Associations between food and beverage purchases and skin carotenoids among diverse small food retail store customers.

OBJECTIVE: To determine if customer purchases at small food stores are associated with healthfulness of the diet as approximated by skin carotenoids. DESIGN: This is a cross-sectional survey of customers in small food stores regarding demographics and food purchases. Food and beverage purchases were classified as 'healthy' or 'non-healthy' and 'carotenoid' v. 'non-carotenoid' using a systematic classification scheme. Fruit and vegetable intake was objectively assessed using a non-invasive device to measure skin carotenoids. Associations between variables of interest were examined using Pearson's correlation coefficients, t tests and multiple linear regression analyses. SETTING: Twenty-two small food retail stores in rural (n 7 stores) and urban (n 15) areas of North Carolina. PARTICIPANTS: Customers of small food stores. RESULTS: Of study participants (n 1086), 55·1 % were male, 60·0 % were African American/Black and 4·2 % were Hispanic, with a mean age of 43·5 years. Overall, 36 % purchased at least one healthy item, and 7·6 % of participants purchased a carotenoid-containing food/beverage. Healthy foods and beverages purchased included produce, lean meats, 100 % juices, plain popcorn, plain nuts, milk and yogurt. Unhealthy items included non-100 % juices, crackers, chips, candy, cakes and donuts. Purchase of a healthy or carotenoid-containing item was positively associated with skin carotenoid scores (P = 0·002 and 0·006, respectively). CONCLUSIONS: A relatively small proportion of customers purchased any healthy or carotenoid-containing foods and beverages, and those who did purchase healthy options had higher skin carotenoid scores. Future research should confirm these findings in different populations.

Bidirectional Relations Between Daily Stress and Sleep Among Black Emerging Adults.

BACKGROUND: Black adults experience higher levels of stress and more dysfunctional sleep patterns compared to their White peers, both of which may contribute to racial disparities in chronic health conditions. Dysfunctional sleep patterns are also more likely in emerging adults compared to other age groups. Daily stress-sleep relations in Black emerging adults are understudied. PURPOSE: This study used ecological momentary assessment (EMA) and wrist-worn actigraphy to examine bidirectional associations between daily stress and sleep among Black emerging adults. METHODS: Black college freshmen (N = 50) completed an EMA protocol (i.e., five EMA prompts/day) and wore an accelerometer for 7 days. The first EMA prompt of each day assessed sleep duration and quality. All EMA prompts assessed stress. Wrist-worn actigraphy assessed nocturnal sleep duration, sleep onset latency, sleep efficiency, and waking after sleep onset. RESULTS: At the within-person level, stress experienced on a given day was not associated with any sleep metrics that night (p > .05). On evenings when actigraphy-based sleep duration was shorter (B = -0.02, p = .01) and self-reported sleep quality was poorer (B = -0.12, p = .02) than usual, stress was greater the following day. At the between-person level, negative bidirectional relations existed between stress and actigraphy-based waking after sleep onset (stress predicting sleep: B = -0.35, p = .02; sleep predicting stress: B = -0.27, p = .04). CONCLUSIONS: Among Black emerging adults, associations between daily sleep and stress vary at the between- and within-person level and are dependent upon the sleep metric assessed. Future research should compare these relations across different measures of stress and different racial/ethnic groups to better understand health disparities.

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.

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.

Addressing Food Insecurity through a Health Equity Lens: a Case Study of Large Urban School Districts during the COVID-19 Pandemic.

Reduced access to school meals during public health emergencies can accelerate food insecurity and nutritional status, particularly for low-income children in urban areas. To prevent the exacerbation of health disparities, there is a need to understand the implementation of meal distribution among large urban school districts during emergencies and to what degree these strategies provide equitable meal access. Our case study of four large urban school districts during the COVID-19 pandemic aims to address these knowledge gaps. Guided by the Getting to Equity (GTE) framework, we conducted a mixed-methods study evaluating emergency meal distribution and strategy implementation in four large urban school districts (Chicago Public Schools, Houston Independent School District, Los Angeles Unified School District, and New York City Department of Education). We gathered data from school district websites on (1) meal service and delivery sites and (2) district documents, policies, communication, and resources. Using qualitative coding approaches, we identified unique and shared district strategies to address meal distribution and communications during the pandemic according to the four components of the GTE framework: increase healthy options, reduce deterrents, build on community capacity, and increase social and economic resources. We matched district census tract boundaries to demographic data from the 2018 American Community Survey and United States Department of Agriculture food desert data, and used geographic information systems (GIS) software to identify meal site locations relative to student population, areas of high poverty and high minority populations, and food deserts. We found that all districts developed strategies to optimize meal provision, which varied across case site. Strategies to increase healthy options included serving adults and other members of the general public, providing timely information on meal site locations, and promoting consumption of a balanced diet. The quantity and frequency of meals served varied, and the degree to which districts promoted high-quality nutrition was limited. Reducing deterrents related to using inclusive language and images and providing safety information on social distancing practices in multiple languages. Districts built community capacity through partnering with first responder, relief, and other community organizations. Increased social and economic resources were illustrated by providing technology assistance to families, childcare referrals for essential workers, and other wellness resources. Geospatial analysis suggests that service locations across cities varied to some degree by demographics and food environment, with potential gaps in reach. This study identifies strategies that have the potential to increase equitable access to nutrition assistance programs. Our findings can support (1) ongoing efforts to address child food insecurity during the pandemic and (2) future meal provision through programs like the Summer Food Service Program and Seamless Summer Option. Future research should further examine the rationale behind meal site placement and how site availability changed over time.

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.

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.

Associations between neighborhood-level factors related to a healthful lifestyle and dietary intake, physical activity, and support for obesity prevention polices among rural adults.

We examined cross-sectional associations among neighborhood- and individual-level factors related to a healthful lifestyle and dietary intake, physical activity (PA), and support for obesity prevention polices in rural eastern North Carolina adults. We examined perceived neighborhood barriers to a healthful lifestyle, and associations between neighborhood barriers to healthy eating and PA, participants' support for seven obesity prevention policies, and dependent variables of self-reported dietary and PA behaviors, and measured body mass index (BMI) (n = 366 study participants). We then used participants' residential addresses and Geographic Information Systems (GIS) software to assess neighborhood-level factors related to access to healthy food and PA opportunities. Correlational analyses and adjusted linear regression models were used to examine associations between neighborhood-level factors related to a healthful lifestyle and dietary and PA behaviors, BMI, and obesity prevention policy support. The most commonly reported neighborhood barriers (from a list of 18 potential barriers) perceived by participants included: not enough bicycle lanes and sidewalks, not enough affordable exercise places, too much crime, and no place to buy a quick, healthy meal to go. Higher diet quality was inversely related to perceived and GIS-assessed neighborhood nutrition barriers. There were no significant associations between neighborhood barriers and PA. More perceived neighborhood barriers were positively associated with BMI. Support for obesity prevention policy change was positively associated with perceptions of more neighborhood barriers. Neighborhood factors that promote a healthful lifestyle were associated with higher diet quality and lower BMI. Individuals who perceived more neighborhood-level barriers to healthy eating and PA usually supported policies to address those barriers. Future studies should examine mechanisms to garner such support for health-promoting neighborhood changes.

Farmers' market use is associated with fruit and vegetable consumption in diverse southern rural communities.

BACKGROUND: While farmers' markets are a potential strategy to increase access to fruits and vegetables in rural areas, more information is needed regarding use of farmers' markets among rural residents. Thus, this study's purpose was to examine (1) socio-demographic characteristics of participants; (2) barriers and facilitators to farmers' market shopping in southern rural communities; and (3) associations between farmers' market use with fruit and vegetable consumption and body mass index (BMI). METHODS: Cross-sectional surveys were conducted with a purposive sample of farmers' market customers and a representative sample of primary household food shoppers in eastern North Carolina (NC) and the Appalachian region of Kentucky (KY). Customers were interviewed using an intercept survey instrument at farmers' markets. Representative samples of primary food shoppers were identified via random digit dial (RDD) cellular phone and landline methods in counties that had at least one farmers' market. All questionnaires assessed socio-demographic characteristics, food shopping patterns, barriers to and facilitators of farmers' market shopping, fruit and vegetable consumption and self-reported height and weight. The main outcome measures were fruit and vegetable consumption and BMI. Descriptive statistics were used to examine socio-demographic characteristics, food shopping patterns, and barriers and facilitators to farmers' market shopping. Linear regression analyses were used to examine associations between farmers' market use with fruit and vegetable consumption and BMI, controlling for age, race, education, and gender. RESULTS: Among farmers' market customers, 44% and 55% (NC and KY customers, respectively) reported shopping at a farmers' market at least weekly, compared to 16% and 18% of NC and KY RDD respondents. Frequently reported barriers to farmers' market shopping were market days and hours, "only come when I need something", extreme weather, and market location. Among the KY farmers' market customers and NC and KY RDD respondents, fruit and vegetable consumption was positively associated with use of farmers' markets. There were no associations between use of farmers' markets and BMI. CONCLUSIONS: Fruit and vegetable consumption was associated with farmers' market shopping. Thus, farmers' markets may be a viable method to increase population-level produce consumption.

Multi-Method Formative Evaluation of a Digital Online Grocery Shopping Assistant Among Special Supplemental Nutrition Program for Women, Infants, and Children Participants.

OBJECTIVE: Assess the acceptability of a digital grocery shopping assistant among rural women with low income. DESIGN: Simulated shopping experience, semistructured interviews, and a choice experiment. SETTING: Rural central North Carolina Special Supplemental Nutrition Program for Women, Infants, and Children clinic. PARTICIPANTS: Thirty adults (aged ≥18 years) recruited from a Special Supplemental Nutrition Program for Women, Infants, and Children clinic. PHENOMENON OF INTEREST: A simulated grocery shopping experience with the Retail Online Shopping Assistant (ROSA) and mixed-methods feedback on the experience. ANALYSIS: Deductive and inductive qualitative content analysis to independently code and identify themes and patterns among interview responses and quantitative analysis of simulated shopping experience and choice experiment. RESULTS: Most participants liked ROSA (28/30, 93%) and found it helpful and likely to change their purchase across various food categories and at checkout. Retail Online Shopping Assistant's reminders and suggestions could reduce less healthy shopping habits and diversify food options. Participants desired dynamic suggestions and help with various health conditions. Participants preferred a racially inclusive, approachable, cartoon-like, and clinically dressed character. CONCLUSIONS AND IMPLICATIONS: This formative study suggests ROSA could be a beneficial tool for facilitating healthy online grocery shopping among rural shoppers. Future research should investigate the impact of ROSA on dietary behaviors further.

Associations between access to farmers' markets and supermarkets, shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, U.S.A.

OBJECTIVE: We examined associations between access to food venues (farmers' markets and supermarkets), shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, U.S.A. DESIGN: Access to food venues was measured using a Geographic Information System incorporating distance, seasonality and business hours, to quantify access to farmers' markets. Produce consumption was assessed by self-report of eating five or more fruits and vegetables daily. BMI and blood pressure were assessed by clinical measurements. Poisson regression with robust variance was used for dichotomous outcomes and multiple linear regression was used for continuous outcomes. As the study occurred in a university town and university students are likely to have different shopping patterns from non-students, we stratified analyses by student status. SETTING: Eastern North Carolina. SUBJECTS: Low-income women of reproductive age (18­44 years) with valid address information accessing family planning services at a local health department (n 400). RESULTS: Over a quarter reported ever shopping at farmers' markets (114/400). A larger percentage of women who shopped at farmers' markets consumed five or more fruits and vegetables daily (42.1%) than those who did not (24.0%; P < 0.001). The mean objectively measured distance to the farmers' markets where women reported shopping was 11.4 (SD 9.0) km (7.1 (SD 5.6) miles), while the mean distance to the farmers' market closest to the residence was 4.0 (SD 3.7) km (2.5 (SD 2.3) miles). CONCLUSIONS: Among non-students, those who shopped at farmers' markets were more likely to consume five or more servings of fruits and vegetables daily. Future research should further explore potential health benefits of farmers' markets.

A community assessment to inform a multilevel intervention to reduce cardiovascular disease risk and risk disparities in a rural community.

To complete a formative evaluation to identify community-level assets and barriers to healthy lifestyle choices, we conducted qualitative interviews, community audits, and secondary data analyses. We solicited local leaders' perspectives regarding winnability of obesity prevention policy options. Participants noted that many resources were available, yet a barrier was high cost. There were more parks per capita in low-income areas, but they were of lower quality. The most winnable obesity prevention policy was incentives for use of food from local farms. Results are being used to inform an intervention to reduce cardiovascular disease risk in rural eastern North Carolina.

Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: engaging stakeholders for a healthy corner store initiative, part 2.

INTRODUCTION: We examined the feasibility of increasing access to healthful food in corner stores to inform a Communities Putting Prevention to Work (CPPW) initiative by engaging stakeholders (corner store owners and customers) in a formative evaluation. METHODS: Qualitative interviews were conducted with corner store owners and managers (n = 11). Customer intercept surveys (n = 179) were also conducted with customers of 9 stores. Corner stores were located in rural food deserts (municipalities without a chain supermarket) and in low-income, urban municipalities in eastern North Carolina. Interviews were transcribed verbatim and double-coded. Qualitative themes related to feasibility of increasing access to healthful foods were extracted. Shopping patterns of rural and urban customers were compared by using t tests. RESULTS: Corner store owners were willing to stock more healthful foods, but they perceived that customer demand for these foods was low. Rural customers reported more frequently shopping at corner stores than urban customers and more frequently stated that the reason they do not eat more fruits and vegetables is that the stores in which they shop do not sell them. Most customers reported they would be very or somewhat likely to purchase fresh produce at a corner store. CONCLUSION: Corner stores may be an important source of food for rural and low-income residents and thus a good place in which to intervene. The results of this formative evaluation were used to plan and evaluate a CPPW healthy corner store initiative.

Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: assessing the rural food environment, part 1.

INTRODUCTION: Obesity prevalence in the rural United States is higher than in urban or suburban areas, perhaps as a result of the food environment. Because rural residents live farther from supermarkets than their urban- and suburban-dwelling counterparts, they may be more reliant on smaller corner stores that offer fewer healthful food items. METHODS: As part of a Communities Putting Prevention to Work (CPPW) healthy corner store initiative, we reviewed audit tools in the fall of 2010 to measure the consumer food environment in eastern North Carolina and chose the NEMS-S-Rev (Nutrition Environment Measures Survey-Stores-Revised) to assess 42 food stores. During the spring and summer of 2011, 2 trained graduate assistants audited stores, achieving interrater reliability of at least 80%. NEMS-S-Rev scores of stores in rural versus urban areas were compared. RESULTS: Overall, healthful foods were less available and of lower quality in rural areas than in urban areas. NEMS-S-Rev scores indicated that healthful foods were more likely to be available and had similar pricing and quality in rural corner stores than in urban corner stores. CONCLUSION: Food store audit data provided a baseline to implement and evaluate a CPPW healthy corner store initiative in Pitt County. This work serves as a case study, providing lessons learned for engaging community partners when conducting rural food store audits.

Associations between body mass index, shopping behaviors, amenity density, and characteristics of the neighborhood food environment among female adult Supplemental Nutrition Assistance Program (SNAP) participants in eastern North Carolina.

We examined associations between body mass index (BMI) and the food environment among adult female Supplemental Nutrition Assistance Program (SNAP) participants (N = 197) in eastern North Carolina. Food venue proximity to residential addresses was calculated using a geographic information system. Walk Score was used as a measure of amenity density. Correlation and linear regression analyses were used to examine associations between BMI and distance to and use of food venues, and residential amenity density. Frequency of supercenter use was significantly inversely associated with distance to supercenters. Walk Score was significantly inversely associated with BMI. BMI was not associated with distance to or use of any particular food venue. Future studies should examine specific health-promoting elements of amenity-dense neighborhoods accessible to limited-income populations.

Evidence of Geospatial and Socioeconomic Disparities in Access to Online Grocery Shopping for Fresh and Frozen Produce in North Carolina.

BACKGROUND: Online grocery shopping is a rapidly growing food procurement approach in the United States with the potential to improve food access. Limited research has focused on understanding differential access to online grocery shopping that provides healthier items such as fresh or frozen fruits and vegetables. OBJECTIVE: The study aim was to understand geospatial, socioeconomic, and racial disparities in the availability of healthy online grocery shopping and online Supplemental Nutrition Assistance Program (SNAP) acceptance in North Carolina. DESIGN: A cross-sectional study was conducted during spring 2021. PARTICIPANTS/SETTING: A listing of grocery stores with online shopping was generated using a systematic search strategy. Stores were geocoded and spatially joined to relevant contextual (rural/urban [based on US Department of Agriculture Rural Urban Continuum codes]), broadband Internet availability, socioeconomic variables (ie, percent poverty and Social Vulnerability Index), and demographic variables (ie, percent racial minority) in geographic information systems software. MAIN OUTCOME MEASURES: Prevalence rate ratios (PRRs) of healthy online grocery shopping (availability of curbside pickup or home delivery of fresh and frozen produce), and online SNAP acceptance (ie, availability of online SNAP), at the census tract level (n = 2,162). STATISTICAL ANALYSES PERFORMED: PRRs for availability of healthy online grocery shopping and SNAP online acceptance at the census tract level (n = 2,162) were modeled using Poisson regression with robust standard errors. RESULTS: This study found disparities in access to healthy online grocery shopping and SNAP online shopping availability in North Carolina. Healthy online shopping availability rates were higher in urban census tracts (PRR 1.68, 95% CI 1.47 to 1.92), areas with lower Social Vulnerability Index scores (PRR 0.99, 95% CI 0.98 to 0.99), higher Internet Availability Index scores (PRR 1.21, 95% CI 1.17 to 1.25), and lower percent poverty (PRR 0.94, 95% CI 0.90 to 0.98). SNAP online shopping availability rates were higher in urban census tracts (PRR 1.41, 95% CI 1.16 to 1.65), areas with higher Social Vulnerability Index scores (PRR 1.02, 95% CI 1.01 to 1.04), higher Internet Availability Index scores (PRR 1.15, 95% CI 1.10 to 1.20), and higher percent minority (PRR 1.02, 95% CI 1.0001 to 1.03). SNAP online shopping availability rates were lower in areas with higher percent poverty (PRR 0.90, 95% CI 0.85 to 0.95). CONCLUSIONS: This study found disparities in access to healthy online grocery shopping and SNAP online shopping for rural areas, and areas with higher poverty, and lower broadband Internet access in North Carolina. Further research is needed to identify effective strategies for addressing these disparities.