Associations between food and beverage purchases and skin carotenoids among diverse small food retail store customers.

OBJECTIVE: To determine if customer purchases at small food stores are associated with healthfulness of the diet as approximated by skin carotenoids. DESIGN: This is a cross-sectional survey of customers in small food stores regarding demographics and food purchases. Food and beverage purchases were classified as 'healthy' or 'non-healthy' and 'carotenoid' v. 'non-carotenoid' using a systematic classification scheme. Fruit and vegetable intake was objectively assessed using a non-invasive device to measure skin carotenoids. Associations between variables of interest were examined using Pearson's correlation coefficients, t tests and multiple linear regression analyses. SETTING: Twenty-two small food retail stores in rural (n 7 stores) and urban (n 15) areas of North Carolina. PARTICIPANTS: Customers of small food stores. RESULTS: Of study participants (n 1086), 55·1 % were male, 60·0 % were African American/Black and 4·2 % were Hispanic, with a mean age of 43·5 years. Overall, 36 % purchased at least one healthy item, and 7·6 % of participants purchased a carotenoid-containing food/beverage. Healthy foods and beverages purchased included produce, lean meats, 100 % juices, plain popcorn, plain nuts, milk and yogurt. Unhealthy items included non-100 % juices, crackers, chips, candy, cakes and donuts. Purchase of a healthy or carotenoid-containing item was positively associated with skin carotenoid scores (P = 0·002 and 0·006, respectively). CONCLUSIONS: A relatively small proportion of customers purchased any healthy or carotenoid-containing foods and beverages, and those who did purchase healthy options had higher skin carotenoid scores. Future research should confirm these findings in different populations.

Creating Teams of Family Medicine Residents and High School Culinary Students Reduces Some Barriers to Implementing a Culinary Medicine Hands-On Workshop.

Background: Barriers to implementation of culinary medicine in resident training include lack of facilities, administrative support, and community engagement. Activity: Twenty-five family medicine residents were teamed with 17 high school culinary arts students to prepare recipes aligned with the Mediterranean diet (MED) and the USDA low, moderate, and liberal cost food plans. Results: The workshop took place in the high school teaching kitchens. A pre-survey informed the planning committee's design of a 4-h hands-on workshop that was considered a success. Discussion: Post-surveys documented improved resident confidence and skills in recommending MED to their patients and interaction with their own peers and high school students, as well as enjoyment by all participants of this hands-on approach.

Nursing staff participation in end-of-life nutrition and hydration decision-making in a nursing home: A qualitative study.

AIM: To better understand the participation of nursing staff in end-of-life nutrition and hydration decision-making in an American nursing home. DESIGN: A qualitative exploration with ethnographic focus. METHODS: In April 2017, in-person, semi-structured interviews were performed with 19 nursing staff members in a nursing home located in the south-eastern United States. Additional information was gathered through participant observation during interviews and review of organizational and regulatory policies. Transcripts were coded and analysed using qualitative methods described by Roper and Shapira (2000). RESULTS: Three primary themes relating to nursing staff participation in end-of-life nutrition and hydration decision-making were identified: (a) Formal decision-making: decisions made and implemented by persons with the authority to make legal and binding care decisions in the nursing home setting; (b) Informal decision-making: decisions not requiring medical orders; and (c) Influential factors: factors that influence actions of nursing staff. CONCLUSION: A variety of factors have an impact on nursing staff participation in end-of-life nutrition and hydration decision-making. Participation is closely aligned with the type of decision, whether formal or informal, and role, whether Certified Nursing Assistant/Aide, Licensed Practical/Vocational Nurse, or Registered Nurse. IMPACT: End-of-life nutrition and hydration decision-making in nursing homes differs from decision-making in other care settings and presents a challenge globally. Interventions that support the participation of nursing staff in end-of-life nutrition and hydration decision-making have the potential to positively impact the experiences of residents and family members faced with these issues in the nursing home setting.

Integrating Registered Dietitian Nutritionists Into Primary Care Practices to Work With Children With Overweight.

Despite increased reimbursement for registered dietitian nutritionists (RDNs), few studies have assessed the potential of integrating them into primary care clinics to support pediatric weight management. To assess the feasibility and effectiveness of this approach, RDNs were introduced into 8 primary care practices in North Carolina. This mixed-methods study combined (1) interviews and focus groups with RDNs and clinic personnel, (2) comparison of change in body mass index (BMI) z-score in study practices to change in historical comparison groups, and (3) analysis of behavior and BMI change for RDN utilizers. Qualitative data were coded thematically, and McNemar's and Wilcoxon signed-rank tests were used for quantitative data. RDN integration was good, but average referral rate for eligible children was 19.4%; 48.4% of those referred utilized the RDN (most fewer than 3 times). Using the full analysis set, there was no difference in change in BMI z-score for intervention and comparison groups. For RDN utilizers, the average change in BMI z-score was -0.089 (P < .001), and there was statistically significant improvement in 7 of 8 health behaviors. Integrating RDNs into primary care practices was feasible and possibly effective for utilizers. Reaping potential benefits of RDN co-location would require increasing low referral and utilization rates.

Advancing Nutrition Education, Training, and Research for Medical Students, Residents, Fellows, Attending Physicians, and Other Clinicians: Building Competencies and Interdisciplinary Coordination.

Nutrition plays an important role in health promotion and disease prevention and treatment across the lifespan. Physicians and other healthcare professionals are expected to counsel patients about nutrition, but recent surveys report minimal to no improvements in medical nutrition education in US medical schools. A workshop sponsored by the National Heart, Lung, and Blood Institute addressed this gap in knowledge by convening experts in clinical and academic health professional schools. Representatives from the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the American Society for Nutrition provided relevant presentations. Reported is an overview of lessons learned from nutrition education efforts in medical schools and health professional schools including interprofessional domains and competency-based nutrition education. Proposed is a framework for coordinating activities of various entities using a public-private partnership platform. Recommendations for nutrition research and accreditation are provided.

A "Hands-On" Thread, Part of a Medical Nutrition Education Curriculum.

Required "hands-on" medical nutrition education sessions are woven through years 1-3 at the Brody School of Medicine. An elective opportunity also is available for third and fourth year students. These active learning sessions focus on diet and chronic disease, including obesity, prevention, and treatment.

Exploring the Associations Among Nutrition, Science, and Mathematics Knowledge for an Integrative, Food-Based Curriculum.

BACKGROUND: Explore associations between nutrition, science, and mathematics knowledge to provide evidence that integrating food/nutrition education in the fourth-grade curriculum may support gains in academic knowledge. METHODS: Secondary analysis of a quasi-experimental study. Sample included 438 students in 34 fourth-grade classrooms across North Carolina and Ohio; mean age 10 years old; gender (I = 53.2% female; C = 51.6% female). Dependent variable = post-test-nutrition knowledge; independent variables = baseline-nutrition knowledge, and post-test science and mathematics knowledge. Analyses included descriptive statistics and multiple linear regression. RESULTS: The hypothesized model predicted post-nutrition knowledge (F(437) = 149.4, p < .001; Adjusted R = .51). All independent variables were significant predictors with positive association. CONCLUSIONS: Science and mathematics knowledge were predictive of nutrition knowledge indicating use of an integrative science and mathematics curriculum to improve academic knowledge may also simultaneously improve nutrition knowledge among fourth-grade students. Teachers can benefit from integration by meeting multiple academic standards, efficiently using limited classroom time, and increasing nutrition education provided in the classroom.

Diet for a Healthy Lactating Woman.

The nutrient and caloric requirements for lactation are set by the Institute of Medicine. The dietary pattern to meet those needs is found in the Dietary Guidelines for Americans. Only deficiency states for selected nutrients and/or prolonged inadequate caloric intake appear to affect the volume and quality of breast milk. Other dietary concerns of lactating women include "dieting" to return to prepregnancy weight; low maternal intake of selected nutrients due to health conditions or food choices; need for supplementation of calcium, vitamin D, and fatty acids; and use of non-nutritive sweeteners, caffeine, herbal supplements, and alcohol.

Using synchronous distance-education technology to deliver a weight management intervention.

OBJECTIVE: To compare the effectiveness of online delivery of a weight management program using synchronous (real-time), distance-education technology to in-person delivery. METHODS: Synchronous, distance-education technology was used to conduct weekly sessions for participants with a live instructor. Program effectiveness was indicated by changes in weight, body mass index (BMI), waist circumference, and confidence in ability to eat healthy and be physically active. RESULTS: Online class participants (n = 398) had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants (n = 1,313). Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence. CONCLUSIONS AND IMPLICATIONS: This project demonstrates the feasibility of using synchronous distance-education technology to deliver a weight management program. Synchronous online delivery could be employed with no loss to improvements in BMI, weight, and waist circumference.

Teaching by example: educating medical students through a weight management experience.

BACKGROUND AND OBJECTIVES: Surgeons General, the Institute of Medicine, and others have called for physicians to be role models for meeting the obesity epidemic. There are few published reports describing undergraduate medical education obesity curriculum elements. Physician experiences, knowledge, and attitudes have been shown to affect patient counseling behavior of physicians. METHODS: Required and extra credit obesity educational interventions were designed for third-year family medicine clerkship. For extra credit, students completed a personal weight management experience that spanned at least 4 weeks, included calculations of body mass index (BMI), waist circumference, caloric needs, description of eating and physical activity and monitoring plan, and a final report and reflection. RESULTS: During 2011--2012, 72% of the students completed this extra credit activity with almost all losing or maintaining their weight. Most reflected gratitude for this opportunity and their increased empathy for patients as they struggle with weight issues. CONCLUSIONS: Medical students completing a weight management experience during their third-year clerkship can see the effects on their own health while developing empathy for and understanding of the weight management struggles of their patients. Minimal faculty time commitment is required.

Development of a movement and state plan for obesity prevention, Eat Smart, Move More North Carolina.

This report outlines the evolution of the Eat Smart, Move More North Carolina movement and publications in support of the movement, including North Carolina's Plan to Address Obesity: Healthy Weight and Healthy Communities, 2013-2020. This evidence-based plan guides the efforts of many organizations as they work to fulfill the mission of Eat Smart, Move More North Carolina: to reverse the rising tide of obesity and chronic disease among North Carolinians by helping them to eat smart, move more, and achieve a healthy weight.

Comparison of predictive equations and measured resting energy expenditure among obese youth attending a pediatric healthy weight clinic: one size does not fit all.

BACKGROUND: The Academy of Nutrition and Dietetics recommends the use of indirect calorimetry for calculating caloric targets for weight loss in obese youth. Practitioners typically use predictive equations since indirect calorimetry is often not available. The objective of this study was to compare measured resting energy expenditure (MREE) with that estimated using published predictive equations in obese pediatric patients. MATERIAL AND METHODS: Youth aged 7 to 18 years (n = 80) who were referred to a university-based healthy weight clinic and who were greater than the 95th percentile BMI for age and gender participated. MREE was measured via a portable indirect calorimeter. Predicted energy expenditure (pEE) was estimated using published equations including those commonly used in children. pEE was compared to the MREE for each subject. Absolute mean difference between MREE and pEE, mean percentage accuracy, and mean error were determined. RESULTS: Mean percentage accuracy of pEE compared with MREE varied widely, with the Harris-Benedict, Lazzer, and Molnar equations providing the greatest accuracy (65%, 61%, and 60%, respectively). Mean differences between MREE and equation-estimated caloric targets varied from 197.9 kcal/day to 307.7 kcal/day. CONCLUSIONS: The potential to either overestimate or underestimate calorie needs in the clinical setting is significant when comparing EE derived from predictive equations with that measured using portable indirect calorimetry. While our findings suggest that the Harris-Benedict equation has improved accuracy relative to other equations in severely obese youth, the potential for error remains sufficiently great to suggest that indirect calorimetry is preferred.

Delivering a behavior-change weight management program to teachers and state employees in North Carolina.

PURPOSE: To ascertain the effectiveness of a behavior-change weight management program offered to teachers and state employees in North Carolina (NC). DESIGN: Fifteen-week weight management program with premeasures and postmeasures. SETTING: State agencies and public K-12 schools in five NC counties. SUBJECTS: A total of 2574 NC state employees enrolled in 141 classes. INTERVENTION: Eat Smart, Move More, Weigh Less (ESMMWL) is a 15-week weight management program delivered by trained instructors. Lessons inform, empower, and motivate participants to live mindfully as they make choices about eating and physical activity. MEASURES: Height, weight, body mass index (BMI), waist circumference, blood pressure, confidence in ability to eat healthy and be physically active, changes in eating, and physical activity behaviors. ANALYSIS: Descriptive statistics, t-tests, χ(2) tests, and analyses of variance. RESULTS: Data are reported for 1341 participants in ESMMWL who completed the program, submitted an evaluation, and had not participated in the program in the past; 89% were female and mean age was 48.8 years. Average BMI and waist circumference decreased significantly. Confidence in eating healthfully and being physically active increased significantly. The percentage of participants with a BMI < 30 kg/m(2) increased from 40% to 45% and those with a normal blood pressure increased from 23% to 32.5%. Participants reported being more mindful of what and how much they ate (92%), being more mindful of how much daily physical activity they got (88%), and eating fewer calories (87.3%). CONCLUSION: This project demonstrated the feasibility of implementing a behavior change-based weight management program at the worksite to achieve positive outcomes related to weight, blood pressure, healthy eating, and physical activity behaviors. Programs such as this have the potential to provide health care cost savings.

Participation in community-originated interventions is associated with positive changes in weight status and health behaviors in youth.

PURPOSE: To assess changes in children's health behaviors and weight status after participation in community-originated interventions. DESIGN: Prospective cohort study following body mass index (BMI) z-score trajectory over time. SETTING: Schools and community settings in 19 locations in North Carolina. SUBJECTS: A total of 1144 children, with an average age of 9.5 years, participating in community-originated physical activity and nutrition interventions, such as active recess and healthy cafeteria offerings, and environment and policy changes designed to prevent and reduce the prevalence of childhood obesity. Retention from baseline to final collection was 54%. Measures . Self-reported physical activity and eating behaviors; measured height and weight were collected at baseline and after interventions (average of 20 months). Z-score was compared with expected growth without intervention. ANALYSIS: Descriptive statistics, χ(2) tests and t-tests, and ANOVA analyses of variance to assess changes in health behaviors and weight status. RESULTS: More than 11% of children improved their weight status, and 86% of children who began at a healthy weight remained there. The average BMI for children who were overweight at enrollment was significantly lower after intervention (1.1 kg/m(2) lower for boys and 0.88 kg/m(2) lower for girls). Overweight and obese children who made improvements in key health behaviors showed greater decreases in BMI z-score than those who did not improve those behaviors (increased fruit [-.2207 vs. -.0793] and vegetable [-.2215 vs. -.0855] intake, and drinking less soda [-.1985 vs. -.0912]). There were no significant increases in physical activity, and changes in physical activity were not related to decreases in BMI z-score in this study. CONCLUSION: Community-originated interventions to raise awareness about food choices and to change policies and environments may improve BMI z-scores.

Treating pediatric obesity in the primary care setting to prevent chronic disease: perceptions and knowledge of providers and staff.

BACKGROUND: The national and international epidemic of chronic disease, including among children, is largely fueled by increasing obesity. It is recommended that primary care play a key role in the treatment of pediatric obesity. METHODS: A written survey was administered to providers and staff at 13 primary care practices across North Carolina, assessing perceptions on multiple dimensions of pediatric obesity treatment and knowledge of dietitian services. RESULTS: The response rate for the survey was 66.9% (n = 273). Although providers reported feeling comfortable and confident in many areas of childhood obesity, perceived effectiveness was low. Moreover, comfort and confidence were lower for non-primary care providers (PCPs) involved in obesity treatment than for PCPs, and PCP comfort and confidence levels were low for the ability to conduct motivational interviewing and for knowledge of billing for obesity as a diagnosis. Personnel perceived that there were benefits to having a registered dietitian (RD) in their practice and generally understood RD capacity. Survey results provided no evidence that integration of an RD into the practice changed perceptions or knowledge over the course of 1 year. LIMITATIONS: The present study included only 13 practices, mostly rural and all of at least moderate size. CONCLUSION: Significant change is required if primary care practices are to play the role envisioned for them in stemming childhood obesity and chronic disease. Change will require identifying and addressing specific knowledge and skill gaps, such as those identified in this study. Respondents' positive perceptions of the benefits of RD integration suggest the importance of exploring this clinical model.

A pilot study of training family medicine residents in procedural skills at a community health center.

BACKGROUND AND OBJECTIVES: There are many challenges to providing procedural skills training as well as exposure to rural practice for family medicine residents, especially within the allowed hours of training. METHODS: A curriculum for self study was developed based on a Society of Teachers of Family Medicine consensus statement on procedural skills, resident interest and faculty experience. An agreement to offer a pilot procedural clinic at a community health center staffed by a family medicine faculty and resident was negotiated and delivered. Residents completed an evaluation of the experience. RESULTS: One faculty and 13 residents delivered 19 different procedures, with a total of 65 procedures, over an 11-month period at a community health center. Minor barriers to providing services such as initially low referral rates and lack of instruments were overcome. CONCLUSIONS: Residents agreed that participating in this clinic increased the likelihood of adding procedures to their clinical practice and enhanced their appreciation for practice in a rural setting but may not have impacted their likelihood of practicing in a rural area.