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ACCESSION NO: 0220540  SUBFILE: CRIS 
PROJ NO: IND030462R1 AGENCY: NIFA IND 
PROJ TYPE: HATCH PROJ STATUS: TERMINATED  MULTISTATE PROJ NO: W-2003 
START: 01 OCT 2009 TERM: 30 SEP 2013 FY: 2012

INVESTIGATOR: Boushey, C. J.

PERFORMING INSTITUTION: 
PURDUE UNIVERSITY 
WEST LAFAYETTE, INDIANA 47907

HOW TO MOTIVATE PARENTS TO PROMOTE INTAKE OF CALCIUM RICH FOODS AMONG EARLY
ADOLESCENTS (FROM W1003)

NON-TECHNICAL SUMMARY: Successful completion of the proposed Multistate Research project will have three
important immediate impacts. These impacts are all based on four parental factors shown to be associated with
intake of CRF by early adolescents in W-1003 (availability, role modeling, encouragement and expectations): 1)
Subgroups based on the four parental factors will be identified from data previously collected as part of W-1003. The
descriptive characteristics of these subgroups related to the four parental factors will serve as a basis for the
development of tailored messages to motivate parents to promote intake of CRF. 2) The underlying motivations
driving the four parental factors will be determined with population groups at risk for developing osteoporosis as older
adults - Asian, Hispanic and non-Hispanic whites, and 3) Messages based on the four parental factors will be
identified and pretested with selected subgroups of the target audience. Longer term impacts include the use of
messages which met evaluation criteria for potential relevance in future osteoporosis prevention programs for
parents. The results of the proposed project should provide a strong basis from which to compete for further funding.

OBJECTIVES: Objectives: 1. Segment parents into homogenous subgroups based on promotion of CRF to early
adolescents. 2. Explore motivations and/or perceived benefits and barriers underlying parental factors which include
making CRF available, encouraging intake of CRF, setting expectations for beverage consumption, and role modeling
intake of CRF to early adolescents. 3. Identify relevant messages and delivery methods that will motivate parents to
promote CRF to early adolescents. Outputs: 1) The project team along with marketing consultants will segment
parents based on survey data collected as part of W-1003 to identify subgroup characteristics for message tailoring.
Publications reporting results of this work will be prepared and submitted for publication. 2) Each state will collect
focus group and/or individual interview data from parents regarding underlying motivations driving parenting factors
associated with CRF intake of early adolescents and transcribe into verbatim transcripts. Interview data will be
evaluated and summarized by teams including researchers from several states. States will communicate through
conference calls and will prepare a summary report for the annual meeting. Publications reporting results of
qualitative work will be prepared and submitted for publication. 3) Each state will participate in message development
through conference calls and work at annual meetings. Each state will collect focus group and/or individual interview
data to test messages and strategies for relevance, acceptance, comprehension and potential impact. A summary
report will be prepared for the annual meeting. Publications reporting results of the qualitative formative evaluation
will be prepared and submitted for publication. 4) A report will define how the messages could be incorporated into
future parent educational interventions. 5) Each state will participate in a review of qualitative research methodology
at an annual meeting including the use of projective techniques/exercises to complement qualitative data collection
methods. States will communicate through conference calls and will prepare a summary report for the annual
meeting.

APPROACH: Milestones: Objective 1. Segment parents into homogenous subgroups based on promotion of CRF to
early adolescents. Timeline: October, 2008 - September 2009 Steps: Conduct segmentation analysis, interpret
results, and prepare narrative description of segments for use in message development, present overview of process
to multistate partners at the annual meeting Objective 2. Explore motivations and/or perceived benefits and barriers
underlying parental factors which include making CRF available, encouraging intake of CRF, setting expectations for
beverage consumption, and role modeling intake of CRF to early adolescents. Timeline: October, 2008- September,
2011 Steps: Conduct exploratory focus group interviews with parents of early adolescent Asian, Hispanic and non-
Hispanic white children, analyze and write manuscript(s). Objective 3. Identify relevant messages and delivery
methods that will motivate parents to promote CRF to early adolescents. Timeline: October, 2010- September, 2012
Steps: Develop messages based on preferred delivery methods and evaluation criteria. Timeline: October, 2013-
September, 2014 Steps: Conduct individual and focus group interviews with parents to pretest messages, analyze
results, revise messages as appropriate. Continue manuscript and grant proposal development. Plan future
intervention components in cooperation with state partners. Indiana will contribute to all three project objectives.

PROGRESS: 2009/10 TO 2013/09
OUTPUTS: Dr. Boushey is no longer a member of the Purdue University faculty and did not participate during the
reporting period in this multistate project. PARTICIPANTS: Nothing significant to report during this reporting period.
TARGET AUDIENCES: Dietitians and nutrition scientists. PROJECT MODIFICATIONS: Nothing significant to report
during this reporting period.

IMPACT: 2009/10 TO 2013/09
Final publications are listed below.

PUBLICATIONS (not previously reported): 2009/10 TO 2013/09

1. Eicher-Miller HA, Mason AC, Weaver CM, McCabe GP, Boushey CJ. Food insecurity is associated with diet and
bone mass disparities in early adolescent males but not females in the United States. J Nutr 2011; 141(9): 1738-45
2. Franks MM, Shields CG, Lim E, Sands LP, Mobley S, Boushey CJ. I will if you will: similarity in married partners
readiness to change health risk behaviors. Health Educ Behav 2011
3. Osborne DL, Weaver CM, McAbe LD, McCabe GM, Novotny R, Boushey C, Savaiano DA. Tanning predicts bone
mass but not structure in adolescent females living in Hawaii. Am J Hum Biol 2011; 23(4): 470-8
4. Renicks M, Ballejos ME, Goodell LS, Gunther C, Richards R, Wong SS, Auld G, Boushey CJ, Bruhn C, Cluskey M,
Misner S, Olson B, Zaghloul S. Individual and family correlates of calcium rich food intake among parents of early
adolescent children. J Am Diet Assoc 2011; 111(3): 376-84.
5. Schap TE, Six BL, Delp EJ, Ebert DS, Kerr DA, Boushey CJ. Adolescents in the United States can identify familiar
foods at the time of consumption and when prompted with an image 14 h postprandial, but poorly estimate portions.
Public Health Nutr 2011;14(7): 1184-1191.
6. Sheean PM, Bruemmer B, Gleason P, Harris J, Boushey C, Van Horn L. Publishing nutrition research: a review of
multivariate techniques:Part 1. J Am Diet Assoc 2011;111(1): 103-10.
7. Fialkowski MK, McCrory MA, Roberts SM, Tracy JK, Grattan LM, Boushey CJ. Estimated nutrient intakes from
food generally do not meet dietary reference intakes among adult members of pacific Northweat Tribal Nations. J
Nutr 2010;140: 992-8
8. Gleason PM, Harris JE, Sheean PM, Boushey CJ, Bruemmer B. Publishing nutrition research: validity, reliability
and diagnostic test assessment in nutrition-related research. J Am Diet Assoc 2010;110:409-19.
9. Fialkowski MK, McCrory MA, Roberts SM, Tracy JK, Grattan LM, Boushey CJ. Evaluation of dietary assessment
tools used to assess the diet of adults participating in the communities Advancing the Studies of Tribal Nations
Across the Lifespan (CoASTAL) cohort. J Am Diet Assoc 2010; 110:55-64.
10. Yang, YJ, Martin BR, Boushey CJ. Development and evaluation of a brief calcium assessment tool (BCAT) for
adolescents. J Am Diet Assoc 2010;110:111-115.
11. Six BL, Schap TE, Zhu FM, Mariappan A, Delp EJ, Ebert DS, Kerr DA, Boushey CJ. Evidence-based
development of a mobile telephone food record. J Am Diet Assoc 2010;110: 74-79.

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ACCESSION NO: 0222898  SUBFILE: CRIS 
PROJ NO: IND030670 AGENCY: NIFA IND 
PROJ TYPE: HATCH PROJ STATUS: TERMINATED 
START: 01 OCT 2010 TERM: 30 SEP 2015 FY: 2015

INVESTIGATOR: Franks, M. M.; Boushey, C. J.; Shields, C. G.

PERFORMING INSTITUTION: 
PURDUE UNIVERSITY 
WEST LAFAYETTE, INDIANA 47907
A DYADIC STUDY OF PATIENTS' AND SPOUSES' DAILY DIET QUALITY AND
DIABETES MANAGEMENT

NON-TECHNICAL SUMMARY: Daily adherence to a healthy diet is a critical lifestyle

component in the management of diabetes that poses a considerable challenge to
patients. The purpose of our research projects is to investigate the influence of the
social environment, particularly the marital partner, on patients' daily adherence to a
high quality diet in the management of diabetes. Understanding the influence of the
shared social environment on patients' daily dietary adherence is likely to have an
impact on patients, their families, and society through the design and delivery of
interventions intended to aid patients in remaining vigilant to their dietary regimen. In
primary care settings, patients who are involved in treatment decision-making, have
better assessments of their diabetes management (e.g., Heisler et al., 2003).
Importantly, because health behaviors such as diet often are shared with a spouse,
modifications to daily meals may not be a decision that patients can easily carry out on
their own. For this reason, involving spouses in treatment decisions could benefit
patients' adherence to dietary recommendations, and minimize their risk of serious
complications. Additionally, recognizing the influence of the social environment on
individuals' risk behaviors has the potential to alter public health interventions by
broadening the focus of primary and secondary prevention messages from individual-
centered behavior change to relationship-centered behavior change. In this way, the
proposed work may contribute to increased longevity and quality of life among patients
and also among their relationship partners who are at heightened risk for developing
these conditions.

OBJECTIVES: Decisions with considerable health consequences are made each and

every day by older patients managing one or more chronic diseases, such as type 2
diabetes. Diabetes affects approximately one in five Americans over the age of 60, and
poor management of this disease cumulatively, and sometimes irreversibly, affects the
health of these older patients. Proper daily management of diabetes, including careful
daily adherence to nutrition recommendations, reduces the risk of serious
complications. Despite encouragement from health-care providers and warnings about
the harmful consequences of diet non-adherence, many patients are unsuccessful in
sustaining recommended dietary behaviors. Although decisions about daily diet are
likely to be shared between marital partners, little is known about spouses' influence on
patients' day-to-day dietary management, and subsequently, their health outcomes. We
propose to address this gap in empirical knowledge with findings from three multi-
method studies examining married partners' daily diet-related interactions and behaviors
as predictors of disease-related outcomes of older patients with diabetes. Our dyadic,
multi-method investigations are guided by these specific aims: AIM 1. Investigate
associations among spouses' daily diet-related behaviors (support, control and diet
quality) and patients' daily disease-related health outcomes (daily diabetes-related
physical symptoms, blood glucose levels, psychological distress and HbA1c). AIM 2.
Elucidate a key mechanism through which spouses' daily diet-related behaviors are
associated with patients' disease-related health outcomes (i.e., daily diet quality), and
conditions under which this mechanism operates (e.g., patient gender).
APPROACH: In light of anticipated interrelationships among social (e.g., shared health
risk behaviors of married partners), behavioral (diet adherence), physiological (glycemic
control) and psychological (distress) components of patients' disease management, we
will examine married partners' diet-related interactions and behaviors as predictors of
disease-related outcomes among older patients with diabetes and their spouses. Our
focus on married patients and their spouses reflects U. S. Census data estimates that
70 percent of young-old Americans (ages of 55 to 74) are married and co-reside with
their spouse. Specific to the context of diabetes, our dyadic approach is consistent with
calls for a social systems perspective on diabetes management (e.g., Fisher & Weihs,
2000). Additionally, our dyadic investigation affords an exemplary opportunity to
contribute to a growing body of work delineating the role of marital interactions in
shaping the health and well-being of married women and men (Kiecolt-Glaser &
Newton, 2001). We will employ a combination of methodological approaches to
examine daily changes and global patterns in spouse behaviors and patient disease
management. Importantly, we will use dyadic data available from each of three ongoing
studies. Two studies involve daily diary data and one study involves observational data
of married partners' communication with a healthcare provider. All three studies involve
interview and survey data to capture more global aspects of partners' interpersonal
interactions and diet behaviors (each of these studies is briefly described below). Our
multi-method approach affords a comprehensive investigation of social, behavioral,
psychological, and physiological daily data from both patients with diabetes and their
most significant relationship partner, their spouse. Our daily diaries provide a window to
specific, proximal behaviors and interpersonal exchanges of patients and spouses and
their relatively immediate and short-term (daily) health effects, whereas our in-person
interviews provide a window to more stable patterns of behavior that may influence
broader and more distal diabetes-related outcomes. Whether daily or global patterns of
subjective experience are more consequential for patients' management of a disease is
an empirical question that remains poorly understood. Our dyadic data collection
strategy using electronic daily diaries involves data nested within a hierarchical
structure, and thus the nonindependence encountered in dyadic (and diary) data
requires special statistical consideration (see Bolger et al., 2003). For analysis of daily
diary data, we have chosen a mixed effects modeling approach because it has several
distinct advantages over other approaches (e.g., difference or gain scores, repeated-
measures ANOVA), including explicitly modeling individual change over time,
Specifically, this approach will afford the opportunity to examine systematic individual
variation in patients' daily diet quality and health outcomes associated with daily
behaviors of their spouses.

PROGRESS: 2010/10 TO 2015/09
Target Audience:Our research was accepted for presentation at health and aging
focused conferences during this reporting period. The target audience reached by our
efforts includes the members and conference attendees of these organizations such as
The Gerontological Society of America. Changes/Problems: Nothing Reported What
opportunities for training and professional development has the project provided?
Throughout the project period, several undergraduate and graduate students have
gained experience with developing research ideas and presenting research findings
through involvement with our Relationships and Healthcare lab. How have the results
been disseminated to communities of interest?Our results have been disseminated to
communities of interest through conference presentations, book chapters, and peer-
reviewed journal articles across the project period. What do you plan to do during the
next reporting period to accomplish the goals? Nothing Reported

IMPACT: 2010/10 TO 2015/09
What was accomplished under these goals? We have contributed findings to the
literature on spouse involvement in chronic disease management of ill partners. Our
findings help to distinguish how spouses' interactions can sometimes facilitate
behavioral adherence of patients, but at other times, can interfere with patients'
adherence. Our findings also demonstrate that spouses' use of health-related control
can detract from the emotional well-being of the partner with diabetes, and from their
own well-being. Additionally, our work has addressed couples' interactions in the
medical setting and associations with their day-to-day health-related interactions. These
findings may inform healthcare professionals of available support for patients managing
chronic illness. These projects and related papers and presentations have provided pilot
work for the development of an intervention project designed to promote increases in
physical activity among older adult couples. The communication of couples about health
behaivor change is a central component of this physical activity intervention.

PUBLICATIONS (not previously reported): 2010/10 TO 2015/09

1. Type: Book Chapters Status: Awaiting Publication Year Published: 2016 Citation:
Franks, M. M., Wehrspann, E., August, K. J., Rook, K. S., & Stephens, M. A. P.
(forthcoming). Chronic disease management in older couples: Spousal support vs
control strategies. In J. Bookwala (Ed.), Couple relationships in mid and late life: Their
nature, complexity, and role in health and illness. Washington, DC: APA.
2. Type: Conference Papers and Presentations Status: Accepted Year Published: 2015
Citation: Hemphill, R., Martire, L. M., Stephens, M. A. P., Rook, K. S., & Franks, M. M.
(2015, November). Daily marital quality and illness management among older adults
with diabetes or osteoarthritis. Paper presented at the Annual Scientific Meeting of the
Gerontological Society of America, Orlando, FL.
3. Type: Conference Papers and Presentations Status: Accepted Year Published: 2015
Citation: August, K. J., Rook, K. S., Choi, S., Franks, M. M., & Stephens, M. A. P. (2015,
February,). Spousal support, stress reactivity and glycemic control among patients with
type 2 diabetes. Poster presented at the 16th Annual Convention of the Society for
Personality and Social Psychology, Long Beach, CA.
4. Type: Conference Papers and Presentations Status: Accepted Year Published: 2015
Citation: Marshall, M., Briggs, J., Oates, S., Franks, M.M., & Shields, C.G. (2015,
November). Language use in married couples during diabetes medical encounters.
Poster presented at the International Conference on Communication in Healthcare, New
Orleans, LA.