Examining Potential Modifiers of Human Skin and Plasma Carotenoid Responses in a Randomized Trial of a Carotenoid-Containing Juice Intervention.

BACKGROUND: Skin carotenoid measurements are emerging as a valid and reliable indicator of fruit and vegetable intake and carotenoid intake. However, little is known about the extent to which skin carotenoid responsivity to dietary changes differs based on demographic and physiologic characteristics. OBJECTIVES: This study examined potential effect modifiers of skin carotenoid and plasma carotenoid responses to a carotenoid-rich juice intervention. METHODS: We leveraged data from 2 arms of a 3-site randomized controlled trial of a carotenoid-containing juice intervention (moderate dose = 6 ounces juice, 4 mg total carotenoids/d, high dose = 12 ounces juice, 8 mg total carotenoids/d) (n = 106) to examine effect modification by age, self-categorized race/ethnicity, biological sex, baseline body fat, body mass index, skin melanin, skin hemoglobin, skin hemoglobin saturation, skin coloration, sun exposure, and baseline intake of carotenoids from foods. Skin carotenoid concentrations were assessed using pressure-mediated reflection spectroscopy (Veggie Meter), and plasma carotenoid concentrations were measured using high-performance liquid chromatography. RESULTS: In bivariate analyses, among the high-dose group (8 mg/d), those of older age had lower skin carotenoid responsiveness than their younger counterparts, and those with greater hemoglobin saturation and lighter skin had higher skin carotenoid score responsiveness. In the moderate-dose group (4 mg/d), participants from one site had greater plasma carotenoid responsiveness than those from other sites. In multivariate analyses, participants with higher baseline skin carotenoids had smaller skin carotenoid responses to both moderate and high doses. CONCLUSIONS: Changes in skin carotenoid scores in response to interventions to increase fruit and vegetable intake should be interpreted in the context of baseline skin carotenoid scores, but other variables (e.g., self-categorized race/ethnicity, biological sex, baseline body fat, body mass index, skin melanin, and sun exposure) do not significantly modify the effect of carotenoid intake on changes in skin carotenoid scores. This trial was registered at clinicaltrials.gov as NCT04056624.

A Mixed-Methods Study to Evaluate the Feasibility and Acceptability of Implementing an Electronic Health Record Social Determinants of Health Screening Instrument into Routine Clinical Oncology Practice.

BACKGROUND: Routine screening for social determinants of health (SDOH) in the outpatient oncology setting is uncommon. The primary goal of this study was to prospectively evaluate the feasibility and acceptability of implementing an electronic health record (EHR) SDOH screening instrument into routine, clinical, oncology practice. METHODS: Adult patients with newly diagnosed gastrointestinal cancer presenting to a regional cancer center (November 2020 to July 2021) were eligible. Based on the consolidated framework for implementation research, feasibility measures included screening completion, median clinic visit time, and acceptability by the inter-professional care team and patients as measured by semistructured, qualitative interviews and surveys. Secondary outcomes included SDOH needs identified. RESULTS: Of 137 eligible patients, 112 (81.8%) were screened for SDOH. Demographics of the cohort included: 41.1% black (n = 46), 48.2% rural (n = 54), 4.5% uninsured (n = 5), and 6.3% Medicaid-insured (n = 7) patients. Median visit time was 97 min (95% CI 70-107 min) before and 100 min after implementation (95% CI 75-119 min; p = 0.95). In total, 95.5% (n = 107) reported at least one SDOH need. Clinicians (7/10) reported that SDOH screening was not disruptive and were supportive of ongoing use. Patients (10/10) found the screening acceptable. Screening staff (5/5) reported workflow barriers. Patients and staff also recommended revision of specific instrument questions. CONCLUSIONS: Routine collection of SDOH in an outpatient oncology setting using an EHR instrument is feasible and does not result in increased visit time for patients or clinicians. However, staff perceptions of clinic workflow disruption were reported. Further investigation to determine whether standardized SDOH assessment can improve cancer care delivery and outcomes is ongoing.

Cost analysis and cost effectiveness of a subsidized community supported agriculture intervention for low-income families.

BACKGROUND: The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts. METHODS: Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives. RESULTS: F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity. CONCLUSIONS: Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources. TRIAL REGISTRATION: ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www. CLINICALTRIALS: gov/ct2/show/NCT02770196 .

Fruit and Vegetable Preparation Changes During and After Cost-Offset Community-Supported Agriculture Plus Nutrition Education.

OBJECTIVE: Inadequate consumption of fruits and vegetables (FV) can negatively impact health. Cost-offset, or subsidized, community-supported agriculture (CO-CSA) may change FV preparation behaviors among caregivers in low-income households. We assessed changes in FV preparation frequency and methods during and after participation in a CO-CSA plus tailored nutrition education intervention. DESIGN: Longitudinal comparison of outcomes at baseline, end of CO-CSA season, and 1 year later. PARTICIPANTS: Caregivers of children aged 2-12 years from households with low income in rural areas of 4 US states (n = 148). INTERVENTION: Summer season, half-price CO-CSA share plus tailored nutrition education classes. Comparison to a control group not included in this analysis. VARIABLES MEASURED: Monthly frequency of preparing 9 FV for children's snacks and 5 vegetables for dinner; use of healthy preparation methods for dinner. ANALYSIS: Repeated measures ANCOVA including state with Bonferroni correction and 95% confidence. RESULTS: At baseline, caregivers prepared fruit for children's snacks and vegetables for dinner almost daily and vegetables for children's snacks every other day. The frequency of total FV preparation and most vegetable varieties increased during the intervention. Increases in total vegetables for snacks, dinner, and leafy greens were maintained 1 year later (n = 107). CONCLUSIONS AND IMPLICATIONS: Community-supported agriculture plus education is a promising approach to sustained increases in vegetable preparation for children's snacks and dinner meals.

Evidence of Geospatial and Socioeconomic Disparities in Access to Online Grocery Shopping for Fresh and Frozen Produce in North Carolina.

BACKGROUND: Online grocery shopping is a rapidly growing food procurement approach in the United States with the potential to improve food access. Limited research has focused on understanding differential access to online grocery shopping that provides healthier items such as fresh or frozen fruits and vegetables. OBJECTIVE: The study aim was to understand geospatial, socioeconomic, and racial disparities in the availability of healthy online grocery shopping and online Supplemental Nutrition Assistance Program (SNAP) acceptance in North Carolina. DESIGN: A cross-sectional study was conducted during spring 2021. PARTICIPANTS/SETTING: A listing of grocery stores with online shopping was generated using a systematic search strategy. Stores were geocoded and spatially joined to relevant contextual (rural/urban [based on US Department of Agriculture Rural Urban Continuum codes]), broadband Internet availability, socioeconomic variables (ie, percent poverty and Social Vulnerability Index), and demographic variables (ie, percent racial minority) in geographic information systems software. MAIN OUTCOME MEASURES: Prevalence rate ratios (PRRs) of healthy online grocery shopping (availability of curbside pickup or home delivery of fresh and frozen produce), and online SNAP acceptance (ie, availability of online SNAP), at the census tract level (n = 2,162). STATISTICAL ANALYSES PERFORMED: PRRs for availability of healthy online grocery shopping and SNAP online acceptance at the census tract level (n = 2,162) were modeled using Poisson regression with robust standard errors. RESULTS: This study found disparities in access to healthy online grocery shopping and SNAP online shopping availability in North Carolina. Healthy online shopping availability rates were higher in urban census tracts (PRR 1.68, 95% CI 1.47 to 1.92), areas with lower Social Vulnerability Index scores (PRR 0.99, 95% CI 0.98 to 0.99), higher Internet Availability Index scores (PRR 1.21, 95% CI 1.17 to 1.25), and lower percent poverty (PRR 0.94, 95% CI 0.90 to 0.98). SNAP online shopping availability rates were higher in urban census tracts (PRR 1.41, 95% CI 1.16 to 1.65), areas with higher Social Vulnerability Index scores (PRR 1.02, 95% CI 1.01 to 1.04), higher Internet Availability Index scores (PRR 1.15, 95% CI 1.10 to 1.20), and higher percent minority (PRR 1.02, 95% CI 1.0001 to 1.03). SNAP online shopping availability rates were lower in areas with higher percent poverty (PRR 0.90, 95% CI 0.85 to 0.95). CONCLUSIONS: This study found disparities in access to healthy online grocery shopping and SNAP online shopping for rural areas, and areas with higher poverty, and lower broadband Internet access in North Carolina. Further research is needed to identify effective strategies for addressing these disparities.

Participation in Cost-offset Community Supported Agriculture by Low-income Households in the U.S. is Associated with Community Characteristics and Operational Practices.

OBJECTIVE: Subsidized or cost-offset community supported agriculture (CO-CSA) connects farms directly to low-income households and can improve fruit and vegetable intake. This analysis identifies factors associated with participation in CO-CSA. DESIGN: Farm Fresh Foods for Healthy Kids (F3HK) provided a half-price, summer CO-CSA plus healthy eating classes to low-income households with children. Community characteristics (population, socio-demographics, health statistics) and CO-CSA operational practices (share sizes, pick-up sites, payment options, produce selection) are described and associations with participation levels examined. SETTING: Ten communities in New York (NY), North Carolina (NC), Vermont, and Washington states in USA. PARTICIPANTS: Caregiver-child dyads enrolled in spring 2016 or 2017. RESULTS: Residents of micropolitan communities had more education and less poverty than in small towns. The one rural location (NC2) had the fewest college graduates (10%) and most poverty (23%), and poor health statistics. Most F3HK participants were white, except in NC where 45.2% were African American. CO-CSA participation varied significantly across communities from 33% (NC2) to 89% (NY1) of weeks picked-up. Most CO-CSAs offered multiple share sizes (69.2%) and participation was higher than when not offered (76.8% vs. 57.7% of weeks); whereas 53.8% offered a community pick-up location, and participation in these communities was lower than elsewhere (64.7% vs. 78.2% of weeks). CONCLUSION: CO-CSAs should consider offering choice of share size and innovate to address potential barriers such as rural location and limited education and income among residents. Future research is needed to better understand barriers to participation, particularly among participants utilizing community pick-up locations.

Pressure-Mediated Reflection Spectroscopy Criterion Validity as a Biomarker of Fruit and Vegetable Intake: A 2-Site Cross-Sectional Study of 4 Racial or Ethnic Groups.

BACKGROUND: Valid biomarkers of fruit and vegetable (FV) intake are needed for field-based nutrition research. OBJECTIVES: To examine criterion-related validity of pressure-mediated reflection spectroscopy as a proxy measure of FV intake, using plasma carotenoids and self-reported FV and carotenoid intake as primary and secondary criterion measures, respectively. METHODS: Healthy adults 18-65 y of age, self-identifying as African American/black (n = 61), Asian (n = 53), white (n = 70), or Hispanic (n = 29), in North Carolina and Minnesota were recruited. Skin carotenoids were assessed via pressure-mediated reflection spectroscopy (Veggie Meter), skin melanin via spectrophotometer, and total plasma carotenoid concentration by HPLC-photodiode array detection. Self-reported carotenoid and FV intake was assessed using a semiquantitative FFQ. Relations between skin carotenoids, plasma carotenoids, FV, and carotenoid intake, with differences by race or ethnicity, age, sex, weight status, cholesterol, and melanin index, were examined by bivariate correlations and adjusted multivariate linear regressions. RESULTS: The overall unadjusted correlation between skin and total plasma carotenoids was r = 0.71 and ranged from 0.64 (non-Hispanic black) to 0.80 (Hispanic). Correlations between skin carotenoids and self-reported FV intake ranged from 0.24 (non-Hispanic black) to 0.53 (non-Hispanic white), with an overall correlation of r = 0.35. In models adjusted for age, sex, racial or ethnic group, and BMI, skin carotenoids were associated with plasma carotenoids (R2 = 0.55), FV (R2 = 0.17), and carotenoid intake (R2 = 0.20). For both plasma carotenoid and FV measures, associations with skin carotenoids did not vary by race, but these relations did differ by skin melanin-those with lower melanin had a lower correlation between skin and plasma carotenoids. CONCLUSIONS: Reflection spectroscopy-assessed skin carotenoids may be a reasonable alternative to measurement of plasma carotenoids, a biomarker used to approximate FV intake.

A meta-analysis of studies examining associations between resonance Raman spectroscopy-assessed skin carotenoids and plasma carotenoids among adults and children.

CONTEXT: No meta-analyses appeared to have been conducted to examine overall correlations between resonance Raman spectroscopy (RRS)-assessed skin carotenoids and plasma/serum carotenoids. OBJECTIVE: To review the available literature and quantify the association between RRS-assessed skin carotenoids and plasma/serum carotenoids via a meta-analysis of observational studies. DATA SOURCES: To identify relevant publications, we searched the PubMed, Embase, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ProQuest, and Scopus databases in April 2020 for items combining 3 concepts: Raman spectroscopy, skin, and plasma or serum. DATA EXTRACTION: Criteria for inclusion were publication in a peer-reviewed journal between 1990 and 2020, available in English language, and results reported as a baseline Pearson correlation coefficient. In teams of 2, the researchers independently reviewed titles and abstracts of 2212 nonduplicate papers with initial screening yielding 62 papers for full-text review, of which 15 were deemed eligible for inclusion. DATA ANALYSIS: A random-effects model in R (version 4.0.0) "meta" package was used to analyze the correlation between RRS-assessed skin and plasma/serum carotenoids. A subgroup analysis was conducted for studies involving adults and children, respectively. CONCLUSIONS: The 15 studies included 1155 individuals: 963 adults and 192 children. One study included children and adults. The random-effects model yielded an overall correlation of 0.68 (95%CI, 0.61-0.74; I2 = 74%; P < 0.01). The results were similar when grouped by adults and children. Among 963 adults, the correlation in the random-effects model was 0.69 (95%CI, 0.61-0.75; I2 = 78%; P < 0.01). Among 192 children, the correlation in the random-effects model was 0.66 (95%CI, 0.52- 0.77; I2 = 55%; P = 0.06). Overall, there was a positive, statistically significant correlation between RRS-assessed skin carotenoids and plasma/serum carotenoids in a pooled meta-analysis of 15 studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (record number 178835).

Perceived barriers and facilitators to participating in the North Carolina Healthy Food Small Retailer Program: a mixed-methods examination considering investment effectiveness.

OBJECTIVE: The North Carolina Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP. DESIGN: The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners. SETTING: Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP. PARTICIPANTS: Owners of corner stores participating in the HFSRP. RESULTS: All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment. CONCLUSIONS: All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.

Community supported agriculture plus nutrition education improves skills, self-efficacy, and eating behaviors among low-income caregivers but not their children: a randomized controlled trial.

BACKGROUND: Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a 'share' of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children. METHODS: The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016-2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children's diet quality, body mass index (BMI), and physical activity; caregivers' nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed. RESULTS: No significant net effects on children's dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers' cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security. CONCLUSIONS: Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security. TRIAL REGISTRATION: ClinicalTrials.gov . NCT02770196 . Registered 5 April 2016. Retrospectively registered.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts.

BACKGROUND: The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers. METHODS: Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code. RESULTS: Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases. CONCLUSIONS: Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Fruit and Vegetable Intake Assessed by Repeat 24 h Recalls, but Not by A Dietary Screener, Is Associated with Skin Carotenoid Measurements in Children.

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute's All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2-12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/-1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

A four-year observational study to examine the dietary impact of the North Carolina Healthy Food Small Retailer Program, 2017-2020.

BACKGROUND: The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016-2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers' purchases and diets. METHODS: Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017-2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases ("bag checks"); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores. RESULTS: There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1-12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores' HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores. CONCLUSIONS: Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Perceptions of nutrition education classes offered in conjunction with a community-supported agriculture intervention among low-income families.

OBJECTIVE: To examine participants' experiences with nutrition education classes that were implemented with and designed to complement a cost-offset community-supported agriculture (CSA) programme. DESIGN: Qualitative analysis of data from twenty-eight focus groups with ninety-six participants enrolled in Farm Fresh Foods for Healthy Kids (F3HK). Transcribed data were coded and analysed by a priori and emergent themes. SETTING: Rural and micropolitan communities in New York, North Carolina, Vermont and Washington (USA). PARTICIPANTS: Ninety-six F3HK participants. RESULTS: Participants found recipes and class activities helpful and reported improvements in nutrition knowledge, food preservation skills and home cooking behaviours for themselves and their children; they also reported that classes promoted a sense of community. Some educators better incorporated CSA produce into lessons, which participants reported as beneficial. Other obligations and class logistics were barriers to attendance; participants recommended that lessons be offered multiple times weekly at different times of day. Other suggestions included lengthening class duration to encourage social engagement; emphasising recipes to incorporate that week's CSA produce and pantry staples and offering additional strategies to incorporate children in classes. CONCLUSION: Complementing a cost-offset CSA with nutrition education may enhance programme benefits to low-income families by improving nutrition knowledge and cooking behaviours. However, future interventions will benefit from ongoing coordination between educators and local growing trajectories to maximise timely coverage of unfamiliar produce in lessons; synchronous scheduling of CSA pick-up and classes for participant convenience and creative strategies to engage children and/or provide childcare.

Making community-supported agriculture accessible to low-income families: findings from the Farm Fresh Foods for Healthy Kids process evaluation.

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p = .005) than eligible nonenrollees (n = 243) and more likely to be female (p < .001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19-23). Median CSA pickup was 88% of the weeks (IQR: 40-100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 ("very useful"). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact.

Associations between shopping patterns, dietary behaviours and geographic information system-assessed store accessibility among small food store customers.

OBJECTIVE: To examine associations between geographic information systems (GIS)-assessed accessibility to small food stores, shopping patterns and dietary behaviours among small food store customers. DESIGN: Residential addresses and customer shopping patterns (frequency of shopping, and previous purchase of fruits and vegetables) were gathered through customer intercept surveys. Addresses were geocoded, and GIS-assessed distance and driving time from the participants' residence to the store were calculated. Dietary status and behaviours were assessed using an objective non-invasive measure of skin carotenoids, the National Cancer Institute Fruit and Vegetable Screener, and items to assess sugary beverage intake. Associations between distance and driving time, demographics, shopping frequency, prior reported purchase of fruits and vegetables at the store and dietary behaviours were examined. SETTING: Small food stores (n 22) across North Carolina. PARTICIPANTS: Cross-sectional convenience samples of English-speaking customers aged 18 years or older (n 692). RESULTS: Participants living closer to the small store had lower income and formal education, were more likely to be Black, more likely to have previously bought fruits and vegetables at the store and more frequently shopped at the store. In adjusted models, skin carotenoids (n 644) were positively associated with distance to the store from home in miles (P = 0·01). CONCLUSIONS: Customers who lived closer to the stores were more frequent shoppers and more likely to have previously purchased fruits and vegetables at the store yet had lower skin carotenoids. These results support continued efforts to examine how to increase the availability and promotion of healthful foods at small food retail stores.

Comparison of food and beverage products' availability, variety, price and quality in German and US supermarkets.

OBJECTIVE: To assess availability, variety, price and quality of different food products in a convenience sample of supermarkets in Germany and the USA. DESIGN: Cross-sectional study using an adapted version of the Bridging the Gap Food Store Observation Form. SETTING: Information on availability, quality, price and variety of selected food products in eight German and seven US supermarkets (discount and full service) was obtained and compared by country. RESULTS: A general tendency for lower prices of fruits and vegetables in Germany was observed, while produce quality and variety did not seem to differ between countries, with the exception of the variety of some vegetables such as tomatoes. Chips and cereals did not differ significantly in variety nor price. In both countries, high energy-dense foods were lower in energy costs than lower energy-dense foods. CONCLUSIONS: The influence of food prices and availability on consumption should be further explored, including the impact of country differences.

Perceived Advantages and Disadvantages of Online Grocery Shopping among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants in Eastern North Carolina.

This study's purpose was to qualitatively examine perceived advantages and disadvantages of online grocery shopping among participants (n = 7) in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Initial in-depth, qualitative interviews were conducted, after which participants completed an episode of online grocery shopping, picked up the online order at the store, and completed an in-store shopping episode and a follow-up in-depth interview. Interviews were audio-recorded, transcribed verbatim, and analyzed deductively. Participants stated that in-store impulse purchases occurred at the check-out and cookie aisles and included chips and candy, but sometimes healthier foods such as fruit. Advantages of online grocery shopping included ease, convenience, and saving time. Disadvantages included inadequate substitutions, the online shopping fee, lack of control over selection of perishable goods, and inability to find good deals online versus in the store. Further research is needed to determine how to encourage healthy grocery purchases online.