State Legislation Related to School Nutrition: Predictors of Bill Passage From 2010-2019.

OBJECTIVE: This study aimed to discover the prevalence of school nutrition state legislation and to identify the correlates of enactment. DESIGN, SETTING, AND PARTICIPANTS: An online legislative database, Legiscan, was used to collect bills related to school nutrition from the US from 2010 to 2019. Bills were coded and compiled into a study database with state-level dietary variables (obesity prevalence, fruit, and vegetable intake, sugar-sweetened beverage consumption), community variables (percent White, poverty), and bill-characteristic variables (party affiliation in legislature, strength of language, party of governor, school gardens, vegetable intake, and other salient variables). Multivariable models were built to examine predictors of bill enactment. RESULTS: Of the 462 bills introduced, 38.7% (n = 156) were enacted. In a multivariable model, the strength of bill language, political party affiliation, implementation of school gardens, and vegetable intake were the variables associated with bill passage. Bills with strong language were less likely to be enacted (P <0.001). Bills introduced by Democrats were more likely to be enacted (P = 0.01). CONCLUSION AND IMPLICATION: This study showed a better understanding of legislative support for child nutrition via policy surveillance of bills and their correlates of enactment. This information can be used to prioritize advocacy efforts and identify ways research can better inform policy.

Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States.

BACKGROUND: While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US). METHODS: This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance. RESULTS: A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH. CONCLUSION: Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

The Effects of Potato Presentation on Vegetable Intake in School-Aged Children: A Cross-Over Study.

Vegetables are an essential component of a healthy dietary pattern in children; however, their consumption is often insufficient due to lack of preference. To address this, the influence of combining vegetables (mixed peas and carrots-MPACs) with potatoes, a generally liked food, on overall vegetable consumption among children aged 7-13 years was explored. The research involved a cross-over study design with 65 participants who completed five lunchtime meal conditions, each with different combinations of MPACs and potatoes versus a control (MPACs with a wheat roll). The meals were provided in a cafeteria setting, and plate waste was used to measure vegetable consumption. Anthropometric data and other variables were also measured. Notably, self-reported hunger did not significantly differ between conditions. Meal condition was a significant predictor of MPACs (F = 5.20; p = 0.0005), with MPAC consumption highest when combined with shaped potato faces in the same bowl (+8.77 g compared to serving MPACs and shaped potato faces in separate bowls) and lowest when combined with diced potatoes in the same bowl (-2.85 g compared to serving MPACs and diced potatoes in separate bowls). The overall model for MPAC consumption was influenced by age, height z-score, body fat percentage z-score, and condition (likelihood ratio = 49.1; p < 0.0001). Age had the strongest correlation with vegetable consumption (r = 0.38), followed by male gender, height z-score (r = 0.30), and body fat z-score (r = -0.15). The results highlight the positive impact of combining potatoes with vegetables in school meals, particularly when using shaped potato faces. These findings emphasize the potential of potatoes as a valuable vegetable option in promoting healthier eating habits among children. Additionally, future research could explore the impact of different potato combinations and investigate other factors influencing meal consumption in school settings.

Discretizing continuous variables in nutrition and obesity research: a practice that needs to be cut short.

BACKGROUND/OBJECTIVES: Nutrition and obesity researchers often dichotomize or discretize continuous independent variables to conduct an analysis of variance to examine group differences. We describe consequences associated with dichotomizing and discretizing continuous variables using two cross-sectional studies related to nutrition. SUBJECTS/METHODS: Study 1 investigated the effects of health literacy and nutrition knowledge on nutrition label accuracy (n = 612). Study 2 investigated the effects of cognitive restraint and BMI on fruit and vegetable (F/V) intake (n = 586). We compare analytic approaches where continuous independent variables were either discretized/dichotomized or analyzed as continuous variables. RESULTS: In Study 1, dichotomization of health literacy and nutrition knowledge for 2 × 2 ANOVA revealed health literacy had an effect on nutrition label accuracy. Nutrition knowledge has an effect on nutrition label accuracy, but the health literacy by nutrition knowledge interaction was not significant. When analyzed using regression, the nutrition knowledge effect was significant. The simple effect of health literacy was also significant when health literacy equals zero. Finally, the quadratic effect of health literacy was negative and significant. In Study 2, dichotomization and discretization of cognitive restraint and BMI were used for three ANOVAs, which discretized BMI in three ways. For all ANOVAs, the BMI main effect for predicting fruit and vegetable intake was significant, the interaction between BMI and cognitive restraint was non-significant, and cognitive restraint was only significant when both variables were dichotomized. When analyzed using regression, the continuous mean-centered variables, and their interaction each significantly predicted F/V intake. CONCLUSIONS: Dichotomizing continuous independent variables resulted in distortions of effect sizes across studies, an inability to assess the quadratic effect of health literacy, and an inability to detect the moderating effect of BMI. We discourage researchers from dichotomizing and discretizing continuous independent variables and instead use multiple regression to examine relationships between continuous independent and dependent variables.

The Commit to Be Fit framework: a community case study of a multi-level, holistic school-based wellness initiative in rural Virginia.

Background: Public health interventions that target children's physical, mental, and emotional health will enhance their ability to learn and grow. Although more complex, school initiatives that address multiple ecological levels and take a holistic view may be more effective and likely to lead to lasting change. Aims: This article presents the framework of Commit to Be Fit (C2BF) as an example of how schools can integrate multi-level and holistic approaches for health. This innovative school-based intervention includes activities addressing individual, home, school, and community to create a culture of wellness. We describe the implementation of C2BF and its basis in ecological models and give examples of activities across three components: cafeteria, classroom, and community. We discuss challenges and note that leadership engagement and alignment were critical elements for C2BF's success thus far. Discussion: C2BF uses a school-based multi-level approach to creating a culture of wellness and holistic health for students, teachers, and community members. C2BF is unique compared to other school-based programming and includes activities that address all eight domains posited for program sustainability within public health. Built to be flexible and adaptive, C2BF was able to successfully pivot during the COVID pandemic and also follow new science. Conclusion: C2BF and other multi-level holistic approaches are more likely to achieve long-term change by utilizing strategies across the multiple levels of the ecological model to improve health and wellbeing.

Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy.

Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.

COVID-19 and Psychosocial Well-Being: Did COVID-19 Worsen U.S. Frontline Healthcare Workers' Burnout, Anxiety, and Depression?

Healthcare workers are highly regarded for their compassion, dedication, and composure. However, COVID-19 created unprecedented demands that rendered healthcare workers vulnerable to increased burnout, anxiety, and depression. This cross-sectional study assessed the psychosocial impact of COVID-19 on U.S. healthcare frontliners using a 38-item online survey administered by Reaction Data between September and December 2020. The survey included five validated scales to assess self-reported burnout (Maslach Summative Burnout Scale), anxiety (GAD-7), depression (PHQ-2), resilience (Brief Resilience Coping Scale), and self-efficacy (New Self-Efficacy Scale-8). We used regression to assess the relationships between demographic variables and the psychosocial scales index scores and found that COVID-19 amplified preexisting burnout (54.8%), anxiety (138.5%), and depression (166.7%), and reduced resilience (5.70%) and self-efficacy (6.5%) among 557 respondents (52.6% male, 47.5% female). High patient volume, extended work hours, staff shortages, and lack of personal protective equipment (PPE) and resources fueled burnout, anxiety, and depression. Respondents were anxious about the indefinite duration of the pandemic/uncertain return to normal (54.8%), were anxious of infecting family (48.3%), and felt conflicted about protecting themselves versus fulfilling their duty to patients (44.3%). Respondents derived strength from their capacity to perform well in tough times (74.15%), emotional support from family/friends (67.2%), and time off work (62.8%). Strategies to promote emotional well-being and job satisfaction can focus on multilevel resilience, safety, and social connectedness.

Nutrition and Health Programming and Outreach in Grocery Retail Settings: A Community Coalition in Action.

Grocery stores can provide a conducive environment for interventions targeting healthy eating and access to health services, particularly in low-income communities. A wide array of organizations deliver nutrition and related programs in community settings, but rarely in a coordinated fashion. Collaboration of local health promotion organizations with grocery stores could increase consumers' access to and selection of healthy foods and related services. This evaluation of the In-Store Programming and Outreach Coalition (IPOC) uses thematic analysis of first-person accounts from coalition members. To our knowledge, this is the first study of such a coalition. We present perspectives from six stakeholders about the IPOC strengths, challenges, and recommendations for strengthening the delivery of in-store interventions. Themes identified include partnership, increased client reach and cross-referrals, conflicting work schedules, leadership, and recommendations to identify coalition leaders and expand services to other grocery stores. We conclude that grocery stores can offer a suitable setting for programming and community outreach through coalitions.

Beyond Proximity: Utility-Based Access from Location-Based Services Data.

Understanding who in a community has access to its resources-parks, libraries, grocery stores, etc.-has profound equity implications, but typical methods to understand access to these resources are limited. Travel time buffers require researchers to assert mode of access as well as an arbitrary distance threshold; further, these methods do not distinguish between destination quality attributes in an effective way. In this research, we present a methodology to develop utility-based accessibility measures for parks, libraries, and grocery stores in Utah County, Utah. The method relies on passive location-based services data to model destination choice to these community resources; the destination choice model utility functions in turn allow us to develop a picture of regional access that is sensitive to: the quality and size of the destination resource; continuous (non-binary) travel impedance by multiple modes; and the sociodemographic attributes of the traveler. We then use this measure to explore equity in access to the specified community resources across income level in Utah County: the results reveal a discrepancy between which neighborhoods might be targeted for intervention using space-based analysis.

Driving Distance and Food Accessibility: A Geospatial Analysis of the Food Environment in the Navajo Nation and Border Towns.

The Navajo Nation, an area home to approximately 173,000 people in the southwest United States, experiences the highest rates of food insecurity in the United States and is classified as a food desert. The present study assessed the accessibility to food outlets (grocery stores, convenience stores, and restaurants) as measured by driving time on the Navajo Nation and in selected surrounding border towns. Food outlets located in neighboring border towns were examined using network analysis tools in ArcGIS Pro to calculate driving distance and examine the potential impact of driving time within the Navajo Nation on accessibility to nutritious foods. There were 14 grocery stores, 21 convenience stores, and 65 restaurants identified in the Navajo Nation using Mergent Intellect, a proprietary database, as compared to border towns which had a total of 542 grocery stores, 762 convenience stores, and 3,329 restaurants equaling a ratio of about 50:1 (grocery, 39:1; convenience, 36:1; restaurants, 51:1) when comparing food outlets nearby versus on the Navajo Nation. This ecological study presents a visual representation of driving time and food accessibility, revealing geographic areas within the Navajo Nation where access to border town food stores is sparse, and food insecurity may be elevated.

Sensory Disabilities and Social Isolation Among Hispanic Older Adults: Toward Culturally Sensitive Measurement of Social Isolation.

OBJECTIVES: Sensory disabilities, including vision disability and hearing disability, increase risk for social isolation, which is associated with multiple negative health outcomes. Existing literature suggests that the cultural value of familism may provide a buffer against social isolation. We examined the longitudinal trajectory of social isolation among Hispanic older adults with self-reported vision disability (SRVD) and self-reported hearing disability and tested a modified measure of social isolation incorporating familism. METHODS: We compared 8-year trajectories of social isolation among Hispanics (n = 445) and non-Hispanic Whites (n = 4,861) from the National Health and Aging Trends Study. We used structural equation modeling to explore the longitudinal relationships between sensory disability and social isolation while comparing 2 measures of social isolation. RESULTS: Social isolation increased longitudinally for both groups, with SRVD significantly associated with higher initial levels. Social isolation started and remained higher across time among Hispanics. Using an adjusted measure of social isolation (added familial support), neither initial levels nor trajectories of social isolation differed between Hispanic and non-Hispanic White participants. DISCUSSION: Initially, Hispanics appeared more socially isolated, reporting less social support from outside the home. Yet, we found that they were more likely to report family social connections. Traditional measures of social isolation focusing on social support outside of the home (neglecting support by family) may lack content validity among Hispanic groups. Culturally sensitive measures of social isolation will be increasingly consequential for future research and health policy to meet the needs of a diverse older population.

Eat Well El Paso!: Lessons Learned From a Community-Level Restaurant Initiative to Increase Availability of Healthy Options While Celebrating Local Cuisine.

PURPOSE: Restaurants have the potential to improve nutrition and positively shape social norms. We describe lessons learned and recommended strategies from Eat Well El Paso! (EWEP), a local restaurant initiative. DESIGN: Descriptive case study. SETTING: EWEP partnered with local restaurants from 2012-2017 in El Paso, Texas, along the US/Mexico border. SAMPLE: Our sampling frame included EWEP staff and managers/owners at participating restaurants, of which the majority participated (80% and 85%, respectively). INTERVENTION: EWEP was a local restaurant initiative led by the city public health department. EWEP contracted registered dietitians to assist locally-owned restaurants to increase availability of healthy menu options. MEASURES: Observation, key informant interviews, and document review assessed participation, barriers, and facilitators to restaurant participation and program sustainability. ANALYSIS: Thematic and descriptive analyses. RESULTS: 57% of restaurants completed the full on-boarding process, but long-term retention was low (24% of completers). Restaurant managers/owners perceived value in marketing, nutritional analysis, and menu design. Barriers included scheduling, complexity of restaurant culture, fear of food inspections, restaurant turnover, competing responsibilities, and lack of dedicated funding. CONCLUSION: Although local context and sample size may limit generalizability, lessons learned and recommended strategies are relevant and informative for communities working to increase restaurants' healthy menu options.

Practical Strategies to Improve Your Writing: Lessons Learned From Public Health Practitioners Participating in a Writing Group.

Many public health professionals (researchers and practitioners) do not regularly spend time writing. We often receive no formal training in the practices that lead one to become a productive writer. In addition, many internal (mental/emotional) and external (schedules/distractions) barriers make writing consistently even less appealing and may lead to a cycle of avoidance followed by binge writing. This commentary demonstrates how one writing group became an effective means of providing career and professional development. Each week for 9 months we held a 1-hour writing group meeting designed around a commitment to ground rules, accountability, training opportunities, and feedback. Our experiences suggest that engaging in a writing group can help us develop as writers by allowing us to learn new practices and skills. Adopting new practices like writing regularly for short blocks of time, in turn, led to benefits like reduced anxiety and increased productivity. In the process, we became better writers, reviewers, and mentors. We provide recommendations and resources for groups and individuals who are interested in improving their writing as an essential component of their continuing education and professional development. Whatever your professional role, using a writing group to become a more powerful and productive writer will make you more effective.

Optical assessment of skin carotenoid status as a biomarker of vegetable and fruit intake.

Resonance Raman spectroscopy (RRS) and reflection spectroscopy (RS) are optical methods applicable to the non-invasive detection of carotenoids in human skin. RRS is the older, more thoroughly validated method, whereas RS is newer and has several advantages. Since collective skin carotenoid levels serve as a biomarker for vegetable and fruit intake, both methods hold promise as convenient screening tools for assessment of dietary interventions and correlations between skin carotenoids and health and disease outcomes. In this manuscript, we describe the most recent optimized device configurations and compare their use in various clinical and field settings. Both RRS and RS devices yield a wide range of skin carotenoid levels between subjects, which is a critical feature for a biomarker. Repeatability of the methods is 3-15% depending on the subject's skin carotenoid level and the uniformity of its local distribution. For 54 subjects recruited from an ophthalmology clinic, we first checked the validity of the relatively novel RS methodology via biochemical serum carotenoid measurements, the latter carried out with high performance liquid chromatography (HPLC). A high correlation between RS skin and serum HPLC carotenoid levels was established (R = 0.81; p < 0.001). Also, a high correlation was found between RS and RRS skin levels (R = 0.94 p < 0.001). Subsequent comparisons of skin carotenoid measurements in diverse age groups and ethnicities included 569 Japanese adults, 947 children with ages 2-5 screened in 24 day care centers in San Francisco, and 49 predominantly Hispanic adults screened at an outdoor health fair event. Depending on the particular subject group, correlation coefficients between the RRS and RS methods ranged between R ∼0.80 and R ∼0.96. Analysis of the Japanese screening showed that, on average, skin carotenoid levels are higher in women compared to men, skin levels do not depend on age, and tobacco smokers have reduced levels versus non-smokers. For the two most ethnically diverse groups with widely varying melanin levels, we investigated the effect of dermal melanin on RS and RRS skin carotenoid levels. The analysis revealed that large variations in skin carotenoid levels remain detectable independent of the particular melanin index. This behavior is consistent with the absence of melanin effects on the skin carotenoid levels generated with the instrument configurations. The RS method has an advantage over RRS in its relative simplicity. Due to its detection of skin reflection over a wide spectral range from the near UV to the near IR, it has the unique ability to quantify each of the major tissue chromophores and take them into account in the derivation of skin carotenoid levels.

Comparing the Functioning of Youth and Adult Partnerships for Health Promotion.

Youth partnerships are a promising but understudied strategy for prevention and health promotion. Specifically, little is known about how the functioning of youth partnerships differs from that of adult partnerships. Accordingly, this study compared the functioning of youth partnerships with that of adult partnerships. Several aspects of partnership functioning, including leadership, task focus, cohesion, participation costs and benefits, and community support, were examined. Standardized partnership functioning surveys were administered to participants in three smoke-free youth coalitions (n = 44; 45 % female; 43 % non-Hispanic white; mean age = 13) and in 53 Communities That Care adult coalitions (n = 673; 69 % female; 88 % non-Hispanic white; mean age = 49). Multilevel regression analyses showed that most aspects of partnership functioning did not differ significantly between youth and adult partnerships. These findings are encouraging given the success of the adult partnerships in reducing community-level rates of substance use and delinquency. Although youth partnership functioning appears to be strong enough to support effective prevention strategies, youth partnerships faced substantially more participation difficulties than adult partnerships. Strategies that youth partnerships can use to manage these challenges, such as creative scheduling and increasing opportunities for youth to help others directly, are discussed.

Improved Cardiovascular Risk among Hispanic Border Participants of the Mi Corazón Mi Comunidad Promotores De Salud Model: The HEART II Cohort Intervention Study 2009-2013.

BACKGROUND: Community resources (parks, recreational facilities) provide opportunities for health promotion, but little is known about how to promote utilization of these resources and their impact on cardiovascular disease risk (CVD). METHODS: This cohort study evaluated the impact of an intervention called Mi Corazon Mi Comunidad (MiCMiC), which consisted of promoting use of community physical activity and nutrition resources by Promotoras de Salud/Community Health Workers. Participants were assessed at baseline and following the 4-month intervention. Attendance records were objectively collected to assess utilization of intervention programing. RESULTS: A total of five consecutive cohorts were recruited between 2009 and 2013. Participants were mostly females (86.0%), on average 46.6 years old, and 81% were low in acculturation. Participants who completed follow-up (n = 413) showed significant improvements in reported health behaviors and body composition. Higher attendance significantly predicted greater improvements. The baseline to 4-month change for the highest vs. the lowest attendance quartiles were for weight (-5.2 vs. +0.01 lbs, p < 0.001), waist circumference (-1.20 vs. -0.56 inches, p = 0.047), hip circumference (-1.13 vs. -0.41 inches, p < 0.001); hours of exercise/week (+3.87 vs. +0.81 hours, p < 0.001), proportion of participants eating five servings of fruits and vegetables/day (+54.7 vs. 14.7%, p < 0.001). CONCLUSION: Following the Promotora-led MiCMiC intervention, substantial improvements in health behaviors and modest improvements in cardiovascular risk factors were found. Greater utilization of community resources was associated with more favorable changes. This study provided preliminary evidence for the effectiveness of Promotora-led interventions for promoting use of existing community resources in CVD risk reduction.

Optical detection of carotenoids in living tissue as a measure of fruit and vegetable intake.

Circulating blood carotenoids have long been accepted as the most accurate biomarker of total fruit and vegetable intake. Recent technological developments have led to a novel optical detection method of carotenoids in living human tissue, allowing for a non-invasive and rapid method to assess fruit and vegetable intake. Future technological advances to increase sensitivity and molecular specificity, reduce cost, and detect other biomedically important compounds would expand use of this methodology.