Protocol for the Support Application for Food PAntrieS trial: design, implementation, and evaluation plan for a digital application to promote healthy food access and support food pantry operations.

Introduction: Food-insecure households commonly rely on food pantries to supplement their nutritional needs, a challenge that was underscored during the COVID-19 pandemic. Food pantries, and the food banks that supply them, face common challenges in meeting variable client volume and dietary needs under normal and emergency (e.g., pandemic, natural disaster) conditions. A scalable digital strategy that has the capacity to streamline the emergency food distribution system, while promoting healthy food options, managing volunteer recruitment and training, and connecting to emergency management systems in times of need, is urgently required. To address this gap, we are developing a working mobile application (app) called the Support Application for Food PAntrieS (SAFPAS) and will evaluate its feasibility and impact on food pantry staff preparedness, stocking, and client uptake of healthful foods and beverages in two urban United States settings. Methods: This paper describes the protocol for a randomized controlled trial of the SAFPAS mobile application. We will conduct formative research in Baltimore, Maryland and Detroit, Michigan to develop and refine the SAFPAS app and increase scalability potential to other urban settings. Then we will test the app in 20 food pantries in Baltimore randomized to intervention or comparison. The impact of the app will be evaluated at several levels of the emergency food system, including food pantry clients (n = 360), food pantry staff and volunteers (n = 100), food pantry stock, and city agencies such as the local food bank and Office of Emergency Management. The primary outcome of the SAFPAS trial is to improve the healthfulness of the foods received by food pantry clients, measured using the Food Assessment Scoring Tool (FAST). Post-trial, we will conduct additional formative research in Detroit to prepare the app for scale-up. Discussion: We anticipate that SAFPAS will improve alignment in the supply and demand for healthy foods among food pantry clients, food pantries, and city agencies which supply food in Baltimore. Real-time, bidirectional communication between entities across the system allows for increased situational awareness at all levels during normal and emergency operations. By conducting formative research in Detroit, we hope to increase the scalability of the SAFPAS app to additional settings nationwide. Clinical trial registration: NCT87654321. https://classic.clinicaltrials.gov/ct2/show/NCT05880004.

Design of an innovative digital application to facilitate access to healthy foods in low-income urban settings.

Background: Under-resourced urban minority communities in the United States are characterized by food environments with low access to healthy foods, high food insecurity, and high rates of diet-related chronic disease. In Baltimore, Maryland, low access to healthy food largely results from a distribution gap between small food sources (retailers) and their suppliers. Digital interventions have the potential to address this gap, while keeping costs low. Methods: In this paper, we describe the technical (I) front-end design and (II) back-end development process of the Baltimore Urban food Distribution (BUD) application (app). We identify and detail four main phases of the process: (I) information architecture; (II) low and high-fidelity wireframes; (III) prototype; and (IV) back-end components, while considering formative research and a pre-pilot test of a preliminary version of the BUD app. Results: Our lessons learned provide valuable insight into developing a stable app with a user-friendly experience and interface, and accessible cloud computing services for advanced technical features. Conclusions: Next steps will involve a pilot trial of the app in Baltimore, and eventually, other urban and rural settings nationwide. Once iterative feedback is incorporated into the app, all code will be made publicly available via an open source repository to encourage adaptation for desired communities. Trial Registration: ClinicalTrials.gov NCT05010018.

Lifestyle Medicine Implementation in 8 Health Systems: Protocol for a Multiple Case Study Investigation.

BACKGROUND: Lifestyle medicine (LM) is the use of therapeutic lifestyle changes (including a whole-food, plant-predominant eating pattern; regular physical activity; restorative sleep; stress management; avoidance of risky substances; and positive social connection) to prevent and treat chronic illness. Despite growing evidence, LM is still not widely implemented in health care settings. Potential challenges to LM implementation include lack of clinician training, staffing concerns, and misalignment of LM services with fee-for-service reimbursement, but the full range of factors facilitating or obstructing its implementation and long-term success are not yet understood. To learn important lessons for success and failure, it is crucial to understand the experiences of different LM programs. OBJECTIVE: This study aims to describe in depth the protocol used to identify barriers and facilitators impacting the implementation of LM in health systems. METHODS: The study team comprises team members at the American College of Lifestyle Medicine (ACLM), including staff and researchers with expertise in public health, LM, and qualitative research. We recruited health systems that were members of the ACLM Health Systems Council. From among 15 self-nominating health systems, we selected 7 to represent a diversity of geographic location, type, size, expertise, funding, patients, and LM services. Partway through the study, we recruited 1 additional contrasting health system to serve as a negative case. For each case, we conducted in-depth interviews, document reviews, site visits (limited due to the COVID-19 pandemic), and study team debriefs. Interviews lasted 45-90 minutes and followed a semistructured interview guide, loosely based on the Consolidated Framework for Implementation Research (CFIR) model. We are constructing detailed case narrative reports for each health system that are subsequently used in cross-case analyses to develop a contextually rich and detailed understanding of various predetermined and emergent topics. Cross-case analyses will draw on a variety of methodologies, including in-depth case familiarization, inductive or deductive coding, and thematic analysis, to identify cross-cutting themes. RESULTS: The study team has completed data collection for all 8 participating health systems, including 68 interviews and 1 site visit. We are currently drafting descriptive case narratives, which will be disseminated to participating health systems for member checking and shared broadly as applied vignettes. We are also conducting cross-case analyses to identify critical facilitators and barriers, explore clinician training strategies to facilitate LM implementation, and develop an explanatory model connecting practitioner adoption of LM and experiences of burnout. CONCLUSIONS: This protocol paper offers real-world insights into research methods and practices to identify barriers and facilitators to the implementation of LM in health systems. Findings can advise LM implementation across various health system contexts. Methodological limitations and lessons learned can guide the execution of other studies with similar methodologies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51562.

Fresh Shelves, Healthy Pantries: A Pilot Intervention Trial in Baltimore City Food Pantries.

The objective of this study was to evaluate the impact of a multi-modal pilot intervention on the stocking and acquisition of healthy foods in urban food pantries. An intervention that consisted of three 8-week phases, each focused on promotion of one food group: (1) lean & low-sodium proteins; (2) fruits & vegetables; and (3) healthy carbohydrates was conducted in 3 intervention and 4 comparison food pantries. Food stocking variety scores measured changes in the stocking of promoted healthful foods at pantries. Food Assortment Scoring Tool (FAST) scores measured healthfulness of client bags. Intervention and comparison pantries showed an increase during the study in the total variety score for promoted options, with no significant differences between groups. Mean healthfulness scores for intervention client bags (n = 34) significantly increased from 58.2 to 74.9 (p < 0.001). This pilot trial identified logistically feasible strategies to promote healthy options effectively in food pantries, even in pantries with limited resources.

Enhancing Artificial Intelligence for Twitter-based Public Discourse on Food Security During the COVID-19 Pandemic.

OBJECTIVE: Food security during public health emergencies relies on situational awareness of needs and resources. Artificial intelligence (AI) has revolutionized situational awareness during crises, allowing the allocation of resources to needs through machine learning algorithms. Limited research exists monitoring Twitter for changes in the food security-related public discourse during the COVID-19 pandemic. We aim to address that gap with AI by classifying food security topics on Twitter and showing topic frequency per day. METHODS: Tweets were scraped from Twitter from January 2020 through December 2021 using food security keywords. Latent Dirichlet Allocation (LDA) topic modeling was performed, followed by time-series analyses on topic frequency per day. RESULTS: 237,107 tweets were scraped and classified into topics, including food needs and resources, emergency preparedness and response, and mental/physical health. After the WHO's pandemic declaration, there were relative increases in topic density per day regarding food pantries, food banks, economic and food security crises, essential services, and emergency preparedness advice. Threats to food security in Tigray emerged in 2021. CONCLUSIONS: AI is a powerful yet underused tool to monitor food insecurity on social media. Machine learning tools to improve emergency response should be prioritized, along with measurement of impact. Further food insecurity word patterns testing, as generated by this research, with supervised machine learning models can accelerate the uptake of these tools by policymakers and aid organizations.

The Baltimore Urban Food Distribution (BUD) App: Study Protocol to Assess the Feasibility of a Food Systems Intervention.

Low-income urban communities in the United States commonly lack ready access to healthy foods. This is due in part to a food distribution system that favors the provision of high-fat, high-sugar, high-sodium processed foods to small retail food stores, and impedes their healthier alternatives, such as fresh produce. The Baltimore Urban food Distribution (BUD) study is a multilevel, multicomponent systems intervention that aims to improve healthy food access in low-income neighborhoods of Baltimore, Maryland. The primary intervention is the BUD application (app), which uses the power of collective purchasing and delivery to affordably move foods from local producers and wholesalers to the city's many corner stores. We will implement the BUD app in a sample of 38 corner stores, randomized to intervention and comparison. Extensive evaluation will be conducted at each level of the intervention to assess overall feasibility and effectiveness via mixed methods, including app usage data, and process and impact measures on suppliers, corner stores, and consumers. BUD represents one of the first attempts to implement an intervention that engages multiple levels of a local food system. We anticipate that the app will provide a financially viable alternative for Baltimore corner stores to increase their stocking and sales of healthier foods, subsequently increasing healthy food access and improving diet-related health outcomes for under-resourced consumers. The design of the intervention and the evaluation plan of the BUD project are documented here, including future steps for scale-up. Trial registration #: NCT05010018.

Moving Food Assistance into the Digital Age: A Scoping Review.

One of the most basic needs globally, food assistance refers to the multitude of programs, both governmental and non-governmental, to improve food access and consumption by food-insecure individuals and families. Despite the importance of digital and mobile Health (mHealth) strategies in food insecurity contexts, little is known about their specific use in food assistance programs. Therefore, the purpose of this study was to address that gap by conducting a scoping review of the literature. Keywords were defined within the concepts of food assistance and digital technology. The search included relevant peer-reviewed and grey literature from 2011 to 2021. Excluded articles related to agriculture and non-digital strategies. PRISMA guidelines were followed to perform a partnered, two-round scoping literature review. The final synthesis included 39 studies of which most (84.6%) were from the last five years and United States-based (93.2%). The top three types of articles or studies included text and opinion, qualitative research, and website, application, or model development (17.9%). The top three types of digital tools were websites (56.4%), smartphone applications (20.5%), and chatbots (5.1%). Nineteen digital features were identified as desirable. Most tools included just one or two features. The most popular feature to include was online shopping (n = 14), followed by inventory management, and client tracking. Digital tools for individual food assistance represent an opportunity for equitable and stable access to programs that can enhance or replace in-person services. While this review identified 39 tools, all are in early development and/or implementation stages. Review findings highlight an overall lack of these tools, an absence of user-centered design in their development, and a critical need for research on their effectiveness globally. Further analysis and testing of current digital tool usage and interventions examining the health and food security impacts of such tools should be explored in future studies, including in the context of pandemics, where digital tools allow for help from a distance.

Strengthening Nutrition Education and Behavior Research for Academicians and Practitioners.

Nutrition education and behavior research is essential for translating scientific nutrition-related evidence into actionable strategies at the individual, family, community, and policy levels. To enhance the impact of nutrition educators and researchers' efforts, there is a need for continued and directed support to sustain the rigor of research. It is the perspective of this paper that the field of nutrition education and behavior research address its inherent complexities to meet the diverse investigative strategies used by academicians as well as practitioners. Such strategies could ensure the role of nutrition education and behavior in ongoing nationwide efforts to address emerging and novel nutrition research.

A qualitative inquiry of food insecurity in Belize.

OBJECTIVE: To explore and provide contextual meaning around issues surrounding food insecurity, namely factors influencing food access, as one domain of food security. DESIGN: A community-based, qualitative inquiry using semi-structured face-to-face interviews was conducted as part of a larger sequential mixed-methods study. SETTING: Cayo District, Belize, May 2019-August 2019. PARTICIPANTS: Thirty English-speaking individuals (eight males, twenty-two females) between the ages of 18-70, with varying family composition residing within the Cayo District. RESULTS: Participants describe a complex interconnectedness between family- and individual-level barriers to food access. Specifically, family composition, income, education and employment influence individuals' ability to afford and access food for themselves or their families. Participants also cite challenges with transportation and distance to food sources and educational opportunities as barriers to accessing food. CONCLUSION: These findings provide insight around food security and food access barriers in a middle-income country and provide avenues for further study and potential interventions. Increased and sustained investment in primary and secondary education, including programmes to support enrollment, should be a priority to decreasing food insecurity. Attention to building public infrastructure may also ease burdens around accessing foods.

A cross-sectional description of mobile food vendors and the foods they serve: potential partners in delivering healthier food-away-from-home choices.

BACKGROUND: Food away from home (FAFH) in the US is associated with adverse health outcomes, and food dollars spent on FAFH continues to increase. FAFH studies have typically focused on restaurants and carryout establishments, but mobile food vendors - popularly known in the US as food trucks - have become more numerous and are an understudied segment of FAFH. The objective of this study was to assess mobile food vendors, their attitudes toward health and nutrition, and the foods they serve. METHODS: This was a cross-sectional study of 41 mobile food vendors in Michigan, US. The survey contained questions about food and nutrition attitudes, such as barriers to putting healthy items on menus and perceived agreement with healthy food preparation practices. Participants were classified into a healthy and a less healthy attitude group based on whether they believed healthy menu items could be successful or not. In addition, participant menus were collected and analyzed according to whether menu items were healthy, moderately healthy, or unhealthy. Descriptive, univariate, and bivariate analyses were conducted. RESULTS: Two-thirds of the participants felt that healthy menu items could be successful, and yet taste and value were the most important menu item success factors, each rated as important by 100% of the participants. Low consumer demand was the biggest barrier to putting healthy items on the menu (76%) whereas lack of chef interest (29%) and need for special training (24%) were the smallest. 72% of the vendors offered at least one healthy menu item, but only 20% of all reviewed menu items were healthy overall. There was no difference in the proportion of menu items that were healthy when comparing those with healthy attitudes (23% of menu items healthy) to those less healthy attitudes (17% of menu items healthy, p = 0.349). CONCLUSIONS: Mobile food vendors had positive views about putting healthy items on menus. However, a low proportion of menu items were classified as healthy. This suggests that mobile food vendors are promising potential public health partners in improving the health profile of FAFH, but that education of vendors is needed to ensure the success of healthier items.

The Michigan Healthy School Action Tools process generates improvements in school nutrition policies and practices, and student dietary intake.

The Michigan Healthy School Action Tools (HSAT) is an online self-assessment and action planning process for schools seeking to improve their health policies and practices. The School Nutrition Advances Kids study, a 2-year quasi-experimental intervention with low-income middle schools, evaluated whether completing the HSAT with a facilitator assistance and small grant funding resulted in (1) improvements in school nutrition practices and policies and (2) improvements in student dietary intake. A total of 65 low-income Michigan middle schools participated in the study. The Block Youth Food Frequency Questionnaire was completed by 1,176 seventh-grade students at baseline and in eighth grade (during intervention). Schools reported nutrition-related policies and practices/education using the School Environment and Policy Survey. Schools completing the HSAT were compared to schools that did not complete the HSAT with regard to number of policy and practice changes and student dietary intake. Schools that completed the HSAT made significantly more nutrition practice/education changes than schools that did not complete the HSAT, and students in those schools made dietary improvements in fruit, fiber, and cholesterol intake. The Michigan HSAT process is an effective strategy to initiate improvements in nutrition policies and practices within schools, and to improve student dietary intake.

An interactive parents' guide for feeding preschool-aged children: pilot studies for improvement.

There are few motivational materials to help families with limited resources develop optimal, practical feeding strategies for young children to reduce dietary risk for poor diet and weight status. Formative evaluation strategies consisting of both qualitative and quantitative data helped to refine the parent feeding guide Eat Healthy, Your Children are Watching, A Parent's Guide to Raising a Healthy Eater. An interdisciplinary planning team developed a five-topic, multimedia, interactive guide addressing the strategies most associated with improved diet quality and weight status of children aged 3 to 5 years. Research staff conducted iterative phases of field testing, reformatting, in-depth interviews, and materials testing with Head Start or Supplemental Nutrition Assistance Program-Education caregivers (N=38) of children aged 3 to 5 years during 2011 and 2012. Convergence of feedback from caregivers' interviews and each booklet's attention, relevance, confidence, and satisfaction subscale scores were used to determine and affirm areas for improvement. Lower than desired attention, relevance, confidence, and satisfaction scores (optimal score=5) in 2011 and too much text resulted in revisions and reformatting that improved scores from 3.8 to 4.9 in 2012. The revision of materials to reflect less text, additional white space, checklists of mealtime behaviors, and learning activities for preschool-aged children resulted in dramatically improved materials and greater acceptance by parents, as shown by both quantitative and qualitative evaluations. Formative evaluation procedures involving the use of data-based decision making allowed for the development of intervention materials that met the unique needs of the population served.

PACES: a Physical Activity Campus Environmental Supports Audit on university campuses.

PURPOSE: This study evaluated the policy and built and recreation environmental supports for physical activity on 13 university campuses. DESIGN: Environmental audit survey. SETTING: Thirteen U.S. universities, 2009. Subjects. University policies, recreation programs and facilities, and at least five additional buildings per campus. MEASURES: The Physical Activity Campus Environmental Supports Audit was developed for this study. ANALYSIS: Analysis of variance with post hoc Tukey's B and χ(2) assessed differences by institution and building type. RESULTS: The mean obesogenic policy score was significantly lower than the desired score, ≥7 (p = .002), with only one campus scoring 10. The mean built environment audit score (5.4 ± 1.7) was low, with significant differences between institutions (p < .001) and only three campuses scoring above the desired score, ≥7. Although generally stairwells were clean and well lighted, there was a lack of signage to encourage stair use (p < .001). Overall, recreation programs (7.1 ± .7) and facilities (7.1 ± 1.2) scored well, but amenities scores were lower for satellite (2.8 ± 1.6) versus main (4.1 ± 1.8) recreation facilities (p = .04). CONCLUSION: On these 13 university campuses, recreation programs and facilities were supportive of healthful lifestyles for obesity prevention, but policies and the built environment were not. This physical activity environmental audit survey requires testing in a wider sample of postsecondary institutions to corroborate its utility and provide evidence to support initiatives to improve campus environments for physical activity.

Evaluation of the food store environment on and near the campus of 15 postsecondary institutions.

PURPOSE: This study evaluated the food stores on and near postsecondary campuses varying in institutional size. DESIGN: The design of the study is an environmental audit survey. SETTING: Fifteen U.S. postsecondary education institutions participated in this study between 2009-2011. SUBJECTS: Eighty-one stores (44% grocery, 17% campus, and 39% convenience/drug) were evaluated. MEASURES: The Nutrition Environment Measures Survey for Stores was modified to evaluate food stores. Analysis. Analysis of variance with post hoc Tukey B and t-tests assessed differences between store types and by institutional size. RESULTS: Grocery stores had significantly higher scores than campus/convenience stores for healthy foods (19.5 ± 3.8 vs. 2.4 ± 1.7), and for the availability (19.5 ± 3.8 vs. 2.4 ± 1.7) and quality (5.9 ± 0.5 vs. 1.8 ± 2.2) of fruits/vegetables (p < .001). Healthy foods and beverages were significantly more expensive (-0.6 ± 3.4 vs. 0.9 ± 2.0; p < .031) than their less healthful alternatives in grocery stores, but not in convenience stores. There were no differences by institutional size for grocery stores; however, smaller institutions' convenience stores had significantly lower availability and quality of fruits/vegetables and total food store environment scores. CONCLUSION: A college campus provides a food environment with an array of shopping venues, most of which are not consistent with dietary recommendations for obesity prevention. The limited quality of healthy food in on-campus and convenience stores and the exacerbated deficiencies for small postsecondary institutions provide evidence to support environmental and policy initiatives to improve the quality of campus food store environments.

Sneakers and spokes: an assessment of the walkability and bikeability of U.S. postsecondary institutions.

The purpose of the study described in this article was to assess the walkability and bikeability of 15 U.S. postsecondary education campuses. The Centers for Disease Control and Prevention's evidence-based Healthier Worksite Initiative Walkability Audit was modified to rate campus walking and biking path segments for path safety, quality, and comfort. Universities (n = 13) assessed an average of 44 path segments, which earned a mean score of 72.71 +/- 10.77 SD (possible range 0 to 100). Postsecondary technical schools (n = 2) assessed 20 path segments, which received an average score of 76.56 +/- 13.15. About 70% of path segments received a grade A or B, but almost 1 in 10 received a failing or poor support score for walking and biking. Nearly half or more campus environments scored significantly below an acceptable score on many path safety and quality criteria. Postsecondary education campuses that are supportive of walking and biking offer numerous benefits to the environment and people. Findings from environmental assessments like the data reported here can provide valuable input to campus planners.

Axonal metabolic recovery and potential neuroprotective effect of glatiramer acetate in relapsing-remitting multiple sclerosis.

Glatiramer acetate (GA) is a disease-modifying therapy for relapsing-remitting multiple sclerosis (RRMS) with several putative mechanisms of action. Currently, there is paucity of in vivo human data linking the well-established peripheral immunologic effects of therapy with GA to its potential effects inside the central nervous system (CNS). Brain proton magnetic resonance spectroscopy (MRS) allows in vivo examination of axonal integrity by quantifying the resonance intensity of the neuronal marker N-acetylaspartate (NAA). In a pilot study to investigate the effect of GA on axonal injury, we performed combined brain magnetic resonance imaging (MRI) and MRS studies in 18 treatment naïve RRMS patients initiating therapy with GA at baseline and annually for two years on therapy. A small group of four treatment naïve RRMS patients, electing to remain untreated, served as controls. NAA/Cr was measured in a large central brain volume of interest (VOI) as well as the normal appearing white matter (NAWM) within the VOI. After two years, NAA/Cr in the GA-treated group increased significantly by 10.7% in the VOI (2.17 +/- 0.26 versus 1.96 +/- 0.24, P = 0.03) and by 71% in the NAWM (2.23 +/- 0.26 versus 2.08 +/- 0.31, P = 0.04). In the untreated group, NAA/Cr decreased by 8.9% at two years in the VOI (2.01 +/- 0.16 versus 1.83 +/- 0.21, P = 0.03) and 8.2% in the NAWM (2.07 +/- 0.24 versus 1.90 +/- 0.29, P = 0.03). Our data shows that treatment with GA leads to axonal metabolic recovery and protection from sub-lethal axonal injury. These results support an in situ effect of GA therapy inside the CNS and suggest potential neuroprotective effects of GA.

Folic acid awareness in Michigan, 1996-1999.

OBJECTIVE: To evaluate the prevalence and trend of folic acid awareness among Michigan mothers during 1996-1999 and to identify maternal characteristics predictive of folic acid awareness. METHODS: We analyzed data from the Michigan Pregnancy Risk Assessment Monitoring System, a population-based survey of women with recent live births. A positive response to the question, "Before you became pregnant, did you know that folic acid could help prevent some birth defects?" was used as an indicator of folic acid awareness. Logistic regression was used to evaluate trends in folic acid awareness prevalence and the association between folic acid awareness and certain maternal characteristics. RESULTS: Of the women invited to participate, 7252 responded (67.3%). Overall, folic acid awareness increased from 1996 to 1999 (60.3-71.4%; P < .001). However, folic acid awareness decreased for women with no high school education from 1997 to 1999 (59.3-13.8%, P = .05). In addition, folic acid awareness was lower among black women (adjusted odds ratio [OR] 0.43; 95% confidence interval [CI] 0.4, 0.5, versus other races), women with unplanned pregnancies (adjusted OR 0.6; 95% CI 0.5, 0.8, versus those with planned pregnancies), and those with no high school education (adjusted OR 0.08; 95% CI 0.03, 0.2, versus women with college education). CONCLUSION: Although folic acid awareness has increased among Michigan mothers overall during 1996-1999, it has decreased among women with less than a high school education, and substantial gaps exist among socioeconomic subgroups. Continued efforts are needed to improve folic acid awareness and consumption of folic acid among women of reproductive age, with special attention focused on populations experiencing gaps or declines in folic acid awareness.