A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice.

BACKGROUND: Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. METHODS: Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. RESULTS: Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black (n = 46), 48.2% rural (n = 54), 4.5% uninsured (n = 5), and 6.3% Medicaid-insured (n = 7) patients. Median visit time was 97 min (95% CI 70-107 min) before and 100 min after implementation (95% CI 75-119 min; p = 0.95). In total, 95.5% (n = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. CONCLUSIONS: Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.

Examining Potential Modifiers of Human Skin and Plasma Carotenoid Responses in a Randomized Trial of a Carotenoid-Containing Juice Intervention.

BACKGROUND: Skin carotenoid measurements are emerging as a valid and reliable indicator of fruit and vegetable intake and carotenoid intake. However, little is known about the extent to which skin carotenoid responsivity to dietary changes differs based on demographic and physiologic characteristics. OBJECTIVES: This study examined potential effect modifiers of skin carotenoid and plasma carotenoid responses to a carotenoid-rich juice intervention. METHODS: We leveraged data from 2 arms of a 3-site randomized controlled trial of a carotenoid-containing juice intervention (moderate dose = 6 ounces juice, 4 mg total carotenoids/d, high dose = 12 ounces juice, 8 mg total carotenoids/d) (n = 106) to examine effect modification by age, self-categorized race/ethnicity, biological sex, baseline body fat, body mass index, skin melanin, skin hemoglobin, skin hemoglobin saturation, skin coloration, sun exposure, and baseline intake of carotenoids from foods. Skin carotenoid concentrations were assessed using pressure-mediated reflection spectroscopy (Veggie Meter), and plasma carotenoid concentrations were measured using high-performance liquid chromatography. RESULTS: In bivariate analyses, among the high-dose group (8 mg/d), those of older age had lower skin carotenoid responsiveness than their younger counterparts, and those with greater hemoglobin saturation and lighter skin had higher skin carotenoid score responsiveness. In the moderate-dose group (4 mg/d), participants from one site had greater plasma carotenoid responsiveness than those from other sites. In multivariate analyses, participants with higher baseline skin carotenoids had smaller skin carotenoid responses to both moderate and high doses. CONCLUSIONS: Changes in skin carotenoid scores in response to interventions to increase fruit and vegetable intake should be interpreted in the context of baseline skin carotenoid scores, but other variables (e.g., self-categorized race/ethnicity, biological sex, baseline body fat, body mass index, skin melanin, and sun exposure) do not significantly modify the effect of carotenoid intake on changes in skin carotenoid scores. This trial was registered at clinicaltrials.gov as NCT04056624.

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 .

Pressure-Mediated Reflection Spectroscopy Criterion Validity as a Biomarker of Fruit and Vegetable Intake: A 2-Site Cross-Sectional Study of 4 Racial or Ethnic Groups.

BACKGROUND: Valid biomarkers of fruit and vegetable (FV) intake are needed for field-based nutrition research. OBJECTIVES: To examine criterion-related validity of pressure-mediated reflection spectroscopy as a proxy measure of FV intake, using plasma carotenoids and self-reported FV and carotenoid intake as primary and secondary criterion measures, respectively. METHODS: Healthy adults 18-65 y of age, self-identifying as African American/black (n = 61), Asian (n = 53), white (n = 70), or Hispanic (n = 29), in North Carolina and Minnesota were recruited. Skin carotenoids were assessed via pressure-mediated reflection spectroscopy (Veggie Meter), skin melanin via spectrophotometer, and total plasma carotenoid concentration by HPLC-photodiode array detection. Self-reported carotenoid and FV intake was assessed using a semiquantitative FFQ. Relations between skin carotenoids, plasma carotenoids, FV, and carotenoid intake, with differences by race or ethnicity, age, sex, weight status, cholesterol, and melanin index, were examined by bivariate correlations and adjusted multivariate linear regressions. RESULTS: The overall unadjusted correlation between skin and total plasma carotenoids was r = 0.71 and ranged from 0.64 (non-Hispanic black) to 0.80 (Hispanic). Correlations between skin carotenoids and self-reported FV intake ranged from 0.24 (non-Hispanic black) to 0.53 (non-Hispanic white), with an overall correlation of r = 0.35. In models adjusted for age, sex, racial or ethnic group, and BMI, skin carotenoids were associated with plasma carotenoids (R2 = 0.55), FV (R2 = 0.17), and carotenoid intake (R2 = 0.20). For both plasma carotenoid and FV measures, associations with skin carotenoids did not vary by race, but these relations did differ by skin melanin-those with lower melanin had a lower correlation between skin and plasma carotenoids. CONCLUSIONS: Reflection spectroscopy-assessed skin carotenoids may be a reasonable alternative to measurement of plasma carotenoids, a biomarker used to approximate FV intake.

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.

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.

A four-year observational study to examine the dietary impact of the North Carolina Healthy Food Small Retailer Program, 2017-2020.

BACKGROUND: The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016-2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers' purchases and diets. METHODS: Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017-2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases ("bag checks"); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores. RESULTS: There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1-12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores' HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores. CONCLUSIONS: Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Perceptions of nutrition education classes offered in conjunction with a community-supported agriculture intervention among low-income families.

OBJECTIVE: To examine participants' experiences with nutrition education classes that were implemented with and designed to complement a cost-offset community-supported agriculture (CSA) programme. DESIGN: Qualitative analysis of data from twenty-eight focus groups with ninety-six participants enrolled in Farm Fresh Foods for Healthy Kids (F3HK). Transcribed data were coded and analysed by a priori and emergent themes. SETTING: Rural and micropolitan communities in New York, North Carolina, Vermont and Washington (USA). PARTICIPANTS: Ninety-six F3HK participants. RESULTS: Participants found recipes and class activities helpful and reported improvements in nutrition knowledge, food preservation skills and home cooking behaviours for themselves and their children; they also reported that classes promoted a sense of community. Some educators better incorporated CSA produce into lessons, which participants reported as beneficial. Other obligations and class logistics were barriers to attendance; participants recommended that lessons be offered multiple times weekly at different times of day. Other suggestions included lengthening class duration to encourage social engagement; emphasising recipes to incorporate that week's CSA produce and pantry staples and offering additional strategies to incorporate children in classes. CONCLUSION: Complementing a cost-offset CSA with nutrition education may enhance programme benefits to low-income families by improving nutrition knowledge and cooking behaviours. However, future interventions will benefit from ongoing coordination between educators and local growing trajectories to maximise timely coverage of unfamiliar produce in lessons; synchronous scheduling of CSA pick-up and classes for participant convenience and creative strategies to engage children and/or provide childcare.

Perceived barriers and facilitators to participating in the North Carolina Healthy Food Small Retailer Program: a mixed-methods examination considering investment effectiveness.

OBJECTIVE: The North Carolina Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP. DESIGN: The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners. SETTING: Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP. PARTICIPANTS: Owners of corner stores participating in the HFSRP. RESULTS: All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment. CONCLUSIONS: All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts.

BACKGROUND: The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers. METHODS: Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code. RESULTS: Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases. CONCLUSIONS: Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Comparison of food and beverage products' availability, variety, price and quality in German and US supermarkets.

OBJECTIVE: To assess availability, variety, price and quality of different food products in a convenience sample of supermarkets in Germany and the USA. DESIGN: Cross-sectional study using an adapted version of the Bridging the Gap Food Store Observation Form. SETTING: Information on availability, quality, price and variety of selected food products in eight German and seven US supermarkets (discount and full service) was obtained and compared by country. RESULTS: A general tendency for lower prices of fruits and vegetables in Germany was observed, while produce quality and variety did not seem to differ between countries, with the exception of the variety of some vegetables such as tomatoes. Chips and cereals did not differ significantly in variety nor price. In both countries, high energy-dense foods were lower in energy costs than lower energy-dense foods. CONCLUSIONS: The influence of food prices and availability on consumption should be further explored, including the impact of country differences.

Associations between shopping patterns, dietary behaviours and geographic information system-assessed store accessibility among small food store customers.

OBJECTIVE: To examine associations between geographic information systems (GIS)-assessed accessibility to small food stores, shopping patterns and dietary behaviours among small food store customers. DESIGN: Residential addresses and customer shopping patterns (frequency of shopping, and previous purchase of fruits and vegetables) were gathered through customer intercept surveys. Addresses were geocoded, and GIS-assessed distance and driving time from the participants' residence to the store were calculated. Dietary status and behaviours were assessed using an objective non-invasive measure of skin carotenoids, the National Cancer Institute Fruit and Vegetable Screener, and items to assess sugary beverage intake. Associations between distance and driving time, demographics, shopping frequency, prior reported purchase of fruits and vegetables at the store and dietary behaviours were examined. SETTING: Small food stores (n 22) across North Carolina. PARTICIPANTS: Cross-sectional convenience samples of English-speaking customers aged 18 years or older (n 692). RESULTS: Participants living closer to the small store had lower income and formal education, were more likely to be Black, more likely to have previously bought fruits and vegetables at the store and more frequently shopped at the store. In adjusted models, skin carotenoids (n 644) were positively associated with distance to the store from home in miles (P = 0·01). CONCLUSIONS: Customers who lived closer to the stores were more frequent shoppers and more likely to have previously purchased fruits and vegetables at the store yet had lower skin carotenoids. These results support continued efforts to examine how to increase the availability and promotion of healthful foods at small food retail stores.

Food and Beverage Options at Highway Rest Areas in North Carolina: A Mixed-Methods Audit and Geospatial Approach.

INTRODUCTION: Each year, millions of people purchase food at highway rest areas. Rest areas are potential sites for health promotion because they are operated by the public sector; they are frequently visited by professional truck drivers, who have a disproportionate burden of chronic disease; and they are easily accessible. To our knowledge, no research has systematically examined the healthfulness of food offerings at rest areas. The objective of this study was to determine the accessibility and healthfulness of food and beverages offered at highway rest areas in North Carolina using a mixed-methods audit and geospatial approach. METHODS: We conducted a cross-sectional audit of all rest areas offering foods and beverages in North Carolina (N = 30) in summer 2018. We used the Nutrition Environment Measures Survey-Vending (NEMS-V) to record the 1) type, price, and size of all foods and beverages and 2) healthfulness of items offered (based on NEMS-V categorization). Two researchers independently double coded NEMS-V data. We used geospatial analysis to examine proximity of rest areas to food stores. We analyzed data by using univariate and bivariate analysis. RESULTS: The mean number of vending machines per site was 8.0 (range, 2-12, standard deviation, 2.8). The healthfulness of offerings varied across sites. Most food items (88.1%; 2,922 of 3,315) and beverage items (63.7%; 1,567 of 2,459) were classified as least healthful. Cold beverage machines had a greater percentage of healthful items (38.2%; 778 of 2,036) than snack machines (11.4%; 374 of 3,270) (P < .001), mainly because of water and diet soda in beverage machines. CONCLUSION: Policy changes are needed to increase the number and presentation of healthful food options at highway rest areas. Policy changes could provide travelers with more healthful options conveniently located along their travel route.

Online grocery shopping: promise and pitfalls for healthier food and beverage purchases.

OBJECTIVES: (i) To determine the current state of online grocery shopping, including individuals' motivations for shopping for groceries online and types of foods purchased; and (ii) to identify the potential promise and pitfalls that online grocery shopping may offer in relation to food and beverage purchases. DESIGN: PubMed, ABI/INFORM and Google Scholar were searched to identify published research. SETTING: To be included, studies must have been published between 2007 and 2017 in English, based in the USA or Europe (including the UK), and focused on: (i) motivations for online grocery shopping; (ii) the cognitive/psychosocial domain; and (iii) the community or neighbourhood food environment domain. SUBJECTS: Our search yielded twenty-four relevant papers. RESULTS: Findings indicate that online grocery shopping can be a double-edged sword. While it has the potential to increase healthy choices via reduced unhealthy impulse purchases, nutrition labelling strategies, and as a method to overcome food access limitations among individuals with limited access to a brick-and-mortar store, it also has the potential to increase unhealthy choices due to reasons such as consumers' hesitance to purchase fresh produce online. CONCLUSIONS: Additional research is needed to determine the most effective ways to positively engage customers to use online grocery shopping to make healthier choices.

The perceived influence of cost-offset community-supported agriculture on food access among low-income families.

OBJECTIVE: To examine perspectives on food access among low-income families participating in a cost-offset community-supported agriculture (CO-CSA) programme. DESIGN: Farm Fresh Foods for Healthy Kids (F3HK) is a multicentre randomized intervention trial assessing the effect of CO-CSA on dietary intake and quality among children from low-income families. Focus groups were conducted at the end of the first CO-CSA season. Participants were interviewed about programme experiences, framed by five dimensions of food access: availability, accessibility, affordability, acceptability and accommodation. Transcribed data were coded on these dimensions plus emergent themes. SETTING: Nine communities in the US states of New York, North Carolina, Washington and Vermont. SUBJECTS: Fifty-three F3HK adults with children. RESULTS: CSA models were structured by partner farms. Produce quantity was abundant; however, availability was enhanced for participants who were able to select their own produce items. Flexible CSA pick-up times and locations made produce pick-up more accessible. Despite being affordable to most, payment timing was a barrier for some. Unfamiliar foods and quick spoilage hindered acceptability through challenging meal planning, despite accommodations that included preparation advice. CONCLUSIONS: Although CO-CSA may facilitate increased access to fruits and vegetables for low-income families, perceptions of positive diet change may be limited by the ability to incorporate share pick-up into regular travel patterns and meal planning. Food waste concerns may be particularly acute for families with constrained resources. Future research should examine whether CO-CSA with flexible logistics and produce self-selection are sustainable for low-income families and CSA farms.

A possible dose-response association between distance to farmers' markets and roadside produce stands, frequency of shopping, fruit and vegetable consumption, and body mass index among customers in the Southern United States.

BACKGROUND: The association between farmers' market characteristics and consumer shopping habits remains unclear. Our objective was to examine associations among distance to farmers' markets, amenities within farmers' markets, frequency of farmers' market shopping, fruit and vegetable consumption, and body mass index (BMI). We hypothesized that the relationship between frequency of farmers' market shopping and BMI would be mediated by fruit and vegetable consumption. METHODS: In 15 farmers' markets in northeastern North Carolina, July-September 2015, we conducted a cross-sectional survey among 263 farmers' market customers (199 provided complete address data) and conducted farmers' market audits. To participate, customers had to be over 18 years of age, and English speaking. Dependent variables included farmers' market shopping frequency, fruit and vegetable consumption, and BMI. Analysis of variance, adjusted multinomial logistic regression, Poisson regression, and linear regression models, adjusted for age, race, sex, and education, were used to examine associations between distance to farmers' markets, amenities within farmers' markets, frequency of farmers' market shopping, fruit and vegetable consumption, and BMI. RESULTS: Those who reported shopping at farmers' markets a few times per year or less reported consuming 4.4 (standard deviation = 1.7) daily servings of fruits and vegetables, and those who reported shopping 2 or more times per week reported consuming 5.5 (2.2) daily servings. There was no association between farmers' market amenities, and shopping frequency or fruit and vegetable consumption. Those who shopped 2 or more times per week had a statistically significantly lower BMI than those who shopped less frequently. There was no evidence of mediation of the relationship between frequency of shopping and BMI by fruit and vegetable consumption. CONCLUSIONS: More work should be done to understand factors within farmers' markets that encourage fruit and vegetable purchases.

Farm Fresh Foods for Healthy Kids (F3HK): An innovative community supported agriculture intervention to prevent childhood obesity in low-income families and strengthen local agricultural economies.

BACKGROUND: Childhood obesity persists in the United States and is associated with serious health problems. Higher rates of obesity among children from disadvantaged households may be, in part, attributable to disparities in access to healthy foods such as fruits and vegetables. Community supported agriculture can improve access to and consumption of fresh produce, but the upfront payment structure, logistical barriers, and unfamiliarity with produce items may inhibit participation by low-income families. The aim of this project is to assess the impact of subsidized, or "cost-offset," community supported agriculture participation coupled with tailored nutrition education for low-income families with children. METHODS/DESIGN: The Farm Fresh Foods for Healthy Kids community-based, randomized intervention trial will build on formative and longitudinal research to examine the impact of cost-offset community supported agriculture on diet and other health behaviors as well as the economic impacts on local economies. The intervention will involve reduced-price community supported agriculture shares which can be paid for on a weekly basis, nine skill-based and seasonally-tailored healthy eating classes, and the provision of basic kitchen tools. Low income families with at least one child aged 2-12 years will be recruited to join existing community supported agriculture programs in New York, North Carolina, Vermont, and Washington. In each program, families will be randomized 1:1 to intervention or delayed intervention groups. Data will be collected at baseline, and in the fall and spring for 3 years. The primary outcomes are children's intake of fruits and vegetables and foods high in sugar and/or (solid) fat, as well as diet quality; secondary outcomes include physical, behavioral, psychosocial, and environmental variables. Cost-effectiveness and economic impact at the farm and community levels also will be assessed. DISCUSSION: This integrated project will provide important information and contribute to the evidence base regarding the use of local agricultural interventions to improve children's dietary behaviors and weight maintenance. Findings also will inform the development of a toolkit for farmers and education modules related to local food system innovations for undergraduate and graduate students. TRIAL REGISTRATION: ClinicalTrials.gov NCT02770196 . Registered 5 April 2016.

Farmers' market shopping and dietary behaviours among Supplemental Nutrition Assistance Program participants.

OBJECTIVE: Because farmers' markets include a variety of fruits and vegetables, shopping at farmers' markets would likely improve diet quality among low-income consumers, as well as promote sustainable direct farm-to-consumer business models. However, not much is known about how to promote farmers' market shopping among low-income consumers. Therefore, the purpose of the present paper was to examine barriers to and facilitators of shopping at farmers' markets and associations between shopping at farmers' markets and self-reported dietary behaviours (fruit and vegetable, sugar-sweetened beverage and fast-food consumption) and BMI. DESIGN: Cross-sectional analyses of associations between farmers' market shopping frequency, awareness of markets, access to markets, dietary behaviours and BMI. SETTING: Department of Social Services, Pitt County, eastern North Carolina, USA. SUBJECTS: Between April and July 2013, Supplemental Nutrition Assistance Program (SNAP) participants (n 205) completed a quantitative survey. RESULTS: Barriers to shopping at farmers' markets included does not accept SNAP/electronic benefit transfer, out of the way and lack of transportation. Farmers' market shopping was associated with awareness of farmers' markets (estimate =0·18 (se 0·04), P<0·001). Fruit and vegetable consumption was positively associated with farmers' market shopping (estimate =1·06 (se 0·32), P=0·001). CONCLUSIONS: Our study is one of the first to examine SNAP participants' farmers' market shopping, distance to farmers' markets and dietary behaviours. Barriers to shopping at farmers' markets and increasing awareness of existing markets should be addressed in future interventions to increase SNAP participants' use of farmers' markets, ultimately improving diet quality in this high-risk group.