Mental and Social Health Commons^™

Barriers And Facilitators To Recruitment And Enrollment Of Hiv-Infected Individuals With Opioid Use Disorder In A Clinical Trial, Kim Hoffman, Robin Baker, Lynn Elizabeth Kunkel, Elizabeth Needham Waddell, Paula J. Lum, Dennis Mccarty, P. Todd Korthuis

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study.

Main text

Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study …

Trace Amine-Associated Receptor Gene Polymorphism Increases Drug Craving In Individuals With Methamphetamine Dependence, Jennifer M. Loftis, Michael Lasarev, Xiao Shi, Jodi Lapidus, Aaron Janowsky, William Hoffman, Marilyn Huckans

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Methamphetamine (MA) is a potent agonist at the trace amine-associated receptor 1 (TAAR1). This study evaluated a common variant (CV) in the human TAAR1 gene, synonymous single nucleotide polymorphism (SNP) V288V, to determine the involvement of TAAR1 in MA dependence.

Methods: Participants (n = 106) with active MA dependence (MA-ACT), in remission from MA dependence (MA-REM), with active polysubstance dependence, in remission from polysubstance dependence, and with no history of substance dependence completed neuropsychiatric symptom questionnaires and provided blood samples. In vitro expression and function of CV and wild type TAAR1 receptors were also measured.

Results: The V288V polymorphism …

Exploring The Extent Of The Hikikomori Phenomenon On Twitter: Mixed Methods Study Of Western Language Tweets, Pereira-Sanchez, Miguel Angel Alvarez-Mon, Angel Asunsolo Del Barco, Melchor Alvarez-Mon, Alan R. Teo

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Hikikomori is a severe form of social withdrawal, originally described in Japan but recently reported in other countries. Debate exists as to what extent hikikomori is viewed as a problem outside of the Japanese context. Objective: We aimed to explore perceptions about hikikomori outside Japan by analyzing Western language content from the popular social media platform, Twitter. Methods: We conducted a mixed methods analysis of all publicly available tweets using the hashtag #hikikomori between February 1 and August 16, 2018, in 5 Western languages (Catalan, English, French, Italian, and Spanish). Tweets were first classified as to whether they described …

Relative Wealth, Subjective Social Status, And Their Associations With Depression: Cross-Sectional, Population-Based Study In Rural Uganda, Meghan L. Smith, Bernard Kakuhikire, C. Baguma, Justin D. Rasmussen, David Bangsberg, Multiple Additional Authors

OHSU-PSU School of Public Health Faculty Publications and Presentations

Depression is a leading cause of disability worldwide, and has been found to be a consistent correlate of socioeconomic status (SES). The relative deprivation hypothesis proposes that one mechanism linking SES to health involves social comparisons, suggesting that relative SES rather than absolute SES is of primary importance in determining health status. Using data from a whole-population sample of 1,620 participants residing in rural southwestern Uganda, we estimated the independent associations between objective and subjective relative wealth and probable depression, as measured by the depression subscale of the Hopkins Symptom Checklist (HSCLD). Objective relative wealth was measured by an asset …

When A Little Goes A Long Way: Expanding Home Care Services To Adults With Disabilities, Serena Hasworth, Jaclyn Winfree, Ozcan Tunalilar, Diana L. White

Institute on Aging Publications

Policy makers are increasingly interested in reducing public spending while maintaining quality of life. Since 1975, Oregon Project Independence (OPI) has supported community-based adults aged 60 and older to avoid or delay the need for residential long-term care services by increasing access to personal and home care services. The program also aims to prevent the need for Medicaid by optimizing personal resources and natural supports. In 2014, the OPI Expansion (OPI-E) pilot project began to serve adults aged 18-59 with disabilities in seven of Oregon’s seventeen Area Agencies on Aging (AAAs). This poster describes the evaluation of the expansion using …

Supporting Nursing Home Staff Through Person-Centered Care Practices, Diana White, Sarah Dys, Jaclyn Winfree, Serena Hasworth, Ozcan Tunalilar

Institute on Aging Publications

Policies and practices have increasingly focused on person-centered care (PCC) to improve quality of life for long-term care residents and staff. Adequate staffing has been a consistent barrier to implementing and sustaining PCC practices. The purpose of this paper is to explore the association between job satisfaction and PCC practices. This research was conducted in a stratified random sample of 33 Oregon nursing homes which were representative in terms of quality, profit/nonprofit ownership, and urban/rural location. Data were collected from 415 staff who completed the staff assessment of person-directed care, direct care worker job satisfaction scale, turnover intention, and organizational …

Emerging Strategies For Engaging Young People In Systems Of Care, Research And Training Center For Pathways To Positive Futures, Portland State University

School of Social Work Faculty Publications and Presentations

Systems of care are increasingly serving older youth and young adults up to age 24, and in our research and training work with providers, we hear about the challenges of engaging young people in typical services. Many providers are responding to the unique developmental needs of this population by adapting the design and delivery of their services to better engage and retain young people in system of care supports. Overall, strategies include expansion of drop-in center programming, adaptations to practice models like Wraparound, and new outreach efforts using social media and other technologies. Our purpose here is to share some …

Development And Testing Of An Assessment Of Youth/Young Adult Voice In Agency-Level Advising And Decision Making, Janet S. Walker, Brie Masselli, Jennifer E. Blakeslee, Caitlin Baird, Kristin Thorp

School of Social Work Faculty Publications and Presentations

There is a range of stakeholder benefits when youth- and young adult-serving agencies include service recipient “voice” in advising and decision making regarding agency policies and programming. Yet many agency stakeholders lack awareness of strategic best practices to ensure the consistent and meaningful participation of young people in decision-making processes, and few tools exist to evaluate agency efforts. This paper describes the development and validation of the Youth/Young Adult Voice at the Agency Level (Y-VAL), an assessment of the extent to which agencies have implemented best practices for supporting meaningful participation. The Y-VAL is intended for research purposes, as well …

Internalized Hiv Stigma, Art Initiation And Hiv-1 Rna Suppression In South Africa: Exploring Avoidant Coping As A Longitudinal Mediator, Valerie A. Earnshaw, Laura M. Bogart, Jean-Philippe Laurenceau, Brian T. Chan, Brendan G. Maughan-Brown, Janan Dietrich, Ingrid Courtney, Gugu Tshabalala, Catherine Orrell, Glenda E. Gray, David Bangsberg, Ingrid T. Katz

OHSU-PSU School of Public Health Faculty Publications and Presentations

Introduction: Cross‐sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV‐1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations.

Methods: Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self‐report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and …

Framing Physical Activity: Weight Control Frames And Physical Activity Motivation, Kristin Spurkland

Dissertations and Theses

Public health institutions and popular media frequently frame weight loss and weight control as primary benefits of physical activity. This exploratory, descriptive study examined how respondents rated statements exemplifying three physical activity frames: a weight control frame, a medical frame, and an active embodiment frame. An anonymous, online survey was conducted in March 2018; respondents rated frame statements in terms of inspiring motivation to engage in physical activity, and in terms of perceived credibility. They also provided anthropometric data and physical activity data. Data were analyzed for the entire sample as well as stratified by multiple variables, including body mass …

Exploring The Association Of Victimization And Alcohol And Marijuana Use Among American Indian Youth Living On Or Near Reservations: A Mixed Methods Study, Lindsay Nicole Merritt

Dissertations and Theses

Adolescent substance use research has yet to consider victimization as a potential risk factor contributing to alcohol and marijuana use among American Indian youth living on or near reservations, despite the presence of traumatic experiences, childhood adverse events, racism, and discrimination. Contribution to this lack of attention may be due to little being known about American Indian youth victimization. Even less is known about its association with alcohol and marijuana use in general and for those youth living on or near reservations in particular.

This study utilizes mixed methods with a nationally representative sample of American Indian youth living on …

Reaching Those At Risk For Psychiatric Disorders And Suicidal Ideation: Facebook Advertisements To Recruit Military Veterans, Alan R. Teo, Samuel B.L. Liebow, Benjamin Chan, Steven K. Dobscha, Amanda L. Graham

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans.

Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health.

Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, …

Is Therapy Going To The Dogs? Evaluating Animal Assisted Therapy For Early Identified At-Risk Children, Leah Faith Brookner

Dissertations and Theses

This study explores the historical context of human-animal relationships and examines the important ways that humans benefit from various types of interactions with domesticated animals. Therapeutic approaches that incorporate animals have been shown to have multiple benefits, including improved physical and mental health. Although this area of study is still largely overlooked in scientific fields of study, including social work, Animal Assisted Therapy (AAT) has become increasingly prevalent in various mental health settings. Despite its popularity and anecdotal support, research on the benefits of AAT with children is minimal; there are no studies examining the ways in which this approach …

Food Insecurity, Social Networks And Symptoms Of Depression Among Men And Women In Rural Uganda: A Cross-Sectional, Population-Based Study, Jessica M. Perkins, Viola N. Nyakato, Bernard Kakuhikire, Alexander C. Tsai, Sv Subramanian, David Bangsberg, Nicholas A. Christakis

OHSU-PSU School of Public Health Faculty Publications and Presentations

Objective: To assess the association between food insecurity and depression symptom severity stratified by sex, and test for evidence of effect modification by social network characteristics.

Design: A population-based cross-sectional study. The nine-item Household Food Insecurity Access Scale captured food insecurity. Five name generator questions elicited network ties. A sixteen-item version of the Hopkins Symptom Checklist for Depression captured depression symptom severity. Linear regression was used to estimate the association between food insecurity and depression symptom severity while adjusting for potential confounders and to test for potential network moderators.

Setting: In-home survey interviews in south-western Uganda. Subjects: All adult residents …

Social Network Correlates Of Ipv Acceptance In Rural Honduras And Rural Uganda, Holly B. Shakya, Jessica M. Perkins, Margaret Traeger, Alexander C. Tsai, David Bangsberg, Bernard Kakuhikire, Nicholas A. Christakis

OHSU-PSU School of Public Health Faculty Publications and Presentations

We investigated the household-level social network correlates of acceptance of intimate partner violence (IPV) in rural, agrarian settings of Honduras and Uganda, two low-income countries with unequal access to resources based upon gender. We collected complete social network data in each location (Honduras in 2014 and Uganda in 2012), across a diverse range of relationships, and then created a measure of household cohesion by calculating the degree to which members of a household nominated each other as important social connections. Our measure of IPV acceptance was based on 4 questions from the Demographic Health Survey to assess the conditions under …

Lessons Learned From The Implementation Of A Medically Enhanced Residential Treatment (Mert) Model Integrating Intravenous Antibiotics And Residential Addiction Treatment, Talitha Wilson, Devin Collins, Elena Phoutrides, Melissa B. Weimer, P. Todd Korthuis, Jessica Calcagni, Christina Nicolaidis

School of Social Work Faculty Publications and Presentations

BACKGROUND: Hospitalizations for severe infections associated with substance use disorder (SUD) are increasing. People with SUD often remain hospitalized for many weeks instead of completing intravenous antibiotics at home; often, they are denied skilled nursing facility admission. Residential SUD treatment facilities are not equipped to administer intravenous antibiotics. We developed a medically enhanced residential treatment (MERT) model integrating residential SUD treatment and long-term IV antibiotics as part of a broader hospital-based addiction medicine service. MERT had low recruitment and retention, and ended after six months. The goal of this study was to describe the feasibility and acceptability of MERT, to …

Diagnostic Performance Of Blood Inflammatory Markers For Tuberculosis Screening In People Living With Hiv, Katherine Farr, Resmi Ravindran, Luke Strnad, Emily Chang, Leah H. Chaisson, Christina Yoon, William Worodria, Alfred Andama, Irene Ayakaka, Priscilla Bbosa Nalwanga, Multiple Additional Authors

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background

Approaches to screening for active tuberculosis (TB) among people living with HIV are inadequate, leading to missed diagnoses and poor implementation of preventive therapy.

Methods

Consecutive HIV-infected adults hospitalized at Mulago Hospital (Kampala, Uganda) between June 2011 and July 2013 with a cough ≥ 2 weeks were enrolled. Patients underwent extensive evaluation for pulmonary TB. Concentrations of 43 cytokines/chemokines were measured at the same time point as C-reactive protein (CRP) in banked plasma samples using commercially-available multiplex kits. Advanced classification algorithms were used to rank cytokines/chemokines for their ability to identify TB, and to model the specificity of the …

Mitigating Early Loss Of Community Participation In Early Psychosis Services: State Of The Science, Tamara G. Sale, Dora M. Raymaker, Mariam Rija, Veronica Gould, Christina Wall, Ryan P. Melton

School of Social Work Faculty Publications and Presentations

In the early stages of treatment for psychosis, community engagement and social networks are threatened through a combination of symptomology and negative messages and reactions from the environment which may result in internalized stigma, disempowerment, and prolonged isolation. While treatment programs attempt to mitigate these factors, ambivalence toward treatment and the basic concept of psychosis, along with difficulty engaging in conversation, make initial engagement more difficult. Self-determination theory and growing recovery literature point to the importance of maintaining a sense of community relatedness and connection, and developing a sense of agency and competence as important to active recovery and retention …

Focus Groups To Increase The Cultural Acceptability Of A Contingency Management Intervention For American Indian And Alaska Native Communities, Katherine A. Hirchak, Emily Leickly, Jalene Herron, Jennifer Shaw, Jordan Skalisky, Lisa G. Dirks, Jaedon P. Avey, Multiple Additional Authors

Psychology Faculty Publications and Presentations

Introduction

Many American Indian and Alaska Native (AI/AN) people seek evidence-based, cost-effective, and culturally acceptable solutions for treating alcohol use disorders. Contingency management (CM) is a feasible, low-cost approach to treating alcohol use disorders that uses “reinforcers” to promote and support alcohol abstinence. CM has not been evaluated among AI/AN communities. This study explored the cultural acceptability of CM and adapted it for use in diverse AI/AN communities.

Methods

We conducted a total of nine focus groups in three AI/AN communities: a rural reservation, an urban health clinic, and a large Alaska Native healthcare system. Respondents included adults …

Preliminary Findings Of A Technology-Delivered Sexual Health Promotion Program For Black Men Who Have Sex With Men: Quasi-Experimental Outcome Study, Charles H. Klein, Tamara Kuhn, Danielle Huxley, Jamie Kennel, Elizabeth Withers, Carmela Lomonaco

Anthropology Faculty Publications and Presentations

Background: Human immunodeficiency virus (HIV) disproportionately affects black men who have sex with men (MSM), yet there are few evidence-based interventions specifically designed for black MSM communities. In response, the authors created Real Talk, a technology-delivered, sexual health program for black MSM.

Objective: The objective of our study was to determine whether Real Talk positively affected risk reduction intentions, disclosure practices, condom use, and overall risk reduction sexual practices.

Methods: The study used a quasi-experimental, 2-arm methodology. During the first session, participants completed a baseline assessment, used Real Talk (intervention condition) or reviewed 4 sexual health brochures (the standard of …

Household Water Insecurity, Missed Schooling, And The Mediating Role Of Caregiver Depression In Rural Uganda, Christine E. Cooper-Vince, Bernard Kakuhikire, Dagmar Vořechovská, Amy Q. Mcdonough, Jessica M. Perkins, Atheendar S. Venkataramani, Rumbidzai Mushavi, Charles Baguma, Scholastic Ashaba, David Bangsberg, Alexander C. Tsai

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: School attendance rates in sub-Saharan Africa are among the lowest worldwide, placing children at heightened risk for poor educational and economic outcomes. One understudied risk factor for missed schooling is household water insecurity, which is linked to depression among women and may increase children’s water-fetching burden at the expense of educational activities, particularly among children of depressed caregivers. In this study conducted in rural Uganda, we assessed the association between household water insecurity and child school participation and the mediating pathways behind these associations.

Method: We conducted a population-based, cross-sectional study of female household heads (N = 257) and …

The Influence Of Sense Of Community On The Relationship Between Community Participation And Recovery For Individuals With Serious Mental Illnesses, Rachel Elizabeth Terry

Dissertations and Theses

The Community Mental Health Act of 1963 launched the deinstitutionalization movement, whereby individuals with serious mental illnesses were released from psychiatric hospitals and began living and receiving mental health care in the community (Carling, 1995). However, these actions have not necessarily integrated those individuals into all aspects of community life (Dewees, Pulice, & McCormick, 1996). This is unfortunate because people with serious mental illnesses frequently report that community integration is not only important to them, but that it also aids in reducing symptoms and promoting recovery (Townley, 2015). Although past research suggests that receiving mental health care in the community …

Foundational Knowledge And Other Predictors Of Commitment To Trauma-Informed Care, Stephanie Anne Sundborg

Dissertations and Theses

Trauma-informed care (TIC) is an approach to service delivery based on the understanding of the prevalence of psychological trauma among service users, knowledge about the impact trauma has on engagement to services, and recognition that service settings can be re-traumatizing. For more than a decade, momentum has been building on this topic. Practitioners are pursuing the knowledge and skills needed to implement trauma-informed service delivery, while organizations are building infrastructure and processes aimed at supporting this approach. Disciplines across many human service sectors are eager to incorporate TIC into policy and practice. Despite this enthusiasm, implementation efforts are slow. Acquiring …

Measuring Personal Beliefs And Perceived Norms About Intimate Partner Violence: Population-Based Survey Experiment In Rural Uganda, Alexander C. Tsai, Bernard Kakuhikire, Jessica M. Perkins, Dagmar Vořechovská, Amy Q. Mcdonough, Elizabeth L. Ogburn, Jordan M. Downey, David R. Bangsberg

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Demographic and Health Surveys (DHS) conducted throughout sub-Saharan Africa indicate there is widespread acceptance of intimate partner violence, contributing to an adverse health risk environment for women. While qualitative studies suggest important limitations in the accuracy of the DHS methods used to elicit attitudes toward intimate partner violence, to date there has been little experimental evidence from sub-Saharan Africa that can be brought to bear on this issue.

Methods and Findings: We embedded a randomized survey experiment in a population-based survey of 1,334 adult men and women living in Nyakabare Parish, Mbarara, Uganda. The primary outcomes were …

Mindfulness Meditation As A Stress Reactivity Intervention: An Event-Related Potential Study, Jessica L. Trottier, Barry S. Oken

Student Research Symposium

The biological and neural mechanisms of stress have been extensively studied and supported, but are still unclear. Event-related potentials (ERP’s) emitted by neurons in the brain are a useful tool in measuring stress because they reflect neural response in real-time, to the millisecond, versus typical biological markers, which are typically evaluated before and after a stress test. The neurobiological relationship between ERP’s and stress originates in the anterior cingulate cortex, which in turn activates the hypothalamic–pituitary–adrenal axis; the main physiological cascade fueling the stress response and its chronically harmful symptoms. Malfunctions in the stress response, as in the cases of …

Psychosocial Challenges Facing Women Living With Hiv During The Perinatal Period In Rural Uganda, Scholastic Ashaba, Angela Kaida, Jessica N. Coleman, Bridget F. Burns, Emma Dunkley, Kasey O'Neil, Jasmine Kastner, Naomi Sanyu, Cecilia Akatukwasa, David R. Bangsberg, Lynn T. Matthews, Christina Psaros

OHSU-PSU School of Public Health Faculty Publications and Presentations

The complexities of navigating pregnancy while living with HIV predispose women to additional stress. Finding ways to minimize psychosocial challenges during the perinatal period may maximize the well-being of mothers living with HIV and their children. The goal of this study was to explore psychosocial challenges experienced by women living with HIV (WLWH) during pregnancy and the postpartum.

We conducted individual in-depth interviews with 20 WLWH recruited from an HIV treatment cohort study in Mbarara, Uganda as part of a larger study exploring perinatal depression. We conducted content analyses to identify themes related to challenges of WLWH during pregnancy and …

A Qualitative Examination Of Pain Centrality Among Veterans Of Iraq And Afghanistan Conflicts, Samantha D. Outcalt, Christina Nicolaidis, Matthew J. Bair, Laura J. Myers, Edward J. Miech, Marianne S. Matthias

School of Social Work Faculty Publications and Presentations

Objective. Centrality of pain refers to the degree to which a patient views chronic pain as integral to his or her life or identity. The purpose of this study was to gain a richer understanding of pain centrality from the perspective of patients who live with chronic pain.

Methods. Face-to-face interviews were conducted with 26 Veterans with chronic and disabling musculoskeletal pain after completing a stepped care intervention within a randomized controlled trial. Qualitative data were analyzed using an immersion/crystallization approach. We evaluated the role centrality plays in Veterans’ lives and examined whether and how their narratives differ when centrality …

Emergency Medical Services Responders’ Perceptions Of The Effect Of Stress And Anxiety On Patient Safety In The Out-Of-Hospital Emergency Care Of Children: A Qualitative Study, Jeanne-Marie Guise, Matthew Hansen, Kerth O'Brien, Caitlin Dickinson, Garth Meckler, Phillip Engle, William E. Lambert, Jonathan Jui

Psychology Faculty Publications and Presentations

_OBJECTIVE:

Prehospital emergency medical services (EMS) providers report anxiety as the second most common contributor to paediatric patient safety events. The objective of this study was to understand how EMS providers perceive the effect of stress and anxiety on paediatric out-of-hospital patient safety.

_SETTING:

This was a nationwide study of EMS providers from 44 of 50 (88%) US states.

_{PARTICIPANTS:}

A total of 753 eligible EMS professionals, including emergency medical technicians, emergency department physicians and nurses (general and paediatric), and respiratory therapists who participate in out-of-hospital transports.

_{PRIMARY AND SECONDARY OUTCOME MEASURES:}

Outcomes included responses to: (1) clinical situations where …

One-Year Postpartum Outcomes Following A Weight Management Intervention In Pregnant Women With Obesity, Kimberly K. Vesco, Michael C. Leo, Njeri Karanja, Matthew W. Gillman, Cindy T. Mcevoy, Janet C. King, Cara L. Eckhardt, K. Sabina Smith, Nancy Perrin, Victor J. Stevens

Community Health Faculty Publications and Presentations

Objective

This analysis was focused on 1-year maternal and infant follow-up of a randomized trial that tested a weight management intervention conducted during pregnancy.

Methods

One hundred fourteen women with obesity (mean BMI 36.7 kg/m²) were randomly assigned at a mean of 15 weeks gestation to a weight management intervention or usual care control condition. The intervention ended at delivery and resulted in less gestational weight gain and a lower proportion of large-for-gestational-age newborns among intervention compared with control participants. The primary outcome at 12 months postpartum was maternal weight. Secondary outcomes included infant weight-for-age and weight-for-length z …

Dietary And Physical Activity Acculturation And Weight Status In Chinese College Students, Yanni Zhang

Dissertations and Theses

This cross-sectional study examined the relationships between length of residence in the United States (U.S.) and dietary and physical activity acculturation, and the relationships between dietary and physical activity acculturation and weight status in 55 Chinese college students. Length of residence in the U.S. was positively associated with larger portion size, greater amount of physical activity, and change in BMI in male participants. Adoption of a Western diet was associated with weight gain. Portion size change was positively associated with BMI change. Lunch size change was positively correlated with BMI change in males while negatively correlated with BMI change in …