Vendors' Perceptions and Experiences with WIC Online Shopping Implementation.

Background: Online shopping (OS) holds promise for improving the shopping experience for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). However, little is known about vendors' perspectives on implementing OS in the context of WIC. Objectives: The present study aimed to understand vendors' experiences, needs, and barriers to WIC OS implementation. Methods: We recruited vendors at various stages of WIC OS planning and implementation (n = 16). Semistructured interviews were conducted, transcribed, and coded using subconstructs of the i-PARIHS framework domains (e.g., Characteristics of the Innovation, recipient, context, and facilitation) to assess determinants related to adoption and implementation of WIC OS among vendors. Results: Interviewees represented various organizations, including local (n = 5), regional (n = 4), and national (n = 5) entities, along with enablement platforms (n = 2). The interviews yielded themes related to experiences planning and implementing a WIC OS system (n = 7) and perceived needs and barriers (n = 3). Vendors drew on prior experiences with Supplemental Nutrition Assistance Program (SNAP) OS to inform WIC OS projects, stressing the importance of building relationships and collaborating, particularly in technical partnerships, during WIC OS implementation. They also highlighted the value of leveraging existing OS systems to implement WIC OS projects, discussed WIC OS perceived benefits, emphasized the role of educating staff and participants on its usage, and valued WIC OS implementation guidance provided by WIC agencies. Needs and barriers for vendors contemplating WIC OS implementation included the need for evidence of successful implementation of WIC OS projects, understanding current regulatory implications, and appraising existing priorities and financial considerations for adopting and implementing WIC OS. Conclusions: WIC OS innovations are integral to modernizing the federal food assistance program. The present study highlights the role of vendor engagement, collaboration, guidance from WIC agencies, and knowledge sharing in ensuring WIC OS success. These insights can inform how WIC State agencies engage vendors to implement WIC OS.

Advancing Nutrition and Dietetics Research in Global Food and Nutrition Security: A Roundtable Meeting Report.

Food and nutrition security remains a relevant issue globally, impacting nutritional status and other health outcomes. This is further complicated by various environmental factors that impact stable access to, availability of, and utilization of nutritious foods. Nutrition and dietetics practitioners play an important role in the identification and treatment of food and nutrition security and are also well positioned to advance research that can support food and nutrition security solutions. To address this important issue, the Academy of Nutrition and Dietetics' Council on Research convened a Global Food and Nutrition Security Research Task Force (Task Force). To leverage existing information and expertise in this area and identify the need for future evidence, the Task Force hosted a virtual roundtable with key internal and external stakeholders. This 2-day event included discussions on research gaps, potential entry points for nutrition and dietetics practitioners, and important equity considerations in the area of food and nutrition security research. The identified research gaps included the need for standardized terminology for consistent data collection, the need for validated screening and assessment tools that can be used across settings and also assess diet quality, additional translational and implementation science research, multi-sectoral and multi-pronged approaches, interdisciplinary collaboration with community partners, incorporation of research into policy development, and additional evidence on food systems approaches to target food and nutrition security. To more clearly identify the entry points for practitioners, five examples from various countries were included to identify food and nutrition security issues and how nutrition and dietetics practitioners can be involved in research to address food and nutrition security. The Task Force would like this information to inform a research agenda and be leveraged by the larger scientific community to drive future funding and research opportunities for food and nutrition professionals on this topic.

A Mixed-Methods Study of Perceived Implementation Challenges for WIC Online Ordering and Transactions.

BACKGROUND: Federal food assistance programs are working towards online grocery shopping. Online ordering in Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is emerging following successful implementation in Supplemental Nutrition Assistance Program (SNAP). OBJECTIVE: To identify anticipated challenges, potential solutions, and expected costs of WIC online ordering. DESIGN: Cross-sectional, mixed-methods, web-based, survey research. SUBJECTS AND SETTING: Data were collected from December 2020 to January 2021. Purposeful and snowball sampling included WIC stakeholders involved in developing processes and systems required for WIC online ordering. Respondents represented diverse geographic areas, levels of intraorganizational authority, and WIC benefit card types. STATISTICAL ANALYSES PERFORMED: The research team used a rapid analysis and lean coding approach to identify emergent themes from open-ended survey responses. Descriptive statistics were used to describe the distribution of responses across themes and stakeholder types. RESULTS: Respondents (n = 145) described 812 anticipated challenges within 20 themes grouped into five topic areas: rules and regulations; shopping experience; security, confidentiality, fraud, and WIC State agency processes; training, assistance, and education; and equitable access and buy-in. Addressing anticipated regulatory issues were among the few concrete potential solutions described. The two most frequent costs reported were increased staff time and start-up and ongoing technology costs. CONCLUSIONS: This study identified several, critical anticipated challenges and considerations that will help prepare WIC state agencies for opportunities to expand online ordering to WIC participants.

Development of a Data Visualization Tool to Evaluate the Impact of a Maternal and Child Health (MCH) Nutrition Training Program on MCH Populations.

INTRODUCTION: Maternal and Child Health (MCH) Nutrition Training Programs aim to train graduate-level registered dietitian/nutritionists (RDNs) to improve the health of MCH populations. Metrics exist to evaluate the production and success of skilled graduates; however, metrics are needed regarding the reach of MCH professionals. This study aimed to develop, validate, and administer a survey to estimate the reach of a MCH Nutrition Training Program's alumni within the MCH population. METHODS: First, content validity of the survey was established with input from an expert panel (n = 4); face validity was established using cognitive interviews (n = 5) with RDNs; a test-retest (n = 37) was conducted to establish instrument reliability. The final survey, emailed to a convenience sample of alumni, received a response rate of 57% s(n = 56 of 98). Descriptive analyses were completed to identify MCH populations that alumni served. Survey responses were used to develop a storyboard. RESULTS: Most respondents were employed (93%; n = 52) and serving MCH populations (89%; n = 50). Of those serving MCH populations, 72% indicated working with families, 70% with mothers/women, 60% with young adults, 50% with children, 44% with adolescents, 40% with infants, and 26% with children and youth with special health care needs. The storyboard was created and visually represents connections between public health nutrition employment classification, direct reach, and indirect reach of sampled alumni to MCH populations served. CONCLUSION: The survey and storyboard are important tools that allow MCH Nutrition training programs to demonstrate their reach and to justify the impact of workforce development investments on MCH populations.

Using Explainable Artificial Intelligence to Discover Interactions in an Ecological Model for Obesity.

Ecological theories suggest that environmental, social, and individual factors interact to cause obesity. Yet, many analytic techniques, such as multilevel modeling, require manual specification of interacting factors, making them inept in their ability to search for interactions. This paper shows evidence that an explainable artificial intelligence approach, commonly employed in genomics research, can address this problem. The method entails using random intersection trees to decode interactions learned by random forest models. Here, this approach is used to extract interactions between features of a multi-level environment from random forest models of waist-to-height ratios using 11,112 participants from the Adolescent Brain Cognitive Development study. This study shows that methods used to discover interactions between genes can also discover interacting features of the environment that impact obesity. This new approach to modeling ecosystems may help shine a spotlight on combinations of environmental features that are important to obesity, as well as other health outcomes.

A cross sectional assessment of basic needs insecurity prevalence and associated factors among college students enrolled at a large, public university in the Southeastern U.S.

BACKGROUND: There is increasing evidence of problematic rates of food insecurity among college students, yet few studies have gone beyond this to examine housing insecurity rates or rates of basic need insecurity (BNI), which is defined as having both food and housing insecurity, among the postsecondary population. BNI may have significant impacts on the mental and social health, and academic outcomes of college students, yet remains understudied. The researchers of this study are among the first to assess the prevalence of food insecurity, housing insecurity, and basic needs insecurity among college students enrolled at a large, public university in the Southeast and to identify factors associated with experiencing food, housing, and basic needs insecurity. METHODS: A cross-sectional online survey was conducted at a large, public university in the Southeast United States. All eligible, enrolled students (n = 23,444) were asked to complete an online survey, 2634 responded (11.2% response rate). Multivariate logistic regression models were used to assess relationships between demographic and financial factors and the outcomes of interest (food, housing, and basic needs insecurity). RESULTS: High rates of food insecurity (48.5%), housing insecurity (66.1%), and basic needs insecurity (37.1%) were identified. After controlling for confounders, factors that were significantly associated with increased odds of students having basic needs insecurity included previous food insecurity (p < 0.001; Odds Ratio (OR) = 3.36; Confidence Interval (CI) = 2.64-4.28), being employed (p < 0.001, OR = 1.70; CI = 1.34-2.17), not receiving family financial support (p < 0.001, OR = 1.61; CI = 1.30-2.00), and living off-campus (p < 0.001, OR = 1.67; CI = 1.25-2.22). Juniors (p < 0.001, OR = 1.78; CI = 1.31-2.42), seniors (p < 0.001, OR = 2.06; CI = 1.52-2.78), Masters (p = 0.004, OR = 1.68; CI = 1.18-2.40), and PhD or EdD (p = 0.029, OR = 1.55; CI = 1.05-2.31) students were significantly more likely to experience basic needs insecurity than sophomore students. CONCLUSIONS: This research identifies high rates of food, housing, and basic needs insecurity among college students enrolled at a large, public university. Financial factors such as being food insecure prior to attending college, working during college, and not having familial financial support were all related to BNI in this sample. Students who were more advanced in their education experienced more BNI than less advanced students. Innovative interventions with enhanced BNI measures, for example, partnering with financial aid offices to screen and refer students to food resources, are likely needed to address this multi-faceted problem.

Online Pilot Grocery Intervention among Rural and Urban Residents Aimed to Improve Purchasing Habits.

Online grocery shopping has the potential to improve access to food, particularly among low-income households located in urban food deserts and rural communities. The primary aim of this pilot intervention was to test whether a three-armed online grocery trial improved fruit and vegetable (F&V) purchases. Rural and urban adults across seven counties in Kentucky, Maryland, and North Carolina were recruited to participate in an 8-week intervention in fall 2021. A total of 184 adults were enrolled into the following groups: (1) brick-and-mortar "BM" (control participants only received reminders to submit weekly grocery shopping receipts); (2) online-only with no support "O" (participants received weekly reminders to grocery shop online and to submit itemized receipts); and (3) online shopping with intervention nudges "O+I" (participants received nudges three times per week to grocery shop online, meal ideas, recipes, Facebook group support, and weekly reminders to shop online and to submit itemized receipts). On average, reported food spending on F/V by the O+I participants was USD 6.84 more compared to the BM arm. Online shopping with behavioral nudges and nutrition information shows great promise for helping customers in diverse locations to navigate the increasing presence of online grocery shopping platforms and to improve F&V purchases.

Perceptions and Impact of a Youth-led Childhood Obesity Prevention Intervention among Youth-leaders.

OBJECTIVE: To evaluate the impact of a youth-led nutrition intervention on youth-leaders themselves. DESIGN: Mixed methods, including: in-depth interviews and a quasi-experimental quantitative study comparing youth-leaders and nonparticipant comparison youth. ANALYSIS: Qualitative analysis using direct content analysis. Difference-in-differences analyses assessing quantitative program impact. RESULTS: Youth-leaders perceived that the intervention impacted themselves, the youth-participants, and their respective social networks. Youth-leaders experienced greater increases in intentions to eat healthfully (p=0.04), and greater decreases in support for healthy eating from their friends (p=0.01), than the comparison group. CONCLUSIONS/IMPLICATIONS: Youth-leaders reported multiple levels of intervention impact, and increased intentions for healthy eating; however, additional research is needed to enhance impact on behavioral outcomes.

Food Shopping Frequency of Rural Tennessee Adults With Comparisons by Federal Nutrition Assistance Participation.

OBJECTIVE: To describe food shopping frequency across 7 store types in a rural context and compare food shopping frequency between federal nutrition assistance recipients and nonrecipients. METHODS: This cross-sectional study was conducted at county fairs in rural Tennessee. RESULTS: Reported overall mean food shopping frequency was 18.4 (SD, 13.9) times in the past 30 days. A mean of 3.1 (SD, 1.2) store types were visited, with supermarkets, convenience stores, and dollar stores the most frequented stores. Federal nutrition assistance program recipients shopped significantly less frequently than nonrecipients for overall shopping frequency (P = 0.02), supermarkets (P = 0.02), and farmers' markets (P = 0.04). CONCLUSIONS AND IMPLICATIONS: Educating and counseling individuals on how food shopping frequency may promote nutrition and health may be important. Federal nutrition assistance programs that distribute benefits monthly may impact food shopping frequency.

WIC Participants' Perspectives of Facilitators and Barriers to Shopping With eWIC Compared With Paper Vouchers.

OBJECTIVES: (1) To describe facilitators and barriers to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food shopping via electronic benefits transfer (eWIC) compared with paper vouchers. (2) To explore suggestions that WIC participants had for modifying the program to enhance their overall WIC experience. DESIGN: Qualitative, semistructured, in-depth interviews. SETTING: WIC participants in East Tennessee. PARTICIPANTS: Twenty-four primary food shoppers of WIC-participating households aged at least 18 years were recruited using a purposive sampling strategy. PHENOMENON OF INTEREST: Perceived facilitators and barriers to use of eWIC as compared with paper vouchers. ANALYSIS: Interview transcripts were analyzed using a grounded theory approach to identify emergent themes. RESULTS: Participants identified several ways eWIC has improved their food shopping experience, including ad hoc redemption of WIC benefits and a quicker, more discrete checkout. Participants' chief complaint about eWIC was transaction errors at checkout. Participants identified other barriers to shopping for WIC foods that cannot be addressed by the card alone, such as difficulty identifying WIC items in-store. Participants reported changes to their benefit tracking behaviors and provided suggestions to improve WIC further. CONCLUSIONS AND IMPLICATIONS: The transition to eWIC was viewed favorably among WIC participants, although participants identified a need for additional support in addressing transaction errors. This finding presents an opportunity to modify messages delivered to WIC participants by WIC nutrition educators and enhance collaboration between WIC agencies, retailers, and e-commerce technology providers.

A Model Depicting the Retail Food Environment and Customer Interactions: Components, Outcomes, and Future Directions.

The retail food environment (RFE) has important implications for dietary intake and health, and dramatic changes in RFEs have been observed over the past few decades and years. Prior conceptual models of the RFE and its relationships with health and behavior have played an important role in guiding research; yet, the convergence of RFE changes and scientific advances in the field suggest the time is ripe to revisit this conceptualization. In this paper, we propose the Retail Food Environment and Customer Interaction Model to convey the evolving variety of factors and relationships that convene to influence food choice at the point of purchase. The model details specific components of the RFE, including business approaches, actors, sources, and the customer retail experience; describes individual, interpersonal, and household characteristics that affect customer purchasing; highlights the macro-level contexts (e.g., communities and nations) in which the RFE and customers behave; and addresses the wide-ranging outcomes produced by RFEs and customers, including: population health, food security, food justice, environmental sustainability, and business sustainability. We believe the proposed conceptualization helps to (1) provide broad implications for future research and (2) further highlight the need for transdisciplinary collaborations to ultimately improve a range of critical population outcomes.

Breakfast Consumption Frequency and Its Relationships to Overall Diet Quality, Using Healthy Eating Index 2010, and Body Mass Index among Adolescents in a Low-Income Urban Setting.

The aim of this study was to describe the relationship of breakfast frequency to diet quality and BMI among low-income, predominantly African American adolescents aged 9-15 (n = 239). Mean frequency of breakfast consumption was 5.0 ± 0.15 times per week. A significant, positive relationship was seen between HEI scores and frequency of breakfast consumption (p = .01). Dairy (p = .02) and whole grains (p < .01) HEI component scores were significantly related to breakfast frequency. No relationship was seen between breakfast frequency and BMI. Research with more rigorous designs should be conducted to assess the potential effects of breakfast consumption on diet quality in this population.

Food in My Neighborhood: Exploring the Food Environment through Photovoice with Urban, African American Youth.

This study adapted Photovoice methodology for younger participants to better understand the perceptions of urban African American youth on their food environments and diets. Youth (n = 17, ages 10-13 years) photographed and described, using novel narrative-based activities, the myriad places they regularly acquired "junk food" from environments saturated with such but differed in their assessments of the availability and desirability of more nutritious alternative foods. Youth often discussed specific foods as well as peers and adults in their lives as either entirely "healthy" or "unhealthy." This concrete thinking should be considered when designing messaging strategies to improve diets in similar populations. Overall, Photovoice is an engaging and effective method to engage youth in efforts to improve food environments and diets.

Inconsistency between Self-Reported Energy Intake and Body Mass Index among Urban, African-American Children.

BACKGROUND: To prevent obesity, it is important to assess dietary habits through self-reported energy intake (EI) in children. We investigated how EI is associated with body mass index and which elements of dietary habits and status are associated with EI among African-American (AA) children. METHODS: We assessed and included data from 218 10-14-year-old AA children in Baltimore, MD, USA. EI was calculated using a food frequency questionnaire. The basal metabolic rate (BMR) was used as the predicted minimal rate of energy expenditure of children. A fully adjusted multiple logistic regression was used to determine the prevalence of obesity (≥ 95th BMI-for-age percentile) among the quartiles of EI/BMR ratio using the third quartile for the reference. The differences in the age-adjusted mean EI/BMR among the categories of dietary habits, social support, and socio economic status were analyzed using a general linear model. RESULTS: Children with the lowest EI/BMR had significantly higher adjusted odds ratio (aOR) of obesity as compared to those in the third quartile of EI/BMR (boys aOR 4.3; 95% confidence interval 1.08, 20 and girls aOR 4.1; 1.02, 21). In girls, the adjusted mean EI/BMR in the group that prepared food less than the means (3.8 times/week) was significantly lower than the group that prepared food over the means (P = 0.03). Further, the group that reported eating breakfast under 4 times/week indicated an adjusted mean EI/BMR lower than the group that ate breakfast over 5 times/week in both sexes. CONCLUSIONS: When EI was under-reported with reference to BMR, we may observe high prevalence of obesity. Further, food preparation by children and frequent consumption of breakfast may instill food cognition with usual dietary habits. Therefore, holistic assessments including dietary habits are required to examine self-reported food intake especially among overweight/obese children.

Food insecurity, overweight and obesity among low-income African-American families in Baltimore City: associations with food-related perceptions.

OBJECTIVE: To examine associations between food insecurity, excess body weight, psychosocial factors and food behaviours among low-income African-American families. DESIGN: Cross-sectional survey of participants in the baseline evaluation of the B'More Healthy Communities for Kids (BHCK) obesity prevention trial. We collected data on socio-economic factors, food source destinations, acquiring food, preparation methods, psychosocial factors, beliefs and attitudes, participation in food assistance programmes, anthropometry and food security. We used principal component analysis to identify patterns of food source destinations and logistic regression to examine associations. SETTING: Fourteen low-income, predominantly African-American neighbourhoods in Baltimore City, MD, USA. SUBJECTS: Two hundred and ninety-eight adult caregiver-child (10-14 years old) dyads. RESULTS: Of households, 41·6 % had some level of food insecurity and 12·4 % experienced some level of hunger. Food-insecure participants with hunger were significantly more likely to be unemployed and to have lower incomes. We found high rates of excess body weight (overweight and obesity) among adults and children (82·8 % and 37·9 % among food insecure without hunger, 89·2 % and 45·9 % among food insecure with hunger, respectively), although there were no significant differences by food security status. Food source usage patterns, food acquisition, preparation, knowledge, self-efficacy and intentions did not differ by food security. Food security was associated with perceptions that healthy foods are affordable and convenient. Greater caregiver body satisfaction was associated with food insecurity and excess body weight. CONCLUSIONS: In this setting, obesity and food insecurity are major problems. For many food-insecure families, perceptions of healthy foods may serve as additional barriers to their purchase and consumption.

Monitoring capabilities of the Omron HJ-720ITC pedometer.

PURPOSE: The purpose of our study was to examine the monitoring capabilities of the Omron HJ-720ITC pedometer and determine the feasibility of using it in physical activity interventions. METHODS: Using data from an 8-week lifestyle-intervention study, we tested the capabilities of the pedometer for recording physical activity data. Data from a total of 28 subjects were used in our analysis. The total number of patient steps per day was recorded over the duration of an intervention, as well as "aerobic steps per day" (ie, those taken at a cadence of > 60 steps per minute for ≥ 10 consecutive minutes). Daily wear time was computed in order to ascertain participant compliance in wearing the pedometer. In addition, aerobic steps per minute were computed, providing an assessment of activity intensity during continuous walking bouts. RESULTS: Total steps per day and aerobic steps per day increased from baseline assessment to Week 8. Participants exceeded 100 steps/minute for 89% of their aerobic minutes, suggesting that they were in the moderate-intensity range (3-6 metabolic equivalent tasks) when performing continuous bouts of walking (> 10 minutes). CONCLUSION: The new pedometer is a reasonably priced, wearable activity monitor that is feasible for use in clinical and research settings.

Combining Ground-Truthing and Technology to Improve Accuracy in Establishing Children's Food Purchasing Behaviors.

Developing nutrition-focused environmental interventions for youth requires accurate assessment of where they purchase food. We have developed an innovative, technology-based method to improve the accuracy of food source recall among children using a tablet PC and ground-truthing methodologies. As part of the B'more Healthy Communties for Kids study, we mapped and digitally photographed every food source within a half-mile radius of 14 Baltimore City recreation centers. This food source database was then used with children from the surrounding neighborhoods to search for and identify the food sources they frequent. This novel integration of traditional data collection and technology enables researchers to gather highly accurate information on food source usage among children in Baltimore City. Funding is provided by the NICHD U-54 Grant #1U54HD070725-02.

Reducing TV watching during adult obesity treatment: two pilot randomized controlled trials.

The more time adults spend being sedentary, the greater the risk of obesity. The effect of reducing television (TV) watching, a prominent sedentary behavior, on weight loss has not been tested in an adult standard behavioral obesity intervention, and the mechanisms by which reducing TV watching influences energy balance behaviors are not well understood. Two, 8-week, pilot, randomized controlled trials were conducted examining the effect of a reduced TV watching prescription on energy balance behaviors and weight loss within an adult standard behavioral obesity intervention. In the first study, participants (n=24) were randomized into one of two conditions: (a) reduce energy intake and increase moderate to vigorous physical activity (MVPA) (INCREASE PA); or (b) reduce energy intake and decrease TV watching (DECREASE TV). As findings from the first pilot study did not show an increase in MVPA in the DECREASE TV group, the second study was designed to examine the effect of adding a reduced TV prescription to a standard intervention to optimize outcomes. In Pilot Study 2, participants (n=28) were randomized to INCREASE PA or to INCREASE PA+DECREASE TV. Outcomes included objectively measured TV watching and MVPA, self-reported light physical activity (LPA-Pilot Study 2 only), self-reported dietary intake while watching TV, and weight. Conditions with TV watching prescriptions significantly reduced TV watching. Both studies showed medium to large effect sizes for conditions with TV watching prescriptions to show greater reductions in dietary intake while watching TV. Pilot Study 1 found a trend for an increase in MVPA in INCREASE PA and Pilot Study 2 found significant increases in MVPA in both conditions. Pilot Study 2 found a significant increase in LPA in the INCREASE PA+DECREASE TV. Results indicate adding a TV watching prescription to a standard obesity intervention did not enhance increases in MVPA, but may assist with reducing dietary intake while TV watching and increasing LPA. Future research should examine the effect of reducing TV watching during obesity treatment over a longer time frame in a larger sample.

The effects of an energy density prescription on diet quality and weight loss: a pilot randomized controlled trial.

Dietary goals specific for lowering energy density (ED) may promote a nutrient-dense diet and weight loss. This pilot study examined the effects of ED-based diet prescriptions on diet quality and weight loss during a 3-month behavior-based obesity intervention conducted in a research setting. Forty-four adults with overweight/obesity (age 52.1±7.6 years, body mass index [BMI; calculated as kg/m(2)] 34.8±4.8, 81.8% women, and 93.2% white) were recruited between December 2009 and March 2010 and randomly assigned to: Low ED (consume ≥10 foods ≤1.0 kcal/g dietary ED and ≤2 foods ≥3.0 kcal/g dietary ED per day (n=15); Low-Energy, Low-Fat (1,200 to 1,500 kcal/day, ≤30% energy from fat (n=15); or Low-ED, Low-Energy, Low-Fat (n=14). Participants received 12 weekly group sessions led by a research interventionist. Dietary intake (measured by 3-day food records), self-reported physical activity, and weight were measured at baseline and 3 months. Intent-to-treat analyses showed all conditions reduced dietary ED and energy intake (P<0.001). Low-ED and Low-ED, Low-Energy, Low-Fat interventions increased fruit consumption (P<0.05). All conditions increased self-reported physical activity (P<0.001), with no difference between conditions. Although participants in all conditions lost weight (P<0.001), those in the Low-ED condition lost more (P<0.05) than those in the Low-ED, Low-Energy, Low-Fat condition (Low-ED -20.5±7.0 lb, Low-Energy, Low-Fat -16.9±10.1 lb, and Low-ED, Low-Energy, Low-Fat -12.5± 6.5 lb). A diet prescription that lowered ED increased fruit intake and enhanced weight loss compared with other weight loss prescriptions.