Community-Based Cluster-Randomized Trial to Reduce Opioid Overdose Deaths.

BACKGROUND: Evidence-based practices for reducing opioid-related overdose deaths include overdose education and naloxone distribution, the use of medications for the treatment of opioid use disorder, and prescription opioid safety. Data are needed on the effectiveness of a community-engaged intervention to reduce opioid-related overdose deaths through enhanced uptake of these practices. METHODS: In this community-level, cluster-randomized trial, we randomly assigned 67 communities in Kentucky, Massachusetts, New York, and Ohio to receive the intervention (34 communities) or a wait-list control (33 communities), stratified according to state. The trial was conducted within the context of both the coronavirus disease 2019 (Covid-19) pandemic and a national surge in the number of fentanyl-related overdose deaths. The trial groups were balanced within states according to urban or rural classification, previous overdose rate, and community population. The primary outcome was the number of opioid-related overdose deaths among community adults. RESULTS: During the comparison period from July 2021 through June 2022, the population-averaged rates of opioid-related overdose deaths were similar in the intervention group and the control group (47.2 deaths per 100,000 population vs. 51.7 per 100,000 population), for an adjusted rate ratio of 0.91 (95% confidence interval, 0.76 to 1.09; P = 0.30). The effect of the intervention on the rate of opioid-related overdose deaths did not differ appreciably according to state, urban or rural category, age, sex, or race or ethnic group. Intervention communities implemented 615 evidence-based practice strategies from the 806 strategies selected by communities (254 involving overdose education and naloxone distribution, 256 involving the use of medications for opioid use disorder, and 105 involving prescription opioid safety). Of these evidence-based practice strategies, only 235 (38%) had been initiated by the start of the comparison year. CONCLUSIONS: In this 12-month multimodal intervention trial involving community coalitions in the deployment of evidence-based practices to reduce opioid overdose deaths, death rates were similar in the intervention group and the control group in the context of the Covid-19 pandemic and the fentanyl-related overdose epidemic. (Funded by the National Institutes of Health; HCS ClinicalTrials.gov number, NCT04111939.).

"A win-win for all of us": COVID-19 sheds light on the essentialness of child care as key infrastructure.

Child care centers in the United States allow many parents and caregivers to work in and outside of the home and support the growth and development of children. Child care closures and COVID-19 mitigation measures at the onset of the pandemic heightened the need for and awareness of the role of child care as core infrastructure. The purpose of our study was to examine the perceived role and benefits of child care based on the lived experiences of parents/caregivers and staff navigating child care during the pandemic. We conducted in-depth qualitative interviews with parents/caregivers (n = 20) of children who attended child care and staff (n = 12) who were working at child care programs in Ohio from September to November 2020. Qualitative data were coded and analyzed through the lens of four frameworks (i.e., capabilities, developmental, economics, and mutualism) related to child well-being. Our results highlight the perceived value of child care (a) for fostering capabilities and developmental growth in children; (b) for providing economic benefits for children, parents, and staff of child care programs; and (c) as an essential infrastructure that mutually benefits children, parents, families, staff, and the community. Findings support existing evidence regarding the broader impacts of child care and further investigation into the role of child care. We highlight the potential need for further investments in policies, resources, and supports for child care that reflects its essentialness and generative role.

Association between ambient air pollution and county-level cardiovascular mortality in the United States by social deprivation index.

BACKGROUND: Air pollution and socioeconomic status have both been strongly associated with cardiovascular (CV) outcomes. We sought to determine if socioeconomic status modifies the risk association between fine particulate matter air pollution (PM2.5) and CV mortality. METHODS: We linked county-level age-adjusted CV mortality data from Multiple Cause of Death files (2000-2016, ICD10: I00-I99) with 2015 Social Deprivation Index (SDI), a validated estimate of socioeconomic status, and modelled spatial and temporal mean annual PM2.5 exposures (2012-2018). Higher SDI suggests greater deprivation and lower socioeconomic status. Associations between PM2.5 and age adjusted CV mortality were estimated using linear models. RESULTS: A total of 5,769,315 cardiovascular deaths from 2012-2018 across 3106 United States counties were analyzed. Both PM2.5 (ß (SE) 7.584 (0.938), P < .001) and SDI scores (ß (SE) 0.591 (0.140), P < .001) were independently associated with age-adjusted CV mortality (R2 = 0.341). The association between PM2.5 and CV mortality were stronger among counties with highest SDI, P value for interaction = .012. CONCLUSION: Social deprivation and PM2.5 exposures were independently associated with county level age-adjusted CV mortality. The associations between PM2.5 and CV mortality were stronger in counties with high vs low social deprivation. SDI and PM2.5 represent potential targets to reduce CV mortality disparities and interventions to reduce PM2.5 exposure may be most impactful in communities of low socioeconomic status.

Food security moderates relationship between perceived food environment and diet quality among adults in communities with low access to healthy food retail.

OBJECTIVE: To examine the relationship between food security status, diet quality measured using Healthy Eating Index-2010 (HEI-2010) scores, demographics and the following factors: perceptions of healthy food availability, healthy eating identity and perceived control of healthy eating. DESIGN: A cross-sectional study in 2016-2017 using three 24-h dietary recalls and one psychosocial survey. SETTING: Two urban communities in Cleveland and Columbus, Ohio, USA, with low access to healthy food retailers. PARTICIPANTS: Primary food shoppers living in the targeted geographic areas (N 450). RESULTS: Our results indicated that high school graduates had lower HEI-2010 scores compared with participants who had some college education or more (ß = -2·77, P = 0·02). Participants receiving Supplemental Nutrition Assistance Program (SNAP) benefits had lower HEI-2010 scores (ß = -2·69, P = 0·03). Healthy eating identity was associated with higher HEI-2010 scores (ß = 1·85, P = 0·004). Food security status moderated the relationship between perception of healthy food availability and HEI-2010 scores. Among participants with very low food security (VLFS), greater perceptions of healthy food availability were associated with higher HEI-2010 scores (ß = 3·25, P = 0·03), compared with food secure participants. Only 14 % of VLFS participants used a personal vehicle as transportation to their primary food shopping store. CONCLUSIONS: Findings offer targets for future intervention development and evaluation to promote community nutrition. These targets include strategies to improve the value of SNAP benefits, promote access to quality education, increase transportation options to healthy food retailers and develop nutrition programming to promote healthy eating identity.

Identification of factors related to food insecurity and the implications for social determinants of health screenings.

BACKGROUND: Food insecurity and other social determinants of health are increasingly being measured at routine health care visits. Understanding the needs and behaviors of individuals or families who screen positive for food insecurity may inform the types of resources they need. The goal of this research was to identify modifiable characteristics related to endorsement of two food insecurity screener questions to better understand the resources necessary to improve outcomes. METHODS: Analysis was conducted focusing on cross-sectional survey data collected in 2015-2016 from participants (N = 442) living in urban neighborhoods in Ohio with limited access to grocery stores. Food insecurity was assessed by the endorsement of at least one of two items. These were used to categorize participants into two groups: food insecure(N = 252) or food secure (N = 190). Using logistic regression, we estimated the association between several variables and the food insecure classification. RESULTS: Those that used their own car when shopping for food had lower odds of reporting food insecurity, as did those with affirmative attitudes related to the convenience of shopping for and ease of eating healthy foods. As shopping frequency increased, the odds of food insecurity increased. Food insecurity also increased with experience of a significant life event within the past 12 months. There was an 81% increase in the odds of reporting food insecurity among participants who received Supplemental Nutrition Assistance Program benefits compared to those not receiving Supplemental Nutrition Assistance Program benefits. CONCLUSIONS: Along with referrals to SNAP, clinicians can further address screening-identified food insecurity through provision of transportation supports and linkages to other social services while collaborating on community initiatives to promote convenient and easy access to healthy foods. The needs and behaviors associated with screens indicating food insecurity also have implications for impacting other SDH, and thus, health outcomes.

Racialized Experiences Differentiate Food Security Among African American Adults.

BACKGROUND: Patterns of food security persistently vary by race, yet limited research has examined how community-specific experiences of race and racism are associated with nutritional outcomes. OBJECTIVES: This analysis describes a novel approach for classifying experiences of race and racism and explores the relationship between identified classes and measures of food security and diet quality. METHODS: Cross-sectional self-reported survey data from 306 African American adults living in two urban midwestern cities were collected in 2017-2018. Measures of racialized experiences assessed consciousness of race, perceived discrimination, and health effects of perceived discrimination. Food security was measured with a six-item screener and diet quality with the Healthy Eating Index-2010. Latent class analysis was used to generate racialized classes. Bivariate analyses were conducted to examine differences in class membership by sociodemographics and nutrition outcomes. RESULTS: Participants were majority women who were receiving Supplemental Nutrition Assistance Program benefits. Three racialized classes were identified: Class 1 reported few racialized experiences (42.8% of the sample), Class 2 was racially conscious with few experiences of discrimination (45.1%), and Class 3 was both racially conscious and affected by racialized actions (12.1%). Racialized classes were significantly different in mean household income, level of education, home ownership, and job loss in the past year. Class 3 was the least represented among those that were food secure and the most represented among those that were very low food secure. There were no differences by class in Healthy Eating Index-2010 scores. DISCUSSION: Findings offer an innovative method for measuring exposures to racism and for assessing its relationship to food security. Findings highlight heterogeneity of racialized experiences in similar contexts as well as potential root cause targets such as wages, education, home ownership, and employment that may be modulated to mitigate the effects of racism on food insecurity.

Small Improvements in an Urban Food Environment Resulted in No Changes in Diet Among Residents.

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers.

Severity of household food insecurity and lifetime racial discrimination among African-American households in South Carolina.

OBJECTIVES: In 2014, 30% of African-American households with children had low or very low food security, a rate double that of white households with children. A household has low food security if its members experience food shortages and reductions in food quality attributable to a lack of household resources or access and very low food security if its members also experience reductions in food intake and disrupted eating patterns. Households that are either low or very low food secure are known collectively as food insecure. We examined the association between the severity of household food insecurity and reports of lifetime racial discrimination among a sample of food-insecure African-American households in South Carolina. DESIGN: Data were collected from 154 African-American respondents. Food insecurity was measured using the US Department of Agriculture's Household Food Security Survey Module. Lifetime racial discrimination was measured using the Perceived Ethnic Discrimination Questionnaire-Community Version (PEDQ-CV). We used logistic regression to test the association between severity of food insecurity (low vs. very low food secure), PEDQ-CV score and PEDQ-CV subscales. All models were adjusted for demographic and socioeconomic variables. RESULTS: A one-unit increase in the frequency of lifetime racial discrimination was associated with a 5% increase in the odds of being very low food secure (odds ratio (OR) 1.05, P < .05). More reports of discrimination that were stigmatizing or devaluing (OR 1.16, P < .05), took place at a workplace or school (OR 1.15, P < .05) or were threatening or aggressive (OR 1.39, P < .05) increased the odds of being very low food secure. More reports of racial discrimination that were excluding or rejecting did not significantly increase the odds of being very low food secure (OR 1.07, P > .05). CONCLUSIONS: Severity of household food insecurity is associated with lifetime racial discrimination among African-American households in South Carolina.

Predictors of Farmers' Market Shopping among People Receiving Supplemental Nutrition Assistance Program Benefits.

Promoting use of farmers' markets (FMs) is a promising community-level strategy to increase access to nutritious foods such as fruits and vegetables. Yet, FM shopping among people with Supplemental Nutrition Assistance Program (SNAP) benefits remains low. This research examined predictors of FM shopping among SNAP recipients living within 1 mile of a FM. A cross-sectional survey of SNAP participants (N = 270) was conducted in 2015 in Cleveland and East Cleveland, OH, USA. Multinomial regression and zero-truncated Poisson regression analyses were conducted to examine factors associated with FM shopping. Results indicate 48% reported shopping at a FM at least once in the past year, 26% had shopped at a FM before, but not in the last year, and 26% had never shopped at a FM. The multivariable analyses found awareness of FMs and a healthy food incentive program, and four dimensions of healthy food access are significantly associated with FM shopping among SNAP recipients. The food access dimensions included service delivery, spatial-temporal, personal, and social access. Findings highlight modifiable leverage points for improving the reach of FMs among low-income populations.

Developing multidimensional measures of healthy food access among low-income adults in Cleveland, Ohio, USA.

OBJECTIVE: Access to nutritious foods is key to achieving health promotion goals. While there is evidence that nutritious food access is complex, measures assessing multiple domains of access, including spatial-temporal, economic, social, service delivery and personal, are lacking. The current study evaluates psychometric properties of scales designed to measure perceptions of multiple domains of nutritious food access among low-income populations. DESIGN: A cross-sectional survey was conducted in 2015. Eighty-one items were selected or developed to represent five domains of nutritious food access for food shopping overall and specific to shopping at farmers' markets. Evaluation of the items included exploratory factor analysis within each domain and internal consistency reliability for each of the sub-scales. SETTING: Data were collected in seventeen urban neighbourhoods in Greater Cleveland, Ohio, USA that have high levels of poverty. All participants had access to at least one farmers' market within 1·6 km (1 mile) of their home to standardize spatial access to nutritious foods. SUBJECTS: Adults (n 304) receiving Supplemental Nutrition Assistance Program benefits. RESULTS: Each domain included multiple sub-domains: spatial-temporal (four), service delivery (two), economic (two), social (three) and personal (three), for a total of fourteen subdomains. The internal consistency reliability for one of the sub-domains was outstanding (>0·90), seven were excellent (0·80-0·89), five were very good (0·70-0·79) and one scale had poor reliability (0·58). CONCLUSIONS: Multiple sub-domains of nutritious food access can be assessed using short measures that have been tested for internal consistency. These measures are suitable for assessing the complex phenomena of nutritious food access among low-income populations.

Comparison of the Availability and Cost of Foods Compatible With a Renal Diet Versus an Unrestricted Diet Using the Nutrition Environment Measures Survey.

OBJECTIVE: Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey. DESIGN: Cross-sectional study. SETTING: Twelve grocery stores in Northeast Ohio. MAIN OUTCOME MEASURE: Availability and cost of food items in 12 categories. RESULTS: The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74). CONCLUSION: The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases.

Geographic measures of retail food outlets and perceived availability of healthy foods in neighbourhoods.

OBJECTIVE: To examine associations between geographic measures of retail food outlets and perceived availability of healthy foods. DESIGN: Cross-sectional. SETTING: A predominantly rural, eight-county region of South Carolina, USA. SUBJECTS: Data from 705 household shoppers were analysed using ordinary least-squares regression to examine relationships between geographic measures (presence and distance) of food outlets obtained via a geographic information system and perceived availability of healthy foods (fresh fruits and vegetables and low-fat foods). RESULTS: The presence of a supermarket within an 8·05 km (5-mile) buffer area was significantly associated with perceived availability of healthy foods (ß=1·09, P=0·025) when controlling for all other food outlet types. However, no other derived geographic presence measures were significant predictors of perceived availability of healthy foods. Distances to the nearest supermarket (ß=-0·16, P=0·003), dollar and variety store (ß=-0·15, P=0·005) and fast-food restaurant (ß=0·11, P=0·015) were all significantly associated with perceptions of healthy food availability. CONCLUSIONS: Our results suggest that distance to food outlets is a significant predictor of healthy food perceptions, although presence is sensitive to boundary size. Our study contributes to the understanding and improvement of techniques that characterize individuals' food options in their community.

Planting Healthy Roots: Using Documentary Film to Evaluate and Disseminate Community-Based Participatory Research.

Documentary filmmaking approaches incorporating community engagement and awareness raising strategies may be a promising approach to evaluate community-based participatory research. The study purpose was 2-fold: (1) to evaluate a documentary film featuring the formation and implementation of a farmers' market and (2) to assess whether the film affected awareness regarding food access issues in a food-desert community with high rates of obesity. The coalition model of filmmaking, a model consistent with a community-based participatory research (CBPR) approach, and personal stories, community profiles, and expert interviews were used to develop a documentary film (Planting Healthy Roots). The evaluation demonstrated high levels of approval and satisfaction with the film and CBPR essence of the film. The documentary film aligned with a CBPR approach to document, evaluate, and disseminate research processes and outcomes.

Implementing a Community Empowerment Center to Build Capacity for Developing, Implementing, and Sustaining Interventions to Promote Community Health.

The Community Empowerment Center used a community-engaged approach to build capacity among residents to develop and implement interventions focused on creating a healthier environment. The Center partnered with residents living in a public housing community and adjacent low-income neighborhood and provided support through a mini-grant program. A six-session training program guided community members in mini grant development; 25 individuals attended at least one session. Six grant proposals were submitted; three were awarded $12,000 each for intervention implementation. Findings offer a model for engaging residents from low-resource settings in intervention development, implementation, and sustainability for community health promotion.

The Cleveland-Cuyahoga County Food Policy Coalition: "we have evolved".

Several pieces of legislation passed in Cleveland, Ohio, from 2007 to 2011, focused on improving the city's food environment through urban agriculture initiatives. We used qualitative, case study methods, including interviews with 7 key informants, to examine the policy development process and investigate the role of the Cleveland-Cuyahoga County Food Policy Coalition in developing and implementing 4 pieces of legislation. In this article, we focus on 2 pieces of legislation: zoning designation of an urban garden and allowance of small farm animals and bees on residential property. Five key themes emerged: impetus for policy came from community needs; education and raising awareness helped mitigate barriers; a cultural shift took place among policy makers; social connections and individual champions were needed; and concerns over food access and health influenced policy decisions. Legislative actions are important tools to influence the nutrition environment, as long as they are based on local needs and context.

Environmental influences on fruit and vegetable intake: results from a path analytic model.

OBJECTIVE: Fruit and vegetable (F&V) intake is influenced by behavioural and environmental factors, but these have rarely been assessed simultaneously. We aimed to quantify the relative influence of supermarket availability, perceptions of the food environment and shopping behaviour on F&V intake. DESIGN: A cross-sectional study. SETTING: Eight counties in South Carolina, USA, with verified locations of all supermarkets. SUBJECTS: A telephone survey of 831 household food shoppers ascertained F&V intake with a seventeen-item screener, primary food store location, shopping frequency and perceptions of healthy food availability, and supermarket availability was calculated with a geographic information system. Path analysis was conducted. We report standardized beta coefficients on paths significant at the 0·05 level. RESULTS: Frequency of grocery shopping at primary food store (ß = 0·11) was the only factor exerting an independent, statistically significant direct effect on F&V intake. Supermarket availability was significantly associated with distance to utilized food store (ß = -0·24) and shopping frequency (ß = 0·10). Increased supermarket availability was significantly and positively related to perceived healthy food availability in the neighbourhood (ß = 0·18) and ease of shopping access (ß = 0·09). Collectively considering all model paths linked to perceived availability of healthy foods, this measure was the only other factor to have a significant total effect on F&V intake. CONCLUSIONS: While the majority of the literature to date has suggested an independent and important role of supermarket availability for F&V intake, our study found only indirect effects of supermarket availability and suggests that food shopping frequency and perceptions of healthy food availability are two integral components of a network of influences on F&V intake.

Comparing farmers' market revenue trends before and after the implementation of a monetary incentive for recipients of food assistance.

INTRODUCTION: We examined the influence of an intervention to increase fruit and vegetable purchases at farmers' markets for recipients of food assistance, Shop N Save (SNS), on revenue trends at a farmers' market located at a federally qualified health center (FQHC) in rural South Carolina. We compared revenue trends for 20 weeks before the intervention (2011) and 20 weeks after (2012). METHODS: SNS provided one $5 monetary incentive per week to customers spending $5 or more in food assistance at the farmers' market. SNS was available to any farmers' market customer using Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and/or Senior or WIC Farmers' Market Nutrition Program (FMNP) vouchers. Sales receipts were recorded for each transaction at the farmers' market to document payment type and the cost of the purchase. All SNS participants completed a one-time enrollment survey. RESULTS: A total of 336 customers self-enrolled in SNS from June through October 2012. Most SNS participants were female, African American, and patients at the FQHC. In total, the use of all forms of food assistance (SNAP, WIC, and FMNP) at the farmers' market increased significantly after the intervention (from 10% before, to 25% after, P = .003). Senior FMNP vouchers and SNAP usage increased the most. CONCLUSION: Interventions that provide incentives to recipients of food assistance programs at farmers' markets are a viable strategy for increasing food assistance usage and revenue.

Innovative and community-driven communication practices of the South Carolina cancer prevention and control research network.

The South Carolina Cancer Prevention and Control Research Network (SC-CPCRN) is 1 of 10 networks funded by the Centers for Disease Control and Prevention and the National Cancer Institute (NCI) that works to reduce cancer-related health disparities. In partnership with federally qualified health centers and community stakeholders, the SC-CPCRN uses evidence-based approaches (eg, NCI Research-tested Intervention Programs) to disseminate and implement cancer prevention and control messages, programs, and interventions. We describe the innovative stakeholder- and community-driven communication efforts conducted by the SC-CPCRN to improve overall health and reduce cancer-related health disparities among high-risk and disparate populations in South Carolina. We describe how our communication efforts are aligned with 5 core values recommended for dissemination and implementation science: 1) rigor and relevance, 2) efficiency and speed, 3) collaboration, 4) improved capacity, and 5) cumulative knowledge.

Extending cancer prevention to improve fruit and vegetable consumption.

Consuming a diet that is rich in fruits and vegetables is critical for preventing cancer and cancer-related disparities. Food systems approaches that increase spatial-temporal, economic, and social access to fruits and vegetables may ultimately result in improved consumption patterns among Americans. Engaging the triad of Cooperative Extension Services, public health systems, and community health centers may yield maximal public health benefits from food systems interventions. These entities have a mutual interest in promoting health equity and community and economic vitality that provides common ground to (a) implement solutions through the dissemination of evidence-based programs and (b) share resources to foster grassroots support for sustained change. Working together, these systems have an unprecedented opportunity to build on their common ground to implement, evaluate, and disseminate evidence-based food systems interventions in communities and with populations experiencing disparate risk for cancer and cancer-related diseases.

Identifying emergent social networks at a federally qualified health center-based farmers' market.

Identifying potential mechanisms connecting farmers' market interventions with health, economic, and community outcomes could inform strategies for addressing health disparities. The present study used social network theory to guide the in-depth examination of naturally occurring social interactions at a farmers' market located at a federally qualified health center located in a rural, low-income community. Trained observers recorded 61 observation logs at the market over 18 weeks. Thematic analysis revealed a range of actors and nonhuman facilitators instrumental to the farmers' market context. These actors connected with one another for communication and relationship development, economic and financial exchange, education, resource sharing, community ownership of the farmers' market, and conflict resolution. These interactions provided opportunities for social networks to develop among attendees, which may have facilitated the acquisition of social supports related to improved health, economic and community outcomes. Results provide insight into the role social networks may play in mediating the relationship between a farmers' market intervention and individual benefits. Findings also contribute to defining the typology of social networks, which may further disentangle the complex relationships between social networks and health outcomes. Future research should identify strategies for purposefully targeting social networks as a way to reduce diet-related health disparities.