Within-store fast food marketing: The association between food swamps and unhealthy advertisement.

Previous studies have linked food consumption outside the home and fast food to poor diet quality and living within a food swamp to an increased likelihood of obesity. A growing amount of research has linked food marketing to food choice. Still, limited information is available on how this dynamic may work within fast food establishments and if the marketing strategies used may vary by neighborhood food swamp status. Utilizing the Environment Assessment (EAT) Tool, we examined the within-store marketing environment of fast food restaurants to understand the factors potentially influencing food choice. A cross-sectional study design surveyed fast food outlets (n = 170) for unhealthy advertisements. Each fast-food outlet was assigned an FSI score based on its geographic location and proximity to unhealthy outlets. Outlets were assessed for associations between food swamp status and unhealthy advertisements. Poisson Regression was performed to assess the relationship between unhealthy advertisements and FSI score. Low FSI had a mean unhealthy advertisement score of 36.79 (11.06). Moderate and High FSI had mean unhealthy advertisement scores of 33.03 (14.67) and 31.71 (12.63), respectively. The number of unhealthy advertisements did not differ by food swamp categories (Moderate FSI IRR: 0.90, 95% CI: 0.74-1.09; High FSI IRR: 0.86, 95% CI: 0.73-1.01 vs. low FSI). Differences in marketing environments by food swamp status were not observed. Future research should examine other factors of the food swamp environment and additional factors such as television or social media to understand its association with food choice.

Mediation of the Association between Social Environmental Characteristics of Family Childcare Home and Weight Status in Children by Diet Quality.

Background: The food and beverages served in family childcare homes (FCCHs) may play an important role in the development of childhood overweight and obesity. This analysis examines whether children's diet quality mediates the relationship between foods and beverages served in FCCHs and preschool-aged children's weight status. Methods: Trained and certified staff conducted observations for two days in each FCCH, using the Environment and Policy Assessment and Observation (EPAO) measure to determine the foods and beverages served to children (N=370) in FCCHs (N=120). They also used the Dietary Observation in Child Care (DOCC) protocol to assess children's food and beverage intake during childcare, from which we calculated the Healthy Eating Index-2015 (HEI), a measure of diet quality. Height and weight were measured for each child with parent consent from which the child's body mass index (BMI) z-scores were calculated from. A multilevel mediation analysis was conducted to indicate whether children's diet quality mediates the relations between food and beverage served in FCCHs and preschool-aged children's weight status. Results: Children's total HEI scores significantly mediated the relationship between the EPAO subscale "Food provided" and children's BMI z-scores (B=-.01, p<.05, 95% CI = [-.03, -.002]). Further, the EPAO subscale "Food provided" was positively associated with the total HEI score (B=.75, p<.01, 95% CI = [.32, 1.18]). Total HEI scores were negatively associated with BMI z-score (B=-.01, p<.05, 95% CI = [-.02, -.001]). Conclusion: Children's diet quality did significantly mediate the relationship between the food served in FCCHs and children's weight status. More longitudinal studies with longer follow-up periods need to be conducted to confirm these relationships. Further, future studies need to examine the relationships between a broader spectrum of FCCH environmental characteristics and home environment with children's weight status, as well as other mediators including physical activity.

Effect of Applying Best Practices for Physical Activity and Screen Time to Family Childcare Homes.

INTRODUCTION: Early childcare has been identified as an influential setting for children's physical activity. Our objective was to determine whether children aged 2 to 5 years had more accelerometer-measured minutes of physical activity when caregivers in their family childcare home (FCCH) adhered to best practices for physical activity and screen time. METHODS: We analyzed baseline 2-day observation data collected by using the Environment and Policy Assessment and Observation measure from a cluster-randomized trial. Multilevel linear regression models assessed the association between caregivers' meeting best practices for physical activity and screen time and children's time spent sedentary or in moderate-to-vigorous physical activity (MVPA). RESULTS: All FCCH caregivers (N = 120) in our study were female, and 67.5% were Hispanic. Participating children (N = 349) were 52.1% female and 57.4% Hispanic. A higher score among caregivers for physical activity best practices was associated with more MVPA (B = 0.79; 95% CI, 0.02 to 1.56; P = .04) for children and less sedentary time (B = -2.07; 95% CI, -3.94 to -0.19; P = .04). A higher caregiver score for screen time best practices was associated with less sedentary time (B = -2.07; 95% CI, -3.94 to -0.19; P = .04) and more MVPA time (B = 0.65; 95% CI, 0.03 to .27; P = .04). Children in homes where caregivers offered them 60 minutes or more of outdoor play and participated in outdoor physical activity had more MVPA and less sedentary time. We found no association between various screen-time best practices and children's sedentary time. DISCUSSION: Children with caregivers who used more best practices for physical activity and screen time had higher activity levels and spent less time sedentary. These findings could help policy makers and people caring for young children modify existing policies and develop programs to help early childhood caregivers implement best practices to promote children's physical activity.

Applying a Social Determinants of Health Framework to Guide Digital Innovations That Reduce Disparities in Chronic Disease.

ABSTRACT: Chronic diseases are among the top causes of global death, disability, and health care expenditure. Digital health interventions (e.g., patient support delivered via technologies such as smartphones, wearables, videoconferencing, social media, and virtual reality) may prevent and mitigate chronic disease by facilitating accessible, personalized care. Although these tools have promise to reach historically marginalized groups, who are disproportionately affected by chronic disease, evidence suggests that digital health interventions could unintentionally exacerbate health inequities. This commentary outlines opportunities to harness recent advancements in technology and research design to drive equitable digital health intervention development and implementation. We apply "calls to action" from the World Health Organization Commission on Social Determinants of Health conceptual framework to the development of new, and refinement of existing, digital health interventions that aim to prevent or treat chronic disease by targeting intermediary, social, and/or structural determinants of health. Three mirrored "calls to action" are thus proposed for digital health research: a) develop, implement, and evaluate multilevel, context-specific digital health interventions; b) engage in intersectoral partnerships to advance digital health equity and social equity more broadly; and c) include and empower historically marginalized groups to develop, implement, and access digital health interventions. Using these "action items," we review several technological and methodological innovations for designing, evaluating, and implementing digital health interventions that have greater potential to reduce health inequities. We also enumerate possible challenges to conducting this work, including leading interdisciplinary collaborations, diversifying the scientific workforce, building trustworthy community relationships, and evolving health care and digital infrastructures.

A multi-component tailored intervention in family childcare homes improves diet quality and sedentary behavior of preschool children compared to an attention control: results from the Healthy Start-Comienzos Sanos cluster randomized trial.

BACKGROUND: Childcare settings are important environments for influencing child eating and physical activity (PA). Family childcare homes (FCCH) care for many children of low-income and diverse racial/ethnic backgrounds who are at greater risk for poor diet quality, low PA, and obesity, but few interventions have targeted this setting. The aim of this study was to assess the efficacy of a multicomponent intervention conducted in FCCH on the diet quality and PA of 2-5 year old children in their care. TRIAL DESIGN: Cluster randomized trial. METHODS: The cluster-randomized trial, Healthy Start/Comienzos Sanos (2015-2019) evaluated an 8-month nutrition and PA intervention that included four components: (1) monthly telephone calls from a support coach using brief motivational interviewing, (2) tailored reports, newsletters and videos, (3) group support meetings, and (4) active play toys. After completing baseline measurement, FCCH were randomized into intervention or comparison groups in matched pairs. Both groups received the same intervention components but on different topics (intervention: nutrition/PA vs. comparison: reading readiness/literacy). Evaluation staff were blinded to group assignment. Child primary outcome measures collected at baseline and 8-months included: 1) Healthy Eating Index (HEI-2015) scores calculated from diet observation, and 2) accelerometer measurement of PA. Process measures were collected from field data and provider surveys. Generalized Estimating Equation Models assessed changes in HEI-2015 scores and PA over time by experimental condition. RESULTS: Ethnically diverse FCCH providers (n = 119) and 2-to-5-year-old children in their care (n = 377) were included in the final analysis. Process evaluation showed high participation in all intervention components except for group meetings. Compared to children in comparison group FCCH, children in intervention FCCH increased total HEI-2015 scores by 7.2 points (p < .001) including improvement in component scores for vegetables (0.84 points, p = .025) and added sugar (0.94 points, p = .025). For PA, compared to children in the comparison group, children in intervention FCCH decreased sedentary time by 5.7% (p = .021). CONCLUSIONS: The multicomponent Healthy Start intervention was effective in improving diet quality and sedentary behavior of children in FCCH, which demonstrates the promise of obesity prevention interventions in this setting. Future research could include enhancing the Healthy Start intervention to strengthen the PA component, considering virtual peer support, and determining how to best translate and disseminate the intervention into FCCH nationally. TRIAL REGISTRATION: National Institutes of Health, NCT02452645 . Registered 5 May 2015.

Micronutrient Adequacy in Preschool Children Attending Family Child Care Homes.

Limited data is available on the micronutrient intake and adequacy in preschool children enrolled in family child care homes (FCCH). The goal of this paper is to describe the micronutrient adequacy relative to age-specific recommendations of preschool-aged children (aged 2-5 years) attending FCCH in Rhode Island (RI). Dietary data among younger preschoolers (aged 2-3 years), n = 245) and older preschoolers (aged 4-5 years), n = 121) in 118 RI FCCH (N = 366 children) were analyzed. Nutrient adequacy was assessed as the amount of nutrient per 1000 kcal of the diet that would meet the Institute of Medicine nutrient requirements (critical nutrient density), and it was compared to the observed nutrient densities of the children. The sodium:potassium ratio was also calculated. For most micronutrients, the observed density met or exceeded the recommendation, meaning the children's intake was adequate. However, a high proportion of children had nutrient densities under the recommendation for vitamins D, E, K, and potassium (86.1%, 89.1%, 70.8%, and 99.2% of children, respectively). The mean vitamin B12, potassium, and zinc densities were statistically higher in younger vs. older preschoolers (p < 0.05 for all). Low densities in calcium and vitamins K and B5 were more frequent in older children vs. younger children (p < 0.05). In addition, older preschoolers had a higher sodium:potassium ratio than younger children (p < 0.05). The micronutrient intake density was adequate for most nutrients. However, intake of some nutrients was of concern. Further attention to training and compliance in FCCH may improve the diet quality of those cared for in these settings.

Ingredient bundles and recipe tastings in food pantries: a pilot study to increase the selection of healthy foods.

OBJECTIVE: The present study examined the effect of ingredient bundles (i.e. measured ingredients with recipes) and recipe tastings as a strategy to increase the selection of healthy, target foods (kale, brown rice and whole-wheat pasta). DESIGN: Each of the three conditions was tested once per week for three weeks. The conditions were: Treatment 1 (T1), recipe tastings only; Treatment 2 (T2), ingredient bundle plus recipe tastings; and Control, no intervention. SETTING: A food pantry in Bridgeport, CT, USA.ParticipantsFood pantry clients. RESULTS: Controlling for family size and intervention week, the likelihood of clients in T2 (n 160) selecting at least one target item compared with the Control group (n 160) was 3·20 times higher for kale, 4·76 times higher for brown rice and 7·25 times higher for whole-wheat pasta. Compared with T1 (n 128), T2 clients were 2·67 times more likely to select kale, 7·67 times more likely to select brown rice and 11·43 times more likely to select whole-wheat pasta. No differences between T1 and the Control group were found. CONCLUSIONS: Findings suggest that innovative, nudging strategies such as ingredient bundles may increase appeal of foods and encourage pantry clients to select healthier options.

Multilevel approaches to increase fruit and vegetable intake in low-income housing communities: final results of the 'Live Well, Viva Bien' cluster-randomized trial.

BACKGROUND: Fruit and vegetable (F&V) intake can reduce risks for chronic disease, but is much lower than recommended amounts in most Western populations, especially for those with low income levels. Rigorous research is needed on practical, cost-effective interventions that address environmental as well as personal determinants of F&V intake. This paper presents the results of a cluster randomized controlled trial evaluating the efficacy of 'Live Well, Viva Bien' (LWVB), a multicomponent intervention that included discount, mobile fresh F&V markets in conjunction with nutrition education. METHODS: Fifteen subsidized housing sites in Providence County, Rhode Island (8 intervention and 7 control sites) were randomized using a random number generator. Of these, nine housed elderly and/or disabled residents and six housed families. A total of 1597 adult housing site residents (treatment n = 837; control n = 760) were enrolled (73% women, 54% Hispanic, 17% black, Mean age 54 years). A year-long multicomponent intervention including mobile F&V markets plus nutrition education (e.g. campaigns, DVDs, newsletters, recipes, and chef demonstrations) was implemented at intervention sites. Physical activity and stress interventions were implemented at control sites. Follow-up occurred at 6 and 12 months. The main outcome measure was F&V consumption measured by National Cancer Institute's 'Eating at America's Table All Day Screener'. RESULTS: From baseline to 12 months, the intervention group increased total F&V intake by 0.44 cups with the control group decreasing intake by 0.08 cups (p < .02). Results also showed an increased frequency of F&V eating behaviors compared to the control group (p < .01). There was a clear dose response effect of the F&V markets with participants who reported attending all or most of the markets increasing F&V intake by 2.1 cups and 0.86 cups, respectively compared with less than half cup increases for lower levels of market attendance (p < .05). Use of the DVDs, recipes and taste-testings was also associated with greater increases in F&V intake; however, use of other educational components was not. CONCLUSIONS: LWVB is the first cluster, randomized controlled trial to demonstrate the efficacy of year-round F&V markets on improving F&V intake for low-income adults, which provides an evidence-base to bolster the mission of mobile produce markets. Further, the results more broadly support investment in environmental changes to alleviate disparities in F&V consumption and diet-related health inequities. TRIAL REGISTRATION NUMBER: Clinicatrials.gov registration number: NCT02669472.