Welcome to the Thesis Proposal of Amber Brouillette & Hannah Griswold

Welcome to the Thesis Proposal of Amber Brouillette & Hannah Griswold
Substudy of Study of Household Purchasing Patterns, Eating and Recreation (or SHoPPER) Study: A Pilot H Welcome to the Thesis Proposal of Amber Brouillette & Hannah Griswold Advisor: Christy Tangney, Ph.D., CNS, FACN Committee: Brad Appelhans, PhD and Chris Hartney, MS, RD, LDN, CNSC

Relation of Home Food Inventory (HFI) and the Nutrition Environment Measures Survey (NEMS) Scores of Stores Patronized by SHoPPER Participants A Amber Brouillette

Nutrition Environment Quality (NEMS) of Patronized Stores Compared to Diet Quality (HEI-2010) of Patrons Intakes in SHoPPER Participants: Impact of Socioeconomic Status H Hannah Griswold

What’s the big picture? A 5-9
We want to briefly go over how this research can help you in your careers. What’s the big picture?

Oh, how times have changed…
1940s: First McDonalds opens 1960s: Over 200 chain restaurants in the U.S. 1970s: Drive through window opens Spring, 2015: 630,511 fast food restaurants in the U.S. Wood, Chris. "When Food Became Fast!" - Restaurants of the 1950’s: Fast Food Is Born. N.p., n.d. Web. 14 Dec "Restaurant Numbers U.S | Statistic." Statista. N.p., n.d. Web. 14 Dec

Fast Food: 1950

Fast Food: 2015

Diet quality now? Quality of food is changing
Need for instant gratification Quality of food is changing Food Landscapes (NEMS) are changing Fast Food Restaurant Industry Booms Diet quality now? Fast is even faster with drive-through windows Big Picture How has the food environment changed Fast food 1950 vs 2010 Pictures Where is the delayed gratification Food quality has changes over time – this affects diet quality Food landscape = NEMS Quality of food everywhere We will examine this through NEMS

Model: Community Nutrition Environments
1. Community Nutrition Environment – Type and location of food outlets, accessibility (e.g. hours, drive through) This will be measured using the Nutrition Environment Measures Survey (NEMS-S) Our pilot studies will be assessing how this micro-environmental level impacts the household or individual. To the best of our knowledge, there is no research that currently looks at this association. 2. The family/Individual environmental level will be demonstrated as the home food inventory for the current study. 3. The eating behaviors, which will be measured using the HEI, are affected by all levels of influence. Adapted from: Karen Glanz, Measuring Food Environments in Communities: Observations and Surveys Presentation

H Introduction

Socioeconomic Status (SES)
Defined as median household income for neighborhood Those with a lower income… Can they afford the healthier, higher priced options? Do they have access to stores with healthier food options? Are they purchasing high quality foods that are healthier? Know what foods are healthier? Based on literature SES is defined many ways such as income, occupation, education, or PIR, but our study will be defining it as…. Research in the area has focused on affordability, accessibility, and price. Researchers have shown that those with a lower income may not be able to afford the healthier, higher priced options and this price gap may influence what type of food one is able to purchase The location and type of the stores available may influence the types of foods purchased. Those with a lower SES may not have access to stores that provide healthy food options or the quality of these options may not be adequate. We know the other piece of the puzzle is the knowledge of what foods are healthy, however we are not measuring this in our study Therefore, we chose income as a proxy for SES for our study

Influences on Eating Behaviors
Income Built : encompasses everything including government policy which ultimately affects the local food environment. Local: This local food environment is within the built environment and includes all food retail locations. For the purpose of our study, we will be focusing on grocery stores and supermarkets. Household: big picture is that it is affected by the local food environment Individual: so this is a funnel effect, so built environment affects the local food environment, which affects the household environment and ultimately impacts the food choices people make Big question: does the local, household, and individual environment differ by income status? Individual Behaviors HEI Adapted from Gidding SS, Lichtenstein AH, Faith MS, Karpyn A, Mennella JA, Popkin B, Rowe J, Van Horn L, Whitsel L. Implementing american heart association pediatric and adult nutrition guidelines. Circulation 2009;119:

Local Food Environment Measures
Frost HEI-2005 A Multiple measures of the local food environment in terms of diet quality and determining healthfulness exist We researched these and the one that had the greatest evidence for reliability and validity was the NEMS tool, which we will describe later in the presentation NEMS will be used to measure the local food environement NEMS

Household Food Environment Quality: Home Food Inventory (HFI)
Availability of foods in the home has been shown to be significantly associated with dietary practices, intake, and eating patterns Instruments that provide a more comprehensive assessment of food and energy availability in the home are currently unavailable A Household food inventories (not the HFI, because there are so many) - ALL HFI TOOLS ARE Driven by availability

Diet Quality: Healthy Eating Index (HEI)
Food environment may influence food choice and thus ultimately, the dietary quality of an individual Various tools used to assess an individual’s dietary quality Healthy Eating Index (HEI-2005 and 2010) Developed by US government according to Dietary Guidelines of Americans (DGA) Alternative Healthy Eating Index (AHEI-2010) Modified version of HEI-2010 developed by Harvard researchers based on own research Moving onto the diet quality of the individual we already discussed that the food environment may influence food choice and thus ultimately, the dietary quality of an individual. The few studies that have looked at this include these tools. First we have the HEI-2005 which was updated to the HEI-2010 and… The other tool was….

Rationale Change NEMS  change HFI  change HEI
The presence of unhealthy foods in the home environment has been shown to increase unhealthful food choices in children, adolescents, and other adults living in the home. Ultimately, the food availability of the home and local food environment may impact food choice. {{118 Eckstein,K.C. 2006;}}. More healthful foods in supermarkets, grocery stores, and restaurants may contribute to healthier household foods, and thus, healthier diets {{118 Eckstein,K.C. 2006;}}. Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. Parents' perceptions of their child's weight and health. Pediatrics. 2006;117(3): Grimm GC, Harnack L, Story M. Factors associated with soft drink consumption in school-aged children. J Am Diet Kratt P, Reynolds K, Shewchuk R. The role of availability as a moderator of family fruit and vegetable consumption. Health Educ Behav. 2000;27(4): Young EM, Fors SW, Hayes DM. Associations between perceived parent behaviors and middle school student fruit and vegetable consumption. J Nutr Educ Behav. 2004;36(1):2-12

The Role of Availability as a Moderator of Family Fruit and Vegetable Consumption, Kratt et al.
Research Question: Does F&V availability act as a moderator for the F&V intake and, if so, what is the impact of availability on intakes? n=1196 parent-child dyads The food inventory was composed of 31 “yes”/“no” questions and was administered to the parent. This is a larger scale study using a different HFI tool than what I will be using in the proposed study. However, this study represents the impact that the home food inventory can have on diet quality. Therefore, it is important to discuss. Based on the scores, the parent-child pairs were divided into one of three groups; low availability (0-16 points), medium availability (17-20 points), and high availability (21-29 points). As reported by the parent, the family income was associated with availability; income, using chi-square analysis, varies significantly by availability grouping, with greater availability in higher income households (p> .001) {{182 Kratt,P. 2000;}}. Intakes were also significantly differenct based on availability. ***before rationall Kratt P, Reynolds K, Shewchuk R. The role of availability as a moderator of family fruit and vegetable consumption. Health Educ Behav. 2000;27(4):

Brief Study Outline 1 = Amber’s Study 2 = Hannah’s Study A
1 – Does neighborhood income, dichotimized as high and low impact NEMS scores 2- Does neighborhood income, dichotimized as high and low impact HFI scores 3- Does neighborhood income, dichotimized as high and low impact HEI-2010 scores 4 & 5 – if our sample is large enough, will NEMS score (mediated by income status) impact HFI or HEI 1 = Amber’s Study 2 = Hannah’s Study

A Purpose & Objectives Amber Brouillette

Purpose Amber Brouillette Determine if low- versus high-income status of neighborhoods affects the local food environment (i.e. NEMS scores), and Determine if the stores patronized by participants affects the food environment of the household (i.e. Home Food Inventory [HFI] scores) A

Objectives 1 2 3 Amber Brouillette Objective 1:
SES HFI NEMS Objective 1: Determine the difference between local environment (NEMS scores) of low- and high-income households. Objective 2: Determine if HFI scores differ between high- and low-income households. Objective 3 (Long term – only if adequate sample size is available): Determine associations between NEMS scores and HFI scores. 1 2 A 3

H Purpose & Objectives Hannah Griswold

Purpose Hannah Griswold Examine if neighborhood SES impacts a measure of the food environment (NEMS-S) patronized by participants in SHoPPER, and Examine if neighborhood SES impacts quality of diets (HEI-2010) consumed by participants in SHoPPER H

Objectives 1 2 3 Hannah Griswold Objective 1: Objective 2:
SES HEI NEMS Objective 1: To determine if the food environment operationally defined by scores from NEMS-S (supermarkets) differs by neighborhood SES. Objective 2: To determine if the diet quality operationally defined by HEI scores differs by neighborhood SES. Objective 3: (Long term – only if adequate sample size available): A) To determine if NEMS predicts diet quality, and B) To determine if NEMS predicts diet quality when mediated by SES 1 2 H My objectives are the same except I will be looking at individual diet quality rather than household as measured by the HEI-2010 3

H Review of Literature

Income NEMS-S HFI H HEI

Neighborhood Selection
This is a picture showing the Chicago census tract data. Dark red indicates the high income strata and the light pink/white indicates the lowest income strata We are going to be using this data to select our stores, which we will discuss further in our methods

Tools NEMS-S Income HFI A HEI

Criteria for Selecting a Nutrition Environment Measures Tool
High inter-rater reliability (kappa > 0.8) Capable of scoring the appropriate environments Have a relatively short administer time Applied to other food environments A

NEM-S: Development The objectives of the study were as follows:
Develop a measure Test the inter-rater and test-retest reliability Examine sampling and generalizability A Dr. Glanz and researchers created the NEMS-S tool, which stands for Nutrition Environment Measures Survey in Store, to survey the food retail stores. They tests the inter-rater and test-retest reliability and examined the sampling and generalizability issues Conducted in Atlanta

NEMS-S Measures Food Categories Availability (0 to 30)
Healthful food choices Prices (-9 to 18) Healthy versus less healthy options Grocery versus convenience stores Quality (0 to 6) Fresh produce Milk Frozen Dinners Fruit Cereals Vegetables Baked Goods Ground Beef Beverages Hot Dogs Chips A The NEMS-S tool measures three components - availability, price, and quality. Availability – whether healthy food options are available or not Prices – whether there is a difference in price in healthy vs not healthy foods Quality – whether the quality (ex. bruised bananas, moldy fruit, etc.) differs in healthy vs not healthy foods The 10 Indicator food categories were developed using an iterative process involving field work, research team deliberation, and expert consultation “Healthful” was defined based on publications of federal agencies and health professional organizations and researchers. Glanz K, Sallis JF, Saelens BE, Frank LD. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 2007;32:282-9

NEMS-S Scoring A The score is summative; availability score range from 0 to 30, price scores range from -9 to 18, and quality scores range from 0 to 6. The highest score is 54, with higher scores indicating healthier stores. Foods were selected based on the types of food products that contribute the most fat and calories to the American diet and those that are most recommended for healthful eating.

NEMS-S: Results 88 Stores (90.8% completion rate)
24 Grocer Stores 64 Convenience Stores Inter-rater reliability % agreement for all food categories (Kappas ) Test-retest reliability % agreement for all food categories (Kappas ) Average time to complete measure: Convenience Store: 14.4 minutes Grocery Store: 41.8 minutes H Reason we picked NEMS because, not only are many investigators using the tool, but based on our research, it is the only tool that demonstrated adequate validity and reliability In the study by Glanz and researchers, a total of 88 stores including 24 grocery stores and 64 convenience stores were surveyed Both inter-rater and test-retest reliability was high and the average time to complete the NEMS-S stool was about 40 minutes. This is a reason why we can’t complete a lot of stores Glanz K, Sallis JF, Saelens BE, Frank LD. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 2007;32:282-9

NEMS-S: Results Cont. H Table 4 shows the availability comparisons by store type and neighborhood socioeconomic status (SES). After completeing this study, Glanz and collegues created more NEMS tools, incluidn g a tool specifically for the use in convenience stores. There are noted differences between availability in grocery store versus convenience stores, however, because the NEMS-S tool is specifically for larger food retail locations, we will only be looking at these store types. Please direct you attention to the right of the screen where we are talking about what our study is looking at. For example, are reduce calorie frozen dinners more less or more available in low and high income areas? According to Glanz, there was a 3 fold difference in the availability between high and low income areas. Glanz K, Sallis JF, Saelens BE, Frank LD. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 2007;32:282-9

NEMS-S: Results Cont. (0-30) (-9-18) (0-6) (up to 54) H
Looking into each component of the NEMS score, availability, price and quality, significant difference were found between high and low SES. Higher SES had significantly higher scores for availability, quality and total. (0-30) (-9-18) (0-6) (up to 54) Adapted from: Glanz K, Sallis JF, Saelens BE, Frank LD. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 2007;32:282-9

Locations where the NEMS-S tool has been studied
Locations Within the U.S # of Articles Baltimore 42 Philadelphia Alaskan Villages Maine Georgia Locations where the NEMS-S tool has been studied Locations Outside the U.S # of Articles Canada 4 Paraguay Brazil H The NEMS-S tool has been used in many other locations and will be easily applied to the Chicago area because it has been used in other metropolitan areas such as Baltimore and Philadelphia as well as other locations outside the US such as Canada. To the best of our knowledge, we are going to be the first to use this tool in Chicago, which will be adding to research Glanz, Karen. "Mountain Environments and Communities." (2001): n. pag. Web.

Tools Income NEMS-S HFI Resummarize HEI

Home Food Inventory: HFI
Purpose: Develop and validate a home food inventory tool Must include healthful and less healthful foods that can measure obesogenic scores *** too many words **TO THE BEST OF MY KNOWLEDGE that are validated which assess the home food availability. Understanding the home food inventory may be beneficial to understanding the effects of environmental influence on energy balance and obesity. Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5.

HFI, Fulkerson et al.: Objectives
Brief field testing n= 5 assess ease of completion and comprehension Develop a home food inventory tool which is easily administered n= 51 Participants vs. Gold Standard (trained staff) Demonstrate criterion validity n= 349 families Parents: HFI vs. Diet History Questionnaire (DHQ) Children: HFI vs. 24-hour recall dietary interviews Demonstrate construct validity Trained research staff traveled to the participants' homes to complete consent procedures and complete to the HFI. Although participants and staff completed inventories at the same time, they began their assessments in different parts of the home and were instructed not to communicate with each other as they completed the inventory. For the construct validation phase, 349 families (one student between the ages of 10 and 17 years and one parent/ guardian or other adult caregiver) were recruited Parents received a packet of instruments to take home to complete and return by mail. Included in this packet were the HFI and the DHQ. The DHQ is a food frequency that has been widely used with adults (NCI). Students were told to expect that three dietary recall interviews would be conducted with them by telephone within the next month, and were provided with a two-dimensional food model packet to help them estimate portion size. Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5.

HFI, Fulkerson et al.: Tool
190 item tool Checklist format Is “item” available? Yes/No Scores ranged from 0-190 Higher scores indicated higher availability in the home HFI, Obesogenic Score (HFI-O) Each food was assessed by its typical fat and sugar content A summative score was created that includes: Regular-fat versions of cheese, milk, yogurt, other dairy, frozen desserts, prepared desserts, savory snacks, added fats Regular-sugar beverages Processed meat High-fat quick, microwavable foods Candy Access to unhealthy foods in refrigerator and kitchen HFI-O scores range from 0-71 Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5.

HFI, Fulkerson et al.: Results
Minutes to administer: 30-45 Develop a home food inventory tool which is easily administered K = all > 0.60 Rho = .71 (frozen desserts) to .97 (candy) Demonstrate criterion validity See next two slides Demonstrate construct validity Trained research staff traveled to the participants' homes to complete consent procedures and complete to the HFI. Although participants and staff completed inventories at the same time, they began their assessments in different parts of the home and were instructed not to communicate with each other as they completed the inventory. For the construct validation phase, 349 families (one student between the ages of 10 and 17 years and one parent/ guardian or other adult caregiver) were recruited Parents received a packet of instruments to take home to complete and return by mail. Included in this packet were the HFI and the DHQ. The DHQ is a food frequency that has been widely used with adults (NCI). Students were told to expect that three dietary recall interviews would be conducted with them by telephone within the next month, and were provided with a two-dimensional food model packet to help them estimate portion size. Spearman correlations between staff and participant major food category scores ranged from). Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5.

HFI, Fulkerson et al.: Results Cont.
Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5.

HFI in Practice Purpose: To determine the extent to which the presence and accessibility of healthful and less healthful foods in children’s homes vary with level of food security. Food insecurity acts as a proxy for income status n= 41 parents who have at least 1 child Using the HFI developed by Fulkerson et al. Only measuring the obesogenic environment (HFI-O) Nackers LM, Appelhans BM. Food insecurity is linked to a food environment promoting obesity in households with children. J Nutr Educ Behav. 2013;45(6):

HFI in Practice Cont. Different study, different proxy for income, we are expecting to see numbers along the same lines as Dr Nackers and Dr. Applehans Significantly different from high food-security households in adjusted linear regression models at P < .05; bSignificantly different from high food-security households in adjusted linear regression models at P < .01; cThe summative obesogenic home food availability score was composed of 71 obesity-promoting foods (ie, discretionary caloric beverages, regular-fat dairy, snacks, desserts, candy, and microwavable or quick-cook frozen foods, but not including frozen vegetables or fruits); dUnhealthful and healthful kitchen and refrigerator access were based on whether foods in these subscales were visible and readily accessible in the kitchen and refrigerator, respectively. Note: Estimates shown are unadjusted means and SDs. Significance levels are for group differences in fully adjusted linear regression models controlling for household income, food assistance receipt, household size, and race or ethnicity, with high food-security households as the reference group. Except for the obesogenic home food availability score, which was tested at a 1⁄4 .05, dependent variables were tested at adjusted a 1⁄4 .02. Nackers LM, Appelhans BM. Food insecurity is linked to a food environment promoting obesity in households with children. J Nutr Educ Behav. 2013;45(6):

HEI Tools Income NEMS-S HFI
So now we are going to talk about the individual diet quality measure The reason we selected the HEI because it was selected to be used in the larger study HEI

Measuring Diet Quality of an Individual
HEI-2005 - Compliance to Dietary Guidelines of Americans (DGA) - 12 different calorie levels by USDA HEI-2010 - Includes changes recommended by USDA Food Patterns & 2010 DGA - 12 components already adjusted with calorie levels AHEI-2010 - Developed by the Harvard group - Includes 11 components predictive of incidence of chronic disease It is important to understand the types of measures out there to measure the diet quality of the individual HEI-2005 contains evidenced-based guidelines developed by the US government and includes 12 different calorie levels by USDA HEI-2010 Includes changes recommended by USDA Food Patterns and the 2010 DGA that are used to establish the scoring values and has 12 components already adjusted with calorie levels AHEI-2010 was developed by the Harvard group and includes 11 components predictive of incidence of chronic disease

Discriminative validity
Healthy Eating Index-2010 Validation Does HEI-2010 obtain max scores from sample menus known to have high diet quality? Scores were at or near the max levels for the exemplary menus (ranged from ) Face Validity Can it distinguish between groups with known differences in diet quality? Smokers diet quality (45.7) was poorer than nonsmokers (53.3) (P < 0.01) Discriminative validity Does it measure diet quality independently of energy intake? Low correlations with energy were observed for both total and component scores (|r| ≤ 0.21) Concurrent Validity We are going to be using the HEI It is important to know that our tools are valid, just as we did for the HFI. So based on Patricia Gunether’s work using the 2003–2004 NHANES, she provides evidence of different forms of validity. She first looked at…. Concurrent validity: If people eat more calories, it shouldn’t impact the actual scores because each of the scores have already been adjusted for energy To assess the validity and reliability of the HEI-2010, exemplary menus were scored and 2 24-h dietary recalls from individuals aged >2 y. from the were used to estimate multivariate usual intake distributions and assess whether the HEI-2010 has a distribution wide enough to detect meaningful differences in diet quality among individuals whether maximum HEI-2005 scores are achieved in 4 sample menus known to have high diet quality including MyPyramid, the DASH Eating Plan, Harvard’s Healthy Eating Pyramid, and the American Heart Association’s No-Fad Diet distinguishes between groups with known differences in diet quality by using t tests Whether the HEI-2005 scores of diets of smokers differ from those of nonsmokers measures diet quality independently of energy intake by using Pearson correlation coefficients, Whether diet quality is independent of quantity, measured by energy intake, when comparing the total score of the food components to the energy Because each of the scores have already been adjsuted for energy has >1 underlying dimension by using principal components analysis (PCA), and is internally consistent by calculating Cronbachs coefficient a. Guenther PM, et al. The Healthy Eating Index-2010 Is a Valid and Reliable Measure of Diet Quality According to the 2010 Dietary Guidelines for Americans. Am J Clin Nutr 2014:

Alternative Healthy Eating Index (AHEI)
Purpose: Compare the ability of the AHEI and the HEI to predict disease risk using FFQ data collected from two large studies of health professionals Results: AHEI scores associated with a reduced risk of major chronic disease in men [multivariate relative risk (RR): 0.80; 95% CI: 0.71, 0.91] and in women [RR: 0.89; 95% CI: 0.82, 0.96] Participants whose diet closely matched the AHEI goals had a lower risk for developing a major chronic disease (20% for men and 11% for women) A total of about 40,000 men from the Health Professional’s Follow-up Study and over 67,001 women from the Nurses’ Health Study completed dietary questionnaires. Major chronic disease defined as the initial occurrence of CVD, cancer, or nontraumatic death AHEI scores were based on foods present in the Harvard 130 item food frequency questionnaire. Major chronic disease was defined as the first occurrence of cardiovascular disease (myocardial infarction, stroke, or sudden death), cancer, or non-trauma-related death. First used HEI-2005, then made AHEI -2010, didn’t make AHEI-2005 - McCullough et al (2002) modified the HEI to develop the AHEI containing 9 food components associated with decreased likelihood of developing chronic diseases - Purpose: Compare the ability of the AHEI and the HEI to predict disease risk using FFQ data collected from two large studies of health professionals - Results: - When comparing the lowest to the highest quintiles, high AHEI scores were associated with a lower risk of major chronic disease development in men [multivariate relative risk (RR): 0.80; 95% CI: 0.71, 0.91] and in women [RR: 0.89; 95% CI: 0.82, 0.96] - Participants whose diet closely matched the AHEI goals had a lower risk for developing a major chronic disease (20% for men and 11% for women) McCullough ML, Feskanich D, Stampfer MJ, Giovannucci EL, Rimm EB, Hu FB, Spiegelman D, Hunter DJ, Colditz GA, Willett WC. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr 2002;76:

The other major thing is the number of components (12 vs 11)
REFERENCE TO HANDOUT So the AHEI contains more food groups that have previously been associated with disease development (HEI was never initially looked at to look at disease development) The other major thing is the number of components (12 vs 11) Total scoring difference (HEI scoring based on serving per caloric intake and AHEI scoring is based on serving size per day) HEI- already energy adjusted AHEI – adjust for calories at analysis Wang DD, Leung CW, Li Y, Ding EL, Chiuve SE, Hu FB, Willett WC. Trends in Dietary Quality Among Adults in the United States, 1999 Through JAMA Intern Med 2014;E1-E9.

SES effect on diet quality
In a systematic review by Darmon et al (2008), researchers asked the question whether socioeconomic status has an impact on diet quality. They used indicator foods that they believed would represent good/bad diet quality that would be associated with SES, which was defined a number of different ways, either as education, income, and/or occupation. You can see that those with low-SES had higher intakes of refined grains, starchy vegetables, especially potatoes, fatty/fried meats, whole milk, and overall, higher fat intake and those with a higher SES had a higher intakes of whole grains, lean meat, fish and other seafood, and low-fat milk versus those with lower SES who had higher intakes of… Darmon N, Drewnowski A. Does social class predict diet quality? Am J Clin Nutr 2008;87:

SES effect on diet quality
Now we are going to look at a study by Wang and researchers that uses a tool driven by data. They at how diet quality (AHEI-2010) was modified by SES, defined as PIR and education level. They used 2, 24 hour recall data from NHANES cycles The researchers found that those with a higher SES had higher AHEI-2010 scores and showed greater improvement in AHEI-2010 scores than participants with low SES. It’s also interesting to note that the gap between low and high SES significantly widened over time and as time goes on, we don’t see an improvement in the low SES whereas in high SES we see an improvement. The authors defined the cutoffs for low SES (<1.30 for PIR and <12 years education achievement) and high SES (≥3.50 for PIR and ≥12 years education achievement). Wang DD, Leung CW, Li Y, Ding EL, Chiuve SE, Hu FB, Willett WC. Trends in Dietary Quality Among Adults in the United States, 1999 Through JAMA Intern Med 2014;E1-E9.

A Methods

Bigger Study - SHoPPER    SHoPPER Study 3 24 hour recalls
HFI measured Demographics Receipt Collection  Score for HEI  Score for HFI SHoPPER Study A 3 24-hour recalls in a 2 week period From which we can code the HEI 2010 HFI measured Demographics Receipt Collection for 2 weeks Specified Exact Address of Store’s Locations Bosed on these addresses, we will pick stores that are frequented that fall into the loswet and highest quintiles of income Going to these sites Assess the local food environemtn quality that is availablle Intake data – 3 24-hour recalls by trained professionals Graduates of the MS/DI program Home food inventory – no extensive review of lit because HFI was already selected/being collected (Brad previously published which is why I shared that study)\ Both come fro SHoPPER study And we will be adding to this information by incorporating NEMS  Addresses of stores to conduct NEMS-S

Study of Household Purchasing Patterns, Eating, and Recreation (SHoPPER)
The proposed study tests a behavioral model of food choice based on the ability to delay gratification Assessing nutrient content and diet quality of household food purchases as well as individual intake using three 24 hour recalls Using the sample from this study, we will select stores frequented by SHoPPER participants to then analyze Study Population Convenience sample drawn from an ongoing study, Delay Discounting and Household Food Choices or SHoPPER (Study of Household Purchasing Patterns, Eating and Recreation) Dr. Brad Appelhans, Principal Investigator at Rush University Medical Center in Chicago, IL A And that’s the sample from which we will draw our sample size We have 150 subjects - we know the household income and purchases made in a 2 week period and in that period our expert RD collect 2 24 hour dietary recalls and HFI…

Sample Selection Determine stores location in relation to census tract household income Look at aggregation of the stores Select stores in the highest and lowest quintile Goal is selection of 5 to 7 from each income strata (10-14 total) A Neighborhood selection will be based on SHoPPER purchasing data in context of the American Community surveyed data from the 2010 U.S. Census Tract. Map of the city of Chicago Median household incomes based on census data from Looking at regions in which the median household incomes are as follows Where are the individuals living, where are they shopping, pick stores in the highest and lowest quintile Select from the two most extremes (maximize the experimental variance) Higher SES in places such as: 7 = Lincoln Park 6 = Lakeview 12 = Forest Glen Lower SES in places such as: 38 = Grand Boulevard 40 = Washington Park

Data Collection for NEMS
1 Data from SHoPPER 2 Remove restaurants & convenience stores 3 Sort according to street address, census tract and participant ID 4 Overlay median household income for neighborhood 5 Stratify into top & bottom quintiles 6 5 stores in each of the extreme income strata 7 Conduct NEMS-S on selected store Data Collection for NEMS A Based on census.gov data look at participants who shop in lower quintile…. 5 – median household income of to 26,789 from American Community Survey In attempts to minimize data collection time, stores that can be used for both companion studies will be selected

Conducting a Pilot Study
Goals: Familiarity with data collection tool Determine inter-rater reliability Uniformity: Data collection occurs at similar times/days of the week every time Plan: Assessing 5 grocery stores close by using the online data collection form Spearman’s Rho will be calculated to determine the concordance between the two raters in NEMS-S total and component scores (availability, price and quality) rs > 0.7 will be used to establish high inter- rater agreement % agreement and Kappa will be calculated for availability scored as yes/no Conducting a Pilot Study H How do you know that youll get the same answers again if you visited – glanz had this for test-retest (with r values) we will visit at similar times/days of the week every time (tues-thu) How do you know you would get same answers if you went back again? – validated in studies Goals: Familarize ourselves with the data collection tool to increase our speed determines inter-rater reliability and gives us freedom incase we collect data separately Trying to keep uniformity is: Same time of day/week Grocery stores are defined as having 3 or more cash registers Relying on data from Glanz (test-retest reliability)

Example of Online Data Collection Software: NEMS-S
H

Sample size needed is 94 (47 stores per group)
Glanz et al (2007): Effect size = 0.59, Sample size needed is 94 (47 stores per group) Independent T-test: α = 0.05 β= 0.8 Group 1 (high SES, n=44): ± 10.25 Group 2 (low SES, n=41): 7.83 ± 7.66 Power Analysis Using G*Power computer program H The calculation results indicated an effect size of and determined the total sample size needed to measure the effect is 94, where 47 stores are needed per group. Since we are conducting a pilot study, data will be collected from only stores. With this small sample size, we will only have a power of to find a difference in NEMS-S scores. Pilot Study: stores Power =

Statistics NEMS NEMS ?  Income  Income Objective 1
Determine the difference between local environment (NEMS scores) of low- and high- income neighborhoods NEMS-S scores Interval – mean ± SD or median (IQR) Analysis between each component score (availability, price and quality) and the total score SES (median household income) Nominal – stratified into top & bottom 1/5 T-test or Mann Whitney U Statistics Amber Brouillette & Hannah Griswold Objective 1 A Comparing 4 different scores for NEMS Interval but we don’t know that its normal Both measuring NEMS Starting with NEMS – first asking if there is a difference in income strata ? NEMS NEMS  Income  Income

Determine if HFI scores differ between high- and low-income households
Interval – mean ± SD or median (IQR) SES (median household income) Nominal – stratified into top & bottom 1/5 T-test or Mann Whitney U Statistics Amber Brouillette Objective 2 A WE DON’T KNOW IF IT WILL BE NORMAL OR NOT We would anticipate mean +/- SD but with such a small n we will likely not have 0-190 in low income 0-190 in high income 0-71 in low income 0-71 in high income reporting data – may be median (IQR) – ensure report distribution this score for high, low income – either doing t-test or a=mann whitney… visual for stats

To determine if the diet quality operationally defined by HEI-2010 scores differs by neighborhood SES HEI-2010 scores Interval using mean ± SD or median (IQR) SES Nominal – stratified into top & bottom 1/5 T-test or Mann Whitney U Statistics Hannah Griswold Objective 2 Objective 1: A t-test will be used to determine what difference exists in diet quality between low and high neighborhood SES. Further analysis will be performed using General Linear Model (GLM) to test for differences in HEI-2010 across the 2 income strata. Possible adjustments will be made (the number of covariates depend on the sample size).

Determine associations between NEMS scores and HFI scores.
A) To determine if NEMS predicts home food inventory, and B) To determine if NEMS predicts home food inventory when mediated by SES Further models will be performed Statistics Amber Brouillette Objective 3 If we see differences in income in nems And if we see differences in HFI, it is likely that they will be related

Long term – only if significant differences are detected in objectives 1 & 2:
A) To determine if NEMS predicts diet quality, and B) To determine if NEMS predicts diet quality when mediated by SES Further models will be performed Statistics Hannah Griswold Objective 3 Objective 3: further models will be performed to address the following questions:

Limitations To measure the nutrition environment using NEMS-S:
1. Only looking at grocery stores 2. NEMS is not reflective of all foods 3. Not measuring participants knowledge 4. Small number of stores 5. Based in Chicago H Using the NEMS-S measure does come with some limitations including…. Only looking at grocery stores – not looking at other stores people are frequenting (restaurants, bodegas, corner stores, vending machines, etc.) NEMS is not reflective of all foods that contribute to good/bad food quality We are not measuring the participants knowledge so we don’t know whether they are picking foods to be healthy or not. Unlikely will be able to detect a significant difference (small n = small power) Based in Chicago, therefore results will not be nationally representative, however it is also an advantage because NEMS-S has not been conducted in Chicago So even with these limitation….. *next slide*

Concluding Statement Based on our study, we are hoping to achieve a better understanding of how income impacts resources available in stores food available in the household diet quality In order to improve diet quality (using the HEI-2010), it is important to know where nutritional gaps lie, and whether its in the household (HFI) or food environment (NEMS-S) that enhance or mitigate these gaps A change in the local environment contributes to change of household environment and therefore contributes to a change in food intake and diet quality H We hoping to build a better understanding… Income of household matches income of neighborhood in which they shop The overall goal of using these measurements is to get a general idea of what dietary characteristics are present or lacking in individual’s diets so that improvements in these areas can be made.

Timeline Event Date Obtain Inter-Rater Agreement December 2015
Collect Data January 2016 Data Analysis January-March 2016 Defense Preparation March 2016 Thesis Defense April 2016 H

References "Restaurant Numbers U.S | Statistic." Statista. N.p., n.d. Web. 14 Dec Darmon N, Drewnowski A. Does social class predict diet quality? Am J Clin Nutr 2008;87: Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ. Parents' perceptions of their child's weight and health. Pediatrics. 2006;117(3): Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5. Gidding SS, Lichtenstein AH, Faith MS, Karpyn A, Mennella JA, Popkin B, Rowe J, Van Horn L, Whitsel L. Implementing american heart association pediatric and adult nutrition guidelines. Circulation 2009;119: Glanz K, Sallis JF, Saelens BE, Frank LD. Nutrition Environment Measures Survey in stores (NEMS-S): development and evaluation. Am J Prev Med 2007;32:282-9 Glanz, Karen. "Mountain Environments and Communities." (2001): n. pag. Web Grimm GC, Harnack L, Story M. Factors associated with soft drink consumption in school-aged children. J Am Diet Guenther PM, Kirkpatrick SI, Reedy J, Krebs-Smith SM, Buckman DW, Dodd KW, Casavale KO, Carroll RJ. The Healthy Eating Index-2010 Is a Valid and Reliable Measure of Diet Quality According to the 2010 Dietary Guidelines for Americans. Am J Clin Nutr 2014: Kratt P, Reynolds K, Shewchuk R. The role of availability as a moderator of family fruit and vegetable consumption. Health Educ Behav. 2000;27(4): McCullough ML, Feskanich D, Stampfer MJ, Giovannucci EL, Rimm EB, Hu FB, Spiegelman D, Hunter DJ, Colditz GA, Willett WC. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr 2002;76: Nackers LM, Appelhans BM. Food insecurity is linked to a food environment promoting obesity in households with children. J Nutr Educ Behav. 2013;45(6): Nutrition Environment Measures Survey. Internet: Wang DD, Leung CW, Li Y, Ding EL, Chiuve SE, Hu FB, Willett WC. Trends in Dietary Quality Among Adults in the United States, 1999 Through JAMA Intern Med 2014;E1-E9. Wood, Chris. "When Food Became Fast!" - Restaurants of the 1950’s: Fast Food Is Born. N.p., n.d. Web. 14 Dec Young EM, Fors SW, Hayes DM. Associations between perceived parent behaviors and middle school student fruit and vegetable consumption. J Nutr Educ Behav. 2004;36(1):2-12 H

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Welcome to the Thesis Proposal of Amber Brouillette & Hannah Griswold

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Welcome to the Thesis Proposal of Amber Brouillette & Hannah Griswold

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