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Background The context in which a behavioral intervention is delivered is an important source of variability and systematic approaches are needed to identify and quantify contextual factors that may influence intervention efficacy. Machine learning-based phenotyping methods can contribute to a new precision health paradigm by informing personalized behavior interventions. Two primary goals of precision health, identifying population subgroups and highlighting behavioral intervention targets, can be addressed with psychosocial-behavioral phenotypes. We propose a method for psychosocial-behavioral phenotyping that models social determinants of health in addition to individual-level psychological and behavioral factors. Purpose To demonstrate a novel application of machine learning for psychosocial-behavioral phenotyping, the identification of subgroups with similar combinations of psychosocial characteristics. Methods In this secondary analysis of psychosocial and behavioral data from a community cohort (n = 5,883), we optimized a multichannel mixed membership model (MC3M) using Bayesian inference to identify psychosocial-behavioral phenotypes and used logistic regression to determine which phenotypes were associated with elevated weight status (BMI ≥ 25kg/m2). Results We identified 20 psychosocial-behavioral phenotypes. Phenotypes were conceptually consistent as well as discriminative; most participants had only one active phenotype. Two phenotypes were significantly positively associated with elevated weight status; four phenotypes were significantly negatively associated. Each phenotype suggested different contextual considerations for intervention design. Conclusions By depicting the complexity of psychological and social determinants of health while also providing actionable insight about similarities and differences among members of the same community, psychosocial-behavioral phenotypes can identify potential intervention targets in context.

The 1500mg/day dietary sodium-restriction commonly recommended for patients with heart failure has recently been questioned. Poor adherence to sodium restricted diets makes assessing the efficacy of sodium restriction challenging. Therefore, successful behavioral interventions are needed. We reviewed sodium restriction trials and descriptive studies of sodium restriction to: 1) determine if sodium restriction was achieved in interventions among heart failure patients; and 2) characterize predictors of successful dietary sodium restriction. Among 638 identified studies, 10 intervention trials and 25 descriptive studies met inclusion criteria. We used content analysis to extract information about sodium restriction and behavioral determinants of sodium restriction. Dietary sodium was reduced in seven trials; none achieved 1500 mg/day (range=1938–4564mg/day). The interventions implemented in the interventional trials emphasized knowledge, skills, and self-regulation strategies, but few addressed the determinants correlated with successful sodium restriction in the descriptive studies (e.g., social/cultural norms, social support, taste preferences, food access, self-efficacy). Findings suggest incorporating determinants predictive of successful dietary sodium restriction may improve the success of interventional trials. Without effective interventions to deploy in trials, the safety and efficacy of sodium restriction remains unknown.

Digital phenotyping consists of moment-by-moment quantification of behavioral data from individual people, typically collected passively from smartphones and other sensors. Within the evolving context of precision health, digital phenotyping can advance the use of mobile health -based self-management tools and interventions by enabling more accurate prediction for prevention and treatment, facilitating supportive strategies, and informing the development of features to motivate self-management behaviors within real-world conditions. This represents an advancement in self-management science: with digital phenotyping, nurse scientists have opportunities to tailor interventions with increased precision. In this paper, we discuss the emergence of digital phenotyping, the historical background of ecological momentary assessment, and the current state of the science of digital phenotyping, with implications for research design, computational requirements, and ethical considerations in self-management science, as well as limitations.

Health information technology is a leading cause of clinician burnout and career dissatisfaction, often because it is poorly designed by nonclinicians who have limited knowledge of clinicians' information needs and health care workflow.Describe how we engaged primary care clinicians and their patients in an iterative design process for a software application to enhance clinician-patient diet discussions.Descriptive study of the steps followed when involving clinicians and their at-risk patients in the design of the content, layout, and flow of an application for collaborative dietary goal setting. This began with individual clinician and patient interviews to detail the desired informational content of the screens displayed followed by iterative reviews of intermediate and final versions of the program and its outputs.Primary care clinicians practicing in an urban federally qualified health center and two academic primary care clinics, and their patients who were overweight or obese with diet-sensitive conditions.Descriptions of the content, format, and flow of information from pre-visit dietary history to the display of evidence-based, guideline-driven suggested goals to final display of dietary goals selected, with information on how the patient might reach them and patients' confidence in achieving them.Through three iterations of design and review, there was substantial evolution of the program's content, format, and flow of information. This involved "tuning" of the information desired: from too little, to too much, to the right amount displayed that both clinicians and patients believed would facilitate shared dietary goal setting.Clinicians' well-founded criticisms of the design of health information technology can be mitigated by involving them and their patients in the design of such tools that clinicians may find useful, and use, in their everyday medical practice.

Background: Surgical feeding ostomies (SFO, e.g. gastrostomy) have replaced natural orifice feeding tubes (NOFT, e.g. nasogastric feeding tube) as the preferred route for long-term enteral nutrition. Reports of complication rates for SFO vary. Many hospitalized patients are required to accept SFO before hospital discharge due to skilled nursing facilities (SNFs) policy, and without supportive data. We compare adverse event rates between SFO and NOFT. Methods: A prospective cohort study of enterally fed inpatients using semiweekly focused physical exam, scripted survey, and chart review. Findings: Over the course of nine weeks, 226 unique patients were seen an average of 6.25 times each for a total of 1118 unique observations. Demographic data were comparable between subgroups. There were 148 subjects with NOFT and 113 subjects with SFO. 35 NOFT crossed over to SFO during the study. More NOFT than SFO observations took place in ICUs (p

To explore the degree and predictors of and barriers to school garden integration (termed success).A 30-item online survey consisting of demographic, garden characteristic, and barrier questions, as well as the School Garden Integration Scale, was conducted in 266 school garden organizations (13 national, 8 regional, and 245 state or local).A total of 414 school gardeners from 38 states and Puerto Rico.School garden success using the GREEN Tool.Descriptive statistics were used to determine the degree of success of school garden programs and explore barriers. Multiple regression analysis was conducted to determine independent predictors of school garden success.The average score was 37 (range 1-53, of a possible 57 points), indicating moderate success. Operating budget (P.001), operating time (P.05), and planting in-ground (P.01) had a positive significant influence on success score, whereas rural location (P.01) and lacking community interest (P.01) had a negative significant influence, controlling for race/ethnicity, region, total garden investment, and Community Need Index score (a proxy for socioeconomic status).Results indicate that success of school garden programs may be more difficult for the schools located in a rural area or in the absence of school or community-at-large interest. This study found that race/ethnicity of students and socioeconomic status are not related to success score, which is promising as other research indicates that successful school gardens may be especially impactful for low-income people of color. Causal research is needed to identify strategies that increase school garden success, with a focus on engaging key stakeholders (administrators, teachers, parents, the community at large, and garden coordinators).

We compared 2014–15 New York State Science Assessment scores of fourth grade students who received the New York Sun Works (NYSW) Program (n = 638) with two comparison groups: students who received ...

Objective To evaluate Food, Health, & Choices, two 10-month interventions. Design Cluster-randomized, controlled study with 4 groups: curriculum, wellness, curriculum plus wellness, and control. Setting Twenty elementary schools (5/group) in New York City. Participants Fifth-grade students (n = 1,159). At baseline, 44.6% were at the ≥85th body mass index (BMI) percentile for age and 86% qualified for free or reduced-price lunch. Intervention Curriculum was 23 science lessons based on social cognitive and self-determination theories, replacing 2 mandated units. Wellness was classroom food policy and physical activity bouts of Dance Breaks. Main Outcome Measures For obesity, age- and sex-specific BMI percentiles were used (anthropometric measures). The researchers also employed 6 energy balance-related behaviors and 8 theory-based determinants of behavior change (by questionnaire). Analysis Pairwise adjusted odds in hierarchical logistic regression models were determined for >85th BMI percentile. Behaviors and theory-based determinants were examined in a 2-level hierarchical linear model with a 2 × 2 design for intervention effects and interactions. Results Obesity showed no change. For behaviors, there was a negative curriculum intervention change in physical activity (P = .04). The wellness intervention resulted in positive changes for sweetened beverages frequency (P = .05) and size (P = .006); processed packaged snacks size (P = .01); candy frequency (P = .04); baked good frequency (P = .05); and fast food frequency (P = .003), size (P = .01), and combo meals (P = .002). Theory-based determinants demonstrated no change. Conclusions and Implications The findings of the lack of a decrease in obesity, behavior changes only for the wellness intervention, and no changes in theory-based determinants warrant further research.

OBJECTIVES: To expand on previous survey-based research that provided a basic understanding of dietitian perspectives on app use by exploring factors that are influencing dietitian decision-making regarding the use and recommendation of apps with individual clients. METHODS: 20–60-minute semi-structured interviews conducted in-person, over the phone, or via videoconferencing from November 2019 to July 2020 with U.S. dietitians (n = 20) working in outpatient practice. Interview audio transcribed verbatim. Qualitative thematic analysis of interview transcripts. The creation of an audit trail, memos, and peer debriefing were used to enhance trustworthiness. RESULTS: Years in practice ranged from 2–42. Weight management and diabetes were most common counseling topics. Several factors that influence dietitian decision-making appear to limit a dietitians’ optimal use of apps, including current payment structure, limited app usability, and a dietitian's familiarity with available apps. Current payment structures typically don't compensate dietitians for time spent outside of visits to review app data or communicate/provide feedback to clients via the app. Participants described having difficulty finding apps for non-English speaking clients, clients with low literacy, and clients with complex dietary restrictions. A dietitian's familiarity with available apps also influenced if they were able to find apps that included desired features. CONCLUSIONS: Despite noting potential benefits of app use, dietitians are not utilizing apps as frequently as desired due to current payment structures, app feature and usability limitations, and the overabundance of apps without sufficient time or guidance for assessing available apps. Future research and policies to address these limitations could greatly improve the efficacy and use of apps in dietetics. FUNDING SOURCES: None

Objective To identify school garden attributes and practices that most strongly contribute to garden use and sustainability and translate them into recommendations for improving garden-based nutrition education. Design Surveys were developed and administered to school stakeholders to assess the barriers, strategies, and resources for successful school garden-based nutrition education. A panel of school garden experts identified thriving school gardens. Logistic regression was used to identify which attributes predicted thriving school garden programs. Setting Approximately 109 schools across Greater Austin, TX. Participants A total of 523 school teachers and 174 administrators. Outcomes Barriers, strategies, and resources relevant to successful school gardening nutrition programs. Results Thriving school gardens were 3-fold more likely to have funding and community partner use (P = 0.022 and P = 0.024), 4 times more likely to have active garden committees (P = 0.021), available garden curriculum (P = 0.003), teacher training (P = 0.045), ≥ 100 students who used the garden annually (P = 0.047), and 12 times more likely to have adequate district and administrator support (P = 0.018). Conclusions and Implications Adequate administrative and district support is fundamental when implementing a school garden. Schools may benefit from finding additional funding, providing teacher garden training, providing garden curriculum, forming garden leadership committees, and partnering with local community organizations to improve garden-based nutrition education.

The use of Extended Reality (XR) (i.e. Virtual and Augmented Reality) for nutrition education and behavior change has not been comprehensively reviewed. This paper presents findings from a scoping review of current published research. Articles (n = 92) were extracted from PubMed and Scopus using a structured search strategy and selection approach. Pertinent study information was extracted using a standardized data collection form. Each article was independently reviewed and coded by two members of the research team, who then met to resolve any coding discrepancies. There is an increasing trend in publication in this area, mostly regarding Virtual Reality. Most studies used developmental testing in a lab setting, employed descriptive or observational methods, and focused on momentary behavior change like food selection rather than education. The growth and diversity of XR studies suggest the potential of this approach. There is a need and opportunity for more XR technology focused on children and other foundational theoretical determinants of behavior change to be addressed within nutrition education. Our findings suggest that XR technology is a burgeoning approach in the field of nutrition, but important gaps remain, including inadequate methodological rigor, community application, and assessment of the impact on dietary behaviors.

Objectives. To elucidate details about the barriers (time, funding, staffing, and space) to integrating and sustaining school gardens. Methods. A total of 99 school gardeners from 15 states participated in an online survey in June 2017. The 29-item survey contained qualitative and quantitative items that we analyzed using descriptive statistics and inductive content analysis. Results. In order of greatest to least barrier, gardeners ranked time, staff, funding, curriculum, and space. Time for classes to use the garden (66% of respondents) and time for staff training (62%) were the most frequently listed time-related challenges. Respondents also reported low engagement within the school community. An overall lack of funding was the most common funding-related barrier, and gardeners were unaware of how to obtain more funding. Conclusions. We identified 3 aspects of school gardens as opportunities to address time- and staff-related issues: strengthening of garden committees, professional development, and community outreach. Better channels are needed to disseminate funding opportunities within schools and to communicate with communities at large. Ultimately, doing so will strengthen existing school gardens as a vehicle to promote dietary, physical, and social health within communities.

Results from clinical trials have shown that sugar-sweetened beverages (SSBs) lead to increased body mass index (BMI) and obesity. This relationship has yet to be explored in observational data for nonclinical populations of adults.To compare adults who drank 4+ SSBs daily to those who drank 0 in the population of adults in New York City, and to better understand adult risk factors associated with higher daily SSB consumption and BMI.Secondary analysis of cross-sectional data using propensity score matching.The 2009 New York City Community Health Survey (N=9,934) was used.BMI.For each participant who consumed 4+ SSBs daily, propensity score matching identified matched comparisons who did not drink any SSBs. BMI in unadjusted and matched pairs was tested using t tests. A post hoc analysis compared features of those likely to drink SSBs and those not likely to drink SSBs.In unmatched analyses, participants who consumed 4+ SSBs daily (n=475) had higher BMI than those who consumed 0 SSBs (n=3,818; BMI difference=1.4±0.29; t value=4.81; P0.001); however, when compared with similar participants using nearest neighbor with replacement matching (n=1,062), the difference between those who consumed 4+ SSBs daily and those who consumed none decreased (BMI difference=0.37±0.36; t value=1.01; P=0.32). Analyses also indicated that those likely to drink SSBs and those unlikely to drink SSBs differed in several important characteristics, including sex, age, race, ethnicity, socioeconomic status, education, diet, and exercise.The data preclude strong causal conclusions about the role of SSB in obesity. However, our results suggest that there is a subset of participants demographically and behaviorally similar with higher BMI regardless of their self-reported SSB intake. In addition to targeting SSBs, public health policies and programs should identify and address other modifiable aspects of this profile and tailor approaches to the groups identified to be most affected by high BMI.

OBJECTIVES: mHealth tools may support dietary management of type 2 diabetes. However, sustaining user engagement is a challenge. We used mixed methods to explore usage of a motivationally tailored custom smartphone application. METHODS: Platano is a self-determination theory-based app that promotes self-tracking of diet and blood glucose in diabetes. The app has four different interfaces that are tailored to users’ level of extrinsic or intrinsic motivation: monetary reward, registered dietitian feedback on diet goal(s), self-assessment of diet goal(s), or post-meal blood glucose forecast. For PI-TECH, Platano is being evaluated in a pilot Sequential Multiple Assignment Randomized Trial (SMART): participants are sequentially randomized to receive interfaces that match or do not match their level of motivation based on the Treatment Self-Regulation Questionnaire. Here, we report on preliminary results from the initial subset of participants (n = 16, mean age = 54+/−8, 82% female, 94% non-white, 69% household income

Background and significance Data-driven interventions for health can help to personalize self-management of Type 2 Diabetes (T2D), but lack of sustained engagement with self-monitoring among disadvantaged populations may widen existing health disparities. Prior work developing approaches to increase motivation and engagement with self-monitoring holds promise, but little is known about applicability of these approaches to underserved populations. Objective To explore how low-income, Latino adults with T2D respond to different design concepts for data-driven solutions in health that require self-monitoring, and what features resonate with them the most. Material and methods We developed a set of mockups that incorporated different design features for promoting engagement with self-monitoring in T2D. We conducted focus groups to examine individuals’ perceptions and attitudes towards mockups. Multiple interdisciplinary researchers analyzed data using directed content analysis. Results We conducted 14 focus groups with 25 English- and Spanish-speaking adults with T2D. All participants reacted positively to external incentives. Social connectedness and healthcare expert feedback were also well liked because they enhanced current social practices and presented opportunities for learning. However, attitudes were more mixed towards goal setting, and very few participants responded positively to self-discovery and personalized decision support features. Instead, participants wished for personalized recommendations for meals and other health behaviors based on their personal health data. Conclusion This study suggests connections between individuals’ degree of internal motivation and motivation for self-monitoring in health and their attitude towards designs of self-monitoring apps. We relate our findings to the self-determination continuum in self-determination theory (SDT) and propose it as a blueprint for aligning incentives for self-monitoring to different levels of motivation.

Objective To develop a computational system that uses dietary recall data to prioritize behavioral goals to facilitate efficient, personalized collaborative goal-setting in primary care. Use of Theory or Research The Chronic Care Model posits that synergy between the healthcare system and patient self-management will improve chronic disease outcomes. Thus, improving how diet is addressed in primary care could augment the benefit of dietary self-management. Collaborative goal-setting with primary care providers (PCPs) can facilitate patient behavior change. However, PCPs lack time and training to set effective diet goals with patients. NutriPCP aims to address this gap by presenting PCPs with a set of evidence-based goals prioritized using patient data. Target Audience PCPs Program Description NutriPCP uses ASA24 diet recall data to compute patient status for each of 9 previously developed, MyPlate-based goals (eg, “Make half my grains whole”). NutriPCP's inference engine consists of Python rule statements that synthesize a patient's data and compare it to evidence-based targets for nutrient consumption personalized for patient characteristics (eg, kcal intake/sex/age). PCPs are then presented with a list of the patient's status for each goal prioritized by degree of improvement needed. Evaluation Methods We tested our inference engine with test data (n = 12), and our team of nutrition, technology, and clinical experts validated the output. We used NHANES data to establish reasonable population-wide estimates. Results Testing revealed challenges for goal prioritization because datasets reflected consumption far from evidence-based targets. Therefore, we created standardized ranges to improve variability for relative ranking across goals. For goals with upper and lower limits (eg, “Reduce portion size”) we added warnings for inadequate intake. Conclusion We demonstrated that computational rules can automatically process recall data into prioritized behavioral goals. To our knowledge, this is the first system that personalizes MyPlate recommendations based on an individual's data. This has implications for nutrition education in primary care. Future research will examine implementation feasibility for PCPs and patients.

Childhood obesity is a complex, worldwide problem. Significant resources are invested in its prevention, and high-quality evaluations of these efforts are important. Conducting trials in school settings is complicated, making process evaluations useful for explaining results. Intervention fidelity has been demonstrated to influence outcomes, but others have suggested that other aspects of implementation, including participant responsiveness, should be examined more systematically. During Food, Health & Choices (FHC), a school-based childhood obesity prevention trial designed to test a curriculum and wellness policy taught by trained FHC instructors to fifth grade students in 20 schools during 2012–2013, we assessed relationships among facilitator behaviors (i.e., fidelity and teacher interest), participant behaviors (i.e., student satisfaction and recall), and program outcomes (i.e., energy balance-related behaviors) using hierarchical linear models, controlling for student, class, and school characteristics. We found positive relationships between student satisfaction and recall and program outcomes, but not fidelity and program outcomes. We also found relationships between teacher interest and fidelity when teachers participated in implementation. Finally, we found a significant interaction between fidelity and satisfaction on behavioral outcomes. These findings suggest that individual students in the same class responded differently to the same intervention. They also suggest the importance of teacher buy-in for successful intervention implementation. Future studies should examine how facilitator and participant behaviors together are related to both outcomes and implementation. Assessing multiple aspects of implementation using models that account for contextual influences on behavioral outcomes is an important step forward for prevention intervention process evaluations.

Background: Nursing home admission policies are one driver of increased and earlier gastrostomy placement, a procedure that is not always medically or ethically indicated among patients needing short-term nutrition support. This important clinical decision should be based upon patient prognosis, goals, and needs. We compared nursing home enteral nutrition-related admission policies in New York City and other regions of the United States. We also explored motivations for these policies. Methods: We conducted a telephone survey with skilled nursing facility administrators in New York City and a random sample of facilities throughout the United States about enteral nutrition-related admission policies. Survey data were matched with publically available data about facility characteristics from the Centers for Medicare and Medicaid Services. The relationship between facility location and admission policies was described with regression models. Reasons for these policies were thematically analyzed. Results: New York City nursing homes were significantly less likely to admit patients with nasogastric feeding tubes than were nursing homes nationwide, after we controlled for facility characteristics (odds ratio = 0.111; 95% CI, 0.032-0.344). Reasons for refusing nasogastric tubes fell into 5 categories: safety, capacity, policy, perception of appropriate level of care, and patient quality of life. Conclusion: Our findings indicate that enteral nutrition-related admission policies vary greatly between nursing homes in New York City and nationwide. Many administrators cited safety and policy as factors guiding their institutional policies and practices, despite a lack of evidence. This gap in research, practice, and policy has implications for quality and cost of care, length of hospital stay, and patient morbidity and mortality.

Knowing which barriers to buying and preparing/cooking vegetables at home are linked with the home availability of vegetables and how food-security status impacts this relationship will facilitate the tailoring of future public health interventions. Baseline data were used from an elementary-school-based intervention. Data on household food-security status, availability of vegetables at home, and barriers to buying and preparing/cooking vegetables were collected from 1942 parents. Differences between food-secure and food-insecure households were examined for barriers to buying and preparing/cooking vegetables. Mixed-effects linear regression was used to estimate the associations between barriers to buying and preparing/cooking vegetables and food-security status on the home availability of vegetables. Food insecurity was reported in 27% of households. Food-insecure households were significantly more likely to report barriers to buying and preparing/cooking vegetables. The barriers to purchasing/cooking vegetables score was associated with a decrease in the home availability of vegetables score ( = &minus, 0.77, 95% CI: &minus, 0.88, &minus, 0.65, p &lt, 0.001). Compared to food-secure households, food-insecure households were 15% less likely to have home vegetable availability ( = &minus, 1.18, 1.45, &minus, 0.92, 0.001). Although home availability of vegetables does not guarantee consumption, this study identified specific barriers that were associated with availability that can be targeted in future interventions seeking to improve vegetable consumption in the homes of low-income families.

The purpose of this study was to determine the level of integration of school gardens and identify factors that predict integration. 211 New York City schools completed a survey that collected demographic information and utilized the School Garden Integration Scale. A mean garden integration score was calculated, and multiple regression analysis was conducted to determine independent predictors of integration and assess relationships between individual integration characteristics and budget. The average integration score was 34.1 (of 57 points) and ranged from 8 to 53. Operating budget had significant influence on integration score, controlling for all other factors ( p < .0001). Partner organizations, evaluation/feedback, planning the physical space, and characteristics of the physical space were positively and significantly related to budget. The results of this study indicate that any garden can become well integrated, as budget is a modifiable factor. When adequate funding is secured, a well-integrated garden may be established with proper planning and sound implementation.

Background Dietary self-monitoring is a key strategy in diabetes self-management and may be facilitated by mHealth. However, smartphone applications are typically designed for high resource audiences and may exacerbate health inequity if they fail to meet user needs in underserved groups. Objective We aimed to understand user experiences with a dietary self-monitoring smartphone application designed for patients with Type 2 diabetes in a New York City neighborhood with high levels of health disparity. Study Design, Settings, Participants As part of the Personal Informatics Technology for Engagement in Community Health (PI-TECH) study, we applied user-centered design to develop Platano, a self-determination theory-based app that promotes self-tracking of diet and blood glucose in diabetes via motivationally-tailored user interfaces. During an ongoing pilot evaluation, we conducted face-to-face, in-depth interviews with English-speaking users (n = 9, age range = 28-61, 88% female, 89% non-white, 88% household income Measurable Outcome/Analysis Interviews were recorded and transcribed verbatim; data were managed in NVivo 12. Two authors coded interviews using Thematic Analysis, resolving differences through consensus. Results Five themes emerged: a) context: external circumstances (e.g., food insecurity, cultural norms) were central to participants’ user experience; b) flexible tool: participants used Platano for both self-discovery and accountability, reporting benefits including learning their personal glycemic response to specific foods and maintaining self-discipline in making dietary choices; c) empowerment: users attributed dietary changes, weight loss, and improved patient-provider communication to Platano; d) individual characteristics (e.g., nutrition literacy, motivation, self-efficacy), and e) in-the-moment barriers (e.g., social pressure) both influenced app usage and diet goal adherence. Conclusion Findings suggest Platano was well-received and viewed as a supporting tool for diabetes self-management among underserved urban adults. Further, findings reinforce the need for more comprehensive and personalized solutions to reduce barriers to engaging in dietary behavior change to improve diabetes outcomes.

Variability in individuals’ responses to interventions may contribute to small average treatment effects of childhood obesity prevention interventions. But, neither the causes of this individual variability nor the mechanism by which it influences behavior are clear. We used qualitative methods to characterize variability in students’ responses to participating in a childhood obesity prevention intervention and psychosocial characteristics related to the behavior change process. We interviewed 18 students participating in a school-based curriculum and policy behavior change intervention. Descriptive coding, summary, and case-ordered descriptive meta-matrices were used to group participants by their psychosocial responses to the intervention and associated behavior changes. Four psychosocial phenotypes of responses emerged: (a) Activated—successful behavior-changers with strong internal supports; (b) Inspired—motivated, but not fully successful behavior-changers with some internal supports, whose taste preferences and food environment overwhelmed their motivation; (c) Reinforced—already practiced target behaviors, were motivated, and had strong family support; and (d) Indifferent—uninterested in behavior change and only did target behaviors if family insisted. Our findings contribute to the field of behavioral medicine by suggesting the presence of specific subgroups of participants who respond differently to behavior change interventions and salient psychosocial characteristics that differentiate among these phenotypes. Future research should examine the utility of prospectively identifying psychosocial phenotypes for improving the tailoring of nutrition behavior change interventions.

Many nutrition programs include classroom-based education. Schoolteachers are relied upon to deliver these programs despite gaps in nutrition education motivation, knowledge, and self-efficacy. Teacher professional development (PD) for these nutrition education programs has been identified as a strategy for improving program effectiveness, yet many interventions do not include a PD component and still fewer describe it. A literature search was conducted between January and February 2017; articles were collected from PubMed, ERIC, and EBSCOhost. Article inclusion criteria were as follows: 1) published in an English-language peer-reviewed or scholarly journal, 2) published after 2000, 3) empirical research, 4) research conducted in a K-12 classroom, 5) research included nutrition education component, and 6) program delivered by a classroom teacher. Twenty-seven interventions were identified. A team of 2 researchers performed content analysis based on an evidence-based set of 7 PD components to assess if and how these components were incorporated before, during, or after program implementation. Little information was provided that described the role of teacher PD in the course of delivering nutrition education in classroom-based programs. The most common elements of PD described in the literature were the time spent in PD and follow-up with instructors during or after program implementation. There was a notable lack of methodologic description of teacher PD, and this limited reporting may decrease researchers' ability to work with teachers in a consistent and effective manner.

BACKGROUND: Pediatric long-term care facilities (pLTCF) serve a complicated and resource-intensive patient population with high usage of nutrition support. However, the relationship between nutrition support and outcomes among pLTCF residents is not well understood. We described this relationship in three metropolitan New York pLTCF and a subsample of infants from one of these facilities with a specialized unit for feeding disorders. METHODS: In this prospective cohort study, we used logistic regression to assess relationships between enteral nutrition (EN), and acute respiratory infections (ARI) among residents (n=720, 50% male, mean enrollment age=5.5 years, mean number comorbidities=2.1) and the infant subsample (n=208, 50% male, mean number comorbidities=2.0). We then tested these associations in multivariable models controlling for number of comorbidities and number of infections. RESULTS: Many residents received nutrition via percutaneous (59%) or nasogastric (15%) feeding tubes. In univariate analyses, residents receiving EN had more comorbidities. In multivariable analyses, EN was associated with ARI (Incidence rate ratio=1.65, p

OBJECTIVES: Dietary sodium restriction guidelines are controversial due to a lack of studies assessing their effect on heart failure outcomes. An important aspect of this problem is the effectiveness of behavioral nutrition interventions to reduce patients’ sodium intake. We systematically reviewed randomized controlled trials (RCTs) of sodium restricted diets and descriptive studies relating mediators of behavior to successful adherence to sodium restricted diets in patients with heart failure. METHODS: We queried PubMed, CINAHL, and Cochrane databases with relevant search terms for studies published in English January 2000-December 2018. Included were RCTs of interventions for heart failure patients, with sodium restriction as a primary or secondary outcome, and quantitative and qualitative descriptive studies of adherence to sodium restricted diets. Included studies may or may not have reported clinical outcomes (health events, quality of life, etc.). Reviewers noted setting, methods, and outcomes as well as theoretical mediators of dietary behavior change in included studies. We then compared behavioral mediators addressed by the RCTs and behavioral mediators identified in the descriptive studies. RESULTS: Of 638 studies identified, 445 were excluded by title. 2 reviewers assessed 60 abstracts and included 36 studies in this analysis: 10 RCTs and 26 descriptive studies. 6 of 10 intervention RCTs were successful, but no interventions achieved the recommended 1500 mg/day sodium intake (mean for all studies 3271 mg/day). Interventions that reduced sodium intake were behaviorally focused, were delivered by an RN and/or RD, and included individual feedback and counseling. RCTs intervened only through knowledge, skills, and social support. Behavioral mediators identified in descriptive studies included perceived risk, perceived benefits, outcome expectations, cultural norms, social norms, social support, taste preferences, determinism, self-efficacy, knowledge, skills, and habits. These were not included in the RCTs, which signifies a mismatch between evidence-based moderators of behavior and intervention designs. CONCLUSIONS: RCTs have been unable to achieve the recommended goal of 1500 mg/day of sodium. More effective interventions should consider evidence-based mediators, rather than focusing on knowledge and skills. FUNDING SOURCES: Dr. Burgermaster received funding from NHLBI T32 training grant.

Despite a heightened emphasis on building evaluation capacity and evaluation quality, there is a lack of tools available to identify high-quality evaluation. In the context of testing the Systems Evaluation Protocol (SEP), quantitative rubrics were designed and tested to assess the quality of evaluation plans and models. Interview data were also collected and analyzed using a priori codes. A mixed methods approach was used to synthesize quantitative and qualitative data and explore trends. Consistencies between data types were found for attitude and capacity, and disconnects were found for knowledge, cyberinfrastructure, time, and quality. This approach to data integration represents a novel way to tap the generative potential of divergence that arises when different methods produce contradictory results.

BACKGROUND Schools are frequent settings for childhood obesity prevention; however, intervention results are mixed. Classroom context may hold important clues to improving these interventions. METHODS We used mixed methods to examine classroom context during a curriculum intervention taught by trained instructors in fifth grade classrooms. We identified classrooms with high and low buy-in using cluster analysis and compared intervention delivery and reception, student energy balance-related behavior, and student perceptions about supports and barriers to energy balance. RESULTS Delivery and reception did not differ between the groups. Between-group differences in unhealthy behaviors were smaller at posttest, due to improvement in low buy-in classes. Although student perceptions of supports and barriers to energy balance were similar across groups, students in high buy-in classes indicated food preferences as a support while students in low buy-in classes indicated food preferences as a barrier. Neighborhood environment emerged as a universal barrier. CONCLUSIONS Trained instructors may improve intervention delivery and reception regardless of classroom context. Social norms could explain high levels of unhealthy behavior in low buy-in classes at baseline; improvement at posttest suggests that the curriculum may have motivated change. All children need more strategies and supportive policies to overcome a challenging food environment.

Objective. Sample size and statistical power calculation should consider clustering effects when schools are the unit of randomization in intervention studies. The objective of the current study was to investigate how student outcomes are clustered within schools in an obesity prevention trial. Method. Baseline data from the Food, Health & Choices project were used. Participants were 9- to 13-year-old students enrolled in 20 New York City public schools ( n = 1,387). Body mass index (BMI) was calculated based on measures of height and weight, and body fat percentage was measured with a Tanita® body composition analyzer (Model SC-331s). Energy balance–related behaviors were self-reported with a frequency questionnaire. To examine the cluster effects, intraclass correlation coefficients (ICCs) were calculated as school variance over total variance for outcome variables. School-level covariates, percentage students eligible for free and reduced-price lunch, percentage Black or Hispanic, and English language learners were added in the model to examine ICC changes. Results. The ICCs for obesity indicators are: .026 for BMI-percentile, .031 for BMI z-score, .035 for percentage of overweight students, .037 for body fat percentage, and .041 for absolute BMI. The ICC range for the six energy balance–related behaviors are .008 to .044 for fruit and vegetables, .013 to .055 for physical activity, .031 to .052 for recreational screen time, .013 to .091 for sweetened beverages, .033 to .121 for processed packaged snacks, and .020 to .083 for fast food. When school-level covariates were included in the model, ICC changes varied from −95% to 85%. Conclusions. This is the first study reporting ICCs for obesity-related anthropometric and behavioral outcomes among New York City public schools. The results of the study may aid sample size estimation for future school-based cluster randomized controlled trials in similar urban setting and population. Additionally, identifying school-level covariates that can reduce cluster effects is important when analyzing data.