How Would You Manage This Patient With Obesity? Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

In 2022, 1 in 8 people in the world were living with obesity, and lifestyle interventions that include diet, exercise, and behavioral modification have been the foundation for management of obesity. Recently, pharmacologic therapies have been developed for management of obesity, the newest of these being glucagon-like peptide 1 receptor agonists. With the development of new pharmacologic options, the American Gastroenterological Association developed a guideline in 2022 to provide evidence-based recommendations for the pharmacologic management of obesity in adults and recommended, for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions, adding pharmacologic agents to lifestyle interventions over continuing lifestyle interventions alone. In this article, 2 experts review the available evidence to answer the following questions: How effective are lifestyle interventions for the treatment of obesity? How effective are pharmacologic interventions for the treatment of obesity? Given these options, how do you engage in a shared decision-making discussion to develop a mutually agreed-on treatment plan?

Internal Medicine Program Directors' Perceptions About Accommodating Residents with Disabilities: A Qualitative Study.

BACKGROUND: While 26% of US adults are disabled, only 3.1 to 9.3% of practicing physicians report having a disability. Ableism within medical training and practice diminishes physician diversity and wellbeing and contributes to healthcare disparities. OBJECTIVE: Explore physician barriers to disability equity and inclusion by examining internal medicine (IM) program directors' (PD) perspectives about recruiting and accommodating residents with disabilities (RWD). DESIGN: Qualitative study involving semi-structured virtual interviews (conducted December 2022-September 2023; analyzed through December 2023). PARTICIPANTS: PDs were recruited via email. Purposive sampling captured program diversity in size, location, and affiliations. Convenience sampling ensured PD diversity by gender, race/ethnicity, and age. APPROACH: Coders analyzed thematic and discursive content of interview transcripts to characterize PD perspectives about RWDs and accommodations. KEY RESULTS: Of the 15 programs represented, 4 had ≤ 49 and 8 had ≥ 100 total residents. Three were community-based; the rest had academic affiliations. On average, PDs had 17 (SD 8.2) years in practice. Most (11/15) identified as White race; 8/15 as female; and none as disabled. PDs characterized disability as a source of grit and empathy but also as an intrinsic deficit. They worried RWDs could have unpredictable absences and clinical incompetencies. Perceived accommodation challenges included inexperience, workload distribution, information asymmetry about accommodation needs or options, barriers to disclosure (e.g., discrimination concerns), and insufficient accommodation advertising. Perceived facilitators included advanced planning; clear, publicized processes; and access to expertise (e.g., occupational health, ombudsmen). CONCLUSIONS: PDs held contradictory views of RWDs. PD insights revealed opportunities to alleviate PD-RWD information asymmetry in recruitment/accommodation processes, which could help align needs and improve representation and inclusion.

Genetic predisposition to macronutrient preference and workplace food choices.

Prior research identified genetic variants influencing macronutrient preference, but whether genetic differences underlying nutrient preference affect long-term food choices is unknown. Here we examined the associations of polygenic scores for carbohydrate, fat, and protein preference with 12 months' workplace food purchases among 397 hospital employees from the ChooseWell 365 study. Food purchases were obtained retrospectively from the hospital's cafeteria sales data for the 12 months before participants were enrolled in the ChooseWell 365 study. Traffic light labels, visible to employees when making purchases, measured the quality of workplace purchases. During the 12-month study period, there were 215,692 cafeteria purchases. Each SD increase in the polygenic score for carbohydrate preference was associated with 2.3 additional purchases/month (95%CI, 0.2 to 4.3; p = 0.03) and a higher number of green-labeled purchases (ß = 1.9, 95%CI, 0.5-3.3; p = 0.01). These associations were consistent in subgroup and sensitivity analyses accounting for additional sources of bias. There was no evidence of associations between fat and protein polygenic scores and cafeteria purchases. Findings from this study suggest that genetic differences in carbohydrate preference could influence long-term workplace food purchases and may inform follow-up experiments to enhance our understanding of the molecular mechanisms underlying food choice behavior.

Association between participation in the supplemental nutrition assistance program and perception of limited availability and choice of healthy foods.

BACKGROUND: Nutrition security encompasses stable and equitable access, availability, affordability, and utilization of healthy foods. AIM: To evaluate the relationship of two newly created dichotomous measures that represent aspects of nutrition security (i.e., perceived limited availability and healthfulness choice) with Supplemental Nutrition Assistance Program (SNAP) participation. METHODS: Logistic regression models were run for each outcome separately with adjustment for age, income-to-poverty ratio, gender, education, race, and food security. RESULTS: Adults using social services (e.g., food pantries) were enrolled (N = 402) in this cross-sectional analysis. SNAP participants (61.7%) were not different from non-SNAP participants in perceiving limited availability (aOR [95% CI]: 1.21 [0.75, 1.95]) or limited ability to choose (aOR [95% CI]: 0.69 [0.43, 1.12]) healthy foods. CONCLUSIONS: Both SNAP and non-SNAP participants with low socioeconomic status report limited availability of healthy foods in their environment and a limited ability to choose healthy foods.

Using Positive Psychology to Address Emotional Barriers to Physical Activity After Bariatric Surgery: Proof-of-Concept Trial of the Gaining Optimism After Weight Loss Surgery (GOALS) Project.

Physical activity promotes health and longevity after metabolic/bariatric surgery (MBS), but most patients do not meet recommended levels. The Gaining Optimism After weight Loss Surgery (GOALS) Project was a positive psychological intervention designed to address common emotional barriers to physical activity in patients who have recently undergone MBS (e.g., low confidence around exercise, internalized weight bias, fear of injury) and use motivational interviewing and standard behavior change techniques (e.g., self-monitoring) to increase physical activity. This single-arm proof-of-concept trial was designed to refine the intervention, test feasibility and acceptability, and explore pre-post changes in behavioral and psychological outcomes. Participants were 12 adults 6-12 months post-MBS (M age of 46, 58% female, 67% non-Hispanic white). GOALS was a 10-week telephone counseling program that introduced new positive psychological skills and physical activity topics each week. Participants tracked physical activity with a Fitbit and set weekly goals. Results showed that the intervention was feasible (85% of sessions completed) and acceptable (average participant ratings of session ease and utility above 8.0 on a 0-10 scale). There were medium-to-large effect size improvements in physical activity and psychological well-being (e.g., depressive symptoms). The GOALS intervention will next be tested in a pilot randomized controlled trial with longer-term follow-up to assess its effect more robustly.

Strengthening US Food Policies and Programs to Promote Equity in Nutrition Security: A Policy Statement From the American Heart Association.

Nutritionally inadequate dietary intake is a leading contributor to chronic cardiometabolic diseases. Differences in dietary quality contribute to socioeconomic and racial and ethnic health disparities. Food insecurity, a household-level social or economic condition of limited access to sufficient food, is a common cause of inadequate dietary intake. Although US food assistance policies and programs are designed to improve food security, there is growing consensus that they should have a broader focus on nutrition security. In this policy statement, we define nutrition security as an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease. Despite existing policies and programs, significant gaps remain for achieving equity in nutrition security across the life span. We provide recommendations for expanding and improving current food assistance policies and programs to achieve nutrition security. These recommendations are guided by several overarching principles: emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across programs, ensuring stability of access to programs across the life course, and ensuring equity and dignity for access and utilization. We suggest a critical next step will be to develop and implement national measures of nutrition security that can be added to the current US food security measures. Achieving equity in nutrition security will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand existing food assistance policies and programs and to develop and implement new policies and programs that will improve cardiovascular health and reduce disparities in chronic disease.

Participant Characteristics Associated with High Responsiveness to Personalized Healthy Food Incentives: a Secondary Analysis of the Randomized Controlled Crossover Smart Cart Study.

BACKGROUND: Personalized dietary behavioral interventions could be enhanced by understanding factors accounting for individual variability in dietary decisions. OBJECTIVE: This study was a secondary analysis of the Smart Cart randomized controlled trial to determine whether participant characteristics predicted high responsiveness to personalized grocery incentives for purchasing healthy food. METHODS: This secondary analysis of a 9-mo crossover study included 192 regular shoppers (86%) from a Rhode Island supermarket. To analyze whether health, behavioral, and/or sociodemographic characteristics predicted responsiveness to a personalized grocery incentive intervention, participants were divided into 3 categories [high (n = 47), moderate (n = 50), and unresponsive (n = 95)] based on percentage changes in their Grocery Purchase Quality Index scores during the intervention versus control period calculated from sales data. We tested whether participant characteristics, including individual, household, and intervention-related factors, differed across responsiveness groups using ANOVA and whether they predicted the likelihood of being high responsive versus unresponsive or moderate responsive using logistic regression. RESULTS: Participants had a mean (SD) age of 56.0 (13.8) y and were 89% female. Education, self-reported BMI, income, diet-related medical condition, food insecurity, cooking adequacy, and value consciousness differed across responsiveness categories (P < 0.1). High versus moderate and unresponsive participants increased their percentage of spending on targeted foods (P < 0.0001) and purchased fewer unique items (P = 0.01). In multinomial adjusted models, the odds of being high versus unresponsive or moderate responsive were lower for participants with a BMI (in kg/m2) <25 versus ≥25 (OR: 0.41; 95% CI: 0.19, 0.90) and higher with a diet-related medical condition present (OR: 3.75; 95% CI: 1.20, 11.8). Other characteristics were not associated with responsiveness. CONCLUSIONS: Findings demonstrated that a BMI ≥25 and having a diet-related medical condition within the household predicted high responsiveness to a personalized grocery purchasing intervention, suggesting that personalized dietary interventions may be particularly effective for households with higher health risk. This trial is registered at www.clinicaltrials.gov as NCT03748056.

Importance of Nutrition Security to CVD Prevention Efforts in the USA.

PURPOSE OF REVIEW: The importance of addressing nutrition security for the primary and secondary prevention of cardiovascular disease (CVD) in the USA is reviewed by describing the relationships between food security, diet quality, and CVD risk along with the ability of governmental, community, and healthcare policies and interventions to address nutrition security. RECENT FINDINGS: Existing safety net programs have shown to be effective at improving food security and diet quality and reducing risk for CVD, but continued efforts to increase reach and improve standards are needed. Adoption of policies, healthcare initiatives, and community- and individual-level interventions addressing the nutritional intake of socioeconomically disadvantaged populations may also lessen CVD burden, but scaling interventions remains a key challenge. Research suggests simultaneously addressing food security and diet quality is feasible and could help reduce socioeconomic disparities in CVD morbidity and mortality. Intervening at multiple levels among high-risk groups should be a priority.

Effects of in-store marketing on food and beverage purchases: a longitudinal study of households with children.

OBJECTIVE: Most food retailers display foods in prominent locations as a marketing strategy (i.e. 'placement promotions'). We examined the extent to which households with children change their food and beverage purchases in response to these promotions. DESIGN: We analysed a novel dataset of all products promoted in two supermarkets from 2016 to 2017, including promotion dates and locations (e.g. aisle endcaps and front registers). We linked promotions to all purchases from the supermarkets from 2016 to 2017 by a cohort of households with children. We calculated the number of weekly promotions in each of thirteen food and beverage groups (e.g. bread; candy) and used fixed effects regressions to estimate associations between number of weekly promotions and households' weekly food purchases, overall and by Supplemental Nutrition Assistance Program (SNAP) participation. SETTING: Two large supermarkets in Maine, USA. PARTICIPANTS: Eight hundred and twenty-one households with children. RESULTS: Most promotions (74 %) were for less healthy foods. The most promoted food groups were sweet and salty snacks (mean = 131·0 promotions/week), baked goods (mean = 68·2) and sugar-sweetened beverages (mean = 41·6). Households generally did not change their food group purchases during weeks when they were exposed to more promotions for those groups, except that a 1-sd increase in endcap candy promotions (about 1 promotion/week) was associated with $0·19/week (about 14·5 %) increase in candy purchases among SNAP nonparticipants (adjusted P < 0·001). CONCLUSIONS: In-store placement promotions for food groups were generally not associated with purchases of promoted food groups, perhaps because exposure to unhealthy food marketing was consistently high. Substantial changes to in-store food marketing may be needed to promote healthier purchases.

Housing instability and cardiometabolic health in the United States: a narrative review of the literature.

Housing instability is variably defined but generally encompasses difficulty paying rent, living in poor or overcrowded conditions, moving frequently, or spending the majority of household income on housing costs. While there is strong evidence that people experiencing homelessness (i.e., lack of regular housing) are at increased risk for cardiovascular disease, obesity, and diabetes, less is known about housing instability and health. We synthesized evidence from 42 original research studies conducted in the United States examining the association of housing instability and cardiometabolic health conditions of overweight/obesity, hypertension, diabetes, and cardiovascular disease. The included studies varied widely in their definitions and methods of measuring housing instability, but all exposure variables were related to housing cost burden, frequency of moves, living in poor or overcrowded conditions, or experiencing eviction or foreclosure, measured at either the individual household level or at a population level. We also included studies examining the impact of receipt of government rental assistance, which serves as a marker of housing instability given that its purpose is to provide affordable housing for low-income households. Overall, we found mixed but generally adverse associations between housing instability and cardiometabolic health, including higher prevalence of overweight/obesity, hypertension, diabetes, and cardiovascular disease; worse hypertension and diabetes control; and higher acute health care utilization among those with diabetes and cardiovascular disease. We propose a conceptual framework for pathways linking housing instability and cardiometabolic disease that could be targeted in future research and housing policies or programs.

A food bank program to help food pantries improve healthy food choices: mixed methods evaluation of The Greater Boston Food Bank's Healthy Pantry Program.

BACKGROUND: The Greater Boston Food Bank's (GBFB) Healthy Pantry Program (HPP) is an online training that teaches food pantry staff to implement behavioral nudges (e.g., traffic-light nutrition labels, choice architecture) to promote healthier client choices. This study assessed if HPP was associated with healthier food bank orders by food pantries and identified implementation facilitators and barriers. METHODS: This mixed methods study collected quantitative data from a matched cohort of 10 HPP food pantries and 99 matched control food pantries in eastern Massachusetts that allow clients to choose their own food, and qualitative data from structured individual interviews with 8 HPP pantry staff. A difference-in-differences analysis compared changes in percentage of pantries' food bank orders (by weight) of foods labeled green/yellow (healthier choices) and fresh produce from baseline to 6 and 10 months between HPP and control pantries. Interviews were coded for implementation facilitators and barriers. RESULTS: Before starting HPP, green-yellow ordering was 92.0% (SD 4.9) in control and 87.4% (SD 5.4) in HPP pantries. Participation in HPP was not associated with changes in green-yellow or fresh produce ordering at 6 or 10 months. HPP implementation facilitators included HPP training being accessible (sub-themes: customizable, motivating) and compatible with client-choice values. Barriers included resource limitations (sub-themes: staff shortage, limited space) and concerns about stigmatizing client food choices with use of labels for unhealthy foods. CONCLUSIONS: An online program to help pantries promote healthier client choices was not associated with changes in how much healthy food pantries ordered from the food bank, suggesting it did not substantially change client choices. Implementation challenges and high baseline healthy ordering may have influenced HPP's effectiveness.

Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States.

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Impact of Sit-to-Stand and Treadmill Desks on Patterns of Daily Waking Physical Behaviors Among Overweight and Obese Seated Office Workers: Cluster Randomized Controlled Trial.

BACKGROUND: Sit-to-stand and treadmill desks may help sedentary office workers meet the physical activity guideline to "move more and sit less," but little is known about their long-term impact on altering the accumulation patterns of physical behaviors. OBJECTIVE: This study explores the impact of sit-to-stand and treadmill desks on physical behavior accumulation patterns during a 12-month multicomponent intervention with an intent-to-treat design in overweight and obese seated office workers. METHODS: In total, 66 office workers were cluster randomized into a seated desk control (n=21, 32%; 8 clusters), sit-to-stand desk (n=23, 35%; 9 clusters), or treadmill desk (n=22, 33%; 7 clusters) group. Participants wore an activPAL (PAL Technologies Ltd) accelerometer for 7 days at baseline, 3-month follow-up (M3), 6-month follow-up (M6), and 12-month follow-up (M12) and received periodic feedback on their physical behaviors. Analyses of physical behavior patterns included total day and workday number of sedentary, standing, and stepping bouts categorized into durations ranging from 1 to 60 and >60 minutes and usual sedentary, standing, and stepping bout durations. Intervention trends were analyzed using random-intercept mixed linear models accounting for repeated measures and clustering effects. RESULTS: The treadmill desk group favored prolonged sedentary bouts (>60 min), whereas the sit-to-stand desk group accrued more short-duration sedentary bouts (<20 min). Therefore, compared with controls, sit-to-stand desk users had shorter usual sedentary bout durations short-term (total day ΔM3: -10.1 min/bout, 95% CI -17.9 to -2.2; P=.01; workday ΔM3: -20.3 min/bout, 95% CI -37.7 to -2.9; P=.02), whereas treadmill desk users had longer usual sedentary bout durations long-term (total day ΔM12: 9.0 min/bout, 95% CI 1.6-16.4; P=.02). The treadmill desk group favored prolonged standing bouts (30-60 min and >60 min), whereas the sit-to-stand desk group accrued more short-duration standing bouts (<20 min). As such, relative to controls, treadmill desk users had longer usual standing bout durations short-term (total day ΔM3: 6.9 min/bout, 95% CI 2.5-11.4; P=.002; workday ΔM3: 8.9 min/bout, 95% CI 2.1-15.7; P=.01) and sustained this long-term (total day ΔM12: 4.5 min/bout, 95% CI 0.7-8.4; P=.02; workday ΔM12: 5.8 min/bout, 95% CI 0.9-10.6; P=.02), whereas sit-to-stand desk users showed this trend only in the long-term (total day ΔM12: 4.2 min/bout, 95% CI 0.1-8.3; P=.046). The treadmill desk group accumulated more stepping bouts across various bins of duration (5-50 min), primarily at M3. Thus, treadmill desk users had longer usual stepping bout durations in the short-term compared with controls (workday ΔM3: 4.8 min/bout, 95% CI 1.3-8.3; P=.007) and in the short- and long-term compared with sit-to-stand desk users (workday ΔM3: 4.7 min/bout, 95% CI 1.6-7.8; P=.003; workday ΔM12: 3.0 min/bout, 95% CI 0.1-5.9; P=.04). CONCLUSIONS: Sit-to-stand desks exerted potentially more favorable physical behavior accumulation patterns than treadmill desks. Future active workstation trials should consider strategies to promote more frequent long-term movement bouts and dissuade prolonged static postural fixity. TRIAL REGISTRATION: ClinicalTrials.gov NCT02376504; https://clinicaltrials.gov/ct2/show/NCT02376504.

2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association.

Poor diet quality is strongly associated with elevated risk of cardiovascular disease morbidity and mortality. This scientific statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. Evidence-based dietary pattern guidance to promote cardiometabolic health includes the following: (1) adjust energy intake and expenditure to achieve and maintain a healthy body weight; (2) eat plenty and a variety of fruits and vegetables; (3) choose whole grain foods and products; (4) choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms); (5) use liquid plant oils rather than tropical oils and partially hydrogenated fats; (6) choose minimally processed foods instead of ultra-processed foods; (7) minimize the intake of beverages and foods with added sugars; (8) choose and prepare foods with little or no salt; (9) if you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake; and (10) adhere to this guidance regardless of where food is prepared or consumed. Challenges that impede adherence to heart-healthy dietary patterns include targeted marketing of unhealthy foods, neighborhood segregation, food and nutrition insecurity, and structural racism. Creating an environment that facilitates, rather than impedes, adherence to heart-healthy dietary patterns among all individuals is a public health imperative.

Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco's Mission District: a qualitative study.

BACKGROUND: People experiencing homelessness have unique health needs and barriers to medical and behavioral health care (mental health, substance use disorder, and overall well-being) compared to housed people. It remains unclear why many people experiencing homelessness do not access care when community-based homeless health care resources are available at low or no cost. This qualitative study examined perspectives of people experiencing homelessness and staff members at community-based homeless health and service organizations in San Francisco's Mission District on unmet medical and behavioral health needs and barriers to accessing care. METHODS: We conducted 34 interviews between September and November 2020: 23 with people experiencing homelessness and 11 with staff at community-based homeless health and service organizations in the Mission District. Qualitative interviews were transcribed, coded, and analyzed using the Framework Method on NVivo Qualitative Data Analysis Software. RESULTS: Both staff and homeless participants reported unmet and common health needs of mental illness, physical injury and disability, food and nutrition insecurity, and substance use disorder. Barriers to care included negative prior health care experiences, competing priorities, and provider turnover. Recommendations for improving services included building more trust with people experiencing homelessness by training clinic staff to treat patients with respect and patience and expanding clinical outreach and health education programs. CONCLUSIONS: People experiencing homelessness face many different health needs and barriers to care, some of which community-based organizations have the ability to address. These findings can help inform future strategies for homeless health care programs to identify and target the specific unmet health needs and barriers to care of people experiencing homelessness in their communities.

Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO).

BACKGROUND: Health-related social needs (HRSN) are associated with higher chronic disease prevalence and healthcare utilization. Health systems increasingly screen for HRSN during routine care. In this study, we compare the differential prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO) and identify the patient and practice characteristics associated with reporting social needs in a different domain from social risks. METHODS: Cross-sectional study of patient responses to HRSN screening February 2019-February 2020. HRSN screening occurred as part of routine primary care and assessed social risk factors in eight domains and social needs by requesting resources in these domains. Participants included adult and pediatric patients from 114 primary care practices. We measured patient-reported social risk factors and social needs from the HRSN screening, and performed multivariable regression to evaluate patient and practice characteristics associated with reporting social needs and concordance to social risks. Covariates included patient age, sex, race, ethnicity, language, and practice proportion of patients with Medicaid and/or Limited English Proficiency (LEP). RESULTS: Twenty-seven thousand four hundred thirteen individuals completed 30,703 screenings, including 15,205 (55.5%) caregivers of pediatric patients. Among completed screenings, 13,692 (44.6%) were positive for ≥ 1 social risk factor and 2,944 (9.6%) for ≥ 3 risks; 5,861 (19.1%) were positive for social needs and 4,848 (35.4%) for both. Notably, 1,013 (6.0%) were negative for social risks but positive for social needs. Patients who did not identify as non-Hispanic White or were in higher proportion LEP or Medicaid practices were more likely to report social needs, with or without social risks. Patients who were non-Hispanic Black, Hispanic, preferred non-English languages or were in higher LEP or Medicaid practices were more likely to report social needs without accompanying social risks. CONCLUSIONS: Half of Medicaid ACO patients screened for HRSN reported social risk factors or social needs, with incomplete overlap between groups. Screening for both social risks and social needs can identify more individuals with HRSN and increase opportunities to mitigate negative health outcomes.

Contributions of Food Environments to Dietary Quality and Cardiovascular Disease Risk.

PURPOSE OF REVIEW: To evaluate the multidimensional influence of food environments on food choice, dietary quality, and diet-related health and identify critical gaps necessary to develop effective population interventions that influence food choice. RECENT FINDINGS: Multicomponent interventions that interact with multiple layers of the food environment show limited but consistent effects on dietary behaviors and may have wider and substantive population-level reach with greater incorporation of validated, holistic measurement tools. Opportunities to use smartphone technology to measure multiple components of the food environment will facilitate future interventions, particularly as food environments expand into online settings and interact with consumers in novel ways to shape food choice. While studies suggest that all dimensions of the food environment influence diet and health outcomes, robust and consistent measurements of food environments that integrate objective and subjective components are essential for developing stronger evidence needed to shift public policies.

The utility of household Grocery Purchase Quality Index scores as an individual diet quality metric.

The Grocery Purchase Quality Index (GPQI) reflects concordance between household grocery purchases and US dietary recommendations. However, it is unclear whether GPQI scores calculated from partial purchasing records reflect individual-level diet quality. This secondary analysis of a 9-month randomised controlled trial examined concordance between the GPQI (range 0-75, scaled to 100) calculated from 3 months of loyalty-card linked partial (≥50 %) household grocery purchasing data and individual-level Healthy Eating Index (HEI) scores at baseline and 3 months calculated from FFQ (n 209). Concordance was assessed with overall and demographic-stratified partially adjusted correlations; covariate-adjusted percentage score differences, cross-classification and weighted κ coefficients assessed concordance across GPQI tertiles (T). Participants were middle aged (55·4 (13·9) years), female (90·3 %), from non-smoking households (96·4 %) and without children (70·7 %). Mean GPQI (54·8 (9·1) %) scores were lower than HEI scores (baseline: 73·2 (9·1) %, 3 months: 72·4 (9·4) %) and moderately correlated (baseline r 0·41 v. 3 months r 0·31, P < 0·001). Correlations were stronger among participants with ≤ bachelor's degree, obesity and children. Scores showed moderate agreement (κ = 0·25); concordance was highest in T3. Participants with high (T3) v. low (T1) GPQI scores had 7·3-10·6 higher odds of having HEI scores >80 % at both time points. Household-level GPQI was moderately correlated with self-reported intake, indicating their promise for evaluating diet quality. Partial purchasing data appear to moderately reflect individual diet quality and may be useful in interventions monitoring changes in diet quality.

Comparing shopper characteristics by online grocery ordering use among households in low-income communities in Maine.

OBJECTIVE: Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations - especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store. DESIGN: We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store). SETTING: Two Maine supermarkets. PARTICIPANTS: 863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials. RESULTS: Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30-39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186-300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online. CONCLUSIONS: In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes.

BACKGROUND: The prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging-which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes. METHODS: The study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received. DISCUSSION: Targeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes - a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709 .