A community-driven approach to identifying "winnable" policies using the Centers for Disease Control and Prevention's Common Community Measures for Obesity Prevention.

Federally funded, community-based participatory research initiatives encourage the development and implementation of obesity prevention policies. In 2009, the Centers for Disease Control and Prevention (CDC) published the Common Community Measures for Obesity Prevention (COCOMO), which include recommended strategies and measures to guide communities in identifying and evaluating environmental and policy strategies to prevent obesity. Agreeing on "winnable" policy issues can be challenging for community members. We used CDC's COCOMO to structure in-depth interviews and group discussions with local stakeholders (ie, planners, town managers, and a local community advisory council) to stimulate interest in and identify health-promoting policies for local policy and planning agendas. We first asked stakeholders to rank the COCOMO recommendations according to feasibility and likelihood of success given community culture, infrastructure, extent of leadership support, and likely funding support. Rankings were used to identify the most and least "winnable" COCOMO policy strategies. We then used questions from the evidence-based Community Readiness Handbook to aid discussion with stakeholders on the facilitators and barriers to enacting the most and least winnable policy options identified. Finally, we discuss potential adaptations to COCOMO for rural jurisdictions.

Promoting use of nutrition and physical activity community resources among women in a family planning clinic setting.

Research increasingly supports promotion of nutrition and physical activity community resources to support individual-level health promotion interventions. However, even when such resources exist, they are often not well used. In this article, the authors describe the results of formative research regarding patient and health promotion professionals' perspectives on methods to encourage use of community resources among patients accessing family planning services at a local health department in eastern North Carolina. In March through May of 2010, the authors conducted qualitative in-depth interviews with 30 female patients, aged 18-44 years, and five local key informants. Interviews were transcribed verbatim, imported into Atlas Ti for data management, and independently double-coded. Free, easily accessible, and family-friendly resources were most appealing to participants. Key informants offered creative ideas for promoting the use of resources, such as parks and farmers' markets, and included integration of such resources into health care provider prescriptions and taking group trips to resources. Results of this study can guide similar programs attempting to promote the use of resources among hard-to-reach groups.

Examination of facilitators and barriers to home-based supplemental feeding with ready-to-use food for underweight children in western Uganda.

Poor complementary feeding practices and low-quality complementary foods are significant causes of growth faltering and child mortality throughout the developing world. Ready-to-use foods (RUF) are energy-dense, lipid-based products that do not require cooking or refrigeration that have been used to prevent and treat malnutrition among vulnerable children. The effectiveness of these products in improving child nutritional status depends on household use by caregivers. To identify the key facilitators and barriers that influence appropriate in-home RUF consumption by supplemental feeding program beneficiaries, we conducted individual interviews among caregivers (n = 80), RUF producers (n = 8) and program staff (n = 10) involved in the Byokulia Bisemeye mu Bantu supplemental feeding program in Bundibugyo, Uganda. By documenting caregiver perceptions and feeding practices related to RUF, we developed a conceptual framework of factors that affect appropriate feeding with RUF. Findings suggest that locally produced RUF is well received by caregivers and children, and is perceived by caregivers and the community to be a healthy supplemental food for malnourished children. However, child feeding practices, including sharing of RUF within households, compromise the nutrient delivery to the intended child. Interventions and educational messages informed by this study can help to improve RUF delivery to targeted beneficiaries.

Associations between maternal employment and time spent in nutrition-related behaviours among German children and mothers.

OBJECTIVE: To examine associations between maternal employment and time spent engaging in nutrition-related behaviours among mothers and children using a nationally representative sample of households in West and East Germany. DESIGN: A cross-sectional analysis was performed using time-use data for a sample of mother-child dyads. Associations between maternal employment and time spent in nutrition-related activities such as eating at home, eating away from home and food preparation were estimated using a double-hurdle model. SETTING: German Time Budget Survey 2001/02. SUBJECTS: The overall sample included 1071 households with a child between 10 and 17 years of age. The time-use data were collected for a 3 d period of observation (two weekdays and one weekend day). RESULTS: Maternal employment was associated with the time children spent on nutrition-related behaviours. In households with employed mothers, children spent more time eating alone at home and less time eating meals with their mothers. Moreover, employed mothers spent less time on meal preparation compared with non-employed mothers. There were regional differences in time spent on nutrition-related behaviours, such that East German children were more likely to eat at home alone than West German children. CONCLUSIONS: Maternal employment was associated with less time spent eating with children and preparing food, which may be related to the increasing childhood obesity rates in Germany. Future national surveys that collect both time-use data and health outcomes could yield further insight into mechanisms by which maternal time use might be associated with health outcomes among children.

Conducting community audits to evaluate community resources for healthful lifestyle behaviors: an illustration from rural eastern North Carolina.

A community audit is a qualitative and quantitative research technique in which researchers drive through a community to observe its physical and social attributes, primarily through windshield tours and "ground truthing." Ground truthing is a verification process that uses data gathered by direct observation to corroborate data gathered from secondary sources. Community audits have been used for epidemiologic studies and in program planning for health-promotion interventions. Few studies have detailed the methodology for conducting community audits in rural areas or the extent to which community audits can contribute to an accurate assessment of community characteristics (eg, presence of sidewalks) and nutrition and physical activity resources (eg, produce stands, parks) that may promote healthful lifestyle behaviors. The objective of this article is to describe our approach to conducting a community audit (consisting of windshield tours and ground truthing) to enumerate resources, to assess community characteristics, and to inform revisions to a community guide on nutrition and physical activity resources. We conducted an audit in 10 communities in a rural eastern North Carolina county in 2010. We also collected data from secondary sources to make comparisons with community audit data. The initial resource guide included 42 resources; the community audits identified 38 additional resources. There was moderate to high agreement between windshield tour observations and secondary data sources for several community characteristics, such as number of fast-food restaurants (67% agreement) and existence of sidewalks (100% agreement). Community audits improved the description of health-promoting community resources and the context in which people make lifestyle choices.

Associations between food insecurity, supplemental nutrition assistance program (SNAP) benefits, and body mass index among adult females.

Obesity disproportionately affects low-income and minority individuals and has been linked with food insecurity, particularly among women. More research is needed to examine potential mechanisms linking obesity and food insecurity. Therefore, this study's purpose was to examine cross-sectional associations between food insecurity, Supplemental Nutrition Assistance Program (SNAP) benefits per household member, perceived stress, and body mass index (BMI) among female SNAP participants in eastern North Carolina (n=202). Women were recruited from the Pitt County Department of Social Services between October 2009 and April 2010. Household food insecurity was measured using the validated US Department of Agriculture 18-item food security survey module. Perceived stress was measured using the 14-item Cohen's Perceived Stress Scale. SNAP benefits and number of children in the household were self-reported and used to calculate benefits per household member. BMI was calculated from measured height and weight (as kg/m(2)). Multivariate linear regression was used to examine associations between BMI, SNAP benefits, stress, and food insecurity while adjusting for age and physical activity. In adjusted linear regression analyses, perceived stress was positively related to food insecurity (P<0.0001), even when SNAP benefits were included in the model. BMI was positively associated with food insecurity (P=0.04). Mean BMI was significantly greater among women receiving <$150 in SNAP benefits per household member vs those receiving ≥$150 in benefits per household member (35.8 vs 33.1; P=0.04). Results suggest that provision of adequate SNAP benefits per household member might partially ameliorate the negative effects of food insecurity on BMI.

Associations between natural amenities, physical activity, and body mass index in 100 North Carolina counties.

PURPOSE: To examine associations between county-level natural amenities, physical activity (PA), and body mass index (BMI). DESIGN AND SETTING: Cross-sectional study among 100 North Carolina counties. MEASURES: We obtained percentage of county residents meeting PA criteria and county-wide means for reported height and weight from the North Carolina Behavioral Risk Factor Surveillance System, combining years 2003, 2005, and 2007. The county natural amenities scale was the independent variable. Potential county-level covariates were percentage rural, percentage black, median age, and median household income (Census 2000). ANALYSIS: We conducted weighted bivariate and linear regression analyses to examine relationships between natural amenities, aggregate PA, and aggregate BMI. RESULTS: BMI and natural amenities were negatively associated (parameter estimate  =  -.13 (.06), p  =  .03). When percentage meeting PA criteria was included, the parameter estimate attenuated 15%. CONCLUSION: There was an inverse relationship between natural amenities and BMI, partially mediated by PA.

Association between travel times and food procurement practices among female supplemental nutrition assistance program participants in eastern North Carolina.

OBJECTIVE: To examine associations between self-reported vehicular travel behaviors, perceived stress, food procurement practices, and body mass index among female Supplemental Nutrition Assistance Program (SNAP) participants. ANALYSIS: The authors used correlation and regression analyses to examine cross-sectional associations between travel time and distance, perceived stress, food procurement practices (grocery shopping frequency, fast-food consumption, home meal consumption), and body mass index among female SNAP participants aged 20-65 years (n = 215) in eastern North Carolina. RESULTS: There were positive associations (P < .05) between travel patterns and stress (r = 0.18 for average miles traveled), grocery shopping frequency (r = 0.16 for average miles traveled), and fast-food consumption (r = 0.19 for average miles traveled, r = 0.29 for average minutes traveled). CONCLUSIONS AND IMPLICATIONS: SNAP education materials should focus on healthful interactions with the food environment, even when participants must travel long distances.

The association between the food environment and weight status among eastern North Carolina youth.

OBJECTIVE: To examine associations between various measures of the food environment and BMI percentile among youth. DESIGN: Cross-sectional, observational. SETTING: Pitt County, eastern North Carolina. SUBJECTS: We extracted the electronic medical records for youth receiving well child check-ups from January 2007 to June 2008. We obtained addresses for food venues from two secondary sources and ground-truthing. A geographic information systems database was constructed by geocoding home addresses of 744 youth and food venues. We quantified participants' accessibility to food venues by calculating 'coverage', number of food venues in buffers of 0·25, 0·5, 1 and 5 miles (0·4, 0·8, 1·6 and 8·0 km) and by calculating 'proximity' or distance to the closest food venue. We examined associations between BMI percentile and food venue accessibility using correlation and regression analyses. RESULTS: There were negative associations between BMI percentile and coverage of farmers' markets/produce markets in 0·25 and 0·5 mile Euclidean and 0·25, 0·5 and 1 mile road network buffers. There were positive associations between BMI percentile and coverage of fast-food and pizza places in the 0·25 mile Euclidean and network buffers. In multivariate analyses adjusted for race, insurance status and rural/urban residence, proximity (network distance) to convenience stores was negatively associated with BMI percentile and proximity to farmers' markets was positively associated with BMI percentile. CONCLUSIONS: Accessibility to various types of food venues is associated with BMI percentile in eastern North Carolina youth. Future longitudinal work should examine correlations between accessibility to and use of traditional and non-traditional food venues.

Food stamp participation is associated with fewer meals away from home, yet higher body mass index and waist circumference in a nationally representative sample.

OBJECTIVE: To examine associations between Food Stamp (FS) participation, meals away from home (MAFH), body mass index (BMI), and waist circumference (WC). DESIGN: Cross-sectional study. SETTING: Nationally representative. PARTICIPANTS: Data from low-income, FS-eligible individuals (N = 945) ages 20-65 years, responding to the 2005-2006 National Health and Nutrition Examination Survey. MAIN OUTCOME MEASURE(S): MAFH per week, BMI, and WC. ANALYSIS: Multiple linear regression models were used to examine associations between FS participation and MAFH, BMI, and WC, adjusting for age, sex, race, and education level. RESULTS: Food Stamp authorization was associated with fewer MAFH (P = .004). Among females, FS authorization was associated with higher BMI (P = .04) and WC (P = .04). Among females reporting amount of benefits in the prior month, more FS benefits received were associated with lower BMI (P = .03) and WC (P < .001). CONCLUSIONS AND IMPLICATIONS: Seemingly contradictory results regarding associations between FS authorization and FS benefits received in the previous month and BMI and WC should be explored further. Effective nutrition education and environmental change strategies are needed, particularly among female FS recipients.

Examining associations among obesity and per capita farmers' markets, grocery stores/supermarkets, and supercenters in US counties.

Fruit and vegetable consumption is an important component of a healthful diet, yet fruits and vegetables are underconsumed, especially among low-income groups with high prevalence rates of obesity. This study used data from the US Department of Agriculture Economic Research Service Food Environment Atlas to examine county-level associations among obesity prevalence and per capita farmers' markets, grocery stores/supermarkets, and supercenters, adjusted for natural amenities, percent black, percent Hispanic, median age, and median household income, stratified by county metropolitan status. In models that included all three of the food venues, supercenters and grocery stores per capita were inversely associated with obesity in the combined (metro and nonmetro) and metro counties. Farmers' markets were not significant in the model for combined (metro and nonmetro) or for metro counties alone, but were significantly inversely related to obesity rates in the model for nonmetro counties. In this ecologic study, density of food venues was inversely associated with county-level obesity prevalence. Thus, future research should examine similar associations at the individual-level.

Commute times, food retail gaps, and body mass index in North Carolina counties.

INTRODUCTION: The prevalence of obesity is higher in rural than in urban areas of the United States, for reasons that are not well understood. We examined correlations between percentage of rural residents, commute times, food retail gap per capita, and body mass index (BMI) among North Carolina residents. METHODS: We used 2000 census data to determine each county's percentage of rural residents and 1990 and 2000 census data to obtain mean county-level commute times. We obtained county-level food retail gap per capita, defined as the difference between county-level food demand and county-level food sales in 2008, from the North Carolina Department of Commerce, and BMI data from the 2007 North Carolina Behavioral Risk Factor Surveillance System. To examine county-level associations between BMI and percentage of rural residents, commute times, and food retail gap per capita, we used Pearson correlation coefficients. To examine cross-sectional associations between individual-level BMI (n = 9,375) and county-level commute times and food retail gap per capita, we used multilevel regression models. RESULTS: The percentage of rural residents was positively correlated with commute times, food retail gaps, and county-level BMI. Individual-level BMI was positively associated with county-level commute times and food retail gaps. CONCLUSION: Longer commute times and greater retail gaps may contribute to the rural obesity disparity. Future research should examine these relationships longitudinally and should test community-level obesity prevention strategies.

Measuring the retail food environment in rural and urban North Carolina counties.

BACKGROUND: Development of accurate and sensitive methods to characterize the food environment is needed. Thus, we examined convergent and criterion validity of 2 retail food environment data sources and then examined differences in predictive validity between 3 ways of measuring the rural and urban food environment. METHODS: Ten counties were selected in each of 3 North Carolina regions (n = 30). Number of fast-food restaurants and chain supermarkets were calculated using 2 data sources. Convergent validity was percent agreement between the 2 sources. Criterion validity was percent agreement between each source and the most accurate venue count. Predictive validity of food environment measures (Retail Food Environment Index, fast-food restaurants/capita, and supermarkets/capita) was calculated by associations with county-level mean-weighted body mass index (BMI). RESULTS: Percent agreement for fast-food restaurants ranged from 50% to 100% (mean = 87%) and for supermarkets ranged from 58% to 100% (mean = 89%). The 2 data sources had similar percent agreement with the most accurate count. Retail Food Environment Index was positively associated with BMI, while fast-food restaurants per capita were negatively associated with BMI. CONCLUSIONS: Our results lend support to studies using both food environment data sources examined.

Rationale and development of the Move More North Carolina: Recommended Standards for After-School Physical Activity.

The purpose of this article is to describe the rationale and procedure employed in developing the Move More North Carolina: Recommended Standards for After-School Physical Activity, which was publicly released statewide in April 2009. The Standards outline evidenced-based best practices for after-school programs to implement in order to increase amount and quality of physical activity (PA) among program participants. The Standards can be applied in any after-school program and were developed to benefit the approximately 152,000 school-aged children who are served by NC after-school programs each year. These programs often serve children at high risk for physical inactivity, including children from racial/ethnic minorities, impoverished areas, with disabilities, and/or living in neighborhoods with limited PA opportunities. The rationale for developing standards for PA in after-school programs is threefold: (1) such programs can provide enjoyable, safe, and age-appropriate PA; (2) they can facilitate family involvement, community partnership, and increase access to PA resources; and (3) they serve children at risk for inactivity. Recommended best practices are included for the following categories: time/intensity, qualified staff/training, curriculum, program size, facilities, equipment, and evaluation. Methods used to inform The Standards included a planning team, on-line surveys, focus groups, a systematic literature review, a consensus panel, and external expert review. The impact of The Standards is yet to be seen, but the collaborative process used in their creation can serve as a model for the development of similar PA standards in other states.

A qualitative examination of perceived barriers and facilitators of physical activity for urban and rural youth.

Many adolescents, both rural and urban, are not meeting the recommended levels for physical activity (PA). This investigation was designed to elicit socioecologic barriers and facilitators for PA in rural and urban middle school youth and their parents. Thirteen focus groups were conducted with 41 youth and 50 parents from eastern North Carolina. Distance, cost, crime/danger and television were mentioned as the primary barriers among parents. Youth mentioned school policies related to PA and crime/danger as the main PA barriers. The most salient facilitators discussed by parents were social/peer facilitators, facilities available and parental role modeling of PA. The primary facilitators mentioned by youth were social outlets and facilities available. Results indicate that intrapersonal, interpersonal, environmental and policy factors related to PA resonated with both youth and parents. Since rural and urban residents often perceive and interact differently with PA environments, more research is needed to properly adapt interventions.

Qualitative perspectives on the use of traditional and nontraditional food venues among middle- and low-income women in Eastern North Carolina.

The purpose of this qualitative study was to examine motivations for use of food venues among 23 urban and rural women from eastern North Carolina. Women were eligible if they cared for children, were non-Hispanic black or white, and were English speakers. Interviews elicited participants' decisions for food venue use. Reasons for use of supermarkets were low cost, convenient location, quality/availability of specific foods, and customer service. Main reasons for use of supercenters were bulk foods at low prices and one-stop shopping. Rural and urban nonworking women shopped more frequently at discount superstores compared to urban working women.

Iterative design, implementation and evaluation of a supplemental feeding program for underweight children ages 6-59 months in Western Uganda.

OBJECTIVE: In this paper we describe the development, implementation, evaluation, and subsequent improvements of a supplemental feeding program that provides community-based care to underweight children in a rural East African setting, using a locally-sourced and produced ready-to-use food (RUF). METHODS: Production teams were trained to grind soybeans and groundnuts (peanuts), which were then mixed with moringa oleifera leaf powder to form an energy-dense supplemental food, designed for use as an RUF. Eligible children (based on low weight-for-age or mid-upper-arm circumference < 12 cm) received RUF of approximately 682 kcal per day for five weeks. Weekly growth monitoring and caregiver education were provided by trained health center staff and community volunteers. The program was evaluated by examining RUF nutrient composition, weight gain velocity, and qualitative data from key-informant interviews and home feeding observations. RESULTS: Locally-produced RUF had similar energy density but higher protein content than commercial RUTF (ready-to-use therapeutic food). Mean weight gain of children was 2.5 g/kg/day (range 0.9-6.0). Feeding observations revealed that caregivers were diluting the RUF fed to children. Production team members desired increased financial compensation for their work but were enthusiastic about the program as helpful to malnourished children. CONCLUSIONS: Locally-produced RUF is a promising strategy for community-based care of moderately malnourished children. Through the production team's entrepreneurship, a small business was formed, whereby financial incentives encouraged continued RUF production. Future efforts are needed to educate caregivers on correct RUF use and improve commercial viability in local markets.

Perceptions of the community food environment and related influences on food choice among midlife women residing in rural and urban areas: a qualitative analysis.

INTRODUCTION: Qualitative research on food choice has rarely focused on individuals' perceptions of the community food environment. Women remain gatekeepers of the family diet and food purchasing. Therefore we assessed midlife, Southern women's perceptions of the food environment. Related influences on food choices at work and at home were also examined. METHODS: We recruited 28 low- and moderate-income, midlife (37-67 years) women from rural and urban areas of southeastern North Carolina, using typical case and snowball sampling. They responded to questions about multilevel influences on food choice in semi-structured, in-depth interviews. RESULTS: Women perceived differences between urban and rural food environments, with rural areas having fewer supermarkets and fast food restaurants compared to urban areas, which had fewer produce stands. Workplace food choices were affected by the social environment (co-workers), personal health concerns, and the surrounding food environment. Food chosen at home was primarily influenced by family members, health concerns, and convenient food sources. DISCUSSION: While future studies should explore findings in more representative populations, potential intervention strategies can be inferred, including emphasizing healthful aspects of the food environment. Intervention and advocacy efforts are needed to improve aspects of the food environment that make healthy choices difficult.

Randomized trial of a clinic-based, community-supported, lifestyle intervention to improve physical activity and diet: the North Carolina enhanced WISEWOMAN project.

OBJECTIVE: To determine if a clinic-based behavioral intervention program for low-income mid-life women that emphasizes use of community resources will increase moderate intensity physical activity (PA) and improve dietary intake. METHODS: Randomized trial conducted from May 2003 to December 2004 at one community health center in Wilmington, NC. A total of 236 women, ages 40-64, were randomized to receive an Enhanced Intervention (EI) or Minimal Intervention (MI). The EI consisted of an intensive phase (6 months) including 2 individual counseling sessions, 3 group sessions, and 3 phone calls from a peer counselor followed by a maintenance phase (6 months) including 1 individual counseling session and 7 monthly peer counselor calls. Both phases included efforts to increase participants' use of community resources that promote positive lifestyle change. The MI consisted of a one-time mailing of pamphlets on diet and PA. Outcomes, measured at 6 and 12 months, included the comparison of moderate intensity PA between study groups as assessed by accelerometer (primary outcome) and questionnaire, and dietary intake assessed by questionnaire and serum carotenoids (6 months only). RESULTS: For accelerometer outcomes, follow-up was 75% at 6 months and 73% at 12 months. Though moderate intensity PA increased in the EI and decreased in the MI, the difference between groups was not statistically significant (p=0.45; multivariate model, p=0.08); however, moderate intensity PA assessed by questionnaire (92% follow-up at 6 months and 75% at 12 months) was greater in the EI (p=0.01; multivariate model, p=0.001). For dietary outcomes, follow-up was 90% for questionnaire and 92% for serum carotenoids at 6 months and 74% for questionnaire at 12 months. Dietary intake improved more in the EI compared to the MI (questionnaire at 6 and 12 months, p<0.001; serum carotenoid index, p=0.05; multivariate model, p=0.03). CONCLUSION: The EI did not improve objectively measured PA, but was associated with improved self-reported and objective measures of dietary intake.

Surviving but not quite thriving: anthropometric survey of children aged 6 to 59 months in a rural Western Uganda district.

Located in Western Uganda, Bundibugyo District has enjoyed nearly a decade of relative political stability. However, the current nutritional status of young children is not known. A survey conducted in 1999 assessed the prevalence of global malnutrition, but not stunting. The purpose of this study was to estimate the prevalence of global malnutrition and stunting in three of the 10 subcounties in Bundibugyo District, and to describe efforts to address malnutrition in Bundibugyo. An anthropometric survey of children aged 6 to 59 months was conducted, informed by guidelines for two-stage cluster sampling. Ten villages from each subcounty were chosen at random. The following indicators were measured for 30 children (not randomly selected) per village: age in months, sex, weight in kilograms, length/height in centimeters, mid-upper arm circumference in centimeters, presence of edema, presence of mother in the home, and presence of father in the home. The overall prevalence estimate of global malnutrition, defined as weight-for-height less than -2 z scores, was 2.7% (includes severe malnutrition). The prevalence estimate for stunting, defined as height-for-age less than -2 z scores, was 44.8%. There were no observed cases of kwashiorkor. Because results indicate that stunting is a major problem, programmatic efforts should emphasize young child feeding practices that will lead to decreased incidence of stunting, which would likely contribute to the development potential of the district. The authors describe efforts to address global malnutrition as well as stunting in Bundibugyo.