Change and Continuity in Low-Income Working Mothers' Food Practices for Young Children in Response to Life Events.

OBJECTIVE: To understand how changes in low-income mothers' work, home, and childcare environments impact their food practices for young children. METHODS: The grounded theory, theory-guided, design included two in-depth qualitative interviews (6 to 8 months apart) with each of 19 low income, working/student mothers of Head Start children, living in a rural county in Upstate New York. Interviews covered mothers' experiences of employment, school, family, household, and childcare events over one school year and whether and how events changed child food practices. Emergent themes related to mothers' experiences of life events, with attention to influences on child food practices, were open-coded using a constant comparative approach. A life course approach and a transactional model of the stress process informed interpretation. RESULTS: Within the study period, most mothers reported at least one life event, with many experiencing one or more changes in employers, job schedules, residence, household members, or childcare situation. Emergent patterns of adjustment in child food practices linked with life events were shaped by mothers' appraisals of life events, the availability of coping resources, and their adaptations to events, based on temporal, financial, and social resources. The findings support a view of child feeding informed by the transactional model of stress. CONCLUSIONS: Instability in work, family, household, and childcare highlight changing contexts for child food practices in daily life. Research and practice should acknowledge the changing nature of the child feeding context and the need for children's caregivers to make adjustments in response to changing resources.

"Doing our best to keep a routine:" How low-income mothers manage child feeding with unpredictable work and family schedules.

Significant changes in work and family conditions over the last three decades have important implications for understanding how young children are fed. The new conditions of work and family have placed pressures on families. The aim of this study was to explore the work and family pressures shaping the ways parents feed their young children on a day-to-day basis. Twenty-two purposively recruited low-income employed mothers of 3-4 year old children from a rural county Head Start program in Upstate New York reported details about the context of their children's eating episodes in a 24-h qualitative dietary recall. Participating mothers were employed and/or in school at least 20 h a week and varied in partner and household characteristics. Interview transcripts were open coded using the constant comparative method for usual ways of feeding children. A typology of three emergent child feeding routines was identified based on mothers' accounts of the recurring ways they fed their child. Mothers' feeding routines were distinguished by a combination of four recurring key strategies - planning ahead, delegating, making trade-offs, and coordinating. Work schedule predictability and other adults helped mothers maintain feeding routines. Unexpected daily events, such as working overtime or waking up late, disrupted child feeding routines and required modifications. These findings suggest that understanding how young children are fed requires recognizing the socio-ecological environments that involve working mothers' daily schedules and household conditions and the multiple ways that mothers manage food and feeding to fit environmental constraints. There is a need to look at more than just family meals to understand parents' daily strategies for feeding young children and their implications for child nutrition.

Innovative approaches to weight loss in a high-risk population: The small changes and lasting effects (SCALE) trial.

OBJECTIVE: To evaluate the efficacy of a small change behavioral weight loss intervention with or without a positive affect/self-affirmation (PA/SA) component on weight loss at 12 months. METHODS: Black and Hispanic adults (N = 405) with body mass index 25-50 kg/m2 selected one of ten small change eating strategies and a physical activity goal, randomly with/without PA/SA. Participants were followed by community health workers at set intervals (weekly in months 1-3; biweekly in months 4-9; once monthly in months 10-12). RESULTS: There was no difference in weight loss at 12 months between participants in the small change approach alone (1.1%) versus the small change PA/SA intervention (1.2%). During treatment, 9% of participants lost at least 7% of their initial body weight. Participants who reported more interval life events had a lower likelihood of losing weight (P < 0.0001). However, those randomized to the small change PA/SA intervention gained less weight (+0.3% vs. 2.3% gain; P < 0.0001). CONCLUSIONS: The small change PA/SA intervention did not lead to a significant difference in weight loss in comparison to the small change approach alone. It did, however, decrease the negative impact of psychosocial stressors on weight gain among participants with more interval life events.

Obese women experience multiple challenges with breastfeeding that are either unique or exacerbated by their obesity: discoveries from a longitudinal, qualitative study.

Obese women are at risk for shorter breastfeeding duration, but little is known about how obese women experience breastfeeding. The aim of this study was to understand obese women's breastfeeding experiences. We enrolled pregnant women in upstate New York, who were either obese [n = 13; body mass index (BMI) ≥30 kg/m2 ] or normal weight (n = 9; BMI 18.5-24.9 kg/m2 ) before conception and intended to breastfeed. A longitudinal, qualitative study was conducted from February 2013 through August 2014 with semi-structured interviews during pregnancy and at specific times post-partum through 3 months. Interviews were audio recorded, transcribed and analyzed using content analysis. Themes that emerged in analysis were compared between obese and normal-weight women. Differences were identified and described. Prenatally, obese women expressed less confidence about breastfeeding than normal-weight women. Post-partum, obese women and their infants had more health issues that affected breastfeeding, such as low infant blood glucose. Compared with normal-weight women, they also experienced more challenges with latching and positioning their infants. Breastfeeding required more time, props and pillows, which limited where obese women could breastfeed. Obese women also experienced more difficulty finding nursing bras and required more tangible social support than normal-weight women. In conclusion, obese women experienced more challenges than women of normal weight; some challenges were similar to those of normal-weight women but were experienced to a greater degree or a longer duration. Other challenges were unique. Obese women could benefit from targeted care prenatally and during the hospital stay as well as continued support post-partum to improve breastfeeding outcomes. © 2016 John Wiley & Sons Ltd.

Characteristics associated with the application of an ecological approach to preventing childhood obesity.

OBJECTIVE: Applying an ecological approach to childhood obesity prevention requires a new way of thinking and working for many community-based practitioners who are used to focusing on individual behaviour change. The present study investigated individual and organizational characteristics associated with the application of an ecological approach by practitioners 6 months post-training. DESIGN: Individual and organizational characteristics and outcomes of a 6-week online training course were assessed at pre-course, post-course and 6-month follow-up. The application of an ecological approach was measured by three outcomes (application of course content, implementation of an action plan and trying a different approach) and analysed using a generalized estimating equation model with a binomial distribution and logit link and linear mixed models. SETTING: An online course for participants in the USA and abroad. SUBJECTS: Public health nutrition and youth development educators and their community partners, and other community practitioners, who completed the course and all three surveys (n 240). RESULTS: One individual characteristic (networking utility) and three organizational characteristics (ecological approach within job scope, funding, course content applied to work) were positively and significantly associated with the application of an ecological approach (P<0·05). Individual characteristics that were negatively and significantly associated with the application of an ecological approach were being a registered dietitian and having ≥16 years of work experience (P<0·05). CONCLUSIONS: Training of community practitioners and the scope and funding of their positions should explicitly emphasize the usefulness or utility of networking and the use of an ecological approach for preventing childhood obesity.

Environmental influences on small eating behavior change to promote weight loss among Black and Hispanic populations.

Small eating behavior changes are proposed as more feasible to achieve and maintain than larger changes used in traditional behavioral weight loss studies. However, it is unclear whether overweight Black and Hispanic adults in a low-income urban setting experience small changes as feasible and what might influence feasibility. Participants' experiences in a 12-week pilot weight loss intervention were explored qualitatively to determine the feasibility of making small eating behavior changes in this population. After the intervention (69% retention), semi-structured interviews with 46 men and women (mean age 51, 50% Non-Hispanic Black, 43% Hispanic) revealed that making small eating changes was a process shaped by participants' intrapersonal and interpersonal eating environments. Participants responded to intrapersonal and interpersonal eating environmental challenges by adapting small change strategies, navigating eating environments, and negotiating household eating practices. Findings highlight how even small eating behavior changes called for adaptation, navigation, and negotiation of complex eating environments in daily life. These findings were used to improve the trial that followed and underline the importance of feasibility studies to inform community trials. Findings also add to understanding of contextual challenges and the skills needed to implement small changes in a low income, ethnic minority population.

The Relationship between Social Network Body Size and the Body Size Norms of Black and Hispanic Adults.

OBJECTIVE: To examine the relationship between the body size norms of Black and Hispanic adults and the body sizes of their social network members. METHODS: Egocentric network data were examined for 245 adults recruited from 2012-2013 in New York City. A multivariable regression model was used to examine the relationship between participants' perception of normal body size and the body sizes of their network members adjusted for participant age, education, race/ethnicity and network size. Participants' body size norms were also examined stratified by the following characteristics of obese network members: frequency of contact, living proximity, relationship, and importance of relationship. RESULTS: Index participants were 89% female with mean body mass index 33.5 kg/m2. There were 2,571 network members identified (31% overweight, 10% obese). In the fully adjusted multivariable model, perception of normal body size increased as the number of network members with obesity increased (p<0.01). Larger body size norms were associated with increased frequency of contact with obese network members (p=0.04), and obese members living in the home (p=0.049). CONCLUSIONS: These findings support a relationship between the body size norms of Black and Hispanic adults and their social network body size.

"Because we missed the way that we eat at the middle of the day:" Dietary acculturation and food routines among Dominican women.

Better understanding of dietary change mechanisms among growing immigrant populations is needed in light of increased risk for diet-related chronic health conditions and inconsistent associations between acculturation and diet. This grounded theory research aimed to understand the lived experiences of interactions between food culture and social, economic, and physical environments in an immigrating population, Dominican women living in the Dominican Republic and New York City. Twenty-nine Dominican women participated in qualitative interviews about food and eating behaviors, life course experiences, and environments. Daily food and eating routines, framed by shopping for, preparation of, and consumption of 'la comida' or the main meal, emerged as dominant themes reflecting differences in women's economic, social, and physical environments. Routines were shaped by employment, household characteristics, and the food environment. Participating women attributed weight gain to changes in their food routines following immigration. The construction, disruption, and reconstruction of food and eating routines in response to differing economic, social, and physical environments in the sending and the receiving cultures provided new insights into the relationship between structural and cultural contexts of food and eating in an immigrant population. A food routines framework provides new insights into behavioral and weight changes with immigration.

Images of a Healthy Worksite: A Group-Randomized Trial for Worksite Weight Gain Prevention With Employee Participation in Intervention Design.

OBJECTIVES: We assessed the effects of a worksite multiple-component intervention addressing diet and physical activity on employees' mean body mass index (BMI) and the percentage of employees who were overweight or obese. METHODS: This group-randomized trial (n = 3799) was conducted at 10 worksites in the northeastern United States. Worksites were paired and allocated into intervention and control conditions. Within- and between-groups changes in mean BMIs and in the percentage of overweight or obese employees were examined in a volunteer sample. RESULTS: Within-group mean BMIs decreased by 0.54 kilograms per meter squared (P = .02) and 0.12 kilograms per meter squared (P = .73) at the intervention and control worksites, respectively, resulting in a difference in differences (DID) decrease of 0.42 kilograms per meter squared (P = .33). The within-group percentage of overweight or obese employees decreased by 3.7% (P = .07) at the intervention worksites and increased by 4.9% (P = .1) at the control worksites, resulting in a DID decline of 8.6% (P = .02). CONCLUSIONS: Our findings support a worksite population strategy that might eventually reduce the prevalence of overweight and obesity by minimizing environmental exposures to calorically dense foods and increasing exposures to opportunities for energy expenditure within worksite settings.

Small Changes and Lasting Effects (SCALE) Trial: the formation of a weight loss behavioral intervention using EVOLVE.

BACKGROUND: Obesity is a major health problem that disproportionately affects Black and Hispanic adults. This paper presents the rationale and innovative design of a small change eating and physical activity intervention (SC) combined with a positive affect and self-affirmation (PA/SA) intervention versus the SC intervention alone for weight loss. METHODS: Using a mixed methods translational model (EVOLVE), we designed and tested a SC approach intervention in overweight and/ or obese African American and Hispanic adults. In Phase I, we explored participant's values and beliefs about the small change approach. In Phase II, we tested and refined the intervention and then, in Phase III we conducted a RCT. Participants were randomized to the SC approach with PA/SA intervention vs. a SC approach alone for 12 months. The primary outcome was clinically significant weight loss at 12 months. RESULTS: Over 4.5 years a total of 574 participants (67 in Phase I, 102 in Phase II and 405 in Phase III) were enrolled. Phase I findings were used to create a workbook based on real life experiences about weight loss and to refine the small change eating strategies. Phase II results shaped the recruitment and retention strategy for the RCT, as well as the final intervention. The RCT results are currently under analysis. CONCLUSION: The present study seeks to determine if a SC approach combined with a PA/SA intervention will result in greater weight loss at 12 months in Black and Hispanic adults compared to a SC approach alone.

Eating Together at the Firehouse: How Workplace Commensality Relates to the Performance of Firefighters.

Cooperative activities among coworkers can provide valuable group-level benefits; however, previous research has often focused on artificial activities that require extraordinary efforts away from the worksite. We investigate organizational benefits that firms might obtain through various supports for coworkers to engage in commensality (i.e., eating together). We conducted field research within firehouses in a large city to explore the role that interacting over food might have for work-group performance. Using a mix of qualitative and quantitative methods, our field research shows a significant positive association between commensality and work-group performance. Our findings establish a basis for research and practice that focuses on ways that firms can enhance team performance by leveraging the mundane and powerful activity of eating.

Health professionals' experiences providing breastfeeding-related care for obese women.

BACKGROUND: Obese women are at high risk of early breastfeeding cessation, and health professionals (HPs) have a unique opportunity to provide them with breastfeeding support. Our objective was to describe HPs' experiences providing breastfeeding care for obese women during the prenatal, peripartum, and postpartum periods. MATERIALS AND METHODS: In-depth, qualitative interviews were conducted with 34 HPs (including obstetricians, midwives, pediatricians, nurses, and lactation consultants) who care for pregnant or lactating women. They were recruited from a variety of settings in central New York. Interviews were audio-recorded, transcribed, verified for accuracy, and then analyzed qualitatively. RESULTS: HPs identified obesity in multiple ways, some of which were consistent with standard cutoffs, whereas others implied extreme obesity. Nearly all HPs discussed ways they perceive obese women have challenges with breastfeeding. Some HPs described challenges as specific to obese women (e.g., limited mobility), whereas others described challenges as universal but more likely to occur among obese women (e.g., difficulties positioning the infant to breastfeed). Across professions, HPs described providing breastfeeding care for obese women as requiring more time and physical work and as being more challenging. HPs acknowledged stigma around obesity and discussed treating obese women with dignity and the same as other women. Strategies were suggested for improving breastfeeding support for obese women. CONCLUSIONS: HPs identified multiple challenges that obese women encounter with breastfeeding, as well as their own challenges with providing care. Comprehensive strategies are needed to assist obese women with breastfeeding and to alleviate strain on HPs who provide their care.

A second chance: meanings of body weight, diet, and physical activity to women who have experienced cancer.

OBJECTIVE: To understand the meanings of diet, physical activity, and body weight in the context of women's cancer experiences. DESIGN: Grounded theory using 15 qualitative interviews and 3 focus groups. SETTING: Grassroots community cancer organizations in the northeastern United States. PARTICIPANTS: Thirty-six white women cancer survivors; 86% had experienced breast cancer. MAIN OUTCOME MEASURES: Participants' views of the meanings of body weight, diet, and physical activity in the context of the cancer. ANALYSIS: Procedures adapted from the constant comparative method of qualitative analysis using iterative open coding. RESULTS: Themes emerged along 3 intersecting dimensions: vulnerability and control, stress and living well, and uncertainty and confidence. Diet and body weight were seen as sources of increased vulnerability and distress. Uncertainty about diet heightened distress and lack of control. Physical activity was seen as a way to regain control and reduce distress. CONCLUSIONS AND IMPLICATIONS: Emergent themes of vulnerability-control, stress-living well, and uncertainty-confidence may aid in understanding and promoting health behaviors in the growing population of cancer survivors. Messages that resonated with participants included taking ownership over one's body, physical activity as stress reduction, healthy eating for overall health and quality of life, and a second chance to get it right.

Diet and body composition outcomes of an environmental and educational intervention among men in treatment for substance addiction.

OBJECTIVE: To determine the effect of an educational and environmental intervention on diet, body mass index, and waist circumference of men in substance addiction treatment. METHODS: One hundred three racially/ethnically diverse men in 6 urban substance addiction residential treatment facilities in Upstate New York participated in weekly nutrition and food classes and food environment changes to increase healthful food choices. The main outcomes of this controlled, quasi-experimental, pre-post evaluation study were diet, body mass index, and waist circumference. RESULTS: Forty-three (42%) participants with complete data reported significantly greater intakes of fruits and vegetables, lower intakes of calories from sweets and desserts, and a reduction in waist circumference (P ≤ .05) following the intervention, compared to the control period. CONCLUSIONS AND IMPLICATIONS: An educational and environmental intervention can be effective in promoting positive dietary behavior and reducing waist circumference among men in residential treatment. These results need to be confirmed in a larger, randomized trial.

Eating maps: places, times, and people in eating episodes.

This project developed a method for constructing eating maps that portray places, times, and people in an individual's eating episodes. Researchers used seven consecutive days of qualitative eating recall interviews from 42 purposively sampled U.S. adults to draw a composite eating map of eating sites, meals, and partners for each person on a template showing home, work, automobile, other homes, and other places. Participants evaluated their own maps and provided feedback. The eating maps revealed diverse places, times, and partners. Eating maps offer a flexible tool for eliciting, displaying, validating, and applying information to visualize eating patterns within contexts.

Process evaluation of an environmental and educational nutrition intervention in residential drug-treatment facilities.

OBJECTIVE: To evaluate the implementation of a controlled, 6-week, environmental and educational intervention to improve dietary intake and body composition, and to study the association of implementation fidelity with diet and body composition outcomes. DESIGN: A process evaluation documented participation, dose of nutrition education delivered, participant satisfaction, fidelity and completeness of the food environment intervention implementation, and context through observations and interviews with staff and residents. Intervention sites were scored and categorized as high or low participation and implementation and compared on essential elements of the food environment and on diet and body composition outcomes. SETTING: Six urban residential drug-treatment facilities in Upstate New York. SUBJECTS: Fifty-five primarily black and white men in residential drug-treatment programmes. RESULTS: Participants were exposed to 94 % and 69 % of the educational and environmental elements, respectively. High implementation sites were significantly more likely to provide water and 100 % juice, offer fruit or vegetable salad, offer choices of fruits and vegetables, and limit fried foods. Mixed-model analysis of covariance revealed that participants in the high participation and implementation sites reported greater reductions in total energy, percentage of energy from sweets, daily servings of fats, oils and sweets, and BMI over the intervention period. Participants in low participation and implementation sites reported greater reductions in percentage of energy from fat. Differential implementation of environmental elements limited the intervention impact. CONCLUSIONS: These findings document the contribution of changes in eating environments to facilitate dietary behaviour change in community residential substance-abuse settings.

Process evaluation of an environmental walking and healthy eating pilot in small rural worksites.

Small Steps are Easier Together (SS) was a pilot environmental intervention in small rural worksites in Upstate New York in collaboration with Extension educators. Worksite leaders teamed with co-workers to select and implement environmental changes to increase walking steps over individual baseline and to choose healthy eating options over 10 weeks. Participants were 226 primarily white, women employees in 5 sites. A mixed methods process evaluation, conducted to identify determinants of intervention effectiveness and to explain differences in outcomes across worksites, included surveys, self-reports of walking and eating, interviews, focus groups, and an intervention log. The evaluation assessed reach, characteristics of recruited participants, dose delivered, dose received, and context and compared sites on walking and eating outcomes. Emergent elements of participant-reported dose received included: active leadership, visible environmental changes, critical mass of participants, public display of accomplishments, accountability to co-workers, and group decision making. Participants at sites with high reach and dose were significantly more likely than sites with low reach and dose to achieve intervention goals. Although this small pilot needs replication, these findings describe how these evaluation methods can be applied and analyzed in an environmental intervention and provide information on trends in the data.

Online course increases nutrition professionals' knowledge, skills, and self-efficacy in using an ecological approach to prevent childhood obesity.

OBJECTIVE: To assess the impact of an online continuing education course on the knowledge, skills, and self-efficacy of nutrition professionals to use an ecological approach to prevent childhood obesity. DESIGN: Quasi-experimental design using intervention and delayed intervention comparison groups with pre/post-course assessments. SETTING: Online continuing education course. PARTICIPANTS: Nutrition and health professionals in an online course (n = 105) and a delayed intervention comparison group (n = 37). INTERVENTION: A 6-week, facilitated online course titled, Preventing Childhood Obesity: An Ecological Approach. MAIN OUTCOME MEASURES: Changes in knowledge, skills, and self-efficacy in using an ecological approach to address childhood obesity. ANALYSIS: Paired and independent sample t tests, factor analysis, regression analysis. RESULTS: In contrast to a comparison group, nutrition and health professionals who participated in a 6-week online course had statistically significant increases (P < .01) in their knowledge, skills, and self-efficacy related to using an ecological approach to prevent childhood obesity. CONCLUSIONS AND IMPLICATIONS: A facilitated online course can be effective at increasing the knowledge, skills, and self-efficacy of community-based nutrition and health professionals in using an ecological approach to prevent childhood obesity in their communities.

Behavioral contexts, food-choice coping strategies, and dietary quality of a multiethnic sample of employed parents.

Employed parents' work and family conditions provide behavioral contexts for their food choices. Relationships between employed parents' food-choice coping strategies, behavioral contexts, and dietary quality were evaluated. Data on work and family conditions, sociodemographic characteristics, eating behavior, and dietary intake from two 24-hour dietary recalls were collected in a random sample cross-sectional pilot telephone survey in the fall of 2006. Black, white, and Latino employed mothers (n=25) and fathers (n=25) were recruited from a low/moderate income urban area in upstate New York. Hierarchical cluster analysis (Ward's method) identified three clusters of parents differing in use of food-choice coping strategies (ie, Individualized Eating, Missing Meals, and Home Cooking). Cluster sociodemographic, work, and family characteristics were compared using χ(2) and Fisher's exact tests. Cluster differences in dietary quality (Healthy Eating Index 2005) were analyzed using analysis of variance. Clusters differed significantly (P≤0.05) on food-choice coping strategies, dietary quality, and behavioral contexts (ie, work schedule, marital status, partner's employment, and number of children). Individualized Eating and Missing Meals clusters were characterized by nonstandard work hours, having a working partner, single parenthood and with family meals away from home, grabbing quick food instead of a meal, using convenience entrées at home, and missing meals or individualized eating. The Home Cooking cluster included considerably more married fathers with nonemployed spouses and more home-cooked family meals. Food-choice coping strategies affecting dietary quality reflect parents' work and family conditions. Nutritional guidance and family policy needs to consider these important behavioral contexts for family nutrition and health.

"Watching a person who knows how to cook, you'll learn a lot". Linked lives, cultural transmission, and the food choices of Puerto Rican girls.

In-depth individual interviews were conducted with mainland- and island-dwelling Puerto Rican girls (n=23) to determine how migration, acculturation, and family contexts influenced food choices. Interview data from girls with diverse migration experiences (U.S. mainland raised, recent migrants to U.S. mainland, and Puerto Rico raised) were triangulated with extensive participant observation conducted in New York State and Puerto Rico. Data analysis using a ground theory approach revealed that participants' access to traditional foods varied in three domains: mothers' (cultural orientation, health, work, and cooking skills); household (composition, presence of Puerto Rican grandmother, and cooking skills); and girls' (migration experience, food preferences and values, and cooking skills) characteristics. Four food choice types emerged from participant narratives that differed in these domains: everybody cooks, tradition keeper, seeker, and on my own. Varied language orientations and migration experiences were represented among girls across all four food choice types, ranging from consistent to limited access to traditional food, demonstrating the limitations of one-dimensional models for understanding dietary acculturation. Findings demonstrate how a multidimensional, culture-specific model, including both cultural and structural characteristics, can influence dietary acculturation at the family and household level and food choices among immigrant adolescent girls, and guide future research and interventions.