Perspectives From Extension Staff on Building and Sustaining Community Wellness Coalitions.

BACKGROUND: Community wellness coalitions are an important part of functioning program infrastructure and have been effective in promoting policy, systems, and environmental (PSE) change, especially when paired with technical support by a community champion or Extension staff. PSE strategies are critical to support long-lasting behavior change but can be challenging to implement. Extension is an established and equipped organization that has potential to help community overcome those challenges. The aim of this article was to identify and describe experiences of Extension staff working as community coaches. METHODS: A mixed-methods design to assess the impact of Extension staff working with Community Champions included a quantitative Extension Coaching Confidence Scorecard and an Extension Key Informant Interview. RESULTS: The total Extension Coaching Confidence score significantly increased from pre- to post-intervention (55.1 ± 35.3 vs. 81.7 ± 37.7, p = .03). Five facilitators and two barriers to wellness coalition development were identified by Extension staff. DISCUSSION: The results of this study indicate that the model of community coaching used was effective at addressing the foundational components of the Component Model of Infrastructure (CMI). However, comprehensive training for Extension staff in the CMI and technical assistance are needed in order to build capacity, achieve outcomes, and promote sustainability. IMPLICATIONS FOR PRACTICE: Individuals seeking to transition to PSE work should be provided with a foundation of specific, targeted training in the CMI and evidence-based technical assistance methods. Practitioners should recognize the essential role of community champions in PSE work. Completing the Extension Coaching Confidence Scorecard periodically can inform evolving training needs.

Facilitating Nutrition and Physical Activity-Focused Policy, Systems, and Environmental Change in Rural Areas: A Methodological Approach Using Community Wellness Coalitions and Cooperative Extension.

Obesity prevalence is higher among rural populations than urban, which may be related to differences in environments. Rural counties face barriers to accessing healthy foods and physical activity opportunities including isolation, transportation distances, and lack of facilities. As part of the Centers for Disease Control and Prevention Division of Nutrition, Physical Activity, and Obesity High Obesity Program, community-based wellness coalitions were established in six South Dakota counties with adult obesity prevalence >40%. The community coalitions were charged with improving access to healthy foods and safe and accessible places to participate in physical activity within their rural, underserved communities. Coalitions were created and members were recruited by Cooperative Extension staff who had existing relationships with key stakeholders within the community. Within these coalitions, champions were identified to provide leadership and ensure project implementation. Ongoing support and technical assistance were provided to the community coalitions by Cooperative Extension staff as they completed a community needs assessment, disseminated results of the needs assessment with the community, created action plans based on needs assessment data, implemented evidence-based interventions to support nutrition and physical activity policy, system and environmental changes, and assessed impact within their community. Overall, the purpose of this article is to share the project methodology, which capitalized on using Cooperative Extension, to build capacity to improve the nutrition and physical activity environment in rural, unserved communities. Sustainability of this work, along with lessons learned, is also discussed.

Breakfast Consumption Is Positively Associated with Usual Nutrient Intakes among Food Pantry Clients Living in Rural Communities.

BACKGROUND: Breakfast consumption has declined over the past 40 y and is inversely associated with obesity-related diet and health outcomes. The breakfast pattern of food pantry clients and its association with diet is unknown. OBJECTIVE: The objective is to investigate the association of breakfast consumption with diet quality and usual nutrient intakes among food pantry clients (n = 472) living in rural communities. METHODS: This was an observational study using cross-sectional analyses. English-speaking participants ≥18 y (or ≥19 y in Nebraska) were recruited from 24 food pantries in rural high-poverty counties in Indiana, Michigan, Missouri, Nebraska, Ohio, and South Dakota. Participants were surveyed at the pantry regarding characteristics and diet using 24-h recall. A second recall was self-completed or completed via assisted phone call within 2 wk of the pantry visit. Participants were classified as breakfast skippers when neither recall reported breakfast ≥230 kcal consumed between 04:00 and 10:00; breakfast consumers were all other participants. The Healthy Eating Index-2010 was modeled with breakfast pattern using multiple linear regression. Mean usual intake of 16 nutrients was estimated using the National Cancer Institute Method and compared across breakfast pattern groups. Usual nutrient intake was compared with the Estimated Average Requirement (EAR) or Adequate Intake (AI) to estimate the proportion of population not meeting the EAR or exceeding the AI. RESULTS: A total of 56% of participants consumed breakfast. Compared with breakfast skippers, breakfast consumers had 10-59% significantly higher usual mean intakes of all nutrients (P ≤ 0.05), and had 12-21% lower prevalence of at-risk nutrient intakes except for vitamin D, vitamin E, and magnesium. CONCLUSIONS: Adult food pantry clients living in rural communities experienced hardships in meeting dietary recommendations. Breakfast consumption was positively associated with usual nutrient intakes in this population. This trial was registered at clinicaltrials.gov as NCT03566095.

Gardening for Health: Using Garden Coordinators and Volunteers to Implement Rural School and Community Gardens.

Gardens provide access to healthy food, increase access to nutrition and physical activity opportunities, and are a focal point for community interventions. We used a gardening intervention to improve local access to and consumption of fruits and vegetables and as an integral part of overall efforts of local wellness coalitions. Seasonal garden coordinators were hired, and action plans included goals for nutrition and physical activity education programs and youth and adult engagement. The characteristics of each garden (size, items planted, number of volunteers) and pre- and post-intervention surveys were used to understand how the gardens affected communities. Thirteen gardens were planted, and volunteers provided 18,136 hours; adults from the community reported an increased awareness of garden benefits. The community garden intervention provided opportunities for collaboration with a variety of schools, community organizations, and city and tribal organizations, thereby increasing the sustainability of the intervention.

Voices for food: methodologies for implementing a multi-state community-based intervention in rural, high poverty communities.

BACKGROUND: Rural communities experience unique barriers to food access when compared to urban areas and food security is a public health issue in rural, high poverty communities. A multi-leveled socio-ecological intervention to develop food policy councils (FPCs), and improve food security in rural communities was created. Methods to carry out such an intervention were developed and are described. METHODS: A longitudinal, matched treatment and comparison study was conducted in 24 rural, high poverty counties in South Dakota, Indiana, Missouri, Michigan, Nebraska and Ohio. Counties were assigned to a treatment (n = 12) or comparison (n = 12) group. Intervention activities focus on three key components that impact food security: 1) community coaching by Extension Educators/field staff, 2) FPC development, and 3) development of a MyChoice food pantry. Community coaching was only provided to intervention counties. Evaluation components focus on three levels of the intervention: 1) Community (FPCs), 2) Food Pantry Organization, and 3) Pantry Client & Families. Participants in this study were community stakeholders, food pantry directors, staff/volunteers and food pantry clients. Pantry food access/availability including pantry food quality and quantity, household food security and pantry client dietary intake are dependent variables. DISCUSSION: The results of this study will provide a framework for utilizing a multi-leveled socio-ecological intervention with the purpose of improving food security in rural, high poverty communities. Additionally, the results of this study will yield evidence-based best practices and tools for both FPC development and the transition to a guided-client choice model of distribution in food pantries. TRIAL REGISTRATION: ClinicalTrials.gov; NCT03566095 . Retrospectively registered on June, 21, 2018.

The Effects of Food Deserts on the Weight Status of South Dakota Children.

INTRODUCTION: Childhood obesity continues to be a public health issue in the U.S. Research prior to this study demonstrated that children living on food deserts (FD) had greater weight statuses than children who did not live on FDs. Based on U.S. Department of Agriculture classification, almost half of the state of South Dakota is classified as a food desert, and childhood obesity continues to be an issue in the state. The purpose of this study was to determine if FDs play a role in childhood obesity in South Dakota, more specifically whether South Dakota children who live on FDs or on the border of FDs have greater weight statuses than children who live on non-FDs. METHODS: School height and weight data collected by the South Dakota Department of Health was used to calculate weight status for students in six schools; weight was categorized as underweight, healthy weight, overweight, and obese. RESULTS: It was discovered that the pair of border-FD areas had the lowest total percentage of students who were classified as obese while the non-FD areas had the highest percentage of students who were classified as obese. The FD areas fell in between the aforementioned areas. CONCLUSIONS: By utilizing this research and identifying precursors for obesity, such as where an individual lives and their access to healthy food, health care leaders and their multidisciplinary team can help facilitate community interventions that target areas most impacted by childhood obesity.

Evaluating a Food Pantry-Based Intervention to Improve Food Security, Dietary Intake, and Quality in Midwestern Food Pantries.

BACKGROUND: Voices for Food was a longitudinal community, food pantry-based intervention informed by the social ecological model, and designed to improve food security, dietary intake, and quality among clients, which was carried out in 24 rural food pantries across 6 Midwestern states. OBJECTIVE: Our objective was to evaluate changes in adult food security, dietary intake, and quality from baseline (2014) to follow-up (2016), and to assess the role of adult food security on dietary outcomes. DESIGN: A multistate, longitudinal, quasi-experimental intervention with matched treatment and comparison design was used to evaluate treatment vs comparison group changes over time and changes in both groups over time. PARTICIPANTS/SETTING: Adult food pantry clients (n = 617) completed a demographic food security survey, and up to three 24-hour dietary recalls at baseline (n = 590) and follow-up (n = 160). INTERVENTION: Community coaching served as the experimental component, which only "treatment" communities received, and a food council guide and food pantry toolkit were provided to both "treatment" and matched "comparison" communities. MAIN OUTCOME MEASURES: Change in adult food security status, mean usual intakes of nutrients and food groups, and Healthy Eating Index-2010 scores were the main outcome measures. STATISTICAL ANALYSES PERFORMED: Linear mixed models estimated changes in outcomes by intervention group and by adult food security status over time. RESULTS: Improvements in adult food security score (-0.7 ± 0.3; P = .01), Healthy Eating Index-2010 total score (4.2 ± 1.1; P < .0001), and empty calories component score (3.4 ± 0.5; P <.0001) from baseline to follow-up were observed in treatment and comparison groups, but no statistically significant changes were found for adult food security status, dietary quality, and usual intakes of nutrients and food groups between the 2 groups over time. The intervention effect on dietary quality and usual intake changes over time by adult food security status were also not observed. CONCLUSIONS: Food pantry clients in treatment and comparison groups had higher food security and dietary quality at the follow-up evaluation of the Voices for Food intervention trial compared with baseline, despite the lack of difference among the groups as a result of the experimental coaching component.

Quantifying the Food and Physical Activity Environments in Rural, High Obesity Communities.

The built environment contributes to an individual's health, and rural geographies face unique challenges for healthy eating and active living. The purpose of this descriptive study was to assess the nutrition and physical activity environments in rural communities with high obesity prevalence. One community within each of six high obesity prevalence counties in a rural Midwest state completed the Nutrition Environment Measures Survey for Stores (NEMS-S) and the Rural Active Living Assessment (RALA). Data were collected by trained community members and study staff. All communities had at least one grocery store and five had at least one convenience store. Grocery stores had higher mean total NEMS-S scores than convenience stores (26.6 vs. 6.0, p < 0.001), and higher scores for availability (18.7 vs. 5.3, p < 0.001) and quality (5.4 vs. 0, p < 0.001) of healthful foods (higher scores are preferable). The mean RALA town-wide assessment score across communities was 56.5 + 15.6 out of a possible 100 points. The mean RALA program and policy assessment score was 40.8 + 20.4 out of a possible 100 points. While grocery stores and schools are important for enhancing food and physical environments in rural areas, many opportunities exist for improvements to impact behaviors and address obesity.

Fruit and Vegetable Healthy Eating Index Component Scores of Distributed Food Bags Were Positively Associated with Client Diet Scores in a Sample of Rural, Midwestern Food Pantries.

BACKGROUND: Food pantries have the potential to improve the quality of clients' diets. OBJECTIVE: This study evaluated the relationship between the quality of the mix of foods in pantry inventories and client food bags (separately), as assessed by the Healthy Eating Index-2010 (HEI-2010), with client diet quality and how these relationships varied by food security status. DESIGN: This cross-sectional, secondary analysis used baseline data from the Voices for Food intervention study (Clinical Trial Registry: NCT03566095). A demographic questionnaire, the US Household Food Security Survey Module, and up to three 24-hour dietary recalls on nonconsecutive days, including weekdays and weekends, were collected. Foods available in pantry inventories and distributed in client food bags were recorded at one time point during baseline data collection. PARTICIPANTS AND SETTING: A convenience sample of adult food pantry clients (N = 575) from 24 rural, food pantries in the US Midwest was recruited from August to November 2014. MAIN OUTCOME MEASURES: Pantry inventories, client food bags, and client diets were scored using the HEI-2010. Main outcomes were client HEI-2010 scores. STATISTICAL ANALYSES PERFORMED: Linear regression models estimated associations between HEI-2010 total and component scores for pantry inventories and client food bags (in separate models) and the corresponding scores for client dietary intake. The interaction of client food security status, and potential pantry- and client-level confounders, was considered. RESULTS: Client food bag HEI-2010 scores were positively associated with client diet scores for total vegetables, greens and beans, and total fruit components, whereas pantry inventory HEI-2010 scores were negatively associated with client diet scores for total fruit, total protein foods, and seafood and plant proteins components. Client food bag whole-grains scores were more strongly associated with very low food secure compared with food secure client diet scores (all P values < 0.05). CONCLUSIONS: The quality of client food bags, but not of pantry inventories, was positively associated with client diet quality in a rural sample in the US Midwest.

Dietary Quality and Usual Intake of Underconsumed Nutrients and Related Food Groups Differ by Food Security Status for Rural, Midwestern Food Pantry Clients.

BACKGROUND: Food pantry users represent a predominantly food insecure population, yet dietary intake may differ among food secure (FS), low FS, and very low FS clients. Usual intake of food groups and nutrients by food security status has not previously been compared among food pantry clients. OBJECTIVE: This study aimed to estimate the usual intakes of underconsumed nutrients (ie, potassium; dietary fiber; choline; magnesium; calcium; vitamins A, D, E, and C; and iron) and related food groups (ie, vegetables, fruits, whole grains, and dairy) and dietary quality, and to evaluate their relationship with food security status. DESIGN: This cross-sectional, secondary analysis used baseline data from a prior intervention study (Clinical Trial Registry: NCT03566095). A demographic questionnaire, the US Household Food Security Survey Module, and up to three 24-hour dietary recalls on nonconsecutive days, including weekdays and weekends, were collected. PARTICIPANTS/SETTING: This community-based study included a convenience sample of adult, midwestern food pantry clients (N=579) recruited from August to November 2014. MAIN OUTCOME MEASURES: Main outcomes evaluated were Healthy Eating Index-2010 scores and usual intakes of underconsumed nutrients and related food groups. STATISTICAL ANALYSES PERFORMED: Linear regression models and the National Cancer Institute method, adjusting for confounders, were used to estimate associations of food security with diet quality and usual intake, respectively. RESULTS: Being FS was associated with a higher whole grains HEI-2010 score and higher mean usual intake of whole grains compared with being low FS. Being FS was associated with higher usual intakes of iron and dairy compared with being very low FS. Being FS was associated with a higher mean usual intake of dark green vegetables compared with being low FS and very low FS. Usual intakes were below federal guidance for all subgroups of food security. CONCLUSIONS: Although food security status may differentiate dietary intake among food pantry clients, improvements are needed among all clients.

The development and use of an assessment tool to capture changes in the food pantry nutrition environment and system of food distribution.

Rural food pantries aim to improve food access but low-quality nutritional environments and prescribed systems of food distribution may limit these efforts. Voices for Food (VFF) is a six-state U.S. Department of Agriculture-funded intervention, including community coaching and a VFF Food Pantry Toolkit to guide food pantries in transitioning to a healthier nutritional environment and a food distribution system based on client choice and support.The purpose of the article was to create a novel tool (MyChoice Scorecard) to assess the food pantry environment, including client choice, and to use the tool to quantify change in VFF intervention pantries compared with comparison pantries longitudinally over the 3-year study period. Food pantries in rural, high-poverty counties in six Midwestern states participated in a longitudinal, matched treatment and comparison study. Pantries were assigned to treatment (n = 12) or comparison (n = 12) group. A MyChoice Scorecard was completed pre-, mid- and post-intervention. Mixed models were generated with MyChoice Scorecard score as the outcome and included main effects for intervention group and time since pre-intervention visit. Pre-intervention, MyChoice scores did not differ significantly between intervention and comparison pantries (8.5 ± 1.5 vs. 9.1 ± 1.5, p = .19). Marginal mean values for MyChoice Scorecard score differed significantly between treatment and comparison groups at both mid-intervention (14.6 ± 1.4 vs. 10.8 ± 1.4, p = .05) and post-intervention (21.8 ± 1.2 vs. 11.8 ± 1.2, p < .001). The MyChoice Scorecard, either alone or as part of the VFF intervention, can be used by community public health professionals, such as Extension staff, to document and facilitate meaningful change in the nutritional environment of food pantries.

Daily Dietary Intake Patterns Improve after Visiting a Food Pantry among Food-Insecure Rural Midwestern Adults.

Emergency food pantries provide food at no cost to low-resource populations. The purpose of this study was to evaluate single-day dietary intake patterns before and after visiting a food pantry among food-secure and food-insecure pantry clients. This observational cohort study comprised a paired, before-and-after design with a pantry visit as the intervention. Participants (n = 455) completed a demographic and food security assessment, and two 24-h dietary recalls. Adult food security was measured using the U.S. Household Food Security Survey Module. Dietary intake patterns were assessed using Automated Self-Administered 24-h Recall data and classified by Healthy Eating Index (HEI-2010) scores, dietary variety, number of eating occasions, and energy intake. Paired t-tests and Wilcoxon signed-rank tests compared outcomes before and after a pantry visit. Mean dietary variety increased after the pantry visit among both food-secure (p = 0.02) and food-insecure (p < 0.0001) pantry clients. Mean energy intake (p = 0.0003), number of eating occasions (p = 0.004), and HEI-2010 component scores for total fruit (p < 0.001) and whole fruit (p < 0.0003) increased among food-insecure pantry clients only. A pantry visit may improve dietary intake patterns, especially among food-insecure pantry clients.

Utilizing Talking Circles as a Means of Gathering American Indian Stories for Developing a Nutrition and Physical Activity Curriculum.

This qualitative study used a focus group approach (talking circles) to elicit tribal elder insight on important concepts for the purpose of creating a curriculum to teach tribal youth in South Dakota about nutrition and physical activity in culturally appropriate ways. The focus groups were part of a larger project that is exploring mechanisms for creating culturally relevant nutrition and physical activity education for American Indian youth. A series of "Eat Smart, Play Hard" posters, created by South Dakota State University Extension, served as the starting point for talking circle conversations with tribal elders about teaching nutrition and physical activity to children. Data from the talking circles were analyzed using qualitative content analysis for themes in elder dialogs. In open-ended conversations, elders discussed barriers and success in achieving good nutrition and physical activity, important aspects of the Siouan food culture, and historical relationships with food. They shared insights on food ingredients and methods of obtaining and preparing food that were and are currently important to their communities. These data were used to better understand the Native cultural perspectives on nutrition and physical activity and to create effective educational material for Native youth that could be used to teach them in culturally relevant ways.