Process evaluation of the Yéego! Program to increase healthy eating and gardening among American Indian elementary school children.

BACKGROUND: American Indian children are at increased risk for obesity and diabetes. School-based health promotion interventions are one approach to promoting healthy behaviors to reduce this risk, yet few studies have described their implementation and fidelity. We conducted a qualitative process evaluation of the Yéego! Healthy Eating and Gardening Program, a school-based intervention to promote healthy eating among Navajo elementary school children. The intervention included a yearlong integrated curriculum, as well as the construction and maintenance of a school-based garden. METHODS: Our process evaluation included fidelity checklists completed by program staff and qualitative interviews with program staff and classroom teachers after the intervention was implemented. We used content analysis to identify themes. RESULTS: We identified several themes related to evidence of delivery adherence, program satisfaction, and lessons learned about delivery. Intervention staff followed similar procedures to prepare for and deliver lessons, but timing, teaching styles, and school-level factors also impacted overall implementation fidelity. Teachers and students had positive perceptions of the program, especially lessons that were highly visual, experiential, and connected to Navajo culture and the surrounding community. Teachers and program staff identified ways to enhance the usability of the curriculum by narrowing the scope, relating content to student experiences, and aligning content with school curriculum standards. CONCLUSIONS: The program was implemented with moderately high fidelity across contexts. We identified areas where modifications could improve engagement, acceptability, efficacy, and sustainability of the program. Our results have implications for the evaluation and dissemination of school-based health interventions to promote healthy eating among children, especially in American Indian communities.

Development of an Assessment Tool to Measure Healthy Eating in Navajo Children and Their Families.

Background: To estimate the efficacy of interventions to improve healthy eating, valid measures are essential. Although simple dietary intake tools have been developed with other populations, few have been culturally tailored and assessed for validity and reliability among Navajo. Objectives: This study aimed to develop a simple dietary intake tool tailored to Navajo culture, derive healthy eating indices, and assess their validity and reliability in Navajo children and adults and to describe the process used to develop this tool. Methods: A picture-sort tool using typically consumed foods was developed. Elementary school children and family members provided qualitative feedback in focus groups, used to refine the tool. Next, school-aged children and adults completed assessments at baseline and follow-up. Baseline behavior measures including child self-efficacy for fruits and vegetables (F&V) were examined for internal consistency. Healthy eating indices were derived from intake frequencies from picture sorting. The convergent validity of the indices and behavior measures for children and adults were examined. The reliability of the indices at the 2 time points was derived using Bland-Altman plots. Results: The picture-sort was refined from feedback provided by the focus groups. Baseline measures from 25 children and 18 adults were obtained. In children, a modified Alternative Healthy Eating Index (AHEI) and 2 other indices from the picture-sort were correlated with self-efficacy for eating F&V and had good reliability. In adults, the modified AHEI and 3 other indices from the picture-sort had significant correlations with adult abbreviated food frequency of F&V or obesogenic dietary index and had good reliability. Conclusions: The Navajo foods picture-sort tool developed for Navajo children and adults is proven to be acceptable and feasible to implement. Indices derived from the tool has good convergent validity and repeatability, supporting use in evaluating dietary change interventions in Navajo, with the potential for broader use of the approach in other underserved populations.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States.

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Effectiveness of a Worksite-Based Lifestyle Intervention on Employees' Obesity Control and Prevention in China: A Group Randomized Experimental Study.

Background: This study was to culturally adapt a lifestyle intervention for employees' obesity control and prevention using a participatory process, and evaluate the effectiveness of the project at worksites. Methods: A group randomized experimental study included four worksites (two intervention, two control) in the Yangtze River Delta in China was conducted. A total of 388 participants (216 in the intervention worksites and 172 in the control worksites) were finally recruited from 955 employees at the four worksites (464 in the intervention worksites and 491 in the control worksites). The final evaluation was completed by two hundred and seventy-eight employees (159 in the intervention worksites and 119 in the control worksites, respectively). Data of demographic information, weight, BMI, waist circumference, hip circumference and weight-related behaviors including diary behaviors and physical activities were collected before and after a 12-month intervention and analyzed using descriptive statistics, t-test, chi-square test, linear mixed regression and logistic mixed regression. Results: Although the intervention worksites had a reduction in body mass index (23.21 to 22.95, p < 0.01), hip circumference (95.97 to 95.28, p = 0.03) and waist-to-height ratio (0.49 to 0.48, p = 0.01), the differential changes compared to those of the control group were not statistically significant. The frequency of sweet beverages (−1.81, 95%CI: −0.52, −3.11), frequency of vegetable intake (5.66, 95%CI: 1.59, 9.74), daily servings of vegetables (0.53, 95%CI: 0.24, 0.82), frequency of fruit intake (3.68, 95%CI: 1.25, 6.12), daily servings of fruit (0.26, 95%CI: 0.44, 0.92), daily servings of vegetables and fruit (0.79, 95%CI: 0.43, 1.16), daily steps (863.19, 95%CI: 161.42, 1564.97) and self-efficacy to change physical activity (OR = 1.91, 95%CI: 1.02,3.60) were more improved in the intervention group than were those measures in the control group. Conclusions: The worksite-based lifestyle intervention project for obesity control and prevention improved several employees' dietary behaviors and physical activities at worksites in China in a short time. Long-term intervention with larger samples in more worksites should be further examined.

Associations between Genetic Variants and Blood Biomarkers of One-Carbon Metabolism in Postmenopausal Women from the Women's Health Initiative Observational Study.

BACKGROUND: Genetic variation in one-carbon metabolism may affect nutrient concentrations and biological functions. However, data on genetic variants associated with blood biomarkers of one-carbon metabolism in US postmenopausal women are limited, and whether these associations were affected by the nationwide folic acid (FA) fortification program is unclear. OBJECTIVES: We investigated associations between genetic variants and biomarkers of one-carbon metabolism using data from the Women's Health Initiative Observational Study. METHODS: In 1573 non-Hispanic White (NHW) and 282 Black/African American, American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic/Latino women aged 50-79 y, 288 nonsynonymous and tagging single-nucleotide variants (SNVs) were genotyped. RBC folate, plasma folate, pyridoxal-5'-phosphate (PLP), vitamin B-12, homocysteine, and cysteine concentrations were determined in 12-h fasting blood. Multivariable linear regression tested associations per variant allele and for an aggregated genetic risk score. Effect modifications before, during, and after nationwide FA fortification were examined. RESULTS: After correction for multiple comparisons, among NHW women, 5,10-methylenetetrahydrofolate reductase (MTHFR) rs1801133 (677C→T) variant T was associated with lower plasma folate (-13.0%; 95% CI: -17.3%, -8.6%) and higher plasma homocysteine (3.5%; 95% CI: 1.7%, 5.3%) concentrations. Other associations for nonsynonymous SNVs included DNMT3A rs11695471 (T→A) with plasma PLP; EHMT2 rs535586 (G→A), TCN2 rs1131603 (L349S A→G), and TCN2 rs35838082 (R188W G→A) with plasma vitamin B-12; CBS rs2851391 (G→A) with plasma homocysteine; and MTHFD1 rs2236224 (G→A) and rs2236225 (R653Q G→A) with plasma cysteine. The influence of FA fortification on the associations was limited. Highest compared with lowest quartiles of aggregated genetic risk scores from SNVs in MTHFR and MTRR were associated with 14.8% to 18.9% lower RBC folate concentrations. Gene-biomarker associations were similar in women of other races/ethnicities. CONCLUSIONS: Our findings on genetic variants associated with several one-carbon metabolism biomarkers may help elucidate mechanisms of maintaining B vitamin status in postmenopausal women.

Mortality Associated with Healthy Eating Index Components and an Empirical-Scores Healthy Eating Index in a Cohort of Postmenopausal Women.

BACKGROUND: Studies of diet and chronic disease include a recent important focus on dietary patterns. Patterns are typically defined by listing dietary variables and by totaling scores that reflect whether consumption is encouraged or discouraged for listed variables. However, precision may be improved by including total energy consumption among the dietary variables and by scoring dietary variables empirically. OBJECTIVES: To relate Healthy Eating Index (HEI)-2010 components and total energy intake to all-cause and cause-specific mortality in Women's Health Initiative (WHI) cohorts and to define and evaluate an associated Empirical-Scores Healthy Eating Index (E-HEI). METHODS: Analyses are conducted in WHI cohorts (n = 67,247) of healthy postmenopausal women, aged 50-79 y, when enrolled during 1993-1998 at 40 US clinical centers, with embedded nutrition biomarker studies. Replicate food-frequency assessments for HEI-2010 ratio variables and doubly labeled water total energy assessments, separated by ∼6 mo, are used as response variables to jointly calibrate baseline dietary data to reduce measurement error influences, using 2 nutrition biomarker studies (n = 199). Calibrated dietary variables are associated with mortality risk, and an E-HEI is defined, using cross-validated HR regression estimation. RESULTS: Of 15 dietary variables considered, all but empty calories calibrated well. Ten variables related significantly (P < 0.05) to total mortality, with favorable fruit, vegetable, whole grain, refined grain, and unsaturated fat associations and unfavorable sodium, saturated fat, and total energy associations. The E-HEI had cross-validated total mortality HRs (95% CIs) of 0.87 (0.82, 0.93), 0.80 (0.76, 0.86), 0.77 (0.72, 0.82), and 0.74 (0.69, 0.79) respectively, for quintiles 2 through 5 compared with quintile 1. These depart more strongly from the null than do HRs for HEI-2010 quintiles, primarily because of total energy. CONCLUSIONS: Mortality among US postmenopausal women depends strongly on diet, as evidenced by a new E-HEI that differs substantially from earlier dietary pattern score specifications.

Group Randomized Trial of Healthy Eating and Gardening Intervention in Navajo Elementary Schools (Yéego!).

Introduction: Few healthy eating, school-based interventions have been rigorously evaluated in American Indian communities. Gardening and healthy eating are priorities in the Navajo Nation. Collaborations between researchers and local partners supported the design and implementation of this project. Design: The Yéego! Healthy Eating and Gardening Study was a group-randomized controlled trial to evaluate a school-based healthy eating and gardening intervention in 6 schools in the Navajo Nation. Schools were randomized 1:2 to intervention or comparison. Setting/participants: The Shiprock and Tsaile/Chinle areas in the Navajo Nation were selected. Elementary schools were screened for eligibility. All students in third and fourth grades were invited to participate in the assessments. Intervention: Delivered during 1 school year in the intervention schools, the intervention included a culturally relevant nutrition and gardening curriculum and a school garden. Main outcome measures: Student self-efficacy for eating fruits and vegetables, student self-efficacy for gardening, and student healthy foods score from a modified Alternative Healthy Eating Index were assessed in third and fourth graders at the beginning and end of a school year affected by the COVID-19 pandemic. Primary analyses used repeated measures linear mixed models accounting for students nested within schools to estimate the intervention effect and 95% CIs. Results: Students in the intervention schools had self-efficacy scores for eating fruits and vegetables that were 0.22 points greater (95% CI=0.04, 0.41) than those in the comparison schools, although the student healthy foods score increased in the intervention schools by 2.0 (95% CI=0.4, 3.6); the differential change was modest at 1.7 (95% CI=-0.3, 3.7). The self-efficacy to grow fruits and vegetables in the school garden increased among those in the intervention schools (OR=1.92; 95% CI=1.02, 3.63) but not significantly more than it increased in the comparison schools (OR=1.29; 95% CI=0.60, 2.81). Conclusions: The intervention was efficacious in improving self-efficacy for eating fruits and vegetables among third- and fourth-grade students over a school year. The findings warrant further evaluation of the intervention in larger-group randomized trials with schools in Navajo communities. Trial registration: This study is registered at clinicaltrials.gov NCT03778021.

Engaging School and Family in Navajo Gardening for Health: Development of the Yéego Intervention to Promote Healthy Eating among Navajo Children.

OBJECTIVE: Navajo children are at increased risk for obesity, in part due to limited access to healthy foods. School garden interventions have been shown to increase access to fresh fruit and vegetables and consumption of healthy foods. Our study describes the development and pilot testing of a school garden intervention for Navajo elementary school children. METHODS: We reviewed existing school garden interventions and conducted formative research with students, caregivers, and school staff to inform the intervention. The intervention consisted of a garden built at the school and a yearlong curriculum on gardening and healthy eating. We pilot tested the intervention in an elementary school on the Navajo Nation. RESULTS: Formative research revealed the importance of incorporating Diné culture, including traditional growing practices and the preparation of traditional foods into the curriculum. School staff also stressed the value of tying the curriculum to state and Diné educational standards. Students enjoyed opportunities for hands-on activities and snack preparation. CONCLUSIONS: Schools have a meaningful role to play in addressing childhood obesity disparities among Navajo children. School-based interventions that draw on cultural strengths and include healthy traditional practices can be a promising strategy for increasing fruit and vegetable consumption.

Novel Application of Nutritional Biomarkers From a Controlled Feeding Study and an Observational Study to Characterization of Dietary Patterns in Postmenopausal Women.

Dietary guidance emphasizes healthy dietary patterns, but supporting evidence comes from self-reported dietary data, which are prone to measurement error. We explored whether nutritional biomarkers from the Women's Health Initiative Nutrition and Physical Activity Assessment Study Feeding Study (NPAAS-FS) (n = 153; 2010-2014) and the Women's Health Initiative Nutrition and Physical Activity Assessment Study Observational Study (NPAAS-OS) (n = 450; 2006-2009) could identify biomarker signatures of dietary patterns for development of corresponding regression calibration equations to help mitigate measurement error. Fasting blood samples were assayed for a specific panel of vitamins, carotenoids, and phospholipid fatty acids; 24-hour urine samples were assayed for nitrogen, sodium, and potassium levels. Intake records from the NPAAS-FS were used to calculate Healthy Eating Index 2010 (HEI-2010), Alternative Healthy Eating Index 2010 (AHEI-2010), alternative Mediterranean diet (aMED), and Dietary Approaches to Stop Hypertension (DASH) scores. Scores were regressed on blood and urine nutritional measures for discovery of dietary pattern biomarkers using a cross-validated model R2 ≥ 36% criterion (stage 1). Next, stepwise models (P ≤ 0.10 for entry/removal) using NPAAS-OS data were used to regress stage 1 dietary pattern biomarkers on NPAAS-OS self-reported dietary pattern scores using a food frequency questionnaire, a 4-day food record, and a 24-hour recall (stage 2). HEI-2010 and aMED analyses met the cross-validated R2 ≥ 36% criterion in stage 1, while AHEI-2010 and DASH analyses did not. The R2 values for HEI-2010 stage 2 calibration equations were as follows: food frequency questionnaire, 63.5%; 4-day food record, 83.1%; and 24-hour recall, 77.8%. Stage 2 aMED R2 values were 34.9%-46.8%. Dietary pattern biomarkers have potential for calibrating self-reports to enhance studies of diet-disease associations.

Evaluation of potential metabolomic-based biomarkers of protein, carbohydrate and fat intakes using a controlled feeding study.

PURPOSE: Objective biomarkers of dietary exposure are needed to establish reliable diet-disease associations. Unfortunately, robust biomarkers of macronutrient intakes are scarce. We aimed to assess the utility of serum, 24-h urine and spot urine high-dimensional metabolites for the development of biomarkers of daily intake of total energy, protein, carbohydrate and fat, and the percent of energy from these macronutrients (%E). METHODS: A 2-week controlled feeding study mimicking the participants' habitual diets was conducted among 153 postmenopausal women from the Women's Health Initiative (WHI). Fasting serum metabolomic profiles were analyzed using a targeted liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for aqueous metabolites and a direct-injection-based quantitative lipidomics platform. Urinary metabolites were analyzed using 1H nuclear magnetic resonance (NMR) spectroscopy at 800 MHz and by untargeted gas chromatography-mass spectrometry (GC-MS). Variable selection was performed to build prediction models for each dietary variable. RESULTS: The highest cross-validated multiple correlation coefficients (CV-R2) for protein intake (%E) and carbohydrate intake (%E) using metabolites only were 36.3 and 37.1%, respectively. With the addition of established dietary biomarkers (doubly labeled water for energy and urinary nitrogen for protein), the CV-R2 reached 55.5% for energy (kcal/d), 52.0 and 45.0% for protein (g/d, %E), 55.9 and 37.0% for carbohydrate (g/d, %E). CONCLUSION: Selected panels of serum and urine metabolites, without the inclusion of doubly labeled water and urinary nitrogen biomarkers, give a reliable and robust prediction of daily intake of energy from protein and carbohydrate.

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes.

BACKGROUND: The prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging-which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes. METHODS: The study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received. DISCUSSION: Targeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes - a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709 .

Transdisciplinary research outcomes based on the Transdisciplinary Research on Energetics and Cancer II initiative experience.

Intractable public health problems are influenced by interacting multi-level factors. Dynamic research approaches in which teams of scientists collaborate beyond traditional disciplinary, institutional, and geographic boundaries have emerged as promising strategies to address pressing public health priorities. However, little prior work has identified, defined, and characterized the outcomes of transdisciplinary (TD) research undertaken to address public health problems. Through a mixed methods approach, we identify, define, and characterize TD outcomes and their relevance to improving population health using the Transdisciplinary Research on Energetics and Cancer (TREC) II initiative as a case example. In Phase I, TREC II leadership (n = 10) identified nine initial TD outcomes. In Phase II (web-based survey; n = 23) and Phase III (interviews; n = 26; and focus groups, n = 23) TREC members defined and characterized each outcome. The resulting nine outcomes are described. The nine complementary TD outcomes can be used as a framework to evaluate progress toward impact on complex public health problems. Strategic investment in infrastructure that supports team development and collaboration, such as a coordination center, cross-center working groups, annual funded developmental projects, and face-to-face meetings, may foster achievement of these outcomes. This exploratory work provides a basis for the future investigation and development of quantitative measurement tools to assess the achievement of TD outcomes that are relevant to solving multifactorial public health problems.

Can Community Gardens with Workshops Increase Gardening Behavior? A Navajo Wellness Collaboration.

This project evaluated the potential efficacy of a community gardening intervention on the Navajo Nation to increase gardening and healthy eating behaviors, which are potentially important in preventing obesity and related health conditions. Rates of obesity are high among American Indians, including those living on Navajo Nation land. Eating fresh fruits and vegetables is part of healthy eating. However, availability and access to fresh fruits and vegetables are severely limited due to distance and cost. One way to increase both availability and consumption of fresh fruits and vegetables is through community gardening, yet many on the Navajo Nation have limited knowledge and capacity to garden. METHODS: We used a quasi-experimental pre-post study design to estimate the effect of a community gardening intervention. Primary outcomes of interest were gardening frequency and fruit and vegetable consumption. Community gardens were constructed and planted in two communities on the Navajo Nation. In addition, a series of gardening workshops were held in each community. Community members were recruited to complete surveys at time points before and after the workshops. The time between baseline and follow-up was approximately one year. RESULTS: We surveyed 169 participants at one time point at least, across both communities, and 25 of these participated in the gardening workshops. Within the 169, there was a cohort of 32 participants completing both baseline and follow-up surveys. For this cohort, interest in gardening increased from 78% to 97% (p=0.014), but none of the changes in gardening self-efficacy, knowledge or gardening frequency reached statistical significance. There were no measurable changes in reported fruit and vegetable consumption, self-efficacy or knowledge. Overall, the reported financial barriers to gardening increased from baseline to follow-up from 4.6 to 5.5 (p=0.035). Among those who completed follow-up, those who attended at least one workshop gardened more frequently than those who did not attend any workshops (21 times per month compared to 10 times per month (p=0.065). CONCLUSION: Despite enthusiasm for the community garden in both the communities studied and the increased interest in gardening, workshop attendance and participant retention in the study were low. These factors limited our ability to evaluate the potential efficacy of the intervention on gardening and healthy eating behaviors. Nonetheless, we found some evidence that participating in gardening workshops may lead to increased gardening frequency. Future studies should augment the intervention to include explicit efforts to reduce barriers to long term engagement and extend intervention reach.

Associations between Plasma Choline Metabolites and Genetic Polymorphisms in One-Carbon Metabolism in Postmenopausal Women: The Women's Health Initiative Observational Study.

BACKGROUND: Choline plays an integral role in one-carbon metabolism in the body, but it is unclear whether genetic polymorphisms are associated with variations in plasma choline and its metabolites. OBJECTIVES: This study aimed to evaluate the association of genetic variants in choline and one-carbon metabolism with plasma choline and its metabolites. METHODS: We analyzed data from 1423 postmenopausal women in a case-control study nested within the Women's Health Initiative Observational Study. Plasma concentrations of choline, betaine, dimethylglycine (DMG), and trimethylamine N-oxide were determined in 12-h fasting blood samples collected at baseline (1993-1998). Candidate and tagging single-nucleotide polymorphisms (SNPs) were genotyped in betaine-homocysteine S-methyltransferase (BHMT), BHMT2, 5,10-methylenetetrahydrofolate reductase (MTHFR), methylenetetrahydrofolate dehydrogenase (NADP+ dependent 1) (MTHFD1), 5-methyltetrahydrofolate-homocysteine methyltransferase (MTR), and 5-methyltetrahydrofolate-homocysteine methyltransferase reductase (MTRR). Linear regression was used to derive percentage difference in plasma concentrations per variant allele, adjusting for confounders, including B-vitamin biomarkers. Potential effect modification by plasma vitamin B-12, vitamin B-6, and folate concentrations and folic-acid fortification periods was examined. RESULTS: The candidate SNP BHMT R239Q (rs3733890) was associated with lower concentrations of plasma betaine and DMG concentrations (-4.00% and -6.75% per variant allele, respectively; both nominal P < 0.05). Another candidate SNP, BHMT2 rs626105 A>G, was associated with higher plasma DMG concentration (13.0%; P < 0.0001). Several tagSNPs in these 2 genes were associated with plasma concentrations after correction for multiple comparisons. Vitamin B-12 status was a significant effect modifier of the association between the genetic variant BHMT2 rs626105 A>G and plasma DMG concentration. CONCLUSIONS: Genetic variations in metabolic enzymes were associated with plasma concentrations of choline and its metabolites. Our findings contribute to the knowledge on the variation in blood nutrient concentrations in postmenopausal women.

Associations of social, physical, and financial factors with diet quality among older, community-dwelling women.

OBJECTIVE: This analysis examined whether specific social, physical, and financial factors were associated with diet quality among older, community-dwelling women. METHODS: This cross-sectional analysis was conducted in a subset of 6,094 community-dwelling Women's Health Initiative participants who completed a food frequency questionnaire, administered from 2012 to 2013, and a self-administered supplemental questionnaire, administered approximately 1 year later. The supplemental questionnaire included five questions assessing social, physical, and financial factors related to eating. Diet quality was assessed with the Healthy Eating Index-2010 (HEI-2010; range of 0-100; higher score indicates a higher quality diet). The total HEI-2010 score was calculated by summing individual scores representing the intake of nine adequacy components (beneficial food groups) and three moderation components (food groups to limit). Associations of responses to the five questions on the supplemental questionnaire with HEI-2010 scores were examined with multiple linear regression, adjusting for relevant covariates. RESULTS: Mean ±â€Šstandard deviation age of participants was 78.8 ±â€Š6.7 years. Reporting eating fewer than two meals per day, having dental or other mouth problems causing problems with eating, and not always being able to shop, cook, or feed oneself were associated with statistically significantly lower HEI-2010 scores, compared with those not reporting these issues, after multivariable adjustment: 5.37, 2.98, and 2.39 lower scores, respectively (all P values <0.0001). Reporting eating alone most of the time and not always having enough money to buy food were not associated with HEI-2010 scores. CONCLUSIONS: Among older, community-dwelling women, eating fewer than two meals per day, dental and other mouth problems, and diminished ability to shop for food, prepare meals, and feed oneself were associated with lower diet quality. These are potential targets for interventions to improve diet quality in older women. : Video Summary:http://links.lww.com/MENO/A561.

Video Summary:http://links.lww.com/MENO/A561.

Comparison of Methods Used to Correct Self-Reported Protein Intake for Systematic Variation in Reported Energy Intake Using Quantitative Biomarkers of Dietary Intake.

BACKGROUND: Multiple methods of correcting nutrient intake for misreported energy intake have been proposed but have not been extensively compared. The availability of the Women's Health Initiative (WHI) data set, which includes several objective recovery biomarkers, offers an opportunity to compare these corrections with respect to protein intake. OBJECTIVE: We compared 5 energy-correction methods for self-reported dietary protein against urinary nitrogen-derived protein intake. METHODS: As part of the WHI Nutritional Biomarkers Study (NBS) 544 participants (50- to 80-y-old women) completed a FFQ and biomarker assessments using doubly labeled water (DLW) for total energy expenditure (TEE) and 24-h urinary nitrogen. Correction methods evaluated were as follows: 1) DLW-TEE; 2) the Institute of Medicine's (IOM's) estimated energy requirement (EER) TEE prediction equation based on sex, height, weight, and age; 3) published NBS total energy TEE prediction (WHI-NBS-TEE) using age, BMI, race, and income; 4) reported protein versus reported energy linear regression-based residual method; and 5) a Goldberg cutoff to exclude subjects reporting energy intakes <1.35 times their basal metabolic rate. Efficacy was evaluated using correlations obtained by regressing corrected protein against biomarker protein (6.25 × urinary nitrogen/0.81). RESULTS: Unadjusted self-reported protein intake from the FFQ (mean = 66.7 g) correlated weakly (r = 0.31) with biomarker protein (mean = 74.9 g). DLW-TEE-corrected self-reported protein intake (mean = 90.7 g) had the strongest correlation with biomarker protein (r = 0.47). Other energy corrections yielded lower, but still significant correlations: EER, r = 0.44 (mean = 92.1 g); WHI-NBS-TEE, r = 0.37 (mean = 90.4 g); Goldberg cutoff, r = 0.36 (mean = 88.4 g); and residual method, r = 0.35 (mean = 66.7 g). CONCLUSIONS: Our data indicate that proportional correction of reported protein intake using a measure of energy requirement from DLW-TEE or IOM-EER performed modestly better than other methods in this cohort. These energy adjustments, however, yielded corrected protein exceeding the biomarker protein, indicating that energy adjustment alone does not eliminate all self-reported protein reporting bias.

Women's beliefs about what causes obesity: variation by race/ethnicity and acculturation in a Washington State sample.

Objective: Individuals' beliefs about the causes of multifactorial health conditions (causal attributions) shape how they conceptualize and respond to health threats and are therefore important for health promotion. Studies of racial/ethnic and cultural variation in obesity causal beliefs, however, are scarce. To address this gap, this study described beliefs about the underlying causes of obesity (genetic inheritance, diet, and physical activity) in Hispanic and non-Hispanic White women participating in a longitudinal cohort study in South King County, Washington State (n = 1,002).Design: Analysis of baseline survey data. Self-reported obesity causal beliefs were compared by race/ethnicity and acculturation indicators (survey language and nativity) using marginal effect estimates generated from multinomial logistic regression models.Results: Hispanic women had a higher probability of not believing 'at all' in inheritance and physical activity as causes of obesity - an absolute increase of 33% and 5% over non-Hispanic White women, respectively. Both acculturation indicators were also associated with a higher probability of not believing 'at all' in inheritance as a cause of obesity, though Hispanic women who completed the survey in English and were born in the United States had genetic causal beliefs similar to non-Hispanic White women. Behavioral attributions did not vary by acculturation indicators in Hispanic women.Conclusions: Differences in obesity casual beliefs, particularly genetic attributions, exist and may be important for developing and delivering effective obesity-related health promotion interventions. Identifying the determinants and public health consequences of cultural variation in obesity attributions should be the focus of future research.

It's Absolutely Relative: The Effect of Age on the BMI-Mortality Relationship in Postmenopausal Women.

OBJECTIVE: The use of relative and absolute effect estimates has important implications for the interpretation of study findings. Likewise, examining additive and multiplicative interaction can lead to differing conclusions about the joint effects of two exposure variables. The aim of this paper is to examine the relationship between BMI and mortality on the relative and absolute scales and investigate interaction between BMI and age. METHODS: Data from 68,132 participants in the Women's Health Initiative (WHI) study were used. The risk ratio and risk difference of BMI on mortality were estimated. A product term was also included to examine interaction between BMI and age on the multiplicative scale, and the relative excess risk of interaction was calculated to measure additive interaction. RESULTS: Results demonstrated that the mortality risk ratio decreased as women aged, but the mortality risk difference increased as women aged. Evidence of additive and multiplicative interaction between age and BMI was found. CONCLUSIONS: In postmenopausal women, the relative mortality risk associated with high BMI decreased with increasing age, but the absolute risk of high BMI increased with increasing age. This indicates the importance of considering the interaction between age and BMI to understand mortality risk in older women.

Disseminating Evidence-Based Interventions in Small, Low-Wage Worksites: A Randomized Controlled Trial in King County, Washington (2014-2017).

Objectives. To determine whether (1) participating in HealthLinks, and (2) adding wellness committees to HealthLinks increases worksites' evidence-based intervention (EBI) implementation.Methods. We developed HealthLinks to disseminate EBIs to small, low-wage worksites. From 2014 to 2017, we conducted a site-randomized trial in King County, Washington, with 68 small worksites (20-200 employees). We assigned worksites to 1 of 3 arms: HealthLinks, HealthLinks plus wellness committee (HealthLinks+), or delayed control. At baseline, 15 months, and 24 months, we assessed worksites' EBI implementation on a 0% to 100% scale and employees' perceived support for their health behaviors.Results. Postintervention EBI scores in both intervention arms (HealthLinks and HealthLinks+) were significantly higher than in the control arm at 15 months (51%, 51%, and 23%, respectively) and at 24 months (33%, 37%, and 24%, respectively; P < .001). Employees in the intervention arms perceived greater support for their health at 15 and 24 months than did employees in control worksites.Conclusions. HealthLinks is an effective strategy for disseminating EBIs to small worksites in low-wage industries.Public Health Implications. Future research should focus on scaling up HealthLinks, improving EBI maintenance, and measuring impact of these on health behavior.

Eating Occasions, Obesity and Related Behaviors in Working Adults: Does it Matter When You Snack?

Reported relationships between frequency, type, and timing of eating occasions and obesity-risk among adults are mixed while associations with obesogenic eating behaviors remain unexplored. The Physical Activity and Changes in Eating (PACE) study was a group-randomized controlled trial to prevent weight gain among 34 small worksites in Seattle from 2005-2009. Baseline surveys assessed body mass index (BMI), obesogenic eating behaviors (e.g., fast food and distracted-eating), and eating occasions (i.e., snacks and meals) among 2265 employees. BMI and waist circumference were measured on a subset (n = 567). Time-periods for analyses included: morning (12:00 a.m. to 10:59 a.m.), mid-day (11:00 a.m. to 4:29 p.m.), and evening (4:30 p.m. to 11:59 p.m.). Multilevel linear models estimated associations between snack timing, obesity, and related behaviors while adjusting for meal timing, gender, and worksite random effects. Greater morning snacking was associated with increased fruit and vegetable consumption, while greater evening snacking was associated with higher BMI, higher obesogenic dietary index (intake of fast food, French fries, and soft drinks), and higher percent time eating while distracted. Associations with mid-day snacking were mixed. Patterns of association were consistent across repeated and objective measures. Findings suggest that evening snacking is more detrimental to healthy weight compared to snacking at other times of day. Reducing evening snacks may be an important and simple message for population-level obesity prevention efforts.