The Relationship between Lifestyle Behaviors and Mental Illness in Women in College.

Women, particularly those in college, have the highest prevalence of any mental illness (MI), which negatively impacts social connection, academic performance, and health. Research into alternative treatment methods suggests that lifestyle behaviors are safer and more effective than medication at reducing MI symptoms. This study explores the relationship between lifestyle behaviors and MI in college women through an online survey. The survey included a food frequency questionnaire (Diet History Questionnaire II) and questions about lifestyle behaviors, symptoms of MI, and sociodemographic information. Diet quality was calculated using the Healthy Eating Index (HEI), and MI was assessed using the Depression, Anxiety, and Stress Scale-21. Independent sample t-tests, ANOVA, and chi-square analyses were conducted. A total of 222 women completed the survey. Overall, diet quality was poor, with a mean HEI of 62.6 ± 10.4. No significant differences or associations were found between MI groups for total HEI score, sleep, or tobacco use. However, alcohol use was significantly associated with MI (p = 0.049). Individuals with fewer concurrent unhealthy lifestyle behaviors had less severe symptoms of depression (p = 0.009) and anxiety (p < 0.001) compared to those with more unhealthy lifestyle behaviors. In this study, alcohol use was the only independent lifestyle behavior associated with symptoms of MI. We also found an association between the number of concurrent unhealthy lifestyle behaviors and depression and anxiety symptoms. Future research should explore the benefits of a healthy lifestyle on MI in a more diverse sample of women.

Prenatal Dietary Patterns and Associations With Weight-Related Pregnancy Outcomes in Hispanic Women With Low Incomes.

Background: Dietary patterns during pregnancy may contribute to gestational weight gain (GWG) and birthweight, but there is limited research studying these associations in racial and ethnic minority groups. The objective of this study was to evaluate associations between prenatal dietary patterns and measures of GWG and birthweight in a cohort of culturally diverse Hispanic women with low incomes. Methods: Data were analyzed from 500 mother-infant dyads enrolled in the Starting Early Program, a childhood obesity prevention trial. Diet over the previous year was assessed in the third trimester of pregnancy using an interviewer-administered food frequency questionnaire. Dietary patterns were constructed using the Healthy Eating Index-2015 (HEI-2015) and principal components analysis (PCA) and analyzed as tertiles. GWG and birthweight outcomes were abstracted from medical records. Associations between dietary pattern tertiles and outcomes were assessed by multivariable linear and multinomial logistic regression analyses. Results: Dietary patterns were not associated with measures of GWG or adequacy for gestational age. Greater adherence to the HEI-2015 and a PCA-derived dietary pattern characterized by nutrient-dense foods were associated with higher birthweight z-scores [ß: 0.2; 95% confidence interval (CI): 0.04 to 0.4 and ß: 0.3; 95% CI: 0.1 to 0.5, respectively], but in sex-specific analyses, these associations were only evident in male infants (ß: 0.4; 95% CI: 0.03 to 0.7 and ß: 0.3; 95% CI: 0.03 to 0.6, respectively). Conclusions: Among a cohort of culturally diverse Hispanic women, adherence to healthy dietary patterns during pregnancy was modestly positively associated with increased birthweight, with sex-specific associations evident only in male infants.

Moving beyond Weight: A Narrative Review of the Dietary and Lifestyle Management for Reducing Cardiometabolic Risk in Polycystic Ovary Syndrome (PCOS).

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder experienced by women. PCOS is a lifelong condition associated with reproductive, metabolic, and psychological presentations. PCOS is also linked with increased prevalence of cardiometabolic risk factors. While an association between body weight and PCOS has been noted, cardiometabolic risk factors are prevalent in individuals with PCOS across body weights. Currently, no consensus exists as to the most appropriate lifestyle strategy for mitigating cardiometabolic risk in PCOS. A large proportion of the literature is focused on weight loss for individuals with PCOS who are overweight or experience obesity, despite PCOS being prevalent across body sizes. The aim of this narrative review is to assess dietary and lifestyle interventions aimed at reducing cardiometabolic risk in individuals with PCOS across body sizes. A total of 51 articles are included in this review. Overall, randomized controlled trials are limited and most studies focus on weight loss, excluding individuals classified within a healthy body weight range. Studies that modified the dietary pattern without an energy deficit saw improvements in cardiometabolic risk. Thus, less restrictive dietary approaches may be effective at reducing cardiometabolic risk in this population. This review also highlights the need for more sustainable lifestyle interventions that meet the needs of individuals with PCOS of varying body weights.

An Evaluation of Alternative Technology-Supported Counseling Approaches to Promote Multiple Lifestyle Behavior Changes in Patients With Type 2 Diabetes and Chronic Kidney Disease.

OBJECTIVES: Although technology-supported interventions are effective for reducing chronic disease risk, little is known about the relative and combined efficacy of mobile health strategies aimed at multiple lifestyle factors. The purpose of this clinical trial is to evaluate the efficacy of technology-supported behavioral intervention strategies for managing multiple lifestyle-related health outcomes in overweight adults with type 2 diabetes (T2D) and chronic kidney disease (CKD). DESIGN AND METHODS: Using a 2 × 2 factorial design, adults with excess body weight (body mass index ≥27 kg/m2, age ≥40 years), T2D, and CKD stages 2-4 were randomized to an advice control group, or remotely delivered programs consisting of synchronous group-based education (all groups), plus (1) Social Cognitive Theory-based behavioral counseling and/or (2) mobile self-monitoring of diet and physical activity. All programs targeted weight loss, greater physical activity, and lower intakes of sodium and phosphorus-containing food additives. RESULTS: Of 256 randomized participants, 186 (73%) completed 6-month assessments. Compared to the ADVICE group, mHealth interventions did not result in significant changes in weight loss, or urinary sodium and phosphorus excretion. In aggregate analyses, groups receiving mobile self-monitoring had greater weight loss at 3 months (P = .02), but between 3 and 6 months, weight losses plateaued, and by 6 months, the differences were no longer statistically significant. CONCLUSIONS: When engaging patients with T2D and CKD in multiple behavior changes, self-monitoring diet and physical activity demonstrated significantly larger short-term weight losses. Theory-based behavioral counseling alone was no better than baseline advice and demonstrated no interaction effect with self-monitoring.

The Relationship between School Infrastructure and School Nutrition Program Participation and Policies in New York City.

School nutrition programs (SNP) provide much needed access to fruits, vegetables, and other healthy foods at low or no cost. Yet, the infrastructure of school kitchens and cafeteria vary across schools, potentially contributing to systematic barriers for SNP operation and equity. The purpose of this paper is to examine the association between school infrastructure and outcomes including meal participation, untraditional lunch periods, and having an open campus. Regression analyses were conducted using administrative data for 1804 schools and school nutrition manager survey data (n = 821) in New York City (NYC). Co-location was significantly associated with open campus status (OR = 2.84, CI: 1.11, 7.26) and high school breakfast participation (ß = -0.056, p = 0.003). Overcrowding was associated with breakfast (elementary: ß = -0.046, p = 0.03; middle: ß = 0.051, p = 0.04; high: ß = 0.042, p = 0.04) and lunch participation (elementary: ß = -0.031, p = 0.01) and untraditional lunchtimes (elementary: OR = 2.47, CI: 1.05, 5.83). Higher enrollment to cafeteria capacity ratios was associated with breakfast (elementary: ß = -0.025, p = 0.02) and lunch (elementary: ß = -0.015, p = 0.001; high: ß = 0.014, p = 0.02) participation and untraditional lunchtimes (middle: OR = 1.66, CI: 1.03, 2.68). Infrastructure characteristics are an important source of variation across NYC schools that may hinder the equity of school nutrition programs across the city.

The Relationship Between Dietary Intake and Dietary-Focused Lifestyle Interventions on Risk Factors Associated with Cardiovascular Disease in Firefighters.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of death to on-duty firefighters and is a substantial health concern. Preventative measures, including dietary interventions, may improve CVD in firefighters. The purpose of this review is to examine the literature on the relationship between dietary intake, dietary lifestyle interventions, and risk of CVD in firefighters. RECENT FINDINGS: Existing evidence, albeit limited, suggests that firefighters do not meet dietary guidelines. Lifestyle modifications featuring dietary interventions are effective in improving risk factors associated with CVD in firefighters. Unfortunately, no consistent nutrition-related trend was identified across the retrieved studies and only a limited number of randomized controlled trials have examined the efficacy of lifestyle intervention studies on CVD in firefighters. Although this review suggests dietary lifestyle interventions may facilitate decreases in risk factors associated with CVD in firefighters, current evidence is limited, and additional research is needed.

Feasibility and Acceptability of mHealth Interventions for Managing Hyperphosphatemia in Patients Undergoing Hemodialysis.

OBJECTIVE: The objective of the study was to evaluate the feasibility and acceptability of mobile health (mHealth) phosphorus management programs in hemodialysis (HD) patients. METHODS: Patients receiving thrice-weekly HD who had 3-month average serum phosphorus of >5.5 mg/dL were randomized to one of the three self-directed phosphorus management programs delivered using tablet PCs: (1) educational videos and handouts (Education), (2) education intervention plus mobile self-monitoring with email feedback (Monitoring), or (3) education and monitoring interventions plus social cognitive theory-based behavioral videos (Combined). Feasibility and acceptability were assessed based on enrollment and retention and training needs (feasibility) and adherence to self-monitoring and reported satisfaction (acceptability). RESULTS: Of 312 patients, 56 expressed interest, and 40 were enrolled. The majority of participants (80%) completed the 6-month study; none withdrew for intervention-related reasons. The Monitoring and Combined groups received 44 ± 15 minutes of technology training, which was considered adequate by most (75%). Self-monitoring rates were initially high, with 78% and 71% of the participants recording at least one meal and phosphate binder in week 1, respectively, but decreased over time to 15% and 9% in the final week. Most participants reported that self-monitoring helped them stay motivated (64%), track nutrients (80%), and understand how to change diet (76%), and nearly two-thirds of participants (64%) stated that they would like to continue using the tablet PC to manage their health. However, few participants (16%) indicated that self-monitoring was worth the effort. The Monitoring and Combined groups did not differ from the Education group in study outcomes. CONCLUSION: Although the mHealth programs were generally well received, self-monitoring rates decreased substantially over time and were unaffected by social cognitive theory-based videos. Self-directed mHealth programs may be a useful adjunct to standard care but should be compared to more resource intensive programs (e.g., involving more "live" contact with a dietitian) to determine overall cost-effectiveness and role in HD care.

Correlates of Prenatal Diet Quality in Low-Income Hispanic Women.

BACKGROUND: Low-income Hispanic women are at-risk of poor prenatal diet quality. Correlates associated with prenatal diet quality in this group of women are understudied. OBJECTIVE: The objective of this study was to examine the associations between financial, cultural, psychosocial, and lifestyle correlates and prenatal diet quality in low-income Hispanic women. DESIGN: This cross-sectional analysis used data from pregnant women enrolled in the Starting Early Trial, a randomized-controlled trial of a primary-care based child obesity prevention program beginning in pregnancy. The trial enrolled women from clinics affiliated with a large urban medical center in New York City from 2012 to 2014. Financial, cultural, psychosocial, and lifestyle variables were collected using a comprehensive baseline questionnaire. Usual dietary intakes over the past year were assessed using the Block Food Frequency Questionnaire 2005 bilingual version. PARTICIPANTS: The study enrolled low-income Hispanic women between 28 and 32 gestational weeks (N=519). MAIN OUTCOME MEASURES: Prenatal diet quality was measured by the Healthy Eating Index 2015. STATISTICAL ANALYSES PERFORMED: Unadjusted and adjusted multivariable linear regression analyses were performed to determine independent associations between financial, cultural, psychosocial, and lifestyle correlates and Healthy Eating Index 2015 total score. RESULTS: Overall prenatal diet quality was poor (mean Healthy Eating Index 2015 total score=69.0±9.4). Most women did not meet the maximum score for total vegetables (65.3%), whole grains (97.1%), dairy (74.8%), fatty acids (84.4%), refined grains (79.8%), sodium (97.5%), saturated fats (92.9%), and added sugars (66.5%). Women who reported screen time ≤2 hours/day, physical activity before and/or during pregnancy, and being born outside the United States had higher mean Healthy Eating Index 2015 total score than women with screen time >2 hours/day, no physical activity, and those born in the United States. CONCLUSIONS: Prenatal diet quality of low-income pregnant Hispanic women was suboptimal. This cross-sectional study revealed associations between cultural and lifestyle factors and prenatal diet quality in low-income Hispanic women. Longitudinal studies are needed to determine long-term influences and specific behaviors to target for effective intervention studies.

Comparison of Dietary Patterns, Perceptions of Health, and Perceived Barriers to a Heart Healthy Diet Before and After Coronary Artery Angiography.

Poor dietary patterns are associated with coronary artery disease (CAD) and cardiovascular events. The aim of this study was to determine whether reported dietary patterns change after undergoing invasive coronary angiography. Participants without a history of coronary revascularization were prospectively enrolled before undergoing coronary angiography at a tertiary center between February 2015 and February 2017. Enrolled participants completed the Rate Your Plate (RYP) survey at baseline (before angiography), 1-month, and 6-month follow-ups. RYP scores range from 24 to 72 (higher scores indicate healthier dietary patterns) are presented as median (interquartile range), and are compared from baseline to follow-up using a nonparametric related-sample test. No dietary guidance was given outside of usual care. Of the 400 participants, 326 (82%) completed at least 1 follow-up survey with no differences in baseline characteristics of participants who had at least 1 versus no follow-up survey. The median RYP score significantly improved from baseline (53 [47 to 57]) to 1-month (58 [52 to 62]) and 6-month (59 [54 to 63]) follow-ups (p <0.001). Angiography demonstrated severe CAD in 125 (38%) and normal or nonobstructive CAD in 201 (62%) participants. RYP scores significantly improved over time in both groups (p <0.001), but the percent change in RYP score over time was greater in participants with versus without severe CAD (13.9% [5.8 to 22.5] vs 9.6% [4.8 to 19.1], p = 0.03). In conclusion, self-reported dietary patterns improved after invasive coronary angiography, particularly in the subset with CAD. Future studies to determine how best to utilize the periprocedural period to further improve dietary patterns in this population are warranted.

Anti-Inflammatory Effects of a Vegan Diet Versus the American Heart Association-Recommended Diet in Coronary Artery Disease Trial.

Background Dietary interventions may play a role in secondary cardiovascular prevention. hsCRP (High-sensitivity C-reactive protein) is a marker of risk for major adverse cardiovascular outcomes in coronary artery disease. Methods and Results The open-label, blinded end-point, EVADE CAD (Effects of a Vegan Versus the American Heart Association-Recommended Diet in Coronary Artery Disease) trial randomized participants (n=100) with coronary artery disease to 8 weeks of a vegan or American Heart Association-recommended diet with provision of groceries, tools to measure dietary intake, and dietary counseling. The primary end point was high-sensitivity C-reactive protein. A linear regression model compared end points after 8 weeks of a vegan versus American Heart Association diet and adjusted for baseline concentration of the end point. Significance levels for the primary and secondary end points were set at 0.05 and 0.0015, respectively. A vegan diet resulted in a significant 32% lower high-sensitivity C-reactive protein (ß, 0.68, 95% confidence interval [0.49-0.94]; P=0.02) when compared with the American Heart Association diet. Results were consistent after adjustment for age, race, baseline waist circumference, diabetes mellitus, and prior myocardial infarction (adjusted ß, 0.67 [0.47-0.94], P=0.02). The degree of reduction in body mass index and waist circumference did not significantly differ between the 2 diet groups (adjusted ß, 0.99 [0.97-1.00], P=0.10; and adjusted ß, 1.00 [0.98-1.01], P=0.66, respectively). There were also no significant differences in markers of glycemic control between the 2 diet groups. There was a nonsignificant 13% reduction in low-density lipoprotein cholesterol with the vegan diet when compared with the American Heart Association diet (adjusted ß, 0.87 [0.78-0.97], P=0.01). There were no significant differences in other lipid parameters. Conclusions In patients with coronary artery disease on guideline-directed medical therapy, a vegan diet may be considered to lower high-sensitivity C-reactive protein as a risk marker of adverse outcomes. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02135939.

A Low Glycemic Index and Glycemic Load Diet Decreases Insulin-like Growth Factor-1 among Adults with Moderate and Severe Acne: A Short-Duration, 2-Week Randomized Controlled Trial.

BACKGROUND: A high glycemic index (GI) and glycemic load (GL) diet may stimulate acne proliferative pathways by influencing biochemical factors associated with acne. However, few randomized controlled trials have examined this relationship, and this process is not completely understood. OBJECTIVE: This study examined changes in biochemical factors associated with acne among adults with moderate to severe acne after following a low GI and GL diet or usual eating plan for 2 weeks. DESIGN: This study utilized a parallel randomized controlled design to compare the effect of a low GI and GL diet to usual diet on biochemical factors associated with acne (glucose, insulin, insulin-like growth factor [IGF]-1, and insulin-like growth factor binding protein [IGFBP]-3) and insulin resistance after 2 weeks. PARTICIPANTS: Sixty-six participants were randomly allocated to the low GI and GL diet (n=34) or usual eating plan (n=32) and included in the analyses. MAIN OUTCOME MEASURES: The primary outcomes were biochemical factors of acne and insulin resistance with dietary intake as a secondary outcome. STATISTICAL ANALYSES: Independent sample t tests assessed changes in biochemical factors associated with acne, dietary intake, and body composition pre- and postintervention, comparing the two dietary interventions. RESULTS: IGF-1 concentrations decreased significantly among participants randomized to a low GI and GL diet between pre- and postintervention time points (preintervention=267.3±85.6 mg/mL, postintervention=244.5±78.7 ng/mL) (P=0.049). There were no differences in changes in glucose, insulin, or IGFBP-3 concentrations or insulin resistance between treatment groups after 2 weeks. Carbohydrate (P=0.019), available carbohydrate (P<0.001), percent energy from carbohydrate (P<0.001), GI (P<0.001), and GL (P<0.001) decreased significantly among participants following a low GI/GL diet between the pre- and postintervention time points. There were no differences in changes in body composition comparing groups. CONCLUSIONS: In this study, a low GI and GL diet decreased IGF-1 concentrations, a well-established factor in acne pathogenesis. Further research of a longer duration should examine whether a low GI and GL diet would result in a clinically meaningful difference in IGF-1 concentrations leading to a reduction in acne. This trial was registered at clinicaltrials.gov as NCT02913001.

Assessment of Nutrient Status in Athletes and the Need for Supplementation.

Nutrition assessment is a necessary first step in advising athletes on dietary strategies that include dietary supplementation, and in evaluating the effectiveness of supplementation regimens. Although dietary assessment is the cornerstone component of the nutrition assessment process, it should be performed within the context of a complete assessment that includes collection/evaluation of anthropometric, biochemical, clinical, and environmental data. Collection of dietary intake data can be challenging, with the potential for significant error of validity and reliability, which include inherent errors of the collection methodology, coding of data by dietitians, estimation of nutrient composition using nutrient food tables and/or dietary software programs, and expression of data relative to reference standards including eating guidance systems, macronutrient guidelines for athletes, and recommended dietary allowances. Limitations in methodologies used to complete anthropometric assessment and biochemical analysis also exist, as reference norms for the athlete are not well established and practical and reliable biomarkers are not available for all nutrients. A clinical assessment collected from history information and the nutrition-focused physical exam may help identify overt nutrient deficiencies but may be unremarkable in the well-trained athlete. Assessment of potential food-drug interactions and environmental components further helps make appropriate dietary and supplement recommendations. Overall, the assessment process can help the athlete understand that supplement intake cannot make up for poor food choices and an inadequate diet, while a healthy diet helps ensure maximal benefit from supplementation. Establishment of reference norms specifically for well-trained athletes for the nutrition assessment process is a future research priority.

Association between diet quality and measures of body adiposity using the Rate Your Plate survey in patients presenting for coronary angiography.

BACKGROUND: Diet is a modifiable risk factor for cardiovascular disease; however, dietary patterns are historically difficult to capture in the clinical setting. Healthcare providers need assessment tools that can quickly summarize dietary patterns. Research should evaluate the effectiveness of these tools, such as Rate Your Plate (RYP), in the clinical setting. HYPOTHESIS: RYP diet quality scores are associated with measures of body adiposity in patients referred for coronary angiography. METHODS: Patients without a history of coronary revascularization (n = 400) were prospectively approached at a tertiary medical center in New York City prior to coronary angiography. Height, weight, and waist circumference (WC) were measured; body mass index (BMI) and waist-to-height ratio (WHtR) were calculated. Participants completed a 24-question RYP diet survey. An overall score was computed, and participants were divided into high (≥58) and low (≤57) diet quality groups. RESULTS: Participants in the high diet quality group (n = 98) had significantly lower measures of body adiposity than did those in the low diet quality group (n = 302): BMI (P < 0.001), WC (P = 0.001), WHtR (P = 0.001). There were small but significant inverse correlations between diet score and BMI, WC, and WHtR (P < 0.001). These associations remained significant after adjustment for demographics, tobacco use, and socioeconomic factors. CONCLUSIONS: Higher diet quality scores are associated with lower measures of body adiposity. RYP is a potential instrument to capture diet quality in a high-volume clinical setting. Further research should evaluate the utility of RYP in cardiovascular risk-factor control.

The Healthy Hearts and Kidneys (HHK) study: Design of a 2×2 RCT of technology-supported self-monitoring and social cognitive theory-based counseling to engage overweight people with diabetes and chronic kidney disease in multiple lifestyle changes.

Patients with complex chronic diseases usually must make multiple lifestyle changes to limit and manage their conditions. Numerous studies have shown that education alone is insufficient for engaging people in lifestyle behavior change, and that theory-based behavioral approaches also are necessary. However, even the most motivated individual may have difficulty with making lifestyle changes because of the information complexity associated with multiple behavior changes. The goal of the current Healthy Hearts and Kidneys study was to evaluate, different mobile health (mHealth)-delivered intervention approaches for engaging individuals with type 2 diabetes (T2D) and concurrent chronic kidney disease (CKD) in behavior changes. Participants were randomized to 1 of 4 groups, receiving: (1) a behavioral counseling, (2) technology-based self-monitoring to reduce information complexity, (3) combined behavioral counseling and technology-based self-monitoring, or (4) baseline advice. We will determine the impact of randomization assignment on weight loss success and 24-hour urinary excretion of sodium and phosphorus. With this report we describe the study design, methods, and approaches used to assure information security for this ongoing clinical trial. Clinical Trials.gov Identifier: NCT02276742.

Competition Level Not Associated With Diet Quality in Marching Artists.

Marching artists are a unique group of athletes whose performance can be influenced by nutrition. Because physical demands are thought to be moderate to high, adequate energy and a variety of nutrient-dense foods are needed. The purpose of this study was to examine diet quality, physical activity, and eating behavior of marching artists across elite and nonelite competition levels. This cross-sectional analysis used the validated National Cancer Institute Diet History Questionnaire II, International Physical Activity Questionnaire, and Eating Behavior Patterns Questionnaire. Diet quality was assessed using the Healthy Eating Index (HEI) 2010. Marching artists who participated in marching band in 2015 were eligible. Those in Drum Corps International (DCI) were considered part of the elite level; all others were considered nonelite. Chi-square analyses assessed associations between categorical variables and competition level, and independent sample t-tests assessed differences between continuous variables among competition level. Participants (n = 323) included 228 (71%) DCI members and 95 (29%) non-DCI members who reported a mean age of 19.8 ± 1.9 years. DCI members reported higher physical activity levels (p < 0.001) and fewer meal-skipping behaviors compared to non-DCI members (p < 0.001). The overall mean HEI score was 58.8 ± 10.3, with no difference between competition levels. Only one participant overall (<1%) met the recommended intake level of whole grains. Additionally, 2% of participants met the sodium restriction recommendation and 7% met the empty calorie upper limit. Suboptimal diet quality combined with high levels of physical activity is a problem for marching artists that should be addressed through carefully planned interventions.

Community Priorities for Healthy Eating in Older Adults.

Community planners such as policymakers and health care and nutrition service providers can create an "age-friendly" environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n = 30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers' markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents' ability to achieve optimal nutritional health.