Characterizing Rural Food Access in Remote Areas.

Residents of rural areas may have limited access to healthy foods, leading to higher incidence of diet related health issues. Smaller grocers in rural areas experience challenges in maintaining fresh produce and other healthy foods available for customers. This study assessed the rural food environment in northeast Lower Michigan in order to inform healthy food financing projects such as the Michigan Good Food Fund. The area's retail food businesses were categorized using secondary licensing, business, and nutrition program databases. Twenty of these stores were visited in person to verify the validity of the categories created, and to assess the availability of healthy foods in their aisles. In-depth interviews with key informants were carried out with store owners, economic development personnel, and other food system stakeholders having knowledge about food access, in order to learn more about the specific challenges that the area faces. Out-shopping, seasonality, and economic challenges were found to affect healthy food availability. Mid-sized independent stores were generally found to have a larger selection of healthy foods, but smaller rural groceries also have potential to provide fresh produce and increase food access. Potential healthy food financing projects are described and areas in need of further research are identified.

Factors influencing food preparation behaviours: findings from focus groups with Mexican-American mothers in southern California.

OBJECTIVE: The purpose of the present study was to explore food preparation behaviours, attitudes, meal planning and shopping among Mexican-American mothers. DESIGN: Data were collected through four focus groups with mothers of Mexican origin/ancestry who considered themselves to be the primary food preparer. Topics included food preparation behaviours and influencers (culture, family, attitudes, barriers, meal planning and shopping). Data were analysed using a qualitative grounded theory approach. All focus groups were audio recorded, transcribed verbatim and coded for themes. SETTING: Data were collected in southern California, USA in 2013. SUBJECTS: Of the sample of twenty-one Mexican-American mothers, thirteen were born outside the USA and the mean household size was five members. RESULTS: Participants reported that food was often prepared using traditional staples and food preparation behaviours were learned from maternal family members. Participants also suggested that health was influenced by foods eaten and how they were prepared. Salient factors influencing food preparation behaviours included culture and tradition, maternal family members' food preparation behaviours, food preparation self-efficacy and attitudes towards healthy eating. Time and busy schedules were cited as barriers. CONCLUSIONS: Future interventions should consider utilizing family-based approaches and teaching culturally relevant food preparation skills, especially to youth, while reinforcing more healthful dietary practices.

Household food insecurity as a determinant of overweight and obesity among low-income Hispanic subgroups: Data from the 2011-2012 California Health Interview Survey.

An estimated 78% of Hispanics in the United States (US) are overweight or obese. Household food insecurity, a condition of limited or uncertain access to adequate food, has been associated with obesity rates among Hispanic adults in the US. However, the Hispanic group is multi-ethnic and therefore associations between obesity and food insecurity may not be constant across Hispanic country of origin subgroups. This study sought to determine if the association between obesity and food insecurity among Hispanics is modified by Hispanic ancestry across low-income (≤200% of poverty level) adults living in California. Data are from the cross-sectional 2011-12 California Health Interview Survey (n = 5498). Rates of overweight or obesity (BMI ≥ 25), Calfresh receipt (California's Supplemental Nutrition Assistance Program), and acculturation were examined for differences across subgroups. Weighted multiple logistic regressions examined if household food insecurity was significantly associated with overweight or obesity and modified by country of origin after controlling for age, education, marital status, country of birth (US vs. outside of US), language spoken at home, and Calfresh receipt (P < .05). Significant differences across subgroups existed for prevalence of overweight or obesity, food security, Calfresh receipt, country of birth, and language spoken at home. Results from the adjusted logistic regression models found that food insecurity was significantly associated with overweight or obesity among Mexican-American women (ß (SE) = 0.22 (0.09), p = .014), but not Mexican-American men or Non-Mexican groups, suggesting Hispanic subgroups behave differently in their association between food insecurity and obesity. By highlighting these factors, we can promote targeted obesity prevention interventions, which may contribute to more effective behavior change and reduced chronic disease risk in this population.

Features in Grocery Stores that Motivate Shoppers to Buy Healthier Foods, ConsumerStyles 2014.

UNLABELLED: We examined nine features in grocery stores shoppers reported motivated them to purchase more healthful foods in the past month. Features were compiled from common supermarket practices for each of the 4 Ps of marketing: pricing, placement, promotion, and product. We examined percentages of the features overall and by shopping frequency using Chi square tests from a 2014 cross sectional web-based health attitudes and behaviors survey, ConsumerStyles. The survey was fielded from June to July in 2014. Participants were part of a market research consumer panel that were randomly recruited by probability-based sampling using address-based sampling methods to achieve a sample representative of the U.S. POPULATION: Data from 4242 adults ages 18 and older were analyzed. About 44 % of respondents indicated at least one feature motivated them to purchase more healthful foods. Top choices included in-store coupons or specials (20.1 %), availability of convenient, ready-to-eat more healthful foods (18.8 %), product labels or advertising on packages (15.2 %), and labels or signs on shelves that highlighted more healthful options (14.6 %). Frequent shoppers reported being motivated to purchase more healthful foods by in-store tastings/recipe demonstrations and coupons/specials more often than infrequent shoppers. Enhancing the visibility and appeal of more healthful food items in grocery stores may help improve dietary choices in some populations but additional research is needed to identify the most effective strategies for interventions.

A workplace farmstand pilot programme in Omaha, Nebraska, USA.

OBJECTIVE: To explore the feasibility of a workplace farmstand programme through the utilization of an online ordering system to build awareness for local food systems, encourage community participation, and increase local fruit and vegetable availability. DESIGN: A 4-week pilot to explore feasibility of workplace farmstand programmes through a variety of outcome measures, including survey, mode of sale, weekly sales totals and intercept interviews. SETTING: A large private company in Sarpy County, Omaha, Nebraska, USA. SUBJECTS: Employees of the company hosting the farmstand programme. RESULTS: Pre-programme, a majority of employees indicated that quality (95·4 %), variety (94·6 %) and cost of fruits and vegetables (86·4 %) were driving factors in their fruit and vegetable selection when shopping. The availability of locally or regionally produced fruits and vegetables was highly important (78·1 %). Participants varied in their definition of local food, with nearly half (49·2 %) reporting within 80·5 km (50 miles), followed by 160·9 km (100 miles; 29·5 %) and 321·9 km (200 miles; 12·1 %). Weekly farmstand purchases (both walk-ups and online orders) ranged from twenty-eight to thirty-nine employees, with weekly sales ranging from $US 257·95 to 436·90 for the producer. The mode of purchase changed throughout the pilot, with higher use of online ordering in the beginning and higher use of walk-up purchasing at the end. CONCLUSIONS: The workplace farmstand pilot study revealed initial interest by both employees and a producer in this type of programme, helped to establish a sustained producer-employer relationship and led to additional opportunities for both the producer and employer.

It is better to be a fat ex-smoker than a thin smoker: findings from the 1997-2004 National Health Interview Survey-National Death Index linkage study.

OBJECTIVE: The aim of this research was to compare the risk of all-cause mortality and mortality from all cancers combined, lung cancer, respiratory diseases, cardiovascular diseases and diabetes mellitus between normal-weight smokers and overweight or obese ex-smokers. METHODS: Data were from 1997 to 2004 National Health Interview Survey (with response rates ranging from 70% to 80%) which were linked to records in the National Death Index. Mortality follow-up was through 31 December 2006. The sample was limited to normal-weight smokers and overweight/obese ex-smokers 25 years of age and older (n=52,819). HR from Cox regression was computed to represent mortality effect. RESULTS: Results showed that in both women and men, normal-weight smokers, relative to overweight or obese ex-smokers, had a higher risk of mortality from all causes combined, all cancers combined, lung cancer, cardiovascular and respiratory diseases. Among women, there was no difference in mortality risk from diabetes mellitus between normal-weight smokers and overweight or obese ex-smokers. Among men, there was some evidence that the risk of mortality was higher in obese ex-smokers than normal-weight smokers. CONCLUSIONS: This article concludes that, overall, mortality risk is smaller in overweight or obese ex-smokers than normal-weight smokers. Smoking cessation interventions can tailor messages that highlight the greater reduction in mortality associated with quitting, compared with potential weight gain.

The Validity and reliability of the Comprehensive Home Environment Survey (CHES).

Few comprehensive measures exist to assess contributors to childhood obesity within the home, specifically among low-income populations. The current study describes the modification and psychometric testing of the Comprehensive Home Environment Survey (CHES), an inclusive measure of the home food, physical activity, and media environment related to childhood obesity. The items were tested for content relevance by an expert panel and piloted in the priority population. The CHES was administered to low-income parents of children 5 to 17 years (N = 150), including a subsample of parents a second time and additional caregivers to establish test-retest and interrater reliabilities. Children older than 9 years (n = 95), as well as parents (N = 150) completed concurrent assessments of diet and physical activity behaviors (predictive validity). Analyses and item trimming resulted in 18 subscales and a total score, which displayed adequate internal consistency (α = .74-.92) and high test-retest reliability (r ≥ .73, ps < .01) and interrater reliability (r ≥ .42, ps < .01). The CHES score and a validated screener for the home environment were correlated (r = .37, p < .01; concurrent validity). CHES subscales were significantly correlated with behavioral measures (r = -.20-.55, p < .05; predictive validity). The CHES shows promise as a valid/reliable assessment of the home environment related to childhood obesity, including healthy diet and physical activity.

Stakeholders' interest in and challenges to implementing farm-to-school programs, Douglas County, Nebraska, 2010-2011.

INTRODUCTION: Schools are uniquely positioned to influence the dietary habits of children, and farm-to-school programs can increase fruit and vegetable consumption among school-aged children. We assessed the feasibility of, interest in, and barriers to implementing farm-to-school activities in 7 school districts in Douglas County, Nebraska. METHODS: We used a preassessment and postassessment survey to obtain data from 3 stakeholder groups: school food service directors, local food producers, and food distributors. We had a full-time farm-to-school coordinator who was able to engage multiple stakeholders and oversee the development and dissemination of a toolkit. We used descriptive statistics to make comparisons. RESULTS: Seven food service directors, 5 distributors identified by the food service directors, and 57 local producers (9 completed only the preassessment survey, 16 completed only the postassessment survey, and 32 completed both) completed various components of the assessment. Interest in pursuing farm-to-school activities to incorporate more local foods in the school lunch program increased during the 2-year project; mean interest in purchasing local foods by food service directors for their districts increased from 4.4 to 4.7 (on a scale of 1 to 5). CONCLUSION: Implementing farm-to-school programming in Douglas County, Nebraska, is feasible, although food safety and distribution is a main concern among food service directors. Additional research on feasibility, infrastructure, and education is recommended.

Measures of the home environment related to childhood obesity: a systematic review.

OBJECTIVE: Due to a proliferation of measures for different components of the home environment related to childhood obesity, the purpose of the present systematic review was to examine these tools and the degree to which they can validly and reliably assess the home environment. DESIGN: Relevant manuscripts published between 1998 and 2010 were obtained through electronic database searches and manual searches of reference lists. Manuscripts were included if the researchers reported on a measure of the home environment related to child eating and physical activity (PA) and childhood obesity and reported on at least one psychometric property. RESULTS: Of the forty papers reviewed, 48 % discussed some aspect of parenting specific to food. Fifty-per cent of the manuscripts measured food availability/accessibility, 18 % measured PA availability/accessibility, 20 % measured media availability/accessibility, 30 % focused on feeding style, 23 % focused on parenting related to PA and 20 % focused on parenting related to screen time. CONCLUSIONS: Many researchers chose to design new measures for their studies but often the items employed were brief and there was a lack of transparency in the psychometric properties. Many of the current measures of the home food and PA environment focus on one or two constructs; more comprehensive measures as well as short screeners guided by theoretical models are necessary to capture influences in the home on food and PA behaviours of children. Finally, the current measures of the home environment do not necessarily translate to specific sub-populations. Recommendations were made for future validation of measures in terms of appropriate psychometric testing.

Who participates in internet-based worksite weight loss programs?

BACKGROUND: The reach and representativeness are seldom examined in worksite weight loss studies. This paper describes and illustrates a method for directly assessing the reach and representativeness of a internet-based worksite weight loss program. METHODS: A brief health survey (BHS) was administered, between January 2008 and November 2009, to employees at 19 worksites in Southwest Virginia. The BHS included demographic, behavioral, and health questions. All employees were blinded to the existence of a future weight loss program until the completion of the BHS. RESULTS: The BHS has a participation rate of 66 percent and the subsequent weight loss program has a participation rate of 30 percent. Employees from higher income households, with higher education levels and health literacy proficiency were significantly more likely to participate in the program (p's < .01). CONCLUSIONS: Worksite weight loss programs should include targeted marketing strategies to engage employees with lower income, education, and health literacy.

Using Secondary 24-Hour Dietary Recall Data to Estimate Daily Dietary Factor Intake From the FLASHE Study Dietary Screener.

INTRODUCTION: The National Cancer Institute's 2014 Family Life, Activity, Sun, Health, and Eating Study utilized a 27-item Dietary Screener tailored to adolescent eating patterns that assessed the frequency of intake of several foods and beverages in parent-adolescent dyads. This study estimated intake of fruits and vegetables (FVs), dairy, added sugars, and whole grains for screener respondents using existing, nationally representative, 24-hour dietary recall data. METHODS: Dietary Screener items were converted from frequency responses to daily intake. Intake (dependent variable) was estimated using regression coefficients and portion sizes of foods and beverages (independent variables) generated from the 2003-2006 National Health and Nutrition Examination Survey 2-day 24-hour recall data set. Means (SDs) were used to examine daily dietary factor intake among parent and adolescents. Analysis was conducted in 2015-2016. The analytic sample consisted of 1,732 parents (aged ≥18 years) and their adolescent aged 12-17 years (n=1,632). RESULTS: Male parents consumed 3.6 cups of FVs, 1.8 cups of dairy, 22.6 teaspoons of added sugars, and 2.1 ounces of whole grains daily; female parents consumed 2.8 cups of FVs, 1.3 cups of dairy, 14.8 teaspoons of added sugars, and 1.4 ounces of whole grains daily. Male adolescents consumed 2.2 cups of FVs, 1.9 cups of dairy, 17.9 teaspoons of added sugars, and 1.0 ounces of whole grains daily; female adolescents consumed 2.2 cups FVs, 1.6 cups of dairy, 14.2 teaspoons of added sugars, and 0.8 ounces of whole grains daily. CONCLUSIONS: Utilizing a dietary screener tailored to adolescent eating patterns in parent-adolescent dyads provided estimated dietary factor intake, underscoring existing 24-hour dietary recall data can be used to calibrate dietary habits.

The Future of the Small Rural Grocery Store: A Qualitative Exploration.

OBJECTIVES: Rural communities face unique challenges to and opportunities for offering more healthful foods and are often understudied in comparison to their urban counterparts. The purpose of this study was to conduct a qualitative assessment of rural storeowners' perceptions of their communities, their business practices, and factors that influences their viability, sustainability, and ability to support healthy food choices. METHODS: We conducted interviews with storeowners (N = 15) in small stores in rural Nebraska and explored perceptions of business practices, role in the community, and consumer demand for more healthful foods. RESULTS: The storeowners reported strategies they employ to remain competitive, such as selling alcohol and tobacco, focusing on customer service, and ensuring quality of products. Manufacturer and distributor agreements often put constraints on their business models. Key challenges reported included a dwindling population and competition with larger chains in neighboring towns set in a sparsely populated landscape. Goals for the future included expanding equipment, largely to offer more prepared foods. CONCLUSIONS: This study adds to the literature around food access in rural communities, and can inform future implementation strategies to work with storeowners to improve healthy food access.

Development and Testing of a Revised Cooking Matters for Adults Survey.

OBJECTIVES: The purpose of this study was to: (1) develop and psychometrically test a survey designed to assess Cooking Matters for Adults (CMA); and (2) assess changes in outcomes from pre- to post-pilot testing in English-speaking CMA classes to support the construct validity of the survey. METHODS: Cognitive interviewing participants were drawn from a low-income convenience sample in Omaha, Nebraska (N = 21). The survey included items to assess dietary patterns and choices, sociodemographics, and psychosocial correlates. Analyses were conducted with SPSS and included descriptive statistics, exploratory factor analysis, Cronbach's alpha, and paired sample t-tests. RESULTS: Cognitive interviewing resulted in changes to survey layout and wording. Factor analysis revealed 4 actors with Cronbach alphas supporting internal consistency. Between pretest and posttest, fruit intake increased (p < .05) and non-fried potatoes decreased (p < .05). Selection of healthy dietary options (low-fat dairy and milk, sodium, lean meats; p's < .05), healthy food preparation (p < .001), and cooking confidence (p < .001) increased and perceived barriers to cooking (p < .01) decreased. CONCLUSIONS: The CMA Survey includes psychometrically sound items and positive self-reported changes. This survey can be a valuable resource for other similar programs.

Development and implementation of the National Cancer Institute's Food Attitudes and Behaviors Survey to assess correlates of fruit and vegetable intake in adults.

BACKGROUND: Low fruit and vegetable (FV) intake is a leading risk factor for chronic disease globally as well as in the United States. Much of the population does not consume the recommended servings of FV daily. This paper describes the development of psychosocial measures of FV intake for inclusion in the U.S. National Cancer Institute's 2007 Food Attitudes and Behaviors Survey. METHODS: This was a cross-sectional study among 3,397 adults from the United States. Scales included conventional constructs shown to be correlated with fruit and vegetable intake (FVI) in prior studies (e.g., self-efficacy, social support), and novel constructs that have been measured in few- to- no studies (e.g., views on vegetarianism, neophobia). FVI was assessed with an eight-item screener. Exploratory factor analysis, Cronbach's alpha, and regression analyses were conducted. RESULTS: Psychosocial scales with Cronbach's alpha ≥0.68 were self-efficacy, social support, perceived barriers and benefits of eating FVs, views on vegetarianism, autonomous and controlled motivation, and preference for FVs. Conventional scales that were associated (p<0.05) with FVI were self-efficacy, social support, and perceived barriers to eating FVs. Novel scales that were associated (p<0.05) with FVI were autonomous motivation, and preference for vegetables. Other single items that were associated (p<0.05) with FVI included knowledge of FV recommendations, FVI "while growing up", and daily water consumption. CONCLUSION: These findings may inform future behavioral interventions as well as further exploration of other potential factors to promote and support FVI.

Fruits and vegetables as a healthier snack throughout the day among families with older children: findings from a survey of parent-child dyads.

Most U.S. youth fail to eat the recommended amount of fruits and vegetables (FV) however many consume too many calories as added sugars and solid fats, often as snacks. The aim of this study was to assess factors associated with serving FV as snacks and with meals using parent-child dyads. A cross-sectional sample of U.S. children aged 9 to 18, and their caregiver/parent (n=1522) were part of a Consumer Panel of households for the 2008 YouthStyles mail survey. Chi-square test of independence and multivariable logistic regression were used to assess associations between serving patterns of FV as snacks with variations in serving patterns, and covariates including dietary habits. Most parents (72%) reported serving FV at meals and as snacks. Fruit was most frequently served as a snack during the day (52%) and vegetables were most frequently served as a snack during the day (22%) but rarely in the morning. Significant differences in child FV intake existed among FV as a snack serving patterns by parents. Compared to children whose parents served FV only at meals, children whose parents reported serving FV as snacks in addition to meals were significantly more likely to have consumed FV the day before (using a previous day screener), P<0.05. Contributing to the growing collection of literature describing parent-child dyad dietary behaviors, these findings suggest promoting FV access and intake throughout the day, not only at meals, by including serving as snacks, may increase FV intake among older children and adolescents.

New NSLP guidelines: challenges and opportunities for nutrition education practitioners and researchers.

The recent revisions of the National School Lunch Program (NSLP) requirements are designed to align with the 2010 Dietary Guidelines for Americans. The introduction and implementation of the new NSLP has been received with positive and negative reactions from school food professionals, students, parents, and teachers. To promote student health, this is an important time for policy makers, practitioners, and researchers to implement and evaluate strategies to support the new NSLP guidelines. The purpose of this viewpoint was to outline the new NSLP guidelines and discuss challenges and opportunities for implementation, strategies for practice, and future research questions.

The food and water system: impacts on obesity.

The Weight of the Nation™ (WON) conference was held in Washington, D.C. This article presents the issues and topics presented and discussed within the Food and Water System: Agriculture, Access and Sustainability track. Areas for opportunity are outlined in this article.

Smart choices for healthy families: a pilot study for the treatment of childhood obesity in low-income families.

This pre-post study used a mixed-methods approach to examine the impact of a family-based weight management program among a low-income population. Smart Choices for Healthy Families was developed through an integrated research-practice partnership and piloted with 26 children and parents (50% boys; mean age = 10.5 years; 54% Black) who were referred by their pediatrician. Smart Choices included six biweekly group sessions and six automated telephone-counseling calls over 3 months. Children displayed reduced body mass index z-scores (p < .05), increased lean muscle mass (p < .001), and increased quality of life (p < .0001). Follow-up interviews indicated that physicians valued the lay leaders' ability to provide lifestyle education, whereas lay leaders extended their reach to more community members. Parents wanted to become positive role models and found that the calls maintained focus on goals. Smart Choices shows promise to initiate weight management for children in low-income families.

Beverage intake in low-income parent-child dyads.

Beverage consumption adds to daily energy intake and often exceeds the recommended amount for discretionary energy. Previous research has shown that children are consuming sugar-sweetened beverages (SSB) in greater frequency and the relationship between parent-child dyads in beverage consumption is meaningful due to the parental influence on the development of beverage consumption behaviors. In particular, low-income families are at greater risk for obesity and higher levels of SSB consumption. The current investigation assessed habitual beverage intake among low-income parent-child dyads (N=95) with children between the ages of 9-17 years. The sample (46% African American; 45% Caucasian) had a mean body mass index (BMI) for the parents of 31.8±8.9 kg/m(2), while the mean BMI percentile for age and gender for the children was 70.3±31.3. Both parents and children consumed fewer nutrient-dense beverages and more energy-dense beverages than the recommended amount. The mean daily energy intake from beverages was 451±236 kcal for the parents and 457±237 kcal for the children. Correlations between parent-child dyad intake was also evident, identifying parents as potential role models and gatekeepers of the home food environment. Future interventions to prevent childhood obesity in low-income populations should address beverage intake, particularly SSB consumption, and determine the degree to which this behavior is learned behavior in the home.