Graduation Year


Document Type




Degree Name

Doctor of Public Health (Dr.PH.)

Degree Granting Department

Public Health

Major Professor

Heewon L. Gray, Ph.D., R.D.N.

Committee Member

Russell S. Kirby, Ph.D., M.S., F.A.C.E.

Committee Member

Jennifer Marshall, Ph.D., C.P.H.

Committee Member

Jamie Holloway, P.T., D.P.T., Ph.D.


ASD, dietary intake, eHealth, social cognitive theory, youth


Background: Youth with autism spectrum disorder (ASD) have an increased likelihood of being overweight or developing obesity. As children and adolescents with ASD exhibit problematic eating behaviors and may consume more energy-dense foods and fewer fruits and vegetables than typically developing youth, nutrition represents a modifiable obesity risk factor for adolescents with ASD, yet there is a lack of interventions to improve healthy eating and reduce the risk of obesity in this population.

Purpose: The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a virtual implementation of BALANCE (Bringing Adolescent Learners with Autism Nutrition and Culinary Education), an 8-week theory-driven nutrition intervention for adolescents with ASD.

Methods: Six groups of adolescents (n=27; group size ranged 2-7) diagnosed with ASD and aged 12-20 years participated in the Social Cognitive Theory (SCT) based intervention via Microsoft Teams. Fidelity checklists measured attendance, participation, homework, fidelity, and technical difficulties. Feasibility of assessing outcome measures, including the Block Kids Food Frequency Questionnaire (FFQ), a validated psychosocial survey, and height and weight, was evaluated on response rate, completion, and data quality. Six adolescent focus groups (n=12) and 21 parent interviews were audio-recorded, transcribed, and analyzed for a priori and emergent themes regarding intervention acceptability, perceived benefits, and unintended consequences. Height and weight were measured via ruler and scale as virtually instructed by research staff. Wilcoxon signed-ranked tests were used to compare pre- and post-intervention means for psychosocial determinants of dietary intake, dietary intake, and anthropometric measures.

Results: Mean lesson attendance was 88%, participation was 3.5 of 4, homework completion was 51.9%, fidelity was 98.9%, and prevalence of technical difficulties was 0.4 of 2 (no technical difficulties or minor difficulties for all lessons). Baseline response rate was 100% for all outcome measures, with 98.9-100% completion. Post-intervention response rate was 92.6%-96.3%, with 99.5%-100% completion. Data quality was high for 88% of the matched FFQs and 100% of the psychosocial surveys. The intervention was generally acceptable to participants based on the focus groups and interviews with adolescents and their parents. Themes for acceptability included “virtual format,” “group setting,” “autonomy/independence,” “sensory components,” “interaction,” “reinforcement,” and “parent component.” Themes for perceived benefits included “diet changes,” “healthy weight,” “knowledge/awareness,” “behavioral skills,” “self-efficacy,” “outcome expectations,” “outcome expectancies,” and “other lifestyle changes.” “Anxiety/discomfort” during intervention lessons was an emergent theme regarding unintended consequences. Post-intervention means for three of seven psychosocial determinants of dietary intake improved after the 8-week intervention: behavioral strategies (p=0.010), self-efficacy (p<0.001), and outcome expectations (p=0.009). Mean added sugar intake decreased (p=0.026), while there was no significant difference in fruit or vegetable intake. BMI percentile (p=0.013) and BMI z-score significantly decreased (p=0.010).

Conclusion: BALANCE was feasible and acceptable to adolescents and parents. The findings suggest that the intervention may improve some psychosocial determinants of dietary intake immediately after the 8-week intervention. The results are also promising regarding added sugar intake and BMI z-score. Future research should examine efficacy of the intervention compared to a control group and include follow-up measures to detect longer-term outcomes.

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