Food (in)security in relation to nutrition (in)security in a national cross-sectional sample of Supplemental Nutrition Assistance Program participants: considerations of an emerging construct.

BACKGROUND: Food insecurity, lack of access to sufficient food for an active, healthy life, is a persistent problem in the United States. Recently, nutrition security has emerged as a new concept. However, limited research exists examining how nutrition security relates to the established concept of food security. OBJECTIVES: This study assessed a recent metric of nutrition security and explored how well it describes the underlying construct among a sample of Supplemental Nutrition Assistance Program (SNAP) participants. We examined the correlation between food and nutrition security and demographic predictors of joint food and nutrition security status. METHODS: We conducted a national, web-based survey (Qualtrics; 30 September-19 October, 2022) in English and Spanish of adults aged ≥18 y (n = 1454) who reported receiving SNAP benefits in the past 12 mo. We measured food security using the US Department of Agriculture 6-item Food Security Survey and assessed nutrition security using the Gretchen Swanson Center for Nutrition Household Nutrition Security measure. We used multinominal logistic regression to examine demographic predictors of food and nutrition security. RESULTS: The majority (80.4%) of SNAP participants experienced food insecurity, and 59.1% reported experiencing nutrition insecurity. Food and nutrition security were moderately correlated (0.41); 55.6% of SNAP participants were both food and nutrition insecure, 3.5% were food secure but nutrition insecure, 24.8% were food insecure but nutrition secure, and 16.1% were both food and nutrition secure. Of SNAP participants, 24.8% reported experiencing food insecurity but not nutrition insecurity. Hispanic ethnicity and Southern residence were associated with joint food and nutrition insecurity. CONCLUSIONS: These findings raise questions about how nutrition security is conceptualized and measured and its added value beyond existing food security measurement scales. Further research is needed to understand differences in food and nutrition security experiences and risk factors and determine a validated definition and measure of nutrition security for future policy solutions.

The Quality of Menu Offerings in Independently Owned Restaurants in Baltimore, Maryland: Results from Mixed-Methods Formative Research for the FRESH Trial.

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers' acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore's IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.

Characterizing Food Policy Councils' Network Partnerships and COVID-19 Responses.

The COVID-19 pandemic pushed millions of Americans into food insecurity. Food policy councils (FPCs) across the country played a vital role in organizing coordinated food responses across multiple sectors. We used a social network analysis (SNA) approach to investigate: (1) the network of partnering organizations and agencies within FPCs; (2) how the characteristics of FPCs' network partnerships (i.e., degree, coreness, and density) related to programmatic, policy, and advocacy actions in response to the pandemic; and (3) how FPCs' use of a racial or social equity framework shifted their network partnerships and responses. Local government agencies and food supply chain actors were core in FPCs' network partnerships, while public utilities, correctional facilities, social justice groups, and others were non-core partners. Network density was more likely to be associated with any action by FPCs, and it was especially pronounced for advocacy actions taken by FPCs; trends were similar among FPCs that reported using a racial or social equity framework. The findings begin to uncover core actors in FPCs' partnerships and opportunities to establish new partnerships, particularly with social justice groups. The results also suggest that network density (interconnectedness) may be more important than other network characteristics when responding to food-related needs.

"We Want to Eat and be Healthy just like Everybody Else:" How Social Infrastructures Affect Nutrition Equity in a Racialized Urban Community in the United States.

Background: Food security and nutrition equity, 2 social determinants of health, are impacted by the coronavirus disease 2019 (COVID-19) pandemic and the racialization of urban communities. Few studies to date have examined how the use of social infrastructures in the United States during COVID-19 affected the ability to achieve food security and nutrition equity. Objectives: To describe how the use of social infrastructures impacts food security and nutrition equity in a majority Black and urban community in the United States. Methods: Semistructured in-depth interviews were conducted with 40 low-income, urban, and predominately Black people living in Buffalo, New York in May-July 2022.A thematic analysis using a phronetic iterative approach informed by the Social Ecological Model, Walsh's Family Resilience Framework, and a framework focused on the advancement of nutrition equity. Results: We identified 9 themes mapped across 3 interrelated domains that impact nutrition equity, including 1) meeting food needs with dignity, 2) supply and demand for fresh and healthy foods, and 3) community empowerment and food sovereignty. We found that people used coping strategies, such as food budgeting and cooking skills, paired with different social infrastructures to meet food needs. People commonly used the Supplemental Nutrition Assistance Program and food pantries to meet food needs over receiving support from family members or friends outside of the household. Poverty, challenges accessing and affording healthy food, and the inability to reciprocate support to others undermined the advancement of nutrition equity despite social infrastructures being available for use. Historical and ongoing acts of disempowerment and disinvestment also hindered the advancement of nutrition equity. Conclusions: Sustained, community-led investment is needed to address structural inequities preventing the advancement of nutrition equity. Social infrastructures should be expanded to inclusively support low-income populations, so wealth generation is possible to address the root cause of food insecurity.

Inclusive and intersectoral: community health improvement planning opportunities to advance the social determinants of health and health equity.

BACKGROUND: Community health improvement plans (CHIPs) are strategic planning tools that help local communities identify and address their public health needs. Many local health departments have developed a CHIP, yet there is a lack of research on the extent to which these plans address root causes of health disparities such as the social determinants of health. This study aims to inventory the social determinants of health included in 13 CHIPs and examine facilitators and challenges faced by local health departments and partners when trying to include the social determinants of health. METHODS: We conducted a comparative plan evaluation by scoring 13 CHIPs on their inclusion of equity orientation, inclusive planning processes, and five social determinants of health: health care access and quality, the neighborhood and built environment, economic stability, social and community context, and education access and quality. To supplement the plan evaluation, we conducted 32 in-depth interviews with CHIP leaders and stakeholders to understand the factors contributing to the inclusion and exclusion of the social determinants of health in the planning process. RESULTS: CHIPs received an average score of 49/100 for the inclusion of the social determinants of health. Most plans addressed health care access and quality and the neighborhood and built environment, but they often did not address economic stability, the social and community context, and education access and quality. Regarding their overall equity orientation, CHIPs received an average score of 35/100, reflecting a relative lack of attention to equity and inclusive planning processes in the plans. Interviews revealed that challenges engaging partners, making clear connections between CHIPs and social determinants, and a lack of capacity or public and partner support often led to the exclusion of the social determinants of health. Recommendations to improve planning processes include improving data infrastructure, providing resources for dedicated planning staff and community engagement incentives, and centering equity throughout the planning process. CONCLUSIONS: Although local health departments can leverage CHIPs to improve population health and address health disparities, they face a range of challenges to including the social determinants of health in CHIPs. Additional resourcing and improved data are needed to facilitate broader inclusion of these determinants, and more work is needed to elevate equity throughout these planning processes.

A Systems Approach to Identify Factors Influencing Participation in Two Tribally-Administered WIC Programs.

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.

Revisiting revitalization: exploring how structural determinants moderate pathways between neighborhood change and health.

Vacant housing can produce many issues that affect residents' quality of life, especially in historically segregated communities of color. To address these challenges, local governments invest in strategic, place-based revitalization initiatives focused on the regeneration of vacant housing. Yet, the outcomes of these efforts remain contested. To maximize health benefits of revitalization investments, a more nuanced understanding of pathways between neighborhood changes and residents' responses, adaptations, and ability to thrive is necessary, though, remains largely absent in the literature. Using the Vacants to Value initiative in Baltimore, MD as a case study, we explore (1) how health manifests among certain groups in the context of vacant housing revitalization; (2) how vacant housing and its regeneration engender social and cultural environmental change i.e., gentrification; and (3) what structural determinants (cultural norms, policies, institutions, and practices) contribute to the distribution of material resources and benefits of revitalization. Results suggest that vacant housing revitalization requires more than just physical remedies to maximize health. Our findings demonstrate how vacant housing revitalization influences the physical environment, social environment, and structural determinants of material resources and community engagement that can ultimately impact residents' physical, mental, and social health. This study recommends that because housing disparities are rooted in structural inequalities, how policies, practices, and processes moderate pathways for residents to adapt and benefit from neighborhood changes is consequential for health and health equity. Establishing shared governance structures is a promising approach to foster equitable decision-making and outcomes. Going forward in urban regeneration, pathways to retain and strengthen the social environment while revitalizing the physical environment may be promising to achieve healthy communities.

Applications of Complex Systems Models to Improve Retail Food Environments for Population Health: A Scoping Review.

Retail food environments (RFEs) are complex systems with important implications for population health. Studying the complexity within RFEs comes with challenges. Complex systems models are computational tools that can help. We performed a systematic scoping review of studies that used complex systems models to study RFEs for population health. We examined the purpose for using the model, RFE features represented, extent to which the complex systems approach was maximized, and quality and transparency of methods employed. The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines were followed. Studies using agent-based modeling, system dynamics, discrete event simulations, networks, hybrid, or microsimulation models were identified from 7 multidisciplinary databases. Fifty-six studies met the inclusion criteria, including 23 microsimulation, 13 agent-based, 10 hybrid, 4 system dynamics, 4 network, and 2 discrete event simulation models. Most studies (n = 45) used models for experimental purposes and evaluated effects of simulated RFE policies and interventions. RFE characteristics simulated in models were diverse, and included the features (e.g., prices) customers encounter when shopping (n = 55), the settings (e.g., restaurants, supermarkets) where customers purchase food and beverages (n = 30), and the actors (e.g., store managers, suppliers) who make decisions that influence RFEs (n = 25). All models incorporated characteristics of complexity (e.g., feedbacks, conceptual representation of multiple levels), but these were captured to varying degrees across model types. The quality of methods was adequate overall; however, few studies engaged stakeholders (n = 10) or provided sufficient transparency to verify the model (n = 12). Complex systems models are increasingly utilized to study RFEs and their contributions to public health. Opportunities to advance the use of these approaches remain, and areas to improve future research are discussed. This comprehensive review provides the first marker of the utility of leveraging these approaches to address RFEs for population health.

Acquisition, mobility and food insecurity: integrated food systems opportunities across urbanicity levels highlighted by COVID-19.

OBJECTIVE: To investigate acquisition and mobility experiences of food-insecure individuals across urbanicity levels (i.e., urban, suburban, rural) in the early months of the COVID-19 pandemic. DESIGN: Cross-sectional study using a nationally representative online panel to measure where food-insecure individuals acquired food, food acquisition barriers and mobility to food sources, which were evaluated across urbanicity levels using chi-squared tests and 95 % CI. SETTING: USA. PARTICIPANTS: 2011 adults (18 years or older). RESULTS: Food insecurity impacted 62·3 % of adults in urban areas, 40·5 % in rural areas and 36·7 % in suburban areas (P < 0·001). Food acquisition barriers that were significantly more prevalent among food-insecure adults in urban areas were a change in employment status (34·2 %; 95 % CI 27·2 %, 41·1 %; P < 0·0001) and limited availability of food in retailers (38·8 %; 95 % CI 31·7 %, 45·9 %; P < 0·001). In rural areas, food-insecure adults primarily acquired food for the household from supercentres (61·5 %; 95 % CI 50·4 %, 72·5 %; P < 0·05), while locally sourced foods were less common among food-insecure adults in rural areas (6·9 %; 95 % CI 0·01 %, 13·0 %) compared to urban areas (19·8 %; 95 % CI 14·3 %, 25·4 %; P < 0·01). Transportation as a barrier did not vary significantly by urbanicity, but food-insecure adults across urbanicity levels reported utilising a range of transportation modes to acquire food. CONCLUSIONS: A planning approach that links urban and rural areas could address food insecurity by enhancing the integration of food production, transportation and food distribution, building towards a more resilient and equitable food system for all Americans.

Mobility Patterns Before, During, and Anticipated After the COVID-19 Pandemic: An Opportunity to Nurture Bicycling.

INTRODUCTION: The purpose of this study is to quantify the immediate and anticipated effect of the COVID-19 pandemic on local travel in the U.S. METHODS: A national survey of a representative sample of U.S. adults was conducted using The Harris Poll panel. The online survey was conducted from June 17 to 29, 2020. Respondents reported the frequency of travel before the pandemic, during the pandemic, and anticipated travel when normal activities resume for walking, bicycling, personal vehicle use, and public transit. Analyses were conducted in July and August 2020. RESULTS: During the pandemic, local travel significantly decreased (-10.36%, 95% CI= -16.26, -4.02) relative to prepandemic levels. Within travel modes, significant decreases were reported for public transit, personal vehicle use, and walking. There was no change in reported bicycle use during the pandemic period relative to prepandemic levels. When normal activities resume, respondents anticipated a significant increase in bicycling (24.54%, 95% CI=3.24, 50.24). Anticipated travel using personal vehicles, public transit, and walking were not significantly different from the prepandemic levels. CONCLUSIONS: Unlike the other local travel modes, bicycling did not decrease during the pandemic and is anticipated to significantly increase. Investment in bicycle-safe infrastructure could sustain the anticipated increase in bicycling.

International trade and the neoliberal diet in Central America and the Dominican Republic: Bringing social inequality to the center of analysis.

Scholarship on international trade and health analyzes the effects of trade and investment policies on population exposure to non-nutritious foods. These policies are linked to the nutrition transition, or the dietary shift towards meat and processed foods associated with rising overweight and obesity rates in low- and middle-income countries. We argue for expanding the trade and health literature's focus on population exposure through the concept of the neoliberal diet, which centers subnational social inequality as both an outcome of neoliberal agri-food trade policies and a determinant of dietary change. We develop this perspective through a regional analysis of non-nutritious food availability following the implementation of the Dominican Republic-Central America Free Trade Agreement (CAFTA-DR), together with an extended case study, from the late 1990s to the present, of household expenditure and food price changes in the Dominican Republic, the region's largest food importer. Our analysis demonstrates that low-income consumers face increasing household food expenditures in a context of overall food price inflation, in addition to relatively higher price increases for healthy versus ultraprocessed foods. Neoliberal policies not only contribute to restructuring the availability and pricing of healthy food for low-income consumers, but they also exacerbate social inequality in the food system through corporate-controlled supply chains and farmer displacement. Our findings support policy proposals for socially distributive forms of healthy food production to stem the negative effects of the nutrition transition.

A community-based system dynamics approach suggests solutions for improving healthy food access in a low-income urban environment.

Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community-based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime.

Process Evaluation and Lessons Learned From Engaging Local Policymakers in the B'More Healthy Communities for Kids Trial.

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Simulation modeling to assist with childhood obesity control: perceptions of Baltimore City policymakers.

Computational simulation models have potential to inform childhood obesity prevention efforts. To guide their future use in obesity prevention policies and programs, we assessed Baltimore City policymakers' perceptions of computational simulation models. Our research team conducted 15 in-depth interviews with stakeholders (policymakers in government and non-profit sectors), then transcribed and coded them for analysis. We learned that informants had limited understanding of computational simulation modeling. Although they did not understand how the model was developed, they perceived the tool to be useful when applying for grants, adding to the evidence base for decision-making, piloting programs and policies, and visualizing data. Their concerns included quality and relevance of data used to support the model. Key recommendations for model design included a visual display with explanations to facilitate understanding and a formal method for gathering feedback during model development.

Identifying Financially Sustainable Pricing Interventions to Promote Healthier Beverage Purchases in Small Neighborhood Stores.

INTRODUCTION: Residents of low-income communities often purchase sugar-sweetened beverages (SSBs) at small, neighborhood "corner" stores. Lowering water prices and increasing SSB prices are potentially complementary public health strategies to promote more healthful beverage purchasing patterns in these stores. Sustainability, however, depends on financial feasibility. Because in-store pricing experiments are complex and require retailers to take business risks, we used a simulation approach to identify profitable pricing combinations for corner stores. METHODS: The analytic approach was based on inventory models, which are suitable for modeling business operations. We used discrete-event simulation to build inventory models that use data representing beverage inventory, wholesale costs, changes in retail prices, and consumer demand for 2 corner stores in Baltimore, Maryland. Model outputs yielded ranges for water and SSB prices that increased water demand without loss of profit from combined water and SSB sales. RESULTS: A 20% SSB price increase allowed lowering water prices by up to 20% while maintaining profit and increased water demand by 9% and 14%, for stores selling SSBs in 12-oz cans and 16- to 20-oz bottles, respectively. Without changing water prices, profits could increase by 4% and 6%, respectively. Sensitivity analysis showed that stores with a higher volume of SSB sales could reduce water prices the most without loss of profit. CONCLUSION: Various combinations of SSB and water prices could encourage water consumption while maintaining or increasing store owners' profits. This model is a first step in designing and implementing profitable pricing strategies in collaboration with store owners.

Simulating the Impact of Sugar-Sweetened Beverage Warning Labels in Three Cities.

INTRODUCTION: A number of locations have been considering sugar-sweetened beverage point-of-purchase warning label policies to help address rising adolescent overweight and obesity prevalence. METHODS: To explore the impact of such policies, in 2016 detailed agent-based models of Baltimore, Philadelphia, and San Francisco were developed, representing their populations, school locations, and food sources, using data from various sources collected between 2005 and 2014. The model simulated, over a 7-year period, the mean change in BMI and obesity prevalence in each of the cities from sugar-sweetened beverage warning label policies. RESULTS: Data analysis conducted between 2016 and 2017 found that implementing sugar-sweetened beverage warning labels at all sugar-sweetened beverage retailers lowered obesity prevalence among adolescents in all three cities. Point-of-purchase labels with 8% efficacy (i.e., labels reducing probability of sugar-sweetened beverage consumption by 8%) resulted in the following percentage changes in obesity prevalence: Baltimore: -1.69% (95% CI= -2.75%, -0.97%, p<0.001); San Francisco: -4.08% (95% CI= -5.96%, -2.2%, p<0.001); Philadelphia: -2.17% (95% CI= -3.07%, -1.42%, p<0.001). CONCLUSIONS: Agent-based simulations showed how warning labels may decrease overweight and obesity prevalence in a variety of circumstances with label efficacy and literacy rate identified as potential drivers. Implementing a warning label policy may lead to a reduction in obesity prevalence. Focusing on warning label design and store compliance, especially at supermarkets, may further increase the health impact.

Relationships between Vacant Homes and Food Swamps: A Longitudinal Study of an Urban Food Environment.

Research indicates that living in neighborhoods with high concentrations of boarded-up vacant homes is associated with premature mortality due to cancer and diabetes, but the mechanism for this relationship is unclear. Boarded-up housing may indirectly impact residents' health by affecting their food environment. We evaluated the association between changes in vacancy rates and changes in the density of unhealthy food outlets as a proportion of all food outlets, termed the food swamp index, in Baltimore, MD (USA) from 2001 to 2012, using neighborhood fixed-effects linear regression models. Over the study period, the average food swamp index increased from 93.5 to 95.3 percentage points across all neighborhoods. Among non-African American neighborhoods, increases in the vacancy rate were associated with statistically significant decreases in the food swamp index (b = -0.38; 90% CI, -0.64 to -0.12; p-value: 0.015), after accounting for changes in neighborhood SES, racial diversity, and population size. A positive association was found among low-SES neighborhoods (b = 0.15; 90% CI, 0.037 to 0.27; p-value: 0.031). Vacant homes may influence the composition of food outlets in urban neighborhoods. Future research should further elucidate the mechanisms by which more distal, contextual factors, such as boarded-up vacant homes, may affect food choices and diet-related health outcomes.

Longitudinal Associations between Change in Neighborhood Social Disorder and Change in Food Swamps in an Urban Setting.

Few studies have examined how neighborhood contextual features may influence the food outlet mix. We evaluated the relationship between changes in neighborhood crime and changes in the food environment, namely the relative density of unhealthy (or intermediate) food outlets out of total food outlets, or food swamp score, in Baltimore City from 2000 to 2012, using neighborhood fixed-effects linear regression models. Comparing neighborhoods to themselves over time, each unit increase in crime rate was associated with an increase in the food swamp score (b = 0.13; 95% CI, -0.00017 to 0.25). The association with food swamp score was in the same direction for violent crime and in the inverse direction for arrests related to juvenile crimes (proxy of reduced crime), but did not reach statistical significance when examined separately. Unfavorable conditions, such as crime, may deter a critical consumer base, diminishing the capacity of a community to attract businesses that are perceived to be neighborhood enhancing. Addressing these more distal drivers may be important for policies and programs to improve these food environments.

A systems approach to obesity.

Obesity has become a truly global epidemic, affecting all age groups, all populations, and countries of all income levels. To date, existing policies and interventions have not reversed these trends, suggesting that innovative approaches are needed to transform obesity prevention and control. There are a number of indications that the obesity epidemic is a systems problem, as opposed to a simple problem with a linear cause-and-effect relationship. What may be needed to successfully address obesity is an approach that considers the entire system when making any important decision, observation, or change. A systems approach to obesity prevention and control has many benefits, including the potential to further understand indirect effects or to test policies virtually before implementing them in the real world. Discussed here are 5 key efforts to implement a systems approach for obesity prevention: 1) utilize more global approaches; 2) bring new experts from disciplines that do not traditionally work with obesity to share experiences and ideas with obesity experts; 3) utilize systems methods, such as systems mapping and modeling; 4) modify and combine traditional approaches to achieve a stronger systems orientation; and 5) bridge existing gaps between research, education, policy, and action. This article also provides an example of how a systems approach has been used to convene a multidisciplinary team and conduct systems mapping and modeling as part of an obesity prevention program in Baltimore, Maryland.

Factors associated with physical inactivity and sedentary behavior among women living in the urban area of Santos City, Brazil / Fatores Associados à Inatividade Física e Sedentarismo de Mulheres Moradoras da Zona Urbana do Município de Santos, Brasil

We aimed to assess the association between individual, socioeconomic, and environmental variables and sedentary behavior and physical inactivity (PI) among urban Brazilian women of varying economic status in Santos. Through a cross-sectional design in a home-based study, we interviewed 538 women with children under 10 years. We assessed PI through two different indices: the International Physical Activity Questionnaire (IPAQ) and the physical activity time/week as recommended by the World Health Organization (WHO). Sedentary behavior was assessed by sitting-time (>360min/week). Using adjusted logistic regression, walking and driving remained significantly correlated to IPAQ's score (OR 0.24 95% CI 0.11; 0.50; OR 1.87 95% IC 1.25; 2.81) and to WHO's guideline (OR 0.20 95% CI 0.08; 0.48; OR 1.77 95% CI 1.16; 2.70). Sedentary behavior was associated with having housekeeper in the household (OR 2.14 95% IC 1.31; 3.50) and perceiving as a barrier for physical activity not having money (OR 0.29 95% CI 0.12; 0.65). Physical inactivity and sedentary behavior were associated with individual, psychosocial and environmental perceptions factors among women with children. Therefore, environmental and policy interventions with multilevel approach may be considered in urban areas to promote health and to prevent obesity among maternal-infant group.

Este estudo teve como objetivo investigar os fatores associados à inatividade atividade e comportamento sedentário em relação às variáveis individuais, socioeconômicas e ambientais de mulheres residentes em uma zona urbana de diferentes níveis socioeconômicos. Estudo transversal, com coleta dados através de entrevistas domiciliares em 538 mulheres com filhos de até 10 anos. Inatividade física foi avaliada por três diferentes indicadores: classificações do Questionário Internacional de Atividade Física (IPAQ), tempo por semana de atividade física recomendado pela Organização Mundial da Saúde (OMS) (mínimo150 minutos/semana) e o tempo gasto sentado em um dia de semana maior que 360 minutos/semana como indicador de comportamento sedentário. Modelos de regressão logística foram ajustados a fim de encontrar os fatores associados a cada indicador. Caminhada como uma atividade de lazer e usar carro como meio de transporte permaneceram associados ao escore de inatividade física do IPAQ (OR 0,24 95% IC 0,11; 0,50; OR 1,87 95% IC 1,25; 2,81) e das recomendações da OMS (OR 0,20 95% IC 0,08; 0,48; OR 1,77 95% IC 1,16; 2,70). O comportamento sedentário foi associado à presença de empregada doméstica na residência (OR 2.14 IC 95% 1.31; 3.50) e perceber como barreira para a atividade física não ter dinheiro (OR 0.29 IC 95% 0.12; 0.65). A inatividade física das mulheres investigadas esteve associada a fatores individuais, psicossociais e de percepção do ambiente. Assim, o delineamento de intervenções, programas e políticas públicas em áreas urbanas deve considerar a interação de todos os fatores numa abordagem compreensiva e sistêmica para a promoção da saúde e prevenção da obesidade no grupo materno infantil.