Health equity in action: using community-engaged research to update an intervention promoting a healthy home food environment to Black/African American families.

PURPOSE: Describe the method for conducting community-engaged research to identify needed changes for an existing evidence-based intervention, and prepare it for implementation in a community setting within the Dan L Duncan Comprehensive Cancer Center catchment area in an effort to achieve more equitable outcomes in diet-related disease risk factors. METHODS: The intervention, Family Eats, was developed over 10 years ago. It works directly with parents of Black/African American 9-12 year old children to create a healthy home food environment to support prevention of obesity and related cancers. Data collection with community stakeholders occurred through a series of  Community Advisory Board (CAB) meetings guided by the Delphi Technique, an iterative approach for gaining group consensus on a topic. RESULTS: Key information on needed changes and potential implementation strategies were identified. Perceived level of engagement among CAB members was high overall and in terms of both quantity and quality. CONCLUSION: The Delphi Technique shows promise as a method for conducting community-engaged research that promotes engagement and identifies key information needed to adapt and implement an existing intervention in a community setting.

Development of a Nutrition Education Intervention for Food Bank Clients.

The focus of this article is the development of a nutrition education intervention for food bank clients. Formative research using mixed-methods (qualitative and quantitative) and community-based participatory research principles was conducted to assess the nutrition education needs of clients obtaining service from the Houston Food Bank (HFB). Participants were HFB and pantry staff and clients. Interview data were coded and analyzed using grounded theory approach. Themes were then identified. Quantitative data were analyzed for frequencies and descriptives. Data were used to tailor the curriculum to the target population. Six HFB staff, 49 pantry staff from 17 pantries, and 54 clients from 10 pantries participated in interviews and focus groups and completed questionnaires. The participants provided opinion on the current nutrition education provided via the food bank and made suggestions on strategies for development of an intervention. Their feedback was used to develop the six-session intervention curriculum to be delivered over 6 months. This research provides evidence that it is critical for members of the target audience be included in formative research to develop behavior change programs that are relevant and appealing and target their needs and interests.

Supplemental Nutrition Assistance Program participation did not help low income Hispanic women in Texas meet the dietary guidelines.

OBJECTIVE: Low-income Hispanic women are at greater risk for dietary deficiencies and obesity. We assessed the association between Supplemental Nutrition Assistance Program participation and dietary intake among 661 Hispanic women aged 26-44 years living in Texas. METHODS: Cross-sectional data was collected using standard methods. Analysis of variance and logistic regression examined the influence of Supplemental Nutrition Assistance Program on diet after adjusting for household characteristics, body mass index, and food security status. RESULTS: Most women did not meet recommended dietary guidelines. Supplemental Nutrition Assistance Program participants consumed higher amounts of total sugars, sweets-desserts, and sugar-sweetened beverages than Supplemental Nutrition Assistance Program nonparticipants. High sodium intakes and low dairy consumption were observed in both groups. Only 27% of low-income eligible women received Supplemental Nutrition Assistance Program benefits. DISCUSSION: Low-income Hispanic women participating in Supplemental Nutrition Assistance Program reported less healthful dietary patterns than nonparticipants. This may contribute to the increased obesity prevalence and related comorbidities observed in this population. CONCLUSION: Supplemental Nutrition Assistance Program should play an important role in enhancing the overall dietary quality of low-income households. Policy initiatives such as limiting the purchase of sugar-sweetened beverages and education to enable women to reduce consumption of high sodium processed foods deserve consideration as means to improve the dietary quality of Supplemental Nutrition Assistance Program participants. Effective measures are needed to increase Supplemental Nutrition Assistance Program participation rates among Hispanics.

Relationship between Food Security, Nutrition Security, and Diabetes: The Role of Supplemental Nutrition Assistance Program Participation.

Background: Inadequate nutrition and poor diet quality are associated with a heightened risk of diabetes. The connection between food insecurity measures and diabetes has been established, with evidence indicating that Supplemental Nutrition Assistance Program (SNAP) participation contributes to reductions in food insecurity. Recently developed nutrition security measures, defined as the ability to acquire healthful foods to prevent diseases, and their association with diabetes and SNAP participation are not yet understood. Objectives: This study aimed to assess the relationship between food security and nutrition security in relation to diabetes overall and by SNAP participation and nutrition security as potential modifiers. Methods: Secondary data analysis of cross-sectional pilot study data collected from adults in 5 US states (N = 517). Logistic regression mixed models included moderation analysis and clustering effects by state to address site-level confounding. Results: Higher nutrition security scores among adults, after adjusting for confounders, were significantly associated with lower odds of diabetes risk (adjusted odds ratio = 0.59; 95% confidence interval: 0.40, 0.87; P value = 0.008). Statistically significant interaction effect of differences according to SNAP participation was observed for nutrition security (Phomogeneity/interaction = 0.021), adjusting for age, gender, race/ethnicity, education, employment, National School Lunch Program, Special Supplemental Nutrition Program for Women, Infants, and Children, food pantry use, household with children, survey mode, and food security. The association between food security and diabetes was not statistically significant overall. However, statistically significant interaction effect of differences according to SNAP participation was observed for food security (Phomogeneity/interaction = 0.047). Further, no interaction effect of differences in nutrition security was found between food security and self-reported diabetes/prediabetes (Phomogeneity/interaction = 0.250). Conclusions: This study sheds light on the early exploration of the intricate relationship between nutrition security and diabetes. The findings suggest that a higher nutrition security score, after adjusting for confounders, was significantly associated with lower odds of diabetes risk. Notably, there were statistically significant interaction effects in these associations based on SNAP participation.

Community-Based Participatory Obesity Prevention Interventions in Rural Communities: A Scoping Review.

Child obesity is a worldwide public health concern. In America, children from rural areas have greater odds of obesity in comparison to those from urban areas. Community-engaged research is important for all communities, particularly under-represented communities. This paper reports the results of a scoping review investigating community-engaged research in obesity prevention programs tested with school-aged children in rural America. A literature search of Medline Ovid was conducted to identify interventions reporting the results of obesity prevention interventions that promoted a healthy diet or physical activity (PA) behaviors to school-age children in rural communities of the United States (US). After title and abstract review, potentially relevant citations were further examined by assessing the full text. Each stage of review was conducted by two independent reviewers. Twelve studies met the inclusionary criteria and are included in this review. Most of the studies focused on elementary school participants (n = 7) and improving both diet and PA (n = 9). Out of the twelve studies, only five included the target audience in intervention development or implementation. The most popular type of community engagement was community participation (n = 4). This review revealed that community-engaged research is under-utilized in obesity prevention interventions tested with school-aged children in rural US communities.

Urban-Rural Disparities in Food Insecurity and Weight Status among Children in the United States.

Place of residence (urban versus rural) is a contextual determinant of health that has received less attention in the food insecurity literature. The purpose of this study was to assess the urban-rural disparity in the prevalence of food insecurity and weight status among US children. Using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2016 with three age groups of children (2-5, 6-11, and 12-17 years old), the associations of weight status and child and household food security status by urban-rural residence were examined using Rao-Scott Chi-square tests. Statistical significance was set at p < 0.05. Children living in urban areas were significantly more likely to experience household food insecurity (29.15%) compared to their rural counterparts (19.10%), among those aged 6-11 years. The associations between children's weight status and child and household food security status were significant for children living in urban areas overall and different age groups but not for children living in rural areas. These trends were more pronounced in older age groups. Given the link between food insecurity and higher obesity rates, particularly among urban children, this study highlights the importance of incorporating food security interventions into future obesity prevention programs.

Regional Variability in the Prevalence of Food Insecurity and Diet Quality among United States Children.

Understanding the association between food security status (FSS) and diet quality in children is crucial. This study investigated regional variability in FSS, participation in the federal nutrition assistance program (FNAP), and diet quality among US children. National Health and Nutrition Examination Survey (NHANES) data from 2013 to 2016 were analyzed. The association between FSS, FNAP participation, and diet quality (Healthy Eating Index-HEI-2015) was assessed using multiple linear/logistic regression models. The sample included 6403 children (mean age: 7.5 years; 51% male; 33% Hispanic). Within the sample, 13% reported child food insecurity, and 30% reported household food insecurity. Additionally, 90% participated in the FNAP, and 88% were enrolled in school lunch programs. Children in urban areas were significantly more likely to report household food insecurity than those in rural areas (29.15% vs. 19.10%). The overall HEI-2015 score was 48.2. The associations between child/household FSS and FNAP participation as well as between child/household FSS and diet quality did not differ by urban/rural residence status, irrespective of the children's age groups. There is a need for improvement in children's diet quality, regardless of age or urban/rural residence. The findings suggest that improving children's diets requires broader action as well as the prioritizing of children in urban areas experiencing food insecurity in future dietary interventions.

Dietary Sodium and Potassium Patterns in Adults with Food Insecurity in the Context of Hypertension Risk.

Background: Food insecurity (FIS), characterized by the lack of consistent access to nutritious food, is associated with hypertension and adverse health outcomes. Despite evidence of a higher prevalence of hypertension (HTN) in patients living with FIS, there is limited data exploring the underlying mechanism. Methods: We conducted a cross-sectional analysis of 17,015 adults aged 18-65 years, using dietary recall data from the National Health and Nutrition Examination Survey (2011-2018). Univariate and multivariable analyses were used to examine the association between FIS, HTN, and dietary sodium and potassium levels. Results: Individuals reporting FIS had a significantly lower mean intake of potassium (2.5±0.03 gm) compared to those in food-secure households (2.74±0.02 gm). No significant difference was found in the mean dietary sodium intake based on food security status. Non-Hispanic Black participants showed a high prevalence of HTN and FIS. While Non-Hispanic White and Hispanic participants had a high prevalence of FIS, it did not appear to influence their risk of HTN. Conclusions: Adults with FIS and HTN were more likely to report a lower dietary potassium intake. Increasing access to healthy foods, particularly potassium-rich foods, for individuals facing FIS, may contribute to reducing the HTN prevalence and improving cardiovascular outcomes.

See Me, Hear Me, Know Me: Perspectives on Diet and Physical Activity Influences among Teens Living in Rural Texas Communities.

Teens in rural communities are at greater risk of obesity than teens in urban areas. Diet and physical activity influence obesity risk. Understanding their perspectives is an important step in intervention design. This qualitative investigation explored teen perspectives on how living in a rural community influenced their diet and physical activity choices. Forty parent-teen pairs were recruited. Data collection included surveys and telephone interviews. This paper reports teen perspectives identified in the first interview. Thematic analysis was used to code and analyze the data. Findings revealed that the primary factor driving teens' diet and physical activity behaviors was the teens themselves. They clearly understood their role in the choices they made, although they acknowledged not always making the healthiest choice. This belief was driven by their motivation to engage in healthy behaviors, which was influenced by the perceived benefits derived from making healthy choices and from the synergistic relationship between diet and physical activity. Diet and physical activity, in turn, were influenced by the environment, particularly the home, social, and community environments. Family and friends were particularly influential, as well as resource availability. These findings can serve as a foundation for designing interventions tailored to this population.

Fruit and Vegetable Intake and Home Nutrition Environment among Low-Income Minority Households with Elementary-Aged Children.

Racial/ethnic and socioeconomic differences were shown to have an influence on child fruit and vegetable intake. This study examined the associations between parent and child fruit and vegetable intake and the home nutrition environment among Hispanic/Latino and African American families. Through a cross-sectional study design, self-reported surveys (n = 6074) were obtained from adult-child dyad participants enrolled in Brighter Bites, an evidence-based health promotion program, in the fall of 2018. For every once/day increase in frequency of parent FV intake, there was an increase in child FV intake by 0.701 times/day (CI: 0.650, 0.751, p < 0.001) and 0.916 times/day (CI: 0.762, 1.07; p < 0.001) among Hispanic/Latinos and African Americans, respectively. In Hispanic/Latino participants, significant positive associations were found between fruits as well as vegetables served at mealtimes ≥3 times/week (p < 0.001), family mealtimes 7 times/week (p = 0.018), parent-child communication about healthy eating and nutrition at least sometimes during the past 6 months (p < 0.05), and frequency of child FV intake, after adjusting for covariates. In African American participants, a significant positive association was found in fruits served at mealtimes ≥1 times/week (p < 0.05), and vegetables served at mealtimes ≥5 times/week (p < 0.05). Meals cooked from scratch a few times a day/all the time were significantly positively associated with frequency of child FV intake for both Hispanic/Latino (p = 0.017) and African American (p = 0.007) groups. The relationship between home nutrition environment and child FV intake varied by race and ethnicity. Future programs should consider designing culturally tailored interventions to address racial/ethnic-specific influences that match the child's race, culture, and ethnicity.

Diet Quality among Pre-Adolescent African American Girls in a Randomized Controlled Obesity Prevention Intervention Trial.

Consuming an unhealthy diet increases health risks. This study assessed the impact of a culturally adapted behaviorally innovative obesity prevention intervention (The Butterfly Girls and the Quest for Founder's Rock) on diet quality in pre-adolescent non-Hispanic Black/African American girls. The RCT consisted of three groups (experimental, comparison, and waitlist control); block randomization allocated participants to each group. The two treatment groups varied in terms of whether or not they set goals. Data were collected at baseline (prior to receiving the intervention), post 1 (3 months post-baseline), and post 2 (6 months post-baseline). Two dietitian-assisted 24 h dietary recalls were collected at each timepoint. Healthy Eating Index 2015 (HEI-2015) was used to determine diet quality. A total of 361 families were recruited; 342 completed baseline data collection. No significant differences in overall HEI score or component scores were observed. To attain more equitable health outcomes, future efforts to promote dietary intake change among at-risk children should explore other behavior change procedures and employ more child-friendly dietary assessment methods.

Dietary Intake among Children Attending Childcare Centers: Impact of the New CACFP Meal Guidelines.

Through the Healthy, Hunger-Free Kids Act of 2010, USDA (US Department of Agriculture) made the first major changes in the CACFP (Child and Adult Care Food Program) meal and snack menu patterns. Childcare centers that serve low-income families qualify to participate and receive reimbursement for meals and snacks served. The purpose of this study was to assess what changes in children's dietary behaviors occurred as a result of the new CACFP meal pattern requirements. This study evaluated these changes at childcare centers operating in Houston and San Antonio, Texas, USA, areas enrolled in the CACFP, pre- (Spring 2016) and post-implementation (Fall 2016-Spring 2017) of the new meal patterns. Dietary intake was assessed via observations of children, 3-5 years old, conducted at breakfast, lunch, and snack times. Results showed improvements in adjusted means of several nutrients and food groups consumption, post-implementation of new CACFP meal guidelines compared to baseline, specifically intake of whole grains, milk, and juice. Additional studies are needed to confirm the impact of the revised CACFP meal patterns along with strategies to assist providers in meeting the new standards to increase the access to and intake of items in accordance with the CACFP meal pattern requirements in childcare settings.

Implementation of a food scholarship program improves nutrient intake and dietary quality of college students.

Objective: To determine the impact of a new food scholarship program on nutrient intake and dietary quality. Participants: College students (n = 49), female (78%), single (76%), average age 28 years, and white (49%). Methods: Fruits, vegetables, dairy, meat products and nonperishable foods were distributed twice a month. A one-group pretest post-test intervention compared baseline and 10 weeks data. Food security was measured and three-day food records assessed nutrient intake, Health Eating Index (HEI)-2015 (total and component) scores, and food group servings. Paired t-test at baseline and 10 weeks were performed (SPSS v25) (p < 0.05). Results: Prevalence of food insecurity did not change (baseline 53%, 10 weeks 47%). Protein, (p = 0.001), niacin (p = 0.002), magnesium (p = 0.034), phosphorous (p = 0.039), potassium (p = 0.019), and vegetable servings (p = 0.034) intake increased. Total HEI-2015 scores remained unchanged but HEI-2015 vegetable scores increased (p = 0.023). Conclusion: Increased intake of some nutrients and vegetable servings were achieved with the food scholarship program.

Food Insecurity among Low-Income Households with Children Participating in a School-Based Fruit and Vegetable Co-Op.

The purpose of this study was to evaluate the impact of a nutrition intervention on food insecurity among low-income households with children. Data were collected from 371 parent−child dyads in a quasi-experimental evaluation study of a 1-year intervention (n = 6 intervention schools receiving Brighter Bites, n = 6 wait-list control schools), and longitudinal follow-up of the intervention group 2 years post-intervention in Houston, Texas. Data were collected at three timepoints: at baseline and 1 year for all participants, and at 2 year follow-up for the intervention group (the wait-list control group received the intervention during that time). At baseline, most parents reported food insecurity (60.6%; 70% intervention group, 53.6% control). Food insecurity decreased significantly from 81.3% to 61.7% [(−0.32, −0.07) p = 0.002] among intervention participants immediately post-intervention. After adjusting for ethnicity, 2 years post-intervention the predicted percentage of participants reporting food insecurity decreased significantly by roughly 35.4% from 76.4% at baseline to 41.0% [(−0.49, −0.22), p < 0.001]. Between-group changes were not significant. The re-sults of this study demonstrated a significant positive impact of Brighter Bites on food security in the short and long-term among low-income households with children, albeit results should be in-terpreted with caution.

Fruit and Vegetable Shopping Behavior and Intake among Low-Income Minority Households with Elementary-Aged Children.

Low-income children and families do not meet the recommendations for fruit and vegetable (FV) intake. This study aimed to assess the association between FV shopping behavior and child FV intake through a cross-sectional study design analyzing self-reported surveys (n = 6074) from adult-child dyads of Hispanic/Latino and African American participants enrolled in the Brighter Bites co-op program. Through quantitative mixed effects linear regression models, accounting for school-level clustering and adjusting for covariates, child FV intake was positively associated with shopping for FV at large chain grocery stores (p < 0.001), natural/organic supermarkets (p < 0.001), warehouse club stores (p = 0.002), discount superstores (p < 0.001), small local stores/corner stores (p = 0.038), convenience stores (p = 0.022), ethnic markets (p = 0.002), farmers' markets/co-op/school farm stands (p < 0.001), and gardens (p = 0.009) among Hispanic/Latinos participants. Among African American participants, there was significant positive association between child FV intake and shopping for FV at natural/organic supermarkets (p < 0.001), discount superstores (p = 0.005), and convenience stores (p = 0.031). The relationship between location and frequency of shopping for FV and child FV intake varied between races. Further research is needed to better understand the influence of cultural and physical environmental factors. Nutrition education programs are vital to encouraging families to make healthier food choices and purchases to improve child FV consumption.

Middle-school students' school lunch consumption does not meet the new Institute of Medicine's National School Lunch Program recommendations.

OBJECTIVE: To compare the school lunch consumption of Texas middle-school students with the 2009 Institute of Medicine's (IOM) school meal report recommendations. These new lunch menu patterns increase fruit to one serving and vegetables to two servings, with 50 % wholegrain food. DESIGN: Lunch food records were collected from middle-school students from four schools in south-east Texas in the spring of 2008, and entered into the Nutrition Data System for Research software. Average intake was calculated for those consuming meals according to the National School Lunch Program (NSLP; n 5414) and for those consuming lunch from other sources (n 239). The percentage of students selecting each food group was calculated. SETTING: Middle schools in south-east Texas. SUBJECTS: Middle-school students in south-east Texas. RESULTS: Students consuming NSLP meals reported consuming almost 1/2 serving of fruit, 3/4 serving of vegetables, 8 oz of milk and 1/3 serving of whole grains at lunch. Non-NSLP consumers reported almost no intake of fruit, vegetables or milk, and consumed 1/4 serving of whole grains at lunch. Among NSLP consumers, about 40% selected and consumed a fruit serving. About two-thirds of students selected a vegetable, consuming about 67 %. Less than 4% selected a dark green or orange vegetable. CONCLUSIONS: Students' lunch intake did not meet the new IOM recommendations. Few students selected dark green or orange vegetables, and only 40 % selected fruit. Whole grains consumption was low. Interventions with all stakeholders will be necessary to improve students' food and beverage selections overall when school meal patterns are revised.

Gender Differences in Nutritional Quality and Consumption of Lunches Brought from Home to School.

Gender difference in the lunches brought from home to school and the amount consumed by elementary and intermediate school students were examined using data collected from 12 schools in Texas. The amount and nutritional quality of food items brought and consumed was evaluated, by comparing the results to the 2012 school meal standards, and Dietary Reference Intakes (DRIs). Almost all lunches brought from home contained grain and meat/meat alternatives, and the amount brought and consumed exceeded the NSLP standards. The majority of students did not bring fruits, vegetables, and whole grain foods, but those who brought consumed most of what they brought. Among elementary school students, only 9% of boys and 14% of girls brought vegetables and the amount brought and consumed did not meet the standards. Although carbohydrate and protein consumption were adequate for boys and girls, the intakes of micronutrients and fiber did not meet the requirements across both genders at both school levels. Overall, lunches brought from home were not well balanced and did not meet NSLP standards and DRIs. It is imperative to identify strategies to improve the nutritional quality of lunches brought from home considering gender difference in food choice and educating parents and children on what is a healthy well-balanced lunch.

Did School Meal Programs and SNAP Participation Improve Diet Quality of US Children from Low-Income Households: Evidence from NHANES 2013-2014?

Nutrition assistance programs such as school meals and the Supplemental Nutrition Assistance Program (SNAP) are designed to provide a safety net for the dietary intake of children from low-income families. However, compared with eligible non-participants, the relationship of diet quality with school meals only and school meals + SNAP is not well understood. The objectives of the study include: (1) To explore whether and to what extent nutrition assistance program participation (school meals only and school meals + SNAP) is related to diet quality; and (2) to examine the differences of diet quality between participating in school meals only, school meals + SNAP, or non-participation among American children. Children aged 5 to 18 years old from income eligible households who participated in the 2013-2014 National Health and Nutrition Examination Survey (NHANES) were included in this cross-sectional study (n = 1425). Diet quality was measured using the Healthy Eating Index (HEI)-2015 and its 13 subcomponents. A Rao-Scott Chi-square test, propensity scores approach, and Analysis of Covariance were performed. Covariates included age, sex, race/ethnicity, weight status, and family monthly poverty index. SAS survey procedures were used to incorporate the appropriate sample design weights. Participation in school meals + SNAP was not associated with higher diet quality compared to eligible non-participants or school meals-only participants. Participation in school meals + SNAP improved the intake of total dairy, but not added sugars or total vegetables compared to school meals only. Overall, school meal + SNAP participation did not significantly improve the overall diet quality of children in low-income households relative to comparable non-participants.

The Impact of the COVID-19 Pandemic on Food Distribution at Emergency Food Assistance Organizations in the Southwestern United States: A Qualitative Investigation.

This study aimed to identify changes in food distribution operations at emergency food assistance organizations (EFAOs) during the COVID-19 pandemic. EFAOs across the Houston metro area, TX (human service centers and food pantries) as well as the Houston Food Bank (HFB) participated in the qualitative study. Data were collected via individual semi-structured interviews and focus group (December 2020-February 2021), and coded using semi-structured thematic analysis. Categories were pre-identified based on the interview questions. Direct quotes supported subcategories. Directors from 18 EFAOs were interviewed; 8 HFB leadership staff participated in a focus group. Four major categories of change due to COVID-19 included new safety measures, changes in food distribution process, changes in volunteerism and staffing, and changes in amounts of food distributed. This study helps identify susceptibilities in EFAOs' food distribution chain should be addressed to manage future emergency food insecurity crises more effectively. An understanding of the changes/challenges incurred by EFAOs during the COVID-19 pandemic can inform policymakers to ensure local food distribution organizations are prepared to fill the needs during future a crisis of food insecurity.

Family-Based Obesity Prevention Interventions among Hispanic Children and Families: A Scoping Review.

This scoping review examined intervention and sample characteristics of family-based obesity prevention interventions among Hispanic youth. This review also examined the degree to which existing interventions were culturally-adapted, acknowledged social determinants of health (SDoH), and collaborated with community stakeholders. A comprehensive search across Medline Ovid, Embase, Scopus, PsycInfo, and Pubmed was used to identify 13 studies primarily based in the U.S. (92.3%). Data was extracted by two independent reviewers. Most used a randomized control trial design (69.2%), a behavior change theory (84.6%), and reported moderate to high (≥70%) retention (69.2%). Studies targeted improvements in physical activity (69.2%) and fruit and vegetable intake (92.3%) through nutrition education, cooking demonstrations, and tastings. Younger children from low socioeconomic backgrounds (61.5%) were well represented. Most interventions were culturally-adapted (69.2%), all studies reported collaboration with stakeholders, yet only half used strategies that acknowledged SDoH (46.2%). To increase our understanding of the underlying mechanisms by which family-based approaches can reach and engage Hispanic youth and families, future studies should rigorously evaluate theoretical constructs, family processes, and SDoH that influence program participation and health behaviors. This information will guide the design and development of future interventions aimed at reducing obesity disparities among Hispanic youth.