Imparting child nutritional assessment skills among medical students using hybrid problem-based learning approach in a community setting.

Background: Malnutrition affects up to a third of children in India, with severe and acute malnutrition prevalent among under five children. Nutritional assessment skills for detecting malnutrition in children in primary care settings are vital. Hybrid problem-based learning (HPBL) is an innovative, collaborative, and adaptable instructional learning strategy that can be used to teach medical students clinical skills in a community setting. Methods: A two-month quasi-experimental study was undertaken in a rural setting with third-year medical students. Faculty members were sensitized and subject experts developed a training module addressing the knowledge, attitude, communication, and practice domains. The students underwent a 3-week training module where pre-testing, case presentation, and group formation in first week, an anchoring lecture, tutorial and self-directed learning and role-play by students in subsequent week, and in last week, case discussion, post-testing, and feedback rounds were done. Results: In all domains, knowledge (3.8, 0.01), practice (4.3, 0.01), attitude and communication (3.7, 0.01), and proportional satisfactory responses, the HPBL approach resulted in a significant improvement in nutritional assessment competency. Teachers preferred the practical and engaging character of the approach, stating that doubts and questions were better addressed and that they would use it to teach similar topics. Conclusion: HPBL is an excellent teaching method for clinical skills, like nutritional assessment in simulated/field settings. The novel teaching-learning approach was well received by students and faculty members. Learning outcomes and satisfaction rates enhanced in students and faculty were encouraged to apply the approach to other topics.

Development and evaluation of the Food Bank Health and Nutrition Assessment.

OBJECTIVE: Efforts to improve the nutritional quality and health promotion in the charitable food system have been undertaken. Though methods exist to track these efforts in terms of food banks' inventory, there are not research-tested tools to assess, monitor and influence policy, systems and environmental (PSE) changes. The study objective was to develop and evaluate a novel assessment tool that could be used to evaluate a food bank's efforts to improve the promotion of health and nutritious foods. DESIGN: The study had five phases: (1) initial development; (2) iterative review and revisions; (3) pilot testing; (4) content validity assessment and (5) inter-rater and test-retest assessment. The Food Bank Health and Nutrition Assessment (FB-HANA) was drafted after reviewing existing policies, nutrition-focused charitable food systems guidance and similar tools for food pantries. SETTING: Midwestern United States. PARTICIPANTS: Eleven food banks. RESULTS: Stakeholders and pilot testers provided initial feedback to refine the FB-HANA's flow, ease of completion and collection of contextual information. External experts rated the FB-HANA and each of the eight objectives as content valid. A set of two assessments completed by twenty-six community-based professionals, employed by Extension and fourteen food bank staff across eleven food banks, supported moderate to excellent inter-rater and test-retest reliability for the FB-HANA overall and each of its objectives. CONCLUSIONS: Evidence suggests that the FB-HANA can be used by either food bank or community-based professionals, such as Extension staff, to provide a perspective on ways food banks promote health and nutrition through PSE approaches.

Implementing a Produce Prescription Program in Partnership With a Community Coalition.

Healthy eating reduces risk for chronic disease, but can be out of reach for many Americans experiencing food insecurity. Produce Prescription Programs (PPPs) have emerged as an intervention to address barriers related to fruit and vegetable consumption. Using a social prescribing model, PPPs connect patients with referrals to community resources to reduce barriers to healthy eating. There is evidence of success of PPPs at improving dietary intake, yet little discussion within the literature of practical aspects of implementation. As interest grows around establishing PPPs within communities, increased attention to strategic planning and implementation remains necessary to develop robust and effective programming. We describe implementing the Pontiac Prescription for Health pilot program, highlighting the participatory planning process with partners. Development and implementation included a program model, recruitment methods and materials, a voucher contract and tracking system with produce vendors, physical activity opportunities, culturally competent health education sessions, and evaluation tools. We offer insight into lessons learned and practical implications for future "on-the-ground" planning and implementation. Engaging in a rigorous participatory planning process with all community partners, allowing adequate time to establish service agreements and a voucher system with vendors, and engaging program participants in different ways and spaces throughout the community can enhance program success.

Comparing delivery channels to promote nutrition-sensitive agriculture: A cluster-randomized controlled trial in Bangladesh.

We use a randomized controlled trial in rural Bangladesh to compare two models of delivering nutrition content jointly to husbands and wives: deploying female nutrition workers versus mostly male agriculture extension workers. Both approaches increased nutrition knowledge of men and women, household and individual diet quality, and women's empowerment. Intervention effects on agriculture and nutrition knowledge, agricultural production diversity, dietary diversity, women's empowerment, and gender parity do not significantly differ between models where nutrition workers versus agriculture extension workers provide the training. The exception is in an attitudes score, where results indicate same-sex agents may affect scores differently than opposite-sex agents. Our results suggest opposite-sex agents may not necessarily be less effective in providing training. In South Asia, where agricultural extension systems and the pipeline to those systems are male-dominated, training men to deliver nutrition messages may offer a temporary solution to the shortage of female extension workers and offer opportunities to scale and promote nutrition-sensitive agriculture. However, in both models, we find evidence that the presence of mothers-in-law within households modifies the programs' effectiveness on some nutrition, empowerment, and attitude measures, suggesting that accounting for other influential household members is a potential area for future programming.

Beyond food swamps and food deserts: exploring urban Australian food retail environment typologies.

OBJECTIVE: 'Food deserts' and 'food swamps' are food retail environment typologies associated with unhealthy diet and obesity. The current study aimed to identify more complex food retail environment typologies and examine temporal trends. DESIGN: Measures of food retail environment accessibility and relative healthy food availability were defined for small areas (SA2s) of Melbourne, Australia, from a census of food outlets operating in 2008, 2012, 2014 and 2016. SA2s were classified into typologies using a two-stage approach: (1) SA2s were sorted into twenty clusters according to accessibility and availability and (2) clusters were grouped using evidence-based thresholds. SETTING: The current study was set in Melbourne, the capital city of the state of Victoria, Australia. SUBJECTS: Food retail environments in 301 small areas (Statistical Area 2) located in Melbourne in 2008, 2012, 2014 and 2016. RESULTS: Six typologies were identified based on access (low, moderate and high) and healthy food availability including one where zero food outlets were present. Over the study period, SA2s experienced an overall increase in accessibility and healthiness. Distribution of typologies varied by geographic location and area-level socio-economic position. CONCLUSION: Multiple typologies with contrasting access and healthiness measures exist within Melbourne and these continue to change over time, and the majority of SA2s were dominated by the presence of unhealthy relative to healthy outlets, with SA2s experiencing growth and disadvantage having the lowest access and to a greater proportion of unhealthy outlets.

The knowledge, barriers and opportunities to improve nutrition and physical activity amongst young people attending an Australian youth mental health service: a mixed-methods study.

BACKGROUND: Mental illnesses are the leading cause of disability in young people, and lifestyle interventions in young people at risk of mental illness remain a priority. Opportunities to improve nutrition and physical activity among young people through youth mental health services remain unclear. This study aimed to determine the knowledge and behaviors towards nutrition and physical activity, the barriers and enablers to improving behaviors, and the preferred providers and sources of information for nutrition and physical activity among a sample of young people attending a youth mental health service. METHODS: A mixed-method study was conducted in regional Tasmania, Australia in a sample of young people (15-25 years) attending a youth mental health service (headspace). A quantitative survey (n = 48) determined young people's nutrition and physical activity knowledge, behaviors, barriers and enablers to achieving recommendations, and their preferred providers and sources of information. Structured interviews and a focus group further explored these concepts (n = 8), including the role of the mental health service as a provider of this support. RESULTS: The majority of participants did not meet national recommendations for nutrition and physical activity, despite possessing a high level of knowledge regarding their importance for mental health. Improving mental health was a common enabling factor for participants choosing to alter diet and physical activity habits, but also the leading barrier for participating in physical activity. Young people wanted to receive information from reputable health providers, ideally through social media sources. headspace was seen as an important potential provider of this information. CONCLUSIONS: Our results indicate that there is a clear need to improve diet and physical activity habits to enhance mental and physical health outcomes in this at-risk group, and youth mental health services could provide further interventions to support their clients. Specialized staff (e.g. dietitians and exercise physiologists) may provide additional benefits alongside existing mental health care support.

Exploring Barriers to Food Security Among Immigrants: A Critical Role for Public Health Nutrition.

Upon moving to a new country and new food environment, 2 important public health issues may be experienced by immigrants as they adapt to their new country of residence, namely a higher prevalence of food insecurity and/or a decline in overall health over time postimmigration. Therefore, improving the food environment experienced by new migrants may be an effective strategy to reduce long-term health complications and improve well-being postimmigration. The aim of this paper is to discuss the potential barriers experienced by new immigrants in the access, availability, and utilization of familiar culturally appropriate foods and the subsequent impact on their food security status. Culturally appropriate foods are foods commonly consumed as part of cultural food traditions and are often staples within the diet; however, limited availability of and/or access to these foods can reduce food security. By understanding the barriers to food security and challenges that may be faced by immigrants and refugees, dietitians will be better equipped to assist these individuals in accessing culturally familiar foods and improve quality of life. In this capacity, dietitians can play a critical public health nutrition role by serving as a conduit for new immigrants to access community resources and navigate a new food environment.

Charity- and project-based service learning models increase public service motivation outcomes among dietetic students in a community nutrition course.

OBJECTIVE: To determine whether dietetic students would report a change in their public service motivation (PSM) following a community nutrition service learning (SL) course, and whether the SL model (charity v. project) influences this change differently. DESIGN: Using a pretest-posttest, nonequivalent groups quasi-experimental design, this study compared students' PSM at the beginning and end of a 15-week college-level course. PSM and four component dimensions (attraction to public policy, commitment to public interest, compassion and self-sacrifice) were measured via electronic survey using the PSM scale. Average PSM scores were compared between and within the charity and project groups using independent samples and paired sample t tests, respectively. ANCOVA assessed the effect of SL model on post-survey scores, controlling for pre-survey scores. SETTING: Public university in northeastern United States. PARTICIPANTS: Dietetic students enrolled in six sections of the same undergraduate community nutrition SL course. Students were placed by section in either charity (n 59) or project (n 52) SL experiences and required to complete 14 h in this role. RESULTS: Mean PSM total scores increased between pre-survey and post-survey (3·50 v. 3·58; P = 0·001). Students reported small increases in three PSM dimensions: commitment to public interest, compassion and self-sacrifice (all P ≤ 0·01). Holding pre-scores constant, the charity group reported a higher attraction to public policy post-score, while the project group reported a higher self-sacrifice post-score (both P < 0·05). CONCLUSIONS: Educators should consider adopting SL methods into curricular offerings to enhance students' motivation for public service.

Challenges of making healthy lifestyle changes for families in Aotearoa/New Zealand.

OBJECTIVE: The objective of the current study was to identify challenges of making and sustaining healthy lifestyle changes for families with children/adolescents affected by obesity, who were referred to a multicomponent healthy lifestyle assessment and intervention programme in Aotearoa/New Zealand (NZ). DESIGN: Secondary qualitative analysis of semi-structured interviews. SETTING: Taranaki region of Aotearoa/NZ. PARTICIPANTS: Thirty-eight interviews with parents/caregivers (n 42) of children/adolescents who had previously been referred to a family-focused multidisciplinary programme for childhood obesity intervention, who identified challenges of making healthy lifestyle changes. Participants had varying levels of engagement, including those who declined contact after their referral. RESULTS: Participant-identified challenges included financial cost, impact of the food environment, time pressures, stress, maintaining consistency across households, independence in adolescence, concern for mental health and frustration when not seeing changes in weight status. CONCLUSIONS: Participants recognised a range of factors that contributed towards their ability to make and sustain change, including factors at the wider socio-environmental level beyond their immediate control. Even with the support of a multidisciplinary healthy lifestyle programme, participants found it difficult to make sustained changes within an obesogenic environment. Healthy lifestyle intervention programmes and families' abilities to make and sustain changes require alignment of prevention efforts, focusing on policy changes to improve the food environment and eliminate structural inequities.

Traditional foodstuffs and household food security in a time of crisis.

Traditional foodstuffs play an important role in household food security. No research has, however, attempted to examine traditional foodstuffs in light of disasters and crises. Such research can provide a useful outlook on how traditional foodstuffs can aid households in a situation of disrupted food supply. This outlook becomes relevant in view of future disastrous events that can undermine household food security, especially in poor disadvantaged communities. This study examined the role of traditional foodstuffs during a major crisis. The study adopted an ethnographic perspective and the method of semi-structured household interviews to explore how traditional foodstuffs were used by communities in the city of Mosul, Iraq, under the ISIS administration and during the liberation war (2016-2017). The study showcased the critical role of traditional foodstuffs in survival of local households. It highlighted the importance of cross-generational knowledge of traditional foodstuffs in community preparedness for disasters and crises. The study proposed to integrate traditional foodstuffs into governmental strategies on household food security in Iraq, and beyond. It suggested including traditional foodstuffs in the humanitarian food supply chains in the regions prone to disasters and crises. Future research should examine the prerequisites for such inclusion, especially from the viewpoint of societal and political acceptance of traditional foodstuffs and methods of their production.

A survey of bolus tube feeding prevalence and practice in adult patients requiring home enteral tube feeding.

Anecdotal evidence suggests the use of bolus tube feeding is increasing in the long-term home enteral tube feed (HETF) patients. A cross-sectional survey to assess the prevalence of bolus tube feeding and to characterise these patients was undertaken. Dietitians from ten centres across the UK collected data on all adult HETF patients on the dietetic caseload receiving bolus tube feeding (n 604, 60 % male, age 58 years). Demographic data, reasons for tube and bolus feeding, tube and equipment types, feeding method and patients' complete tube feeding regimens were recorded. Over a third of patients receiving HETF used bolus feeding (37 %). Patients were long-term tube fed (4·1 years tube feeding, 3·5 years bolus tube feeding), living at home (71 %) and sedentary (70 %). The majority were head and neck cancer patients (22 %) who were significantly more active (79 %) and lived at home (97 %), while those with cerebral palsy (12 %) were typically younger (age 31 years) but sedentary (94 %). Most patients used bolus feeding as their sole feeding method (46 %), because it was quick and easy to use, as a top-up to oral diet or to mimic mealtimes. Importantly, oral nutritional supplements (ONS) were used for bolus feeding in 85 % of patients, with 51 % of these being compact-style ONS (2·4 kcal (10·0 kJ)/ml, 125 ml). This survey shows that bolus tube feeding is common among UK HETF patients, is used by a wide variety of patient groups and can be adapted to meet the needs of a variety of patients, clinical conditions, nutritional requirements and lifestyles.

Nutrition risk among an ethnically diverse sample of community-dwelling older adults.

OBJECTIVE: To assess the prevalence of nutritional risk among an ethnically diverse group of urban community-dwelling older adults and to explore if risk varied by race/ethnicity. DESIGN: Demographic characteristics, Katz's activities of daily living and health-care resource utilization were ascertained cross-sectionally via telephone surveys with trained interviewers. Nutrition risk and nutrition symptomology were assessed via the abridged Patient Generated Subjective Global Assessment (abPG-SGA); scores of ≥6 points delineated 'high' nutrition risk. Descriptive statistics and logistic regression analyses were conducted. SETTING: Urban.ParticipantsWhite, Black or Hispanic community-dwelling adults, ≥55 years of age, fluent in English or Spanish, residing in the city limits of Chicago, IL, USA. RESULTS: A total of 1001 participants (37 % white, 37 % Black, 26 % Hispanic) were surveyed. On average, participants were 66·9 years old, predominantly female and overweight/obese. Twenty-six per cent (n 263) of participants were classified as 'high' nutrition risk with 24, 14 and 31 % endorsing decreased oral intake, weight loss and compromised functioning, respectively. Black respondents constituted the greatest proportion of those with high risk scores, yet Hispanic participants displayed the most concerning nutrition risk profiles. Younger age, female sex, Black or Hispanic race/ethnicity, emergency room visits, eating alone and taking three or more different prescribed or over-the-counter drugs daily were significantly associated with high risk scores (P<0·05). CONCLUSIONS: One in four older adults living in an urban community prone to health disparities was classified as 'high' nutrition risk. Targeted interventions to promote healthy ageing are needed, especially for overweight/obese and minority community members.

The Veggie Van: Customer characteristics, fruit and vegetable consumption, and barriers to healthy eating among shoppers at a mobile farmers market in the United States.

OBJECTIVE: Mobile farmers markets may improve local food environments by increasing access to healthy food, yet research is limited. The purpose of this study was to describe customer characteristics and barriers to healthy eating among customers at a mobile farmers market called the Veggie Van. DESIGN: In 2016, a customer intercept design was used to survey English-speaking Veggie Van customers (n = 192; 70.5% survey response rate) aged ≥18 years on sociodemographic and health characteristics, normal daily consumption of fruit and vegetables (F/V) using the Health Information National Trends Survey screener, food acquisition and purchasing habits, and potential barriers to healthy eating. We compared customers to service area neighborhood residents. Within customers, we compared first-time and repeat customers, and those with low and high F/V consumption. RESULTS: Veggie Van customers were more likely to identify as non-Hispanic white and have a bachelor's degree than neighborhood residents. Participants were mostly female (76.0%) and non-Hispanic white (53.7%). Approximately half (45.0%) were first-time customers and many (41.7%) did not meet F/V consumption recommendations. In the total sample, cost was the most frequently reported barrier to healthy eating. Among repeat customers, those with low F/V consumption were more likely to report cost as a barrier than those with high F/V consumption (p = 0.02). Only 8.9% reported no transportation to buy healthy food. CONCLUSIONS: Veggie Van customers may not represent neighborhood residents. Although few participants met F/V recommendations, most had transportation to buy healthy food. Mobile markets have lower overhead costs and greater flexibility than traditional stores and can address geo-spatial barriers to food access, but should ensure that they are serving target customers.

Unreliable and Difficult-to-Access Food for Those in Need: A Qualitative and Quantitative Study of Urban Food Pantries.

For individuals who are food insecure, food pantries can be a vital resource to improve access to adequate food. Access to adequate food may be conceptualized within five dimensions: availability (item variety), accessibility (e.g., hours of operation), accommodation (e.g., cultural sensitivity), affordability (costs, monetary or otherwise), and acceptability (e.g., as related to quality). This study examined the five dimensions of access in a convenience sample of 50 food pantries in the Bronx, NY. The design was cross-sectional. Qualitative data included researcher observations and field notes from unstructured interviews with pantry workers. Quantitative data included frequencies for aspects of food access, organized by the five access dimensions. Inductive analysis of quantitative and qualitative data revealed three main inter-related findings: (1) Pantries were not reliably open: only 50% of pantries were open during hours listed in an online directory (several had had prolonged or indefinite closures); (2) Even when pantries were open, all five access dimensions showed deficiencies (e.g., limited inventory, few hours, pre-selected handouts without consideration of preferences, opportunity costs, and inferior-quality items); (3) Open pantries frequently had insufficient food supply to meet client demand. To deal with mismatch between supply and demand, pantries developed rules for food provision. Rules could break down in cases of pantries receiving food deliveries, leading to workarounds, and in cases of compelling client need, leading to exceptions. Adherence to rules, versus implementation of workarounds and/or exceptions, was worker- and situation-dependent and, thus, unpredictable. Overall, pantry food provision was unreliable. Future research should explore clients' perception of pantry access considering multiple access dimensions. Future research should also investigate drivers of mismatched supply and demand to create more predictable, reliable, and adequate food provision.

Sources of Foods That Are Ready-to-Consume ('Grazing Environments') Versus Requiring Additional Preparation ('Grocery Environments'): Implications for Food-Environment Research and Community Health.

Local businesses that offer foods may create different 'grazing environments' (characterized by sources of ready-to-consume foods) and 'grocery environments' (characterized by source of foods for later preparation). Such environments may be relevant to different populations at different times and may vary by neighborhood. In neighborhoods within two demographically distinct areas of the Bronx, NY [Area A (higher-poverty, greater minority representation, lesser vehicle ownership) vs. Area B], researchers assessed all storefront businesses for food offerings. Food offerings could be ready-to-consume or require additional preparation. 'Healthful' offerings included fruits and vegetables, whole grains, and nuts; 'less-healthful' offerings included 'refined sweets' and 'salty/fatty fare.' 'Food businesses' (those primarily focused on selling food) were distinguished from 'other businesses' (not focused primarily on food selling). Area A had a higher percentage of street segments on which foods were available (28.6% vs. 6.9% in Area B; difference 21.7% points [95% CI 17.0, 26.5]) and a higher percentage of businesses offering foods (46.9% vs. 41.7% in Area B; difference 5.2% points [95% CI - 2.0, 12.4]). 'Less-healthful' items predominated in both 'grazing environments' and overall environments ('grazing' plus 'grocery environments'; the environments researchers typically measure) in both Areas A and B. 'Other businesses' represented about 2/3 of all businesses and accounted for nearly 1/3 of all the businesses offering food in both geographic areas. The lower-income area with greater minority representation and less private transportation had more businesses offering foods on more streets. There was near-perfect overlap between 'grazing environments' and overall environments in both geographic areas. Future research should consider the extent of 'grazing' and 'grocery environments,' and when each might be most relevant to populations of interest.

Association between store food environment and customer purchases in small grocery stores, gas-marts, pharmacies and dollar stores.

BACKGROUND: Purchases at small/non-traditional food stores tend to have poor nutritional quality, and have been associated with poor health outcomes, including increased obesity risk The purpose of this study was to examine whether customers who shop at small/non-traditional food stores with more health promoting features make healthier purchases. METHODS: In a cross-sectional design, data collectors assessed store features in a sample of 99 small and non-traditional food stores not participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Minneapolis/St. Paul, MN in 2014. Customer intercept interviews (n = 594) collected purchase data from a bag check and demographics from a survey. Store measures included fruit/vegetable and whole grain availability, an overall Healthy Food Supply Score (HFSS), healthy food advertisements and in-store placement, and shelf space of key items. Customer nutritional measures were analyzed using Nutrient Databases System for Research (NDSR), and included the purchase of ≥1 serving of fruits/vegetables; ≥1 serving of whole grains; and overall Healthy Eating Index-2010 (HEI-2010) score for foods/beverages purchased. Associations between store and customer measures were estimated in multilevel linear and logistic regression models, controlling for customer characteristics and store type. RESULTS: Few customers purchased fruits and vegetables (8%) or whole grains (8%). In fully adjusted models, purchase HEI-2010 scores were associated with fruit/vegetable shelf space (p = 0.002) and the ratio of shelf space devoted to healthy vs. less healthy items (p = 0.0002). Offering ≥14 varieties of fruit/vegetables was associated with produce purchases (OR 3.9, 95% CI 1.2-12.3), as was having produce visible from the store entrance (OR 2.3 95% CI 1.0 to 5.8), but whole grain availability measures were not associated with whole grain purchases. CONCLUSIONS: Strategies addressing both customer demand and the availability of healthy food may be necessary to improve customer purchases. TRIAL REGISTRATION: ClinialTrials.gov: NCT02774330 . Registered May 4, 2016 (retrospectively registered).

Healthy eating patterns associated with acculturation, sex and BMI among Mexican Americans.

OBJECTIVE: Examine relationships of healthy and unhealthy dietary patterns with BMI, sex, age and acculturation among Mexican Americans. DESIGN: Cross-sectional. Participants completed culturally tailored Healthy and Unhealthy Eating Indices. Multivariable mixed-effect Poisson regression models compared food pattern index scores and dietary intake of specific foods by BMI, sex, age and acculturation defined by language preference and generational status. SETTING: Participants recruited from the Cameron County Hispanic Cohort study, Texas-Mexico border region, between 2008 and 2011. SUBJECTS: Mexican-American males and females aged 18-97 years (n 1250). RESULTS: Participants were primarily female (55·3 %), overweight or obese (85·7 %), preferred Spanish language (68·0 %) and first-generation status (60·3 %). Among first-generation participants, bilingual participants were less likely to have a healthy eating pattern than preferred Spanish-speaking participants (rate ratio (RR)=0·79, P=0·0218). This association was also found in males (RR=0·81, P=0·0098). Preferred English-speaking females were less likely to consume healthy foods than preferred Spanish-speaking females (RR=0·84, P=0·0293). Among second-generation participants, preferred English-speaking participants were more likely to report a higher unhealthy eating pattern than preferred Spanish-speaking participants (RR=1·23, P=0·0114). Higher unhealthy eating patterns were also found in females who preferred English v. females who preferred Spanish (RR=1·23, P=0·0107) or were bilingual (RR=1·26, P=0·0159). Younger, male participants were more likely to have a higher unhealthy eating pattern. BMI and diabetes status were not significantly associated with healthy or unhealthy eating patterns. CONCLUSIONS: Acculturation, age, sex and education are associated with healthy and unhealthy dietary patterns. Nutrition interventions for Mexican Americans should tailor approaches by these characteristics.

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.

Nutrition education linked to agricultural interventions improved child dietary diversity in rural Cambodia.

Poor infant and young child feeding (IYCF) practices are major determinants of chronic malnutrition. The main objective of this study was to assess the impact of a nutrition education (NE) programme aimed at promoting improved IYCF behaviours in combination with an agriculture intervention on children's dietary diversity and nutritional status. From 2012 to 2014, a cluster randomised trial was rolled out in Cambodia in the context of an agriculture and nutrition project of the FAO of the UN. The cross-sectional baseline study was carried out in sixteen pre-selected communes in 2012. Restricted randomisation allotted the communes to either intervention (NE and agriculture intervention) or comparison arms (agriculture intervention only). The impact survey was conducted as a census in all FAO project villages in 2014. Caregivers of children aged 0-23 months were interviewed using standardised questions on socio-economic status and dietary diversity (24-h recall). Anthropometric measurements were taken. A difference-in-differences model was applied. The sample comprised 743 households with children ≥6 months of age at baseline and 921 at impact. After 1 year of NE, 69 % of the intervention households reported to have participated in the NE. Estimated mean child dietary diversity was significantly different at impact between comparison and intervention (3·6 and 3·9, respectively). In particular, the consumption of pro-vitamin A-rich foods and other fruits and vegetables increased. No treatment effects on height-for-age Z-scores could be shown. NE led to improvements in children's diets. For effects on growth, it is assumed that longer NE activities are required to achieve sustainable behaviour change of age-appropriate infant feeding.

Nasogastric tube feeding: a safe option for patients?

This article will show that fine-bore nasogastric tube feeding can be facilitated for patients when long term percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG) options are not suitable. How the safe replacement of these tubes is facilitated, and what instructions the patient and the nursing home are given to support patient care and safety are also discussed. The decision to support this type of feeding must be completely individualised, considering home and external support agencies available to each patient. The risk assessment completed to facilitate this has been based on the patients' individual circumstances, and a nasogastric tube home passport developed to help in the assessment and decision-making process. For fine-bore nasogastric tube feeding to be safe, it does have to be supported once the patient is discharged from the hospital. A good knowledge of the home support and carer support agencies, and what is available, should be discussed. Multidisciplinary team support is essential in ensuring a safe discharge can be planned and managed. Good patient risk assessment and nursing considerations are discussed to show how the challenges that may prevent a patient discharge with this type of feed are managed. This article will show how two very different patients discharges were facilitated by safe fine-bore nasogastric tube feeding in the community. Patient assessment and nursing considerations are discussed, as well as the importance of a multidisciplinary approach to show how this was successfully achieved in a local district hospital.