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Better diet quality regardless of community food access was associated with a higher likelihood of glycemic control in early pregnancy among nulliparous individuals with pregestational diabetes. These findings highlight the need for interventions that address nutrition insecurity for pregnant individuals living with diabetes.
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BACKGROUND: Households experiencing food insecurity may use dynamic strategies to meet food needs. Yet, the relationship between household food sourcing behaviors and food security, particularly in rural settings, is understudied. OBJECTIVE: To identify food sourcing patterns and their associations with food insecurity among households in rural Appalachian Ohio during the COVID-19 pandemic. DESIGN: Survey data were collected from a cohort of households in Athens County, OH, in July 2020, October 2020, January 2021, and April 2021. PARTICIPANTS/SETTING: The sample included 663 households with household food sourcing and food security information for ≥1 survey wave. MAIN OUTCOME MEASURES: Household food sourcing patterns. Households reported the frequency with which they obtained food from various retailers and charitable sources, classified as supercenters, supermarkets, convenience stores, farmers markets, or charitable sources. STATISTICAL ANALYSES: Principal component analysis was used to identify food sourcing patterns. Linear mixed models were used to assess changes in food sourcing behaviors over the study period and to determine whether food sourcing behaviors differed according to food security status. RESULTS: Two patterns were identified: Convenience Stores and Charitable Food and Supermarkets and Farmers Markets, not Supercenters. Relative to July 2020, alignment of households' food sourcing behaviors with the Supermarkets and Farmers Markets, not Supercenters pattern was higher in October 2020 (ß .07, 95% CI .02 to .12) and alignment with the Convenience Stores and Charitable Food pattern was lower in April 2021 (ß -.06, 95% CI -.11 to -.02). Compared with food-secure households, food sourcing behaviors of food-insecure households were more closely aligned with the Convenience Stores and Charitable Food pattern (ß .07, 95% CI .00 to .13); no statistically significant difference in scores was observed for the Supermarkets and Farmers Markets, not Supercenters pattern (ß -.07, 95% CI -.15 to .02). CONCLUSIONS: These findings support efforts to increase access to healthy, affordable options at venues where food-insecure households may be likely to obtain food, such as convenience stores and charitable sources.
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OBJECTIVE: To evaluate the relationship between changes in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment during pregnancy from 2016 to 2019 and rates of adverse pregnancy outcomes in U.S. counties in 2019. METHODS: We conducted a serial, cross-sectional ecologic study at the county level using National Center for Health Statistics natality data from 2016 to 2019 of nulliparous individuals eligible for WIC. The exposure was the change in county-level WIC enrollment from 2016 to 2019 (increase [more than 0%] vs no change or decrease [0% or less]). Outcomes were adverse pregnancy outcomes assessed in 2019 and included maternal outcomes (ie, gestational diabetes mellitus [GDM], hypertensive disorders of pregnancy, cesarean delivery, intensive care unit [ICU] admission, and transfusion) and neonatal outcomes (ie, large for gestational age [LGA], small for gestational age [SGA], preterm birth, and neonatal intensive care unit [NICU] admission). RESULTS: Among 1,945,914 deliveries from 3,120 U.S. counties, the age-standardized rate of WIC enrollment decreased from 73.1 (95% CI, 73.0-73.2) per 100 live births in 2016 to 66.1 (95% CI, 66.0-66.2) per 100 live births in 2019, for a mean annual percent change decrease of 3.2% (95% CI, -3.7% to -2.9%) per year. Compared with individuals in counties in which WIC enrollment decreased or did not change, individuals living in counties in which WIC enrollment increased had lower rates of maternal adverse pregnancy outcomes, including GDM (adjusted odds ratio [aOR] 0.71, 95% CI, 0.57-0.89), ICU admission (aOR 0.47, 95% CI, 0.34-0.65), and transfusion (aOR 0.68, 95% CI, 0.53-0.88), and neonatal adverse pregnancy outcomes, including preterm birth (aOR 0.71, 95% CI, 0.56-0.90) and NICU admission (aOR 0.77, 95% CI, 0.60-0.97), but not cesarean delivery, hypertensive disorders of pregnancy, or LGA or SGA birth. CONCLUSION: Increasing WIC enrollment during pregnancy at the county level was associated with a lower risk of adverse pregnancy outcomes. In an era when WIC enrollment has decreased and food and nutrition insecurity has increased, efforts are needed to increase WIC enrollment among eligible individuals in pregnancy.
Subject(s)
Food Assistance , Pregnancy Outcome , Humans , Female , Pregnancy , Cross-Sectional Studies , Adult , Pregnancy Outcome/epidemiology , United States/epidemiology , Food Assistance/statistics & numerical data , Infant, Newborn , Parity , Pregnancy Complications/epidemiology , Young AdultABSTRACT
Food and nutrition insecurity disproportionately impact low-income households in the United States, contributing to higher rates of chronic diseases among this population. Addressing this challenge is complex because of various factors affecting the availability and accessibility of nutritious food. Short value chain (SVC) models, informally known as local food systems, offer a systemic approach that aims to optimize resources and align values throughout and beyond the food supply chain. Although specific SVC interventions, such as farmers markets, have been studied individually, a comprehensive review of SVC models was pursued to evaluate their relative impact on food security, fruit and vegetable intake, diet quality, health-related markers, and barriers and facilitators to participation among low-income households. Our systematic literature search identified 37 articles representing 34 studies from 2000-2020. Quantitative, qualitative, and mixed-method studies revealed that farmers market interventions had been evaluated more extensively than other SVC models (i.e., produce prescription programs, community-supported agriculture, mobile markets, food hubs, farm stands, and farm-to-school). Fruit and vegetable intake was the most measured outcome; other outcomes were less explored or not measured at all. Qualitative insights highlighted common barriers to SVC use, such as lack of program awareness, limited accessibility, and cultural incongruence, whereas facilitators included health-promoting environments, community cohesion, financial incentives, and high-quality produce. Social marketing and dynamic nutrition education appeared to yield positive program outcomes. Financial incentives were used in many studies, warranting further investigation into optimal amounts across varying environmental contexts. SVC models are increasingly germane to national goals across the agriculture, social, and health care sectors. This review advances the understanding of key knowledge gaps related to their implementation and impact; it emphasizes the need for research to analyze SVC potential comprehensively across the rural-urban continuum and among diverse communities through long-term studies of measurable health impact and mixed-method studies investigating implementation best practices. This trial was registered at PROSPERO as CRD42020206532.
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Diet , Food Security , Food Supply , Fruit , Poverty , Vegetables , Humans , United States , Food Insecurity , Nutritional StatusABSTRACT
BACKGROUND: Higher scores for the American Heart Association Life's Essential 8 (LE8) metrics, blood pressure, cholesterol, glucose, body mass index, physical activity, smoking, sleep, and diet, are associated with lower risk of chronic disease. Socioeconomic status (SES; employment, insurance, education, and income) is associated with LE8 scores, but there is limited understanding of potential differences by sex. This analysis quantifies the association of SES with LE8 for each sex, within Hispanic Americans, non-Hispanic Asian Americans, non-Hispanic Black Americans, and non-Hispanic White Americans. METHODS AND RESULTS: Using cross-sectional data from the National Health and Nutrition Examination Survey, years 2011 to 2018, LE8 scores were calculated (range, 0-100). Age-adjusted linear regression quantified the association of SES with LE8 score. The interaction of sex with SES in the association with LE8 score was assessed in each racial and ethnic group. The US population representatively weighted sample (13 529 observations) was aged ≥20 years (median, 48 years). The association of education and income with LE8 scores was higher in women compared with men for non-Hispanic Black Americans and non-Hispanic White Americans (P for all interactions <0.05). Among non-Hispanic Asian Americans and Hispanic Americans, the association of SES with LE8 was not different between men and women, and women had greater LE8 scores than men at all SES levels (eg, high school or less, some college, and college degree or more). CONCLUSIONS: The factors that explain the sex differences among non-Hispanic Black Americans and non-Hispanic White Americans, but not non-Hispanic Asian Americans and Hispanic Americans, are critical areas for further research to advance cardiovascular health equity.
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Cardiovascular Diseases , United States/epidemiology , Humans , Male , Female , Risk Factors , Nutrition Surveys , Cross-Sectional Studies , Socioeconomic Factors , Cardiovascular Diseases/epidemiology , Social ClassABSTRACT
Food insecurity and inadequate nutrition are two major challenges that contribute to poor health conditions among U.S. households. Ohioans continue to face food insecurity, and rates of food insecurity in rural Southeast Ohio are higher than the state average. The main purpose of this project is to evaluate the associations between Supplemental Nutrition Assistance Program (SNAP) participation and food security in rural Ohio, and to explore the association between SNAP participation and fruit/vegetable consumption. We control for food shopping patterns, such as shopping frequency, because previous research reports a significant relationship between shopping patterns and food security. To achieve our purpose, we use novel household-level data on food insecurity and SNAP participation in rural Southeast Ohio, collected during the COVID-19 pandemic. We find that people who experience higher levels of food insecurity than others are more likely to participate in SNAP, though this is likely a function of selection bias. To correct for the bias, we employ the nearest neighbor matching method to match treated (SNAP participant) and untreated (similar SNAP nonparticipant) groups. We find that participating in SNAP increases the probability of being food secure by around 26 percentage points after controlling for primary food shopping patterns. We do not find any significant association between SNAP participation and estimated intake of fruits and vegetables. This study provides policymakers with suggestive evidence that SNAP is associated with food security in rural Southeast Ohio during the pandemic, and what additional factors may mediate these relationships.
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Food Assistance , Vegetables , Humans , Fruit , Ohio , Pandemics , Food Supply , Poverty , Cross-Sectional Studies , Food InsecurityABSTRACT
Background The American Heart Association's Life's Essential 8 (LE8) are 8 risk factors for cardiovascular disease, with poor attainment across all racial, ethnic, and socioeconomic groups. Attainment is lowest among Americans of low socioeconomic status (SES). Evidence suggests the association of SES with LE8 may vary by race and ethnicity. Methods and Results The association of 4 SES categories (education, income-to-poverty line ratio, employment, insurance) with LE8 was computed in age-adjusted linear regression models, with an interaction term for race and ethnicity, using National Health and Nutrition Examination Survey data, years 2011 to 2018. The sample (n=13 529) had a median age of 48 years (51% female) with weighting to be representative of the US population. The magnitude of positive association of college education (relative to ≤high school) with LE8 was greater among non-Hispanic White Americans (NHWA) compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA had a greater magnitude of positive association of income-to-poverty line ratio with LE8, compared with non-Hispanic Black Americans, Hispanic Americans, and non-Hispanic Asian Americans (all interactions P<0.001). NHWA with Medicaid compared with private insurance had a greater magnitude of negative association with LE8 compared with non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.01). NHWA unemployed due to disability or health condition (compared with employed) had a greater magnitude of negative association with LE8 than non-Hispanic Black Americans, non-Hispanic Asian Americans, or Hispanic Americans (all interactions P<0.05). Conclusions The magnitude of association of SES with LE8 is greatest among NHWA. More research is needed on SES's role in LE8 attainment in minority group populations.
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Ethnicity , Heart Disease Risk Factors , Social Class , Female , Humans , Male , Middle Aged , Ethnicity/statistics & numerical data , Hispanic or Latino , Nutrition Surveys , United States/epidemiology , White , Risk Factors , Black or African American , AsianABSTRACT
BACKGROUND: The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts. METHODS: Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives. RESULTS: F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity. CONCLUSIONS: Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www. CLINICALTRIALS: gov/ct2/show/NCT02770196 .
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Agriculture , Cost-Effectiveness Analysis , Humans , Carotenoids , Costs and Cost Analysis , Poverty , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: A poor diet can result from adverse social determinants of health and increases the risk of adverse pregnancy outcomes. OBJECTIVE: We aimed to assess, using data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be prospective cohort, whether nulliparous pregnant individuals who lived in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert. METHODS: The exposure was living in a food desert based on a spatial overview of food access indicators by income and supermarket access per the Food Access Research Atlas. The outcome was periconceptional diet quality per the Healthy Eating Index (HEI)-2010, analyzed by quartile (Q) from the highest or best (Q4, reference) to the lowest or worst dietary quality (Q1); and secondarily, nonadherence (yes or no) to 12 key aspects of dietary quality. RESULTS: Among 7,956 assessed individuals, 24.9% lived in a food desert. The mean HEI-2010 score was 61.1 of 100 (SD: 12.5). Poorer periconceptional dietary quality was more common among those who lived in a food desert compared with those who did not live in a food desert (Q4: 19.8%, Q3: 23.6%, Q2: 26.5%, and Q1: 30.0% vs. Q4: 26.8%, Q3: 25.8%, Q2: 24.5%, and Q1: 22.9%; overall P < 0.001). Individuals living in a food desert were more likely to report a diet in lower quartiles of the HEI-2010 (i.e., poorer dietary quality) (aOR: 1.34 per quartile; 95% CI: 1.21, 1.49). They were more likely to be nonadherent to recommended standards for 5 adequacy components of the HEI-2010, including fruit, total vegetables, greens and beans, seafood and plant proteins, and fatty acids, and less likely to report excess intake of empty calories. CONCLUSIONS: Nulliparous pregnant individuals living in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.
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Diet , Food Deserts , Pregnancy , Female , Humans , Prospective Studies , Pregnancy Outcome , VegetablesABSTRACT
OBJECTIVE: Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention. DESIGN: Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later. PARTICIPANTS: Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148). INTERVENTION: Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis. VARIABLES MEASURED: Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner. ANALYSIS: Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence. RESULTS: At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107). CONCLUSIONS AND IMPLICATIONS: Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.
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Fruit , Vegetables , Child , Humans , Health Education , Agriculture , Feeding BehaviorABSTRACT
BACKGROUND: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. METHODS: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c ≥7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. SETTING: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. DESIGN: 2 × 2 factorial design. INTERVENTIONS: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. OUTCOMES: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. DISCUSSION: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. CLINICALTRIALS: gov: NCT05472441.
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Diabetes Mellitus, Type 2 , Humans , Diabetes Mellitus, Type 2/therapy , Glycated Hemoglobin , Health Education , Referral and ConsultationABSTRACT
Every Door Direct Mail (EDDM) is a service of the United States Postal Service (USPS) that delivers non-addressed mail to all postal customers on designated mailing routes. Primarily used for marketing, we describe EDDM's efficacy as a research tool for remotely recruiting a representative convenience sample of rural Appalachian households for a longitudinal survey-based health study. In June 2020, recruitment postcards were sent via EDDM to all residential addresses (n = 31,201) within an 18 ZIP code region of Southeastern Ohio. Adults were invited to complete a survey online via QR code or to call for a mailed survey. Respondent demographic characteristics were generated using SPSS and compared with the region's 2019 U.S. Census Bureau statistics. A total of 841 households responded to the invitation, reflecting a response rate higher than marketing estimates (2.7 % vs 2 %). Compared to Census data, a greater proportion of respondents were female (74 % vs 51 %), and highly educated (64 % vs 36 % college graduates); a comparable proportion were non-Hispanic (99 % vs 98 %), white (90 % vs 91 %), and had ≥ 1 adult in the household (1.7 ± 0.9); and a lower proportion had a household income < $50 k (47 % vs 54 %). The median age was higher (56 vs 30 years), and 29 % were retirees. EDDM was a viable method for remote recruitment of a rural geographically-based sample. Further work is needed to explore its efficacy in recruiting representative samples in other contexts and to inform best practices for its use.
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BACKGROUND: Diabetes self-management education and support is the cornerstone of diabetes care, yet only 1 in 2 adults with diabetes attain hemoglobin A1c (HbA1c) targets. Food insecurity makes diabetes management and HbA1c control more difficult. OBJECTIVE: Our aim was to test whether a cooking intervention with food provision and diabetes self-management education and support improves HbA1c and diabetes management. DESIGN: This was a waitlist-controlled, randomized trial. PARTICIPANTS/SETTING: Participants were 48 adults with type 1 or type 2 diabetes. INTERVENTION: Cooking Matters for Diabetes was adapted from Cooking Matters and the American Diabetes Association diabetes self-management education and support intervention into a 6-week program with weekly food provision (4 servings). MAIN OUTCOME MEASURES: Surveys (ie, Summary of Diabetes Self-Care Activities; Medical Outcomes Study Short Form Health Survey, version 1; Diet History Questionnaire III; 10-item US Adult Food Security Survey Module; and Stanford Diabetes Self-Efficacy Scale) were administered and HbA1c was measured at baseline, post intervention, and 3-month follow-up. STATISTICAL ANALYSIS: Mixed-effects linear regression models controlling for sex and study wave were used. RESULTS: Mean (SD) age of participants was 57 (12) years; 65% identified as female, 52% identified as White, 40% identified as Black, and 19 (40%) were food insecure at baseline. Intervention participants improved Summary of Diabetes Self-Care Activities general diet score (0 to 7 scale) immediately post intervention (+1.51; P = .015) and 3 months post intervention (+1.23; P = .05), and improved Medical Outcomes Study Short Form Health Survey, version 1, mental component score (+6.7 points; P = .025) compared with controls. Healthy Eating Index 2015 total vegetable component score improved at 3 months (+0.917; P = .023) compared with controls. At baseline, food insecure participants had lower self-efficacy (5.6 vs 6.9 Stanford Diabetes Self-Efficacy Scale; P = .002) and higher HbA1c (+0.77; P = .025), and demonstrated greater improvements in both post intervention (+1.2 vs +0.4 Stanford Diabetes Self-Efficacy Scale score; P = .002, and -0.12 vs +0.39 HbA1c; P = .25) compared with food secure participants. CONCLUSIONS: Cooking Matters for Diabetes may be an effective method of improving diet-related self-care and health-related quality of life, especially among food insecure patients, and should be tested in larger randomized controlled trials.
Subject(s)
Diabetes Mellitus, Type 2 , Self-Management , Adult , Female , Humans , Middle Aged , Cooking , Diabetes Mellitus, Type 2/therapy , Glycated Hemoglobin , Quality of Life , VegetablesABSTRACT
BACKGROUND: Diabetes self-management education and support is the cornerstone of diabetes care, yet <10% of adults with diabetes manage their condition successfully. Feasible interventions are needed urgently. OBJECTIVE: Our aim was to assess the feasibility of a cooking intervention with food provision and diabetes self-management education and support. DESIGN: This was a waitlist-controlled, randomized trial. PARTICIPANTS/SETTING: Thirteen adults with type 1 or type 2 diabetes who participated in Cooking Matters for Diabetes (CMFD) participated in 2 focus groups. INTERVENTION: CMFD was adapted from Cooking Matters and the American Diabetes Association's diabetes self-management education and support intervention into a 6-week program with weekly lesson-aligned food provisions. MAIN OUTCOME MEASURES: Feasibility was evaluated quantitatively and qualitatively along the following 5 dimensions: demand, acceptability, implementation, practicality, and limited efficacy. STATISTICAL ANALYSIS: Two coders extracted focus group themes with 100% agreement after iterative analysis, resulting in consensus. Administrative data were analyzed via descriptive statistics. RESULTS: Mean (SD) age of focus group participants was 57 (14) years; 85% identified as female; 39% identified as White; 46% identified as Black; and income ranged from <$5,000 per year (15%) to $100,000 or more per year (15%). Mean (SD) baseline hemoglobin A1c was 8.6% (1.2%). Mean attendance in CMFD was 5 of 6 classes (83%) among all participants. Demand was high based on attendance and reported intervention utilization and was highest among food insecure participants, who were more likely to report using the food provisions and recipes. Acceptability was also high; focus groups revealed the quality of instructors and interaction with peers as key intervention strengths. Participant ideas for implementation refinement included simplifying recipes, lengthening class sessions, and offering more food provision choices. Perceived effects of the intervention included lower hemoglobin A1c and body weight and improvements to health-related quality of life. CONCLUSIONS: The CMFD intervention was feasible according to the measured principles of demand, acceptability, implementation, practicality, and limited efficacy.
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Diabetes Mellitus, Type 2 , Self-Management , Adult , Female , Humans , Middle Aged , Cooking , Diabetes Mellitus, Type 2/therapy , Feasibility Studies , Glycated Hemoglobin , Quality of Life , Male , AgedABSTRACT
Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.
Food insecurity can make the self-management of diet-related chronic conditions (e.g., diabetes, hypertension, and obesity) difficult. Clinic-based food referral programs (FRPs) can help address the diet-related needs of food-insecure primary care patients by improving access to nutritious foods. However, the factors contributing to successful FRP implementation in primary care settings are underexplored. The focus of this study was to explore the barriers to and facilitators of implementation of an FRP offered to food-insecure primary care patients with chronic conditions seen at an academic medical center using a multi-stakeholder approach. Competing clinical and patient demands, patient transportation barriers, and food pantry-related stigma were salient factors that prevented healthcare providers and patients from engaging fully with the FRP. Inadequate provider feedback about patients' use of the FRP was also cited as a deterrent to greater provider engagement with the FRP. Critical facilitators of implementation included support and encouragement from program champions and having a coordinated referral process. The intentional branding and presentation of the FRP to eligible patients may have helped encourage its use by destigmatizing the food pantry setting. The impact of optimizing FRP implementation on patient use and program effectiveness warrants further research.
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Health Personnel , Referral and Consultation , Delivery of Health Care , Humans , Mass Screening , Social StigmaABSTRACT
The COVID-19-related lockdowns led to school closures across the United States, cutting off critical resources for nutritious food. Foodservice employees emerged as frontline workers; understanding their experiences is critical to generate innovations for program operations and viability. The purpose of this cross-sectional study was to characterize COVID-19-related foodservice adaptations for summer and school year meal provision. Public school district foodservice administrators across Ohio were surveyed in December 2020. Questions related to meal provision before, during, and after COVID-19-related school closures. Results indicate the majority of districts continued providing meals upon their closure in Spring 2020 (n = 182, 87.1%); fewer did so in Summer (n = 88, 42.1%) and Fall (n = 32, 15.3%). In Spring and Summer, most districts that offered meals functioned as 'open sites' (67.0% and 87.5%, respectively), not limiting food receipt to district-affiliated students. Most districts employed a pick-up system for food distribution (76-84% across seasons), though some used a combination of approaches or changed their approach within-season. Qualitatively, districts reported both "successes" (e.g., supporting students) and "challenges" (e.g., supply chain). Despite being ill-prepared, districts responded quickly and flexibly to demands of the pandemic. This analysis provides insight for future practice (e.g., establishing community partnerships) and policy (e.g., bolstering local food systems).
Subject(s)
COVID-19 , COVID-19/epidemiology , Communicable Disease Control , Cross-Sectional Studies , Humans , Meals , Ohio/epidemiology , Schools , United StatesABSTRACT
OBJECTIVES: To characterize factors influencing the development and sustainability of data sharing in the Mid-Ohio Farmacy (MOF), a produce referral program implemented in partnership between a community-based organization (the Mid-Ohio Food Collective ["Food Collective"]) and an academic medical center (The Ohio State University Wexner Medical Center [OSUWMC]). STUDY DESIGN: We used an in-depth case study approach to identify challenges that arose during implementation of the MOF and related solutions via semistructured interviews with representatives of both organizations (May-September 2020). METHODS: Key informants from OSUWMC (n = 20) and the Food Collective (n = 11) were identified using a combination of purposive and convenience sampling; they included administrators, project champions, clinical providers, and food pantry representatives. Interview transcripts were coded using a deductive dominant approach guided by a logic model aimed at determining the resources and activities relevant to the development of the partnership. RESULTS: Challenges of cross-sector data sharing fit into 3 themes: data sharing regulations, data exchange capabilities, and cross-sector data integration. Overcoming these challenges required creative workarounds-for example, linking patients across organizations was done via establishment of a unique, partnership-specific patient identifier, which was incorporated into the health system's electronic health record for continuity. CONCLUSIONS: Our findings suggest that current regulatory frameworks are misspecified to the growing interest in cross-sector partnerships between health care and community-based organizations. Future efforts to support these relationships should consider clarifying rules around data sharing and increasing Medicaid support for nonmedical, health-related social needs.