The role of the community café in addressing food security: Perceptions of managers and directors

In the United States, the pay-what-you-can restaurant model (community cafes) is an increasingly popular approach to addressing food insecurity in local communities. We conducted semi-structured interviews (n = 13) with community café executive managers and directors to assess their perceptions of the role that their cafes play in addressing food security (FS). Analysis of interviews revealed two major areas of emphasis by participants. Filling an unoccupied space in the food security landscape. Interviewees regularly cited the goal of making meals available through a dependable schedule, convenient location, and welcoming atmosphere for guests to promote regular visits to the café, and they did so with an awareness of how their practices were shaped by perceived shortcomings in comparable services. In addition, guest agency and social aspects of the café as components of utilization, was another major area. Interviewees often regarded the opportunity of the food insecure guest to choose healthy options (i.e., nutritionally dense) over less healthful ones (i.e., calorically dense) from the menu as a critical component of their service. The social component of the café (e.g., community atmosphere, 'dining-out' experience) was another aspect of the café's function that promoted dignity for the guest which can lead to greater likelihood of return visits. Perceptions shared by participants of the café's role in addressing food security suggest that rather than simply adding to the available options of hunger relief services, the café model attempts to address many areas of concern, such as structural and cultural barriers, found in the traditional forms of charitable food provision.

Consideration of nutrition and sustainability in public definitions of 'healthy' food: an analysis of submissions to the US FDA

OBJECTIVE

To better understand how the public defines 'healthy' foods and to determine whether the public considers sustainability, implicitly and explicitly, in the context of healthy eating.

DESIGN

We conducted a content analysis of public comments submitted to the US FDA in 2016 and 2017 in response to an invitation for feedback on use of the term 'healthy' on food labels. The analysis explored the ways in which commenters' definitions of 'healthy' aligned with the 2015-2020 Dietary Guidelines for Americans and whether their definitions considered sustainability.

SETTING

The US Government's Regulations.gov website.

PARTICIPANTS

All 1125 unique comments from individuals and organisations.

RESULTS

Commenters' definitions of 'healthy' generally mirrored the recommendations that the Dietary Guidelines for Americans put forth to promote a 'healthy eating pattern'. Commenters emphasised the healthfulness of fruit, vegetables, whole grains, fish and other minimally processed foods and the need to limit added sugars, sodium, saturated and trans fats and other ingredients sometimes added during processing. One-third of comments (n 374) incorporated at least one dimension of sustainability, mainly the environmental dimension. Commenters who mentioned environmental considerations primarily expressed concerns about synthetic chemicals and genetic modification. Less than 20 % of comments discussed social or economic dimensions of sustainability, and less than 3 % of comments (n 30) used the word 'sustainability' explicitly.

CONCLUSIONS

This novel analysis provides new information about the public's perceptions of 'healthy' foods relative to nutrition and sustainability considerations. The findings can be used to advance policy discussions regarding nutrition labelling and guidance.

A qualitative exploration of the health needs and goals of urban women to inform the tailoring and adaptation of Strong Hearts Healthy Communities: a community-based cardiovascular disease prevention intervention

BACKGROUND

In the United States, cardiovascular diseases (CVD) are the leading cause of death and disability in women. CVD-modifiable risk factors, including poor diet quality and inadequate physical activity, can be addressed through evidence-based interventions (EBIs). Strong Hearts Healthy Communities (SHHC) is an EBI that has demonstrated effectiveness in reducing CVD risk and improving health outcomes among rural white women. The aims of this study were to understand the general health, diet, and physical activity-related needs and goals of women living in an urban community, to inform the tailoring and adaptation of the SHHC EBI to an urban setting and more diverse population.

METHODS

Focus groups (FGs) were conducted with African American/Black and Hispanic/Latinx women in the Dallas metropolitan area who had a BMI ≥ 25 kg/m2 and engaged in ≤ 150 min per week of moderate physical activity. The data were coded using a team-based, deductive, and thematic analysis approach, that included multiple coders and in-depth discussions.

RESULTS

Four FGs with a total of 18 participants (79% Black and 21% Latinx) were conducted, and three themes were developed: (1) participants had adequate knowledge and positive attitudes towards healthy living but faced many barriers to practicing healthy behaviors; (2) culturally-based beliefs and community practices exerted a strong influence on behaviors related to food and stress, revealing barriers to healthy eating and generational differences in stress and stress management; (3) participants desired a more individualized approach to nutrition and physical activity interventions that included familiar and enjoyable activities and social support centered around shared health goals.

CONCLUSIONS

The SHHC intervention and similar health programs for Black/African American and Hispanic/Latinx women in urban settings should emphasize individualized nutrition and practical skills for healthy eating with accessible, familiar, and enjoyable exercises. Additionally, stress management strategies should be culturally and generationally sensitive and social support, whether through family, friends, or other program participants, should be based on shared health goals.

Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0

BACKGROUND

Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating.

OBJECTIVES

This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program.

METHODS

A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models.

RESULTS

At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating).

CONCLUSIONS

SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www.

CLINICALTRIALS

gov as NCT03059472.

Major Gaps in Understanding Dietary Supplement Use in Health and Disease

Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity (n = 5) and/or reproducibility (n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes.

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education

OBJECTIVE

Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention.

DESIGN

Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later.

PARTICIPANTS

Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148).

INTERVENTION

Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis.

VARIABLES MEASURED

Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner.

ANALYSIS

Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence.

RESULTS

At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107).

CONCLUSIONS AND IMPLICATIONS

Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Recruiting experiences of NIH-funded principal investigators for community-based health behavior interventions during the COVID-19 pandemic

Successful recruitment into randomized trials and interventions is essential to advance scientific knowledge to improve health. This rapid assessment study explored how the COVID-19 pandemic affected participant recruitment overall, identified how it exacerbated existing challenges to recruit hard-to-reach populations, and described how NIH-funded Principal Investigators (PIs) responded to COVID-era recruitment challenges. A cross-sectional survey of NIH-funded PIs conducting interventions and trials related to health behaviors was conducted in 2022. The survey was completed by 52 PIs, most of whom were highly experienced in this type of research. Eighteen PIs reported it was very difficult to recruit participants now (39.1%) compared to before COVID-19 when only one did (2.2%). PIs reported changing recruitment and data collection methods (29.4%), increasing staff dedicated to recruitment (29.4%), and increasing participant compensation (23.5%). Recruitment methods shifted from in-person activities to social media and other electronic communications. Barriers to recruitment included reluctance to participate in research, COVID-19 protocols and precautions, overwhelmed community partners, staff burnout and turnover, and limited access to technology for some populations that were already hard to reach. Facilitators to recruitment consisted of increased access and ability to use remote technologies, use of social media, strong community ties, and wanting to be part of something positive. PIs perceived recruitment as much more difficult after the onset of COVID-19, though research teams were able to pivot to more online and remote options. These tools may have a lasting impact in modernizing recruitment, data collection, and intervention techniques in future trials.

Cost analysis and cost effectiveness of a subsidized community supported agriculture intervention for low-income families

BACKGROUND

The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts.

METHODS

Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives.

RESULTS

F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity.

CONCLUSIONS

Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www.

CLINICALTRIALS

gov/ct2/show/NCT02770196 .

Integrating Civic Engagement Into a Lifestyle Intervention for Rural Women - A Mixed Methods Process Evaluation

PURPOSE

The present study aimed to evaluate the implementation of a civic engagement curriculum (HEART Club) designed to catalyze positive environmental change in rural communities.

DESIGN

The HEART Club curriculum was integrated into a six-month community-based health behavior intervention to reduce cardiovascular disease risk.

SETTING

Participants were recruited from eight rural towns in Montana and New York.

SUBJECTS

101 midlife and older women.

INTERVENTION

Participants worked to address an issue related to their local food or physical activity environment and establish progress monitoring benchmarks.

METHOD

Evaluation components included after-class surveys, program leader interviews (n = 15), participant focus groups (n = 8), and post-intervention surveys.

RESULTS

Intervention sites reported high fidelity (78%) to the curriculum. Average attendance was 69% and program classes were rated as highly effective (4.1 out of 5). Despite positive participant feedback, low readiness for civic engagement and insufficient time were implementation challenges. The majority of HEART Club groups had accomplished two or more benchmarks post-intervention. Facilitators of progress included community support, effective leadership, and collective effort. Participants also indicated that trying to affect community change while simultaneously making personal health improvements likely stalled initial progress.

CONCLUSION

These findings highlight the potential and challenges associated with civic engagement within the context of rural lifestyle interventions. Future implementation efforts should focus on reframing civic engagement as an approach to support and maintain behavior change.

Real-time Assessment of the Bidirectional Relationship Between Affective States and Glucose: Protocol for a 14-Day Observational Study

BACKGROUND

Glucose variability increases cardiometabolic disease risk. While many factors can influence glucose levels, postprandial glucose response is the primary driver of glucose variability. Furthermore, affect may directly and indirectly impact glucose variability through its effect on eating behavior. Continuous glucose monitors (CGMs) facilitate the real-time evaluation of blood glucose, and ecological momentary assessment (EMA) can be used to assess affect in real time. Together, data collected from these sources provide the opportunity to further understand the role of affect in glucose levels.

OBJECTIVE

This paper presents the protocol for a study that aims to (1) evaluate the feasibility and acceptability of using CGMs along with EMA in nondiabetic populations and (2) examine the bidirectional relationship between affect and glucose in nondiabetic adults with overweight or obesity using a CGM and EMA.

METHODS

Eligibility criteria for the study include participants (1) aged 18 to 65 years old, (2) with a BMI of ≥25 kg/m², (3) who are able to read and write in English, and (4) who own a smartphone. Individuals will be excluded if they (1) have type 1 or 2 diabetes or have any other condition that requires glucose monitoring, (2) are pregnant, (3) use any medications that have the potential to alter blood glucose levels or interfere with the glucose sensing process, or (4) have a diagnosed gastrointestinal condition or eating disorder. In a 14-day observational study, participants will wear a FreeStyle Libre Pro CGM sensor (Abbott) and will receive mobile phone-based EMA prompts 6 times per day (randomly within six 2-hour windows between 8 AM and 8 PM) to assess positive and negative affect. Participants will also wear a Fitbit Inspire 2 (Fitbit) to continuously monitor physical activity and sleep, which will be included as covariates in the analysis. Multilevel linear regression models will be used to evaluate the acute relationship between glucose level and affect.

RESULTS

Recruitment started in October 2022 and is expected to be completed in March 2023. We will aim to recruit 100 participants. As of December 12, 2022, a total of 39 participants have been enrolled.

CONCLUSIONS

The results of this study will further elucidate the role of affect in glucose variability. By identifying affective states that may lead to glucose excursions, our findings could inform just-in-time behavioral interventions by indicating opportunities for intervention delivery.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45104.

COVID-19 Related Protocol Considerations and Modifications within a Rural, Community-Engaged Health Promotion Randomized Trial

Rural communities are at higher risk for physical inactivity, poor dietary behaviors, and related chronic diseases and obesity. These disparities are largely driven by built environment, socioeconomic, and social factors. A community-based cluster randomized controlled trial of an intervention, the Change Club, aims to address some of these disparities via civic engagement for built environment change. Baseline data collection began in February 2020, only to be paused by the COVID-19 pandemic. In this context, the investigators evaluated multiple approaches for collecting data when the study resumed, focusing on Life’s Simple 7, and additional anthropometric, physiologic, and behavioral outcomes in rural and micropolitan (<50,000 population) communities in Texas and New York. Life’s Simple 7 includes fasting blood glucose, total cholesterol, blood pressure, weight, physical activity, diet, and smoking. Rigor and feasibility were considered across a variety of in-person versus at-home measurement options. After a comprehensive input from participants, partners, staff, researchers, and the funding liaison, the study team chose self-measurement and use of validated questionnaires/surveys to measure the Life’s Simple 7 components. This case provides an example of how a study team might adjust data collection protocol during unexpected and acute events while giving consideration to rigor, feasibility, stakeholder views, and participants’ health and safety.

Changes in physical activity outcomes in the Strong Hearts, Healthy Communities (SHHC-2.0) community-based randomized trial

BACKGROUND

Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial.

METHODS

Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women (n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect.

RESULTS

Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P < 0.001) and at 24 weeks (increase of 6.4 min per day; P = 0.011). Self-reported total MET minutes per week also increased: at 12 weeks (increase of 725.8, P = 0.003) and 24 weeks (increase of 955.9, P = 0.002). Several of the psychosocial variables also showed significant positive changes.

CONCLUSIONS

The SHHC-2.0 intervention successfully increased physical activity level and related outcome measures. Modifications made based upon in-depth process evaluation from SHHC-1.0 appear to have been effective in increasing physical activity in this at-risk population.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03059472. Registered 23 February 2017.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

Implementation of the Texas Community-Engaged Statewide Consortium for the Prevention of COVID-19

The Community Engagement Alliance (CEAL) Against COVID-19 Disparities aims to conduct community-engaged research and outreach. This paper describes the Texas CEAL Consortium's activities in the first year and evaluates progress. The Texas CEAL Consortium comprised seven projects. To evaluate the Texas CEAL Consortium's progress, we used components of the RE-AIM Framework. Evaluation included estimating the number of people reached for data collection and education activities (reach), individual project goals and progress (effectiveness), partnerships established and partner engagement (adoption), and outreach and education activities (implementation). During the one-year period, focus groups were conducted with 172 people and surveys with 2107 people across Texas. Partners represented various types of organizations, including 11 non-profit organizations, 4 academic institutions, 3 civic groups, 3 government agencies, 2 grassroots organizations, 2 faith-based organizations, 1 clinic, and 4 that were of other types. The main facets of implementation consisted of education activities and the development of trainings. Key recommendations for future consortiums relate to funding and research logistics and the value of strong community partnerships. The lessons learned in this first year of rapid deployment inform ongoing work by the Texas CEAL Consortium and future community-engaged projects.

Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial

BACKGROUND

Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors.

METHODS

This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation.

DISCUSSION

Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

Participation in Cost-offset Community Supported Agriculture by Low-income Households in the U.S. is Associated with Community Characteristics and Operational Practices

OBJECTIVE

Subsidized or cost-offset community supported agriculture (CO-CSA) connects farms directly to low-income households and can improve fruit and vegetable intake. This analysis identifies factors associated with participation in CO-CSA.

DESIGN

Farm Fresh Foods for Healthy Kids (F3HK) provided a half-price, summer CO-CSA plus healthy eating classes to low-income households with children. Community characteristics (population, socio-demographics, health statistics) and CO-CSA operational practices (share sizes, pick-up sites, payment options, produce selection) are described and associations with participation levels examined.

SETTING

Ten communities in New York (NY), North Carolina (NC), Vermont, and Washington states in USA.

PARTICIPANTS

Caregiver-child dyads enrolled in spring 2016 or 2017.

RESULTS

Residents of micropolitan communities had more education and less poverty than in small towns. The one rural location (NC2) had the fewest college graduates (10%) and most poverty (23%), and poor health statistics. Most F3HK participants were white, except in NC where 45.2% were African American. CO-CSA participation varied significantly across communities from 33% (NC2) to 89% (NY1) of weeks picked-up. Most CO-CSAs offered multiple share sizes (69.2%) and participation was higher than when not offered (76.8% vs. 57.7% of weeks); whereas 53.8% offered a community pick-up location, and participation in these communities was lower than elsewhere (64.7% vs. 78.2% of weeks).

CONCLUSION

CO-CSAs should consider offering choice of share size and innovate to address potential barriers such as rural location and limited education and income among residents. Future research is needed to better understand barriers to participation, particularly among participants utilizing community pick-up locations.

Growing Opportunities for Equitable, Interdisciplinary Undergraduate Food Systems Education: A Review of Food Systems Education at Land-Grant Institutions and Development of Open-Access Materials

Post-secondary coursework related to agriculture and the food supply has been at the core of the United States' land-grant system for more than 150 years. However, as the complexity of food systems has grown, so too have critiques that the education provided in these programs is too narrow to adequately prepare graduates to address pressing food systems issues. In response, some higher education institutions have developed degrees in food systems. To support development of this burgeoning field, we created, tested, and refined four evidence-informed, interdisciplinary, equity-oriented, open-access teaching modules. These modules are based on our experience conducting a multi-site, multi-year transdisciplinary investigation of subsidized, or “cost-offset”, community supported agriculture and a survey asking instructors at land-grant institutions (n = 66) about topic offerings and current unmet needs for instructional materials. Our collaboration illuminated the potential and challenges of food systems research; underscored the value of transdisciplinary research teams; and identified several equity-oriented topics related to the design, implementation, and evaluation of local food initiatives suitable for advancing sustainable foods systems education. Instructors reported that the most helpful teaching aids would be case studies, lesson plans with active learning components, and reference lists with relevant peer-reviewed publications. The final modules seek to shed light on the complexity of food systems projects and build knowledge, vocabularies, and skills across disciplines engaged with food systems. Per instructor-defined needs, each module features a case study, active-learning activities, and references. We anticipate that the adaptable modules will be suitable for a wide range of students and courses.

Farmers’ Market Nutrition Program Educational Events Are Broadly Accepted and May Increase Knowledge, Self-Efficacy and Behavioral Intentions

The Farmers’ Market Nutrition Program (FMNP) in the U.S. provides coupons for the purchase of fruit and vegetables (FV) to pregnant women and children enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and to income-eligible adults 60+ years of age. The New York State FMNP Education Event Guide was developed to support cooperative extension educators in providing information, food tastings, and cooking demonstrations at farmers’ markets (FM) to encourage consumption of FV. This paper describes implementation at seven FM in New York City, and shopping and eating behaviors in a cross-sectional survey of FM shoppers (n = 377). Three of nine lessons were implemented more than once, typically with food sampling (78.9%). FM shoppers were primarily women (81.5%), racially diverse (30.5% Black, 23.1% White), frequent shoppers (2.4 times/month), and had high FV consumption (2.24 cups fruit; 2.44 cups vegetables daily). Most FM shoppers participated in the FM education event (84%), and participants and non-participants had equivalent shopping and eating behaviors. More than 70% of FM education participants believed that the event positively impacted their knowledge, self-efficacy, and behavioral intentions. FMNP education events at FM were broadly accepted by FM shoppers of all characteristics, and may improve knowledge, self-efficacy, and behavioral intention.

Physical activity and healthy eating behavior changes among rural women: an exploratory mediation analysis of a randomized multilevel intervention trial

Rural women experience disproportionately higher levels of obesity in comparison to their non-rural counterparts. The present exploratory mediation analysis sought to identify mechanisms that might have contributed to rural women's physical activity and diet changes after participating in a 6-month multilevel community-randomized trial: Strong Hearts, Healthy Communities (SHHC). SHHC was conducted in 16 rural towns in Montana and New York, between 2015 and 2016; 194 overweight, sedentary midlife, and older women (mean age 59; 26.8% overweight; 73.2% obese) participated. Participants in eight towns received the SHHC intervention (n = 101), which focused on healthy behavior change at the individual level as well as creating supportive social and built environments for physical activity and healthy eating. Participants in the other eight towns received an education-only control intervention (n = 93). We investigated the direct and indirect effects of the SHHC intervention through changes to self-efficacy, social support, and built environment perception, on changes in participants' physical activity and diet. Compared to the controls, SHHC intervention participants increased their social support from friends for physical activity (p = 0.009) and healthy eating (p = 0.032). Participants' improved social support from friends marginally mediated the intervention effects for walking metabolic equivalent minutes per week, explaining 40.5% of the total effect (indirect effect = +45.24, 95% CI: -1.51, +91.99; p = 0.059). Increasing social support from friends appears to be helpful in encouraging rural women to become more active. Further investigations are needed to better understand how multilevel interventions work in rural communities.

Community supported agriculture plus nutrition education improves skills, self-efficacy, and eating behaviors among low-income caregivers but not their children: a randomized controlled trial

Background

Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a ‘share’ of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children.

Methods

The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016–2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children’s diet quality, body mass index (BMI), and physical activity; caregivers’ nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed.

Results

No significant net effects on children’s dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers’ cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security.

Conclusions

Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security.

Trial registration

ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01168-x.

Making community-supported agriculture accessible to low-income families: findings from the Farm Fresh Foods for Healthy Kids process evaluation

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p = .005) than eligible nonenrollees (n = 243) and more likely to be female (p < .001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19-23). Median CSA pickup was 88% of the weeks (IQR: 40-100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 ("very useful"). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact.

Fruit and Vegetable Intake Assessed by Repeat 24 h Recalls, but Not by A Dietary Screener, Is Associated with Skin Carotenoid Measurements in Children

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

Associations of Number of Daily Eating Occasions with Type 2 Diabetes Risk in the Women's Health Initiative Dietary Modification Trial

BACKGROUND

Over 23 million Americans have type 2 diabetes (T2D). Eating habits such as breakfast consumption, time-restricted eating, and limiting daily eating occasions have been explored as behaviors for reducing T2D risk, but prior evidence is inconclusive.

OBJECTIVES

Our objectives were to examine associations between number of daily eating occasions and T2D risk in the Women's Health Initiative Dietary Modification Trial (WHI-DM) and whether associations vary by BMI, age, or race/ethnicity.

METHODS

Participants were postmenopausal women in the WHI-DM who comprised a 4.6% subsample completing 24-h dietary recalls (24HRs) at years 3 and 6 as part of trial adherence activities (n = 2159). Numbers of eating occasions per day were obtained from the year 3 24HRs, and participants were grouped into approximate tertiles as 1-3 (n = 795), 4 (n = 713), and ≥5 (n = 651) daily eating occasions as the exposure. Incident diabetes was self-reported on semiannual questionnaires as the outcome.

RESULTS

Approximately 15% (15.4%, n = 332) of the WHI-DM 24HR cohort reported incident diabetes at follow-up. Cox proportional hazards regression tested associations of eating occasions with T2D adjusted for neighborhood socioeconomic status, BMI, waist circumference, race/ethnicity, family history of T2D, recreational physical activity, Healthy Eating Index-2005, 24HR energy intake, and WHI-DM arm. Compared with women reporting 1-3 meals/d, those consuming 4 meals/d had a T2D HR = 1.38 (95% CI: 1.03, 1.84) without further increases in risk for ≥5 meals/d. In stratified analyses, associations for 4 meals/d compared with 1-3 meals/d were stronger in women with BMI <30.0 kg/m2 (HR = 1.55; 95% CI: 1.00, 2.39) and women aged ≥60 (HR = 1.61; 95% CI: 1.11, 2.33).

CONCLUSIONS

Four meals per day compared with 1-3 meals/d was associated with increased risk of T2D in postmenopausal women, but no dose-response effect was observed for additional eating occasions. Further studies are needed to understand eating occasions in relation to T2D risk.

Ripple Effects of a Community-Based Randomized Trial for Rural Women: Strong Hearts, Healthy Communities

OBJECTIVE

This study aimed to examine (1) whether the Strong Hearts, Healthy Communities intervention (SHHC) improved social network members' (SNMs') weight, exercise, and diet and (2) whether SNMs' weight and behavioral changes were modified by their relationship closeness and/or spatial closeness with trial participants.

METHODS

Eight towns received the SHHC intervention, which focused on building individual healthy behaviors and creating supportive social and built environments for exercise and healthy eating. Eight towns received an education-only control intervention. SNMs (n = 487) were recruited to complete a questionnaire at baseline and at 6 months that asked about demographics, weight, height, exercise, and eating habits.

RESULTS

SHHC's effect on SNMs differed depending on their relationship closeness with trial participants. Among SNMs who had a very close relationship with trial participants, those associated with the intervention group lost more weight and decreased BMI more than those associated with the control group (weight [kilograms] between-group difference: Δ = -1.68; 95% CI: -3.10 to -0.25; P = 0.021; BMI between-group difference: Δ = -0.60; 95% CI: -1.16 to -0.04; P = 0.034). Spatial closeness did not modify any of SHHC's ripple effects.

CONCLUSIONS

Relationship closeness, rather than spatial closeness, played an important role in influencing a rural community-based intervention's ripple effects.

The Strong Hearts, Healthy Communities Program 2.0: An RCT Examining Effects on Simple 7

INTRODUCTION

Rural women have higher rates of cardiovascular disease than their nonrural counterparts, partially because of their social and environmental contexts. The study objective is to test a refined version of the multilevel Strong Hearts, Healthy Communities intervention, which used extensive process and outcome evaluation data from the original randomized trial to optimize effectiveness as measured by improved Simple 7 score, a composite measure of cardiovascular disease risk.

STUDY DESIGN

The intervention was implemented in a 6-month, delayed intervention, community-randomized trial; control participants received the program following 24-week outcome assessment. The study was conducted in 2017-2018; data analysis occurred in 2018-2019.

SETTING/PARTICIPANTS

The study was conducted in 11 rural, medically underserved towns in New York. Participants were women aged ≥40 years who were either (1) obese or (2) overweight and sedentary.

INTERVENTION

The intervention group received 24 weeks of hour-long, twice-weekly classes including strength training, aerobic exercise, and skill-based nutrition- and health-related education, as well as civic engagement activities focused on healthy food and physical activity environments.

MAIN OUTCOME MEASURES

Measures included weight and height; blood pressure; blood cholesterol; blood glucose; and self-reported smoking, diet, and physical activity behaviors. Individual Simple 7 components were examined, and mixed linear regression analyses were used to examine change in Simple 7 score.

RESULTS

A total of 182 participants were randomized. Compared with control participants, the intervention group had greater improvements in Simple 7 score (difference=1.03, 95% CI=0.44, 1.61, p<0.001) and 3 of the Simple 7 components (physical activity, healthy diet score, and BMI).

CONCLUSIONS

These findings highlight the importance of rigorously evaluating programs in real-world community settings and, when appropriate, revising and retesting interventions to optimize dissemination potential.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03059472.

A Qualitative Evaluation of Double Up Food Bucks Farmers' Market Incentive Program Access

OBJECTIVE

Explore factors affecting access to and use of Double Up Food Bucks (DUFB), a farmers' market program that doubles Supplemental Nutrition Assistance Program benefits for use toward the purchase of fruits and vegetables (FV).

DESIGN

Focus groups.

SETTING

Metro and nonmetro counties in Utah and western Upstate New York.

PARTICIPANTS

Nine groups composed of 62 low-income adults (3-9/group).

PHENOMENA OF INTEREST

Satisfaction with, barriers to, and facilitators of program use; suggestions for improvement.

ANALYSIS

Transcribed verbatim and coded thematically in NVivo 11 software according to template analysis.

RESULTS

Program satisfaction was high and driven by FV affordability, perceived support of local farmers, positive market experiences, and high-quality FV. Primary barriers to using DUFB were lack of program information and inconvenient accessibility. Insufficient program communication was a consistent problem that elicited numerous suggestions regarding expansion of program marketing. Emergent topics included issues related to the token-based administration of DUFB and debate regarding stigma experienced during DUFB participation.

CONCLUSIONS AND IMPLICATIONS

Results suggest that although DUFB elicits many points of satisfaction among users, program reach may be limited owing to insufficient program marketing. Even among satisfied users, discussion of barriers was extensive, indicating that program reach and impact may be bolstered by efforts to improve program accessibility.

Postmenopausal Breast Cancer and Physical Function Change: A Difference-in-Differences Analysis

BACKGROUND/OBJECTIVES

While breast cancer and associated therapies can influence physical function (PF), findings for breast cancer's effects on PF among postmenopausal women are not consistent. This research evaluates the effect of breast cancer on change in PF.

DESIGN

Longitudinal cohort study analyzed using difference-in-differences (DID) method to compare the changes in PF over time between women with and without breast cancer, by invasive status, stage, and age.

SETTING AND PARTICIPANTS

Women's Health Initiative participants, aged 50 to 79 years at baseline, with four completed functional status assessments were eligible for inclusion (mean age = 62.1 ± 6.9 years). Women with breast cancer diagnosed between the 3rd and 11th enrollment year (n = 1636) were compared to women without breast cancer (n = 35 660).

MEASUREMENTS

PF was measured using the Medical Outcomes Study Short Form 36 at baseline and years 3, 11, and 12.

RESULTS

Compared with women without breast cancer, women with breast cancer experienced greater PF decline (P < .0001), after adjustment for age, race, education, income, study/trial arm, and body mass index. Overall, functional declines were greatest among women with invasive breast cancer (DID = -4.87; 95% confidence interval = -7.12 to -2.62). In stratified analyses, the breast cancer effect on PF was greater among women in older age groups.

CONCLUSION

Women diagnosed with breast cancer experienced a significant decline in PF beyond what is observed in typical aging in this cohort. To optimally address survivorship issues, disease sequelae need to be distinguished from normal aging in studies incorporating a cancer-free comparison group. J Am Geriatr Soc 68:1029-1036, 2020.

Serum carotenoids are strongly associated with dermal carotenoids but not self-reported fruit and vegetable intake among overweight and obese women

Background

Accurate assessment of fruit and vegetable intake (FVI) is essential for public health nutrition research and surveillance. Blood carotenoid concentrations are robust biomarkers of FVI, but collecting blood samples typically is not feasible in population-based studies. Understanding how well non-invasive measures compare to blood estimates is important for advancing surveillance and evaluation. The objective of this study was to examine the associations between serum carotenoids and four non-invasive measures of FVI in overweight and obese women.

Methods

This study utilized baseline data from 157 overweight or obese women (95.5% white, mean age 58.56 years ± 9.49 years) enrolled in the Strong Hearts, Healthy Communities randomized trial, including two direct measures of carotenoids and three self-reported measures of FVI. Participants completed a fasting blood draw, dermal carotenoid scans using resonance Raman spectroscopy (RRS), a two-item FVI screener modeled after the American Heart Association’s Life’s Simple 7 “My Life Check” tool (modified AHA tool), the National Cancer Institute’s All-Day Fruit and Vegetable Screener (FVS), multiple 24-h dietary recalls, physical measurements, and demographic and health behavior questions. We analyzed blood for total carotenoids and derived total FVI estimates from self-report tools. We used multivariate linear regression models to examine associations between each non-invasive tool and serum carotenoids under four scenarios analogous to different research contexts in which varying breadths of participant data are available. We also calculated adjusted Pearson’s correlations between serum carotenoids, dermal carotenoids, and the self-reported measures.

Results

Dermal carotenoids were strongly correlated with serum carotenoids (0.71, P < 0.00067) and associated with serum carotenoids in all regression models (0.42–0.43, P < 0.002). None of the self-reported FVI measures were significantly associated with serum or dermal carotenoids in adjusted regression models or correlation analyses.

Conclusions

Compared to self-reported FVI, we found dermal carotenoids measured by RRS to be a superior method to approximate serum carotenoids among overweight and obese women. More research is needed to investigate these assessment methods in diverse populations.

Trial registration

ClinicalTrials.gov Identifier: NCT02499731, registered July 16, 2015.

Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial

BACKGROUND

Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities.

METHODS

Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect.

RESULTS

At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027).

CONCLUSIONS

Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.