Clinical-Community Partnerships to Identify Patients With Food Insecurity and Address Food Needs.

INTRODUCTION: More than 42 million people in the United States are food insecure. Although some health care entities are addressing food insecurity among patients because of associations with disease risk and management, little is known about the components of these initiatives. METHODS: The Systematic Screening and Assessment Method was used to conduct a landscape assessment of US health care entity-based programs that screen patients for food insecurity and connect them with food resources. A network of food insecurity researchers, experts, and practitioners identified 57 programs, 22 of which met the inclusion criteria of being health care entities that 1) screen patients for food insecurity, 2) link patients to food resources, and 3) target patients including adults aged 50 years or older (a focus of this assessment). Data on key features of each program were abstracted from documentation and telephone interviews. RESULTS: Most programs (n = 13) focus on patients with chronic disease, and most (n = 12) partner with food banks. Common interventions include referrals to or a list of food resources (n = 19), case managers who navigate patients to resources (n = 15), assistance with federal benefit applications (n = 14), patient education and skill building (n = 13), and distribution of fruit and vegetable vouchers redeemable at farmers markets (n = 8). Most programs (n = 14) routinely screen all patients. CONCLUSION: The programs reviewed use various strategies to screen patients, including older adults, for food insecurity and to connect them to food resources. Research is needed on program effectiveness in improving patient outcomes. Such evidence can be used to inform the investments of potential stakeholders, including health care entities, community organizations, and insurers.

State-Level Farmers Market Activities: A Review of CDC-Funded State Public Health Actions That Support Farmers Markets.

CONTEXT: Introducing farmers markets to underserved areas, or supporting existing farmers markets, can increase access and availability of fruits and vegetables and encourage healthy eating. Since 2003, the Centers for Disease Control and Prevention (CDC)'s Division of Nutrition, Physical Activity, and Obesity (DNPAO) has provided guidance and funding to state health departments (SHDs) to support the implementation of interventions, including activities around farmers markets, to address healthy eating, and improve the access to and availability of fruits and vegetables at state and community levels. OBJECTIVE: For this project, we identified state-level farmers market activities completed with CDC's DNPAO funding from 2003 to 2013. State-level was defined as actions taken by the state health department that influence or support farmers market work across the state. DESIGN AND PARTICIPANTS: We completed an analysis of SHD farmers market activities of 3 DNPAO cooperative agreements from 2003 to 2013: State Nutrition and Physical Activity Programs to Prevent Obesity and Other Chronic Diseases; Nutrition, Physical Activity and Obesity Program; and Communities Putting Prevention to Work. To identify state farmers market activities, data sources for each cooperative agreement were searched using the key words "farm," "market," "produce market," and "produce stand." State data with at least one state-level farmers market action present were then coded for the presence of itemized activities. RESULTS: Across all cooperative agreements, the most common activities identified through analysis included the following: working on existing markets and nutrition assistance benefit programs, supporting community action, and providing training and technical assistance. Common partners were nutrition assistance benefit program offices and state or regional Department of Agriculture or agricultural extension offices. IMPLICATIONS FOR POLICY & PRACTICE: Common farmers market practices and evidence-based activities, such as nutrition assistance benefits programs and land-use policies, can be adopted as methods for farmers market policy and practice work. CONCLUSION: The activities identified in this study can inform future planning at the state and federal levels on environment, policy, and systems approaches that improve the food environment through farmers markets.

Common ways Americans are incorporating fruits and vegetables into their diet: intake patterns by meal, source and form, National Health and Nutrition Examination Survey 2007-2010.

OBJECTIVE: We explored how Americans aged ≥2 years who consumed the recommended amount of fruits and vegetables on a given day incorporated fruits and vegetables into their diet compared with those who did not consume recommended amounts. DESIGN: We used 1 d of dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 2007-2010 to examine cross-sectional differences in mean intakes of fruits and vegetables in cup-equivalents by meal, source and form between the two groups. SETTING: USA. SUBJECTS: NHANES 2007-2010 participants aged ≥2 years (n 17 571) with 1 d of reliable 24 h recall data. RESULTS: On a given day, the proportions of fruits and vegetables consumed at different meals were similar between those who consumed recommended amounts and those who did not. Among adults, 59-64 % of their intake of fruits was consumed at breakfast or as a snack and almost 90 % came from retail outlets regardless of whether they consumed the recommended amount or not. Adults who consumed the recommended amount of fruits ate more fruits in raw form and with no additions than those who did not. Among children and adults, 52-57 % of vegetables were consumed at dinner by both groups. Retail outlets were the main source of vegetables consumed (60-68 %). CONCLUSIONS: Our findings indicate that habits of when, where and how consumers eat fruits and vegetables might not need to change but increasing the amount consumed would help those not currently meeting the recommendation.

Networking to Improve Nutrition Policy Research.

Effective nutrition and obesity policies that improve the food environments in which Americans live, work, and play can have positive effects on the quality of human diets. The Centers for Disease Control and Prevention's (CDC's) Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) conducts transdisciplinary practice-based policy research and evaluation to foster understanding of the effectiveness of nutrition policies. The articles in this special collection bring to light a set of policies that are being used across the United States. They add to the larger picture of policies that can work together over time to improve diet and health.

Using Behavioral Risk Factor Surveillance System Data to Estimate the Percentage of the Population Meeting US Department of Agriculture Food Patterns Fruit and Vegetable Intake Recommendations.

Most Americans do not eat enough fruits and vegetables with significant variation by state. State-level self-reported frequency of fruit and vegetable consumption is available from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS). However, BRFSS cannot be used to directly compare states' progress toward national goals because of incongruence in units used to measure intake and because distributions from frequency data are not reflective of usual intake. To help states track progress, we developed scoring algorithms from external data and applied them to BRFSS 2011 data to estimate the percentage of each state's adult population meeting US Department of Agriculture Food Patterns fruit and vegetable intake recommendations. We used 24-hour dietary recall data from the National Health and Nutrition Examination Survey, 2007-2010, to fit sex- and age-specific models that estimate probabilities of meeting recommendations as functions of reported consumption frequency, race/ethnicity, and poverty-income ratio adjusting for intraindividual variation. Regression parameters derived from these models were applied to BRFSS to estimate the percentage meeting recommendations. We estimate that 7%-18% of state populations met fruit recommendations and 5%-12% met vegetable recommendations. Our method provides a new tool for states to track progress toward meeting dietary recommendations.

The Association of Meal Practices and Other Dietary Correlates With Dietary Intake Among High School Students in the United States, 2010.

PURPOSE: To examine behavioral and environmental factors that may be related to dietary behaviors among U.S. high school students. DESIGN: Data were obtained from the 2010 National Youth Physical Activity and Nutrition Study, a cross-sectional study. SETTING: The study was school-based. SUBJECTS: Study subjects were a nationally representative sample of students in grades 9 to 12 (n = 11,458). MEASURES: Variables of interest included meal practices, in-home snack availability, and intakes of healthful foods/beverages (fruits, vegetables, water, and milk) and less healthful foods/beverages (fried potatoes, pizza, and sugar-sweetened beverages). ANALYSIS: Sex-stratified logistic regression models were used to examine associations of meal practices and snack availability with dietary intake. Odds ratios (ORs) were adjusted for race/ethnicity and grade. RESULTS: Eating breakfast daily, frequent family dinners, and bringing lunch from home were associated with higher odds of consuming at least three healthful foods or beverages. High fast-food intake was associated with lower odds of healthful dietary intake and higher odds of sugar-sweetened beverage intake (female OR = 3.73, male OR = 4.60). Students who mostly/always had fruits and vegetables available at home had increased odds of fruits (female OR = 3.04, male OR = 2.24), vegetables (female OR = 2.12, male OR = 1.65), water (female OR = 1.82, male OR = 1.85), and milk intake (female OR = 1.45, male OR = 1.64). CONCLUSION: Encouraging daily breakfast consumption, frequent family dinners, and fruit and vegetable availability at home may lead to higher intakes of healthful foods among high school students.

Fruit and vegetable intake during infancy and early childhood.

OBJECTIVES: To examine the association of timing of introduction and frequency of fruit and vegetable intake during infancy with frequency of fruit and vegetable intake at age 6 years in a cohort of US children. METHODS: We analyzed data on fruit and vegetable intake during late infancy, age of fruit and vegetable introduction, and frequency of fruit and vegetable intake at 6 years from the Infant Feeding Practices Study II and the Year 6 Follow-Up (Y6FU) Study. We determined the percent of 6-year-old children consuming fruits and vegetables less than once per day and examined associations with infant fruit and vegetable intake using logistic regression modeling, controlling for multiple covariates (n = 1078). RESULTS: Based on maternal report, 31.9% of 6-year-old children consumed fruit less than once daily and 19.0% consumed vegetables less than once daily. In adjusted analyses, children who consumed fruits and vegetables less than once daily during late infancy had increased odds of eating fruits and vegetables less than once daily at age 6 years (fruit, adjusted odds ratio: 2.48; vegetables, adjusted odds ratio: 2.40). Age of introduction of fruits and vegetables was not associated with intake at age 6 years. CONCLUSIONS: Our study suggests that infrequent intake of fruits and vegetables during late infancy is associated with infrequent intake of these foods at 6 years of age. These findings highlight the importance of infant feeding guidance that encourages intake of fruits and vegetables and the need to examine barriers to fruit and vegetable intake during infancy.

Vital signs: fruit and vegetable intake among children - United States, 2003-2010.

BACKGROUND: Eating more fruits and vegetables adds underconsumed nutrients to diets, reduces the risks for leading causes of illness and death, and helps manage body weight. This report describes trends in the contributions of fruits and vegetables to the diets of children aged 2-18 years. METHODS: CDC analyzed 1 day of 24-hour dietary recalls from the National Health and Nutrition Examination Surveys from 2003 to 2010 to estimate trends in children's fruit and vegetable intake in cup-equivalents per 1,000 calories (CEPC) and trends by sex, age, race/ethnicity, family income to poverty ratio, and obesity status. Total fruit includes whole fruit (all fruit excluding juice) and fruit juice (from 100% juice, foods, and other beverages). Total vegetables include those encouraged in the Dietary Guidelines for Americans, 2010 (i.e., dark green, orange, and red vegetables and legumes), white potatoes, and all other vegetables. RESULTS: Total fruit intake among children increased from 0.55 CEPC in 2003-2004 to 0.62 in 2009-2010 because of significant increases in whole fruit intake (0.24 to 0.40 CEPC). Over this period, fruit juice intake significantly decreased (0.31 to 0.22 CEPC). Total vegetable intake did not change (0.54 to 0.53 CEPC). No socio-demographic group met the Healthy People 2020 target of 1.1 CEPC vegetables, and only children aged 2-5 years met the target of 0.9 CEPC fruits. CONCLUSIONS: Children's total fruit intake increased because of increases in whole fruit consumption, but total vegetable intake remained unchanged. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Increased attention to the policies and food environments in multiple settings, including schools, early care and education, and homes might help continue the progress in fruit intake and improve vegetable intake.

Childhood obesity task forces established by state legislatures, 2001-2010.

INTRODUCTION: States and communities are considering policy and environmental strategies, including enacting legislation, to reduce and prevent childhood obesity. One legislative approach has been to create task forces to understand key issues and develop a course of action. The goal of this study was to describe state-level, childhood obesity task forces in the United States created by legislation from 2001 through 2010. METHODS: We used the Center for Disease Control and Prevention's Division of Nutrition, Physical Activity, and Obesity database to identify state-level childhood obesity task forces created through legislation from 2001 through 2010. RESULTS: We identified 21 states that had enacted legislation creating childhood obesity task forces of which 6 had created more than one task force. Most task forces were charged with both gathering and reviewing information and making recommendations for obesity-prevention actions in the state. Most legislation required that task forces include representation from the state legislature, state agencies, community organizations, and community members. CONCLUSION: Evaluation of the effectiveness of obesity-prevention task forces and the primary components that contribute to their success may help to determine the advantages of the use of such strategies in obesity prevention.

A comparison of fruit and vegetable intake estimates from three survey question sets to estimates from 24-hour dietary recall interviews.

BACKGROUND: Fruit and vegetable (F/V) intake surveillance can provide information critical to the design and evaluation of interventions and the assessment of progress toward national intake objectives. The CDC's Youth Risk Behavior Surveillance System (YRBSS) assesses F/V intake among high school students using six questions about the frequency of intake in times per day. It is not known whether F/V intake frequency in times per day can be used as a proxy for intake in servings per day. OBJECTIVE: To compare F/V intake estimates based on responses to three sets of survey questions, including the standard set of six YRBSS questions, with criterion F/V intake in servings per day based on data from 24-hour dietary recall interviews. PARTICIPANTS/SETTING: Study participants were 610 high school students who completed an in-class questionnaire and three telephone-administered 24-hour dietary recall interviews. The questionnaire asked students how many times they consumed 100% fruit juice and ate fruit, carrots, potatoes, green salad, and other vegetables during the "past 7 days" (set 1), the number of times they did so "yesterday" (set 2), and the number of cup-equivalents of fruits and vegetables they consumed per day (set 3). MAIN OUTCOME MEASURE: Mean estimated F/V intake either as "times/day" or "servings/day" and the percentage of students whose estimated F/V intake was ≥1, ≥2, and ≥3 times/day or servings/day. STATISTICAL ANALYSES PERFORMED: t tests and corrected Pearson correlations were used to compare F/V intake estimates based on survey question responses with estimates based on responses to the 24-hour dietary recall interviews. RESULTS: Mean F/V intake estimates (in times/day or servings/day) based on responses to all sets of survey questions were significantly more than servings/day estimates based on responses to the 24-hour dietary recall interviews, and the percentages of students meeting each intake cutpoint were also more. Of the three sets of survey questions, the standard YRBSS questions produced estimates and percentages that were most consistently closest to 24-hour dietary recall interview estimates. CONCLUSIONS: For brief self-administered questionnaires of high school students, the current YRBSS questions are recommended for monitoring F/V intake even though mean intake estimates in times/day will likely be higher than, and are not a proxy for, mean intake estimates in servings/day.

The food and water system: impacts on obesity.

The Weight of the Nation™ (WON) conference was held in Washington, D.C. This article presents the issues and topics presented and discussed within the Food and Water System: Agriculture, Access and Sustainability track. Areas for opportunity are outlined in this article.

Creating supportive nutrition environments for population health impact and health equity: an overview of the Nutrition and Obesity Policy Research and Evaluation Network's efforts.

Childhood obesity is a major threat to individual health and society overall. Policies that support healthier food and beverage choices have been endorsed by many decision makers. These policies may reach a large proportion of the population or in some circumstances aim to reduce nutrition disparities to ensure health equity. The Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) evaluates policy as a tool to improve food and beverage environments where Americans live, work, play, and learn. The network aspires to address research and evaluation gaps related to relevant policies, create standardized research tools, and help build the evidence base of effective policy solutions for childhood obesity prevention with a focus on reach, equity, cost effectiveness, and sustainability.

Growing the Field: Current Approaches to Data Collection at Farmers' Markets.

There is limited published research about the dietary impacts of farmers' markets. We sought to understand whether market managers collect data about markets and to examine the instruments and strategies used. Of the 359 market managers contacted across the United States, representing 543 markets, 185 managers participated in a telephone survey. A subset supplied copies of data collection tools for further analysis. Ninety-three percent of market managers collect data such as customer surveys, vendor applications, customer counts, or demographics. The potential utility of the data collected by mangers and suggestions for study of the dietary impacts of farmers markets are discussed.

Strategies for pediatric practitioners to increase fruit and vegetable consumption in children.

High intake of fruits and vegetables (FV) is associated with a decreased risk for many chronic diseases and may assist in weight management, but few children and adolescents consume the recommended amounts of FV. The pediatric practitioner can positively influence FV consumption of children through patient-level interventions (eg, counseling, connecting families to community resources), community-level interventions (eg, advocacy, community involvement), and health care facility-level interventions (eg, creating a healthy food environment in the clinical setting). This article reviews the importance of FV consumption, recommended intakes for children, and strategies by which pediatric practitioners can influence FV consumption of children.

A worksite obesity intervention: results from a group-randomized trial.

OBJECTIVES: We used a participatory process to develop an obesity intervention appropriate for elementary school personnel. METHODS: A randomized controlled trial included 16 school worksites (8 intervention, 8 control). Intervention schools formed committees to develop and implement health promotion activities for employees. Anthropometric and self-report data were collected at baseline and postintervention (2 years later). The primary outcome measures were body mass index (BMI), waist-hip ratio, physical activity, and fruit and vegetable consumption. RESULTS: After adjustment for age, ethnicity, and job classification, employees in intervention schools reduced their BMI by an average of 0.04 kg/m2, and those in control schools increased their BMI by an average of 0.37 kg/m2. Comparisons for waist-hip ratio, weekly physical activity minutes, and fruit and vegetable consumption were not significant. CONCLUSIONS: The participatory process appeared to be an effective means for stimulating change. The intervention may have slowed and perhaps reversed the tendency of adults to gain weight progressively with age.

The relationship between parity and overweight varies with household wealth and national development.

BACKGROUND: Recent studies support a positive relationship between parity and overweight among women of developing countries; however, it is unclear whether these effects vary by household wealth and national development. Our objective was to determine whether the association between parity and overweight [body mass index (BMI) > or =25 kg/m(2)] in women living in developing countries varies with levels of national human development and/or household wealth. METHODS: We used data from 28 nationally representative, cross-sectional surveys conducted between 1996 and 2003 (n = 275 704 women, 15-49 years). The relationship between parity and overweight was modelled using logistic regression, controlling for several biological and sociodemographic factors and national development, as reflected by the United Nations' Human Development Index. We also modelled the interaction between parity and national development, and the three-way interaction between parity, household wealth and national development. RESULTS: Parity had a weak, positive association with overweight, which varied by household wealth and national development. Among the poorest women and women in the second tertile of household wealth, parity was positively related to overweight only in the most developed countries. Among the wealthiest women, parity was positively related to overweight regardless of the level of national development. CONCLUSIONS: As development increases, the burden of parity-related overweight shifts to include poor as well as wealthy women. In the least-developed countries, programmes to prevent parity-related overweight should target wealthy women, whereas such programmes should be provided to all women in more developed countries.