The causal associations between interoception, self-regulation, non-purposeful eating behaviors, and weight status in college women: a longitudinal cross-lagged model analysis.

AIMS: Excessive weight gain has led to increased obesity and mortality risk among college students. Issues with maintaining a healthy weight may be attributed to poor internal awareness and unhealthy eating behaviors. The study's purpose was to determine the longitudinal effects among interoception, self-regulation, nonpurposeful eating behaviors, and weight status (BMI) among college women. METHODS: Data from 103 females were collected via Qualtrics over 3 timepoints (T1, T2, T3) during an academic semester. Repeated measures ANOVA and cross-lagged model analyses were used. Significant changes were found in interoceptive responsiveness, external, and uncontrolled eating throughout 3 timepoints. RESULTS: Longitudinally, significant causal effects were found among the study measures. Among all models, higher interoceptive responsiveness (T1) predicted increased self-regulation (T2). Higher non-purposeful eating behaviors (T1) predicted reduced self-regulation (T2). Higher BMI (T1) predicted reduced non-purposeful eating behaviors (T2), however higher BMI (T2) predicted increased non-purposeful eating (T3) and reduced interoceptive responsiveness (T3). Significant causal effects were found within each non-purposeful eating behavior models. CONCLUSION: Overall, the research study provided foundational evidence of the importance of self-regulatory skills to help prevent unhealthy eating behaviors and increased weight status in college women. Future interventions educating college women to become more internally aware and better self-regulate are needed.

The Effect of Time-Equated Concurrent Training Programs in Resistance-Trained Men.

The purpose of this investigation was to compare the effects of three different concurrent training (CT) programs and a resistance training (RT) program. Twenty-three resistance trained men (age: 24 ± 3 years) were randomized into four groups: concurrent RT and high intensity interval cycling (CTH, n = 6), concurrent RT and moderate intensity continuous cycling (CTM, n = 5), RT and barbell circuit training (RTC, n = 6), or RT only (RT, n = 6). Back squat and bench press strength, quadriceps, and pectoralis muscle thickness, VO2peak, and maximum workload (Wmax, Watts) were assessed. Squat strength gains were meaningful in all groups and comparable among CTH (16.88 kg [95% CrI: 11.15, 22.63]), CTM (25.54 kg [95% CrI: 19.24, 31.96]), RTC (17.5 kg [95% CrI: 11.66, 23.39]), and RT (20.36 kg [95% CrI: 15.29, 25.33]) groups. Bench press strength gains were meaningful in all groups and comparable among CTH (11.86 kg [95% CrI: 8.28, 15.47]), CTM (10.3 kg [95% CrI: 6.49, 14.13]), RTC (4.84 kg [95% CrI: 1.31, 8.47]), and RT (10.16 kg [95% CrI: 7.02, 13.22]) groups. Quadriceps hypertrophy was meaningful in all groups and comparable among CTH (2.29 mm [95% CrI: 0.84, 3.76]), CTM (3.41 mm [95% CrI: 1.88, 4.91]), RTC (2.6 mm [95% CrI: 1.17, 4.05]), and RT (2.83 mm [95% CrI: 1.55, 4.12]) groups. Pectoralis hypertrophy was meaningful in CTH (2.29 mm [95% CrI: -0.52, 5.1]), CTM (5.14 mm [95% CrI: 2.1, 8.15]), and RTC (7.19 mm [95% CrI: 4.26, 10.02]) groups, but not in the RT group (1 mm [95% CrI: -1.59, 3.59]); further, between-group contrasts indicated less pectoralis growth in the RT compared to the RTC group. Regarding cardiovascular outcomes, only the RTH and RTM groups experienced meaningful improvements in either measure (VO2peak or Wmax). These data suggest that the interference effect on maximal strength and hypertrophy can be avoided when the aerobic training is moderate intensity cycling, high intensity cycling, or a novel barbell circuit for ~one hour per week and on non-RT days. However, the barbell circuit failed to elicit meaningful cardiovascular adaptations.

Effect of using the snackability app on snack quality among US college students with overweight and obesity: A randomized controlled trial.

OBJECTIVE: To determine if using the Snackability app improves snack intake among college students. PARTICIPANTS: US college students with overweight/obesity were recruited in June 2020-April 2021. METHODS: A randomized controlled trial was conducted to test the Snackability app use for 12 wk on snack scores (calculated from the app) compared to controls. We also explored the effect on diet quality (Healthy Eating Index-2015) and weight. Outcomes were compared between the intervention and the control groups at 4, 8, and 12 wk using repeated measures ANOVA. RESULTS: Participants in the app group significantly increased snack score at week 4 (p < 0.001) and week 8 (p = 0.015) and increased HEI-2020 score (p < 0.001) at week 4 compared to controls. The first 4 wk had the highest app usage. No significant differences were seen in body weight. CONCLUSIONS: The Snackability app can be used as a tool to help improve snack and diet quality in this group.

Interoception and self-regulation of eating behaviors and weight status in college students.

OBJECTIVE: To determine the associations between interoception, self-regulation, eating behaviors, and weight status among college students. PARTICIPANTS: 229 female undergraduates, predominantly classified as Juniors (51.1%) and identified as Hispanic/Latinx (75%) with a mean age of 23.4 (SD = 6.3), were examined. METHODS: Cross-sectional data using baseline measures from a larger, longitudinal study, were examined. Confirmatory factor analyses and structural equation modeling were conducted to test hypotheses. RESULTS: Interoception was directly associated to self-regulation. Interoception and self-regulation were inversely associated with non-purposeful eating. Non-purposeful eating was directly associated with weight status. CONCLUSION: This study provided empirical evidence on the associations between interoception, self-regulation, eating behaviors, and weight status. Our results support the need for programs that target college students' cognitive skills to reduce unhealthy eating behaviors and optimize weight status. Future interventions are needed to enhance interoception and self-regulation skills so that college students can be more purposeful in their eating habits.

Exploring Differences in Physical Health in Young Children With and Without ADHD.

OBJECTIVE: To assess differences in child physical health outcomes and metrices associated with obesity in a sample of predominantly Hispanic/Latinx young children with and without attention-deficit/hyperactivity disorder (ADHD). METHODS: Participants included 127 children diagnosed with ADHD and 96 typically developing (TD) children between 4 and 7 years of age. Objective measures of children's body composition, fitness, and physical activity were conducted. Parents of children completed food recalls to assess their child's dietary intake, diet quality was calculated based on the Healthy Eating Index-2015, and parents completed a survey about their family's health habits. RESULTS: Logistic regression revealed that those with ADHD were more likely to be classified as having an overweight or obese (Ov/O) body mass index (BMI). Linear regression analyses indicated that children with ADHD performed worse on a fitness test and consumed more calories relative to TD children. Moderation analyses indicated that sex differences in steps were prominent in our TD sample, but not among those with ADHD. CONCLUSIONS: Young children with ADHD are at greater risk for having an Ov/O BMI, being less fit, and eating a greater intake of calories compared to TD children.

Life Satisfaction and Emerging Health Behaviors in Underserved Adolescents: A Narrative Review.

Objectives: Obesity rates continue to rise in underserved adolescents. Obesity is linked to poor mental health outcomes. The purpose of this narrative review is to examine existing literature on life satisfaction and obesity-related emerging health behaviors (sugar-sweetened beverage consumption, sleeping patterns, and screen time) in underserved adolescents. Methods: We conducted a review of articles published in English between January 1995 and November 2021 to develop a narrative summary. Results: In general, few studies have been conducted investigating life satisfaction and the emerging behaviors of sugar-sweetened beverage consumption, sleeping patterns, and screen time use with adolescents, especially underserved adolescents. In the studies reviewed, we noted links between lower life satisfaction and more than once-a-day sugar consumption, including sugar-sweetened beverages, lower life satisfaction and lower sleep duration, and life satisfaction and screen-time, with both positive and negative relationships shown. Conclusions: Given the limitations in the number of studies, recommendations are provided for future research.

Snacking behavior is associated with snack quality, overall diet quality, and body weight among US college students.

Snacking behavior may affect snack quality, overall diet quality, and body weight; however, the associations between these variables have not been studied among college students. The objective of this study was to associate snacking behaviors with snack quality, diet quality, and weight status among college students with overweight and obesity. We hypothesized that a higher snacking frequency, accessibility and availability of unhealthy snacks, and lack of knowledge would be associated with lower snack and diet quality, and higher weight. Participants (n = 140) completed a snack behavior questionnaire, three 24-hour dietary recalls to assess diet quality using Healthy Eating Index 2015 (HEI-2015), and snack score using an algorithm based on the US DA Smart Snack guidelines and reported weight and height to calculate body mass index (BMI). Analysis of variance and Pearson correlation was used in the analyses. After adjusting for confounders, snack frequency was not associated with snack score, HEI-2015 score, or BMI, but evening snacks had a significantly lower snack score compared with late afternoon snacks (P = .017). Also, those with more accessibility and availability of unhealthy snacks had a lower snack score (P = .001), lower HEI-2015 score (P = .006), and higher BMI (P = .019). Snacking for pleasure was significantly associated with a lower snack score (P = .037). Snack score was positively correlated with HEI-2015 score but not with BMI. In conclusion, late snacking, unhealthy snack environment, and snacking for pleasure were associated with lower snack and diet quality. These findings could be used in future intervention strategies to improve snacking behaviors and the food environment.

Perceived Role of Asian Indian Fathers in Florida During Mealtimes: Factors to Consider for Their Involvement in Childhood Obesity Prevention.

Research has shown that fathers play an important role in children's mealtimes and dietary habits; yet, little is known about the factors that affect how fathers perceive this role, especially among Asian Indians. This study aimed to examine how Asian Indian fathers perceive their role during child mealtimes and the factors that are associated with fathers' mealtime perceptions. Eighty Asian Indian fathers of 6- to 11-year-old children completed an online survey including measures of demographics, acculturation, gender roles, nutrition knowledge, parental self-efficacy, perceived child weight, and the role of father at mealtime (ROFM). Data were analyzed using descriptive statistics and linear regression. Participants perceived a moderately high level of responsibility during child mealtimes. Regression analysis showed that fathers who had higher income, perceived child weight as being higher, and had higher self-efficacy in feeding children healthy food had higher ROFM. Higher father nutrition knowledge was correlated with lower perceived ROFM, indicating a lack of confidence in utilizing their nutrition knowledge during child mealtimes. The results indicate potential targets to improve Asian Indian fathers' involvement during child mealtimes. These results could be utilized to enhance their engagement in child mealtime healthy eating practices and for childhood obesity prevention.

Impact of a Montessori-Based Nutrition Program on Children's Knowledge and Eating Behaviors.

BACKGROUND: Poor dietary habits in childhood can lead to obesity and chronic diseases later in life. Increasing children's nutrition knowledge and liking of fruits and vegetables are key factors in improving diet quality. The purpose of this study was to assess the effects of a nutrition program on knowledge, liking and intake of fruits and vegetables in Montessori students. METHODS: Clustered-randomized control trial conducted in a Southeastern US Montessori school. Children aged 4-6 years old (intervention, n = 22; control, n = 29) participated in a 4-week nutrition education with taste testing of 12 fruits and vegetables. Nutrition knowledge, fruit and vegetable liking, and intake were measured with questionnaires, and analyzed using repeated measures analysis of covariance and descriptive analyses (SPSS v.23); significance defined as p < 0.05. RESULTS: Controlling for covariates, significant between group effects for nutrition knowledge (F = 24.16, p < 0.001) and liking tomatoes (F = 7.01, p = 0.01) were found. The intervention group increased vegetable intake (Hedges' g = 1.01) compared to the control, although it was not significant between groups (F = 1.95, p = 0.17). CONCLUSIONS: Initial examination of this program indicates that it was effective in increasing knowledge, vegetable liking and intake for young children in the sample. More research is needed to compare outcomes between educational delivery methods.

Dissemination trial for Health for Hearts United: Model development, preliminary outcomes and lessons learned.

Background: Cardiovascular disease CVD), the leading cause of death in the U.S., is a particular problem for African Americans (AAs). Church-based health interventions are effective in reducing CVD risk, yet few have been successfully disseminated. This paper describes the model development, preliminary health outcomes, and lessons learned from the Health for Hearts United (HHU) dissemination trial which evolved from the longitudinal Reducing CVD Risk Study in a two-county area in North Florida. Community-based participatory research approaches and the socio-ecological model guided the study. Methods: Data for this paper were from health leaders (n = 25) in the first six churches investigated, and the outreach participants (n = 86) they engaged. Health leaders completed survey items (daily servings of fruits/vegetables [F/V], fat consumption [FAT], and daily minutes of physical activity [PA]) and clinical measures (body mass index [BMI]; waist, hip and abdomen circumferences; and systolic and diastolic blood pressure [BP]). For outreach participants, a brief CVD Awareness Quiz was administered. Data were analyzed using description statistics, Pearson correlations, and repeated measures analysis of variance. Results: Findings showed that the dissemination model was implemented by 100% of the churches, and resulted in health outcomes changes for health leaders (significant increases between pre- and post-test in F/V; significant decreases in FAT, BMI, abdomen circumference, with educational level and marital status as selected significant covariates) and in a significant increase in CVD awareness for outreach participants. Lessons learned are discussed. Although preliminary, the results suggest that the HHU dissemination model has promise for reducing CVD risk in AA's.

A snapshot of eating behaviors in undergraduate college students living in South Florida.

Objective: To examine a) whether college students' eating behaviors are different by students' sex and/or body mass index (BMI) categories and b) the correlations between college students' eating behaviors and the degree to which they rely on internal bodily signals for food intake. Participants: Undergraduate college students 18-24 years old at a public university located in South Florida. Methods: Eligible students answered questionnaires to examine interoception, intuitive eating, and eating behaviors including emotional eating, restrained eating, cognitive restraint, external eating, and uncontrolled eating. Pearson correlation and independent t test were used (significance: p < 0.05). Results: Females reported lower interoception, intuitive eating, and higher emotional eating than males. Students with lower BMI had higher intuitive eating and lower restrained eating. Interoception was positively correlated with intuitive eating and negatively correlated with emotional, uncontrolled, restrained, and external eating. Conclusion: College students who have a better connection with their bodily signals have healthier eating behaviors and lower BMI.

Calorie Compensation and Self-Regulation of Food Intake in College Students.

OBJECTIVE: To examine self-regulation of food intake among college students. DESIGN: Randomized cross-over study completed between September and November, 2019. SETTING: A large public university, Florida International University in South Florida. PARTICIPANTS: A total of 60 undergraduate college students, mean age of 19.8 ± 1.43 years old, 62% female, 74% Hispanic, 76% White. INTERVENTION(S): Participants attended 2 trials 1 week apart. During each visit, students were offered a preload drink (either 0 or 210 kcal) followed by a buffet-style lunch. Food intake was estimated using weights and pictures of the plates before and after eating and was compared between the 2 sessions. MAIN OUTCOME MEASURE(S): Self-regulation by calculating compensation indices (COMPX) and their correlation with students' body mass index (BMI). ANALYSIS: Intake differences were examined using Welch and t tests. Regression analysis was used to assess correlations. RESULTS: Students exhibited the ability to calorie compensate when intake is manipulated with a mean COMPX of 95.57 ± 71.19. No score was perfect. There was a significant correlation between BMI and COMPX scores (F = 10.71, P < 0.001, r2 = 0.292). Food choices differed between different BMI categories. CONCLUSIONS AND IMPLICATIONS: Participants showed some degree of self-regulation, which suggests opportunities for creating effective interventions to improve health status and promote a more sustainable method to control consumption among college students.

How much and what: Using a buffet to determine self-regulation of food intake among young school-age children.

Energy compensation indices are commonly used to examine self-regulation of food intake in children. However, previous studies failed to consider children's ability to self-regulate under complete autonomy. This study examined self-regulation of food intake among young children and the effect of calorie manipulation on food/nutrient intake using an unlimited lunch buffet paradigm. Participants were 66 children (Mage = 6.14, SD = 1.15 years; 68.2% male; 89.4% Latinx; 59.1% overweight/obese [OV/OB]). Children participated in a crossover research trial, one week apart. Participants consumed 2 different types of preloads followed by an ad-libitum lunch during each trial. A compensation index (COMPX) was calculated to identify the level of self-regulation in food intake. Food/nutrient intake was compared between both sessions. Results indicated OV/OB children showed poorer self-regulation compared to healthy weight children (t = 2.19, p = 0.032; Hedges' g = 0.55). There were significant differences in food intake/selection between OV/OB and healthy weight groups. OV/OB children consumed a higher amount of calorie, fat, and cholesterol after the high energy preload compared to healthy weight children (d's range: 0.31-0.48). Our findings support differences between the amount of self-regulation between normal and OV/OB children as well as the items they select in order to compensate.

A Youth Health Leadership Program: Feasibility and Initial Outcomes.

This study determined the feasibility (attendance, participation and completion) and initial outcomes (food consumption, food acquisition, physical activity and leadership) of a community-based youth health leadership (YHL) program. YHL was developed as a part of a larger childhood obesity prevention coalition in a medium-sized community in North Florida using community-based participatory research approaches. The theory-driven 6-week program included content sessions, application rotation, and health campaign. Data were collected from youth participants (n = 36) and a purposive comparison group (n = 29) via self-administered questionnaire and project records in the first three years of YHL. Feasibility outcomes show that the majority of program participants attended and participated. Completion rates ranged from 61.5% in year one to 100% in years two and three. Significant differences in treatment and comparison groups were noted in frequency of fruit consumption (p < 0.001) and physical activity (p < 0.002). However, there were no clear patterns of improvements for the treatment group. Trends in the data showed that the consumption of foods high in fat, sugar and sodium decreased slightly for the treatment group but increased or remained the same for the comparison group. The leadership outcomes for youth participants show that those reached are furthering their education, participating in activities such as internships, receiving honors, and garnering leadership achievements. This study suggests that a community-based youth health leadership model is feasible, but more work is needed to impact health behaviors. Future research directions are provided.

Tweeting for Nutrition: Feasibility and Efficacy Outcomes of a 6-Week Social Media-Based Nutrition Education Intervention for Student-Athletes.

Coccia, C, Fernandes, SM, and Altiti, J. Tweeting for nutrition: feasibility and efficacy outcomes of a 6-week social media-based nutrition education intervention for student-athletes. J Strength Cond Res 34(7): 2084-2092, 2020-The main objective of this study was to determine the feasibility and efficacy of a social media-based nutrition intervention using Twitter on nutrition knowledge, dietary practices, body mass index (BMI), self-efficacy, and social support among student-athletes. Participants included 50 male and female National Collegiate Athletic Association Division I student-athletes between the ages of 18 and 24 years. Data were collected in October 2014. The study design employed a 6-week social media intervention using Twitter, to increase nutrition knowledge, self-efficacy, social support, and dietary adherence to the recommendations from the Dietary Guidelines for Americans. Descriptive statistics were calculated for all study variables and pre-post differences were assessed using paired t-tests. The results indicate a 6-week nutrition intervention delivered solely through social media resulted in increased nutrition knowledge (t = -2.23; p = 0.035), reduced fat intake (t = -1.57; p = 0.13), and decreased BMI (t = 2.32; p = 0.027) in student-athletes. In conclusion, social media-based nutrition education may provide university-based strength and conditioning coaches and other sports practitioners with a tool for widespread and timely access to students to facilitate healthy dietary behaviors.

Health for Hearts United Longitudinal Trial: Improving Dietary Behaviors in Older African Americans.

INTRODUCTION: Church-based interventions have been shown to improve the dietary health of underserved populations, yet few studies have examined sustainability of health behavior change over time. This paper examines dietary outcomes over a 24-month period (baseline and 6, 18, and 24 months) for fruit and vegetable and fat consumption behaviors of African-American participants in the Health for Hearts United church-based intervention in North Florida. STUDY DESIGN: This quasi-experimental, longitudinal trial was conducted from 2009 to 2012. Data were analyzed in 2018. SETTING/PARTICIPANTS: Six churches in a 2-county area (3 treatment, 3 comparison) were selected for the study using community-based participatory research approaches. Participants were African-American adults (aged ≥45 years; n=211 at baseline) randomly selected from the churches, stratified by age and sex. INTERVENTION: Health for Hearts United intervention was developed by the 3 treatment churches. The 18-month intervention was implemented in 3 6-month phases, framed around 3 conceptual components, which included 4 types of programs and 4 key messages. MAIN OUTCOME MEASURES: Fruit and vegetable consumption was assessed using a single item (fruit and vegetable intake) and the National Cancer Institute Fruit and Vegetable Screener. Fat consumption was determined using a single item (fat intake) and the National Cancer Institute Fat Screener. Background characteristics included age, sex, educational level, and marital status. RESULTS: Significant time effects only were found for daily fruit and vegetable intake (p<0.001), fat intake (p<0.001), and the Fat Screener (p<0.001) with dietary improvements in both treatment and comparison groups across the intervention phases. Fruit and Vegetable Screener results showed that time (p<0.001) and the interaction between time and treatment (p<0.01) were significant, with increases in fruit and vegetable consumption over time for both the treatment and comparison groups and with the increase differing between groups. Post hoc analysis revealed that the treatment group had greater increases in fruit and vegetable consumption than the comparison group between Phases 1 and 3 (p=0.03). CONCLUSIONS: Dietary behaviors of mid-life and older African Americans can be improved and sustained over 24 months using a church-based heart health intervention, with similar improvements noted for both comparison and treatment participants. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.govNCT03339050.

The Breast-Cancer Education and Wellness (BE Well) Intervention: Congregants' Intended Participation, Actual Participation, and Perceived Health Outcomes.

Objective. To evaluate a health leader-focused church-based breast cancer prevention intervention in relation to congregants' intended participation, congregants' actual participation, and perceived health outcomes at both individual and church levels using socio-ecological and theory of planned behavior frameworks. Method. Participants for the study were African American adults (n = 52) from six churches in a North Florida county involved in implementing the 9-month, three-phase intervention. Using a pre/post without comparison group design, data were collected via self-administered surveys and analyzed using qualitative and quantitative (descriptive, analysis of variance, linear regression) procedures. Results. There was general alignment between congregants' intended and actual participation when analyzed by content, especially in the areas of food and nutrition and health education. Regarding the number of intended versus actual activities, there was a significant, negative change in physical activity, a slight decline in health education activities, but a slight increase in food and nutrition activities. No significant relationships were found between extent of participation and the individual health outcomes (health ratings, health status), but significant relationships were found between extent of participation and church health outcomes (perceived role of church in improving health, p < .001; perceived role of the pastor in improving health, p < .001). Conclusions. The findings demonstrate that (1) congregants may follow through and participate in church-based health activities in which they express interest and that are made available and (2) the extent of their participation may be influenced by the perceived role of both the church and the pastor in improving their health.

Effectiveness of the Nutritional App "MyNutriCart" on Food Choices Related to Purchase and Dietary Behavior: A Pilot Randomized Controlled Trial.

OBJECTIVE: To pilot test the effectiveness of "MyNutriCart", a smartphone application (app) that generates healthy grocery lists, on diet and weight. METHODS: A pilot randomized trial was conducted to test the efficacy of using the "MyNutriCart" app compared to one face-to-face counseling session (Traditional group) in Hispanic overweight and obese adults. Household food purchasing behavior, three 24-h food recalls, Tucker's semi-quantitative food frequency questionnaire (FFQ), and weight were assessed at baseline and after 8 weeks. Statistical analyses included t tests, a Poisson regression model, and analysis of covariance (ANCOVA) using STATA. RESULTS: 24 participants in the Traditional group and 27 in the App group completed the study. Most participants were women (>88%), with a mean age of 35.3 years, more than a high school education (>80%), a family composition of at least three members, and a mean baseline body mass index (BMI) of 34.5 kg/m². There were significant improvements in household purchasing of vegetables and whole grains, in individual intakes of refined grains, healthy proteins, whole-fat dairies, legumes, 100% fruit juices, and sweets and snacks; and in the individual frequency of intake of fruits and cold cuts/cured meats within the intervention group (p < 0.05). However, no significant differences were found between groups. No changes were detected in weight. CONCLUSIONS: "MyNutriCart" app use led to significant improvements in food-related behaviors compared to baseline, with no significant differences when compared to the Traditional group. Cost and resource savings of using the app compared to face-to-face counseling may make it a good option for interventionists.

The Development of Health for Hearts United: A Longitudinal Church-based Intervention to Reduce Cardiovascular Risk in Mid-life and Older African Americans.

This article describes Health for Hearts United, a longitudinal church-based intervention to reduce cardiovascular disease (CVD) risk in mid-life and older African Americans. Using community-based participatory research (CBPR) approaches and undergirded by both the Socio-ecological Theory and the Transtheoretical Model of Behavior Change, the 18-month intervention was developed in six north Florida churches, randomly assigned as treatment or comparison. The intervention was framed around three conceptual components: awareness building (individual knowledge development); clinical learning (individual and small group educational sessions); and efficacy development (recognition and sustainability). We identified three lessons learned: providing consistency in programming even during participant absences; providing structured activities to assist health ministries in sustainability; and addressing changes at the church level. Recommendations include church-based approaches that reflect multi-level CBPR and the collaborative faith model.