Impact of the B'more Healthy Communities for Kids
Total Page：16
File Type：pdf, Size：1020Kb
IMPACT OF THE B’MORE HEALTHY COMMUNITIES FOR KIDS INTERVENTION ON DIET AND FOOD-RELATED BEHAVIORS AMONG LOW-INCOME URBAN AFRICAN AMERICAN YOUTH AND THEIR ADULT CAREGIVERS by Angela Cristina Bizzotto Trude, MS A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland October 2018 2018 Angela C. B. Trude All Rights Reserved Abstract Background: Consumption of foods and beverages rich in sugar, fat, and salt remains high across all races and ages in the United States. In view of the multifactorial etiology of weight gain, efforts that simultaneously address multiple levels of the food system are recommended that will impact on food selection and consumption. Thus, multilevel multicomponent interventions to address childhood obesity and improve food-related behaviors and intake are needed, particularly in low-resource settings. It is also important to test whether community interventions are effective in ‘real-world’ conditions and in hard-to-reach populations, as participants need to have sufficient exposure to the intervention. Objective: To evaluate how a multilevel multicomponent childhood obesity prevention intervention impacted the diet and food-related behaviors of low-income urban, predominantly African American families living in neighborhoods with low access to healthy foods in Baltimore City, and to evaluate the patterns of exposure to the different components of the intervention. Methods: B’more Healthy Communities for Kids (BHCK) was a group-randomized controlled trial in 30 low-income areas in Baltimore for 534 African American youth aged 9-15 years old. BHCK components (policy, wholesaler, small stores, youth-mentor led nutrition education, and social media) simultaneously promoted purchase and consumption of low-sugar, low-fat foods/beverages. Exposure to the different intervention components was assessed via post-intervention interviews with 385 youths and their adult caregivers. Exposure scores were generated based on self-reported viewing of BHCK materials and participating in activities. Food consumption in youth ii (n=357) was assessed pre/post-intervention using the Block Kids Food Frequency Questionnaire. Analyses were stratified by age (school-age: 9-12; adolescent: 13-15). Additionally, caregivers’ (n=516) self-reported household food acquisition frequency for food items over 30 days, and usual consumption of fruit and vegetable (FV) was assessed in a sub-sample of 226 caregivers via the NCI FV Screener. Hierarchical multilevel models were conducted with random effects at the community and individual levels and assessed average-treatment-effects (ATE). Treatment-on-the-treated-effect (TTE) analyses evaluated the correlation between behavioral change and exposure to BHCK among adults. Results: The BHCK intervention group was more exposed to the program components, and the comparison group also received some exposure, though to a lesser degree. In ATE analysis, youth in the intervention group purchased almost 1.5 more healthier food/beverage items per week, compared to their counterparts (β = 1.4; 95% CI: 0.1; 2.8). The age-stratified analysis demonstrated that BHCK decreased kcal intake from sweet snacks among intervention adolescents (13-15 years old) by 3.5% compared to their counterparts (β = -3.5; 95% CI: -7.76; -0.05). No significant effect of the intervention was found on caregiver food-related behaviors in the ATE analysis. However, the TTE showed a statistically significant increase in daily intake of fruits by 0.2 servings among adult participants who reported higher exposure to the intervention (0.2+0.1; 95% CI 0.1;0.5). Caregivers reporting greater exposure to social media tripled their daily fruit intake (3.1+0.9; 95% CI 1.3;4.9), compared to baseline. Conclusions: Multilevel, multicomponent environmental childhood obesity programs are a promising strategy to improve eating behaviors among low-income urban youth. Child- iii focused community-based nutrition interventions may also benefit family members. Future community-based environmental intervention trials targeting low-income populations may consider enrolling larger sample sizes and improving program intensity, as the likelihood of low exposure is high. Future multilevel studies should consider using social media to improve reach and engage caregiver participants. DISSERTATION COMMITTEE MEMBERS Advisor: Joel Gittelsohn, PhD, MSc Professor, International Health Johns Hopkins Bloomberg School of Public Health Thesis Readers: Pamela J. Surkan, ScD, MS Associate Professor, International Health Johns Hopkins Bloomberg School of Public Health Susan Carnell, PhD Assistant Professor, Psychiatry and Behavioral Sciences Johns Hopkins School of Medicine Keshia Pollack Porter, PhD, MPH Professor, Health Policy and Management Johns Hopkins Bloomberg School of Public Health Vanessa Garcia Larsen, PhD, MPH (Alternate) Assistant Professor, International Health Johns Hopkins Bloomberg School of Public Health Kristin Mmari, PhD (Alternate) Associate Professor, Population, Family and Reproductive Health Johns Hopkins Bloomberg School of Public Health iv Acknowledgements This work would not have been possible without the incredible support and mentorship I received during my time in the PhD program at Johns Hopkins Bloomberg School of Public Health. I would like to acknowledge my funders: CNPq from the National Brazilian Research for the generous predoctoral fellowship. The Global Obesity Prevention Center for not only funding the B’more Healthy Communities for Kids program, but for all the opportunities, and incredible help and support that continue up to today. Bruce, Sheryl, Sarah, Maggie, Marie, Atiff, it was an incredible honor to work with all of you. The International Health Department for the tuition support, and the Center for Human Nutrition for the various opportunities and for supporting my training. I am grateful to all professors for their guidance and for teaching me so much during these four years. Special thanks to Dr. Keith West and Dr. Laura Caulfield. Thanks to Dr. Jessica Jones- Smith for her guidance and for inspiring me during the program. Thanks to the Human Nutrition staff for the daily smiles and for making our lives so much easier, Peggy, Debra, Lucy, Rhonda, and Tom. To my dissertation committee – I really appreciate all the hours of work you put into this dissertation. Your inputs were invaluable, and I am thankful for your contributions to this work. Pam, thank you for all the support, encouragement and thought-provoking questions throughout the entire process. Keshia thank you for encouraging me to think about the policy implications of this important work. Susan, I am grateful for your valuable suggestions and support. Vanessa, thank you for inspiring me and for the great questions and comments you provided. v To my advisor, Dr. Joel Gittelsohn, I would like to offer my sincerest thanks. Thank you for placing your confidence in me to lead this and other projects. I feel very fortunate to being involved in your team since day one. This certainly enriched my experience and made me a better researcher. Thank you for always being there for me and for all the support and mentorship during these years. This research would not have been possible if it wasn’t for the incredible team of students and staff that formed the B’more Healthy Communities for Kids research team. I am incredibly grateful for the hard work you put into this project. You made work fun and easier, even when there was too much to be done. Special thanks to Cara, Betsy, Anna, Ivory, Bengucan, Teresa, Lisa, Reva, and so many others. To BHCK youth-leaders, thank you for being great role models to all children in recreation centers. It was an honor to work with you every afternoon! To BHCK families, thank you for letting us work in your communities and enter your homes. I learned so much for working with all of you. To the doctoral students in the nutrition program, specially Vanessa, Swetha, Anita, Hyunju, Marie, Jinhee, Farah, Monica: thank you for the encouragement along the way. Your diverse interests and backgrounds have made a valuable contribution to my training at Hopkins. More importantly, I am very grateful for your friendship. To my family, my parents and my in-laws, for being always present even so far. Thank you for inspiring me every day to be a better person. I am forever grateful for all the emotional support and love at every stage of my life. To my brother and sister, who hopefully now know that I do much more than telling people to eat their vegetables! vi Who knew that during the PhD I would meet my best friend and husband. Patrick, it is really hard to put into words how much I am grateful for everything you do. Thank you for bringing joy to my life, for proofreading my work, for listening to my presentations, and for being my safe place. vii Table of Contents TABLES XI FIGURES XII LIST OF TERMS AND ABBREVIATIONS ...................................................................................... XIII CHAPTER 1. INTRODUCTION ....................................................................................................... 1 1.1 STUDY OBJECTIVES ........................................................................................................................... 1 1.2 CONCEPTUAL FRAMEWORK ............................................................................................................... 3 1.3 ORGANIZATION OF THE DISSERTATION .............................................................................................