Food Insecurity Is a Source of Toxic Stress.

This Viewpoint discusses food insecurity as a source of toxic stress that can affect children's health and advocates for developing research, clinical, and policy approaches to address the root causes of food insecurity.

Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities.

Food insecurity and the lack of access to affordable, nutritious food are associated with poor dietary quality and an increased risk of diet-related diseases, including cardiovascular disease, diabetes, and certain types of cancer. Those of lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, are more likely to live in under-resourced food environments, and continue to bear the greatest burden of diet-related chronic diseases in the United States. Despite the growing body of literature in this area, there are still significant gaps in our understanding of the various pathways that link food insecurity and neighborhood food environments to racial/ethnic and socioeconomic disparities in health and the most effective intervention strategies to address these disparities. To better understand the science in this area, the National Institutes of Health, in collaboration with the Centers for Disease Control (CDC) and Prevention and the United States Department of Agriculture (USDA), convened a virtual 3-d workshop 21-23 September 2021: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop brought together a diverse group of researchers, practitioners, policymakers, and federal partners with expertise in nutrition, the food environment, health and social policy, and behavioral and social sciences. The workshop had the following 3 research objectives: 1) summarize the state of the science and knowledge gaps related to food insecurity, neighborhood food environments, and nutrition health disparities, 2) identify research opportunities and strategies to address research gaps, and 3) examine evidence-based interventions and implementation approaches to address food insecurity and neighborhood food environments to promote health equity. This article summarizes workshop proceedings and describes research gaps and future opportunities that emerged from discussions.

Understanding Barriers and Strategies to Accessing Healthy Food in Urban Agriculture for Community Residents in Predominantly Black Communities.

BACKGROUND: Some residents in predominantly Black communities face significant challenges in accessing healthy food. However, urban agriculture is a growing sector that aims to increase overall food production, access to affordable and nutritious produce, and potentially improve community food security. PURPOSE: This study aimed to provide insight into barriers and strategies that urban agriculture growers and advocates identified for accessing urban agriculture markets in their communities. RESEARCH DESIGN AND STUDY SAMPLE: We interviewed and conducted focus groups with 17 urban growers and local food advocates that work in predominantly Black communities in Chicago. DATA COLLECTION AND/OR ANALYSIS: Understanding the complexities of access to healthy food can be challenging; therefore, we used the concept of access - accessibility, availability, affordability, accommodation, and acceptability - to better understand these barriers. RESULTS: Key barriers were the lack of accessibility to traditional food retailers, high availability of processed foods, and cultural acceptability of urban-produced foods. CONCLUSION: Building urban agriculture networks to support growers, connect with consumers, and emphasize political engagement can help to diversify and grow urban agriculture.

Correction: OjiNjideka Hemphill et al. Feasibility Study of Lactobacillus Plantarum 299v Probiotic Supplementation in an Urban Academic Facility among Diverse Pregnant Individuals. Nutrients 2023, 15, 875.

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Experiences of Racial Discrimination and Periconceptional Diet Quality.

BACKGROUND: Racism is a key determinant of perinatal health disparities. Poor diet may contribute to this effect, but research on racism and dietary patterns is limited. OBJECTIVE: We aimed to describe the relation between experiences of racial discrimination and adherence to the 2015‒2020 Dietary Guidelines for Americans. METHODS: We used data from a prospective pregnancy cohort study conducted at 8 United States medical centers (2010‒2013). At 6‒13 weeks of gestation, 10,038 nulliparous people with singleton pregnancies were enrolled. Participants completed a Block food frequency questionnaire, assessing usual diet in the 3 mo around conception, and the Krieger Experiences of Discrimination Scale, assessing the number of situational domains (e.g., at school and on the street) in which participants ever experienced racial discrimination. Alignment of dietary intake with the 2015-2020 Dietary Guidelines for Americans was assessed using the Healthy Eating Index (HEI)-2015. RESULTS: The study showed that 49%, 44%, 35%, and 17% of the Asian, Black, Hispanic, and White participants reported experiences of racial discrimination in any domain. Most participants experienced discrimination in 1 or 2 situational domains. There were no meaningful differences in HEI-2015 total or component scores in any racial or ethnic group according to count of self-reported domains in which individuals experienced discrimination. For example, mean total scores were 57‒59 among Black, 61‒66 among White, 61‒63 among Hispanic, and 66‒69 among Asian participants across the count of racial discrimination domains. CONCLUSIONS: This null association stresses the importance of going beyond interpersonal racial discrimination to consider the institutions, systems, and practices affecting racialized people to eliminate persistent inequalities in diet and perinatal health.

Feasibility Study of Lactobacillus Plantarum 299v Probiotic Supplementation in an Urban Academic Facility among Diverse Pregnant Individuals.

(1) Background: Despite iron intake recommendations, over a quarter of pregnant individuals have iron deficiency. Lactobacillus plantarum 299v (Lp299v®) enhances iron absorption in non-pregnant populations and may have positive effects in pregnancy among those with sufficient iron stores; however, no studies have evaluated the effect of Lp299v® on maternal and neonatal iron status among individuals at risk for iron deficiency anemia in pregnancy. Thus, this study aims to assess the feasibility and preliminary efficacy of daily oral Lp299v® maternal supplementation among diverse pregnant individuals. (2) Methods: In this double-blind placebo-controlled randomized supplementation feasibility study, participants were randomized to probiotic Lp299v® + prenatal vitamin with iron or placebo + prenatal vitamin with iron from 15-20 weeks of gestation through delivery. (3) Results: Of the 20 enrolled and randomized participants, 58% (7/12) from the Lp299v® group and 75% (6/8) from the placebo group were retained. Adherence to supplementation was 72% for Lp299v®/placebo and 73% for the prenatal vitamin. A slower decline in maternal hematological and iron parameters across pregnancy was observed in the Lp299v® group compared to placebo. (4) Conclusions: Lp299v® may be a tolerable therapy during pregnancy and has the potential to affect maternal and neonatal hematological and iron status.

Developmental disparities in sedentary time by period of the day among US youth: a cross-sectional study.

BACKGROUND: Definitive evidence shows sedentary time (ST) is an independent risk factor for chronic disease, irrespective of physical activity. Despite calls to limit youth ST, studies demonstrate a spike in ST at the transition from childhood to adolescence. Identifying periods of the day (e.g., before school, during school, afterschool, and evenings) during which ST is higher in adolescents vs. children-that is, specifying when within daily routines ST disparities emerge-may be important to inform intervention strategies, as periods of the day correspond with variations in setting and supervision. The purpose of this study was to examine device-assessed ST engagement by period of day and developmental stage in a nationally representative sample of United States youth. METHODS: Youth (N = 2,972 between 6-18 years) from the 2003-2004 and 2005-2006 waves of NHANES reported demographic variables and wore an accelerometer for seven consecutive days to determine ST. Linear regression analyses were applied to study associations between ST and developmental stage (childhood or adolescence) by period of the week and weekend days, while controlling for sex, race/ethnicity, annual family income, and body mass index. RESULTS: Adjusted linear regressions (p-values < 0.0001) showed that adolescents were more sedentary than children during school, afterschool, and weekday evening periods as well as all the weekend periods. However, during school (36.3 ± 7.3 vs. 28.2 ± 7.2 min/hour; b = -7.4 [-8.1, -6.6]) and afterschool periods (31.1 ± 7.7 vs. 22.7 ± 7.0 min/hour; b = -7.8 [-8.6, -7.0]) showed the largest weekly ST disparities by developmental stage. Overall, the during school and after school hours constitute most (during school = 35% and afterschool = 16%) of the weekly ST disparity between children and adolescents. CONCLUSIONS: Our data provide interventionists with estimates of the potential for ST reduction in each setting and period of the day among US adolescents. Future research should gather information about the barriers and facilitators of ST in adolescents by period of the day to help understand factors driving disparities.

Efficacy of behavioral interventions to improve maternal mental health and breastfeeding outcomes: a systematic review.

BACKGROUND: Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor associated with barriers and reduced rates of breastfeeding intent, initiation, and continuation. Given evidence of a bidirectional association between maternal mental health and breastfeeding, it is important to consider both factors when examining the efficacy of interventions to improve these outcomes. The purpose of this manuscript is to review the literature on the efficacy of behavioral interventions focused on both maternal mental health and breastfeeding outcomes, examining the intersection of the two. METHODS: This systematic review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Studies were selected if they were available in English, used primary experimental design, and used a behavioral intervention type to examine maternal mental health and breastfeeding outcomes. Articles were identified from PubMed, CINAHL, Embase, and PsycINFO from database inception to 3 March 2022. Study quality was assessed using the Cochrane Risk of Bias tool. Results were synthesized by intervention success for 1. Mental health and breastfeeding, 2. Breastfeeding only, 3. Mental health only, and 4. No intervention effect. PROSPERO CRD42021224228. RESULTS: Thirty interventions reported in 33 articles were identified, representing 15 countries. Twelve studies reported statistically significant positive effect of the intervention on both maternal mental health and breastfeeding; most showing a decrease in self-report depressive and/or anxiety symptoms in parallel to an increase in breastfeeding duration and/or exclusivity. Common characteristics of successful interventions were a) occurring across pregnancy and postpartum, b) delivered by hospital staff or multidisciplinary teams, c) offered individually, and d) designed to focus on breastfeeding and maternal mental health or on breastfeeding only. Our results are not representative of all countries, persons, experiences, circumstances, or physiological characteristics. CONCLUSIONS: Interventions that extend the perinatal period and offer individualized support from both professionals and peers who collaborate through a continuum of settings (e.g., health system, home, and community) are most successful in improving both mental health and breastfeeding outcomes. The benefits of improving these outcomes warrant continued development and implementation of such interventions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021224228.

Pilot study of a culturally sensitive intervention to promote genetic counseling for breast cancer risk.

BACKGROUND: Despite the benefits of genetic counseling and testing, uptake of cancer genetic services is generally low and Black/African American (Black) women are substantially less likely to receive genetic services than non-Hispanic White women. Our team developed a culturally sensitive, narrative decision aid video to promote uptake of genetic counseling among Black women at risk for a hereditary breast cancer syndrome that can be incorporated in conjunction with population-based cancer risk assessment in a clinical setting. We report here a pilot study to demonstrate changes in intention to access genetic counseling and intervention satisfaction. METHODS: Black women who were personally unaffected by breast cancer and were recommended for genetic counseling based on family history screening in a mammography center were recruited at the time of the mammogram. A prospective, pre-post survey study design, guided by theoretical constructs, was used to evaluate baseline and immediate post-intervention psychosocial factors, including intention to participate in genetic counseling and intervention satisfaction. RESULTS: Pilot recruitment goals were met (n = 30). Pre-intervention, 50% of participants indicated that they were extremely likely to make a genetic counseling appointment, compared with 70% post-intervention (p = 0.05). After watching the intervention, 50% of participants indicated that the video changed their mind regarding genetic counseling. CONCLUSIONS: This study demonstrated cultural satisfaction with a decision aid intervention designed to motivate Black women with hereditary breast cancer risk to attend a genetic counseling appointment. Our study showed that intention may be a specific and key construct to target in interventions designed to support decision-making about genetic services. Study results informed the design of a subsequent large scale, randomized implementation study. TRIAL REGISTRATION: Trial registration: Clinicaltrials.gov NCT04082117 . Registered September 9, 2019. Retrospectively registered.

Racial/Ethnic Disparities in Food Pantry Use and Barriers in Massachusetts during the First Year of the COVID-19 Pandemic.

This study sought to describe racial disparities in food insecurity, food pantry use, and barriers to and experiences with food pantries during the first year of the COVID-19 pandemic. We surveyed 2928 adults in Massachusetts regarding food access in the year before and during the first year of the pandemic. Weighted multivariable logistic regression models assessed racial differences in barriers to and experiences with pantry use during the pandemic. Black and Latino adults experienced the highest prevalence of food insecurity and pantry use. Additionally, Black and Latino adults reported more barriers to, but less stigma around, pantry use compared to White adults. Latino adults were less likely to know about pantry hours/locations and encounter staff who spoke their language. Black and Latino adults were also more likely to find pantry hours/locations inconvenient and have difficulty with transportation. The COVID-19 pandemic resulted in increased food insecurity, and food access inequities persisted. Programmatic policies to improve pantry access in communities of color could include increasing the hours/days that pantries are open, increasing bilingual staff, providing transportation or delivery, and creating multilingual public awareness campaigns on how to locate pantries.

Forms of Community Engagement in Neighborhood Food Retail: Healthy Community Stores Case Study Project.

Community engagement is well established as a key to improving public health. Prior food environment research has largely studied community engagement as an intervention component, leaving much unknown about how food retailers may already engage in this work. The purpose of this study was to explore the community engagement activities employed by neighborhood food retailers located in lower-income communities with explicit health missions to understand the ways stores involve and work with their communities. A multiple case study methodology was utilized among seven retailers in urban U.S. settings, which collected multiple sources of data at each retailer, including in-depth interviews, store manager sales reports, store observations using the Nutrition Environment Measures Survey for Stores, public documents, and websites. Across-case analysis was performed following Stake's multiple case study approach. Results indicated that retailers employed a wide variety of forms of community engagement within their communities, including Outreach, Building Relationships through Customer Relations, Giving Back, Partnering with Community Coalitions, and Promoting Community Representation and Inclusiveness. Strategies that built relationships through customer relations were most common across stores; whereas few stores demonstrated community inclusiveness where members participated in store decision making. Findings provide a more comprehensive view of the ways local food retailers aim to develop and sustain authentic community relationships. Additional research is needed to evaluate the impact of community engagement activities on improving community health.

Feasibility of a Web-Based Intervention to Prevent Perinatal Depression and Promote Human Milk Feeding: Randomized Pilot Trial.

BACKGROUND: Mothers who identify as Black or African American are more likely to report depressed moods in late pregnancy and early postpartum and have the lowest rates of human milk feeding compared with all other racial groups in the United States. Internet interventions offer the potential to extend preventative and supportive services as they address key barriers, particularly for those navigating the complex and vulnerable early postpartum period. However, there is limited evidence on the feasibility of such interventions for preventing perinatal mental health disorders and improving human milk feeding outcomes in Black mothers. OBJECTIVE: This pilot study aimed to assess the feasibility and preliminary findings of a web-based cognitive behavioral therapy-based internet intervention, with and without human milk feeding education and support, to prevent perinatal depression and promote human milk feeding in Black mothers. METHODS: Participants were Black-identifying individuals between 20 and 28 weeks of pregnancy with human milk feeding intention and mild to moderate depressive symptoms (Patient Health Questionnaire scores 5-14). Participants were randomized to either Sunnyside, a 6-week cognitive behavioral therapy-based web-based intervention, or Sunnyside Plus, which included additional education and support to promote human milk feeding. Assessments occurred at baseline, third trimester (end of antenatal treatment), 6 weeks postpartum (end of postpartum treatment), and 12 weeks postpartum. The primary focus of this randomized pilot trial was the feasibility and preliminary outcomes of mental health and human milk feeding. RESULTS: A total of 22 tertiary-educated participants were randomized. The mean number of log-ins was 7.3 (SD 5.3) for Sunnyside and 13.8 (SD 10.5) for Sunnyside Plus. Scores of depression and anxiety measures remained below the clinical threshold for referral to treatment in both groups. All the participants initiated human milk feeding (18/18, 100%). Most participants reported at least some human milk feeding at both 6 and 12 weeks postpartum (6/7, 86%; 11/11, 100%, or 10/10, 100%, for Sunnyside and Sunnyside Plus, respectively). CONCLUSIONS: The results suggest that tertiary-educated Black mothers at risk for perinatal depression and who intended to human milk feed were receptive to and satisfied with a web-based cognitive behavioral therapy-based internet intervention, with and without human milk feeding education and support. Preliminary findings indicate that both Sunnyside and Sunnyside Plus interventions have the potential to affect symptoms of depression, anxiety, and human milk feeding outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04128202; https://www.clinicaltrials.gov/ct2/show/NCT04128202.

Bile Acids, Gut Microbes, and the Neighborhood Food Environment-a Potential Driver of Colorectal Cancer Health Disparities.

Bile acids (BAs) facilitate nutrient digestion and absorption and act as signaling molecules in a number of metabolic and inflammatory pathways. Expansion of the BA pool and increased exposure to microbial BA metabolites has been associated with increased colorectal cancer (CRC) risk. It is well established that diet influences systemic BA concentrations and microbial BA metabolism. Therefore, consumption of nutrients that reduce colonic exposure to BAs and microbial BA metabolites may be an effective method for reducing CRC risk, particularly in populations disproportionately burdened by CRC. Individuals who identify as Black/African American (AA/B) have the highest CRC incidence and death in the United States and are more likely to live in a food environment with an inequitable access to BA mitigating nutrients. Thus, this review discusses the current evidence supporting diet as a contributor to CRC disparities through BA-mediated mechanisms and relationships between these mechanisms and barriers to maintaining a low-risk diet.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project.

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

An embedded multiple case study: using CFIR to map clinical food security screening constructs for the development of primary care practice guidelines.

BACKGROUND: Food insecurity (FI), the limited access to healthy food to live an active and healthy life, is a social determinant of health linked to poor dietary health and difficulty with disease management in the United States (U.S.). Healthcare experts support the adoption of validated screening tools within primary care practice to identify and connect FI patients to healthy and affordable food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that may guide wide-scale program implementation. METHODS: This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with N = 19 healthcare staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis. RESULTS: Programs outcomes included: the number of patients screened, identified as FI and that participated in the onsite food assistance program. Study participants reported limited internal resources as implementation barriers for program activities. The implementation climate that leveraged the strength of community collaborations and aligned internal, implementation climate were critical facilitators that contributed to the flexibility of program activities that were tailored to fill gaps in resources and meet patient and clinician needs. CONCLUSION: Highly adaptable programs and the healthcare context enhanced implementation feasibility across settings. These characteristics can support program uptake in other settings, but should be used with caution to preserve program fidelity. A foundational model for the development and testing of standard clinical practice was the product of this study.

Association of Accelerometer-Measured Physical Activity and Cardiovascular Health in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

INTRODUCTION: Evidence regarding the associations between accelerometer-measured moderate-vigorous physical activity (MVPA) and cardiovascular health (CVH) indicators among Hispanic/Latino adults are unavailable. METHODS: Examined cross-sectional data from 12,008 Hispanic/Latino adults aged 18-74 years participating in the Hispanic Community Health Study/Study of Latinos. Accelerometer-measured MVPA was assessed categorically and dichotomously per 2008 PA guidelines. Adverse and ideal CVH indicators were determined by standard cut-points for blood glucose, total cholesterol, blood pressure, body mass index (BMI), and smoking. A composite of low CV risk, defined as achieving all ideal CVH indicators, was included. Adjusted Poisson regression models and complex survey design methods were used for all analyses. RESULTS: Compared to high MVPA, lower MVPA categories were associated with higher prevalence of all adverse CVH indicators, except hypertension, and with lower prevalence of low CV risk and ideal blood glucose, blood pressure, and BMI. Similarly, non-adherence to PA guidelines was associated with a higher prevalence of diabetes (16%), hypercholesterolemia (9%), obesity (28%), and smoking (9%); and lower prevalence of low CV risk (24%), ideal blood glucose (6%), ideal blood pressure (6%), and ideal BMI (22%). CONCLUSION: Overall, high accelerometer-measured MVPA and meeting PA guidelines were associated with favorable CVH in Hispanic/Latino adults.

Emotional Eating Predicts Weight Regain Among Black Women in the SisterTalk Intervention.

OBJECTIVE: This study aimed to assess effects of emotional eating and stress on weight change among Black women in a culturally tailored weight-control program. METHODS: SisterTalk, a cable-TV-delivered weight-control randomized trial, included 331 Black women (aged 18-75 years; BMI ≥ 25 kg/m2) in Boston, Massachusetts. BMI and waist circumference (WC) were assessed at baseline and 3, 8, and 12 months post randomization. Frequency of "eating when depressed or sad" (EWD) and "eating to manage stress" (ETMS) (i.e., "emotional eating") and perceived stress were also assessed. Lagged analyses of data for intervention participants (n = 258) assessed associations of BMI and WC outcomes at each follow-up visit with EWD and ETMS frequency and stress measured at the most recent prior visit. RESULTS: At 3 months (immediately post intervention), BMI decreased for women in all EWD and ETMS categories but increased at later follow-up for women reporting EWD and ETMS always/often. In addition, 8-month EWD and ETMS predicted 12-month BMI change (both P < 0.05). Higher perceived stress was associated with higher EWD and ETMS; however, stress was not associated with lagged BMI or WC at any time. CONCLUSIONS: Addressing emotional eating and related triggers may improve weight maintenance in interventions with Black women.