Appendix

Associations between trait food craving and adolescents’ preferences for and consumption of healthy versus unhealthy foods

Changing food behaviours amongst Canadian Inuit may contribute to rising chronic disease prevalence, and research is needed to develop nutritional behaviour change programmes. The present study examined patterns of food acquisition and preparation behaviours amongst Inuit adults in Nunavut and associations with psychosocial and socioeconomic factors. Developed from behavioural theories and community workshops, Adult Impact Questionnaires were conducted with adult Inuit (≥19 years) from randomly selected households in three remote communities in Nunavut, Canada, to determine patterns of healthy food knowledge, self-efficacy and intentions, frequencies of healthy and unhealthy food acquisition and healthiness of preparation methods. Associations between these constructs with demographic and socioeconomic factors were analysed using multivariate linear regressions. Amongst 266 participants [mean (SD) age 41.2 (13.6) years; response rates 69-93%], non-nutrient-dense foods were acquired a mean (SD) of 2.9 (2.3) times more frequently than nutrient-dense, and/or low sugar/fat foods. Participants tended to use preparation methods that add fat. Intentions to perform healthy dietary behaviours was inversely correlated with unhealthy food acquisition (β=-0.25, P<0.001), and positively associated with healthy food acquisition (β=0.22, P<0.001) and healthiness of preparation methods (β=0.15, P=0.012). Greater healthy food knowledge and self-efficacy were associated with intentions (β=0.21, P=0.003 and β=0.55, P<0.001, respectively). Self-efficacy was associated with healthier preparation (β=0.14, P=0.025) and less unhealthy food acquisition (β=-0.27, P<0.001), whilst knowledge was associated with acquiring healthy foods (β=0.13, P=0.035). Socioeconomic status was positively associated with healthy preparation and food acquisition behaviours. Interventions to improve diet in Nunavut Inuit should target healthy food intentions, knowledge and self-efficacy. Behaviour change strategies emphasising economic benefits of a healthy diet should be employed to target individuals of low socioeconomic status.

The Global Diet Quality Score (GDQS) is a novel food-based score that assesses both nutrient adequacy and chronic disease risk, by evaluating healthy (GDQS+) and unhealthy foods (GDQS-). The aim of this study was to evaluate the association among GDQS, GDQS+, and GDQS- against the 20-year risk of cardiometabolic outcomes in a Mediterranean population. The sample was n = 2169 initially free of cardiovascular disease (CVD) participants of the ATTICA study (2002-2022) that participated in the 20-year follow-up. The incidence of CVD, hypertension, hypercholesterolemia, and type 2 diabetes mellitus (T2DM) was defined according to WHO-ICD-10 criteria. The GDQS was computed based on previously published instructions. In multivariate analyses, a higher diet quality, per 1/49 of the GDQS, was associated with an 8% [95% Confidence Interval-CI: 6-9%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. A higher consumption of healthy foods, per 1/32 of GDQS+, was associated with a 9% [95% CI: 7-11%] and 2% [95% CI: 1-3%] lower CVD and T2DM risk, respectively. Contrarily, a lower consumption of unhealthy foods (GDQS-) was not associated with cardiometabolic events in the adjusted models (all p value< 0.05). In clinical practice or future public health actions to ameliorate dietary habits and prevent CVD and T2DM, more attention should be focused on healthy foods that should be included in our diets.

TV exposure, attitudes about targeted food ads and brands, and unhealthy consumption by adolescents: Modeling a hierarchical relationship

The increased incidence of obesity is a major concern and intervention efforts to thwart this trend in low income minority populations continue. Good nutritional habits and behavioral practices are important for healthy weight management and maintenance. This project was conducted to gain insight the personal and contextual factors, and barriers, impacting food preparation and consumption in rural families'. Focus groups were conducted with 100 low income parents from rural communities to collect cultural perspectives and to identify barriers to healthy eating and food preparation practices. Statements were extracted and categorized from the focus group transcripts. Analysis of the data resulted in themes including general food purchases, preparation practices, and barriers to good nutrition. Food preparation was based primarily on family history and tradition; example ‘fired fish Fridays’, and ‘family member preferences’. Advertising and children in charge were discussed by most of the participants as being significant barriers to healthy eating. Surprisingly, many of the families dining out decisions were determined by daily specials offered at local fast food restaurants with little thought given to the nutritional value of meals.Funding for this project was made possible by 1P20MD0002295 from the National Center on Minority Health and Health Disparities.

Poor eating habits among young adults are a public health concern. This survey examined the eating habits of undergraduate university students in Finland. We assessed students' dietary intake of a variety of food groups, their adherence to international dietary guidelines (whole sample and by gender), and the associations between importance of eating healthy and dietary guidelines adherence (whole sample and by gender). During the 2013-2014 academic year, 1,189 undergraduate students enrolled at the University of Turku in southwestern Finland completed an online self-administered questionnaire. Students reported their eating habits of 12 food groups, the number of daily servings of fruits/vegetables they consume and how important it is for them to eat healthy. For dietary adherence recommendations, we employed WHO guidelines. Chi-square statistic tested the differences in dietary guidelines adherence between males and females and also the associations between the gradients of importance of healthy eating and the self reported eating habits for each of the food groups, for the whole sample and by gender. We observed high levels of dietary adherence (>70%) for most of the 'unhealthy food' items (cake/cookies, snacks, fast food/canned food, and lemonade/soft drinks), and moderate adherence for most of the 'healthy food' items (>50%) (dairy/dairy products, fruit/vegetables servings/day, fresh fruit, salads/raw vegetables and cereal/cereal products). Fish/seafood, meat/sausage products and cooked vegetables had levels <50% for adherence to the guidelines. Women had better adherence for meat/sausage products, fast food/canned food and for most 'healthy food' items (p≤0.001), whereas men had better adherence for sweets (difference=12.8%, p≤0.001), lemonade/soft drinks (difference=16.7%, p≤0.001) and fish/seafood (difference=6.6%, p=0.040) compared to women. Most students considered important to eat healthy (78.8%). The importance of eating healthy was significantly associated with adherence for all food groups besides sweets and cake/cookies. These associations remained significant for women but some of them not for men (cereal/cereal products, snacks and sweets). The results suggest high adherence to the guidelines mainly for 'unhealthy food' groups, and moderate adherence for healthier food groups. There was also accordance between regarding eating healthy as important and actually eating healthy. However, there are improvements to be considered for specific food groups, as well as gender differences when implementing public health strategies related to food intake.

Does immersion or detachment facilitate healthy eating? Comparing the effects of sensory imagery and mindful decentering on attitudes and behavior towards healthy and unhealthy food

To investigate whether geographical location or type of store is associated with differences in healthy and unhealthy food availability in grocery stores. A cross-sectional study using the Victorian Healthy Food Basket to measure food availability (44 'healthy' and 10 'unhealthy' items) in a convenience sample of 112 stores in urban and regional Victoria, Australia. Logistic regression analyses assessed whether location (regional, urban), distance from capital city central business district (km) and type of store (chain supermarket, independent supermarket and general store) predicted the number of missing healthy and unhealthy food items. There were 54 chain supermarkets, 43 independent supermarkets and 15 general stores, with 56% of stores located in urban areas and 44% located regionally. The strongest significant predictor of missing items was being a general store, which had greater odds (odds ratio (OR) = 136, 95% confidence interval (CI) = 13-1399) of having missing 'healthy' items and missing 'unhealthy' items (OR = 63, 95% CI = 7-575), compared with chain supermarkets. Independent supermarkets had increased odds of having missing 'healthy' items (OR = 7, 95% CI = 2-22) compared with chain supermarkets. Regional store location was a significant predictor of missing 'healthy' and 'unhealthy' items, compared with urban location (OR = 6, 95% CI = 2-25) and (OR = 7, 95% CI = 2-29), respectively. Store type was a stronger predictor of stores having missing 'healthy' and 'unhealthy' food items than the store distance from a large urban centre. General stores and independent supermarkets may be important settings for interventions to improve availability of healthy food.

To categorize healthy food groups into categories of low-antioxidant (LAC) or high-antioxidant vitamins and phytochemicals content (HAC) and comparatively associate them with metabolic risk factors for cardiovascular disease (CVD). A total of 6879 women (55±12 years) and 6892 men (56 ± 12 years) were analyzed from the Moli-sani cohort, randomly recruited from the general population. The European Prospective Investigation into Cancer and Nutrition Food Frequency Questionnaire was used for dietary assessment. The antioxidant content of each food group was evaluated using Istituto Nazionale di Ricerca per gli Alimenti e la Nutrizione and United States Department of Agriculture (USDA) food composition tables. Healthy foods, according to a Mediterranean dietary pattern, were categorized into HAC or LAC; total food antioxidant content (FAC) score was constructed for a comparative evaluation of the consumption of these two groups. In men, an increase in FAC score, which represents an increased consumption of HAC with respect to LAC foods, was associated with a decrease in systolic blood pressure, diastolic blood pressure and C-reactive protein (CRP) (β=-0.5, P=0.02, β=-0.3, P=0.02 and β=-0.03, P=0.03, respectively). Logistic regression analyses showed that in men 15% (30 units) increase in FAC score was associated with 6% decrease in the likelihood of having hypertension (odds ratio (OR)=0.94, 95% confidence interval (CI) 0.91-0.98) and 3% decrease in the likelihood of having a high CRP risk level (OR=0.97, 95% CI 0.94-0.99). No significant associations were observed in women. A possible greater protective role of healthy HAC as compared with healthy LAC foods on hypertension and inflammation was detected in men. These results stress the importance of studying healthy foods according to their content in antioxidant vitamins and phytochemicals, in primary prevention of CVD.

BackgroundChildhood obesity has risen dramatically in recent decades, reaching epidemic levels. Children need guidance on and support for maintaining a healthy diet and physical activity to ensure that they grow appropriately and develop healthy eating habits. Serious video games have shown positive effects on promoting the nutritional knowledge, and eating attitudes and behaviors of children; however, research about the usefulness of such games with younger children (8-10 years old) is sparse.ObjectiveThe objective of this study was to design and test the serious video game FoodRateMaster targeting children between 8 and 10 years old. The game includes nutritional information and behavior change techniques to help children improve their knowledge of healthy and unhealthy foods, increase their intake of healthy food, and reduce their intake of ultraprocessed food. In addition, FoodRateMaster was designed as an active game to promote physical activity.MethodsAn interdisciplinary team developed FoodRateMaster following an iterative methodology based on a user-centered design. A total of 60 participants (mean age 9 years, SD 0.8; 53% male) completed 12 individual gaming sessions in 6 weeks. A food knowledge questionnaire and a food frequency questionnaire were completed before and after game play. In addition, 39 of the participants’ parents answered a parent perception questionnaire after the game play.ResultsParticipants showed increased food knowledge from pregame (mean 56.9, SD 10.7) to postgame play (mean 67.8, SD 10.7; P<.001). In addition, there was a greater self-reported frequency in the consumption of cauliflower and broccoli (P<.001) and corn quesadillas (P<.001). They also indicated a lower self-reported intake of 10 unhealthy foods, including french fries (P=.003), candy and chocolate (P<.001), sweet soft cakes (P=.009), and soft drinks (P=.03). Moreover, most of the parents who answered the parent perception questionnaire agreed that their children showed greater interest in explaining why they should avoid some unhealthy foods (67%, 26/39), in distinguishing between healthy and unhealthy foods (64%, 25/39), and in the intake of fruits (64%, 25/39) and vegetables (59%, 23/39). Finally, 14 parents stated that they introduced some changes in their children's diet based on the comments and suggestions they received from their children.ConclusionsIn an initial evaluation, children between 8 and 10 years old indicated an increased level in nutritional knowledge and their self-reported frequency intake of two healthy foods, and a decreased level in their self-reported intake of 10 unhealthy foods after playing FoodRateMaster. Moreover, the participants’ parents agreed that FoodRateMaster positively influenced their children’s attitudes toward several healthy eating behaviors. These results support that health games such as FoodRateMaster are viable tools to help young children increase their food knowledge and improve dietary behaviors. A follow-up randomized controlled trial will be conducted to assess the medium- and long-term effects of FoodRateMaster.

ABSTRACTThis study explores how people respond to images of junk versus healthy food as a function of their eating habits and food knowledge. The experiment reported here proposed and tested the idea that those with unhealthy eating habits but highly knowledgeable about healthy eating would feel more positive and also more negative toward junk food images compared to images of healthy food because they may perceive them as risky—desirable but potentially harmful. The psychophysiological data collected from participants during their exposure to pictures of junk versus healthy food supported this idea. In addition, unhealthy eaters compared to healthy eaters with the same degree of food knowledge responded more positively to all food items. The findings are critical from a health communication perspective. Because unhealthy eaters produce stronger emotional responses to images of junk food, they are more likely to process information associated with junk food with more cognitive effort and scrutiny. Thus, when targeting this group and using images of junk food, it is important to combine these images with strong message claims and relevant arguments; otherwise, if the arguments are perceived as irrelevant or weak, the motivational activation associated with junk food itself may transfer into an increased desire to consume the unhealthy product.

Unhealthy eating patterns present in most Western countries pose a serious threat to economic welfare and have severe consequences for the health and quality of life of the individual consumer. The purpose of this paper is to develop and test a conceptual model for understanding how health authorities and marketers can affect consumption of healthy food – and ultimately body mass index (BMI) – by addressing perceptual antecedents of consumers' involvement and health competencies. A qualitative (n = 16) pilot study and a consumer panel survey (n = 599) assisted in completing this task. The obtained structural equation modelling results confirmed that increasing consumers' competencies concerning healthy food consumption may improve the healthiness of their food behaviour, and ultimately reduce their BMI. Notably, these effects may occur even for consumers who perceive healthy food consumption to be a challenge. Our results also revealed that it may be problematic to improve health competencies for food consumers who are less involved in healthy food consumption. However, our study shows that two perceptual factors, ‘personal food identity’ (the extent to which consumers believe that their health identity is linked to their food behaviour) and ‘unhealthy food taste belief’ (the extent to which consumers believe that unhealthy food is more enjoyable and tastier than healthy food), may assist health authorities and marketers in increasing consumers' involvement in healthy food consumption.

Small food retail stores in many underserved urban settings keep no electronic records, making documentation of program impact on sales difficult to obtain. We examined the feasibility of introducing a point-of-sale tablet (POST) application to track sales of foods and beverages in Baltimore City corner stores. A sample of four geographically and ethnically diverse corner store owners were trained to use POST to track sales of 14 items for eleven days. Feasibility was documented via a structured survey and open-ended interviews. POST had high economic and cultural acceptability, operability, and perceived sustainability, regardless of language differences or familiarity with mobile technology. All store owners reported willingness to use POST again. It is feasible to train corner store owners to use a point-ofsale application for sales monitoring. An upcoming trial will help to ensure that POST provides sufficient value added for corner store owners. Significance for public health In recent decades, research on healthy food purchasing behaviors in small food retail stores has increased. Urban retail food environments lacking in healthy foods and abundant in unhealthy foods are often located in areas with high proportions of underserved African-American residents. Retail food environments such as these are particularly concerning, as they are associated with alarming rates of obesity and chronic disease in ethnic minority populations. Children are also being increasingly affected by what is available for purchase in small food retail stores, leading to lifetime risk for obesity and related diseases. In order for store owners to be better equipped to handle stocking and sales of healthy food items, they require efficient and effective technology to better control business operations. Mobile point-of-sale technology has the potential to improve small food retail environments and can inform future research on the stocking, purchasing, and consumption of healthy foods in similar settings and beyond.

Background: The cultural ideal of thinness, coupled with the much publicised increase in obesity prevalence, has ensured that weight loss is a top priority for many Britons. A desire for weight loss is particularly prevalent in adolescence but little is known about its impact on a range of important health‐related behaviours. Many young people are failing to meet recommendations for physical activity and diet and are engaging in health‐compromising behaviours, such as smoking and consuming alcohol (Health Survey for England, 2006). This study therefore aimed to examine the relationship among young people between weight loss desires and diet, physical activity, smoking and alcohol consumption.Methods: Data were collected from young people aged 12–13 years and 14–15 years attending 260 schools across England during 2005 and 2006. Data were collected by the School Health Education Unit using a self‐completed survey (further information on data collection is available at http://www.sheu.org.uk). Study variables were: (i) weight‐related desires (‘I would like to put on weight’, ‘I am happy with my weight as it is’ and ‘I would like to lose weight’); (ii) meal skipping at breakfast; in the past 7 days, the (iii) consumption of healthy foods (healthy food index score calculated from wholemeal bread, high fibre cereals/muesli, fresh fruit, salad, and vegetable consumption); (iv) consumption of unhealthy foods (unhealthy food index score calculated from chips/roast potatoes, sugar‐coated cereal, fizzy drink (not low calorie), crisps, and sweets/chocolate/chocolate bar consumption); (v) the number of days that included some moderate/vigorous physical activity; (vi) frequency of cigarette smoking; and (vii) units of alcohol consumed. All data were analysed using SPSS, version 15 (SPSS Inc., Chicago, IL, USA) and P &lt; 0.01 was considered statistically significant. The relationship between weight‐related desires and health behaviours were analysed using chi‐squared tests or Kruskal–Wallis test followed by post hoc Mann–Whitney U‐tests as appropriate.Results: Data were collected from 63 275 young people: 7.8% of the sample wanted to put on weight, 49.1% were happy with their weight and 43.2% wanted to lose weight. Compared to young people who were happy with their weight, young people who wanted to lose weight were significantly more likely to skip breakfast (25.7% versus 16.2%, P &lt; 0.001), consume low levels of unhealthy food [8.04 (3.14) versus 7.09 (3.12) points, P &lt; 0.001], consume low levels of healthy food [8.68 (3.30) versus 8.58 (3.22) points, P &lt; 0.01], take part in low levels of physical activity [2.55 (1.34) versus 2.33 (1.27) days, P &lt; 0.001], smoke more frequently [1.32 (7.83) versus 0.77 (5.90) days, P &lt; 0.001] and drink a greater number of alcoholic units week−1 [2.49 (5.82) versus 1.93 (5.01) units, P &lt; 0.001].Discussion: Young people who wanted to lose weight restricted their consumption of unhealthy foods, but they did not counterbalance this by increasing their consumption of healthy foods. Furthermore, participants who wanted to lose weight were more likely to skip breakfast, which is an extremely important meal for young people. Although exercise is an effective method of controlling bodyweight, young people who want to lose weight were significantly less likely to carry out beneficial exercise than other children. It is an unfortunate paradox that young people with weight loss‐desires were also more likely to engage in eating and exercise behaviours that have been associated with weight gain in the long term. In addition, young people who wanted to lose weight were at risk of future health problems as a result of higher rates of smoking and alcohol consumption (DoH, 2004; BMA, 2003).Conclusions: Many young people in England would like to lose weight and need support and education to ensure that they engage in healthy dietary, exercise and coping behaviours.References British Medical Association (2003) Adolescent Health. London: BMA.Department of Health, Department for Education and Skills (2004) National Services Framework for Children, Young People and Maternity Services: Core Standards. London: The Stationery Office.Health Survey for England (2006) Obesity and Other Risk Factors in Children. London: The Stationery Office.

In recent years, several South African Government policies as well as community-focused interventions have been put into effect in an attempt to address household food and nutrition insecurity. This drive is based on the continued challenge of malnutrition, non-communicable diseases, food and nutrition insecurity, as well as hunger within the country. When considering suitable platforms for such health promotion interventions, schools are regarded as suitable environments and unique resources that can promote quality of life, community-wide health and collective well-being through the implementation of school-based interventions. Against this background, we undertook a participatory research project in three purposefully selected primary schools in a resource-constrained community in South Africa, with the purpose of developing and implementing a school-based intervention with Grade 4 to 6 learners to support healthy food and dietary practices in the community. To be more specific, the Wellness in Lifestyle, Intake, Fitness and Environment (Win-LIFE) intervention aimed to facilitate positive change in terms of healthy food choices, production, preparation and consumption within the participating community. The intervention was conceptualised in collaboration with teachers, school principals, governmental officials, university informants and parents of the participating schools, to be facilitated by teachers as part of the national school curriculum in the subjects Life Skills, and Natural Sciences and Technology. The findings of our study indicate that the Win-LIFE intervention was successful in enriching the national school curriculum. As such, we argue in this article that schools can act as sites for social change in vulnerable communities.