Association of Socioeconomic Status With Life's Essential 8 in the National Health and Nutrition Examination Survey: Effect Modification by Sex.

BACKGROUND: Higher scores for the American Heart Association Life's Essential 8 (LE8) metrics, blood pressure, cholesterol, glucose, body mass index, physical activity, smoking, sleep, and diet, are associated with lower risk of chronic disease. Socioeconomic status (SES; employment, insurance, education, and income) is associated with LE8 scores, but there is limited understanding of potential differences by sex. This analysis quantifies the association of SES with LE8 for each sex, within Hispanic Americans, non-Hispanic Asian Americans, non-Hispanic Black Americans, and non-Hispanic White Americans. METHODS AND RESULTS: Using cross-sectional data from the National Health and Nutrition Examination Survey, years 2011 to 2018, LE8 scores were calculated (range, 0-100). Age-adjusted linear regression quantified the association of SES with LE8 score. The interaction of sex with SES in the association with LE8 score was assessed in each racial and ethnic group. The US population representatively weighted sample (13 529 observations) was aged ≥20 years (median, 48 years). The association of education and income with LE8 scores was higher in women compared with men for non-Hispanic Black Americans and non-Hispanic White Americans (P for all interactions <0.05). Among non-Hispanic Asian Americans and Hispanic Americans, the association of SES with LE8 was not different between men and women, and women had greater LE8 scores than men at all SES levels (eg, high school or less, some college, and college degree or more). CONCLUSIONS: The factors that explain the sex differences among non-Hispanic Black Americans and non-Hispanic White Americans, but not non-Hispanic Asian Americans and Hispanic Americans, are critical areas for further research to advance cardiovascular health equity.

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education.

OBJECTIVE: Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention. DESIGN: Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later. PARTICIPANTS: Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148). INTERVENTION: Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis. VARIABLES MEASURED: Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner. ANALYSIS: Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence. RESULTS: At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107). CONCLUSIONS AND IMPLICATIONS: Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.

BACKGROUND: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN: 2 × 2 factorial design. INTERVENTIONS: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS: gov: NCT05472441.

Outcomes of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention.

BACKGROUND: Diabetes self-management education and support is the cornerstone of diabetes care, yet only 1 in 2 adults with diabetes attain hemoglobin A1c (HbA1c) targets. Food insecurity makes diabetes management and HbA1c control more difficult. OBJECTIVE: Our aim was to test whether a cooking intervention with food provision and diabetes self-management education and support improves HbA1c and diabetes management. DESIGN: This was a waitlist-controlled, randomized trial. PARTICIPANTS/SETTING: Participants were 48 adults with type 1 or type 2 diabetes. INTERVENTION: Cooking Matters for Diabetes was adapted from Cooking Matters and the American Diabetes Association diabetes self-management education and support intervention into a 6-week program with weekly food provision (4 servings). MAIN OUTCOME MEASURES: Surveys (ie, Summary of Diabetes Self-Care Activities; Medical Outcomes Study Short Form Health Survey, version 1; Diet History Questionnaire III; 10-item US Adult Food Security Survey Module; and Stanford Diabetes Self-Efficacy Scale) were administered and HbA1c was measured at baseline, post intervention, and 3-month follow-up. STATISTICAL ANALYSIS: Mixed-effects linear regression models controlling for sex and study wave were used. RESULTS: Mean (SD) age of participants was 57 (12) years; 65% identified as female, 52% identified as White, 40% identified as Black, and 19 (40%) were food insecure at baseline. Intervention participants improved Summary of Diabetes Self-Care Activities general diet score (0 to 7 scale) immediately post intervention (+1.51; P = .015) and 3 months post intervention (+1.23; P = .05), and improved Medical Outcomes Study Short Form Health Survey, version 1, mental component score (+6.7 points; P = .025) compared with controls. Healthy Eating Index 2015 total vegetable component score improved at 3 months (+0.917; P = .023) compared with controls. At baseline, food insecure participants had lower self-efficacy (5.6 vs 6.9 Stanford Diabetes Self-Efficacy Scale; P = .002) and higher HbA1c (+0.77; P = .025), and demonstrated greater improvements in both post intervention (+1.2 vs +0.4 Stanford Diabetes Self-Efficacy Scale score; P = .002, and -0.12 vs +0.39 HbA1c; P = .25) compared with food secure participants. CONCLUSIONS: Cooking Matters for Diabetes may be an effective method of improving diet-related self-care and health-related quality of life, especially among food insecure patients, and should be tested in larger randomized controlled trials.

Feasibility of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention.

BACKGROUND: Diabetes self-management education and support is the cornerstone of diabetes care, yet <10% of adults with diabetes manage their condition successfully. Feasible interventions are needed urgently. OBJECTIVE: Our aim was to assess the feasibility of a cooking intervention with food provision and diabetes self-management education and support. DESIGN: This was a waitlist-controlled, randomized trial. PARTICIPANTS/SETTING: Thirteen adults with type 1 or type 2 diabetes who participated in Cooking Matters for Diabetes (CMFD) participated in 2 focus groups. INTERVENTION: CMFD was adapted from Cooking Matters and the American Diabetes Association's diabetes self-management education and support intervention into a 6-week program with weekly lesson-aligned food provisions. MAIN OUTCOME MEASURES: Feasibility was evaluated quantitatively and qualitatively along the following 5 dimensions: demand, acceptability, implementation, practicality, and limited efficacy. STATISTICAL ANALYSIS: Two coders extracted focus group themes with 100% agreement after iterative analysis, resulting in consensus. Administrative data were analyzed via descriptive statistics. RESULTS: Mean (SD) age of focus group participants was 57 (14) years; 85% identified as female; 39% identified as White; 46% identified as Black; and income ranged from <$5,000 per year (15%) to $100,000 or more per year (15%). Mean (SD) baseline hemoglobin A1c was 8.6% (1.2%). Mean attendance in CMFD was 5 of 6 classes (83%) among all participants. Demand was high based on attendance and reported intervention utilization and was highest among food insecure participants, who were more likely to report using the food provisions and recipes. Acceptability was also high; focus groups revealed the quality of instructors and interaction with peers as key intervention strengths. Participant ideas for implementation refinement included simplifying recipes, lengthening class sessions, and offering more food provision choices. Perceived effects of the intervention included lower hemoglobin A1c and body weight and improvements to health-related quality of life. CONCLUSIONS: The CMFD intervention was feasible according to the measured principles of demand, acceptability, implementation, practicality, and limited efficacy.

Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination.

Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.

Food insecurity can make the self-management of diet-related chronic conditions (e.g., diabetes, hypertension, and obesity) difficult. Clinic-based food referral programs (FRPs) can help address the diet-related needs of food-insecure primary care patients by improving access to nutritious foods. However, the factors contributing to successful FRP implementation in primary care settings are underexplored. The focus of this study was to explore the barriers to and facilitators of implementation of an FRP offered to food-insecure primary care patients with chronic conditions seen at an academic medical center using a multi-stakeholder approach. Competing clinical and patient demands, patient transportation barriers, and food pantry-related stigma were salient factors that prevented healthcare providers and patients from engaging fully with the FRP. Inadequate provider feedback about patients' use of the FRP was also cited as a deterrent to greater provider engagement with the FRP. Critical facilitators of implementation included support and encouragement from program champions and having a coordinated referral process. The intentional branding and presentation of the FRP to eligible patients may have helped encourage its use by destigmatizing the food pantry setting. The impact of optimizing FRP implementation on patient use and program effectiveness warrants further research.

Community supported agriculture plus nutrition education improves skills, self-efficacy, and eating behaviors among low-income caregivers but not their children: a randomized controlled trial.

BACKGROUND: Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a 'share' of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children. METHODS: The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016-2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children's diet quality, body mass index (BMI), and physical activity; caregivers' nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed. RESULTS: No significant net effects on children's dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers' cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security. CONCLUSIONS: Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security. TRIAL REGISTRATION: ClinicalTrials.gov . NCT02770196 . Registered 5 April 2016. Retrospectively registered.

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.

Rural Food and Physical Activity Assessment Using an Electronic Tablet-Based Application, New York, 2013-2014.

INTRODUCTION: A community's built environment can influence health behaviors. Rural populations experience significant health disparities, yet built environment studies in these settings are limited. We used an electronic tablet-based community assessment tool to conduct built environment audits in rural settings. The primary objective of this qualitative study was to evaluate the usefulness of the tool in identifying barriers and facilitators to healthy eating and active living. The second objective was to understand resident perspectives on community features and opportunities for improvement. METHODS: Participants were recruited from 4 rural communities in New York State. Using the tool, participants completed 2 audits, which consisted of taking pictures and recording audio narratives about community features perceived as assets or barriers to healthy eating and active living. Follow-up focus groups explored the audit experience, data captured, and opportunities for change. RESULTS: Twenty-four adults (mean age, 69.4 y (standard deviation, 13.2 y), 6 per community, participated in the study. The most frequently captured features related to active living were related to roads, sidewalks, and walkable destinations. Restaurants, nontraditional food stores, and supermarkets were identified in the food environment in relation to the cost, quality, and selection of healthy foods available. In general, participants found the assessment tool to be simple and enjoyable to use. CONCLUSION: An electronic tablet-based tool can be used to assess rural food and physical activity environments and may be useful in identifying and prioritizing resident-led change initiatives. This resident-led assessment approach may also be helpful for informing and evaluating rural community-based interventions.