Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: assessing the rural food environment, part 1.

INTRODUCTION: Obesity prevalence in the rural United States is higher than in urban or suburban areas, perhaps as a result of the food environment. Because rural residents live farther from supermarkets than their urban- and suburban-dwelling counterparts, they may be more reliant on smaller corner stores that offer fewer healthful food items. METHODS: As part of a Communities Putting Prevention to Work (CPPW) healthy corner store initiative, we reviewed audit tools in the fall of 2010 to measure the consumer food environment in eastern North Carolina and chose the NEMS-S-Rev (Nutrition Environment Measures Survey-Stores-Revised) to assess 42 food stores. During the spring and summer of 2011, 2 trained graduate assistants audited stores, achieving interrater reliability of at least 80%. NEMS-S-Rev scores of stores in rural versus urban areas were compared. RESULTS: Overall, healthful foods were less available and of lower quality in rural areas than in urban areas. NEMS-S-Rev scores indicated that healthful foods were more likely to be available and had similar pricing and quality in rural corner stores than in urban corner stores. CONCLUSION: Food store audit data provided a baseline to implement and evaluate a CPPW healthy corner store initiative in Pitt County. This work serves as a case study, providing lessons learned for engaging community partners when conducting rural food store audits.

Convenience stores surrounding urban schools: an assessment of healthy food availability, advertising, and product placement.

Adolescent obesity is a national public health problem, particularly among urban populations. Recent evidence has linked neighborhood food environments to health and nutrition status, with easier access to convenience stores being associated with increased risk for obesity. Little is known about the availability of healthy purchasing options within small, urban food stores, or the extent to which these factors are relevant to youth. The objective of this research was to characterize various features of the food environment within small convenience stores located nearby urban junior high and high schools. In-store audits were conducted in 63 stores located within 800 m of 36 urban Minnesota public secondary schools. Results indicated that a limited number of healthier beverages (i.e., water and 100% fruit juice) and snack options (i.e., nuts and pretzels) were available at most stores (≥85%). However, a wide range of healthy snack options were typically not available, with many specific items stocked in less than half of stores (e.g., low-fat yogurt in 27% of stores and low-fat granola bars in 43%). Overall, 51% of stores had fresh fruit and 49% had fresh vegetables. Few stores carried a range of healthier snack alternatives in single-serving packages. All stores had less healthful impulse purchase items available (e.g., candy) while only 46% carried healthier impulse items (e.g., fruit). Most stores (97%) had food/beverage advertising. Overall, convenience stores located in close proximity to secondary schools represent an important and understudied component of the youth food environment.

Situational characteristics of young adults' eating occasions: a real-time data collection using Personal Digital Assistants.

OBJECTIVE: To examine (i) situational characteristics of young adults' eating occasions, including away-from-home eating, social influences and multi-tasking, and (ii) how these characteristics are associated with specific foods/beverages consumed. DESIGN: Participants logged numerous characteristics of eating occasions (n 1237) in real time over 7 d. SETTING: Minneapolis/St. Paul metropolitan area (Minnesota, USA). SUBJECTS: Forty-eight participants, aged 18-23 years. RESULTS: Half of all eating occasions (46 %) occurred alone, 26 % occurred while watching television and 36 % involved other multi-tasking. Most participants (63 %) did not think about their food choices in advance of eating occasions. Eating that occurred in the absence of television viewing and/or other multi-tasking was less likely to include sweetened beverages and more likely to include items like water, fruit, vegetables, cereal, grains and entrées. Eating occasions occurring alone, and/or those occurring at home, were more likely to include snack foods that required little preparation (e.g. cookies, baked goods) and less likely to include more traditional meal items (e.g. fruits, vegetables, entrée items). CONCLUSIONS: Overall, a large proportion of young adults' eating occasions occurred alone, while engaging in other activities and with little advanced planning. Although many young adults' eating occasions consist of a wide range of highly processed, energy-dense, convenience products, more traditional meal settings (i.e. eating at home with others in the absence of multi-tasking) may result in more structured mealtimes and better food choices, such as more fruits and vegetables. Effective behavioural strategies promoting positive eating patterns, including home meal preparation, are urgently needed among young adults.

Healthy food availability in small urban food stores: a comparison of four US cities.

OBJECTIVE: Given that small food stores may be important retail food sources in low-income urban communities, our objective was to examine cross-city comparative data documenting healthy food availability within such facilities, particularly those located in low-income areas and nearby schools. DESIGN: Food stores in Baltimore, Maryland; Minneapolis/St. Paul, Minnesota; Oakland, California; and Philadelphia, Pennsylvania were selected for assessment based on proximity to low-income schools. Stores were defined as: (i) single-aisle (n 45); (ii) small (2-5 aisles; n 52); and (iii) large (> or = 6 aisles; n 8). Staff conducted in-store audits to assess the presence/absence of twenty-eight healthy items, organized within five categories: (i) fresh fruits/vegetables, (ii) processed fruits/vegetables, (iii) healthy beverages/low-fat dairy, (iv) healthy snacks and (v) other healthy staple foods. RESULTS: The availability of healthy food items was low, particularly in single-aisle and small stores, and there was significant cross-site variability in the availability of healthy snacks (P < 0.0001) and other healthy staple foods (P < 0.0001). No cross-site differences existed for fruits/vegetables or healthy beverages/low-fat dairy availability. Healthy food availability scores increased significantly with store size for nearly all food/beverage categories (P < 0.01). CONCLUSIONS: Overall, healthy food availability in these venues was limited. Region-specific factors may be important to consider in understanding factors influencing healthy food availability in small urban markets. Data suggest that efforts to promote healthy diets in low-income communities may be compromised by a lack of available healthy foods. Interventions targeting small stores need to be developed and tailored for use in urban areas across the USA.

Understanding young adult physical activity, alcohol and tobacco use in community colleges and 4-year post-secondary institutions: A cross-sectional analysis of epidemiological surveillance data.

BACKGROUND: Young adults experience many adverse health behavior changes as they transition from adolescence into adulthood. A better understanding of the relationships between health promoting and risky health behaviors may aid in the development of health promotion interventions for various types of young adult post-secondary students. Therefore, the purpose of this study was to examine associations between alcohol and tobacco use and physical activity among 2-year and 4-year college students. METHODS: Cross-sectional analyses were conducted using 2007 survey data, collected as part of an on-going post-secondary health surveillance system in Minnesota. Students were randomly selected to participant from 14 Minnesota colleges and universities (six 2-year community and/or technical colleges, eight 4-year post-secondary institutions). The 2007 surveillance data included 9,931 respondents. RESULTS: The prevalence of demographic characteristics and health behaviors (e.g., physical activity, tobacco use) differed between young adults attending 2-year and 4-year post-secondary institutions; in general, those attending 2-year institutions are representative of more at-risk populations. Overall, higher levels of moderate, vigorous and strengthening physical activity were associated with higher levels of alcohol consumption and lower levels of smoking. In general, despite the disparities in the prevalence of these risk behaviors, the associations between the behaviors did not differ substantially between 2-year and 4-year post-secondary populations. CONCLUSIONS: These findings illustrate links between leading risk behaviors. Interventions targeting multiple risk behaviors among young adults may warrant further consideration. Overall, future research is needed to support and inform young adult health promotion efforts that may be implemented in a wide array of post-secondary institutions.

Latent class analysis of lifestyle characteristics and health risk behaviors among college youth.

Few studies have examined the context of a wide range of risk behaviors among emerging adults (ages 18-25 years), approximately half of whom in the USA enroll in post-secondary educational institutions. The objective of this research was to examine behavioral patterning in weight behaviors (diet and physical activity), substance use, sexual behavior, stress, and sleep among undergraduate students. Health survey data were collected among undergraduates attending a large, public US university (n = 2,026). Latent class analysis was used to identify homogeneous, mutually exclusive "classes" (patterns) of ten leading risk behaviors. Resulting classes differed for males and females. Female classes were defined as: (1) poor lifestyle (diet, physical activity, sleep), yet low-risk behaviors (e.g., smoking, binge drinking, sexual risk, drunk driving; 40.0% of females), (2) high risk (high substance use, intoxicated sex, drunk driving, poor diet, inadequate sleep) (24.3%), (3) moderate lifestyle, few risk behaviors (20.4%), (4) "health conscious" (favorable diet/physical activity with some unhealthy weight control; 15.4%). Male classes were: (1) poor lifestyle, low risk (with notably high stress, insufficient sleep, 9.2% of males), (2) high risk (33.6% of males, similar to class 2 in females), (3) moderate lifestyle, low risk (51.0%), and (4) "classic jocks" (high physical activity, binge drinking, 6.2%). To our knowledge, this is among the first research to examine complex lifestyle patterning among college youth, particularly with emphasis on the role of weight-related behaviors. These findings have important implications for targeting much needed health promotion strategies among emerging adults and college youth.

Work hours and perceived time barriers to healthful eating among young adults.

OBJECTIVE: To describe time-related beliefs and behaviors regarding healthful eating, indicators of dietary intake, and their associations with the number of weekly hours of paid work among young adults. METHODS: Population-based study in a diverse cohort (N=2287). RESULTS: Working > 40 hours per week was associated with time-related barriers to healthful eating most persistently among young adult men. Associations were found among females working both part-time and > 40 hours per week with both time-related barriers and dietary intake. CONCLUSIONS: Findings indicate that intervention strategies, ideally those addressing time burden, are needed to promote healthful eating among young, working adults.

Young adults and eating away from home: associations with dietary intake patterns and weight status differ by choice of restaurant.

BACKGROUND: Young adults report frequent away-from-home eating; however, little is known regarding what types of restaurants are patronized or whether associations with dietary intake and weight status differ according to restaurant type. OBJECTIVE: This cross-sectional study in a diverse sample of young adults examines sociodemographic differences in the frequency of eating at different types of fast-food and full-service (server brings food to table) restaurants. In addition, this study examines whether associations between away-from-home eating, dietary intake, and weight status differ according to restaurant type. DESIGN: There were 1,030 men and 1,257 women (mean age=25.3 years) who participated in Project EAT-III (Eating and Activity in Teens and Young Adults). Participants were members of a longitudinal cohort who completed baseline surveys at schools in Minneapolis/St Paul, MN, and completed the EAT-III surveys online or by mail in 2008-2009. MAIN OUTCOME MEASURES: Height, weight, and usual dietary intake were self-reported. STATISTICAL ANALYSES PERFORMED: Regression models adjusted for sociodemographic characteristics were used to examine associations between frequency of restaurant use, dietary intake, and weight status. RESULTS: More frequent use of fast-food restaurants that primarily served burgers and french fries was associated with higher risk for overweight/obesity; higher intake of total energy, sugar-sweetened beverages, and fat; and with lower intake of healthful foods and key nutrients. For example, those who reported burger-and-fries restaurant use on three or more occasions per week consumed nearly one additional sugar-sweetened beverage per day compared to those who reported burger-and-fries restaurant use on less than one occasion per week. More frequent use of fast-food restaurants that primarily served sandwiches/subs was related to a few markers of poorer diet quality, but unrelated to weight status. More frequent use of full-service restaurants was also unrelated to weight status and related to higher intake of vegetables. CONCLUSIONS: There may be a need for interventions to promote healthier food choices among young adults who report frequent burger-and-fries restaurant use.

Health risk behaviors of Afghanistan and Iraq war veterans attending college.

PURPOSE. The population of military veterans attending college is rapidly growing as veterans return from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). We sought to describe patterns of student veterans' health-related behaviors and how they might differ from their nonveteran peers. DESIGN. We analyzed data from the 2008 Boynton College Student Health Survey (CSHS). SETTING. CSHS participants completed an anonymous online survey. SUBJECTS. The CSHS sampled students (n  =  8651) attending public, private, 2-year, and 4-year postsecondary educational institutions in Minnesota. MEASURES. The CSHS included items on substance use (including alcohol and tobacco), safety, nutrition, and physical activity. ANALYSIS. We described demographics of OEF/OIF veteran, non-OEF/OIF veteran, and nonveteran students and used Poisson regression to compute adjusted relative risks (ARRs) with 95% confidence intervals (CIs) to characterize associations between veteran status and health behaviors. RESULTS. After controlling for demographics, veteran students reported more safety-, tobacco-, and alcohol-related risk behaviors compared to nonveteran students. For instance, compared to the nonveteran reference group, the ARR for past year smokeless tobacco use and physical fighting among for OEF/OIF veterans was 1.76 (95% CI  =  1.31-2.35) and 1.48 (95% CI  =  1.22-1.79) respectively. Veteran and nonveteran students display similar weight-related behaviors, though OEF/OIF veteran students were more likely to engage in strengthening exercises. CONCLUSIONS. There are specific health risk behaviors that are particularly relevant for veterans attending postsecondary institutions. As veterans enroll in postsecondary education, there is a unique window of opportunity for health promotion in this population.

Weight-related teasing in a racially diverse sample of sixth-grade children.

Negative outcomes are associated with weight-based teasing. Among children, little research to date has explored the extent to which teasing occurs, the effects of teasing, or differences among sources of teasing. The purpose of this secondary data analysis was to assess the prevalence and frequency of weight-related teasing by peers and families in a low-income, multiracial/ethnic sample of children; to determine how bothered children were by the teasing; to evaluate whether teasing varied by overweight status and sex; and to see whether body satisfaction varied based on teasing history. In 2007, baseline data were obtained from 148 children (aged 11 to 12 years) in a classroom intervention pilot study in four public schools serving low-income communities in St Paul, MN. Participants completed a classroom survey assessing body satisfaction and weight-related teasing. Height and weight were measured. Forty percent of children reported being teased by peers and 36% reported being teased by family members about their weight. Significantly more overweight/obese children reported being teased by peers (P<0.01) and family members (P<0.05) than normal weight children. No significant differences were seen between weight status and the degree to which children were bothered by teasing. Body satisfaction was lower among children teased by family members or peers than those who were not teased (P<0.05). These results suggest that weight-related teasing is a problem for children, especially those who are overweight or obese. A better understanding is needed of the long-term effects of teasing on behavioral and psychosocial outcomes in racially/ethnically diverse samples of children.

Post-traumatic stress disorder and health risk behaviors among Afghanistan and Iraq War veterans attending college.

OBJECTIVE: To determine if post-traumatic stress disorder (PTSD) is associated with health risk behaviors among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans attending college. METHOD: Using 2008 Boynton College Student Health Survey data, we tested associations between self-reported PTSD diagnosis and self-reported risk behaviors (n=406). RESULTS: We found PTSD diagnosis to be significantly associated with reporting involvement in a physical fight in the past year (ARR = 3.1; 95% CI: 2.2, 4.4) and marginally associated with highrisk drinking (ARR = 1.3; 95% CI: 1.1, 1.6). However, no association was seen between PTSD and the tobacco use and other safety behaviors that we examined. CONCLUSION: PTSD is likely a factor that contributes to the relationship between military service and certain health risk behaviors.

Young adult eating and food-purchasing patterns food store location and residential proximity.

BACKGROUND: Young adulthood is a critical age for weight gain, yet scant research has examined modifiable contextual influences on weight that could inform age-appropriate interventions. PURPOSE: The aims of this research included describing where young adults eat and purchase food, including distance from home, and estimating the percentage of eating/purchasing locations contained within GIS-generated buffers traditionally used in research. METHODS: Forty-eight participants (aged 18-23 years, n=27 women) represented diverse lifestyle groups. Participants logged characteristics of all eating/drinking occasions (including location) occurring over 7 days (n=1237) using PDAs. In addition, they recorded addresses for stores where they purchased food to bring home. Using GIS, estimates were made of distances between participants' homes and eating/purchasing locations. Data collection occurred in 2008-2009 and data analysis occurred in 2010. RESULTS: Among participants living independently or with family (n=36), 59.1% of eating occasions were at home. Away-from-home eating locations averaged 6.7 miles from home; food-shopping locations averaged 3.1 miles from home. Only 12% of away-from-home eating occasions fell within -mile residential buffers, versus 17% within 1 mile and 34% within 2 miles. In addition, 12%, 19%, and 58% of shopping trips fell within these buffers, respectively. Results were similar for participants residing in dormitories. CONCLUSIONS: Young adults often purchase and eat food outside of commonly used GIS-generated buffers around their homes. This suggests the need for a broader understanding of their food environments.

Review of the nutritional implications of farmers' markets and community gardens: a call for evaluation and research efforts.

The development and promotion of farmers' markets and community gardens is growing in popularity as a strategy to increase community-wide fruit and vegetable consumption. Despite large numbers of farmers' markets and community gardens in the United States, as well as widespread enthusiasm for their use as a health promotion tool, little is known about their influence on dietary intake. This review examines the current scientific literature on the implications of farmers' market programs and community gardens on nutrition-related outcomes in adults. Studies published between January 1980 and January 2009 were identified via PubMed and Agricola database searches and by examining reference lists from relevant studies. Studies were included in this review if they took place in the United States and qualitatively or quantitatively examined nutrition-related outcomes, including dietary intake; attitudes and beliefs regarding buying, preparing, or eating fruits and vegetables; and behaviors and perceptions related to obtaining produce from a farmers' market or community garden. Studies focusing on garden-based youth programs were excluded. In total, 16 studies were identified for inclusion in this review. Seven studies focused on the impact of farmers' market nutrition programs for Special Supplemental Nutrition Program for Women, Infants, and Children participants, five focused on the influence of farmers' market programs for seniors, and four focused on community gardens. Findings from this review reveal that few well-designed research studies (eg, those incorporating control groups) utilizing valid and reliable dietary assessment methods to evaluate the influence of farmers' markets and community gardens on nutrition-related outcomes have been completed. Recommendations for future research on the dietary influences of farmers' markets and community gardens are provided.

State school nutrition and physical activity policy environments and youth obesity.

BACKGROUND: With the epidemic of childhood obesity, there is national interest in state-level school policies related to nutrition and physical activity, policies adopted by states, and relationships to youth obesity. PURPOSE: This study develops a comprehensive state-level approach to characterize the overall obesity prevention policy environment for schools and links the policy environments to youth obesity for each state. METHODS: Using 2006 School Health Policies and Programs Study (SHPPS) state data, qualitative and quantitative methods were used (2008-2009) to construct domains of state-level school obesity prevention policies and practices, establish the validity and reliability of the domain scales, and examine their associations with state-level obesity prevalence among youth aged 10-17 years from the 2003 National Survey of Children's Health. RESULTS: Nearly 250 state-level obesity prevention-policy questions were identified from the SHPPS. Three broad policy topic areas containing 100 food service and nutrition (FSN) questionnaire items; 146 physical activity and education (PAE) items; and two weight assessment (WA) items were selected. Principal components analysis and content validity assessment were used to further categorize the items into six FSN, ten PAE, and one WA domain. Using a proportional scaled score to summarize the number of policies adopted by states, it was found that on average states adopted about half of the FSN (49%), 38% of the PAE, and 17% of the WA policies examined. After adjusting for state-level measures of ethnicity and income, the average proportion of FSN policies adopted by states was correlated with the prevalence of youth obesity at r =0.35 (p=0.01). However, no correlation was found between either PAE or WA policies and youth obesity (PAE policies at r =0.02 [p=0.53] and WA policies at r =0.16 [p=0.40]). CONCLUSIONS: States appear to be doing a better job adopting FSN policies than PA or WA policies, and adoption of policies is correlated with youth obesity. Continued monitoring of these policies seems to be warranted.