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.

Dissemination of healthy kids out of school principles for obesity prevention: A RE-AIM analysis.

Health-promoting behaviors for childhood obesity prevention are needed across multiple environments where children spend time, including out-of-school time (OST). Therefore Healthy Kids Out of School (HKOS) developed intervention strategies to promote three evidence-based principles (Drink Right, Move More, Snack Smart) for obesity prevention in OST. The strategies were developed with stakeholder input, disseminated, and evaluated (2012-2015) in two volunteer-led OST organizations, Boy Scouts of America (BSA) and 4-H, across three US states using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Mixed methods were used involving surveys, key informant interviews, and organizational-level data collection. Sixty out of 81 (74.1%) BSA districts and 4-H counties reaching 84,590 children (72% of children participating in BSA and 4-H in three states) adopted the strategies. 530 surveys completed by local OST leaders at baseline and 294 at follow-up showed the percentage of programs offering healthy beverages and opportunities for physical activity increased from baseline to follow-up (beverages 26% baseline, 35% follow-up, odds ratio (OR) 1.53; physical activity 31% baseline, 45% follow-up, OR 1.79; all p < 0.05). The increasing trend for healthy snacks was statistically non-significant (p = 0.09). Leaders interviewed reported the strategies were easy to implement, a good fit with their program, facilitated success, and they expected to maintain the changes. Integration of HKOS customized materials (BSA patch and 4-H pin) on BSA and 4-H national websites is a broader indicator of maintenance. Intervention strategies developed with stakeholder input and disseminated with training can effectively facilitate healthy environments for children, and have potential for national scale.

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.

A qualitative study of leadership characteristics among women who catalyze positive community change.

BACKGROUND: Leadership is critical to making changes at multiple levels of the social ecological model, including the environmental and policy levels, and will therefore likely contribute to solutions to the obesity epidemic and other public health issues. The literature describing the relative leadership styles and strengths of women versus men is mixed and virtually all research comes from sectors outside of public health. The purpose of this qualitative study is to identify specific leadership skills and characteristics in women who have successfully created change predominantly within the food and physical activity environments in their communities and beyond. The second purpose of this study is to understand best practices for training and nurturing women leaders, to maximize their effectiveness in creating social change. METHODS: Key informant interviews were conducted with 16 women leaders in the public health sector from November 2008 through February 2010. The sample represented a broad spectrum of leaders from across the United States, identified through web searches and through networks of academic and professional colleagues. Most were working on improving the food and physical activity environments within their communities. Questions were designed to determine leaders' career path, motivation, characteristics, definition of success, and challenges. The initial coding framework was based on the questioning structure. Using a grounded theory approach, additional themes were added to the framework as they emerged. The NVivo program was used to help code the data. RESULTS: Respondents possessed a vision, a strong drive to carry it out, and an ability to mobilize others around the vision. Their definitions of success most often included changing the lives of others in a sustainable way. Persistence and communications skills were important to their success. The mentoring they received was critical. Challenges included fundraising and drifting from their original mission. CONCLUSIONS: These findings may be used to help develop or inform a model of women's leadership in public health and to improve the training and nurturance of leaders who promote health in their communities and beyond.

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.

Reducing cardiovascular disease risk in sedentary, overweight women: strategies for the cardiovascular specialist.

PURPOSE OF REVIEW: To describe the issue of cardiovascular disease in women, and to discuss evidence-based strategies for promoting lifestyle changes to reduce risk in sedentary, overweight women. RECENT FINDINGS: Given a recent focus on long-term risk of cardiovascular disease, particularly for women, lifestyle change is especially important. Within practices, motivational interviewing holds promise as an effective counseling approach. Cardiologists may also refer women to evidence-based community programs designed to change diet and physical activity behaviors. SUMMARY: Increasing fitness, improving food intake, and weight control are key elements in prevention. Ideally, motivational interviewing and community-based programs will work synergistically, with health messages and change efforts mutually supported in both settings.

Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association.

OBJECTIVE: To issue a recommendation on the types and amounts of physical activity needed to improve and maintain health in older adults. PARTICIPANTS: A panel of scientists with expertise in public health, behavioral science, epidemiology, exercise science, medicine, and gerontology. EVIDENCE: The expert panel reviewed existing consensus statements and relevant evidence from primary research articles and reviews of the literature. PROCESS: After drafting a recommendation for the older adult population and reviewing drafts of the Updated Recommendation from the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) for Adults, the panel issued a final recommendation on physical activity for older adults. SUMMARY: The recommendation for older adults is similar to the updated ACSM/AHA recommendation for adults, but has several important differences including: the recommended intensity of aerobic activity takes into account the older adult's aerobic fitness; activities that maintain or increase flexibility are recommended; and balance exercises are recommended for older adults at risk of falls. In addition, older adults should have an activity plan for achieving recommended physical activity that integrates preventive and therapeutic recommendations. The promotion of physical activity in older adults should emphasize moderate-intensity aerobic activity, muscle-strengthening activity, reducing sedentary behavior, and risk management.

Factors related to leader implementation of a nationally disseminated community-based exercise program: a cross-sectional study.

BACKGROUND: The benefits of community-based health programs are widely recognized. However, research examining factors related to community leaders' characteristics and roles in implementation is limited. METHODS: The purpose of this cross-sectional study was to use a social ecological framework of variables to explore and describe the relationships between socioeconomic, personal/behavioral, programmatic, leadership, and community-level social and demographic characteristics as they relate to the implementation of an evidence-based strength training program by community leaders. Eight-hundred fifty-four trained program leaders in 43 states were invited to participate in either an online or mail survey. Corresponding community-level characteristics were also collected. Programmatic details were obtained from those who implemented. Four-hundred eighty-seven program leaders responded to the survey (response rate = 57%), 78% online and 22% by mail. RESULTS: Of the 487 respondents, 270 implemented the program (55%). One or more factors from each category - professional, socioeconomic, personal/behavioral, and leadership characteristics - were significantly different between implementers and non-implementers, determined by chi square or student's t-tests as appropriate. Implementers reported higher levels of strength training participation, current and lifetime physical activity, perceived support, and leadership competence (all p < 0.05). Logistic regression analysis revealed a positive association between implementation and fitness credentials/certification (p = 0.003), program-specific self-efficacy (p = 0.002), and support-focused leadership (p = 0.006), and a negative association between implementation and educational attainment (p = 0.002). CONCLUSION: Among this sample of trained leaders, several factors within the professional, socioeconomic, personal/behavioral, and leadership categories were related to whether they implemented a community-based exercise program. It may benefit future community-based physical activity program disseminations to consider these factors when selecting and training leaders.

Strong Hearts, Healthy Communities: A Community-Based Randomized Trial for Rural Women.

OBJECTIVE: The aim of this study was to evaluate a multilevel cardiovascular disease (CVD) prevention program for rural women. METHODS: This 6-month, community-based, randomized trial enrolled 194 sedentary rural women aged 40 or older with BMI ≥ 25 kg/m2 . Intervention participants attended 6 months of twice-weekly exercise, nutrition, and heart health classes (48 total) that included individual-, social-, and environment-level components. An education-only control program included didactic healthy lifestyle classes once a month (six total). The primary outcome measures were change in BMI and weight. RESULTS: Within-group and between-group multivariate analyses revealed that only intervention participants decreased BMI (-0.85 units; 95% CI: -1.32 to -0.39; P = 0.001) and weight (-2.24 kg; 95% CI: -3.49 to -0.99; P = 0.002). Compared with controls, intervention participants decreased BMI (difference: -0.71 units; 95% CI: -1.35 to -0.08; P = 0.03) and weight (1.85 kg; 95% CI: -3.55 to -0.16; P = 0.03) and improved C-reactive protein (difference: -1.15 mg/L; 95% CI: -2.16 to -0.15; P = 0.03) and Simple 7, a composite CVD risk score (difference: 0.67; 95% CI: 0.14 to 1.21; P = 0.01). Cholesterol decreased among controls but increased in the intervention group (-7.85 vs. 3.92 mg/dL; difference: 11.77; 95% CI: 0.57 to 22.96; P = 0.04). CONCLUSIONS: The multilevel intervention demonstrated modest but superior and meaningful improvements in BMI and other CVD risk factors compared with the control program.

Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association.

OBJECTIVE: To issue a recommendation on the types and amounts of physical activity needed to improve and maintain health in older adults. PARTICIPANTS: A panel of scientists with expertise in public health, behavioral science, epidemiology, exercise science, medicine, and gerontology. EVIDENCE: The expert panel reviewed existing consensus statements and relevant evidence from primary research articles and reviews of the literature. PROCESS: After drafting a recommendation for the older adult population and reviewing drafts of the Updated Recommendation from the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) for Adults, the panel issued a final recommendation on physical activity for older adults. SUMMARY: The recommendation for older adults is similar to the updated ACSM/AHA recommendation for adults, but has several important differences including: the recommended intensity of aerobic activity takes into account the older adult's aerobic fitness; activities that maintain or increase flexibility are recommended; and balance exercises are recommended for older adults at risk of falls. In addition, older adults should have an activity plan for achieving recommended physical activity that integrates preventive and therapeutic recommendations. The promotion of physical activity in older adults should emphasize moderate-intensity aerobic activity, muscle-strengthening activity, reducing sedentary behavior, and risk management.

The StrongWomen-Healthy Hearts program in Pennsylvania: RE-AIM analysis.

Dissemination of evidence-based programs is needed to reduce CVD risk among midlife and older women. The aim of this study is to examine the public health impact of StrongWomen-Healthy Hearts in Pennsylvania using the RE-AIM framework. Reach, adoption, implementation, and maintenance were assessed using qualitative and quantitative measures; effectiveness was assessed using a pretest-posttest within-participants design. Reach into the target population was 5 in 100,000. Compared to the target population, a greater percentage of participants were white, married, middle-class, and had a graduate degree. Effectiveness was demonstrated (weight loss -2.0 kg, p < 0.001). Adoption among trained leaders was high (83.3 %), as was fidelity in implementation (average score 9.3 of 10). No leaders maintained the program. To increase impact of the StrongWomen-Healthy Hearts Program, it will be important to lower the costs and modify the recruitment and training strategies to better reach low-income and minority women. Such strategies may also improve program maintenance.

The benefits of strength training for older adults.

Aging is associated with a number of physiologic and functional declines that can contribute to increased disability, frailty, and falls. Contributing factors are the loss of muscle mass and strength as age increases, a phenomenon called sarcopenia. Sarcopenia can result or be exacerbated by certain chronic conditions, and can also increase the burden of chronic disease. Current research has demonstrated that strength-training exercises have the ability to combat weakness and frailty and their debilitating consequences. Done regularly (e.g., 2 to 3 days per week), these exercises build muscle strength and muscle mass and preserve bone density, independence, and vitality with age. In addition, strength training also has the ability to reduce the risk of osteoporosis and the signs and symptoms of numerous chronic diseases such as heart disease, arthritis, and type 2 diabetes, while also improving sleep and reducing depression. This paper reviews the current research on strength training and older adults, evaluating exercise protocols in a variety of populations. It is clear that a variety of strength-training prescriptions from highly controlled laboratory-based to minimally supervised home-based programs have the ability to elicit meaningful health benefits in older adults. The key challenges as this field of exercise science moves forward are to best identify the most appropriate strength-training recommendations for older adults and to greatly increase the access to safe and effective programs in a variety of settings.

The StrongWomen Change Clubs: engaging residents to catalyze positive change in food and physical activity environments.

INTRODUCTION: The epidemic of obesity is a multifaceted public health issue. Positive policy and environmental changes are needed to support healthier eating and increased physical activity. METHODS: StrongWomen Change Clubs (SWCCs) were developed through an academic-community research partnership between researchers at Cornell University and Tufts University and community partners (cooperative extension educators) in rural towns in seven U.S. states. Extension educators served as the local leader and each recruited 10-15 residents to undertake a project to improve some aspect of the nutrition or physical activity environment. Most residents had limited (or no) experience in civic engagement. At 6 and 12 months after implementation, the research team conducted key informant interviews with SWCC leaders to capture their perceptions of program process, benchmark achievement, and self-efficacy. RESULTS: At 12 months, each SWCC had accomplished one benchmark; the majority had completed three or more benchmarks. They described common processes for achieving benchmarks such as building relationships and leveraging stakeholder partnerships. Barriers to benchmark achievement included busy schedules and resistance to and slow pace of change. CONCLUSION: Findings suggest that community change initiatives that involve stakeholders, build upon existing activities and organizational resources, and establish feasible timelines and goals can successfully catalyze environmental change.