Search

Rural women experience disproportionately higher levels of obesity in comparison to their non-rural counterparts. The present exploratory mediation analysis sought to identify mechanisms that might have contributed to rural women’s physical activity and diet changes after participating in a 6-month multilevel community-randomized trial: Strong Hearts, Healthy Communities (SHHC). SHHC was conducted in 16 rural towns in Montana and New York, between 2015 and 2016; 194 overweight, sedentary midlife, and older women (mean age 59; 26.8% overweight; 73.2% obese) participated. Participants in eight towns received the SHHC intervention (n = 101), which focused on healthy behavior change at the individual level as well as creating supportive social and built environments for physical activity and healthy eating. Participants in the other eight towns received an education-only control intervention (n = 93). We investigated the direct and indirect effects of the SHHC intervention through changes to self-efficacy, social support, and built environment perception, on changes in participants’ physical activity and diet. Compared to the controls, SHHC intervention participants increased their social support from friends for physical activity (p = 0.009) and healthy eating (p = 0.032). Participants’ improved social support from friends marginally mediated the intervention effects for walking metabolic equivalent minutes per week, explaining 40.5% of the total effect (indirect effect = +45.24, 95% CI: –1.51, +91.99; p = 0.059). Increasing social support from friends appears to be helpful in encouraging rural women to become more active. Further investigations are needed to better understand how multilevel interventions work in rural communities.

Background Adults and children in the U.S. consume inadequate quantities of fruit and vegetables (FV), in part, due to poor access among households with lower socioeconomic status. One approach to improving access to FV is community supported agriculture (CSA) in which households purchase a ‘share’ of local farm produce throughout the growing season. This study examined the effects of cost-offset (half-price) CSA plus tailored nutrition education for low-income households with children. Methods The Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016–2018) assigned caregiver-child dyads (n = 305) into cost-offset CSA plus education intervention or control (delayed intervention) groups. Following one growing season of CSA participation, changes in children’s diet quality, body mass index (BMI), and physical activity; caregivers’ nutrition knowledge, attitudes, behaviors, and diet quality; and household food access and security were examined using multiple linear or logistic regression, with adjustment for baseline value within an intent-to-treat (ITT) framework in which missing data were multiply imputed. Results No significant net effects on children’s dietary intake, BMI, or physical activity were observed. Statistically significant net improvements were observed after one growing season for caregivers’ cooking attitudes, skills, and self-efficacy; FV intake and skin carotenoid levels; and household food security. Changes in attitudes and self-efficacy remained one-year after baseline, but improvements in caregiver diet and household food security did not. The number of weeks that participants picked up a CSA share (but not number of education sessions attended) was associated with improvements in caregiver FV intake and household food security. Conclusions Cost-offset CSA plus tailored nutrition education for low-income households improved important caregiver and household outcomes within just one season of participation; most notably, both self-reported and objectively measured caregiver FV intake and household food security improved. Households that picked up more shares also reported larger improvements. However, these changes were not maintained after the CSA season ended. These results suggest that cost-offset CSA is a viable approach to improving adult, but not child, FV intake and household food security for low-income families, but the seasonality of most CSAs may limit their potential to improve year-round dietary behavior and food security. Trial registration ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered.

Cost-offset community supported agriculture (CO-CSA) appears to be a promising way to increase low-income households’ access and intake of fresh produce, while also helping CSA farms expand their farm business. Yet single farms operating CO-CSAs may struggle to balance the demands of farming with CO-CSA program administration, funding, and recruitment. To address these chal­lenges, CO-CSA programs operated by nonprofits have emerged, equipped with dedicated infrastruc­ture, resources, and staffing. This study aims to describe organizational models and best practices of nonprofit CO-CSA programs, using a qualitative approach. We conducted interviews with five well-established nonprofit CO-CSA programs in the U.S. Administration of these five nonprofit CO-CSAs took several forms: (1) providing direct sub­sidies to individual CO-CSA member farms; (2) functioning themselves as an aggregator, packer, and distributor of regional produce; and (3) sourcing from an in-house farm incubator or food hub, then packing and coordinating delivery to pick-up sites. Nonprofit CO-CSA funding strategies included grants from federal and local government sources, private donations, fundrais­ing, and grants. Marketing efforts occurred via social media, community events, and word of mouth. Both fundraising and recruitment were greatly facilitated by relationships with community partners. Having dedicated staff, as well as a com­munity that values local agriculture and social jus­tice, were identified as success factors. This descriptive, qualitative study systematically com­pares the attributes of five nonprofit CO-CSA programs. Future research should focus on identifying the cost-effectiveness of nonprofit CO-CSAs, compare the relative merits of single-farm and nonprofit CO-CSAs, and quantify the eco­nomic benefit of CO-CSA programs for farmers and local communities.

Background Accurate assessment of fruit and vegetable intake (FVI) is essential for public health nutrition research and surveillance. Blood carotenoid concentrations are robust biomarkers of FVI, but collecting blood samples typically is not feasible in population-based studies. Understanding how well non-invasive measures compare to blood estimates is important for advancing surveillance and evaluation. The objective of this study was to examine the associations between serum carotenoids and four non-invasive measures of FVI in overweight and obese women. Methods This study utilized baseline data from 157 overweight or obese women (95.5% white, mean age 58.56 years ± 9.49 years) enrolled in the Strong Hearts, Healthy Communities randomized trial, including two direct measures of carotenoids and three self-reported measures of FVI. Participants completed a fasting blood draw, dermal carotenoid scans using resonance Raman spectroscopy (RRS), a two-item FVI screener modeled after the American Heart Association’s Life’s Simple 7 “My Life Check” tool (modified AHA tool), the National Cancer Institute’s All-Day Fruit and Vegetable Screener (FVS), multiple 24-h dietary recalls, physical measurements, and demographic and health behavior questions. We analyzed blood for total carotenoids and derived total FVI estimates from self-report tools. We used multivariate linear regression models to examine associations between each non-invasive tool and serum carotenoids under four scenarios analogous to different research contexts in which varying breadths of participant data are available. We also calculated adjusted Pearson’s correlations between serum carotenoids, dermal carotenoids, and the self-reported measures. Results Dermal carotenoids were strongly correlated with serum carotenoids (0.71, P P Conclusions Compared to self-reported FVI, we found dermal carotenoids measured by RRS to be a superior method to approximate serum carotenoids among overweight and obese women. More research is needed to investigate these assessment methods in diverse populations. Trial registration ClinicalTrials.gov Identifier: NCT02499731, registered July 16, 2015.

Spatial context may be important to direct to con­sumer (DTC) programs aimed at improving fresh fruit and vegetable access for low-income individu­als. The purpose of this study was to examine the sociodemographic and geospatial context (distance to pickup sites, number and density of proximal food retail outlets, etc.) surrounding community supported agriculture (CSA) pickup locations in relation to low-income customer residential loca­tions, and to synthesize this information with inter­view-derived perspectives on the challenges and opportunities of the pickup location from DTC producers and customers. This in-depth study examined cost-offset community supported agri­culture (CO-CSA) operations across four U.S. states (New York, North Carolina, Vermont, and Washington) and varying pickup sites (n=23), with pickup operational decisions determined by farm­ers (n=12). Physical addresses of farms, CO-CSA customers, and pickup sites were collected and geocoded. Geographic information systems (GIS) was used to examine road network distances for pickup locations across the study sites. Demo­graphic information at the census block level (e.g., percent racial minority, percent poverty level) was obtained for all study sites. Descriptive statistics were generated for geospatial variables. In-depth interviews with farmers and focus groups with CO-CSA customers were conducted to understand experiences with the CO-CSA in terms of physical access of pickup sites. We found that pickup sites were an average of 6.2 miles (10 kilometers) from customers’ homes, and on average, further than the supermarket (2.9 miles or 4.7 km). Farmers reported their efforts to select convenient pickup locations for low-income customers, though CO-CSA customers expressed mixed levels of accessi­bility. Spatial inaccessibility and differences in soci­odemographic data for customer versus pickup may explain perceived inaccessibility for some cus­tomers. These findings may help inform future approaches to plan and evaluate DTC operations targeting low-income individuals by consider­ing geospatial context and stakeholder experiences. See the press release for this article.

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p &lt, 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data, and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted.

Background A significant proportion of older women suffer from chronic pain, which can decrease quality of life. The objective of this pilot randomized study was to evaluate the feasibility of a flow-restorative yoga intervention designed to decrease pain and related outcomes among women aged 60 or older. Methods Flow-restorative yoga classes were held twice weekly for 1 hour and led by a certified yoga instructor. Participants randomized to the intervention group attended the yoga classes for 12 weeks and received supplemental materials for at-home practice. Those randomized to the control group were asked to maintain their normal daily routine. Feasibility was evaluated using recruitment and retention rates, class and home practice adherence rates, and participant satisfaction surveys. Outcome measures (self-reported pain, inflammatory markers, functional fitness, quality of life, resilience, and self-reported physical activity) were assessed at baseline and post-intervention. Paired t-tests or Wilcoxon signed-rank tests were used to examine changes in outcome measures within treatment groups. Results Thirty-eight participants were recruited and randomized. Participants were primarily white, college-educated, and higher functioning, despite experiencing various forms of chronic pain. Attendance and retention rates were high (91 and 97%, respectively) and the majority of participants were satisfied with the yoga program (89%) and would recommend it to others (87%). Intervention participants also experienced reductions in pain interference and improvements in energy and social functioning. Conclusions This pilot study provides essential data to inform a full scale randomized trial of flow-restorative yoga for older women with chronic pain. Future studies should emphasize strategies to recruit a more diverse study population, particularly older women at higher risk of disability and functional decline. Trial registration Clinicaltrials.gov, NCT03790098. Registered 31 December 2018 – Retrospectively registered

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p = .005) than eligible nonenrollees (n = 243) and more likely to be female (p < .001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19–23). Median CSA pickup was 88% of the weeks (IQR: 40–100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 (“very useful”). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact.

Objective This study aimed to examine (1) whether the Strong Hearts, Healthy Communities intervention (SHHC) improved social network members' (SNMs') weight, exercise, and diet and (2) whether SNMs' weight and behavioral changes were modified by their relationship closeness and/or spatial closeness with trial participants. Methods Eight towns received the SHHC intervention, which focused on building individual healthy behaviors and creating supportive social and built environments for exercise and healthy eating. Eight towns received an education-only control intervention. SNMs (n = 487) were recruited to complete a questionnaire at baseline and at 6 months that asked about demographics, weight, height, exercise, and eating habits. Results SHHC's effect on SNMs differed depending on their relationship closeness with trial participants. Among SNMs who had a very close relationship with trial participants, those associated with the intervention group lost more weight and decreased BMI more than those associated with the control group (weight [kilograms] between-group difference: Δ = -1.68; 95% CI: -3.10 to -0.25; P = 0.021; BMI between-group difference: Δ = -0.60; 95% CI: -1.16 to -0.04; P = 0.034). Spatial closeness did not modify any of SHHC's ripple effects. Conclusions Relationship closeness, rather than spatial closeness, played an important role in influencing a rural community-based intervention's ripple effects.

Background The Short Physical Performance Battery (SPPB) is an inexpensive, reliable, and easy‐to‐implement measure of lower‐extremity physical function. Strong evidence links SPPB scores with all‐cause mortality, but little is known about its relationship with incident cardiovascular disease (CVD). Methods and Results Women (n=5043, mean age=79±7) with no history of myocardial infarction or stroke completed 3 timed assessments—standing balance, strength (5 chair stands), and usual gait speed (4 m walk)—yielding an SPPB score from 0 (worst) to 12 (best). Women were followed for CVD events (myocardial infarction, stroke, or CVD death) up to 6 years. Hazard ratios were estimated for women with Very Low (0–3), Low (4–6), Moderate (7–9), and High (10–12) SPPB scores using Cox proportional hazard models adjusted for demographic, behavioral, and health‐related variables including objective measurements of physical activity, blood pressure, lipids, and glucose levels. Restricted cubic splines tested linearity of associations. With 361 CVD cases, crude incidence rates/1000 person‐years were 41.0, 24.3, 16.1, and 8.6 for Very Low , Low , Moderate, and High SPPB categories, respectively. Corresponding fully adjusted hazard ratios (95% CIs) were 2.28 (1.50–3.48), 1.70 (1.23–2.36) 1.49 (1.12–1.98), and 1.00 (referent); P ‐trend P P >0.38). Conclusions Results suggest SPPB may provide a measure of cardiovascular health in older adults beyond that captured by traditional risk factors. Because of its high test‐retest reliability and low administrative burden, the SPPB should be a routine part of office‐based CVD risk assessment.

Civic engagement interventions aimed at improving food and physical activity environments hold promise in addressing rural health disparities, but ensuring feasible and sustained dissemination remains a challenge. The present study aimed to evaluate the feasibility of a civic engagement curriculum adapted for online dissemination (Healthy Eating and Activity in Rural Towns (eHEART)). The eHEART curriculum and website were developed based on feedback from local health educators and community members. eHEART groups were facilitated by local Extension educators across three rural towns in three U.S. states (Montana, Wisconsin, and Alaska). Implementation feasibility was assessed through monthly project reports and interviews with educators. All eHEART groups successfully completed curriculum activities and met their project goals after nine months (November 2018 to July 2019). Groups ranged in size from 4 to 8 community residents and implemented varied strategies to improve aspects of their local food and/or physical activity environments. Facilitators of implementation included clear guidance on facilitating curriculum activities and the flexible and community-driven nature of eHEART projects. Recommended changes included more guidance on evaluating projects and contacting stakeholders as well as providing online tools and support for project management. Findings from this work have important implications for creating healthier rural environments. Local health educators and other community groups can feasibly use the eHEART curriculum to foster environmental changes that support healthy eating and active living.

BACKGROUND: Poor diet and insufficient physical activity are major risk factors for non‐communicable diseases. Developing healthy diet and physical activity behaviors early in life is important as these behaviors track between childhood and adulthood. Parents and other adult caregivers have important influences on children's health behaviors, but whether their involvement in children's nutrition and physical activity interventions contributes to intervention effectiveness is not known. OBJECTIVES: • To assess effects of caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors, including those intended to prevent overweight and obesity • To describe intervention content and behavior change techniques employed, drawing from a behavior change technique taxonomy developed and advanced by Abraham, Michie, and colleagues (Abraham 2008; Michie 2011; Michie 2013; Michie 2015) • To identify content and techniques related to reported outcomes when such information was reported in included studies SEARCH METHODS: In January 2019, we searched CENTRAL, MEDLINE, Embase, 11 other databases, and three trials registers. We also searched the references lists of relevant reports and systematic reviews. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi‐RCTs evaluating the effects of interventions to improve children's dietary intake or physical activity behavior, or both, with children aged 2 to 18 years as active participants and at least one component involving caregivers versus the same interventions but without the caregiver component(s). We excluded interventions meant as treatment or targeting children with pre‐existing conditions, as well as caregiver‐child units residing in orphanages and school hostel environments. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures outlined by Cochrane. MAIN RESULTS: We included 23 trials with approximately 12,192 children in eligible intervention arms. With the exception of two studies, all were conducted in high‐income countries, with more than half performed in North America. Most studies were school‐based and involved the addition of healthy eating or physical education classes, or both, sometimes in tandem with other changes to the school environment. The specific intervention strategies used were not always reported completely. However, based on available reports, the behavior change techniques used most commonly in the child‐only arm were "shaping knowledge," "comparison of behavior," "feedback and monitoring," and "repetition and substitution." In the child + caregiver arm, the strategies used most commonly included additional "shaping knowledge" or "feedback and monitoring" techniques, as well as "social support" and "natural consequences." We considered all trials to be at high risk of bias for at least one design factor. Seven trials did not contribute any data to analyses. The quality of reporting of intervention content varied between studies, and there was limited scope for meta‐analysis. Both validated and non‐validated instruments were used to measure outcomes of interest. Outcomes measured and reported differed between studies, with 16 studies contributing data to the meta‐analyses. About three‐quarters of studies reported their funding sources; no studies reported industry funding. We assessed the quality of evidence to be low or very low. Dietary behavior change interventions with a caregiver component versus interventions without a caregiver component Seven studies compared dietary behavior change interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (mean difference [MD] −0.42%, 95% confidence interval [CI] −1.25 to 0.41, 1 study, n = 207; low‐quality evidence) or from sodium intake (MD −0.12 g/d, 95% CI −0.36 to 0.12, 1 study, n = 207; low‐quality evidence). No trial in this comparison reported data for children's combined fruit and vegetable intake, sugar‐sweetened beverage (SSB) intake, or physical activity levels, nor for adverse effects of interventions. Physical activity interventions with a caregiver component versus interventions without a caregiver component Six studies compared physical activity interventions with and without a caregiver component. At the end of the intervention, we did not detect a difference between intervention arms in children's total physical activity (MD 0.20 min/h, 95% CI −1.19 to 1.59, 1 study, n = 54; low‐quality evidence) or moderate to vigorous physical activity (MVPA) (standard mean difference [SMD] 0.04, 95% CI −0.41 to 0.49, 2 studies, n = 80; moderate‐quality evidence). No trial in this comparison reported data for percentage of children's total energy intake from saturated fat, sodium intake, fruit and vegetable intake, or SSB intake, nor for adverse effects of interventions. Combined dietary and physical activity interventions with a caregiver component versus interventions without a caregiver component Ten studies compared dietary and physical activity interventions with and without a caregiver component. At the end of the intervention, we detected a small positive impact of a caregiver component on children's SSB intake (SMD −0.28, 95% CI −0.44 to −0.12, 3 studies, n = 651; moderate‐quality evidence). We did not detect a difference between intervention arms in children's percentage of total energy intake from saturated fat (MD 0.06%, 95% CI −0.67 to 0.80, 2 studies, n = 216; very low‐quality evidence), sodium intake (MD 35.94 mg/d, 95% CI −322.60 to 394.47, 2 studies, n = 315; very low‐quality evidence), fruit and vegetable intake (MD 0.38 servings/d, 95% CI −0.51 to 1.27, 1 study, n = 134; very low‐quality evidence), total physical activity (MD 1.81 min/d, 95% CI −15.18 to 18.80, 2 studies, n = 573; low‐quality evidence), or MVPA (MD −0.05 min/d, 95% CI −18.57 to 18.47, 1 study, n = 622; very low‐quality evidence). One trial indicated that no adverse events were reported by study participants but did not provide data. AUTHORS' CONCLUSIONS: Current evidence is insufficient to support the inclusion of caregiver involvement in interventions to improve children's dietary intake or physical activity behavior, or both. For most outcomes, the quality of the evidence is adversely impacted by the small number of studies with available data, limited effective sample sizes, risk of bias, and imprecision. To establish the value of caregiver involvement, additional studies measuring clinically important outcomes using valid and reliable measures, employing appropriate design and power, and following established reporting guidelines are needed, as is evidence on how such interventions might contribute to health equity.

INTRODUCTION: Rural women have higher rates of cardiovascular disease than their non-rural counterparts, partially due to their social and environmental contexts. The study objective is to test a refined version of the multilevel Strong Hearts, Healthy Communities intervention, which used extensive process and outcome evaluation data from the original randomized trial to optimize effectiveness as measured by improved Simple 7 score, a composite measure of cardiovascular disease risk. STUDY DESIGN: The intervention was implemented in a 6-month, delayed-intervention, community-randomized trial; control participants received the program following 24-week outcome assessment. The study was conducted in 2017–2018; data analysis occurred in 2018–2019. SETTING/PARTICIPANTS: The study was conducted in 11 rural, medically underserved towns in New York. Participants were women aged ≥40 years who were either: (1) obese or (2) overweight and sedentary. INTERVENTION: The intervention group received 24 weeks of hour-long, twice-weekly classes including strength training, aerobic exercise, and skill-based nutrition- and health-related education, as well as civic engagement activities focused on healthy food and physical activity environments. MAIN OUTCOME MEASURES: Measures included weight and height; blood pressure; blood cholesterol; blood glucose; and self-reported smoking, diet, and physical activity behaviors. Individual Simple 7 components were examined and mixed linear regression analyses were used to examine change in Simple 7 score. RESULTS: One hundred eighty-two participants were randomized. Compared with control participants, the intervention group had greater improvements in Simple 7 score (difference=1.03, 95% CI=0.44, 1.61, p

BACKGROUND/OBJECTIVES While breast cancer and associated therapies can influence physical function (PF), findings for breast cancer's effects on PF among postmenopausal women are not consistent. This research evaluates the effect of breast cancer on change in PF. DESIGN Longitudinal cohort study analyzed using difference-in-differences (DID) method to compare the changes in PF over time between women with and without breast cancer, by invasive status, stage, and age. SETTING AND PARTICIPANTS Women's Health Initiative participants, aged 50 to 79 years at baseline, with four completed functional status assessments were eligible for inclusion (mean age = 62.1 ± 6.9 years). Women with breast cancer diagnosed between the 3rd and 11th enrollment year (n = 1636) were compared to women without breast cancer (n = 35 660). MEASUREMENTS PF was measured using the Medical Outcomes Study Short Form 36 at baseline and years 3, 11, and 12. RESULTS Compared with women without breast cancer, women with breast cancer experienced greater PF decline (P

Background Over 23 million Americans have type 2 diabetes (T2D). Eating habits such as breakfast consumption, time-restricted eating, and limiting daily eating occasions have been explored as behaviors for reducing T2D risk, but prior evidence is inconclusive. Objectives Our objectives were to examine associations between number of daily eating occasions and T2D risk in the Women's Health Initiative Dietary Modification Trial (WHI-DM) and whether associations vary by BMI, age, or race/ethnicity. Methods Participants were postmenopausal women in the WHI-DM who comprised a 4.6% subsample completing 24-h dietary recalls (24HRs) at years 3 and 6 as part of trial adherence activities (n = 2159). Numbers of eating occasions per day were obtained from the year 3 24HRs, and participants were grouped into approximate tertiles as 1–3 (n = 795), 4 (n = 713), and ≥5 (n = 651) daily eating occasions as the exposure. Incident diabetes was self-reported on semiannual questionnaires as the outcome. Results Approximately 15% (15.4%, n = 332) of the WHI-DM 24HR cohort reported incident diabetes at follow-up. Cox proportional hazards regression tested associations of eating occasions with T2D adjusted for neighborhood socioeconomic status, BMI, waist circumference, race/ethnicity, family history of T2D, recreational physical activity, Healthy Eating Index-2005, 24HR energy intake, and WHI-DM arm. Compared with women reporting 1–3 meals/d, those consuming 4 meals/d had a T2D HR = 1.38 (95% CI: 1.03, 1.84) without further increases in risk for ≥5 meals/d. In stratified analyses, associations for 4 meals/d compared with 1–3 meals/d were stronger in women with BMI, Four meals/day compared to fewer meals may increase the risk of Type 2 diabetes in older women but no dose response effect seen for higher frequency.

Background Cost-offset, Community-supported Agriculture (CO-CSA) is a model in which low-income households receive subsidized shares of a local farm's harvest. The goal is to address diet and health disparities among a population with historically poor access to and consumption of healthy foods. The appeal of such an intervention, and thus its reach, is limited to a self-selected sub-sample of the low-income population that may be non-representative. Objective To compare characteristics of CO-CSA enrolled adults from low-income households with those of a nationally-representative sample of low-income adults. We hypothesized that CO-CSA enrollees would be less demographically diverse, have greater nutrition-related knowledge, and report better health than the national sample. Study Design, Setting, Participants CO-CSA enrollee data were drawn from the baseline survey of a multi-state randomized controlled trial testing the CO-CSA model in conjunction with nutrition education among low-income households with children in Vermont, New York, North Carolina, and Washington (n=305). Those data were compared to a nationally-representative sample of low-income adults from households with children evaluated via the National Health and Nutrition Examination Survey (2007-2010). Measurable Outcome/Analysis Descriptive statistics for demographic, food security, nutrition knowledge, and self-reported health status data were generated using SPSS for both samples. Results Compared to the national sample, a greater proportion of CO-CSA enrollees were female (97% vs 57%), white (76% vs 45%), highly educated (49% vs 7% college graduates), and food insecure (57% vs 49%); a smaller proportion were Hispanic (6% vs 34%). A greater proportion of CO-CSA enrollees knew the daily recommendation for fruits and vegetables (3-5 cups; 61% vs 16%) and reported being in good or excellent health (34% vs 25%). Conclusions Differences between the CO-CSA and NHANES samples may be related to the CO-CSA study sampling frame (English-speaking households in certain regions of the U.S.). Results support continued exploration into whether CO-CSA and other local food system interventions have the potential to reach beyond female, white, educated, and nutritionally-knowledgeable segments of the target population.

Background Subsidized or ‘cost-offset’ Community-Supported Agriculture (CO-CSA) has the potential to improve food security in low-income households. Furthermore, CO-CSA coupled with tailored nutrition education may affect nutrition knowledge, attitudes, and self-efficacy. To date, many studies of CO-CSA had small samples and no comparison group; few studies incorporated formal nutrition education into CO-CSA. Objective To understand the effect of CO-CSA plus education on nutrition knowledge, attitudes, self-efficacy, and food security among low-income families; whether any observed effects are durable beyond the CO-CSA season; and whether intervention dose mediated net effect. Study Design, Setting, Participants Farm Fresh Foods for Healthy Kids (F3HK), a randomized controlled trial in New York, North Carolina, Vermont, and Washington (2016-2018) that assigned caregiver-child dyads (n = 305) from low-income households into intervention or control. The F3HK intervention included a cost-offset (50% subsidy) CSA, weekly payments (including SNAP-EBT), kitchen equipment, and 9 CSA-tailored education classes. Measureable Outcome/Analysis Household food security was measured using the 6-item Short Form of the US Department of Agriculture Food Security Survey Module (FSSM). Caregiver knowledge was assessed by asking recommended cups of fruit and vegetables (FV) per day and FV as a fraction of a dinner plate. The 4-item Negative Cooking Attitude Scale measured caregiver's attitudes towards cooking. The 4-item Self-Efficacy for Eating/Cooking Fruits and Vegetables Scale measured FV self-efficacy. Results Significant net effects were observed for outcomes related to household food security as well as caregiver nutrition attitudes and self-efficacy. Improvements in caregiver attitudes and self-efficacy remained 6 months post-intervention. Weeks of CSA pick-up mediated changes household food security. Conclusions CO-CSA plus nutrition education for low-income caregivers and their children improved household food security and caregiver attitudes and self-efficacy. Attitude and self-efficacy but not food security effects were maintained post-intervention, indicating both the promise and limitations of seasonal food access interventions. Funding USDA.

Background In cost-offset, community-supported agriculture (CO-CSA), low-income households receive subsidized shares of locally-grown produce with the aim of improving their access to and consumption of fruits and vegetables (FV). Social Cognitive Theory (SCT) is a commonly leveraged behavior change theory and informed the design of a CO-CSA plus nutrition education intervention trial for low-income households. Objective To examine the cross-sectional relationships between SCT-related variables and FV intake among CO-CSA enrollees at baseline. We hypothesized that nutrition-related attitudes, beliefs, and self-efficacy as well as perceived FV availability and accessibility would be significant predictors of FV intake. Study Design, Setting, Participants In Spring 2016 and 2017, adult enrollees (n = 305) completed a baseline questionnaire containing study-specific and validated questions to measure nutrition-related psychosocial (knowledge, attitudes, and beliefs), environmental (FV availability and accessibility), and behavioral factors (self-efficacy) in relation to self-reported and proxy measures of FV intake (National Cancer Institute's All-Day FV Screener and resonance Raman spectroscopy to assess dermal carotenoid status). Measurable Outcome/Analysis Descriptive statistics and multiple regression models were completed in SPSS. Models controlled for demographic characteristics. Self-efficacy to prepare and eat FV (β = 0.27, P ≤ .001) and in-home FV availability (β = 0.13, P = .04) were significant predictors of self-reported daily FV intake (R2 = 0.121, P ≤ .001). In-home FV availability (β = 0.20, P ≤ .001), accurate knowledge of FV recommendations (β = 0.15, P = .008), and perceived geographic access to FV (β = 0.11, P = .046) were significant predictors of carotenoid status (R2 = 0.227, P ≤ .001). Conclusions Among a set of SCT-related variables, knowledge of FV recommendations, geographic access to FV, in-home availability of FV, and self-efficacy to prepare and eat FV were significant predictors of FV intake. However, these only explained 22-23% of outcome variability among a sample of CO-CSA adult enrollees. SCT alone may not be the most appropriate theory through which to understand potential levers of FV intake among adults participating in CO-CSA programs.

Background Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities. Methods Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect. Results At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027). Conclusions Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change. Trial registration clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.