Taren Swindle, Josh Phelps

    Background Early childhood educators have the potential to influence children’s dietary outcomes through daily interactions. However, existing research suggests that educator practices are often suboptimal. Previous research has often focused on individual characteristics that affect practices. There is less study of contextual influences of practices of early childhood educators. Objective The purpose of this study was to understand and describe contextual factors evident in narratives of early childhood educators influencing mealtime and nutrition promotion practices. We use the Promoting Action on Research Implementation in Health Services framework to consider how contextual factors related to practices of early childhood educators. Design This cross-sectional, qualitative study collected data through in-depth interviews with early childhood educators. Analyses of the data reflected a factist perspective and semantic approach to complete thematic content analysis of in-depth interviews. Participants The study used a stratified purposive sampling approach to recruit 28 educators to balance across educator role, agency type (Head Start vs state-funded), and obesity prevalence in the community. Early childhood educators were mostly lead teachers (62%), between the ages of 30 and 49 (82.1%), and white (75%) or African American (14.3%). Results The coders identified three primary themes: Mealtime Structures, Resources, and Classroom/Center Atmosphere. Mealtime Structures associated with detrimental practices included cafeteria meals with rigid schedules. Mealtime Structures associated with evidence-based practices (EBPs) included classroom meal service. Resources associated with detrimental practices included limited funding. Resources associated with EBPs included meals paid for early childhood educators and classroom food experiences. Classroom/Center Atmosphere factors associated with detrimental practices included poor food offerings and policies that conflicted (eg, allowing children to bring in outside foods). Classroom/Center Atmosphere factors associated with EBPs included clarity around meal service rules and healthy, appealing food offerings. Conclusions This study highlighted that it may be difficult for an early childhood educator to adopt and maintain EBPs in certain contexts.

  • Role of Drill Sergeants in Nutrition Behaviors of Soldiers in Basic Combat Training
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-27
    Julianna M. Jayne, Barbara K. Bujak, Toni M. Torres-McGehee, Edward A. Frongillo, Sonya J. Cable, Christine E. Blake

    Background In the US Army, soldiers’ nutrition behaviors have a direct impact on their performance. The emphasis in basic combat training is on “soldierization” (transforming a civilian into a soldier), and drill sergeants are instrumental in this process. Limited information about how drill sergeants use their influence to have an impact on nutrition behaviors of new soldiers is available. Objective This study aimed to determine nutrition attitudes, beliefs, and knowledge of drill sergeants; the ways drill sergeants instill new soldiers with an army identity (eg, warrior athlete, army strong); and how healthy eating is perceived to fit with this new identity. Design This qualitative, phenomenological study used in-depth interviews conducted with army drill sergeants at two southeast US Army posts between July and August 2011 (n=30). Main outcome measures Interviews emphasized drill sergeants’ perceptions of the eating environment during basic training, the drill sergeant role, and drill sergeants' main duties. Data analysis An iterative process of group coding using a constant comparative method was used to find distinct themes. Data were analyzed using qualitative data analysis software. Results Drill sergeants described their main duty as training new soldiers. Drill sergeants identified the ideal soldier as lean and physically fit but did not identify training soldiers how to eat to become the ideal soldier as part of their duties. Confusion about nutrition concepts was common. Overall, drill sergeants recognized that what soldiers eat affects their physical performance and appearance, but they did not see helping soldiers establish healthy eating behaviors as one of their duties or responsibilities during basic combat training. Conclusions Drill sergeants are key individuals in the process by which new recruits develop a soldier identity. Additional resources are necessary to help drill sergeants emphasize nutrition and health during basic combat training and help them guide soldiers toward adopting healthy eating as part of their soldier identity to improve weight management, health, and performance.

  • Food Acquisition and Shopping Patterns among Residents of Low-Income and Low-Access Communities in South Carolina
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-24
    Xiaonan Ma, Patricia A. Sharpe, Bethany A. Bell, Jihong Liu, Kellee White, Angela D. Liese

    Background Little is known about the food acquisition and shopping habits of residents living in food deserts. Objective To identify distinct food acquisition and shopping patterns among residents, most of whom (81%) live in food desert (low income and low access) census tracts, and characterize these patterns with respect to the residents’ socioeconomic status, nutrition knowledge, and perceptions of their food environment. Design This is a cross-sectional study. Participants/setting Four hundred sixty-six primary food shoppers were included from two counties in South Carolina during 2013-2014. Main outcome measures Participants’ self-reported food acquisition and shopping habits, including shopping distance; frequency; store type; transportation mode; use of farmers’ markets, food banks/pantries, and church/social service organizations, were used to develop shopping patterns and group residents. Supplemental Nutrition Assistance Program participation, food security, income, and education, nutrition knowledge, and perceptions of the food environment were used to characterize these groups. Statistical analyses performed Latent class analysis and multinomial logistic regression were used to identify and characterize patterns, respectively. Results Three patterns were identified, including those who use community food resources, are infrequent grocery shoppers, and use someone else’s car or public transportation when shopping (Class 1) (35%), those who use community food resources and are more frequent and proximal shoppers (Class 2) (41%), and those who do not use community food resources and are distal shoppers (Class 3) (24%). Compared with Class 3, Class 1 had comparatively lower socioeconomic status. Class 2 also had comparatively lower socioeconomic attributes except for income. Class 2 was not significantly different from Class 1 except that a higher proportion in Class 1 saw food access as a problem. No significant differences across classes were found regarding fruit and vegetable recommendation knowledge. Conclusions Shopping frequency, use of community food resources, transportation methods, and shopping distance were the key factors that defined distinct patterns among residents living in low-income areas. Future interventions to increase healthy food access in underserved areas should not only consider accessibility but also community food resource use.

  • Caffeine Transiently Affects Food Intake at Breakfast
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-19
    Leah M. Panek-Shirley, Carol DeNysschen, Erin O’Brien, Jennifer L. Temple

    BackgroundCaffeine is frequently added to dietary supplements with claims it facilitates weight loss.ObjectiveThe purpose of this study was to test the hypothesis that caffeine administration reduces laboratory and free-living food intake by reducing appetite and that these effects vary by body mass index (BMI).Participants/settingFifty adults aged 18 to 50 years completed the study (42% male). Exclusion criteria included no previous experience with caffeine, previous adverse event following caffeine consumption, taking any medications or having a medical condition contraindicating caffeine or stimulant consumption or affecting appetite or eating, and reported tobacco use within the past 6 months.Design and interventionParticipants visited the laboratory on four separate occasions to complete a double-blind, placebo-controlled, randomized, crossover study. On the first three visits, participants consumed a beverage containing 0, 1, or 3 mg/kg caffeine (order randomized). Thirty minutes later, participants consumed a buffet breakfast, ad libitum. After leaving the laboratory, participants completed hourly appetite assessments and dietary habit books until midnight or bedtime. The fourth session consisted of questionnaires, debriefing, and compensation.Main outcome measuresTotal and macronutrient intake and appetite sensations in and out of the laboratory were measured.Statistical analyses performedIntake data were analyzed using mixed analysis of covariance (ANCOVA). Appetite sensations were analyzed using repeated measures mixed ANCOVA.ResultsTotal laboratory energy intake was lower (∼10%) after 1 mg/kg caffeine (650.4±52.2 kcal at 1 mg/kg; 721.2±63.2 at 0 mg/kg; 714.7±79.0 at 3 mg/kg) (P=0.046). In the laboratory, appetite sensations were not significantly different by caffeine treatment. Out of the laboratory, neither total intake nor appetite was significantly different by caffeine treatment. There were no significant interactions between caffeine treatment and BMI on intake and appetite sensations in or out of the laboratory.ConclusionsThese results suggest caffeine has weak, transient effects on energy intake and do not support caffeine as an effective appetite suppressant.

  • Improved Access to and Impact of Registered Dietitian Nutritionist Services Associated with an Integrated Care Model in a High-Risk, Minority Population
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-17
    Molly F. Warner, Kristine E. Miklos, Shelley R. Strowman, Kathy Ireland, Rachele M. Pojednic

    Background Integrated health care models create opportunities for registered dietitian nutritionists (RDNs) to provide nutrition-related care and engage in multidisciplinary teams to improve clinical outcomes. While benefits of integrated care (IC) have been reported, little is known about the impact of the RDN within an IC model. Objective Our primary objective was to identify whether IC vs traditional care (TC) increases the number of RDN patient visits. Our secondary objective was to evaluate clinical outcomes of patients seeing an RDN vs not, regardless of care model. Design This was a retrospective cohort study. Participants/setting Patients were aged 3 to 94 years and from a patient-centered medical home in Boston, MA. Main outcome measures We measured 3-month total and average number of patients seen by the RDN in TC vs IC. Changes in adult hemoglobin A1c, weight, and pediatric body mass index (measured as kg/m2) among high-risk patients seen by an RDN compared to patients not seen by an RDN. Statistical analysis Data were obtained from electronic medical records and analyzed utilizing Mann-Whitney U test, analysis of covariance, and paired sample t tests. Results The RDN saw 145 patients (137 adult, 8 pediatric) in the TC model compared to 185 patients (135 adult, 50 pediatric) in the IC model. Mean number of patients seen per session was 3.20 in the TC model vs 4.63 in the IC model (P=0.004). Adult hemoglobin A1c within-group differences decreased by 0.42%±1.49% (P=0.007) for patients seen by an RDN and decreased 0.15%±1.47% (P=0.012) for patients not seen by an RDN. Adult weight within-group differences decreased 1.0±7.2 kg (P=0.15) for patients seen by a RDN and increased 0.1±5.6 kg (P=0.70) for patients not seen by a RDN. Pediatric BMI showed no change between or within groups. Conclusions The IC model increased 3-month total number of patients seen by an RDN. High-risk patients who saw an RDN had a significant decrease in hemoglobin A1c.

  • Examining the Feasibility of Healthy Minimum Stocking Standards for Small Food Stores
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-09
    Allison Karpyn, Robin S. DeWeese, Jennifer E. Pelletier, Melissa N. Laska, Punam Ohri-Vachaspati, Amy Deahl-Greenlaw, Ogheneruona Ughwanogho, Stephanie Bell Jilcott Pitts

    ObjectiveIn response to recent national efforts to increase the availability of healthy food in small stores, we sought to understand the extent to which small food stores could implement the newly published Healthy Small Store Minimum Stocking Recommendations and reflect on the new US Department of Agriculture Food and Nutrition Service's final rule for stocking of staple foods for Supplemental Nutrition Assistance Program–approved retailers.DesignWe collected qualitative and quantitative data from 57 small stores in four states (Arizona, Delaware, Minnesota, and North Carolina) that accepted Supplemental Nutrition Assistance Program but not Special Supplemental Nutrition Assistance Program for Women, Infants, and Children benefits. Data from semistructured, in-depth interviews with managers/owners were transcribed, coded, and analyzed. We collected quantitative store inventory data onsite and later performed descriptive analyses.ResultsStore interviews revealed a reluctant willingness to stock healthy food and meet new recommendations. No stores met recommended fruit and vegetable stocking, although 79% carried at least one qualifying fruit and 74% carried at least one qualifying vegetable. Few stores met requirements for other food categories (ie, whole grains and low-fat dairy) with the exception of lean proteins, where stores carrying nuts or nut butter were more likely to meet the protein recommendation. Water and 100% juice were widely available and 68% met basic healthy beverage criteria.ConclusionsIn contrast to the inventory observed, most owners believed store stock met basic recommendations. Further, findings indicate that small stores are capable of stocking healthy products; however, technical and infrastructure support, as well as incentives, would facilitate shifts from staple to healthier staple foods. Retailers may need support to understand healthier product criteria and to drive consumer demand for new products.

  • How Social, Cultural, and Economic Environments Shape Infant Feeding for Low-Income Women: A Qualitative Study in North Carolina
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-11
    Annie Hardison-Moody, Lillian MacNell, Sinikka Elliott, Sarah Bowen

    BackgroundThis study focuses on the cultural, social, and economic factors that shape infant feeding practices among low-income mothers.ObjectiveThe objective was to understand factors that inhibit or facilitate breastfeeding practices of low-income mothers, including how they are linked to broader social, cultural, and economic processes.DesignIn-depth qualitative interviews were conducted with women about their feeding practices and food environments, including their experiences with breastfeeding and formula feeding.ParticipantsThe sample was comprised of 98 low-income mothers with at least one child between 2 and 9 years old at the time of interview.ResultsSixteen mothers (16.7%) breastfed for 6 months, and six (6.3%) were still breastfeeding at 12 months. Only 11 mothers (11.5%) exclusively breastfed for 6 months. Women reported several factors influencing infant feeding: interactions with medical providers, work environments, shared living spaces and family supports, and concerns about supply and production.ConclusionsThis research highlights the complex interplay of economic and social barriers that shape how and what low-income women feed their infants. The study contributes to a better understanding of the social, cultural, and economic constraints faced by women in poverty. To improve breastfeeding rates among low-income women, it is important to examine the impacts of poverty and food insecurity on infant feeding practices.

  • Reliability and Validity of Digital Imagery Methodology for Measuring Starting Portions and Plate Waste from School Salad Bars
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-12
    Melanie K. Bean, Hollie A. Raynor, Laura M. Thornton, Alexandra Sova, Mary Dunne Stewart, Suzanne E. Mazzeo

    BackgroundScientifically sound methods for investigating dietary consumption patterns from self-serve salad bars are needed to inform school policies and programs.ObjectiveTo examine the reliability and validity of digital imagery for determining starting portions and plate waste of self-serve salad bar vegetables (which have variable starting portions) compared with manual weights.Design/methodsIn a laboratory setting, 30 mock salads with 73 vegetables were made, and consumption was simulated. Each component (initial and removed portion) was weighed; photographs of weighed reference portions and pre- and post-consumption mock salads were taken. Seven trained independent raters visually assessed images to estimate starting portions to the nearest ¼ cup and percentage consumed in 20% increments. These values were converted to grams for comparison with weighed values.Statistical analysesIntraclass correlations between weighed and digital imagery–assessed portions and plate waste were used to assess interrater reliability and validity. Pearson’s correlations between weights and digital imagery assessments were also examined. Paired samples t tests were used to evaluate mean differences (in grams) between digital imagery–assessed portions and measured weights.ResultsInterrater reliabilities were excellent for starting portions and plate waste with digital imagery. For accuracy, intraclass correlations were moderate, with lower accuracy for determining starting portions of leafy greens compared with other vegetables. However, accuracy of digital imagery–assessed plate waste was excellent. Digital imagery assessments were not significantly different from measured weights for estimating overall vegetable starting portions or waste; however, digital imagery assessments slightly underestimated starting portions (by 3.5 g) and waste (by 2.1 g) of leafy greens.ConclusionsThis investigation provides preliminary support for use of digital imagery in estimating starting portions and plate waste from school salad bars. Results might inform methods used in empirical investigations of dietary intake in schools with self-serve salad bars.

  • A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-12
    Kylie Matthews, Jan Hill, Shane Jeffrey, Susan Patterson, Amanda Davis, Warren Ward, Michelle Palmer, Sandra Capra

    BackgroundPatients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using “start low, go slow” refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts.ObjectiveTo compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs.DesignThis was a retrospective pre-test–post-test study.Participants/settingOne hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013.Main outcome measuresDifferences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined.Statistical analysis performedχ2 tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols.ResultsDescriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391).ConclusionsA higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.

  • Body Composition Measurement in Bronchiectasis: Comparison between Bioelectrical Impedance Analysis, Skinfold Thickness Measurement, and Dual-Energy X-ray Absorptiometry before and after Pulmonary Rehabilitation
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-12
    Esperanza Doña, Casilda Olveira, Francisco Javier Palenque, Nuria Porras, Antonio Dorado, Rocío Martín-Valero, Ana M. Godoy, Francisco Espíldora, Victoria Contreras, Gabriel Olveira

    BackgroundIn individuals with bronchiectasis, fat-free mass depletion may be common despite a low prevalence of underweight and is considered a risk factor for increased morbidity and mortality. Techniques to adequately estimate fat-free mass and its changes over time are needed.ObjectiveThe purpose of this study was to assess agreement among values obtained with three different body composition techniques: skinfold thickness measurement (STM), bioelectrical impedance analysis (BIA), and dual-energy x-ray absorptiometry (DXA).DesignThe study was a secondary analysis of data from a randomized controlled trial.Participants/settingA respiratory rehabilitation program was administered for 3 months to individuals with bronchiectasis from the bronchiectasis unit of the Regional University Hospital in Malaga, Spain, from September 2013 to September 2014. Individuals with a body mass index (calculated as kg/m2) >18.5 who were aged 65 years or younger and those with a body mass index >20 who were older than 65 years were included.Main outcome measuresAt baseline and at 3 and 6 months, body composition was determined by DXA and STM.Statistical analyses performedStatistical concordance was assessed with the intraclass correlation coefficient (ICC), kappa coefficient, and the degree of agreement using the Bland Altman method. For comparison of the quantitative variables at baseline vs at 3 months and 6 months, the paired sample t test (or the Wilcoxon test) was used.ResultsThirty participants were included. Strong agreement was observed between body composition values determined by BIA and DXA in fat mass (ICC: 0.92) and fat-free mass (ICC: 0.87). Strong agreement was observed between STM and DXA in the values for fat-free mass (ICC: 0.91) and fat mass (ICC: 0.94), and lower agreement was observed for the longitudinal data and in the regional values. The mean difference between fat-free mass determined by BIA and DXA was + 4.7 with a standard deviation of 2.4 kg in favor of BIA. The mean difference between fat-free mass determined by STM and DXA was +2.3 with a standard deviation of 2.7 kg in favor of STM. Six individuals were classified as having a low fat-free mass index (20%) by DXA vs four by STM (13%; kappa: 0.76) and only two by BIA (6.6%; kappa: 0.44) compared with DXA.ConclusionsDespite good statistical agreement among values obtained with DXA, STM, and BIA, the study findings indicate that STM and BIA, above all, tended to overestimate fat-free mass compared with DXA.

  • A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-22
    Jennifer Burris, James M. Shikany, William Rietkerk, Kathleen Woolf

    BackgroundA high glycemic index (GI) and glycemic load (GL) diet may stimulate acne proliferative pathways by influencing biochemical factors associated with acne. However, few randomized controlled trials have examined this relationship, and this process is not completely understood.ObjectiveThis study examined changes in biochemical factors associated with acne among adults with moderate to severe acne after following a low GI and GL diet or usual eating plan for 2 weeks.DesignThis study utilized a parallel randomized controlled design to compare the effect of a low GI and GL diet to usual diet on biochemical factors associated with acne (glucose, insulin, insulin-like growth factor [IGF]-1, and insulin-like growth factor binding protein [IGFBP]-3) and insulin resistance after 2 weeks.ParticipantsSixty-six participants were randomly allocated to the low GI and GL diet (n=34) or usual eating plan (n=32) and included in the analyses.Main outcome measuresThe primary outcomes were biochemical factors of acne and insulin resistance with dietary intake as a secondary outcome.Statistical analysesIndependent sample t tests assessed changes in biochemical factors associated with acne, dietary intake, and body composition pre- and postintervention, comparing the two dietary interventions.ResultsIGF-1 concentrations decreased significantly among participants randomized to a low GI and GL diet between pre- and postintervention time points (preintervention=267.3±85.6 mg/mL, postintervention=244.5±78.7 ng/mL) (P=0.049). There were no differences in changes in glucose, insulin, or IGFBP-3 concentrations or insulin resistance between treatment groups after 2 weeks. Carbohydrate (P=0.019), available carbohydrate (P<0.001), percent energy from carbohydrate (P<0.001), GI (P<0.001), and GL (P<0.001) decreased significantly among participants following a low GI/GL diet between the pre- and postintervention time points. There were no differences in changes in body composition comparing groups.ConclusionsIn this study, a low GI and GL diet decreased IGF-1 concentrations, a well-established factor in acne pathogenesis. Further research of a longer duration should examine whether a low GI and GL diet would result in a clinically meaningful difference in IGF-1 concentrations leading to a reduction in acne. This trial was registered at clinicaltrials.gov as NCT02913001.

  • Understanding Customers: The Jobs to Be Done Theory Applied in the Context of a Rural Food Pantry
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-30
    J. Mitchell Vaterlaus, Natalie Martineau Cottle, Emily Vaterlaus Patten, Robyn Gibbons

    BackgroundFood insecurity, and particularly rural food insecurity, has unique challenges associated with it. Understanding the customer or patron needs is increasingly important in resolving this national concern. The Jobs to Be Done Theory posits that when considering customers, it is beneficial to move past demographic profiling and focus on what the customer wants to accomplish by using a particular product or service.ObjectiveThis qualitative study aimed to determine customers’ jobs to be done at a rural food pantry. In addition, it seeks to demonstrate the application of contemporary management theory to dietetics practice.DesignA case study approach was used in this study. Case study data collection procedures included six male and six female food pantry patrons in Montana completing in-depth, audio-recorded interviews and surveys. Each person’s interview and survey were constructed into individual case descriptions; the case descriptions were analyzed using uniform categories determined by researchers. To identify themes in the holistic case, word tables were created for each uniform category and assessed for key themes representing patrons’ experiences.ResultsThe key themes that emerged were the customer in context, customers’ food relief needs, connecting with customers, and barriers to utilization.ConclusionsThe application of Jobs to Be Done Theory to rural food pantry customers demonstrates that demographic segmentation does not capture the social, emotional, and functional dimensions for this sample. Investigation of customer experiences, circumstances, and obstacles is important for improving dietetics services.

  • Dietary Intake, Nutrient Status, and Growth Parameters in Children with Autism Spectrum Disorder and Severe Food Selectivity: An Electronic Medical Record Review
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-10
    William G. Sharp, Valentina Postorino, Courtney E. McCracken, Rashelle C. Berry, Kristen K. Criado, T. Lindsey Burrell, Lawrence Scahill

    Background Food selectivity is common in children with autism spectrum disorder (ASD). The clinical characteristics, however, of severe food selectivity in children with ASD is not well documented. Objective This study examined the demographic characteristics, anthropometric parameters, risk of nutritional inadequacy, dietary variety, and problematic mealtime behaviors in a sample of children with ASD with severe food selectivity. Design The study involved a cross-sectional electronic medical record review. Data extraction followed a systematic protocol for data extraction. Participants/setting Children (age 2 to 17 years) with ASD, severe food selectivity, and complete nutritional data who received a multidisciplinary evaluation at a specialty feeding clinic in the southeastern United States between January 2014 and January 2016. Criteria for severe food selectivity used in this clinical practice required complete omission of one or more food groups (eg, fruit, vegetable, protein, grain, dairy) or consuming a narrow range of items on a weekly basis (eg, five or fewer total food items). Main outcome measures Analyses examined demographic characteristics, dietary preferences, risk for nutritional inadequacies, anthropometric parameters, and problematic mealtime behaviors. Results Of the 279 patients evaluated during the 24-month period, 70 children with ASD and severe food selectivity met inclusion criteria. Caregivers reported 67% of the sample (n=47) omitted vegetables and 27% omitted fruits (n=19). Seventy-eight percent consumed a diet at risk for five or more inadequacies. Risk for specific inadequacies included vitamin D (97% of the sample), fiber (91%) vitamin E (83%), and calcium (71%). Children with five or more nutritional inadequacies (n=55) were more likely to make negative statements during meals (P<0.05). Severe food selectivity was not associated with compromised growth or obesity. Conclusion Children with ASD and severe food selectivity may be at increased risk for nutritional inadequacies. Future research should examine causes, consequences, and remediation of severe food selectivity in this population.

  • A Retrospective Study Identifying Breast Milk Feeding Disparities in Infants with Cleft Palate
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-07-12
    Michele M. Gottschlich, Theresa Mayes, Chris Allgeier, Laura James, Jane Khoury, Brian Pan, John A. van Aalst

    Background Breast milk represents the optimal substrate for all infants, including those with a cleft palate for whom growth may be compromised. Objectives Frequency of breast milk feeding at the breast and per feeder (bottle, cup, enteral tube) in infants with cleft palate was determined and compared with rates reported by the Centers for Disease Control and Prevention. A secondary aim was to review growth status of the infants. Design This study represents a 5-year retrospective review using the electronic medical record. Participants and setting Patients were ≤12 months old at the time of the initial, presurgical encounter after a diagnosis of cleft palate had been made and were treated at one of two pediatric cleft palate and craniofacial centers in Ohio between September 30, 2010, and September 30, 2015. Main outcome measures Outcomes measured were breast milk use, reported by mothers and documented in patients' electronic medical records, chronological body weight, as well as weight for length and weight-for-age z scores and percentiles. Statistical analyses performed Descriptive statistics included median with interquartile range and frequency with percentages. World Health Organization z scores were estimated using the Centers for Disease Control and Prevention programs for weight, weight for length, and weight for age at first visit. Comparisons of infants treated at the two hospitals were done using the Wilcoxon rank-sum test or the χ2 test. Results Breast milk consumption (26 infants were breastfed and 84 received human breast milk administered with a device) was 29.5%, markedly below the 2016 Centers for Disease Control and Prevention national statistics for ever receiving breast milk (81%). Anthropometric findings included z scores of −0.95 and −0.42 for weight for age and weight for length, respectively. Conclusions Infants with cleft palate were seldom breastfed, nor was breast milk frequently used. In addition, median weight-for-age and weight-for-length z scores suggest that growth of infants with cleft palate was below normative standards.

  • Latino Fathers’ Perspectives and Parenting Practices Regarding Eating, Physical Activity, and Screen Time Behaviors of Early Adolescent Children: Focus Group Findings
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-06-23
    Youjie Zhang, Ghaffar Ali Hurtado, Rafael Flores, Antonio Alba-Meraz, Marla Reicks

    Background Involvement of Latino fathers in food and activity parenting practices has implications for child obesity prevention yet remains largely unknown. Objective To explore Latino fathers’ perspectives and parenting experiences regarding early adolescents’ eating, physical activity, and screen-time behaviors using the focus group method. Design Twenty-six fathers (primarily Mexican-American men) of 10- to 14-year-old children participated in one of four focus groups between March and October 2016. Focus groups were conducted in Spanish by male moderators. Participants/settings A convenience sample was recruited from three community centers and one charter school in Minneapolis/St Paul, MN. Analysis Audiotaped focus groups were transcribed verbatim in Spanish and translated to English; transcripts were coded and analyzed for themes based on the grounded theory approach. Results Three themes emerged including 1) paternal beliefs and concerns about early adolescents’ diet, physical activity, and screen time; 2) paternal food and activity parenting practices; and 3) factors that may influence paternal involvement in promoting healthy lifestyle behaviors. Father-reported food and activity parenting practices included setting expectations and limits, role modeling, managing availability and accessibility, teaching and reasoning, monitoring, motivating, and doing things together. Factors influencing paternal involvement were identified at intrapersonal, interpersonal, and social-environmental levels, which included paternal dietary and activity behaviors, self-efficacy, time and financial constraints, parental congruency, child resistance, perceived gender role, and environmental challenges. Conclusions Fathers identified eight major food and activity parenting practices they use to promote a healthy lifestyle for their adolescent children and factors that influence their involvement. Health care professionals can use this information to provide culturally appropriate and specific interventions for Latino American fathers of young adolescents.

  • A Cluster-Randomized Trial of a Mobile Produce Market Program in 12 Communities in North Carolina: Program Development, Methods, and Baseline Characteristics
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-06-23
    Lucia A. Leone, Gina L. Tripicchio, Lindsey Haynes-Maslow, Jared McGuirt, Jaqueline S. Grady Smith, Janelle Armstrong-Brown, Sarah D. Kowitt, Ziya Gizlice, Alice S. Ammerman

    Background Mobile markets are an increasingly popular method for providing access to fresh fruits and vegetables (F/V) in underserved communities; however, evaluation of these programs is limited, as are descriptions of their development, study designs, and needs of the populations they serve. Objective Our aim was to describe the development and theoretical basis for Veggie Van (VV), a mobile produce market intervention, the study design for the VV evaluation, and baseline characteristics of the study population. Design The protocol and sample for a cluster-randomized controlled trial with 12 sites are described. Participants/setting Community partner organizations in the Triangle region of North Carolina that primarily served lower-income families or were located in areas that had limited access to fresh produce were recruited. Eligible individuals at each site (older than 18 years of age, self-identified as the main shoppers for their household, and expressed interest in using a mobile market) were targeted for enrollment. A total of 201 participants at 12 sites participated in the VV program and evaluation, which was implemented from November 2013 to March 2016. Main outcome measures Change in F/V intake (cups/day), derived from self-reported responses to the National Cancer Institute F/V screener, was the main outcome measure. Statistical analyses performed We performed a descriptive analysis of baseline sample characteristics. Results Mean reported F/V intake was 3.4 cups/day. Participants reported generally having some access to fresh F/V, and 57.7% agreed they could afford enough F/V to feed their family. The most frequently cited barriers were cost (55.7%) and time to prepare F/V (20.4%). Self-efficacy was lowest for buying more F/V than usual and trying new vegetables. Conclusions By addressing cost and convenience and building skills for purchasing and preparing F/V, the VV has the potential to improve F/V consumption in underserved communities.

  • Latino/Hispanic Participation in Community Nutrition Research: An Interplay of Decisional Balance, Cultural Competency, and Formative Work
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-06-22
    Lillian Karina Diaz Rios, Karen Chapman-Novakofski

    Background Latinos/Hispanics are among the populations at high risk of nutrition disparities. Adequate participation of this group in community nutrition research is necessary to better understand such disparities and propose sensible solutions. Objective To identify factors influencing participation and strategies to effectively reach Latinos/Hispanics for community nutrition research. Design In-depth interviews with experienced community nutrition researchers across the United States, conducted from February to June 2013. Participants/setting Nine academics, including four registered dietitian nutritionists with extensive experience in community nutrition research with Latino/Hispanic groups, were interviewed in person (n=3) or via telephone/Skype (n=6). Main outcome measures Perceived participation barriers, facilitators, and structural factors affecting Latino/Hispanic participation were explored. Successful and unsuccessful recruitment strategies to reaching this group were identified. Analysis A Grounded Theory approach was applied for inductive identification of relevant concepts and deductive interpretation of patterns and relationships among themes. Results Formative work, cultural competency, and decisional balance emerged as the three interdependent factors influencing participation of Latinos/Hispanics in community nutrition research. Several approaches to influence participation were reported to be operationalized at the interpersonal, community and settings, and systems levels of influence. Trust, time, and tailoring were central concepts, postulated to moderate the relationship between the main themes and influence the effectiveness of recruitment tactics. Conclusions Experienced community nutrition researchers identified actions ascribed to formative work as the bedrock of successful reach of Latinos/Hispanics. A robust formative work plan is necessary to achieving a functional level of trust, time, and tailoring tactics, which appear to critically influence participation.

  • Open Access Dietary Supplement Use in a Large, Representative Sample of the US Armed Forces
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-06-19
    Joseph J. Knapik, Krista G. Austin, Emily K. Farina, Harris R. Lieberman

    Background Dietary supplement (DS) use is prevalent among the US Armed Forces personnel, but representative cross-service comparisons and characteristics of personnel using DSs are limited. Objective Examine DS use and characteristics associated with use in a representative sample of US Armed Forces personnel (Army, Navy, Air Force, Marine Corps, and Coast Guard) using data from the 2011 Department of Defense Survey of Health-Related Behaviors. Design and participants A stratified random sample of service members (SMs) was contacted and asked to complete a questionnaire assessing personal characteristics and DS use. Results Overall, 69% of the 39,877 SMs reported using DSs ≥1 time per week. The most commonly used DSs were multivitamin or multiminerals (50%), antioxidants (34%), individual vitamins or minerals (33%), bodybuilding supplements (27%), fish oils (26%), herbals (16%), and weight-loss supplements (16%). Multiple logistic regression indicated overall DS use was higher among women, those with higher educational levels, Marine Corps SMs, officers, those with higher body mass index, those engaged in greater physical activity and weight training, and people in weight control programs. DS use was lower when peer groups or leadership discouraged substance abuse. Conclusions DS use was considerably higher in the US Armed Forces compared with civilian populations, although many demographic and lifestyle factors associated with use were similar. Some categories of DSs extensively used by SMs such as bodybuilding supplements have been associated with adverse events. Discouraging substance abuse through peer groups and leadership actions may reduce use of unnecessary or dangerous DSs.

  • Practice Implications How Do African-American Caregivers Navigate a Food Desert to Feed Their Children? A Photovoice Narrative
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-06-19
    Uriyoán Colón-Ramos, Rafael Monge-Rojas, Tambra R. Stevenson, Haley Burns, Shaneka Thurman, Joel Gittelsohn, Tilly A. Gurman

    Objectives To determine how African-American caregivers living in a food desert navigate neighborhood resources to procure foods for their children and to identify actions to improve those resources. Design Using the Photovoice approach, we conducted two sets of individual in-depth interviews with 16 African-American primary caregivers of children (total of 32 interviews) and one culminating workshop (n=10 participants). Data were systematically analyzed according to the Social Ecological Framework to evaluate the role of different environments in shaping individual decisions. Setting Urban, low-income and geographically marginalized neighborhoods. Results Despite the challenges of living in a food desert, caregivers perceived that they were providing the foods that they wanted for their children. These perceptions were based on their own health concerns, food customs, time and convenience, and responses to their children’s food preferences. Caregivers were resourceful in how they procured these foods, searching for quality and better-priced foods. They relied on their friends, family, and local/national programs to mitigate the challenges of the food desert. Caregivers were interested in taking action to improve the underlying determinants of food access and choice (eg, affordable housing, job training, nutrition knowledge, food shopping experience). Conclusion These African-American caregivers procured foods they thought were best for their children by relying on their strong social relationships and national and local food programs to navigate the food desert. Public health nutrition interventions that aim to reduce diet-related disparities should look beyond the presence or absence of supermarkets in food deserts to address multisectoral determinants of access while shaping food choices.

  • Staff Food-Related Behaviors and Children’s Tastes of Food Groups during Lunch at Child Care in Oklahoma
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-10-05
    Katherine Anundson, Susan B. Sisson, Michael Anderson, Diane Horm, Jill Soto, Leah Hoffman

    Background Young children should consume a variety of nutrient-dense foods to support growth, while limiting added fat and sugar. A majority of children between the ages of 3 and 5 years attend child care in the United States, which makes this environment and the child-care staff influential at meals. Objective The aim was to determine the association between best-practice food-related behaviors and young children’s tastes of fruit, vegetable, low-fat dairy, and high-fat/high-sugar foods at child care. Design This was a cross-sectional study. Participants A community-based study with 201 children ages 3 to 5 years from 25 early care and education centers, including 11 tribally affiliated centers and two Head Start programs across Oklahoma. Data collection occurred from fall 2011 to spring 2014. Main outcome measures Classroom observations used the Environmental Policy Assessment Observation tool to measure the staff behaviors and environment. Staff behavior was compared at three different levels: the composite score of staff nutrition behavior, each constituent staff behavior, and staff behaviors grouped into broader feeding behaviors. Tasted food was measured through the Dietary Observation in Child Care method. The children’s meals were categorized into the following food groups: fruit, vegetable, low-fat dairy, fried vegetable, fried meat, high-fat meat, and high-fat/high-sugar food. Statistical analysis performed Descriptive statistics were calculated for relevant variables. Relationships between the constituent staff behaviors and food groups that children tasted were compared using multilevel mixed-model analysis. Results The mean number of tasted fruit or vegetable items was higher and the mean number of tasted high-fat/high-sugar food items was lower when staff: 1) determined fullness before plate removal when less than half of food was eaten, 2) ate with the children, 3) and talked about healthy food. Conclusions The utilization of the three staff behaviors and their association with higher mean tastes of nutrient-dense items and lower mean tastes of high-fat/high-sugar food items among exposed children demonstrated support for the use of the best practices in early care and education centers.

  • Trends in Fast-Food and Sugar-Sweetened Beverage Consumption and Their Association with Social Environmental Status in South Korea
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-10-05
    Hyunjung Lim, Hae Jeoung Lee, Ryowon Choue, Youfa Wang

    Background As South Korea has enjoyed rapid economic development, Koreans’ diet, particularly consumption of fast food (FF) and sugar-sweetened beverages (SSBs), has changed. Objective To examine time trends in FF and SSB consumption and their associations with social environmental status (SEnS) in South Korea. Design Korean National Health and Nutrition Examination Surveys (KNHANES) were a series of population-based cross-sectional surveys. Participants Data from the KNHANES conducted in 1998, 2001, 2005, and 2007-2009 for 49,826 Koreans aged ≥1 year were used. Main outcome measures Consumption of FF and SSBs were assessed by a 24-hour recall. We defined two FF categories (Western-style and Korean-style) and one SSB category. Sex, age, household income, and residence regions were investigated. Statistical analyses performed The primary sampling units, strata, and sampling weights were taken into account using SAS survey-related procedures. Logistic regression models were used to test associations between SEnS and FF consumption. Results Over an 11-year period, the proportion of participants’ who consumed Western FF and SSBs on the surveyed day doubled (P<0.05). Per capita energy contribution from Western FF also increased in adults, men, and low-income groups. SSB consumption doubled (per capita: 32 to 82 kcal/day, only consumers: 123 to 166 kcal/day), but consumption of Korean-style FF decreased (P<0.05). Compared with the low-income rural resident group, the high-income urban resident group was much more likely to consume Western FF (OR=26.7[3.7, 193.4]) and SSBs (odds ratio [OR]=3.1 [2.4, 4.1]) in 1998. However, in recent years, the patterns changed; the high-income urban resident group was more likely to consume Korean-style FF (OR=2.0[1.3, 2.9]) and SSBs (OR=1.7[1.3, 2.1]). Conclusions In South Korea, people who reported consuming Western FF and SSBs on the surveyed day almost doubled during 1998-2009, whereas those who consumed Korean FF decreased. SEnS was related to FF and SSB consumption.

  • Women’s Perceptions of Usefulness and Ease of Use of Four Healthy Eating Blog Characteristics: A Qualitative Study of 33 French-Canadian Women
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-10-26
    Véronique Bissonnette-Maheux, Audrée-Anne Dumas, Véronique Provencher, Annie Lapointe, Marilyn Dugrenier, Sharon Straus, Marie-Pierre Gagnon, Sophie Desroches

    Background Healthy eating blogs are knowledge translation tools used by nutrition and dietetics practitioners for helping people improve their health behaviors and food choices. Objective Our aim was to explore women’s perceptions of the usefulness and ease of use of healthy eating blog (HEB) characteristics that might increase potential users’ intention to use them as tools to improve their dietary habits. Design We conducted qualitative research using semi-structured individual interviews. Participants Thirty-three women (mean age of 44 years; range=27 to 61 years) living in the Quebec City, Canada, metropolitan area were studied. Intervention Four existing HEBs, written by French-Canadian registered dietitians (RDs) whose main objective was the promotion of a healthy diet, were explored by women during individual interviews. A standardized open-ended interview questionnaire based on the Technology Acceptance Model was used to identify women's perceptions about characteristics of type of blog content delivery, RD blogger's delivery of information, blog layout, and blog design. Main outcome measures Women's perceptions toward the contribution of HEB characteristics to the usefulness and ease of use of those tools to improve their dietary habits were measured. Analyses performed Interviews were audiorecorded, transcribed verbatim, coded, and analyzed through an inductive content analysis using NVivo software. Results The most useful characteristics of type of blog content delivery identified by women were recipes, hyperlinks, and references. Among characteristics of RD blogger's delivery of information, most women reported that interaction between blog readers and the RD blogger created a sense of proximity and of connection that was helpful for improving their dietary behaviors. Women's perceptions toward various characteristics of blog layout and design were also discussed. Conclusions Incorporating specific characteristics when designing HEBs should be considered by RDs and future research to promote the use of those tools to support dietary behavior change efforts of internet users.

  • Association between Fruit and Vegetable Consumption and Risk of Hypertension in Middle-Aged and Older Korean Adults
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-11-04
    Jiwon Kim, Jihye Kim

    Background High fruit and vegetable (F/V) intake may be beneficial for hypertension prevention. However, a prospective association has not been investigated in a Korean population, and differences exist between typical diets in Korea and those of Western populations. Objective The aim of this prospective study was to investigate the association between F/V intake and risk of incident hypertension in middle-aged and older Korean adults using the data from the Korean Genome and Epidemiology Study (KoGES). Design The KoGES is a large community-based cohort study of Korean adults aged 40 to 69 years, which began in May 2001. Questionnaires on demographic information and lifestyle factors were completed at baseline. Anthropometrics and biochemical measurements were conducted biennially. Fruit and vegetable consumption was assessed with a semiquantitative food frequency questionnaire. Hypertension was defined as a systolic blood pressure≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Participants and setting A total of 4,257 participants (2,085 men, 2,172 women) without hypertension at baseline were evaluated. Main outcome measures The primary outcome was incident hypertension. Statistical analysis performed Multivariate Cox proportional hazard models were used to examine hazard ratios (HRs) and 95% CIs for incident hypertension according to F/V consumption. Results During the 8-year follow-up, 1,158 participants (606 men and 552 women) developed hypertension. Among men, frequent fruit consumers (≥4 servings/day) had a 56% lower risk of incident hypertension than did infrequent consumers (<1 serving/day) (HR=0.44, 95% CI=0.32 to 0.60, P for trend <0.0001). Among women, frequent fruit consumers had a 67% lower risk of incident hypertension than did infrequent consumers (HR=0.33, 95% CI=0.24 to 0.45, P for trend <0.0001), after adjustment for potential confounders. However, there was no association between vegetable consumption and risk of incident hypertension in either men or women. Conclusion A higher intake of fruit was prospectively associated with a lower risk of incident hypertension in middle-aged and older Korean adults, regardless of sex.

  • Fresh Fruit and Vegetable Program and Requests for Fruits and Vegetables Outside School Settings
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-01-08
    Punam Ohri-Vachaspati, Elizabeth Dachenhaus, Jessie Gruner, Kristina Mollner, Eric B. Hekler, Michael Todd

    Background Consumption of fruits and vegetables (F/V) among elementary school-aged children remains inadequate, especially among low-income children. The US Department of Agriculture’s Fresh Fruit and Vegetable Program (FFVP) provides F/V as snacks to children during the school day, outside of school meals. School-based initiatives are successful in changing behaviors in school settings; however, their influence on behaviors outside of schools needs investigation. Objective To examine whether FFVP participation is associated with F/V requests at stores, self-efficacy to ask for and choose F/V at home, and F/V consumption. Design Cross-sectional study. Participant/setting Fourth graders in six classrooms (n=296) from three urban, low-income school districts in Phoenix, AZ, were surveyed during 2015; one FFVP and one non-FFVP school from each district that were similar in school size, percent free/reduced-price meal eligibility, and race/ethnicity of enrolled students were selected. Main outcome measures Children’s self-reported F/V requests during shopping, their self-efficacy to ask for and choose F/V at home, and F/V consumption on the previous day (non-FFVP school day) were measured using questions adapted from validated surveys. Statistical analysis Multivariable mixed-effect regression models, adjusting for clustering of students within classes and classes within schools were explored. Results In models adjusting for individual-level factors (ie, age and sex) only, several significant positive associations were observed between school FFVP participation and healthier F/V outcomes. After additionally adjusting for school-level factors (ie, total enrollment and % Hispanic/Latino students) significant associations were observed between school FFVP participation and more requests for vegetables during shopping (P<0.001), higher scores on self-efficacy to choose vegetables at home (P=0.004), stronger preferences for vegetables (P<0.001), and more frequent consumption of fruit (P=0.006). Conclusions School FFVP participation was associated with more requests for vegetables during shopping and higher self-efficacy to make healthy choices at home, suggesting the influence of the FFVP may extend beyond the school day.

  • No Improvements in Postnatal Dietary Outcomes Were Observed in a Two-Arm, Randomized, Controlled, Comparative Impact Trial among Rural, Southern, African-American Women
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-02-01
    Jessica L. Thomson, Lisa M. Tussing-Humphreys, Alicia S. Landry, Melissa H. Goodman

    Background Suboptimal diet quality, prevalent among postpartum women, is troubling for mothers and their children because positive relationships between maternal and child diet quality exist. Objective The primary objective was to determine whether postnatal diet quality scores of participants in the two treatment arms differed or changed over time. Design Delta Healthy Sprouts was a two-arm, randomized, controlled, comparative impact trial. Participants and setting Pregnant women at least 18 years of age, less than 19 weeks pregnant, and residing in three Mississippi counties were recruited between March 2013 and December 2014. Postnatal data was collected from 54 participants between September 2013 and May 2016. The postnatal attrition rates were 17% and 13% for the control and experimental arms. Intervention The control arm received the Parents as Teachers curriculum, and the experimental arm received a nutrition- and physical activity-enhanced Parents as Teachers curriculum. Main outcome measures Multiple-pass 24-hour dietary recalls were collected from participants at the postnatal month 1, 4, 6, 8, and 12 visits. Healthy Eating Index-2010 was used to calculate diet quality. Statistical analysis performed Linear mixed models were used to test for treatment, time, and treatment by time (interaction) effects on postnatal dietary outcomes. Results Control arm mean (95% confidence limits) total Healthy Eating Index-2010 scores were 36.8 (range=32.5 to 41.1), 36.5 (range=31.9 to 41.1), 40.2 (range=35.7 to 44.8), 39.3 (range=34.7 to 43.9), and 36.4 (range=31.8 to 41.0) at postnatal months 1, 4, 6, 8, and 12, respectively. Corresponding experimental arm scores were 42.3 (range=37.5 to 47.0), 41.6 (range=36.3 to 46.9), 40.2 (range=34.8 to 45.7), 45.8 (range=40.5 to 51.1), and 37.6 (range=32.6 to 42.7), respectively. Experimental scores were significantly higher than control scores across time. No other effects were significant. Conclusions Neither the standard Parents as Teachers curriculum nor the enhanced Parents as Teachers curriculum was effective at improving the poor diet quality of this cohort of rural, Southern, African-American women during the 12 months following the birth of their infant.

  • Association between Dietary Glycemic Index and Knee Osteoarthritis: The Korean National Health and Nutrition Examination Survey 2010-2012
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-02-07
    Min Wook So, Sunggun Lee, Seong-Ho Kim

    Background Obesity and metabolic abnormalities are important risk factors for knee osteoarthritis (KOA). Recent epidemiologic studies have found that a high glycemic index (GI) and glycemic load (GL) diet are associated with a higher risk for metabolic complications and cardiovascular mortality. Objective We aimed to examine the association between dietary GI, dietary GL, and KOA among Korean adults. Design This was a cross-sectional study that analyzed data obtained from the Korean National Health and Nutrition Examination Survey 2010-2012. Participants/setting A total of 9,203 participants (5,275 women) aged ≥50 years were included. Main outcome measures KOA was defined as the presence of radiographic features of Kellgren-Lawrence grade ≥2. Chronic knee pain was defined as the presence of knee pain for more than 30 days during the past 3 months. Dietary information was collected using a single 24-hour recall method. Statistical analyses performed The association between the quintiles of dietary GI and dietary GL and knee conditions was analyzed using a multinomial logistic regression analysis adjusting for age, physical activity, obesity, hypertension and diabetes, serum low-density lipoprotein, and total energy intake. Results Among the women, the association between dietary GI and symptomatic KOA was: quintile 1: 1.00 (reference); quintile 2: 1.29 (95% CI 0.87 to 1.92); quintile 3: 1.59 (95% CI 1.11 to 2.28); quintile 4: 1.74 (95% CI 1.21 to 2.51); and quintile 5: 1.77 (95% CI 1.20 to 2.60) (P=0.001). Chronic knee pain without KOA was associated with dietary GI; however, this association was not linear across quintiles. There was no significant association between dietary GI and asymptomatic KOA. Among the men, no significant association was found between dietary GI and any knee conditions. There was no significant association between dietary GL and KOA in both men and women. Conclusions There was a significant positive association between dietary GI and symptomatic KOA in women.

  • Arguments Used in Public Comments to Support or Oppose the US Department of Agriculture’s Minimum Stocking Requirements: A Content Analysis
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-02-13
    Lindsey Haynes-Maslow, Lauri Andress, Stephanie Jilcott Pitts, Isabel Osborne, Barbara Baquero, Lisa Bailey-Davis, Carmen Byker-Shanks, Bailey Houghtaling, Jane Kolodinsky, Brian K. Lo, Emily H. Morgan, Emily Piltch, Elaine Prewitt, Rebecca A. Seguin, Alice S. Ammerman

    Background In 2016, the US Department of Agriculture (USDA)’s Supplemental Nutrition Assistance Program (SNAP) Retailer Rule proposed several changes for SNAP-authorized retailers, including: requiring retailers to have at least 85% of their food sales come from items that are not cooked or heated on site before or after purchase; requiring stores to stock seven varieties of qualifying foods from four staple food groups; requiring stores to carry perishable foods in three of the four staple groups; requiring stores to carry six units of qualifying foods at all times (depth of stock); disqualifying multiple ingredient foods and accessory foods from counting toward depth of stock requirements. Objectives To better understand arguments used to support or oppose the USDA’s proposed rule that all SNAP-authorized retailers carry more nutritious foods. Design We conducted a qualitative content analysis of a random sample of public comments posted to the US Federal Register (a publicly available database) in response to the USDA’s proposed rule. Participants/setting A random sample of 20% of all public comments submitted by individuals and organizations to the US Federal Register were analyzed (n=303) for this study. Results Three main themes were discussed: 1) arguments used in opposition to the rule; 2) arguments used in support of the rule; and 3) facilitators to assist stores in implementing the rule. Some of the subthemes included focusing on definitions used in the rule, reduced food access caused by stores leaving the SNAP program, lack of space and equipment for healthy foods, and the potential for increasing healthy food access. Conclusions Nutrition and dietetics practitioners may be tasked with working with stores to implement healthy changes. Nutrition and dietetics practitioners must understand the role that the USDA has in food policy. In addition, understanding how federal food policy influences the environments in which dietetics professionals’ clients are making food choices is important.

  • Association between Diet Quality Scores and Risk of Hip Fracture in Postmenopausal Women and Men Aged 50 Years and Older
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-02-15
    Teresa T. Fung, Haakon E. Meyer, Walter C. Willett, Diane Feskanich

    Background Although a number of studies showed a lower risk of hip fractures with high-quality diets, few of them were conducted in the United States. Objective This prospective analysis examined the association between several diet quality indexes and risk of hip fractures in US men and women. Design This is a prospective cohort study. Participants/setting The participants were 74,446 postmenopausal women from the Nurses’ Health Study and 36,602 men aged 50 years and older from the Health Professionals Follow-Up Study in the United States. Main outcome measure Hip fractures were self-reported on biennial questionnaires between 1980-2012 in women, and between 1986-2012 in men. Statistical analysis Diet was assessed every 4 years with a validated food frequency questionnaire. Relative risks were computed for hip fracture by quintiles of the Alternate Mediterranean Diet score (aMed), the Alternate Healthy Eating Index-2010 (AHEI-2010), and the Dietary Approaches to Stop Hypertension score using Cox proportional hazards models, adjusting for potential confounders. Results Two thousand one hundred forty-three incident hip fractures in women and 603 in men were reported during follow-up. A significant inverse trend was observed with the cumulative AHEI-2010 score in women (relative risk comparing extreme quintiles 0.87, 95% CI 0.75 to 1.00; P for trend=0.02). There was also a suggestion of an inverse association with the Dietary Approaches to Stop Hypertension score (P for trend=0.03). In addition, significant inverse trends were observed between all three diet quality scores and hip fractures in women younger than age 75 years but not older women. There was no clear association between diet quality indexes and hip fracture in men. Conclusions Higher AHEI-2010 scores were associated with a lower risk of hip fractures in US women. The inverse associations with diet quality may be more apparent among those younger than age 75 years.

  • Early Childhood Vegetable, Fruit, and Discretionary Food Intakes Do Not Meet Dietary Guidelines, but Do Show Socioeconomic Differences and Tracking over Time
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-03-01
    Alison C. Spence, Karen J. Campbell, Sandrine Lioret, Sarah A. McNaughton

    Background Dietary intakes of young children are likely to be important determinants of their short- and long-term health, yet there are few longitudinal dietary studies of this age group, and no previous assessments of diets before age 2 years compared with national dietary guidelines. Objective This study aimed to compare vegetable, fruit, and discretionary food intakes of children aged 9 months to 5 years to dietary guidelines, and to assess differences in intakes by socioeconomic status and tracking of intakes across early childhood. Design This study analyzed longitudinal data from the Melbourne Infant Feeding Activity and Nutrition Trial Program early childhood lifestyle intervention trial, and is the first study to compare diets of children younger than age 2 years to national dietary guidelines. Participants/setting Participants were 467 children in Melbourne, Australia, aged 4 months at baseline (study conducted 2008-2015). Main outcome measures Multiple 24-hour recalls with parents were conducted at child ages 9 months, 1.5 years, 3.5 years, and 5 years. Statistical analyses performed Intakes of vegetables, fruits, and discretionary foods were compared with Australian Dietary Guidelines. Differences by socioeconomic status and tracking of intakes of each food group were assessed by multivariable linear regression. Results Few children (<10%) met guidelines for discretionary food intakes at any age. Most children (≥90%) met vegetable and fruit guidelines at 9 months, but thereafter rates of adequate intakes reduced substantially. Children of higher socioeconomic status consumed diets closer to guidelines for most food groups at most ages. Tracking of intakes was apparent across ages, with the strongest and most consistent tracking for discretionary foods. Conclusions This study shows that diets of Australian children participating in this lifestyle intervention trial were suboptimal from early life. The evidence of differences by socioeconomic status and tracking from age 9 months, particularly for discretionary foods, highlights the importance of research and action to support appropriate introduction of complementary foods during the first year of life, and of focusing these efforts on disadvantaged groups.

  • Contribution of Beverage Selection to the Dietary Quality of the Packed Lunches Eaten by Preschool-Aged Children
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-03-01
    Maria Jose Romo-Palafox, Nalini Ranjit, Sara J. Sweitzer, Cindy Roberts-Gray, Courtney E. Byrd-Williams, Margaret E. Briley, Deanna M. Hoelscher

    Background Sweet drinks early in life could predispose to lifelong consumption, and the beverage industry does not clearly define fruit drinks as part of the sweet drink category. Objectives To ascertain the relationship between beverage selection and dietary quality of the lunches packed for preschool-aged children evaluated using the Healthy Eating Index-2010. Methods Foods packed by parents (n=607) were observed at 30 early care and education centers on two nonconsecutive days. Three-level regression models were used to examine the dietary quality of lunches by beverage selection and the dietary quality of the lunch controlling for the nutrient composition of the beverage by removing it from the analysis. Results Fruit drinks were included in 25% of parent-packed lunches, followed by 100% fruit juice (14%), milk (14%), and flavored milk (3.7%). Lunches with plain milk had the highest Healthy Eating Index-2010 scores (59.3) followed by lunches with 100% fruit juice (56.9) and flavored milk (53.2). Lunches with fruit drinks had the lowest Healthy Eating Index-2010 scores at 48.6. After excluding the nutrient content of the beverage, the significant difference between lunches containing milk and flavored milk persisted (+5.5), whereas the difference between fruit drinks and 100% fruit juice did not. Conclusions Dietary quality is associated with the type of beverage packed and these differences hold when the lunch is analyzed without the nutrient content of the beverage included.

  • “Take Me through the History of Your Weight”: Using Qualitative Interviews to Create Personalized Weight Trajectories to Understand the Development of Obesity in Patients Preparing for Bariatric Surgery
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-03-16
    Amanda I. Lynch, Elizabeth McGowan, Kerstyn C. Zalesin

    Background Obesity can develop during any life stage. Understanding the contexts within which obesity develops can inform our understanding of the disease and help tailor interventions specific to life stages. Objective Using life-course theory as a guiding framework, this study aimed to explain the development of obesity in bariatric surgery patients by creating personalized weight trajectories. Design Qualitative methods using semistructured interviews were used to uncover participants’ experiences with and explanations for the development of obesity. A grounded theory approach using the constant comparative method was used to analyze transcripts for categories and themes. Participants/setting Thirty pre-bariatric surgery patients (24 women, 6 men) were recruited from a bariatric surgery center; 25 participants were available for follow-up. Participants were interviewed before surgery and at 6 and 12 months postsurgery. Results Four weight history groups were created based on patterns of weight changes from adolescence through adulthood: Always Heavy, Late Peak, Steady Progression, and Weight Cycling. Participants’ explanations for weight changes centered around themes of transitions and life-course events or stressors. Differences in the weight history groups could be explained by the timing of transitions, life events, and responses to stress. Conclusions The development of obesity does not follow the same pattern for all individuals. Weight gain patterns can be explained by the timing of life-course events, stressors, and the type and effects of environmental transitions. Weight management counseling should include strategies tailored to an individual’s current life-stage and circumstance, but also acknowledge previous responses to transitions and stressors.

  • Eating School Meals Daily Is Associated with Healthier Dietary Intakes: The Healthy Communities Study
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-03-17
    Lauren E. Au, Klara Gurzo, Wendi Gosliner, Karen L. Webb, Patricia B. Crawford, Lorrene D. Ritchie

    Background Research on the association between school meal consumption and overall dietary intake post-Healthy Hunger-Free Kids Act implementation is limited. Objective This study examines the association between frequency of participating in the National School Lunch and School Breakfast Programs and children’s dietary intakes. Design The Healthy Communities Study was a cross-sectional observational study conducted between 2013 and 2015. Participants and setting US children aged 4 to 15 years (n=5,106) were included. Main outcome measures Dietary measures were assessed using the National Health and Nutrition Examination Survey Dietary Screener Questionnaire. Dietary intake included fruit and vegetables, fiber, whole grains, dairy, calcium, total added sugar, sugar-sweetened beverages, and energy-dense foods of minimal nutritional value. Statistical analysis Multivariate statistical models assessed associations between frequency of eating school breakfast or lunch (every day vs not every day) and dietary intake, adjusting for child- and community-level covariates. Results Children who ate school breakfast every day compared with children who ate 0 to 4 days/wk, reported consuming more fruits and vegetables (0.1 cup/day, 95% CI: 0.01, 0.1), dietary fiber (0.4 g/day, 95% CI: 0.2, 0.7), whole grains (0.1 oz/day, 95% CI: 0.05, 0.1), dairy (0.1 cup/day, 95% CI: 0.05, 0.1), and calcium (34.5 mg/day, 95% CI: 19.1, 49.9). Children who ate school lunch every day, compared with those who ate less frequently, consumed more dairy (0.1 cup/day, 95% CI: 0.1, 0.2) and calcium (32.4 mg/day, 95% CI: 18.1, 46.6). No significant associations were observed between school meal consumption and energy-dense nutrient-poor foods or added sugars. Conclusions Eating school breakfast and school lunch every day by US schoolchildren was associated with modestly healthier dietary intakes. These findings suggest potential nutritional benefits of regularly consuming school meals.

  • Comparison of the Dietary Antioxidant Profiles of 21 a priori Defined Mediterranean Diet Indexes
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-03-24
    Angela Hernández-Ruiz, Belén García-Villanova, Eduardo Guerra-Hernández, Pilar Amiano, María-José Sánchez, Miren Dorronsoro, Esther Molina-Montes

    Background The Mediterranean Diet (MD) is a dietary pattern that features a high quotient of antioxidant-rich foods. Differences in the level of dietary antioxidants intake reflected by different MD indexes has received little research attention. Objective The purpose of this study was to compare the dietary antioxidant profile of 21 a priori defined indexes of adherence to the MD. Design A cross-sectional study. Participants/setting A total of 14,756 participants belonging to two Spanish European Prospective Investigation into Cancer and Nutrition cohorts, aged 32 to 69 years, recruited between 1992 and 1996, were included. Main outcome measure Participants provided information on diet through a validated diet history questionnaire. Antioxidants (vitamin C, beta carotene and α-tocopherol), total antioxidant capacity, total polyphenols, flavonoids, and polyphenol antioxidant content score were estimated using different food composition databases. Twenty-one MD indexes were operationalized. Statistical analysis Spearman correlation coefficients between the indexes were calculated and hierarchical clustering was applied to identify cluster groups. Weighted kappa statistic was estimated to value the scoring agreements between indexes. Antioxidant profiles between the MD indexes were compared based on geometric mean intakes. The relationship between each MD index with the components of the antioxidant profile was evaluated using linear multivariable regression analysis. Results Correlation patterns between the MD indexes showed that about half of the indexes were moderately-to-weakly correlated with each other (rho<0.5). The main cluster groups derived denoted the high-, moderate-, and low-correlated MD indexes. Three MD indexes (MD pattern-2002, Prevention with MD, and Alternate MD index) presented the highest mean intakes of antioxidant vitamins, total antioxidant capacity, total polyphenols, flavonoids, and polyphenol antioxidant content score. These and other indexes (mainly those belonging to the MD Scale group) captured higher intake levels of dietary antioxidants overall. Conclusions The level of dietary antioxidant intake that is captured through the different MD indexes differed due to the variation in their construction. Study results also suggest that some MD indexes reflect a higher antioxidant profile.

  • Online Extra Validation of a Questionnaire to Measure Fruits and Vegetables Selected and Consumed at School Lunch among Second- and Third-Grade Students
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-31
    Matthew M. Graziose, Randi L. Wolf, Pamela A. Koch, Heewon L. Gray, Isobel R. Contento

    Background Interventions designed to encourage fruit and vegetable (F/V) consumption within schools are increasingly common. Thus, there is a need for valid, practical dietary assessment instruments to evaluate their effectiveness. Objective The aim of this study was to examine the validity of a group-administered, paper-and-pencil questionnaire to assess F/V selection and consumption at school lunch relative to digital photography. Design This was a five-phase, method-comparison study in which the questionnaire was iteratively modified between each phase. Participants/setting The study examined sets of questionnaires and photographs of lunch trays (n=1,213) collected on 44 days between May 2015 and June 2016 among second-grade students from three New York City schools (phases 1 to 4) and second- and third-grade students from 20 schools across eight states (phase 5). Main outcome measures Outcomes assessed were selection, amount eaten, preference, and intention to consume F/V. Statistical analyses performed Validity was assessed by percent agreement (categorized as “match, omission, or intrusion” for items on or off tray and “match, overestimation, or underestimation” for amount eaten), Spearman correlation coefficients, and intraclass correlation coefficients (ICC). Results The total match rate for items on tray was substantial (phases 1 to 5: 83%, 84%, 92%, 93%, and 89%), with items more frequently intruded than omitted. For amounts eaten, the total match rates were moderate, but generally improved throughout the study (phases 1 to 5: 65%, 64%, 83%, 83%, and 76%), with overestimations more frequent than underestimations. There was good correspondence between methods in the estimates of amount eaten in a quantitative, cup equivalent amount (fruit ICC=0.61; vegetables ICC=0.64). Significant differences (α=.05) were not observed between second- and third-grade students, respectively, in the match rate for fruits (86% and 89%) or vegetable (89% and 86%) items on tray or fruit (69% and 73%) and vegetables (74% and 76%) amount eaten. Excellent correlations were observed between amount eaten and preference for fruit (r=0.91) and vegetables (r=0.93). Conclusions The questionnaire offers a feasible, valid instrument for assessing F/V selection and consumption among elementary students in schools participating in the National School Lunch Program. Additional research is recommended to test the instrument’s sensitivity and to reproduce these findings using an alternative reference method, such as direct observations.

  • Online Extra Changes in Overall Diet Quality in Relation to Survival in Postmenopausal Women with Breast Cancer: Results from the Women’s Health Initiative
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-30
    Yangbo Sun, Wei Bao, Buyun Liu, Bette J. Caan, Dorothy S. Lane, Amy E. Millen, Michael S. Simon, Cynthia A. Thomson, Lesley F. Tinker, Linda V. Van Horn, Mara Z. Vitolins, Linda G. Snetselaar

    Background Lifestyle factors are important for cancer survival. However, empirical evidence regarding the effects of dietary changes on mortality in breast cancer survivors is sparse. Objective The objective was to examine the associations of changes in overall diet quality, indicated by the Healthy Eating Index (HEI)-2010 score, with mortality in breast cancer survivors. Design This was a prospective cohort study from September 1993 through September 30, 2015. Participants/setting This study included 2,295 postmenopausal women who were diagnosed with invasive breast cancer and completed a food frequency questionnaire both before and after the diagnosis of breast cancer in the Women’s Health Initiative. Main outcome measures The HEI-2010 score (maximum score of 100) was calculated based on consumption of 12 dietary components. The outcomes were mortality from all causes, breast cancer, and causes other than breast cancer. Statistical analyses performed Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios of mortality from all causes, breast cancer, and other causes. Results Over 12 years of follow-up, 763 deaths occurred. Compared with women with relatively stable diet quality (±14.9% change in HEI-2010 score), women who decreased diet quality (≥15% decrease in HEI-2010 score) had a higher risk of death from breast cancer (adjusted hazard ratio 1.66, 95% CI 1.09 to 2.52). Increased diet quality (≥15% increase in HEI-2010 score) was not significantly associated with lower risk of death. These associations persisted after additional adjustment for change in body mass index. Conclusions Among women with breast cancer, decreased diet quality after breast cancer diagnosis was associated with higher risk of death from breast cancer.

  • New Equations to Predict Body Fat in Asian-Chinese Adults Using Age, Height, Skinfold Thickness, and Waist Circumference
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-08
    Christiani Jeyakumar Henry, Shalini D/O Ponnalagu, Xinyan Bi, Sze-Yen Tan

    Background Adiposity is an independent predictor of metabolic disease. However, highly accurate body fat assessment is not routinely done due to limited access to expensive and labor-intensive methods. Objective The aim of the study was to develop body fat prediction equations for Asian-Chinese adults using easily attainable anthropometric measurements. Design Prediction equations of body fat were developed using anthropometric and skinfold thickness measurements obtained from a cross-sectional study. These new equations were then validated using baseline data from an independent randomized controlled study. Participants/setting Healthy participants with no major diseases and not taking long-term medications were recruited in an ongoing cross-sectional study that began in June 2014 (n=439, 170 males, 269 females), as well as a randomized controlled trial (n=108, 58 males, 50 females) conducted from January 2013 to October 2014. Both the studies were conducted at Clinical Nutrition Research Center located in Singapore. Main outcome measures Data used to develop and validate equations were from two original studies that assessed body fat by dual-energy x-ray absorptiometry, age, waist circumference, height, and biceps and triceps skinfolds. Statistical analysis performed Sex-specific percent body fat prediction equations were developed using stepwise regression with Akaike Information Criterion on the cross-sectional data. The equations were then validated using data from the randomized controlled study and also compared against Asian-specific Davidson equations. Results The best body fat prediction model (R2=0.722, standard error of estimation=2.97 for females; R2=0.815, standard error of estimation=2.49 for males) for both sexes included biceps and triceps skinfolds, waist circumference, age, and height. The new equations developed resulted in modest discrepancies in body fat of 1.8%±2.7% in males (P<0.001) and 0.7%±3.1% in females (P=0.125; not significant) compared with the Asian-specific Davidson equations (−7.4%±3.2% [P<0.001] and −7.4%±2.7% [P<0.001], respectively). Conclusions Sex-specific equations to predict the percent body fat of Asian-Chinese adults with a higher degree of accuracy were developed. Ease of use in both field and clinical settings will be a major advantage.

  • Online Extra Trends in Dietary Sodium from Food Sources in Australian Children and Adolescents from 2007 to 2011/12
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-03
    Carley A. Grimes, Ewa A. Szymlek-Gay, Caryl A. Nowson

    Background In western countries, most children eat more sodium than is recommended. In Australia in 2009, voluntary sodium reformulation targets were adopted for nine categories of processed foods, but the impact of this initiative on children’s sodium intake has not been assessed. Objective To compare sodium consumption of Australian children aged 2 to 16 years from 2007 to 2011/12. Design Cross-sectional analysis of data from the 2007 Children’s Nutrition and Physical Activity Survey (n=4,487) and the 2011/12 National Nutrition and Physical Activity Survey (n=2,548). Participants/setting A nationally representative sample of 6,705 Australian children aged 2 to 16 years who provided plausible 24-hour dietary recall data according to Goldberg cutoffs for misreporting of energy intake. Main outcome measures Mean intakes of energy, sodium, and sodium density (mg/1,000 kcal) were assessed via one 24-hour dietary recall; measurement error models with up to two 24-hour dietary recalls were used to estimate usual sodium intake and the proportion of children exceeding the age-specific upper level for sodium. Statistical analyses preformed Statistical analysis incorporated survey weights and accounted for the complex survey design. Two-sample t-tests and two-sample test of proportions were used to assess differences in continuous and categorical variables between survey years. Results Dietary sodium declined by 8% between 2007 and 2011/12 (−188±SE 31 mg/day; P<0.001), and this was in conjunction with a 5% reduction in energy intake (98±19 kcal/day; P<0.001). When stratified by age group, significant reductions in sodium intake remained across all four age groups (ie, 2-3 years, 4-8 years, 9-13 years, and 14-16 years); similarly, with the exception of 2- to 3-year-old children, reductions in energy intake were observed across all other age groups. Overall sodium density declined by 2% (−29 mg/1,000 kcal/day; P=0.01); however, in age subgroup analysis the decline in sodium density only remained among children aged 2 to 3 years. The upper level for sodium was exceeded by 94% or more children in 2007 and 78% or more in 2011/2012. Conclusion Although results suggest a small reduction in reported sodium intake over 5 years, most children in 2011/12 had a sodium intake that exceeded the recommended upper level. Ongoing efforts to reduce sodium in the diets of Australian children are required.

  • Online Extra Managing Complexity in Evidence Analysis: A Worked Example in Pediatric Weight Management
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-02
    James Scott Parrott, Beverly Henry, Kyle L. Thompson, Jane Ziegler, Deepa Handu

    Nutrition interventions are often complex and multicomponent. Typical approaches to meta-analyses that focus on individual causal relationships to provide guideline recommendations are not sufficient to capture this complexity. The objective of this study is to describe the method of meta-analysis used for the Pediatric Weight Management (PWM) Guidelines update and provide a worked example that can be applied in other areas of dietetics practice. The effects of PWM interventions were examined for body mass index (BMI), body mass index z-score (BMIZ), and waist circumference at four different time periods. For intervention-level effects, intervention types were identified empirically using multiple correspondence analysis paired with cluster analysis. Pooled effects of identified types were examined using random effects meta-analysis models. Differences in effects among types were examined using meta-regression. Context-level effects are examined using qualitative comparative analysis. Three distinct types (or families) of PWM interventions were identified: medical nutrition, behavioral, and missing components. Medical nutrition and behavioral types showed statistically significant improvements in BMIZ across all time points. Results were less consistent for BMI and waist circumference, although four distinct patterns of weight status change were identified. These varied by intervention type as well as outcome measure. Meta-regression indicated statistically significant differences between the medical nutrition and behavioral types vs the missing component type for both BMIZ and BMI, although the pattern varied by time period and intervention type. Qualitative comparative analysis identified distinct configurations of context characteristics at each time point that were consistent with positive outcomes among the intervention types. Although analysis of individual causal relationships is invaluable, this approach is inadequate to capture the complexity of dietetics practice. An alternative approach that integrates intervention-level with context-level meta-analyses may provide deeper understanding in the development of practice guidelines.

  • Adjustment Factors Can Improve Estimates of Food Group Intake Assessed Using a Short Dietary Assessment Instrument
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-05-01
    Gilly A. Hendrie, Megan A. Rebuli, Rebecca K. Golley, Manny Noakes

    Background Methods to address misreporting associated with short dietary assessment instruments are needed. Objective Our objective was to develop and evaluate the direct and indirect validity of adjustment factors applied to a short dietary assessment instrument to improve estimates of usual consumption of core and discretionary food and beverage intake. Design Validation of the Short Food Survey relative to 24-hour recalls was performed. The Short Food Survey requires individuals to report their usual intake of fruit, vegetables, grains, meat, dairy, and discretionary choices in multiples of standard servings. Adjustment factors were developed based on a ratio (usual portion size estimated from national data to standard serving size). The estimates of food group intakes (unadjusted and adjusted) were compared to 24-hour recalls. Participants/setting Three population samples were used in this study. The direct validation used data from 61 Australian adults (collected 2013–2014). The indirect validation compared data from the 2011–2013 Australian National Nutrition and Physical Activity Survey (n=9,435) to a sample of 145,975 who completed the Short Food Survey in a format that is freely available online (2015–2016). Main outcome measures Food group intake (in servings) was measured. Statistical analyses performed Descriptive and inferential statistical analyses were conducted. Results Direct validation showed the adjustment factors improved the survey-derived estimates of intake for all food groups except grain foods. For grains, the mean difference went from –0.6 servings to +1.2 to 1.5 servings. The absolute difference in food group intake between the adjusted Short Food Survey and recalls remained statistically significant for fruit, meat, dairy, and grains, but was not different for vegetables and discretionary foods. The indirect validation showed that the adjusted estimates of intake from the online Short Food Survey were closer to the population estimates reported by 24-hour recall for all food groups except meat. Conclusions Adjustment factors can improve estimates of food group intake assessed using a short dietary assessment instrument for some but not all food groups.

  • Measuring Micro-Level Effects of a New Supermarket: Do Residents Within 0.5 Mile Have Improved Dietary Behaviors?
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-08-08
    Stephanie Rogus, Jessica Athens, Jonathan Cantor, Brian Elbel

    Background Local and national policies to encourage supermarket opening or expansion are popular strategies for improving access to healthy food for residents in neighborhoods lacking these types of stores, yet few evaluations of such initiatives exist. Objective Our aim was to test whether a newly opened supermarket in the Bronx, NY, changed household availability of healthy and unhealthy food items and reported daily consumption of these items among respondents residing in close proximity (≤0.5 mile) to the new supermarket. Design This quasi-experimental study evaluated changes in purchasing and consumption habits of residents within 0.5 mile of the new supermarket as compared to residents living more than 0.5 mile from the supermarket. Data were collected through street intercept surveys at three different times: once before the store opened (March to August 2011) and in two follow-up periods (1 to 5 months and 13 to 17 months after the store opened). This study analyzed a subset of successfully geocoded resident intersections from the larger study. Participants/setting We surveyed 3,998 residents older than the age of 18 years in two Bronx neighborhoods about their food-purchasing behaviors before the store opened and in two follow-up periods. Responses from residents whose intersections were successfully geocoded (N=3,378) were analyzed to examine the consumption and purchasing behaviors of those in close proximity to the new store. Intervention A new supermarket opened in a low-access neighborhood in the Bronx with the help of financial incentives through New York City’s Food Retail Expansion to Support Health (FRESH) program. Main outcome measures The primary outcome evaluated was the change in percent of respondents reporting that the following food items were “always available” in the home: milk, fruit juice, soda, pastries, packaged snacks, fruits, and vegetables. As a secondary outcome, we explored changes in self-reported daily servings of these items. Statistical analysis performed A difference-in-difference analysis was performed, controlling for age, education, marital status, income, sex, race, and ethnicity. Results Residents within 0.5 mile of the store had increased household availability of both healthy and unhealthy foods. After the introduction of the supermarket, the percent of residents in close proximity to the store who reported always having produce available in the home increased by 8.8% compared to those living >0.5 mile from the store in the first post-period and by 10.6% compared to those living >0.5 mile from the store in the second post-period. A similar positive increase in household availability of salty snacks and pastries was observed. Residents living in close proximity also reported greater consumption of healthy foods like produce and water, and lower intake of soft drinks and pastries. Conclusions Given the financial support at the national and local levels to encourage supermarket development and expansion in high-need communities, it is imperative to evaluate the impact of such initiatives. Although the findings have so far been equivocal, our findings give weight to the argument that, at a micro-level, the siting of a new supermarket can indeed impact local purchasing and consumption behavior. Although purchasing for both healthy and unhealthy food items increased, reported consumption showed an increase in servings of healthy items (water, vegetables, and fruit) and a decrease in servings of unhealthy foods (soft drinks, salty snacks, and pastries).

  • Does the Transformation of Dietitians from Counseling to Therapy Also Apply to the Physical and Therapeutic Environment? A Case Study of Israeli Practice
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-08-17
    Anat Gesser-Edelsburg, Yael Birman

    Background Lifestyle change can be influenced through effective interaction between care receiver and care provider. The physical environment where the interaction occurs can affect the dynamics of long-term therapeutic treatment. There have been no studies on the perception of the physical environment in nutritional treatment. Objective Our aim was to ascertain the impact of the physical environment on the dynamics and communication between dietitian and patient based on perceptions of dietitians. Design We conducted qualitative constructivist phenomenological research. Participants In-depth interviews (n=10) and eight focus groups (n=62) were held with dietitians who offer treatment in a physical environment designed according to the medical model and/or in a physical dynamic environmental design according to the dynamic model. Results Most dietitians in Israel treat their patients in a physical environment arranged according to the medical model. The participants reported that the physical environment affects the interaction. However, the idea of transforming the physical environment according to the dynamic model raised reservations. Barriers include upsetting therapeutic boundaries, challenging professional authority, and lack of therapeutic tools suitable for the change. Conclusions Changes in the spatial design in which the therapeutic interaction occurs might support the dietitians' transformation from counseling into therapy. The barriers toward such change suggest that professional training is needed to enable dietitians to overcome them. We recommend conducting further research to evaluate the current physical environment, as well as raising dietitians’ awareness and training them to work in the new environment, reflecting a counseling/therapeutic mindset. These changes should be followed by additional research among practitioners to report on their effects.

  • Retailer-Led Sugar-Sweetened Beverage Price Increase Reduces Purchases in a Hospital Convenience Store in Melbourne, Australia: A Mixed Methods Evaluation
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-09-01
    Miranda R. Blake, Anna Peeters, Emily Lancsar, Tara Boelsen-Robinson, Kirstan Corben, Christopher E. Stevenson, Claire Palermo, Kathryn Backholer

    Background Limited evidence has been gathered on the real-world impact of sugar-sweetened beverage price changes on purchasing behavior over time or in community-retail settings. Objective Our aim was to determine changes in beverage purchases, business outcomes, and customer and retailer satisfaction associated with a retailer-led sugar-sweetened beverage price increase in a convenience store. We hypothesized that purchases of less-healthy beverages would decrease compared to predicted sales. Design A convergent parallel mixed methods design complemented sales data (122 weeks pre-intervention, 17 weeks during intervention) with stakeholder interviews and customer surveys. Participants/setting Electronic beverage sales data were collected from a convenience store in Melbourne, Australia (August through November 2015). Convenience store staff completed semi-structured interviews (n=4) and adult customers exiting the store completed surveys (n=352). Intervention Beverages were classified using a state government framework. Prices of “red” beverages (eg, nondiet soft drinks, energy drinks) increased by 20%. Prices of “amber” (eg, diet soft drinks, small pure fruit juices) and “green” beverages (eg, water) were unchanged. Main outcome measures Changes in beverage volume, item sales, and revenue during the intervention were compared with predicted sales. Statistical analyses Sales data were analyzed using time series segmented regression while controlling for pre-intervention trends, autocorrelation in sales data, and seasonal fluctuations. Results Beverage volume sales of red (−27.6%; 95% CI −32.2 to −23.0) and amber (−26.7%; 95% CI −39.3 to −16.0) decreased, and volume of green beverages increased (+26.9%; 95% CI +14.1 to +39.7) in the 17th intervention week compared with predicted sales. Store manager and staff considered the intervention business-neutral, despite a small reduction in beverage revenue. Fifteen percent of customers noticed the price difference and 61% supported the intervention. Conclusions A 20% sugar-sweetened beverage price increase was associated with a reduction in their purchases and an increase in purchases of healthier alternatives. Community retail settings present a bottom-up approach to improving consumer beverage choices.

  • Child Feeding Style and Dietary Outcomes in a Cohort of Latino Farmworker Families
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2017-09-29
    Edward H. Ip, Sarah A. Marshall, Thomas A. Arcury, Cynthia K. Suerken, Grisel Trejo, Joseph A. Skelton, Sara A. Quandt

    Background The high level of obesity in Latino children, especially in farmworker families, may be partly attributed to feeding styles of parents. Feeding styles used in Latino farmworker families have not been well characterized. Objective This study sought to identify and describe feeding styles used by mothers in farmworker families with 2.5- to 3.5-year-old children, describe how styles change over time, and characterize the relationship of feeding styles to dietary outcomes and measures of overweight and obesity. Design This was a longitudinal cohort study, with families participating for a 2-year period; surveys were administered to mothers with varying frequency depending on the instrument, and dietary measurements were collected at baseline and 12 and 24 months. Participants/setting Eligible participants were self-identified Latino women with a co-resident child aged 2.5 to 3.5 years old and at least one household member engaged in farm work during the previous year. The sample included 248 farmworker families enrolled between 2011 and 2012 in the Niños Sanos study, a longitudinal investigation of Latino mothers and their young children in rural North Carolina. Eleven families provided incomplete dietary data, so the analysis included 237 families. Fifteen families were lost to follow-up and 12 withdrew during the course of the study. Main outcome measures Feeding style was assessed using items from the Caregiver’s Feeding Style Questionnaire, selected dietary components were assessed using the Revised Children’s Diet Quality Index, and weight outcomes were determined using body mass index-for-age percentile. Performance on the Caregiver’s Feeding Style Questionnaire items was used to assign mothers to one of four feeding style states. Statistical analyses performed Exploratory factor analysis was conducted on baseline data to verify the replicability of the factor structure of the instrument Caregiver’s Feeding Style Questionnaire. Hidden Markov Model analysis was used to delineate different subtypes of feeding style. Multivariable mixed-effects regression models were used to assess the impact of feeding style on selected dietary components, energy intake, and body mass index-for-age percentile. Results Four distinct states emerged from the Hidden Markov Model: low parent-centered (PC)/moderate child-centered (CC) feeding style (28% at baseline), high PC/CC without physical control (24%), high PC/CC (26%), and moderate PC/CC (22%). The low PC/moderate CC state increased in prevalence over time. Compared to high PC/CC, the low PC/moderate CC state was associated with greater intake of added sugars (P<0.01), lower intake of whole grains and vegetables (P<0.01), and lower overall diet quality (P<0.05). Children in low PC/moderate CC also had higher mean body mass index percentiles (76.2 percentile vs 66.7 percentile in high PC/CC; P<0.001). Conclusions High PC feeding along with high CC feeding is associated with improved diet quality and weight outcomes for children in the study.

  • A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-22
    Jennifer Burris, James M. Shikany, William Rietkerk, Kathleen Woolf

    Background A high glycemic index (GI) and glycemic load (GL) diet may stimulate acne proliferative pathways by influencing biochemical factors associated with acne. However, few randomized controlled trials have examined this relationship, and this process is not completely understood. Objective This study examined changes in biochemical factors associated with acne among adults with moderate to severe acne after following a low GI and GL diet or usual eating plan for 2 weeks. Design This study utilized a parallel randomized controlled design to compare the effect of a low GI and GL diet to usual diet on biochemical factors associated with acne (glucose, insulin, insulin-like growth factor [IGF]-1, and insulin-like growth factor binding protein [IGFBP]-3) and insulin resistance after 2 weeks. Participants Sixty-six participants were randomly allocated to the low GI and GL diet (n=34) or usual eating plan (n=32) and included in the analyses. Main outcome measures The primary outcomes were biochemical factors of acne and insulin resistance with dietary intake as a secondary outcome. Statistical analyses Independent sample t tests assessed changes in biochemical factors associated with acne, dietary intake, and body composition pre- and postintervention, comparing the two dietary interventions. Results IGF-1 concentrations decreased significantly among participants randomized to a low GI and GL diet between pre- and postintervention time points (preintervention=267.3±85.6 mg/mL, postintervention=244.5±78.7 ng/mL) (P=0.049). There were no differences in changes in glucose, insulin, or IGFBP-3 concentrations or insulin resistance between treatment groups after 2 weeks. Carbohydrate (P=0.019), available carbohydrate (P<0.001), percent energy from carbohydrate (P<0.001), GI (P<0.001), and GL (P<0.001) decreased significantly among participants following a low GI/GL diet between the pre- and postintervention time points. There were no differences in changes in body composition comparing groups. Conclusions In this study, a low GI and GL diet decreased IGF-1 concentrations, a well-established factor in acne pathogenesis. Further research of a longer duration should examine whether a low GI and GL diet would result in a clinically meaningful difference in IGF-1 concentrations leading to a reduction in acne. This trial was registered at clinicaltrials.gov as NCT02913001.

  • Online Extra Inuit Country Food Diet Pattern Is Associated with Lower Risk of Coronary Heart Disease
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-21
    Xue Feng Hu, Tiff-Annie Kenny, Hing Man Chan

    Background Inuit have experienced a rapid transition in diet and lifestyle over the past several decades, paralleled by the emergence of chronic diseases such as obesity, diabetes, and hypertension. Objective To identify contemporary dietary patterns among Inuit and investigate their association with cardiovascular disease outcomes. Design This was an association study in a cross-sectional population health and nutrition survey. Participants The participants included 1,570 adults (aged ≥18 years) from Nunavut in the International Polar Year Inuit Health Survey 2007-2008 who completed diet/health questionnaires and provided blood samples. Main outcome measures Outcomes measured included the prevalence of coronary heart disease, myocardial infarction, stroke, hyperlipidemia, and hypertension. Statistical analyses performed Principal component analysis was used to derive dietary patterns based on the consumption of nine market food groups and four country food groups reported in 24-hour dietary recalls. The associations between cardiovascular outcomes and identified dietary patterns were examined with logistic regression. Results Three dietary patterns were identified: market food, country food–fat, and country food–fish. The market food diet, characterized by high consumption of market-bought meat, cereals, vegetables, and added oil, was associated with elevated prevalence of coronary heart disease, myocardial infarction, and hypertension (odds ratio [OR] 1.44, 95% CI 0.82 to 2.51; OR 2.27, 95% CI 0.88 to 5.83; and OR 1.36, 95% CI 0.88 to 2.09). The country food–fish diet, characterized by high fish consumption and low sugar and sweets intake, was inversely associated with the prevalence of coronary heart disease, myocardial infarction, stroke, and hyperlipidemia (OR 0.78, 95% CI 0.43 to 1.37; OR 0.46, 95% CI 0.18 to 1.20; OR 0.34, 95% CI 0.07 to 2.13; and OR 0.69, 95% CI 0.39 to 1.22). The country food–fat diet, characterized by high marine mammal and added fat intake, was positively associated with the prevalence of coronary heart disease. Conclusions A diet featuring high food variety, high fish intake, and low sugar intake was negatively associated with the prevalence of cardiovascular outcomes among Inuit.

  • Online Extra The Mindful Eating Behavior Scale: Development and Psychometric Properties in a Sample of Dutch Adults Aged 55 Years and Older
    J. Acad. Nutr. Diet. (IF 4.021) Pub Date : 2018-04-11
    Laura H.H. Winkens, Tatjana van Strien, Juan Ramón Barrada, Ingeborg A. Brouwer, Brenda W.J.H. Penninx, Marjolein Visser

    Background Earlier scales on mindful eating do not measure mindful eating independent from emotional or external eating, or mindful eating in common situations. Objective The objective was to develop a new instrument to measure the attention element of mindful eating, the Mindful Eating Behavior Scale (MEBS), and to compute the internal structure, reliabilities, and convergent validity of this scale. Design A cross-sectional ancillary study within the Longitudinal Aging Study Amsterdam was conducted between fall 2014 and spring 2015. Participants/setting Participants were 1,227 Dutch adults aged 55 years and older from the Longitudinal Aging Study Amsterdam. Main outcome measure A selection of 20 items from existing instruments was used to design an initial version of the MEBS. Statistical analyses performed The internal structure of the MEBS was evaluated using an exploratory structural equation modeling approach on half of the sample and confirmatory factor analysis on the whole sample to develop the final version of the scale. The measurement invariance of the scores was tested with respect to sex, age, and body mass index. Reliabilities of subscales were determined with Cronbach’s α. To test convergent validity, the scores of the new scale were correlated with theoretically relevant variables. Results Two items were deleted because of low item loadings and one item because of high correlated uniqueness. The final confirmatory factor analysis model with 17 items and four domains (Focused Eating, Hunger and Satiety Cues, Eating with Awareness, and Eating without Distraction) showed good fit (comparative fit index=0.97, Tucker-Lewis index=0.96, and root mean square error of approximation=0.04). Measurement invariance was found for sex, age, and body mass index. Cronbach’s α values were medium to high (.70 to .89). Most correlations were in the expected directions, which indicated good preliminary convergent validity. Conclusions The MEBS was successfully developed consisting of 17 items and four domains. Because of low interfactor correlations, a total score combining the four domains should not be computed. The MEBS showed good internal consistency and preliminary convergent validity in a sample of Dutch adults aged 55 years and older.

Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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