Adults and Children in Low-Income Households that Participate in Cost-Offset Community Supported Agriculture Have High Fruit and Vegetable Consumption.

This paper examines fruit and vegetable intake (FVI) in low-income households that participated in a cost-offset (CO), or 50% subsidized, community-supported agriculture (CSA) program. CSA customers paid farms upfront for a share of the harvest, and received produce weekly throughout the growing season. A cohort of adults and children 2-12 y in a summer CO-CSA were surveyed online twice: August 2015 (n = 41) and February 2016 (n = 23). FVI was measured by the National Cancer Institute's (NCI) Fruit and Vegetable Screener (FVS) and an inventory of locally grown fruits and vegetables. FVI relative to United States (US) recommendations and averages, and across seasons, were tested with non-parametric tests and paired t-tests (p < 0.05). Both adults and children in the CO-CSA had higher FVI than the US averages, and more often met recommendations for vegetables. Some summer fruits and vegetables were more often eaten when locally in-season. The CO-CSA model warrants further examination as an avenue for improving vegetable consumption among adults and children in low-income households. However, causality between CO-CSA participation and FVI cannot be inferred, as CO-CSA participants may be positive deviants with respect to FVI. A multi-state randomized controlled trial is currently underway to evaluate impacts of CO-CSAs on FVI and related outcomes.

A Mixed Methods Comparison of Urban and Rural Retail Corner Stores.

Efforts to transform corner stores to better meet community dietary needs have mostly occurred in urban areas but are also needed in rural areas. Given important contextual differences between urban and rural areas, it is important to increase our understanding of the elements that might translate successfully to similar interventions involving stores in more rural areas. Thus, an in-depth examination and comparison of corner stores in each setting is needed. A mixed methods approach, including windshield tours, spatial visualization with analysis of frequency distribution, and spatial regression techniques were used to compare a rural North Carolina and large urban (Los Angeles) food environment. Important similarities and differences were seen between the two settings in regards to food environment context, spatial distribution of stores, food products available, and the factors predicting corner store density. Urban stores were more likely to have fresh fruits (Pearson chi2 = 27.0423; p < 0.001) and vegetables (Pearson chi2 = 27.0423; p < 0.001). In the urban setting, corner stores in high income areas were more likely to have fresh fruit (Pearson chi2 = 6.00; p = 0.014), while in the rural setting, there was no difference between high and low income area in terms of fresh fruit availability. For the urban area, total population, no vehicle and Hispanic population were significantly positively associated (p < 0.05), and median household income (p < 0.001) and Percent Minority (p < 0.05) were significantly negatively associated with corner store count. For the rural area, total population (p < 0.05) and supermarket count were positively associated (p < 0.001), and median household income negatively associated (P < 0.001), with corner store count. Translational efforts should be informed by these findings, which might influence the success of future interventions and policies in both rural and urban contexts.

Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study.

BACKGROUND: Policies that improve access to healthy, affordable foods may improve population health and reduce health disparities. In the United States most food access policy research focuses on urban communities even though residents of rural communities face disproportionately higher risk for nutrition-related chronic diseases compared to residents of urban communities. The purpose of this study was to (1) identify the factors associated with access to healthy, affordable food in rural communities in the United States; and (2) prioritize a meaningful and feasible rural food policy research agenda. METHODS: This study was conducted by the Rural Food Access Workgroup (RFAWG), a workgroup facilitated by the Nutrition and Obesity Policy Research and Evaluation Network. A national sample of academic and non-academic researchers, public health and cooperative extension practitioners, and other experts who focus on rural food access and economic development was invited to complete a concept mapping process that included brainstorming the factors that are associated with rural food access, sorting and organizing the factors into similar domains, and rating the importance of policies and research to address these factors. As a last step, RFAWG members convened to interpret the data and establish research recommendations. RESULTS: Seventy-five participants in the brainstorming exercise represented the following sectors: non-extension research (n = 27), non-extension program administration (n = 18), "other" (n = 14), policy advocacy (n = 10), and cooperative extension service (n = 6). The brainstorming exercise generated 90 distinct statements about factors associated with rural food access in the United States; these were sorted into 5 clusters. Go Zones were established for the factors that were rated highly as both a priority policy target and a priority for research. The highest ranked policy and research priorities include strategies designed to build economic viability in rural communities, improve access to federal food and nutrition assistance programs, improve food retail systems, and increase the personal food production capacity of rural residents. Respondents also prioritized the development of valid and reliable research methodologies to measure variables associated with rural food access. CONCLUSIONS: This collaborative, trans-disciplinary, participatory process, created a map to guide and prioritize research about polices to improve healthy, affordable food access in rural communities.

Associations between county and municipality zoning ordinances and access to fruit and vegetable outlets in rural North Carolina, 2012.

INTRODUCTION: Zoning ordinances and land-use plans may influence the community food environment by determining placement and access to food outlets, which subsequently support or hinder residents' attempts to eat healthfully. The objective of this study was to examine associations between healthful food zoning scores as derived from information on local zoning ordinances, county demographics, and residents' access to fruit and vegetable outlets in rural northeastern North Carolina. METHODS: From November 2012 through March 2013, county and municipality zoning ordinances were identified and double-coded by using the Bridging the Gap food code/policy audit form. A healthful food zoning score was derived by assigning points for the allowed use of fruit and vegetable outlets. Pearson coefficients were calculated to examine correlations between the healthful food zoning score, county demographics, and the number of fruit and vegetable outlets. In March and April 2013, qualitative interviews were conducted among county and municipal staff members knowledgeable about local zoning and planning to ascertain implementation and enforcement of zoning to support fruit and vegetable outlets. RESULTS: We found a strong positive correlation between healthful food zoning scores and the number of fruit and vegetable outlets in 13 northeastern North Carolina counties (r = 0.66, P = .01). Major themes in implementation and enforcement of zoning to support fruit and vegetable outlets included strict enforcement versus lack of enforcement of zoning regulations. CONCLUSION: Increasing the range of permitted uses in zoning districts to include fruit and vegetable outlets may increase access to healthful fruit and vegetable outlets in rural communities.

Validity of secondary retail food outlet data: a systematic review.

CONTEXT: Improving access to healthy foods is a promising strategy to prevent nutrition-related chronic diseases. To characterize retail food environments and identify areas with limited retail access, researchers, government programs, and community advocates have primarily used secondary retail food outlet data sources (e.g., InfoUSA or government food registries). To advance the state of the science on measuring retail food environments, this systematic review examined the evidence for validity reported for secondary retail food outlet data sources for characterizing retail food environments. EVIDENCE ACQUISITION: A literature search was conducted through December 31, 2012, to identify peer-reviewed published literature that compared secondary retail food outlet data sources to primary data sources (i.e., field observations) for accuracy of identifying the type and location of retail food outlets. Data were analyzed in 2013. EVIDENCE SYNTHESIS: Nineteen studies met the inclusion criteria. The evidence for validity reported varied by secondary data sources examined, primary data-gathering approaches, retail food outlets examined, and geographic and sociodemographic characteristics. More than half of the studies (53%) did not report evidence for validity by type of food outlet examined and by a particular secondary data source. CONCLUSIONS: Researchers should strive to gather primary data but if relying on secondary data sources, InfoUSA and government food registries had higher levels of agreement than reported by other secondary data sources and may provide sufficient accuracy for exploring these associations in large study areas.

Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: engaging stakeholders for a healthy corner store initiative, part 2.

INTRODUCTION: We examined the feasibility of increasing access to healthful food in corner stores to inform a Communities Putting Prevention to Work (CPPW) initiative by engaging stakeholders (corner store owners and customers) in a formative evaluation. METHODS: Qualitative interviews were conducted with corner store owners and managers (n = 11). Customer intercept surveys (n = 179) were also conducted with customers of 9 stores. Corner stores were located in rural food deserts (municipalities without a chain supermarket) and in low-income, urban municipalities in eastern North Carolina. Interviews were transcribed verbatim and double-coded. Qualitative themes related to feasibility of increasing access to healthful foods were extracted. Shopping patterns of rural and urban customers were compared by using t tests. RESULTS: Corner store owners were willing to stock more healthful foods, but they perceived that customer demand for these foods was low. Rural customers reported more frequently shopping at corner stores than urban customers and more frequently stated that the reason they do not eat more fruits and vegetables is that the stores in which they shop do not sell them. Most customers reported they would be very or somewhat likely to purchase fresh produce at a corner store. CONCLUSION: Corner stores may be an important source of food for rural and low-income residents and thus a good place in which to intervene. The results of this formative evaluation were used to plan and evaluate a CPPW healthy corner store initiative.

Formative evaluation for a healthy corner store initiative in Pitt County, North Carolina: assessing the rural food environment, part 1.

INTRODUCTION: Obesity prevalence in the rural United States is higher than in urban or suburban areas, perhaps as a result of the food environment. Because rural residents live farther from supermarkets than their urban- and suburban-dwelling counterparts, they may be more reliant on smaller corner stores that offer fewer healthful food items. METHODS: As part of a Communities Putting Prevention to Work (CPPW) healthy corner store initiative, we reviewed audit tools in the fall of 2010 to measure the consumer food environment in eastern North Carolina and chose the NEMS-S-Rev (Nutrition Environment Measures Survey-Stores-Revised) to assess 42 food stores. During the spring and summer of 2011, 2 trained graduate assistants audited stores, achieving interrater reliability of at least 80%. NEMS-S-Rev scores of stores in rural versus urban areas were compared. RESULTS: Overall, healthful foods were less available and of lower quality in rural areas than in urban areas. NEMS-S-Rev scores indicated that healthful foods were more likely to be available and had similar pricing and quality in rural corner stores than in urban corner stores. CONCLUSION: Food store audit data provided a baseline to implement and evaluate a CPPW healthy corner store initiative in Pitt County. This work serves as a case study, providing lessons learned for engaging community partners when conducting rural food store audits.

Associations between neighborhood amenity density and health indicators among rural and urban youth.

PURPOSE: To examine associations between the built/social environment (neighborhood amenity density, crime) and health indicators (body mass index [BMI] percentile, cardiovascular fitness, and time spent in moderate to vigorous physical activity [MVPA]) among rural and urban youth. DESIGN: Cross-sectional. SETTING: Eastern North Carolina. SUBJECTS: Youth (n = 296) were recruited from three middle schools. MEASURES: Neighborhood density was estimated using Walk Score. Crime was assessed using Regional Analysis and Information Sharing online. BMI percentiles were calculated from measured height and weight. Cardiovascular fitness was estimated using heart rate measured at the conclusion of a 3-minute step test. Time spent in MVPA was measured objectively via accelerometer. ANALYSIS: Bivariate and multivariate statistics were used to examine associations between Walk Score, crime, BMI percentile, cardiovascular fitness (as measured via heart rate), and MVPA. RESULTS: Walk Score was positively correlated with crime. There were positive, statistically significant associations between Walk Score and (1) BMI percentile (p = .0223) and (2) heart rate (p = .0044), and (3) inverse associations between Walk Score and MVPA (p = .0042), indicating that high neighborhood density was associated with greater BMI percentiles, lower fitness, and less MVPA among urban youth. CONCLUSION: These counterintuitive findings may be due to the negative effect of crime on health indicators, which may outweigh potential positive health impacts of high neighborhood amenity density.

A community assessment to inform a multilevel intervention to reduce cardiovascular disease risk and risk disparities in a rural community.

To complete a formative evaluation to identify community-level assets and barriers to healthy lifestyle choices, we conducted qualitative interviews, community audits, and secondary data analyses. We solicited local leaders' perspectives regarding winnability of obesity prevention policy options. Participants noted that many resources were available, yet a barrier was high cost. There were more parks per capita in low-income areas, but they were of lower quality. The most winnable obesity prevention policy was incentives for use of food from local farms. Results are being used to inform an intervention to reduce cardiovascular disease risk in rural eastern North Carolina.

Screening low-income women of reproductive age for cardiovascular disease risk factors.

UNLABELLED: Abstract Background: Identifying and treating chronic diseases, their precursors, and other cardiovascular disease (CVD) risk factors during family planning visits may improve long-term health and reproductive outcomes among low-income women. A cross-sectional study design was used to describe the prevalence of chronic diseases (hypertension, high cholesterol, and diabetes), their precursors (pre-hypertension, borderline high cholesterol, and pre-diabetes), and related CVD risk factors (such as obesity, smoking, and physical inactivity) among low-income women of reproductive age. METHODS: Prevalence of chronic diseases, their precursors, and related CVD risk factors were assessed for 462 out of 859 (53.8%) female family planning patients, ages 18-44 years, who attended a Title X clinic in eastern North Carolina during 2011 and 2012 and consented to participate. Data were obtained from clinical measurements, blood test results, and questionnaire. Differences in distribution of demographic and health care characteristics and CVD risk factors by presence of prehypertension and pre-diabetes were assessed by Pearson chi-square tests. RESULTS: The prevalence of hypertension was 12%, high cholesterol 16%, and diabetes 3%. Nearly two-thirds of women with hypertension were newly diagnosed (62%) as were 75% of women with diabetes. The prevalence of pre-hypertension was 35%, pre-diabetes 31%, obesity 41%, smoking 32%, and physical inactivity 42%. The majority of participants (87%) had one or more chronic disease or related cardiovascular disease risk factor. CONCLUSIONS: CVD screening during family planning visits can identify significant numbers of women at risk for poor pregnancy outcomes and future chronic disease and can provide prevention opportunities if effective interventions are available and acceptable to this population.