Leveraging the Black Girls Run Web-Based Community as a Supportive Community for Physical Activity Engagement: Mixed Methods Study.

BACKGROUND: About 59%-73% of Black women do not meet the recommended targets for physical activity (PA). PA is a key modifiable lifestyle factor that can help mitigate risk for chronic diseases such as obesity, diabetes, and hypertension that disproportionately affect Black women. Web-based communities focused on PA have been emerging in recent years as web-based gathering spaces to provide support for PA in specific populations. One example is Black Girls Run (BGR), which is devoted to promoting PA in Black women. OBJECTIVE: The purpose of this study was to describe the content shared on the BGR public Facebook page to provide insight into how web-based communities engage Black women in PA and inform the development of web-based PA interventions for Black women. METHODS: Using Facebook Crowdtangle, we collected posts (n=397) and associated engagement data from the BGR public Facebook page for the 6-month period between June 1, 2021, and December 31, 2021. We pooled data in Dedoose to analyze the qualitative data and conducted a content analysis of qualitative data. We quantified types of posts, post engagement, and compared post types on engagement: "like," "love," "haha," "wow," "care," "sad," "angry," "comments," and "shares." RESULTS: The content analysis revealed 8 categories of posts: shout-outs to members for achievements (n=122, 31%), goals or motivational (n=65, 16%), announcements (n=63, 16%), sponsored or ads (n=54, 14%), health related (n=47, 11%), the lived Black experience (n=23, 6%), self-care (n=15, 4%), and holidays or greetings (n=8, 2%). The 397 posts attracted a total of 55,354 engagements (reactions, comments, and shares). Associations between the number of engagement and post categories were analyzed using generalized linear models. Shout-out posts (n=22,268) elicited the highest average of total user engagement of 181.7 (SD 116.7), followed by goals or motivational posts (n=11,490) with an average total engagement of 160.1 (SD 125.2) and announcements (n=7962) having an average total engagement of 129.9 (SD 170.7). Significant statistical differences were found among the total engagement of posts (χ72=80.99, P<.001), "like" (χ72=119.37, P<.001), "love" (χ72=63.995, P<.001), "wow" (χ72=23.73, P<.001), "care" (χ72=35.06, P<.001), "comments" (χ72=80.55, P<.001), and "shares" (χ72=71.28, P<.001). CONCLUSIONS: The majority of content on the BGR Facebook page (n=250, 63%) was focused on celebrating member achievements, motivating members to get active, and announcing and promoting active events. These types of posts attracted 75% of total post engagement. BGR appears to be a rich web-based community that offers social support for PA as well as culturally relevant health and social justice content. Web-based communities may be uniquely positioned to engage minoritized populations in health behavior. Further research should explore how and if web-based communities such as BGR can be interwoven into health interventions and health promotion.

An Evaluation of a Personalized Multicomponent Commercial Digital Weight Management Program: Single-Arm Behavioral Trial.

BACKGROUND: Digital behavioral weight loss programs are scalable and effective, and they provide an opportunity to personalize intervention components. However, more research is needed to test the acceptability and efficacy of personalized digital behavioral weight loss interventions. OBJECTIVE: In a 6-month single-arm trial, we examined weight loss, acceptability, and secondary outcomes of a digital commercial weight loss program (WeightWatchers). This digital program included a personalized weight loss program based on sex, age, height, weight, and personal food preferences, as well as synchronous (eg, virtual workshops and individual weekly check-ins) and asynchronous (eg, mobile app and virtual group) elements. In addition to a personalized daily and weekly PersonalPoints target, the program provided users with personalized lists of ≥300 ZeroPoint foods, which are foods that do not need to be weighed, measured, or tracked. METHODS: We conducted a pre-post evaluation of this 6-month, digitally delivered, and personalized WeightWatchers weight management program on weight loss at 3 and 6 months in adults with overweight and obesity. The secondary outcomes included participation, satisfaction, fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, self-compassion, well-being, and behavioral automaticity. RESULTS: Of the 153 participants, 107 (69.9%) were female, and 65 (42.5%) identified as being from a minoritized racial or ethnic group. Participants' mean age was 41.09 (SD 13.78) years, and their mean BMI was 31.8 (SD 5.0) kg/m2. Participants had an average weight change of -4.25% (SD 3.93%) from baseline to 3 months and -5.05% (SD 5.59%) from baseline to 6 months. At 6 months, the percentages of participants who experienced ≥3%, ≥5%, and ≥10% weight loss were 63.4% (97/153), 51% (78/153), and 14.4% (22/153), respectively. The mean percentage of weeks in which participants engaged in ≥1 aspects of the program was 87.53% (SD 23.40%) at 3 months and 77.67% (SD 28.69%) at 6 months. Retention was high (132/153, 86.3%), and more than two-thirds (94/140, 67.1%) of the participants reported that the program helped them lose weight. Significant improvements were observed in fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, and well-being (all P values <.01). CONCLUSIONS: This personalized, digital, and scalable behavioral weight management program resulted in clinically significant weight loss in half (78/153, 51%) of the participants as well as improvements in behavioral and psychosocial outcomes. Future research should compare personalized digital weight loss programs with generic programs on weight loss, participation, and acceptability.

Developing the "Choosing Health" Digital Weight Loss and Maintenance Intervention: Intervention Mapping Study.

BACKGROUND: Digital health promotion programs tailored to the individual are a potential cost-effective and scalable solution to enable self-management and provide support to people with excess body weight. However, solutions that are widely accessible, personalized, and theory- and evidence-based are still limited. OBJECTIVE: This study aimed to develop a digital behavior change program, Choosing Health, that could identify modifiable predictors of weight loss and maintenance for each individual and use these to provide tailored support. METHODS: We applied an Intervention Mapping protocol to design the program. This systematic approach to develop theory- and evidence-based health promotion programs consisted of 6 steps: development of a logic model of the problem, a model of change, intervention design and intervention production, the implementation plan, and the evaluation plan. The decisions made during the Intervention Mapping process were guided by theory, existing evidence, and our own research-including 4 focus groups (n=40), expert consultations (n=12), and interviews (n=11). The stakeholders included researchers, public representatives (including individuals with overweight and obesity), and experts from a variety of relevant backgrounds (including nutrition, physical activity, and the health care sector). RESULTS: Following a structured process, we developed a tailored intervention that has the potential to reduce excess body weight and support behavior changes in people with overweight and obesity. The Choosing Health intervention consists of tailored, personalized text messages and email support that correspond with theoretical domains potentially predictive of weight outcomes for each participant. The intervention content includes behavior change techniques to support motivation maintenance, self-regulation, habit formation, environmental restructuring, social support, and addressing physical and psychological resources. CONCLUSIONS: The use of an Intervention Mapping protocol enabled the systematic development of the Choosing Health intervention and guided the implementation and evaluation of the program. Through the involvement of different stakeholders, including representatives of the general public, we were able to map out program facilitators and barriers while increasing the ecological validity of the program to ensure that we build an intervention that is useful, user-friendly, and informative. We also summarized the lessons learned for the Choosing Health intervention development and for other health promotion programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-040183.

Persisting Effects of a Social Media Campaign to Prevent Indoor Tanning: A Randomized Trial.

BACKGROUND: A social media campaign for mothers aimed at reducing indoor tanning (IT) by adolescent daughters reduced mothers' permissiveness toward IT in an immediate posttest. Whether the effects persisted at 6 months after the campaign remains to be determined. METHODS: Mothers (N = 869) of daughters ages 14-17 in 34 states without bans on IT by minors were enrolled in a randomized trial. All mothers received an adolescent health campaign over 12 months with posts on preventing IT (intervention) or prescription drug misuse (control). Mothers completed a follow-up at 18 months post-randomization measuring IT permissiveness, attitudes, intentions, communication, and behavior, and support for state bans. Daughters (n = 469; 54.0%) just completed baseline and follow-up surveys. RESULTS: Structural equation modeling showed that intervention-group mothers were less permissive of IT by daughters [unstandardized coefficient, -0.17; 95% confidence interval (CI), -0.31 to -0.03], had greater self-efficacy to refuse daughter's IT requests (0.17; 95% CI, 0.06-0.29) and lower IT intentions themselves (-0.18; 95% CI, -0.35 to -0.01), and were more supportive of bans on IT by minors (0.23; 95% CI, 0.02-0.43) than control-group mothers. Intervention-group daughters expressed less positive IT attitudes than controls (-0.16; 95% CI, 0.31 to -0.01). CONCLUSIONS: The social media campaign may have had a persisting effect of convincing mothers to withhold permission for daughters to indoor tan for 6 months after its conclusion. Reduced IT intentions and increased support for bans on IT by minors also persisted among mothers. IMPACT: Social media may increase support among mothers to place more restrictions on IT by minors.

A systematic review of the engagement with social media-delivered interventions for improving health outcomes among sexual and gender minorities.

BACKGROUND: Sexual and gender minority (SGM) persons face a number of physical and mental health disparities closely linked to discrimination, social stigma, and victimization. Despite the acceptability and increasing number of digital health interventions focused on improving health outcomes among SGM people, there is a lack of reviews summarizing whether and how researchers assess engagement with social media-delivered health interventions for this group. OBJECTIVE: The objective of this systematic review was to synthesize and critique the evidence on evaluation of engagement with social media-delivered interventions for improving health outcomes among SGM persons. METHODS: We conducted a literature search for studies published between January 2003 and June 2020 using 4 electronic databases. Articles were included if they were peer-reviewed, in English language, assessed engagement with a social media-delivered health intervention for improving health outcomes among sexual and gender minorities. A minimum of two authors independently extracted data from each study using an a priori developed abstraction form. We assessed quality of data reporting using the CONSORT extension for pilot and feasibility studies and CONSORT statement parallel group randomized trials. RESULTS: We included 18 articles in the review; 15 were feasibility studies and 3 were efficacy or effectiveness randomized trials. The quality of data reporting varied considerably. The vast majority of articles focused on improving HIV-related outcomes among men who have sex with men. Only three studies recruited cisgender women and/or transgender persons. We found heterogeneity in how engagement was defined and assessed. Intervention usage from social media data was the most frequently used engagement measure. CONCLUSION: In addition to the heterogeneity in defining and assessing engagement, we found that the focus of assessment was often on measures of intervention usage only. More purposeful recruitment is needed to learn about whether, how, and why different SGM groups engage with social media-interventions. This leaves significant room for future research to expand evaluation criteria for cognitive and emotional aspects of intervention engagement in order to develop effective and tailored social media-delivered interventions for SGM people. Our findings also support the need for developing and testing social media-delivered interventions that focus on improving mental health and outcomes related to chronic health conditions among SGM persons.

Rationale and design of a large population study to validate software for the assessment of atrial fibrillation from data acquired by a consumer tracker or smartwatch: The Fitbit heart study.

BACKGROUND: Early detection of atrial fibrillation or flutter (AF) may enable prevention of downstream morbidity. Consumer wrist-worn wearable technology is capable of detecting AF by identifying irregular pulse waveforms using photoplethysmography (PPG). The validity of PPG-based software algorithms for AF detection requires prospective assessment. METHODS: The Fitbit Heart Study (NCT04380415) is a single-arm remote clinical trial examining the validity of a novel PPG-based software algorithm for detecting AF. The proprietary Fitbit algorithm examines pulse waveform intervals during analyzable periods in which participants are sufficiently stationary. Fitbit consumers with compatible wrist-worn trackers or smartwatches were invited to participate. Enrollment began May 6, 2020 and as of October 1, 2020, 455,699 participants enrolled. Participants in whom an irregular heart rhythm was detected were invited to attend a telehealth visit and eligible participants were then mailed a one-week single lead electrocardiographic (ECG) patch monitor. The primary study objective is to assess the positive predictive value of an irregular heart rhythm detection for AF during the ECG patch monitor period. Additional objectives will examine the validity of irregular pulse tachograms during subsequent heart rhythm detections, self-reported AF diagnoses and treatments, and relations between irregular heart rhythm detections and AF episode duration and time spent in AF. CONCLUSIONS: The Fitbit Heart Study is a large-scale remote clinical trial comprising a unique software algorithm for detection of AF. The study results will provide critical insights into the use of consumer wearable technology for AF detection, and for characterizing the nature of AF episodes detected using consumer-based PPG technology.

Design and baseline data of a randomized trial comparing two methods for scaling-up an occupational sun protection intervention.

BACKGROUND: Successful methods for scaling-up evidence-based programs are needed to prevent skin cancer among adults who work outdoors in the sun. METHODS: A randomized trial is being conducted comparing two methods of scaling-up the Sun Safe Workplaces (SSW) intervention. Departments of transportation (DOTs) from 21 U.S. states are participating and their 138 regional districts were randomized following baseline assessment. In districts assigned to the in-person method (n = 46), project staff meets personally with managers, conducts trainings for employees, and provides printed materials. In districts assigned to the digital method (n = 92), project staff conduct these same activities virtually, using conferencing technology, online training, and electronic materials. Delivery of SSW in both groups was tailored to managers' readiness to adopt occupational sun safety. Posttesting will assess manager's support for and use of SSW and employees' sun safety. An economic evaluation will explore whether the method that uses digital technology results in lower implementation of SSW but is more cost-effective relative to the in-person method. RESULTS: The state DOTs range in size from 997 to 18,415 employees. At baseline, 1113 managers (49.0%) completed the pretest (91.5% male, 91.1% white, 19.77 years on the job, 66.5% worked outdoors; and 24.4% had high-risk skin types). They were generally supportive of occupational sun safety. A minority reported that the employer had a written policy, half reported training, and two-thirds, messaging on sun protection. CONCLUSIONS: Digital methods are available that may make scale-up of SSW cost-effective in a national distribution to nearly half of the state DOTs. TRIAL REGISTRATION: The ClinicalTrials.gov registration number is NCT03278340.

Insulin pricing and other major diabetes-related concerns in the USA: a study of 46 407 tweets between 2017 and 2019.

INTRODUCTION: Little research has been done to systematically evaluate concerns of people living with diabetes through social media, which has been a powerful tool for social change and to better understand perceptions around health-related issues. This study aims to identify key diabetes-related concerns in the USA and primary emotions associated with those concerns using information shared on Twitter. RESEARCH DESIGN AND METHODS: A total of 11.7 million diabetes-related tweets in English were collected between April 2017 and July 2019. Machine learning methods were used to filter tweets with personal content, to geolocate (to the USA) and to identify clusters of tweets with emotional elements. A sentiment analysis was then applied to each cluster. RESULTS: We identified 46 407 tweets with emotional elements in the USA from which 30 clusters were identified; 5 clusters (18% of tweets) were related to insulin pricing with both positive emotions (joy, love) referring to advocacy for affordable insulin and sadness emotions related to the frustration of insulin prices, 5 clusters (12% of tweets) to solidarity and support with a majority of joy and love emotions expressed. The most negative topics (10% of tweets) were related to diabetes distress (24% sadness, 27% anger, 21% fear elements), to diabetic and insulin shock (45% anger, 46% fear) and comorbidities (40% sadness). CONCLUSIONS: Using social media data, we have been able to describe key diabetes-related concerns and their associated emotions. More specifically, we were able to highlight the real-world concerns of insulin pricing and its negative impact on mood. Using such data can be a useful addition to current measures that inform public decision making around topics of concern and burden among people with diabetes.

Turning Chutes into Ladders for Women Faculty: A Review and Roadmap for Equity in Academia.

Despite significant progress in recent decades, the recruitment, advancement, and promotion of women in academia remain low. Women represent a large portion of the talent pool in academia, and receive >50% of all PhDs, but this has not yet translated into sustained representation in faculty and leadership positions. Research indicates that women encounter numerous "chutes" that remove them from academia or provide setbacks to promotion at all stages of their careers. These include the perception that women are less competent and their outputs of lesser quality, implicit bias in teaching evaluations and grant funding decisions, and lower citation rates. This review aims to (1) synthesize the "chutes" that impede the careers of women faculty, and (2) provide feasible recommendations, or "ladders" for addressing these issues at all career levels. Enacting policies that function as "ladders" rather than "chutes" for academic women is essential to even the playing field, achieve gender equity, and foster economic, societal, and cultural benefits of academia.

Racial/ethnic representation in lifestyle weight loss intervention studies in the United States: A systematic review.

Obesity remains a persistent public health and health disparity concern in the United States. Eliminating health disparities, particularly among racial/ethnic minority groups, is a major health priority in the US. The primary aim of this review was to evaluate representation of racial/ethnic sub-group members in behavioral weight loss interventions conducted among adults in the United States. The secondary aims were to assess recruitment and study design approaches to include racial/ethnic groups and the extent of racial/ethnic sub-group analyses conducted in these studies. PubMed, PsycInfo, Medline, and CINAHL were searched for behavioral weight loss intervention trials conducted in 2009-2015 using keywords: weight, loss, overweight, obese, intervention and trial. Most of the 94 studies included a majority of White participants compared to any other racial/ethnic group. Across the included studies, 58.9% of participants were White, 18.2% were African American, 8.7% were Hispanic/Latino, 5.0% were Asian and 1.0% were Native Americans. An additional 8.2% were categorized as "Other". Nine of the 94 studies exclusively included minority samples. Lack of adequate representation of racial and ethnic minority populations in behavioral trials limits the generalizability and potential public health impact of these interventions to groups that might most benefit from weight loss. Given racial/ethnic disparities in obesity rates and the burden of obesity and obesity-related diseases among minority groups in the United States, greater inclusion in weight loss intervention studies is warranted.

Teens, Tweets, and Tanning Beds: Rethinking the Use of Social Media for Skin Cancer Prevention.

The incidence of skin cancer is rising in the U.S., and melanoma, the deadliest form, is increasing disproportionately among young white women. Indoor tanning is a modifiable risk factor for all skin cancers and continues to be used at the highest rates in young white women. Adolescents and young adults report personal appearance-based reasons for using indoor tanning. Previous research has explored the influences on tanning bed use, including individual factors as well as relationships with peers, family, schools, media influences, legislation, and societal beauty norms. Adolescents and young adults also have high rates of social media usage, and research is emerging on how best to utilize these platforms for prevention. Social media has the potential to be a cost-effective way to reach large numbers of young people and target messages at characteristics of specific audiences. Recent prevention efforts have shown that comprehensive prevention campaigns that include technology and social media are promising in reducing rates of indoor tanning among young adults. This review examines the literature on psychosocial influences on indoor tanning among adolescents and young adults, and highlights ways in which technology and social media can be used for prevention efforts.

State of the art conference on weight management in VA: Policy and research recommendations for advancing behavioral interventions.

This article summarizes outcomes of the behavioral interventions work group for the Veterans Health Administration (VHA) State of the Art Conference (SOTA) for Weight Management. Sixteen VHA and non-VHA subject matter experts, representing clinical care delivery, research, and policy arenas, participated. The work group reviewed current evidence of efficacy, effectiveness, and implementation of behavioral interventions for weight management, participated in phone- and online-based consensus processes, generated key questions to address gaps, and attended an in-person conference in March 2016. The work group agreed that there is strong evidence for efficacy and effectiveness of core behavioral intervention components and processes, but insufficient evidence to determine the comparative effectiveness of multiple clinician-delivered weight management modalities, as well as technologies that may or may not supplement clinician-delivered treatments. Effective strategies for implementation of weight management services in VHA were identified. The SOTA work group's foremost policy recommendations are to establish a system-wide culture for weight management and to identify a population-level health metric to measure the impact of weight management interventions that can be tracked and clearly communicated throughout VHA. The work group's top research recommendation is to determine how to deploy and scale the most effective behavioral weight management interventions for Veterans.

Society for Health Psychology (APA Division 38) and Society of Behavioral Medicine joint position statement on the Medicare Diabetes Prevention Program.

Beginning in January 2018, the Centers for Medicare and Medicaid Services (CMS) plans to cover the Diabetes Prevention Program (DPP), also referred to as Medicare DPP. The American Psychological Association Society for Health Psychology (SfHP) and the Society for Behavioral Medicine (SBM) reviewed the proposed plan. SfHP and SBM are in support of the CMS decision to cover DPP for Medicare beneficiaries but have a significant concern that aspects of the proposal will limit the public health impact. Concerns include the emphasis on weight outcomes to determine continued coverage and the lack of details regarding requirements for coaches. SfHP and SBM are in strong support of modifications to the proposal that would remove the minimum weight loss stipulation to determine coverage and to specify type and qualifications of "coaches."

Integrating Physical Activity in Primary Care Practice.

Based on a collaborative symposium in 2014 hosted by the Society of Behavioral Medicine (SBM) and the American College of Sports Medicine (ACSM), this paper presents a model for physical activity counseling for primary care physicians (PCPs). Most US adults do not meet national recommendations for physical activity levels. Socioecological factors drive differences in physical activity levels by geography, sex, age, and racial/ethnic group. The recent Patient Protection and Affordable Care Act incentivizes PCPs to offer patients physical activity counseling. However, PCPs have reported socioecological barriers to physical activity counseling and also patient barriers to physical activity, spanning from the individual to the environmental (eg, lack of safe spaces for physical activity), policy (eg, reimbursement policies), and organizational (eg, electronic medical record protocols, worksite norms/policies) levels. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide evidence-based strategies and techniques to help PCPs address these counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity using strategies and supports from policy, the primary care team, and other support networks.

Access to care and use of the Internet to search for health information: results from the US National Health Interview Survey.

BACKGROUND: The insurance mandate of the Affordable Care Act has increased the number of people with health coverage in the United States. There is speculation that this increase in the number of insured could make accessing health care services more difficult. Those who are unable to access care in a timely manner may use the Internet to search for information needed to answer their health questions. OBJECTIVE: The aim was to determine whether difficulty accessing health care services for reasons unrelated to insurance coverage is associated with increased use of the Internet to obtain health information. METHODS: Survey data from 32,139 adults in the 2011 National Health Interview Study (NHIS) were used in this study. The exposure for this analysis was reporting difficulty accessing health care services or delaying getting care for a reason unrelated to insurance status. To define this exposure, we examined 8 questions that asked whether different access problems occurred during the previous 12 months. The outcome for this analysis, health information technology (HIT) use, was captured by examining 2 questions that asked survey respondents if they used an online health chat room or searched the Internet to obtain health information in the previous 12 months. Several multinomial logistic regressions estimating the odds of using HIT for each reported access difficulty were conducted to accomplish the study objective. RESULTS: Of a survey population of 32,139 adults, more than 15.90% (n=5109) reported experiencing at least one access to care barrier, whereas 3.63% (1168/32,139) reported using online health chat rooms and 43.55% (13,997/32,139) reported searching the Internet for health information. Adults who reported difficulty accessing health care services for reasons unrelated to their health insurance coverage had greater odds of using the Internet to obtain health information. Those who reported delaying getting care because they could not get an appointment soon enough (OR 2.2, 95% CI 1.9-2.5), were told the doctor would not accept them as a new patient or accept their insurance (OR 2.1, 95% CI 1.7-2.5 and OR 2.1, 95% CI 1.7-2.5, respectively), or because the doctor's office was not open when they could go (OR 2.2, 95% CI 1.9-2.7) had more than twice the odds of using the Internet to obtain health information compared to those who did not report such access difficulties. CONCLUSIONS: People experiencing trouble accessing health care services for reasons unrelated to their insurance status are more likely to report using the Internet to obtain health information. Improving the accuracy and reliability of health information resources that are publicly available online could help those who are searching for information due to trouble accessing health care services.

Access to healthy food stores modifies effect of a dietary intervention.

BACKGROUND: Recent evidence suggests that opening a grocery store in a food desert does not translate to better diet quality among community residents. PURPOSE: This study evaluated the influence of proximity to a healthy food store on the effect of a dietary behavioral intervention on diet among obese adults randomized to either a high fiber or American Heart Association diet intervention. METHODS: Participants were recruited from Worcester County, Massachusetts, between June 2009 and January 2012. Dietary data were collected via 24-hour recalls at baseline and 3, 6, and 12 months post-intervention. Based on in-store inspection data, a store was considered as having adequate availability of healthy foods if it had at least one item available in each of 20 healthy food categories. Linear models evaluated maximum change in dietary outcomes in relation to road distance from residence to the nearest June healthy food store. The analysis was conducted in January to June 2014. RESULTS: On average, participants (N=204) were aged 52 years, BMI=34.9, and included 72% women and 89% non-Hispanic whites. Shorter distance to a healthy food store was associated with greater improvements in consumption of fiber (b=-1.07 g/day per mile, p<0.01) and fruits and vegetables (b=-0.19 servings/day per mile, p=0.03) with and without covariate adjustment. CONCLUSIONS: The effectiveness of dietary interventions is significantly influenced by the presence of a supportive community nutrition environment. Considering the nationwide efforts on promotion of healthy eating, the value of improving community access to healthy foods should not be underestimated. CLINICAL TRIAL REGISTRATION NUMBER: NCT00911885.