A Black American Nutrition Scholar and Advocate: My Journey.

I started my journey as a nutrition scholar in 1974 when I began PhD studies at Cornell University. My journey has been rich with opportunity. I engaged in research on diet-related risks for cardiovascular diseases, diabetes, and cancer, partly motivated by my strong commitment to addressing health disparities affecting Black Americans. Obesity became my major focus and would eventually involve both US and global lenses. This focus was also linked to other dietary intake issues and health disparities and drew on knowledge I had gained in my prior study and practice of social work. I positioned myself as a bridge builder across nutrition, epidemiology, and public health, advocating for certain new ways of thinking and acting in these spheres and in the academy itself. Life skills honed during my formative years living within racially segregated contexts have been critical to any successes I have achieved.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews.

INTRODUCTION: Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening. METHODS: Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community. RESULTS: The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status. DISCUSSION: Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Advancing Health Equity Efforts to Reduce Obesity: Changing the Course.

Population-based solutions are needed to stabilize and then reverse the continued upward trends in obesity prevalence in the US population and worldwide. This review focuses on the related, urgent issue of disparities in obesity prevalence affecting US racial/ethnic minority and other socially marginalized populations. The review provides background on these disparities from a health equity perspective and highlights evidence of progress in equity-focused obesity efforts. Five recommendations for advancing equity efforts are offered as potential approaches to build on progress to date: (a) give equity issues higher priority, (b) adopt a health equity lens, (c) strengthen approaches by using health equity frameworks, (d) broaden the types of policies considered, and (e) emphasize implementation science concepts and tools. Potential challenges and opportunities are identified, including the prospect of longer-term, transformative solutions that integrate global and national initiatives to address obesity, undernutrition, and climate change.

Emotional Eating Predicts Weight Regain Among Black Women in the SisterTalk Intervention.

OBJECTIVE: This study aimed to assess effects of emotional eating and stress on weight change among Black women in a culturally tailored weight-control program. METHODS: SisterTalk, a cable-TV-delivered weight-control randomized trial, included 331 Black women (aged 18-75 years; BMI ≥ 25 kg/m2) in Boston, Massachusetts. BMI and waist circumference (WC) were assessed at baseline and 3, 8, and 12 months post randomization. Frequency of "eating when depressed or sad" (EWD) and "eating to manage stress" (ETMS) (i.e., "emotional eating") and perceived stress were also assessed. Lagged analyses of data for intervention participants (n = 258) assessed associations of BMI and WC outcomes at each follow-up visit with EWD and ETMS frequency and stress measured at the most recent prior visit. RESULTS: At 3 months (immediately post intervention), BMI decreased for women in all EWD and ETMS categories but increased at later follow-up for women reporting EWD and ETMS always/often. In addition, 8-month EWD and ETMS predicted 12-month BMI change (both P < 0.05). Higher perceived stress was associated with higher EWD and ETMS; however, stress was not associated with lagged BMI or WC at any time. CONCLUSIONS: Addressing emotional eating and related triggers may improve weight maintenance in interventions with Black women.

Implementation science should give higher priority to health equity.

BACKGROUND: There is growing urgency to tackle issues of equity and justice in the USA and worldwide. Health equity, a framing that moves away from a deficit mindset of what society is doing poorly (disparities) to one that is positive about what society can achieve, is becoming more prominent in health research that uses implementation science approaches. Equity begins with justice-health differences often reflect societal injustices. Applying the perspectives and tools of implementation science has potential for immediate impact to improve health equity. MAIN TEXT: We propose a vision and set of action steps for making health equity a more prominent and central aim of implementation science, thus committing to conduct implementation science through equity-focused principles to achieve this vision in U.S. research and practice. We identify and discuss challenges in current health disparities approaches that do not fully consider social determinants. Implementation research challenges are outlined in three areas: limitations of the evidence base, underdeveloped measures and methods, and inadequate attention to context. To address these challenges, we offer recommendations that seek to (1) link social determinants with health outcomes, (2) build equity into all policies, (3) use equity-relevant metrics, (4) study what is already happening, (5) integrate equity into implementation models, (6) design and tailor implementation strategies, (7) connect to systems and sectors outside of health, (8) engage organizations in internal and external equity efforts, (9) build capacity for equity in implementation science, and (10) focus on equity in dissemination efforts. CONCLUSIONS: Every project in implementation science should include an equity focus. For some studies, equity is the main goal of the project and a central feature of all aspects of the project. In other studies, equity is part of a project but not the singular focus. In these studies, we should, at a minimum, ensure that we "leave no one behind" and that existing disparities are not widened. With a stronger commitment to health equity from funders, researchers, practitioners, advocates, evaluators, and policy makers, we can harvest the rewards of the resources being invested in health-related research to eliminate disparities, resulting in health equity.

Expanding Implementation Research to Prevent Chronic Diseases in Community Settings.

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

Economics of Interventions to Increase Active Travel to School: A Community Guide Systematic Review.

CONTEXT: The number of children who bicycle or walk to school has steadily declined in the U.S. and other high-income countries. In response, several countries responded in recent years by funding infrastructure and noninfrastructure programs that improve the safety, convenience, and attractiveness of active travel to school. The objective of this study is to synthesize the economic evidence for the cost and benefit of these programs. EVIDENCE ACQUISITION: Literature from the inception of databases to July 2018 were searched, yielding 9 economic evaluation studies. All analyses were done in September 2018-May 2019. EVIDENCE SYNTHESIS: All the studies reported cost, 6 studies reported cost benefit, and 2 studies reported cost effectiveness. The cost-effectiveness estimates were excluded on the basis of quality assessment. Cost of interventions ranged widely, with higher cost reported for the infrastructure-heavy projects from the U.S. ($91,000-$179,000 per school) and United Kingdom ($227,000-$665,000 per project). Estimates of benefits differed in the inclusion of improved safety for bicyclists and pedestrians, improved health from increased physical activity, and reduced environmental impacts due to less automobile use. The evaluations in the U.S. focused primarily on safety. The overall median benefit‒cost ratio was 4.4:1.0 (IQR=2.2:1-6.0:1, 6 studies). The 2-year benefit-cost ratios for U.S. projects in California and New York City were 1.46:1 and 1.79:1, respectively. CONCLUSIONS: The evidence indicates that interventions that improve infrastructure and enhance the safety and ease of active travel to schools generate societal economic benefits that exceed the societal cost.

The hunger-obesity paradox: Exploring food banking system characteristics and obesity inequities among food-insecure pantry clients.

PURPOSE: Heightened obesity risk among food-insecure food pantry clients is a health equity issue because the co-occurrence of obesity and hunger is deeply-rooted in systematic social disadvantage and historical oppression. This qualitative study examined key stakeholders' perspectives of the relationship between the U.S. food banking system and obesity disparities among food insecure clients. METHODS: We conducted in-depth, semi-structured interviews with 10 key stakeholders (e.g., food bank director, food bank board member, advocate) who are familiar with food bank operations. Data were transcribed verbatim, coded in NVivo [v11], and analyzed using thematic analysis. RESULTS: Multiple themes emerged drawing linkages between structural characteristics of the food banking system and disparities in the dual burden of food insecurity and obesity: [a] access to unhealthy food from donors; [b] federal emergency food policy and programming; [c] state-level emergency food policy and programming; [d] geography-based risk profiles; and [e] inadequate food supply versus client need. Interviewees also identified social challenges between system leaders and clients that maintain disparities in obesity risk among individuals with very low food security including: [a] media representation and stereotypes about food pantry clients; [b] mistrust in communities of color; [c] lack of inclusion/representation among food bank system leaders; and [d] access to information. CONCLUSION: Future efforts to alleviate obesity inequities among clients chronically burdened by food insecurity, especially among certain subpopulations of clients, should prioritize policy, systems, and environmental strategies to overcome these structural and social challenges within the food banking system.

Childhood Obesity Evidence Base Project: Methods for Taxonomy Development for Application in Taxonomic Meta-Analysis.

Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2-5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019.

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA's new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force's main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.

New research directions on disparities in obesity and type 2 diabetes.

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

A Framework for Increasing Equity Impact in Obesity Prevention.

One of the most pressing unmet challenges for preventing and controlling epidemic obesity is ensuring that socially disadvantaged populations benefit from relevant public health interventions. Obesity levels are disproportionately high in ethnic minority, low-income, and other socially marginalized US population groups. Current policy, systems, and environmental change interventions target obesity-promoting aspects of physical, economic, social, and information environments but do not necessarily account for inequities in environmental contexts and, therefore, may perpetuate disparities.I propose a framework to guide practitioners and researchers in public health and other fields that contribute to obesity prevention in identifying ways to give greater priority to equity issues when undertaking policy, systems, and environmental change strategies. My core argument is that these approaches to improving options for healthy eating and physical activity should be linked to strategies that account for or directly address social determinants of health.I describe the framework rationale and elements and provide research and practice examples of its use in the US context. The approach may also apply to other health problems and in countries where similar inequities are observed.

Two-Year Results of Think Health! ¡Vive Saludable!: A Primary Care Weight-Management Trial.

OBJECTIVE: Think Health! ¡Vive Saludable! evaluated a moderate-intensity, lifestyle behavior-change weight-loss program in primary care over 2 years of treatment. Final analyses examined weight-change trajectories by treatment group and attendance. METHODS: Adult primary care patients (n = 261; 84% female; 65% black; 16% Hispanic) were randomly assigned to Basic Plus (moderate intensity; counseling by primary care clinician and a lifestyle coach) or Basic (clinician counseling only). Intention-to-treat analyses used all available weight measurements from data collection, treatment, and routine clinical visits. Linear mixed-effects regression models adjusted for treatment site, gender, and age, and sensitivity analyses evaluated treatment attendance and the impact of loss to follow-up. RESULTS: Model-based estimates for 24-month mean (95% CI) weight change from baseline were -1.34 kg (-2.92 to 0.24) in Basic Plus and -1.16 kg (-2.70 to 0.37) in Basic (net difference -0.18 kg [-2.38 to 2.03]; P = 0.874). Larger initial weight loss in Basic Plus was attenuated by a ~0.5-kg rebound at 12 to 16 months. Each additional coaching visit was associated with a 0.37-kg greater estimated 24-month weight loss (P = 0.01). CONCLUSIONS: These findings in mostly black and Hispanic female primary care patients suggest that strategies to improve treatment attendance may improve weight loss resulting from moderate-intensity counseling.

Family food purchases of high- and low-calorie foods in full-service supermarkets and other food retailers by Black women in an urban US setting.

Public health interventions to increase supermarket access assume that shopping in supermarkets is associated with healthier food purchases compared to other store types. To test this assumption, we compared purchasing patterns by store-type for certain higher-calorie, less healthy foods (HCF) and lower-calorie, healthier foods (LCF) in a sample of 35 black women household shoppers in Philadelphia, PA. Data analyzed were from 450 food shopping receipts collected by these shoppers over four-week periods in 2012. We compared the likelihood of purchasing the HCF (sugar-sweetened beverages, sweet/salty snacks, and grain-based snacks) and LCF (low-fat dairy, fruits, and vegetables) at full-service supermarkets and six other types of food retailers, using generalized estimating equations. Thirty-seven percent of participants had household incomes at or below the poverty line, and 54% had a BMI >30. Participants shopped primarily at full-service supermarkets (55%) or discount/limited assortment supermarkets (22%), making an average of 11 shopping trips over a 4-week period and spending mean (SD) of $350 ($222). Of full-service supermarket receipts, 64% included at least one HCF item and 58% at least one LCF. Most trips including HCF (58%) and LCF (60%) expenditures were to full-service or discount/limited assortment supermarkets rather than smaller stores. Spending a greater percent of total dollars in full-service supermarkets was associated with spending more on HCF (p = 0.03) but not LCF items (p = 0.26). These findings in black women suggest a need for more attention to supermarket interventions that change retailing practices and/or consumer shopping behaviors related to foods in the HCF categories examined.

Family PArtners in Lifestyle Support (PALS): Family-based weight loss for African American adults with type 2 diabetes.

OBJECTIVE: To develop and test a family-centered behavioral weight loss intervention for African American adults with type 2 diabetes. METHODS: In this randomized trial, dyads consisting of an African American adult with overweight or obesity and type 2 diabetes (index participant) paired with a family partner with overweight or obesity but not diagnosed with diabetes were assigned in a 2:1 ratio to a 20-week special intervention (SI) or delayed intervention (DI) control group. The primary outcome was weight loss among index participants at the 20-week follow-up. RESULTS: One hundred eight participants (54 dyads-36 (SI) and 18 (DI) dyads) were enrolled: 81% females; mean age, 51 years; mean weight,103 kg; and mean BMI, 37 kg/m2 . At post-intervention, 96 participants (89%) returned for follow-up measures. Among index participants, mean difference in weight loss between groups was -5.0 kg, P <0.0001 (-3.6 kg loss among SI; 1.4 kg gain in DI). SI index participants showed significantly greater improvements in hemoglobin A1c, depressive symptoms, family interactions, and dietary, physical activity, and diabetes self-care behaviors. SI family partners also had significant weight loss (-3.9 kg (SI) vs. -1.0 kg (DI), P = 0.02). CONCLUSIONS: A family-centered, behavioral weight loss intervention led to clinically significant short-term weight loss among family dyads.