Caregiver perceptions of a pediatric produce prescription program during the COVID-19 pandemic.

Introduction: Produce prescription programs are rapidly expanding as a type of Food is Medicine intervention with prospects for mitigating food insecurity and reducing diet-related health disparities. Gaining insight into participant perspectives on program logistics and perceived impacts is crucial to program success and improvements. Methods: Between May and June 2021, we conducted individual and small group interviews with 23 caregivers with children aged 1-5 years who participated in a produce prescription program from 2020 to 2021 in Texas, U.S. They were provided with a gift card to a major national grocery retailer to purchase fresh produce. The card was reloaded $60 monthly for 8 months with automatic roll-over of unused funds to the next month. Participants also received nutrition education in the form of two videos. A deductive analysis approach was employed, and NVivo qualitative data analysis software was used to perform coding and to assist with subsequent analyses. Results: All 23 participants were female, with an average age of 37.5 years, and the majority identified as Hispanic/Latino (83%). About 43% of the families had three or more children. Six themes were generated from interviews. Three of these themes were related to program logistics: (1) ease of program use; (2) participant satisfaction with the incentive; and (3) desire for additional store options. The remaining main themes pertained to program impact: (1) the enhanced ability to purchase produce; (2) the usefulness of the nutrition education; and (3) persistent challenges encountered when preparing the produce for picky eaters and young children. Conclusion: A pediatric produce prescription program was perceived as logistically easy and a helpful source of financial support for accessing fresh produce. Program features such as card-based incentive system and partnership with major grocery retailer were favored by participants. For future program design, it may be beneficial to consider collaborating with multiple grocery outlets and enhancing the intensity and targeting of nutrition education.

Are Caregivers' Feeding Competence and Autonomy Associated with Healthier Restaurant Food Purchases for Their Child at Fast Food or Counter Service Restaurants? A Cross-Sectional Study in a Diverse Sample of U.S. Caregivers.

This study examined the cross-sectional relationship between caregivers' perceived competence and autonomy (as defined by the Self-Determination Theory) and their fast food or counter service restaurant food purchases (side dishes, beverage, and dessert) for their child. A U.S. national convenience sample of caregivers with at least one 3-12-year-old child completed an online survey with questions adapted from the Intrinsic Motivation Inventory that measured perceived competence and autonomy for feeding fruits and vegetables and limiting sugar-sweetened beverages (SSBs) and desserts. The survey included four questions asking about their fast food or counter service restaurant food purchases (side dish, beverage, and dessert). We applied logistic and multinomial logistic regression models to examine the associations between competence or autonomy and restaurant orders. Competence and autonomy were associated with ordering fruits and vegetables as side dishes (OR [95% CI], 1.14 [1.06, 1.24] and 1.09 [1.03, 1.14], respectively). However, higher competence was also associated with ordering desserts at restaurants and higher autonomy was associated with lower odds of ordering water. These findings will inform interventions and programs that aim to support caregivers' psychological needs, like competence and autonomy, to promote supportive environments and healthier restaurant purchases for their children.

The longitudinal association between caregivers' perceived competence and autonomy and children's dietary consumption before and 10 months into the COVID-19 pandemic.

The COVID-19 pandemic has been stressful, potentially affecting caregivers' feeding choices. Caregivers play a role in shaping children's diets, yet few studies have explored how their competence and autonomy, defined by the Self-Determination Theory, impact children's diets. We examined the relationship between caregivers' autonomy and competence and their feeding practices before and during the first year of the pandemic. A national convenience sample of caregivers with 3-12-year-old children completed an online survey during two time-periods. Questions adapted from the Intrinsic Motivation Inventory measured perceived competence and autonomy for feeding fruits and vegetables (F/V) and limiting sugar-sweetened beverages (SSBs) and desserts. National Health and Nutrition Examination Survey Dietary Screener questions measured children's consumption of F/V, SSBs, and desserts. Paired t-tests examined how child consumption and caregiver's perceived competence and autonomy changed, and logistic regressions examined whether caregivers' competence and autonomy predicted the change in child consumption and if changes in competence and autonomy were associated with changes in child consumption. Caregivers (n = 597) were mostly Black/African American (33.0%) or Latina/o/x (42.7%) and older than 30 years (84.1%). Children's consumption did not change overall, but caregivers' competence for feeding F/V increased, and their competence for limiting SSBs and desserts decreased. Caregiver competence and autonomy before COVID-19 did not predict child dietary consumption during the pandemic. However, change in competence was a significant predictor of the change in child consumption of F/V [OR (95%CI): 0.70 (0.57, 0.86)]. The association between caregiver's perceived competence for feeding F/V and child consumption remained positive and significant in both periods [OR (95%CI) pre and during COVID: 2.09 (1.69, 2.57) - 2.40 (1.88, 3.06)]. This study can inform behavioral interventions supporting caregivers' competence and autonomy around feeding choices.

Adoption and implementation of produce prescription programs for under-resourced populations: clinic staff perspectives.

Background: Produce prescription programs represent a promising intervention strategy in the healthcare setting to address disparities in diet quality and diet-related chronic disease. The objective of this study was to understand adoption and implementation factors related to these programs that are common across contexts and those that are context-specific. Methods: In this qualitative case comparison study, we conducted qualitative interviews with eight clinic staff from five primary care "safety net" clinics, identified by a partnering non-profit organization that operated the programs, in April-July 2021. Results: Across clinics, the ability to provide a tangible benefit to patients was a key factor in adoption. Flexibility in integrating into clinic workflows was a facilitator of implementation. Fit with usual operations varied across clinics. Common challenges were the need for changes to the workflow and extra staff time. Clinic staff were skeptical about the sustainability of both the benefits to patients and the ability to continue the program at their clinics. Discussion: This study adds to a growing body of knowledge on the adoption and implementation of produce prescription programs. Future research will further this understanding, providing the evidence necessary to guide adopting clinics and to make informed policy decisions to best promote the growth and financial sustainability of these programs.

Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0.

BACKGROUND: Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating. OBJECTIVES: This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program. METHODS: A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models. RESULTS: At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating). CONCLUSIONS: SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www. CLINICALTRIALS: gov as NCT03059472.

Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States.

BACKGROUND: Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations. METHODS: This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2-17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4-10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI z-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program. RESULTS: After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68-1.02) and 0.26 (95% CI, 0.06-0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52-0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30-2.02]) and children (odds ratio, 2.37 [1.70-3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by -0.29% age points (-0.42 to -0.16); among adults with hypertension, systolic and diastolic blood pressures declined by -8.38 mm Hg (-10.13 to -6.62) and -4.94 mm Hg (-5.96 to -3.92); and among adults with overweight or obesity, BMI decreased by -0.36 kg/m2 (-0.64 to -0.09). Child BMI z-score did not change -0.01 (-0.06 to 0.04). CONCLUSIONS: In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health.

Effect of a Nutrition Intervention on Mediterranean Diet Adherence Among Firefighters: A Cluster Randomized Clinical Trial.

Importance: US firefighters are a working population at risk of chronic diseases, including obesity, cardiovascular disease, and cancer. This risk may be mitigated by a healthy diet. Objective: To evaluate the effect of a Mediterranean nutrition intervention using a behavioral/environmental approach (firefighter/fire station/home) at the individual participant level. Design, Setting, and Participants: This 12-month cluster randomized clinical trial included US career firefighters from fire stations and homes within 2 Indiana fire departments. Participants were randomized by fire station to either Mediterranean diet or control (usual care). The study was conducted from October 2016 to December 2019, and data were analyzed in November 2022. Intervention: For the first 12 months of the study, firefighters located at fire stations randomized to the intervention group were provided with access to supermarket discounts and free samples of Mediterranean diet foods, online nutrition education platforms, email announcements and reminders, family and peer education and support, and chef demonstrations. Firefighters in fire stations allocated to the control group received no intervention and were instructed to follow their usual diet. Main Outcomes and Measures: Change in dietary habits at 12 months as measured by a modified Mediterranean diet score (range, 0 to 51 points) at baseline and 6-month and 12-month follow-up. Cardiometabolic parameters were secondary outcomes. Results: Of 485 included firefighters, 458 (94.4%) were male, and the mean (SD) age was 47 (7.5) years. A total of 241 firefighters (27 fire stations) were randomized to the Mediterranean nutrition intervention, and 244 (25 fire stations) were randomized to usual diet. Outcomes were analyzed using generalized linear mixed models for modified Mediterranean diet score at 6 months (n = 336) and 12 months (n = 260), adjusting for baseline age, sex, race and ethnicity, fire department, physical activity, and waist circumference. In the intervention group compared with the control group, the modified Mediterranean diet score significantly increased by 2.01 points (95% CI, 0.62-3.40; P = .005) at 6 months and by 2.67 points (95% CI, 1.14-4.20; P = .001) at 12 months. Among secondary outcomes, changes in cardiometabolic risk factors were not statistically significant at 1 year. Results from analyses with multilevel multiple imputation for missingness were similar. Conclusions and Relevance: In this Mediterranean nutrition intervention of multicomponent behavioral/environmental changes, career firefighters had increased adherence to a Mediterranean diet. Trial Registration: ClinicalTrials.gov Identifier: NCT02941757.

A new tool to capture dimensions of family dinners in relation to adolescent health and risk-related outcomes: The 'Family Dinner Index'.

There is a strong association between family meals and child and adolescent health. To systematically understand the associations between family meals with a variety of health and risk outcomes, we developed and conducted a validation study of child- and parent-versions of the Family Dinner Index (FDI; FDI-C/FDI-P). We validated the measures with a national sample of 2,090 parent-child dyads. Using factor analysis, we reduced the initial FDIs each to eight items representing communication, enjoyment, and digital distractions; the FDI-C also included meal logistics and the FDI-P, family bonding. Using multivariable log-binomial regression models, we examined the relationships between FDI scores and substance use, violence, weight perception, weight control intention, and health indicators. Children who scored ≥21 on the FDI-C had a significantly lower average prevalence of a 'negative outcome' composite, as well as a lower prevalence of each of the individual behaviors. Children of parents who scored ≥24 on the FDI-P had a significantly lower average prevalence of the 'negative outcome' composite, as well as a lower prevalence of substance use indicators, negative weight perception and intentions to lose weight, less than daily fruit and vegetable consumption, and not meeting guidelines for physical activity. The FDI measures provide support for face and content validity, as well as concurrent criterion validity and construct validity. Further validation with these measures using a longitudinal design will allow for the establishment of predictive validity. Currently, the FDI measures may help researchers and practitioners identify points of emphasis for tailoring family-based prevention programs accordingly.

Exploring health behaviors and the role of pet dogs in households with autistic children: the DANE study.

Introduction: Autism spectrum disorder (ASD) often presents a unique set of risk factors that impact healthy eating and physical activity. Animal-assisted interventions (AAI) are a promising approach for autistic children. There is growing evidence for the positive impact of AAIs on self-regulation, which is necessary for initiating and maintaining behavioral changes. Pet dogs offer several potential advantages as a vehicle for an AAI focused on health behaviors. However, little is known about the experiences of autistic children and their families with respect to dog ownership and the mechanisms through which such an AAI might operate. Methods: We conducted interviews with ten parent-child dyads to explore the role of pet dogs in the lives and lifestyle habits of families with an autistic child. Interview guides were designed to explore the relationship between the autistic child and the pet dog and the role of the dog in family life; attitudes and practices related to physical activity and nutrition; and thoughts about intervention strategies. We used a directed qualitative content analysis approach for analysis. Results: Themes indicate a strong bond between the child and the dog, the child's enjoyment in caring for their dog, and successful integration of dogs within family routines. In contrast, minor themes emerged around the challenges that owning a pet dog posed for families with an autistic child. In terms of nutrition and physical activity, a major theme among children was that healthy eating and exercise were important for both them and their dogs. However, minor themes suggest challenges with healthy eating and exercise and room for improvement for these behaviors. Parents held favorable views toward an intervention that would incorporate the family dog to teach children about nutrition and physical activity, although they expressed some concerns about feasibility. Discussion: This exploratory work suggests that AAIs to improve nutrition and physical activity could build on the strong bond that children have with their pet dogs, but should consider the specific needs of each family, including the needs of the pet dog.

Effectiveness of Theory-Based Physical Activity and Nutrition Interventions in Aging Latino Adults: A Scoping Review.

In the United States (US), Latino individuals older than 50 years face health disparities compared to their White counterparts. Considering the rising life expectancy and the projected increase of older Latino adults in the US, this scoping review aimed to determine the effectiveness of theory-based and culturally relevant strategies that promote healthy aging in Latinos. Web of Science and PubMed databases were searched between December 2022 and February 2023 for peer-reviewed articles assessing healthy aging interventions tailored to community-dwelling aging Latino adults. We included nine studies describing the effects of seven interventions on physical activity- or nutrition-related outcomes. Although not always statistically significant, interventions had a beneficial impact on well-being indicators. The most commonly used behavioral theories were Social Cognitive Theory and Attribution Theory. Latino cultural elements in these studies included partnering with community organizations that serve Latinos (such as Catholic churches), delivery of in-person bilingual group sessions by trusted community members (such as promotoras or Latino dance instructors), and incorporating values such as family and religion into the health curriculum, among others. Future strategies that promote healthy aging in Latino adults should proactively culturally adapt the theoretical foundations and the design, recruitment, and implementation processes to ensure their relevance and effectiveness.

Recruiting experiences of NIH-funded principal investigators for community-based health behavior interventions during the COVID-19 pandemic.

Successful recruitment into randomized trials and interventions is essential to advance scientific knowledge to improve health. This rapid assessment study explored how the COVID-19 pandemic affected participant recruitment overall, identified how it exacerbated existing challenges to recruit hard-to-reach populations, and described how NIH-funded Principal Investigators (PIs) responded to COVID-era recruitment challenges. A cross-sectional survey of NIH-funded PIs conducting interventions and trials related to health behaviors was conducted in 2022. The survey was completed by 52 PIs, most of whom were highly experienced in this type of research. Eighteen PIs reported it was very difficult to recruit participants now (39.1%) compared to before COVID-19 when only one did (2.2%). PIs reported changing recruitment and data collection methods (29.4%), increasing staff dedicated to recruitment (29.4%), and increasing participant compensation (23.5%). Recruitment methods shifted from in-person activities to social media and other electronic communications. Barriers to recruitment included reluctance to participate in research, COVID-19 protocols and precautions, overwhelmed community partners, staff burnout and turnover, and limited access to technology for some populations that were already hard to reach. Facilitators to recruitment consisted of increased access and ability to use remote technologies, use of social media, strong community ties, and wanting to be part of something positive. PIs perceived recruitment as much more difficult after the onset of COVID-19, though research teams were able to pivot to more online and remote options. These tools may have a lasting impact in modernizing recruitment, data collection, and intervention techniques in future trials.

Fish-To Eat or Not to Eat? A Mixed-Methods Investigation of the Conundrum of Fish Consumption in the Context of Marine Pollution in Indonesia.

Background: The Indonesian government faces a dilemma of promoting fish consumption for its health benefits and to ease food insecurity, while at the same time seeking effective approaches to reduce the high levels of marine pollution. However, the factors associated with fish consumption in the face of persistent high levels of marine pollution are not well elucidated in the literature. Objectives: This was an explorative study to investigate the sociodemographic factors related to fish consumption and to understand the perspectives of expert informants on marine pollution and its impact on fish quality and availability in Indonesia. Methods: We characterized fish consumption among respondents aged 15 years and older in the fifth wave of the Indonesian Family Life Survey (n = 31,032), based on their sociodemographic profiles, and developed multinomial regression models to assess the relationship between respondents' sociodemographic profiles and quintiles of fish consumption. We also conducted in-depth interviews on fish consumption and marine pollution with key informants from Indonesia (n = 27). We then used a convergent mixed-methods design to synthesize the results of both datasets. Results: Fish was the most frequently consumed animal-source food reported by survey respondents: 2.8 (±2.6) days/week. More younger respondents (15-19 years) reported relatively lower consumption of fish (9.3% in Q1 versus 5.9% in Q5) compared to respondents 50 years and older (37% in Q1 versus 39.9% in Q5; p < 0.01). When classified by region, more respondents from the Java region reported lower consumption of fish (86.5% in Q1 versus 53% in Q5; p < 0.01). Key-informants' perspectives corroborated the survey results by indicating that the younger generation tends not to want to consume fish; informants expanded the survey results by suggesting that fish is scarce in the Java region due to high levels of marine pollution. Informants further implied that there is low awareness about the impact of marine pollution on fish quality among most of the Indonesian population. Conclusion: Evidence from both data sources converge on differential preference for fish consumption by age group. Informants' perspectives also link marine pollution to fish scarcity, which poses a threat to food security among low-income Indonesians and to human health globally. More studies are needed to corroborate our findings and inform policy guidelines to reduce marine pollution while promoting fish consumption in Indonesia.

Evaluation of a Produce Prescription Program for Patients With Diabetes: A Longitudinal Analysis of Glycemic Control.

OBJECTIVE: Produce prescriptions have shown promise in improving diabetes care, although most studies have used small samples or lacked controls. Our objective was to evaluate the impacts of a produce prescription program on glycemic control for patients with diabetes. RESEARCH DESIGN AND METHODS: Participants included a nonrandom enrollment of 252 patients with diabetes who received a produce prescription and 534 similar control participants from two clinics in Hartford, Connecticut. The start of the COVID-19 pandemic in March 2020 coincided with program implementation. Produce prescription enrollees received vouchers ($60 per month) for 6 months to purchase produce at grocery retail. Controls received usual care. The primary outcome was change in glycated hemoglobin (HbA1c) between treatment and control at 6 months. Secondary outcomes included 6-month changes in systolic (SBP) and diastolic blood pressure (DBP), BMI, hospitalizations, and emergency department admissions. Longitudinal generalized estimating equation models, weighted with propensity score overlap weights, assessed changes in outcomes over time. RESULTS: At 6 months, there was no significant difference in change in HbA1c between treatment and control groups, with a difference of 0.13 percentage points (95% CI -0.05, 0.32). No significant difference was observed for change in SBP (3.85 mmHg; -0.12, 7.82), DBP (-0.82 mmHg; -2.42, 0.79), or BMI (-0.22 kg/m2; -1.83, 1.38). Incidence rate ratios for hospitalizations and emergency department visits were 0.54 (0.14, 1.95) and 0.53 (0.06, 4.72), respectively. CONCLUSIONS: A 6-month produce prescription program for patients with diabetes, implemented during the onset of the COVID-19 pandemic, was not associated with improved glycemic control.

COVID-19 Related Protocol Considerations and Modifications within a Rural, Community-Engaged Health Promotion Randomized Trial.

Rural communities are at higher risk for physical inactivity, poor dietary behaviors, and related chronic diseases and obesity. These disparities are largely driven by built environment, socioeconomic, and social factors. A community-based cluster randomized controlled trial of an intervention, the Change Club, aims to address some of these disparities via civic engagement for built environment change. Baseline data collection began in February 2020, only to be paused by the COVID-19 pandemic. In this context, the investigators evaluated multiple approaches for collecting data when the study resumed, focusing on Life's Simple 7, and additional anthropometric, physiologic, and behavioral outcomes in rural and micropolitan (<50,000 population) communities in Texas and New York. Life's Simple 7 includes fasting blood glucose, total cholesterol, blood pressure, weight, physical activity, diet, and smoking. Rigor and feasibility were considered across a variety of in-person versus at-home measurement options. After a comprehensive input from participants, partners, staff, researchers, and the funding liaison, the study team chose self-measurement and use of validated questionnaires/surveys to measure the Life's Simple 7 components. This case provides an example of how a study team might adjust data collection protocol during unexpected and acute events while giving consideration to rigor, feasibility, stakeholder views, and participants' health and safety.

Better Understanding Wearable Activity Monitor Use and Non-Use Among Older Adults: A Qualitative Study.

We used qualitative methods to better understand wearable activity monitor (WAM) use and its relationship with physical activity (PA) among older adults. Four focus groups, stratified by current/past ("ever") WAM users and "never" WAM users, were conducted with 57 participants aged ≥60 years. Data were coded with deductive and inductive approaches. Among ever WAM users, those with low pre-WAM PA levels reported higher PA related to WAM use while those with high pre-WAM PA levels reported they used WAM for tracking and monitoring their activity. Ever WAM users were motivated to increase PA through rewards and social support. Many never WAM users reported that WAM was unnecessary. WAM may be helpful for some older adults to increase their PA, particularly those who are motivated by setting and achieving PA goals. The results could help develop strategies to overcome barriers to WAM adoption and promote WAM use among older adults.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial.

BACKGROUND: Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact. METHODS: A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance. RESULTS: Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks. CONCLUSIONS: This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03059472.

Evaluation of a civic engagement approach to catalyze built environment change and promote healthy eating and physical activity among rural residents: a cluster (community) randomized controlled trial.

BACKGROUND: Prior studies demonstrate associations between risk factors for obesity and related chronic diseases (e.g., cardiovascular disease) and features of the built environment. This is particularly true for rural populations, who have higher rates of obesity, cancer, and other chronic diseases than urban residents. There is also evidence linking health behaviors and outcomes to social factors such as social support, opposition, and norms. Thus, overlapping social networks that have a high degree of social capital and community cohesion, such as those found in rural communities, may be effective targets for introducing and maintaining healthy behaviors. METHODS: This study will evaluate the effectiveness of the Change Club (CC) intervention, a civic engagement intervention for built environment change to improve health behaviors and outcomes for residents of rural communities. The CC intervention provides small groups of community residents (approximately 10-14 people) with nutrition and physical activity lessons and stepwise built environment change planning workshops delivered by trained extension educators via in-person, virtual, or hybrid methods. We will conduct process, multilevel outcome, and cost evaluations of implementation of the CC intervention in a cluster randomized controlled trial in 10 communities across two states using a two-arm parallel design. Change in the primary outcome, American Heart Association's Life's Simple 7 composite cardiovascular health score, will be evaluated among CC members, their friends and family members, and other community residents and compared to comparable samples in control communities. We will also evaluate changes at the social/collective level (e.g., social cohesion, social trust) and examine costs as well as barriers and facilitators to implementation. DISCUSSION: Our central hypothesis is the CC intervention will improve health behaviors and outcomes among engaged citizens and their family and friends within 24 months. Furthermore, we hypothesize that positive changes will catalyze critical steps in the pathway to improving longer-term health among community residents through improved healthy eating and physical activity opportunities. This study also represents a unique opportunity to evaluate process and cost-related data, which will provide key insights into the viability of this approach for widespread dissemination. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05002660 , Registered 12 August 2021.

You Are What You Eat But Do You Eat What You Are? The Role of Identity in Eating Behaviors-A Scoping Review.

BACKGROUND: Identity is a major construct in the fields of psychology and anthropology that can relate to both the maintenance of eating behaviors and cultural sensitivity. However, there has not been any systematic effort to understand the role of identity in eating behaviors and the maintenance of eating behaviors, or to address multiple aspects of identity within an individual across scientific disciplines. This scoping review aims to understand and describe existing research relating identity to eating behaviors and to detail the measurement of identity. METHODS: We conducted a systematic search of Ovid, PsychINFO, Embase, and Web of Science for articles on identity and eating behaviors published between January 1946 and March 2022. We utilized the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist, and search methods were developed with the assistance of a research librarian. We rated articles from 1 to 5 based on the depth, complexity, and multi-dimensionality of the identity measurement conducted. Scoring criteria included a review of the number of items directly querying or evaluating identity and the extent of measurement of identity domains. RESULTS: In total, 100 articles were included, examining 10 different identities, 8 identity constructs, 11 eating behaviors, and construct contributions from 26 theories. The mean score of all articles was 2.9 on the scale from 1 to 5. A total of 10 studies scored a "1"; 30 scored a "2", indicating the use of 1-2 basic questions about identity; 31 received a "3" for use of a common but non-complex identity instrument; 19 received a "4", meaning they contained strong evaluation and included multiple types of identity but were lacking in terms of depth of measure and/or the comparison of identity effects to constructs; and 10 scored a "5" for their strong, in-depth measure of identity and inclusion of multiple types. Identity was found to be significantly related to eating behaviors in all but one study. CONCLUSION: Identity measurements seldom accounted for complexities such as multiple identities and identity shifting over time. Nonetheless, our findings indicate that multiple aspects of identity reciprocally reinforce behavior and that change maintenance is associated with identity salience and centrality. Identity is underutilized and heterogeneously applied in eating behavior research. The inclusion of identity assessments may lead to better outcomes being obtained within differing cultural, normative, and environmental scenarios.

The Effects of the COVID-19 Pandemic on Nutrition, Health and Environment in Indonesia: A Qualitative Investigation of Perspectives from Multi-Disciplinary Experts.

OBJECTIVES: The COVID-19 pandemic impacted food systems, health systems and the environment globally, with potentially greater negative effects in many lower-middle income countries (LMICs) including Indonesia. The purpose of this qualitative study was to investigate the potential impacts of the COVID-19 pandemic on diets, health and the marine environment in Indonesia, based on the perspectives of a multidisciplinary group of informants. METHODS: We conducted remote in-depth interviews with 27 key informants from many regions of Indonesia, who are either healthcare providers, nutrition researchers or environmental researchers. Interview question guides were developed based on a socio-ecological framework. We analyzed the data using a qualitative content analysis approach. RESULTS: Informants suggested that while the COVID-19 brought increased awareness about and adherence to good nutrition and health behaviors, the impact was transitory. Informants indicated that healthy food options became less affordable, due to job losses and reduced income, suggesting a likely increase in food insecurity and obesity. Environmental researchers described higher levels of marine pollution from increase in hygienic wastes as well as from plastic packaging from food orders. CONCLUSIONS: Our findings reveal perceptions by informants that the increased awareness and adherence to health behaviors observed during the pandemic was not sustained. Our results also suggest that the pandemic may have exacerbated the double-burden paradox and marine pollution in Indonesia. This study offers information for generating hypotheses for quantitative studies to corroborate our findings and inform policies and programs to mitigate the long-term impacts of the COVID-19 on diets, health, and the marine environment in Indonesia.

A Cross-Sectional Assessment of Dietary Patterns and Their Relationship to Hypertension and Obesity in Indonesia.

Background: There is a marked increase in the intake of foods associated with higher risks for hypertension and obesity in Indonesia. However, studies assessing the relationship between dietary patterns and health outcomes are few. Objective: The purpose of this study was to characterize dietary patterns and investigate their relationship with hypertension and obesity in Indonesia. Methods: Exploratory factor analysis was used to derive dietary patterns from a brief food scanner filled by 31,160 respondents aged 15 y and older in the Indonesian Family Life Survey wave 5 (IFLS 5). Age- and gender-specific quintiles of consumption were created for each pattern and the association between quintiles of each dietary pattern and the odds for hypertension and obesity were assessed using multivariate logistic regression analyses. Results: Two dietary patterns were identified: a modern dietary pattern characterized by fast foods, soft drinks, sweet snacks, and salty snacks and a traditional pattern characterized by fish, vegetables, and fruits. Younger age and being male were significantly correlated with higher consumption of the modern pattern (P < 0.0001 and P = 0.03, respectively). Analyses showed no association between hypertension and the modern pattern. However, the traditional pattern revealed lower odds for hypertension among those in the highest quintile compared with the lowest quintile (OR: 0.84; 95% CI: 0.74, 0.95; P-trend < 0.05). Individuals in the highest quintile of each dietary pattern had higher odds of obesity compared with those in the lowest quintile (modern pattern-OR: 1.31; 95% CI: 1.15, 1.49; P-trend < 0.00; traditional pattern-OR: 1.25; 95% CI: 1.10, 1.42; P-trend < 0.01). Conclusions: More studies using gold-standard measures of dietary intake are needed to better understand the relationship between the modern dietary pattern and hypertension in Indonesia. Also, both modern and traditional dietary patterns in Indonesia may be energy dense, leading to higher risk for obesity.