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BACKGROUND Glucose variability increases cardiometabolic disease risk. While many factors can influence glucose levels, postprandial glucose response is the primary driver of glucose variability. Furthermore, affect may directly and indirectly impact glucose variability through its effect on eating behavior. Continuous glucose monitors (CGMs) facilitate the real-time evaluation of blood glucose, and ecological momentary assessment (EMA) can be used to assess affect in real time. Together, data collected from these sources provide the opportunity to further understand the role of affect in glucose levels. OBJECTIVE This paper presents the protocol for a study that aims to (1) evaluate the feasibility and acceptability of using CGMs along with EMA in nondiabetic populations and (2) examine the bidirectional relationship between affect and glucose in nondiabetic adults with overweight or obesity using a CGM and EMA. METHODS Eligibility criteria for the study include participants (1) aged 18 to 65 years old, (2) with a BMI of ≥25 kg/m2, (3) who are able to read and write in English, and (4) who own a smartphone. Individuals will be excluded if they (1) have type 1 or 2 diabetes or have any other condition that requires glucose monitoring, (2) are pregnant, (3) use any medications that have the potential to alter blood glucose levels or interfere with the glucose sensing process, or (4) have a diagnosed gastrointestinal condition or eating disorder. In a 14-day observational study, participants will wear a FreeStyle Libre Pro CGM sensor (Abbott) and will receive mobile phone–based EMA prompts 6 times per day (randomly within six 2-hour windows between 8 AM and 8 PM) to assess positive and negative affect. Participants will also wear a Fitbit Inspire 2 (Fitbit) to continuously monitor physical activity and sleep, which will be included as covariates in the analysis. Multilevel linear regression models will be used to evaluate the acute relationship between glucose level and affect. RESULTS Recruitment started in October 2022 and is expected to be completed in March 2023. We will aim to recruit 100 participants. As of December 12, 2022, a total of 39 participants have been enrolled. CONCLUSIONS The results of this study will further elucidate the role of affect in glucose variability. By identifying affective states that may lead to glucose excursions, our findings could inform just-in-time behavioral interventions by indicating opportunities for intervention delivery. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/45104

Background Glucose variability increases cardiometabolic disease risk. While many factors can influence glucose levels, postprandial glucose response is the primary driver of glucose variability. Furthermore, affect may directly and indirectly impact glucose variability through its effect on eating behavior. Continuous glucose monitors (CGMs) facilitate the real-time evaluation of blood glucose, and ecological momentary assessment (EMA) can be used to assess affect in real time. Together, data collected from these sources provide the opportunity to further understand the role of affect in glucose levels. Objective This paper presents the protocol for a study that aims to (1) evaluate the feasibility and acceptability of using CGMs along with EMA in nondiabetic populations and (2) examine the bidirectional relationship between affect and glucose in nondiabetic adults with overweight or obesity using a CGM and EMA. Methods Eligibility criteria for the study include participants (1) aged 18 to 65 years old, (2) with a BMI of ≥25 kg/m2, (3) who are able to read and write in English, and (4) who own a smartphone. Individuals will be excluded if they (1) have type 1 or 2 diabetes or have any other condition that requires glucose monitoring, (2) are pregnant, (3) use any medications that have the potential to alter blood glucose levels or interfere with the glucose sensing process, or (4) have a diagnosed gastrointestinal condition or eating disorder. In a 14-day observational study, participants will wear a FreeStyle Libre Pro CGM sensor (Abbott) and will receive mobile phone–based EMA prompts 6 times per day (randomly within six 2-hour windows between 8 AM and 8 PM) to assess positive and negative affect. Participants will also wear a Fitbit Inspire 2 (Fitbit) to continuously monitor physical activity and sleep, which will be included as covariates in the analysis. Multilevel linear regression models will be used to evaluate the acute relationship between glucose level and affect. Results Recruitment started in October 2022 and is expected to be completed in March 2023. We will aim to recruit 100 participants. As of December 12, 2022, a total of 39 participants have been enrolled. Conclusions The results of this study will further elucidate the role of affect in glucose variability. By identifying affective states that may lead to glucose excursions, our findings could inform just-in-time behavioral interventions by indicating opportunities for intervention delivery. International Registered Report Identifier (IRRID) DERR1-10.2196/45104

During adolescence, diet quality reaches its lowest point compared to other childhood life stages. Acculturation is associated with decreased diet quality among many groups of United States (US) immigrant adults, but research is limited among adolescents.To investigate the associations between birthplace and length of time living in the US, two proxy measures of acculturation, with diet quality among adolescents (12-19 years old).Data were from the National Health and Nutrition Examination Survey (2007-2018), which included two 24-hour dietary recalls (n = 6,113) to estimate Healthy Eating Index-2015 (HEI-2015) total scores and component scores. Multivariate linear regression and generalized linear models were performed to compare HEI-2015 total scores and component scores between US-born adolescents (n = 5342) and foreign-born adolescents with5 years (n = 244), 5 -10 years (n = 201), and ≥10 years (n = 290) of US residency.Foreign-born adolescents with5 years (53.3±1.2), 5 -10 years (51.4±1.5), and ≥10 years of US residency (49.9±0.8) had higher HEI-2015 total scores than US-born adolescents (47.0±0.3, p0.0001) and higher total vegetables, seafood and plant proteins, and added sugars scores (Ps≤0.0001). Foreign-born adolescents with more years of US residency had higher total fruits, whole fruits, and saturated fats scores than those with fewer years of US residency. Sensitivity analysis revealed this pattern held for Mexican American/other Hispanic adolescents.Being born outside the US and living in the US for less time (among foreign-born adolescents) is associated with higher diet quality. Culturally informed health promotion programs may help to reduce diet-related disparities related to acculturation among adolescents.

Infant- and toddler-feeding (ITF) practices are critical to long-term health and chronic disease prevention. Using mobile applications (apps) to promote desirable ITF practices shows promise for overcoming challenges of in-person education. However, the viability of ITF apps for Latina mothers of low-socioeconomic status (SES) remains unclear. The objective of this study was to characterize stakeholders’ views on Latina mothers’ capability, motivation, and barriers to using ITF apps. New York City-based health professionals who frequently engage with Latina mothers of low SES completed in-depth interviews. Directed content analysis was used to identify themes through theoretical and inductive codes. Participants included dietitians, nutrition educators, and physicians (n = 17). The following themes were identified: (1) Most Latina mothers of low-SES are tech-savvy (i.e., high capability and experience using smartphones and apps), (2) Apps are an appealing way to deliver ITF education, (3) There are challenges to using apps that must be carefully considered for ITF education development. Overall, ITF apps are a viable option as skills and use appear high among Latina mothers. Key considerations for app development include targeted app promotion, detailed instructions for obtaining and using app, more visuals, less text for low literacy and multiple dialects, making key features available offline.

Objectives To explore factors that shape decisions made regarding employee benefits and compare the decision-making process for workplace breastfeeding support to that of other benefits. Methods Sixteen semi-structured, in-depth interviews were conducted with Human Resource Managers (HRMs) who had previously participated in a breastfeeding-support survey. A priori codes were used, which were based on a theoretical model informed by organizational behavior theories, followed by grounded codes from emergent themes. Results The major themes that emerged from analysis of the interviews included: (1) HRMs' primary concern was meeting the needs of their employees, regardless of type of benefit; (2) offering general benefits standard for the majority of employees (e.g. health insurance) was viewed as essential to recruitment and retention, whereas breastfeeding benefits were viewed as discretionary; (3) providing additional breastfeeding supports (versus only the supports mandated by the Affordable Care Act) was strongly influenced by HRMs' perception of employee need. Conclusions for Practice Advocates for improved workplace breastfeeding-support benefits should focus on HRMs' perception of employee need. To achieve this, advocates could encourage HRMs to perform objective breastfeeding-support needs assessments and highlight how breastfeeding support benefits all employees (e.g., reduced absenteeism and enhanced productivity of breastfeeding employee). Additionally, framing breastfeeding-support benefits in terms of their impact on recruitment and retention could be effective in improving adoption.

OBJECTIVES: Pregnant and breastfeeding women are motivated to improve their diets for the health of their infants, but have difficulty maintaining changes postpartum or post-breastfeeding. Tailoring nutrition education to the mother-infant dyad versus individually, and providing mothers with information on the continued connection between them and their infants, may be effective at promoting healthful behaviors for both. However, low-income mothers report barriers to in-person education; technology may therefore help reach this audience. The objective of this study was to explore the receptivity of low-income mothers to the use of technology in providing nutrition education for themselves, their infants and families. METHODS: Women with a child

Background: Postpartum weight retention is often a significant contributor to overweight and obesity. Lactation is typically not sufficient for mothers to return to pre-pregnancy weight. Modifiable health behaviors (e.g., healthy eating and exercise) are important for postpartum weight loss; however, engagement among mothers, especially those who are resource-limited, is low. A deeper understanding of low-income breastfeeding mothers’ healthy-eating and exercise experience, a population that may have unique motivators for health-behavior change, may facilitate creation of effective intervention strategies for these women. Research Aim: To describe the healthy-eating and exercise experiences of low-income postpartum women who choose to breastfeed. Methods: Focus group discussions were conducted with low-income mothers ( N = 21) who breastfed and had a child who was 3 years old or younger. Transcript analysis employed integrated grounded analysis using both a priori codes informed by the theory of planned behavior and grounded codes. Results: Three major themes were identified from five focus groups: (a) Mothers were unable to focus on their own diet and exercise due to preoccupation with infant needs and more perceived barriers than facilitators; (b) mothers became motivated to eat healthfully if it benefited the infant; and (c) mothers did not seek out information on maternal nutrition or exercise but used the Internet for infant-health information and health professionals for breastfeeding information. Conclusion: Low-income breastfeeding mothers may be more receptive to nutrition education or interventions that focus on the mother-infant dyad rather than solely on maternal health.

Background Dietary behaviors, which impact chronic disease risk, are established early, making infant- and toddler-feeding education (ITE) critical to health. Using mobile applications (apps) for ITE shows promise: most Hispanics own smartphones (79%) and health-related apps are accepted among mothers. However, the viability of ITE apps for low-income Hispanic mothers remains unclear. Health professionals, who have insight into Hispanic mothers’ needs, can help clarify ITE apps’ potential. Objective To characterizing health professionals’ views on low-income Hispanic mothers’ capability, motivation, and barriers to using ITE apps. Study Design, Settings, Participants New York City-based health professionals with >3 years’ experience and >1 encounter/week with low-income Hispanic mothers of infants and toddlers (6-24 months) completed a demographic survey and an in-depth, semi-structured virtual interview. Capability, Opportunity, Motivation, and Behavior (COM-B), a well-accepted Dissemination and Implementation framework, informed the interview guide. Measurable Outcome/Analysis A directed content analysis approach was used to identify themes using COM-B theoretical codes and subcodes. Transcripts were coded independently by 2 researchers using NVivo 12. Survey data were analyzed using descriptive statistics. Results Participants included pediatricians, dietitians, WIC practitioners, and Cooperative Extension educators (n = 13); 100% owned a smartphone and 85% used popular apps “several times a week” or more often. The following themes were identified: 1) Mothers are tech-savvy (ie, high capability and use of smartphones and apps); 2) Potential limits to using apps exist (eg, home Internet access, literacy barriers, and multiple Spanish dialects); and 3) Easily accessible information motivates app use but capturing and maintaining interest is challenging (eg, abundance of app options overwhelming; apps are potentially burdensome). Conclusion ITE apps are a viable option as skills and use appear high among low-income Hispanic mothers. Important considerations for app development include availability of features with limited Internet access; strategies for low literacy and multiple dialects (eg, more visuals, less text); targeted app promotion; and careful consideration of user engagement.

Develop and evaluate the Infant Feeding Education Questionnaire (IFEQ) to measure the impact of the Expanded Food and Nutrition Education Program (EFNEP) infant-feeding education on knowledge, attitudes, and behavioral intent.Evaluation included content validity testing through expert reviews and cognitive interviews with low-income mothers (n = 37); construct validity using the known-groups technique (n = 679); convergent validity testing using the Infant Feeding Practices Study II questionnaire (n = 66); and test-retest reliability (n = 66).The IFEQ had strong construct validity for knowledge and attitudes; IFEQ scores were significantly higher for the high-knowledge/attitude group (29.6 ± 3.08) than the low-knowledge/attitude group (14.5 ± 5.81; P.001). The IFEQ failed to show convergent validity. The percent agreement between baseline and retest questions was moderate to high, indicating reliability over time.This study represents the first steps in the development of the IFEQ. There's a need to perform further testing to establish convergent validity and pilot-test the questions following EFNEP infant-feeding education.

Objective Explore current maternal and infant nutrition education practices and family medicine primary care providers' views on a group care model to deliver nutrition education to mother–infant dyads. Design In-depth interviews. Setting Family medicine clinics in 1 Midwestern US hospital system. Participants Family medicine primary care providers (n = 17) who regularly see infants during well-baby visits. Phenomenon of Interest Current maternal and infant nutrition education practices; views on ideal way to deliver nutrition education to mother–infant dyads; feedback on group care model to deliver nutrition education to mother–infant dyads. Analysis Audio recordings transcribed verbatim and coded using conventional content analysis. Results Family medicine primary care providers are limited in the ability to provide maternal and infant nutrition education and desire a different approach. Group care was the preferred method; it was shared most frequently as the ideal approach to nutrition education delivery and participants reacted favorably when presented with this model. However, there were many concerns with group care (eg, moderating difficult conversations, program implementation logistics, sufficient group volume, and interruption in patient–provider relationship). Conclusion and Implications Family medicine primary care providers desire a different approach to deliver nutrition education to mother–infant dyads in clinic. A group care model may be well-accepted among family medicine primary care providers but issues must be resolved before implementation. These results could inform future group care implementation studies and influence provider buy-in.

Community supported agriculture (CSA) programs have become a viable source of locally produced foods and represent a new way to increase fruit and vegetable consumption among individuals. Because CSAs represent a way for consumers to acquire healthy foods while providing financial support to local farmers, CSA involvement could reflect, and be related to, greater concern with both health and environmental impact of food choice. As such, the aim of this study was to examine whether ecological attitudes of CSA members could predict food- and sustainability-related behaviours. Using an online survey, respondents answered questions about attitudes towards the environment, as well behaviours related to food purchases, family food preparation, composting, recycling and minimising food-packaging waste. A total of 115 CSA member responses were collected. Ordinary least squares (OLS) multivariate regression analysis was used to investigate the predictive validity of environmental attitudes on measures of behaviours. A large portion of participants reported the amount and variety of fruits and vegetables their households ate increased as a result of joining a CSA program. Ecological sensitivity was a significant predictor of sustainability-related behaviours as well as money spent eating out and times eaten away from home per week. However, it was not predictive of family involvement in home food preparation.