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Deirdra Chester, PhD, RD Obesity Research Coordinator Food Intake and Energy Regulation Laboratory USDA ARS BHNRC The HEALTH Study

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David before his visit to the US

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David just before leaving for Italy

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The Healthy Eating and Lifestyle for Total Health (HEALTH) Study Prevalence of obesity in the US has doubled in the recent decades. Nearly 1/3 of adults are obese (BMI>30). Overweight among children is high and has been increasing in prevalence since the mid 1970s. (Troiano et al, 1995; Ogden et al, 2002) An estimated 16% of children and adolescents are overweight. Introduction

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Why the Dietary Guidelines (DG) The 2005 DG for Americans provides science-based advice to promote health and reduce risk for major chronic diseases through diet and physical activity. The DG provide food-based recommendations to meet nutrient requirements, as well as recommendations for regular physical activity that together, are designed to promote energy balance. The federal food guidance based on the DG focuses on dietary intake patterns (also referred to as food intake patterns) in which the recommendations are integrated as a health promoting way for Americans. There is a need to understand what barriers prevent adherence and what facilitators promote adherence in order to counsel patients and help the population adhere to the DG.

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Background Research continues to show that many segments of the US population are not meeting the diet recommendations in the Dietary Guidelines (Reeves, 2000; Walker et al., 2007; Casagrande et al.,2007) This is particularly true for some sub-populations such as Latinos who often are also at higher risk for heart disease, cancer, stroke, and diabetes (Hayes-Bautisti et al., web; CaDHS, web) yet whose population is increasing in the United States, such that in 2001 over half of the births in California were to Latino mothers (CaDHS, web). In addition, African Americans are a population group who are at increased risk of heart disease, cancer, stroke, and diabetes. Poor nutrition is linked to not only the high levels of chronic disease in Latinos and African Americans but also poor health outcomes in the general population (DHHS,2005)

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Eating Behaviors, Context, and Body Weight

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Restaurant Food Consumption In 1994-1995, 57% of Americans consumed at least one food item away from home on any given day, compared to 43% in 1977 -1978 (Lin et al, 1999). Meals away from home increased with age, from 18% for preschoolers to 26% for school-age children, and 27 30% for adolescents. Fast-food restaurants accounted for more than half of away- from-home meals (Lin et al, 1998). The increasing proportion of household food income spent on food away from home may help to explain the rising prevalence of obesity in the US.

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Beverage Consumption Soft drink consumption has been replacing more nutritious beverages such as milk and possibly fruit juices among adolescents (Harnack et al, 1999). The proportion of adolescent boys and girls consuming soft drinks daily increased by 74% and 65%, respectively, while milk consumption decreased over the same period. Consumption of soft drinks increased dramatically among adolescents from 1977-79 to 1994 (Borrud et al, 1996).

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Portion Sizes The typical fast food hamburger in 1957 contained 1 oz of cooked meat, compared to up to 6 oz in 1997. The average soda was 8 ounces in 1957, vs. 32 to 64 ounces in 1997. The average theatre popcorn was 3 cups in 1957 vs. 16 cups (medium size) in 1997. Adults consumed more food when served portions 1 times larger than a standard portion size. 5-y-old children consumed greater amounts of food when presented with larger portions.

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Meal Type and Frequency Ninety-eight percent of students reported at least three daily eating occasions, and more than 50% reported five or more (Burghardt, 1995). The percentage eating snacks increased from 60% in 1977-78 to 75% in 1994-1995 (Cross et al, 1994). Nearly all children 1 to 19 years of age reported eating at least one snack per day (CSFII, 1994) and 36% of all children consumed at least four or more different daily snacks (Cross et al, 1994). Children who consumed breakfast had significantly better Healthy Eating Index (HEI) scores for grains, fruits, milk products, and variety than children who did not (Bowman et al, 1998).

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Family Meals Eating dinner as a family has been associated with higher quality diet (Cross et al, 1994). Greater frequency of participation in family dinner associated with higher consumption of fruit and vegetables, fiber, folate, calcium, iron, Vitamins B6, B12, C and E, lower consumption of saturated and trans fatty acids, soda, and fried foods (Gillman et al, 2000).

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Dietary Quality Americans eating has improved since 1989 (Bowman et al, 1998) Despite this positive trend, only 12% of Americans had a diet that could be considered good. Dietary Variety Individuals who consumed the greatest variety of foods from all food groups had the most adequate nutrient intake (Kant et al, 1993).

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Physical Activity Many adults may need up to 60 minutes of moderate to vigorous physical activity on most days to prevent unhealthy weight gain. Children need at least 60 minutes of moderate to vigorous physical activity on most days for maintenance of good health and fitness and for healthy weight during growth.

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Study Purpose The primary goal of the project is to identify barriers and facilitators related to DG (MyPyramid) adherence profiles and examine how differential profiles of adherence relate to obesity. The inclusion of 3 major Racial-Ethnic Group (REG) across 6 sites will provide information that will be valuable in conducting future translational research for developing interventions to combat obesity. Objectives: 1: To construct conceptually, culturally, linguistically and measurement equivalent surveys for caregivers and children to assess DG adherence barriers and facilitators for the most prevalent US racial/ethnic groups (REG) including African-(AA), European- (EA) and Hispanic-American (HA). 2: To examine barriers and facilitators of DG adherence and other factors as they relate to dietary behavior and body mass index (BMI) by administering the surveys to cross-sections of the US population in 6 geographic locations..

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Proposed Overall Design and Sequence of Activities NGT Preparation & Questions Development (Barriers and Facilitators) Conduct NGT Sessions with Caregivers and Children Response Distillation and Survey Item Development Administer Pilot Surveys and Conduct Psychometric Analyses Administer Cross-Sectional Surveys Conduct Analyses to Examine Relationship b/w DG Adherence and: (1) Barriers and Facilitators and (2) BMI in caregivers and children from 6 Geographic Locations served by USDA Human Nutrition Research Sites

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Beltsville Human Nutrition Research Center Where are we now? African Americans European Americans 5 th Graders in public school in Prince Georges County, MD Caregivers Cognitive Interview Nominal Group Technique

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Phase II Barriers and Facilitators Survey (BAFS) Physical Activity Body Composition Demographics Household Food Practices Food Security Mood States Neighborhood Environmental Walkability Scale (NEWS) Acculturation Parenting Dimensions Inventory (PDI-S)

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Hypothesis Individuals with greater DG adherence perceive fewer barriers and more facilitators compared to those with less DG adherence Barriers and facilitators associated with DG adherence differ by age, gender, racial/ethnic (REG) group, SES, geographic location, and other physical, psychological and cultural factors. Full adherence with the DG will occur in less than 5% of a diverse sample of the population. Substantial (> 80%) adherence with the DG occurs in less than 20% of the US population studied. BMI and other body composition measures are associated with DG adherence.

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Potential Benefits Identification and description of current DG adherence profiles as a lifestyle package. Provide insights regarding important relationships between weight status (obesity), profiles of DG adherence, factors that influence adherence, and how these relationships systematically vary as a lifestyle package. Many factors influence barriers and facilitators including age, gender, REG and SES. Understanding the barriers and facilitators of the DG.

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One Last Thought!

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Thank you! The HEALTH Study