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Abstract Background Food-related beliefs and practices during pregnancy may contribute to the high prevalence of chronic energy deficiencies (CED) in Eastern Indonesia, particularly in Southeast Maluku regency, where 21.33% of pregnant women experience CED. Currently, little information on these issues is available. This study investigates food beliefs and practices related to pregnancy on Kei Besar Island in the Maluku province of Eastern Indonesia. Methods A qualitative study was conducted utilizing in-depth interviews, free lists, and pile sort exercises. Data collection was conducted in January 2023 and involved married pregnant women aged 18 and above (n = 12), community health volunteers (n = 2), and traditional healers (n = 3) from 9 villages in Kei Besar District. All participants must be natives of Kei Besar Island, with community health volunteers and traditional healers being respective figures recommended by the local villagers. Results The need to avoid or minimize consumption of certain foods during pregnancy, such as some kinds of fish, chili and spicy food, soda, pineapples, octopus, squid, and ice was reported by more than one-third of all participants. Consumption of prescribed foods, such as cassava leaves, papaya, coconut water, rice during early pregnancies, moringa leaves, bananas, and katok leaves was reported by five or more participants. These food proscriptions and prescriptions were due to concerns about the risks of miscarriage, adverse effects on the fetus and mother, and complications during labor. Participants also reported other practices, such as eating for two during early pregnancy and reducing food intake in late pregnancy. We found that food beliefs have shaped the dietary patterns of most participants. However, they still consumed food recommended by community health volunteers and midwives. Conclusions Food beliefs are present and practiced in the Kei Besar community and may impact the nutritional status of women and their infants. Interventions should target training healthcare providers and community health volunteers to provide culturally appropriate health education that incorporates prescribed local ingredients and provides nutritionally adequate substitutes for the proscribed food items. Trial Registration Not applicable.

In 2020, a mobile application (app) was developed to connect small food retailers with local pro­ducers, recognizing the underutilization of direct-to-retail sales channels. Before piloting the app, formative research was conducted in Charles County, Maryland, to gain an understanding of existing direct-to-retail sales channels for locally grown produce. Seven stores were surveyed to explore current local produce stocking, and four farmers participated in in-depth interviews to pro­vide insights into their experiences with direct-to-retail marketing channels. The results indicate a limited stocking of local produce in the small food stores, some of which was self-procured to obtain adequate quantities. Farmers expressed a passion for contributing to food security in their commu­nity and a willingness to collaborate with store owners to strengthen their direct sales; however, they cited barriers such as the impact of the COVID-19 pandemic, competition with large distributors, and logistical challenges. Considering these existing barriers and facilitators, small food stores may still possess a unique potential to establish direct sale relationships with local farms. Such relationships could be effectively facilitated through the implementation of a digital strategy.

Multi-level interventions promoting healthy weight in rural preschool children aged 2–5 years are limited. With the goal of developing a community-informed obesity prevention intervention for rural preschool-aged children, the purpose of this descriptive study was to identify: (1) community settings and intervention strategies to prioritize for an intervention; (2) potential implementation challenges and solutions; and (3) immediate interventions the study team and community partners could collaboratively implement. Workshops occurred in two rural communities in Indiana (2 workshops) and North Carolina (2 workshops), with high obesity rates. A guide was developed to moderate discussions and participants voted to rank community settings and intervention strategies. There were 9–15 participants per workshop, including parents, childcare providers, and representatives of community organizations. Community settings identified as priorities for child obesity prevention included the home, educational settings (preschools), food outlets, recreational facilities, and social media. Priority intervention strategies included providing nutrition and physical activity education, increasing access to healthy foods and physical activity in the built environment, and enhancing food security. Potential intervention implementation challenges centered on poor parental engagement; using personalized invitations and providing transportation support to families were proffered solutions. Immediate interventions to collaboratively implement focused on making playgrounds esthetically pleasing for physical activity using game stencils, and nutrition education for families via quarterly newsletters. This participatory approach with community partners provided insight into two rural communities’ needs for child obesity prevention, community assets (settings) to leverage, and potential intervention strategies to prioritize. Findings will guide the development of a multi-level community-based intervention.

IntroductionFood-insecure households commonly rely on food pantries to supplement their nutritional needs, a challenge that was underscored during the COVID-19 pandemic. Food pantries, and the food banks that supply them, face common challenges in meeting variable client volume and dietary needs under normal and emergency (e.g., pandemic, natural disaster) conditions. A scalable digital strategy that has the capacity to streamline the emergency food distribution system, while promoting healthy food options, managing volunteer recruitment and training, and connecting to emergency management systems in times of need, is urgently required. To address this gap, we are developing a working mobile application (app) called the Support Application for Food PAntrieS (SAFPAS) and will evaluate its feasibility and impact on food pantry staff preparedness, stocking, and client uptake of healthful foods and beverages in two urban United States settings.MethodsThis paper describes the protocol for a randomized controlled trial of the SAFPAS mobile application. We will conduct formative research in Baltimore, Maryland and Detroit, Michigan to develop and refine the SAFPAS app and increase scalability potential to other urban settings. Then we will test the app in 20 food pantries in Baltimore randomized to intervention or comparison. The impact of the app will be evaluated at several levels of the emergency food system, including food pantry clients (n = 360), food pantry staff and volunteers (n = 100), food pantry stock, and city agencies such as the local food bank and Office of Emergency Management. The primary outcome of the SAFPAS trial is to improve the healthfulness of the foods received by food pantry clients, measured using the Food Assessment Scoring Tool (FAST). Post-trial, we will conduct additional formative research in Detroit to prepare the app for scale-up.DiscussionWe anticipate that SAFPAS will improve alignment in the supply and demand for healthy foods among food pantry clients, food pantries, and city agencies which supply food in Baltimore. Real-time, bidirectional communication between entities across the system allows for increased situational awareness at all levels during normal and emergency operations. By conducting formative research in Detroit, we hope to increase the scalability of the SAFPAS app to additional settings nationwide.Clinical trial registrationNCT87654321. https://classic.clinicaltrials.gov/ct2/show/NCT05880004.

IntroductionThere are currently over 50 dollar stores in Baltimore City, Maryland. Community perceptions of over-saturation and resulting neighborhood impacts have garnered recent attention. A Maryland State Senate Bill required further study of dollar stores in Baltimore City to inform future policy. Therefore, the over-arching goal of this study was to generate community-informed policy recommendations for the Baltimore City Council.MethodsThree methods of data collection were used: (1) in-depth interviews with community members, retail staff/owners, dollar store staff, and policy makers; (2) an online survey of Baltimore City residents; and (3) workshop with community members and one with policy makers. Triangulation across data sources, discussion amongst the research team, and member checking were used to generate the top four policy options: a conditional use ordinance, a community benefits agreements, a dispersal ordinance, and a staple foods ordinance.ResultsThere was strong support for policies that encourage dollar stores to better align with community priorities (e.g., improving store cleanliness and appearance, increasing availability of healthy foods), as opposed to closing or banning dollar stores entirely. There was also strong support for policies that would empower communities to participate in determining the role of dollar stores in their neighborhoods, for example through a conditional use ordinance or community benefits agreement. Key concerns included policy enforcement, given the additional funding required, and current limited capacity at the city government level. Strategies to address such challenges were generated including implementing business licenses at the city level, linking new ordinances to dollar store leases and permits, and encouraging dollar store participation in federal and local programs to more feasibly stock healthier food items (e.g., fresh produce). Dissatisfaction was expressed regarding a lack of policy options to address the existing dollar stores, not just new dollar stores entering the City.DiscussionThis study is the first of its kind to assess community support for dollar store policies at the local level, and serves to inform policies that improve dollar stores. A report of these findings was provided to Baltimore City Council to inform new, community-supported dollar store policies.

Objectives:We sought to understand the social construction of aging in a clinic-based population, with and without HIV, to address gaps in care for older individuals living with HIV in Zambia.Methods:Our exploratory qualitative study included 36 in-depth interviews with clinic clients and four focus group discussions with 36 professional and lay healthcare workers providing services to the clients. We identified themes based on social construction theory.Results:At the individual level, aging was multidimensional, perceived both as an achievement in the HIV era and as a period of cognitive, physical, and economic decline. In social interactions, older individuals were often stereotyped and treated as helpless, poor, and “witches.” Those living with HIV faced the additional stigma of being labeled as promiscuous. Some of the participants living without HIV refused to take daily medication for non-communicable diseases to avoid being mistaken for taking antiretroviral therapy for HIV. Older individuals wanted quality healthcare and family support to address the intersectional stigma of aging, poverty, and chronic illness.Conclusion:Multifaceted interventions are required to combat age-related prejudice, intersectional stigma, and discriminatory practices, particularly for people living with HIV.

BackgroundLifestyle medicine (LM) is the use of therapeutic lifestyle changes (including a whole-food, plant-predominant eating pattern; regular physical activity; restorative sleep; stress management; avoidance of risky substances; and positive social connection) to prevent and treat chronic illness. Despite growing evidence, LM is still not widely implemented in health care settings. Potential challenges to LM implementation include lack of clinician training, staffing concerns, and misalignment of LM services with fee-for-service reimbursement, but the full range of factors facilitating or obstructing its implementation and long-term success are not yet understood. To learn important lessons for success and failure, it is crucial to understand the experiences of different LM programs. ObjectiveThis study aims to describe in depth the protocol used to identify barriers and facilitators impacting the implementation of LM in health systems. MethodsThe study team comprises team members at the American College of Lifestyle Medicine (ACLM), including staff and researchers with expertise in public health, LM, and qualitative research. We recruited health systems that were members of the ACLM Health Systems Council. From among 15 self-nominating health systems, we selected 7 to represent a diversity of geographic location, type, size, expertise, funding, patients, and LM services. Partway through the study, we recruited 1 additional contrasting health system to serve as a negative case. For each case, we conducted in-depth interviews, document reviews, site visits (limited due to the COVID-19 pandemic), and study team debriefs. Interviews lasted 45-90 minutes and followed a semistructured interview guide, loosely based on the Consolidated Framework for Implementation Research (CFIR) model. We are constructing detailed case narrative reports for each health system that are subsequently used in cross-case analyses to develop a contextually rich and detailed understanding of various predetermined and emergent topics. Cross-case analyses will draw on a variety of methodologies, including in-depth case familiarization, inductive or deductive coding, and thematic analysis, to identify cross-cutting themes. ResultsThe study team has completed data collection for all 8 participating health systems, including 68 interviews and 1 site visit. We are currently drafting descriptive case narratives, which will be disseminated to participating health systems for member checking and shared broadly as applied vignettes. We are also conducting cross-case analyses to identify critical facilitators and barriers, explore clinician training strategies to facilitate LM implementation, and develop an explanatory model connecting practitioner adoption of LM and experiences of burnout. ConclusionsThis protocol paper offers real-world insights into research methods and practices to identify barriers and facilitators to the implementation of LM in health systems. Findings can advise LM implementation across various health system contexts. Methodological limitations and lessons learned can guide the execution of other studies with similar methodologies. International Registered Report Identifier (IRRID)DERR1-10.2196/51562

Objective. Diet-related disease is rising, disproportionately affecting minority communities in which small food retail stores swamp supermarkets. Barriers to healthy food access were exacerbated by the pandemic. We examined the following: (1) individual- and household-level factors in a sample of Baltimore community members who regularly shop at corner stores and (2) how these factors are associated with indicators of dietary quality. Design. Cross-sectional data were collected using an online survey to capture sociodemographics, anthropometrics, and food sourcing, spending, and consumption patterns. Concurrent quantitative and qualitative analyses were conducted in Stata 18 and ATLAS.ti. Setting. This study was set in Baltimore, Maryland, USA. Participants. The participants included adults (n = 127) living or working in Baltimore who identified as regular customers of their neighborhood corner store. Results. The respondents were majority Black and low-income, with a high prevalence of food insecurity (62.2%) and overweight/obesity (66.9%). Most (82.76%) shopped in their neighborhood corner store weekly. One-third (33.4%) of beverage calories were attributed to sugar-sweetened beverages, and few met the recommended servings for fruits and vegetables or fiber (27.2% and 10.4%, respectively). Being Black and not owning a home were associated with lower beverage and fiber intake, and not owning a home was also associated with lower fruit and vegetable intake. Food insecurity was associated with higher beverage intake, while WIC enrollment was associated with higher fruit and vegetable and fiber intakes. Open-ended responses contextualized post-pandemic food sourcing and consumption in this setting. Conclusions. This paper helps characterize the consumers of a complex urban food system. The findings will inform future strategies for consumer-engaged improvement of local food environments.

Complex food retail settings, where multiple food retail outlets operate in close proximity are common. Despite their ubiquity, there remains a significant knowledge gap regarding healthy food retail interventions implemented within these settings. Furthermore, understanding the factors affecting the implementation of interventions in these settings remains limited. This systematic review aimed to (1) identify and describe complex food retail settings where interventions were implemented to promote the healthiness of foods purchased, (2) synthesise the evidence on the effectiveness of the interventions implemented, and (3) identify enablers and barriers to the implementation of the interventions in these settings. Four databases, namely, MEDLINE Complete, Global Health, Embase, and Business Source Complete, were searched until December 2022. The Effective Public Health Practice Project quality assessment tool was used. Six studies reported on the implementation of interventions promoting healthy food purchases across multiple food retail outlets. Three studies each described two complex food retail settings: university and hospital. Interventions including promotion and promotion plus price improved the healthiness of foods purchased. There was limited description of institutional food policies, conceptual frameworks, formative research, or evaluation outcomes to inform the implementation of interventions in these settings. No study analysed enablers and barriers to the implementation of interventions. No study identified their settings as complex food retail settings. There is limited evidence describing complex food retail settings, their impact on intervention effectiveness, and associated enablers or barriers. Investigating factors influencing the effectiveness of interventions implemented within complex food retail settings is critical to support their implementation at scale.

Traditional patient- and provider-level hypertension interventions have proven insufficient to halt hypertension as the leading cause of morbidity and mortality globally. Systems-level interventions are required to address factors challenging hypertension control across a social ecological framework, an under-studied topic particularly salient in low- and middle-income countries (LMICs) such as Peru. To inform such interventions, we sought to identify key health systems barriers to hypertension care in Puno, Peru. A participatory stakeholder workshop (October 2021) and 21 in-depth interviews (October 2021-March 2022) were conducted with 55 healthcare professionals (i.e., doctors, nurses, midwives, dentists, nutritionists), followed by a deductive qualitative analysis of transcripts and notes. Participating healthcare providers indicated that low prioritization and lack of national policies for hypertension care have resulted in limited funding and lack of societal-level prevention efforts. Additionally, limited cultural consideration, both in national guidelines as well as by some providers in Puno, results in inadequate care that may not align with local traditions. Providers highlighted that patient care is also hampered by inadequate distribution and occasional shortages of medications and equipment, as well as a lack of personnel and limited opportunities for training in hypertension. Multiple incompatible health information systems, complicated referral systems, and geographic barriers additionally hinder continuity of care and care seeking. Insights gained from health providers on the healthcare system in Puno provide essential contextual information to inform development of organizational-level strategies necessary to improve provider and patient behaviors to achieve better hypertension care outcomes.

Abstract Objective: Although typically serving higher income and younger demographic groups, meal-kit subscription services have the potential to improve food availability and dietary quality in communities experiencing low food access due to systemic discrimination. This study describes the development and characteristics of a pilot community-led meal-kit service (SouthEats) and evaluates key implementation outcomes of adoption, acceptability, and feasibility among households experiencing less income. Design: We utilised a mixed methods study design, including data from administrative records, customer surveys and worker interviews. Thematic qualitative analyses and descriptive quantitative analyses were conducted to illuminate the characteristics and extent the pilot meal-kit service was adopted, acceptable, and financially feasible among the target populations. Setting: The study took place in Washington DC, USA. Participants: Study participants included SouthEats consumers (n 35) and workers (n 3). Results: During the pilot period, sixty-seven community members signed up for the meal-kit service, with 52 % making recurring purchases. Our results suggest that the meal-kit service is acceptable among people living in low food access areas. Our feasibility analysis indicates that, although not without challenges, the SouthEats model could be financially feasible. Conclusion: These preliminary insights can inform the scalability and potential replication of this service and provide foundational evidence for an approach that may be used to improve food access.

Abstract Introduction Urinary incontinence is a significant health problem with considerable social and economic consequences among older adults. The objective of this study was to investigate the financial impact of continuity of care (CoC) among older urinary incontinence patients in South Korea. Methods We used the NHIS-Senior cohort patient data between January 1, 2010, and December 31, 2010. Patients who were diagnosed with urinary incontinence in 2010 were included. Operational definition of CoC included referrals, number of providers, and number of visits. A generalized linear model (GLM) with γ-distributed errors and the log link function was used to examine the relationship between health cost and explanatory variables. Additionally, we conducted a two-part model analysis for inpatient cost. Marginal effect was calculated. Results Higher CoC was associated with a decrease in total medical cost (-0.63, P

Supermarkets are scarce in many under-resourced urban communities, and small independently owned retail stores often carry few fresh or healthy items. The Baltimore Urban food Distribution (BUD) mobile application (app) was previously developed to address supply-side challenges in moving healthy foods from local suppliers to retailers. In-app opportunities for consumers to indicate demand for these foods are crucial, but remain absent. We sought to understand community members’ perspectives on the overall role, function and features of a proposed consumer-engagement module (BUDConnect) to expand the BUD app. A series of initial high-fidelity wireframe mockups were developed based on formative research. In-depth interviews (n = 20) were conducted and thematically analyzed using ATLAS.ti Web. Participants revealed a desire for real-time crowd-sourced information to navigate their food environments safely and effectively, functionality to help build community and social networks among store owners and their customers, opportunities to share positive reviews and ratings of store quality and offerings, and interoperability with existing apps. Rewards and referral systems resulting in the discounted purchasing of promoted healthy items were suggested to increase adoption and sustained app use. Wireframe mockups were further refined for future development and integration into the BUD app, the program and policy implications of which are discussed.

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers’ acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore’s IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.

Abstract Background Obesogenic environment is important in driving obesity epidemic. Children spend large amount of their time in schools. School neighborhood environment, as well as its interaction with socioeconomic status (SES) needs to be explored to provide evidence for children obesity prevention policies. Methods Objective anthropometric measurement, a household structured questionnaire, and school geospatial analyses were carried out on 3670 children (aged 9–12 years) of 26 schools in northeast China. Interaction between SES inter-categorical intersectionality group and school neighborhood environment was tested for the effect on children’s body mass index z scores (z-BMI) and waist–hip ratio z scores (z-WHR), following formulation of SES inter-categorical intersectionality group based on household wealth, parental education, and parental occupation. Results SES groups formed by household wealth, parental education and parental occupation was associated with z-BMI and z-WHR for girls. Those from moderate wealth & self-employed (M&S) families had the highest adjusted z-BMI and z-WHR among all SES groups. School neighborhood environment factors interacted with SES groups in association with WHR for girls. Number of school neighborhood supermarkets and residential sites were negatively associated with z-WHR for girls from M&S families (β= -0.45 (95%CI: -0.76, -0.15) for supermarkets; β= -0.01 (95%CI: -0.03, 0.00) for residential sites). Number of school neighborhood convenience stores and public transport stops were positively associated with z-WHR for girls from M&S families (β = 0.02 (95%CI: 0.00, 0.03) for convenience stores; β = 0.23 (95%CI: 0.15, 0.31) for public transport stops). While non-significant association was found for number of vegetable stores. Conclusion Girls from moderate wealth & self-employed families may be the group susceptible to school neighborhood environment. Local policies targeted at improving the school neighborhood environment may be one avenue for reducing socioeconomic disparities in obesity especially for girls.

Abstract Background Obesity levels are higher in rural versus urban children. Multi-level community-based interventions can be effective in promoting healthy child weight, but few of such interventions have focused on rural children. This formative study assessed barriers, facilitators, and opportunities to promote healthy child weight in two rural communities. Methods Multiple data collection methods were used concurrently in two rural communities in Indiana and North Carolina. Focus groups and interviews were conducted with participants, including parents of children aged 2–5 years (n = 41), childcare providers (n = 13), and stakeholders from 23 community organizations. Observational audits were conducted at 19 food outlets (grocery stores) and 50 publicly-accessible physical activity resources. Focus groups/interviews were analyzed thematically. Surveys were analyzed using descriptive statistics, Fisher’s exact test, and t-tests. Results Family level barriers included limited financial resources and competing priorities, whereas parental role-modeling was perceived as a facilitator of healthy weight behaviors. At the organizational level, childcare providers and community stakeholders cited limited funding and poor parental engagement in health promotion programs as barriers. Childcare providers explained that they were required to comply with strict nutrition and physical activity guidelines, but expressed concerns that similar messages were not reinforced at home. Facilitators at the organizational level included healthy meals provided at no cost at childcare programs, and health promotion programs offered through community organizations. At the community level, lack of public transportation, and limited access to healthy food outlets and physical activity-promoting resources posed barriers, whereas existing physical activity resources (e.g., parks) and some ongoing investment to improve physical activity resources in the community were assets. In designing/implementing a potential child obesity prevention intervention, participants discussed the need to garner community trust, emphasize wellness instead of obesity prevention, establish community partnerships, and leverage existing community resources. Conclusions Rural areas experience multiple challenges that make it difficult for children/families to engage in healthy weight behaviors. This study highlights several assets (existing programs/resources, expertise within communities) that can be leveraged as facilitators. Findings will guide the study team in developing a child obesity prevention intervention for the two rural communities.

The prevalence of stunting in young children is associated with poor growth during the prenatal and early postnatal periods. A maternal mentoring program was developed for Indonesian women to improve birth outcomes. A cluster-randomized controlled trial (CRCT) was conducted in three sub-districts of the Special Region of Yogyakarta, Indonesia. A total of 384 eligible participants were randomly allocated to either an intervention (received the maternal mentoring program and standard care; n = 189) or control (received standard care only; n = 195) group. The maternal mentoring program provided preconception health education; health monitoring; and text message reminders for preconception women. Fetal growth was measured between gestational weeks 27 and 30 using the estimated fetal weight generated from ultrasonographic measurements. Birth weight was measured within 24 h of birth. A structured questionnaire captured women’s demographics, pregnancy readiness, and body mass indexes (BMIs). After adjustment, fetal weight was 14% (95% CI: 5.1–23.0) higher in the intervention group than in the control group, and the average weight-for-length Z-score at birth was 0.16 (95% CI: 0.04–0.30) higher in the intervention group than in the control group. The maternal mentoring program was associated with improved fetal growth and birth weight in this population and should be considered for scale-up to other settings, nationally and globally.

Abstract Background Modifying the environment to promote healthy foods is a population-based approach for improving diet. This study evaluated the outcome effectiveness of a food store intervention that used structural and social change strategies to promote fruits and vegetables. It was hypothesized that intervention versus control store customers would improve their consumption of fruits and vegetables at 6 months. Trial design Clustered randomized controlled trial Methods Sixteen pair-matched stores were randomized to an intervention or wait-list control condition. With the research team’s support, intervention stores modified the availability, accessibility, and promotion of fruits and vegetables, including augmenting produce displays within the store and building employees’ capacity to place and promote fruits and vegetables throughout the store (Phase 1), followed by the delivery of a customer-directed marketing campaign for 6 months (Phase 2). From months 7 to 12, stores were encouraged to maintain strategies on their own (Phase 3). Customer-reported daily fruit and vegetable consumption (cups/day) were collected by blinded research assistants at three time-points (baseline, 6 months and 12 months post-baseline) from 369 participating customers (an average of 23/store). Secondary outcomes included customer-reported fruit and vegetable purchasing and other behaviors. Results The study retained the 16 stores and most customers at 6 (91%) and 12 (89%) months. Although significant differences were not observed in the overall sample for vegetable consumption, male customers of intervention versus control stores consumed significantly more fruit daily at 6 months [mean (standard deviation) cups at baseline and six months; intervention: 1.6 (1.5) to 1.6 (1.5) vs. control: 1.4 (1.2) to 1.1 (0.8)]. However, this difference was not observed at 12 months, or among females. There was an overall increase in dollars spent at the targeted store in the intervention versus control condition among male versus female customers at 6 months; however, no change was observed in the percent of dollars spent on fruits and vegetables at the targeted store. Frequency of shopping at the targeted store did not modify intervention effects. Conclusions Structural and social change interventions can modify customers’ behavior in the short-term. Future research should consider methods for achieving longer-term changes, and potential generalizability to other products (e.g., energy-dense sweet and savory products). Trial registration NCT01475526

This cross-sectional analysis of the baseline evaluation sample of the Obesity Prevention and Evaluation of InterVention Effectiveness in Native Americans 2 (OPREVENT2) study included 601 Native American adults ages 18-75 living in rural reservation communities in the Midwest and Southwest United States. Participants completed a self-report questionnaire for individual and family history of hypertension, heart disease, diabetes and obestiy. Body mass index (BMI), percent body fat, and blood pressure were measured by trained research staff. About 60% of respondents had a BMI >30 kg/m2. Approximately 80% had a waist-to-hip ratio and percent body fat classified as high risk, and nearly 64% had a high-risk blood pressure measurement. Although a large proportion of participants reported a family history of chronic disease and had measurements that indicated elevated risk, relatively few had a self-reported diagnosis of any chronic disease. Future studies should examine potential connections between healthcare access and discordance in self-reported versus measured disease risks and diagnoses.

Background: Antenatal care (ANC) is low in developing countries, with an estimated 20% of Indonesian women not initiating ANC during the first trimester. The present study sought to determine the impact of a mentoring program on the timing of the first ANC visit. Methods: This cluster randomized controlled trial was conducted in 3 subdistricts of the Bantul District, divided into 61 clusters per treatment arm, with a final sample size of 205 confirmed pregnant women. The mentoring program consisted of (1) health education, (2) monitoring, and (3) text-message reminders. The primary outcome was the timing of first ANC visit. A multilevel mixed-effect logistic regression model was used to measure the effect of the program on the likelihood of having an earlier first ANC visit, with statistical significance at α=0.05. Results: At the individual-level, the intervention group had a mean time of first ANC visit±2 days earlier than the control group (P

Native American populations experience highly disproportionate rates of poor maternal-child health outcomes. The WIC program aims to safeguard health by providing greater access to nutritious foods, but for reasons not well understood, participation in many tribally-administered WIC programs has declined to a greater extent compared to the national average decline in participation over the last decade. This study aims to examine influences on WIC participation from a systems perspective in two tribally-administered WIC programs. In-depth interviews were conducted with WIC-eligible individuals, WIC staff, tribal administrators, and store owners. Interview transcripts underwent qualitative coding, followed by identifying causal relationships between codes and iterative refining of relationships using Kumu. Two community-specific causal loop diagrams (CLDs) were developed and compared. Findings from interviews in the Midwest yielded a total of 22 factors connected through 5 feedback loops, and in the Southwest a total of 26 factors connected through 7 feedback loops, resulting in three overlapping themes: Reservation and Food Store Infrastructure, WIC Staff Interactions and Integration with the Community, and State-level Administration and Bureaucracy. This study demonstrates the value of a systems approach to explore interconnected barriers and facilitators that can inform future strategies and mitigate declines in WIC participation.

This study utilized baseline data collected in 2017 from the OPREVENT2 trial, which included 540 Native Americans in six Midwest and Southwest reservation communities. The objective was to identify correlates of fruit, vegetable, and dietary fiber adequacy among participants 18–75 years old who self-identified as the main food purchaser or preparer in their household. Mean daily servings of fruits and vegetables and grams of dietary fiber were quantified based on a 30-day semi-quantitative food frequency questionnaire.Participants consumed an average of 0.5 (±0.4) cup-equivalent servings of fruit, 2.5 (±1.8) cup-equivalent servings of vegetables, and 15.5 (±8.9) grams of fiber per day.

Americans spend the majority of their food dollars at restaurants and other prepared food sources, including quick-service and fast-food restaurants (PFS); independent small restaurants make up 66% of all PFS in the US. In this feasibility study, 5 independent and Latino-owned PFS in the Washington DC metro area worked with academic partners to start offering healthy combo meals with bottled water and promote these using on-site, community, and social media advertising. The number of healthy combos sold was collected weekly, showing that the new combos sold, and customers in all 5 sites were surveyed as they exited the PFS (n=50): >85% had noticed the combo meals; 100% thought it was a good idea to offer it, 68% had ordered the combo (of these, >94% of customers responded that they liked it). Results suggest that it is feasible to work with independent Latino-owned restaurants to promote healthy combos and collect data.

Small food retail stores in many underserved urban settings keep no electronic records, making documentation of program impact on sales difficult to obtain. We examined the feasibility of introducing a point-of-sale tablet (POST) application to track sales of foods and beverages in Baltimore City corner stores. A sample of four geographically and ethnically diverse corner store owners were trained to use POST to track sales of 14 items for eleven days. Feasibility was documented via a structured survey and open-ended interviews. POST had high economic and cultural acceptability, operability, and perceived sustainability, regardless of language differences or familiarity with mobile technology. All store owners reported willingness to use POST again. It is feasible to train corner store owners to use a point-of-sale application for sales monitoring. An upcoming trial will help to ensure that POST provides sufficient value added for corner store owners.

Background: Indonesian school children spend one-third of their time in school, where they are exposed to a variety of foods at school canteens. However, the healthiness of school canteens is not yet well understood. This study was conducted to (1) characterize the healthiness and quality of management of school canteens, and (2) measure readiness of school canteens to reopen following COVID-19 closures. Design and Methods: Mixed-methods were used to conduct a cross-sectional study. Data were collected from schools located in the Bantul District of Indonesia. Primary schools (n=152) were randomly selected, with a final sample size of 147. Data were collected using Google Forms, delivered via WhatsApp or email. School canteens were classified as healthy if they had a Healthy Canteen Score (HCS) >= 10, or unhealthy if they had a HCS < 10. Results: Less than half (43.5%) of school canteens were deemed to be healthy. School canteens were more likely to be healthy if the canteen manager had a formal decision letter (OR=15.2; 95% CI=3.7-62.5); used print material messaging (OR= 3.2 to 4.6 times); or received inspection by external officers periodically (OR=2.8; 95% CI= 1.04-7.5). Readiness to reopen was 4.5 (OR=4.5; 95%CI: 1.1-17.9) times higher among schools that had their own canteen, and 4 (OR=3.9; 95% CI =1.1-13.8) times higher among schools located in rural areas, adjusting for the remaining variables. Conclusions: School canteen healthiness can be improved by implementing national food policy and healthy school canteen standards accompanied by the existence of good management practices within schools, particularly following the COVID-19 pandemic.

Objective: Qualitative methods may help to understand features related to health urban inequalities as a way to include citizens’ perceptions of their neighbourhoods in relation to their health-related behaviours. The aim of this article is to describe the methods and design of a qualitative urban health study. Methods: The Heart Healthy Hoods (HHH) analyses cardiovascular health in an urban environment using mixed methods: electronic health records, quantitative individual questionnaires, physical examination, semi-structured Interviews (SSIs), focus groups (FGs) and participatory technics such as photovoice. This article focuses on the HHH qualitative methods and design. A case study was used to select three neighbourhoods in Madrid with different socioeconomic levels: low, medium, and high. The selection process for these three neighbourhoods was as follows: classification of all Madrid's neighbourhoods (128) according to their socioeconomic level; after ranking this classification, nine neighbourhoods, three by socioeconomic level, were short-listed; different urban sociology criteria and non-participant observation were used for the final selection of three neighbourhoods. After selecting the three neighbourhoods, thirty SSIs were held with residents and six SSIs were held with key informants. Finally, twenty-nine FGs will be conducted over the course of 8 months, between May and December of 2018. Conclusions: Systematization in the selection of neighbourhoods and the use of adequate techniques are essential for the qualitative study of urban health inequalities. Resumen: Objetivo: La metodología cualitativa puede ayudar a entender aspectos relacionados con las desigualdades en salud urbana, incluyendo la percepción de los ciudadanos de su barrio en relación con los comportamientos relacionados con su salud. El objetivo de este artículo es describir los métodos y el diseño de un estudio cualitativo sobre salud urbana. Método: Heart Healthy Hoods (HHH) es un estudio que analiza la salud cardiovascular en un ámbito urbano, utilizando métodos mixtos: registros electrónicos de salud, cuestionarios individuales cuantitativos, exploraciones físicas, entrevistas semiestructuradas (ESE), grupos de discusión (GD) y técnicas participativas como el fotovoz. Este artículo se centra en los métodos y el diseño de la fase cualitativa del HHH. Se aplicó un estudio de caso, seleccionando tres barrios de Madrid con diferente nivel socioeconómico: bajo, medio y alto. El proceso de selección para estos tres barrios fue el siguiente: clasificación de todos los barrios de Madrid (128) según su nivel socioeconómico; tras graduar la clasificación se seleccionaron nueve barrios de Madrid, tres por nivel socioeconómico; se utilizaron diferentes criterios de sociología urbana y observación no participante para la selección final de tres barrios. Tras la elección de los tres barrios, se realizaron 30 ESE a vecinos y 6 ESE a informantes clave. Finalmente, se están organizando 29 GD con vecinos durante 8 meses, entre mayo y diciembre de 2018. Conclusiones: La sistematización en la selección de barrios y la utilización de las técnicas adecuadas son fundamentales para el estudio cualitativo de las desigualdades en el entorno urbano. Keywords: Qualitative method, Urban health, Health inequalities, Neighbourhoods, Palabras clave: Metodología cualitativa, Salud urbana, Desigualdades en salud, Barrios

Abstract Background Food away from home (FAFH) in the US is associated with adverse health outcomes, and food dollars spent on FAFH continues to increase. FAFH studies have typically focused on restaurants and carryout establishments, but mobile food vendors – popularly known in the US as food trucks – have become more numerous and are an understudied segment of FAFH. The objective of this study was to assess mobile food vendors, their attitudes toward health and nutrition, and the foods they serve. Methods This was a cross-sectional study of 41 mobile food vendors in Michigan, US. The survey contained questions about food and nutrition attitudes, such as barriers to putting healthy items on menus and perceived agreement with healthy food preparation practices. Participants were classified into a healthy and a less healthy attitude group based on whether they believed healthy menu items could be successful or not. In addition, participant menus were collected and analyzed according to whether menu items were healthy, moderately healthy, or unhealthy. Descriptive, univariate, and bivariate analyses were conducted. Results Two-thirds of the participants felt that healthy menu items could be successful, and yet taste and value were the most important menu item success factors, each rated as important by 100% of the participants. Low consumer demand was the biggest barrier to putting healthy items on the menu (76%) whereas lack of chef interest (29%) and need for special training (24%) were the smallest. 72% of the vendors offered at least one healthy menu item, but only 20% of all reviewed menu items were healthy overall. There was no difference in the proportion of menu items that were healthy when comparing those with healthy attitudes (23% of menu items healthy) to those less healthy attitudes (17% of menu items healthy, p = 0.349). Conclusions Mobile food vendors had positive views about putting healthy items on menus. However, a low proportion of menu items were classified as healthy. This suggests that mobile food vendors are promising potential public health partners in improving the health profile of FAFH, but that education of vendors is needed to ensure the success of healthier items.

BackgroundObesity prevalence remains high among children of Pacific Islander (PI) origin, Filipino (FI), and American Indian/Alaska Native (AIAN) origins in the United States. While school nutrition policies may help prevent and reduce childhood obesity, their influences specifically among PI, FI, and AIAN children remain understudied. We evaluated the association of the California (CA) state school nutrition policies for competitive food and beverages and the federal policy for school meals (Healthy, Hunger-Free Kids Act of 2010 (HHFKA 2010)) with overweight/obesity among PI, FI, and AIAN students.Methods and findingsWe used an interrupted time series (ITS) design with FitnessGram data from 2002 to 2016 for PI (78,841), FI (328,667), AIAN (97,129), and White (3,309,982) students in fifth and seventh grades who attended CA public schools. Multilevel logistic regression models estimated the associations of the CA school nutrition policies (in effect beginning in academic year 2004 to 2005) and HHFKA 2010 (from academic year 2012 to 2013) with overweight/obesity prevalence (above the 85 percentile of the age- and sex-specific body mass index (BMI) distribution). The models were constructed separately for each grade and sex combination and adjusted for school district-, school-, and student-level characteristics such as percentage of students eligible for free and reduced price meals, neighborhood income and education levels, and age. Across the study period, the crude prevalence of overweight/obesity was higher among PI (39.5% to 52.5%), FI (32.9% to 36.7%), and AIAN (37.7% to 45.6%) children, compared to White (26.8% to 30.2%) students. The results generally showed favorable association of the CA nutrition policies with overweight/obesity prevalence trends, although the magnitudes of associations and strengths of evidence varied among racial/ethnic subgroups. Before the CA policies went into effect (2002 to 2004), overweight/obesity prevalence increased for White, PI, and AIAN students in both grades and sex groups as well as FI girls in seventh grade. After the CA policies took place (2005 to 2012), the overweight/obesity rates decreased for almost all subgroups who experienced increasing trends before the policies, with the largest decrease seen among PI girls in fifth grade (before: log odds ratio = 0.149 (95% CI 0.108 to 0.189; p < 0.001); after: 0.010 (-0.005 to 0.025; 0.178)). When both the CA nutrition policies and HHFKA 2010 were in effect (2013 to 2016), declines in the overweight/obesity prevalence were seen among White girls and FI boys in fifth grade. Despite the evidence of the favorable association of the school nutrition policies with overweight/obesity prevalence trends, disparities between PI and AIAN students and their White peers remained large after the policies took place. As these policies went into effect for all public schools in CA, without a clear comparison group, we cannot conclude that the changes in prevalence trends were solely attributable to these policies.ConclusionsThe current study found evidence of favorable associations of the state and federal school nutrition policies with overweight/obesity prevalence trends. However, the prevalence of overweight/obesity continued to be high among PI and AIAN students and FI boys. There remain wide racial/ethnic disparities between these racial/ethnic minority subgroups and their White peers. Additional strategies are needed to reduce childhood obesity and related disparities among these understudied racial/ethnic populations.

There is a gap in the literature regarding the specific methods used by supermarkets to engage community members in operations and decision-making processes. Free-listing is an engagement method that allows individuals to list all possible items associated with a particular topic or domain. This study explores the application of free-listing as a method to assess the availability and affordability of food items at DMG Foods, a nonprofit super­market in Baltimore, Maryland, to assist with mak­ing stocking decisions and increasing store use. Twenty residents in central northeast Baltimore participated in free-listing desirable foods and frequented supermarkets. All selected participants were over 18 years of age, Black, and regularly shopped in the central northeast region of Balti­more. We calculated the saliency of food items and stores based on an item’s frequency and order of mention in the free-listing. We then conducted store observations of the top salient stores three times at three-week intervals to identify the availa­bility and accessibility of the top salient food items. Fifteen items had saliency scores greater than 0.1 and were retained for observation. Five stores had saliency scores greater than 0.1 and were within a five-mile (8-km) radius from DMG Foods. Larger supermarkets carried the widest variety of salient items, and the prices of items varied between stores, highlighting the importance of community-driven stocking for smaller supermarkets. Free-listing is a simple engagement method that store managers with limited research experience can use to identify foods that are desirable to residents of the community, ultimately leading to improved community food environments and increased store success.

Access to healthy food is a necessity for all people. However, there is still a lack of reviews on the assessment of respondent-based measures of neighborhood food environments (perceived food environments). The aim of this systematic review was to evaluate the measurement tools for perceived food environments by five dimensions of food access and to obtain the overview of their associations with dietary habits among people aged 18 years and older in middle- and high-income countries. Observational studies using perceived food environment measures were identified through a systematic review based on two databases for original studies published from 2010 to 2020. A total of 19 final studies were extracted from totally 2926 studies. Pertaining to the five dimensions of food access, 12 studies dealt with accessibility, 13 with availability, 6 with affordability, 10 with acceptability, 2 with accommodation, and 8 with a combination of two or more dimensions. Perceived healthy food environments were positively associated with healthy dietary habits in 17 studies, but 8 of them indicated statistically insignificant associations. In conclusion, this review found accessibility and availability to be major dimensions of perceived food environments. The relationship between healthy food environments and healthy diets is presumably positive and weak.

Abstract Background Consumption of foods and beverages rich in sugar remains high across all races and ages in the United States. Interventions to address childhood obesity and decrease sugar intake are needed, particularly in low-income settings. Methods B’more Healthy Communities for Kids (BHCK) was a group-randomized, controlled trial implemented among 9–15-year olds in 30 low-income areas of Baltimore. We increased access to low-sugar foods and beverages at wholesalers and small food stores. Concurrently, we encouraged their purchase and consumption by children through youth-led nutrition education in recreation centers, in-store promotions, text messaging and a social media program directed at caregivers. Sugar consumption (sugar sweetened beverage (SSB), sweets) in youth was assessed pre- (n = 534) and post-intervention (n = 401) using the Block Kids Food Frequency Questionnaire. Purchasing of 38 healthier and 28 less healthier food/beverage varieties in the previous 7 days was assessed via self-report. Multilevel models at the community and individual levels were used. Analyses were stratified by age (younger: 9–12-year olds (n = 339) vs older: 13–15 (n = 170)). Models were controlled for child’s sex, race, total daily caloric intake, and caregiver’s age and sex. Results Overall baseline mean healthier food purchasing was 2.5 (+ 3.6; min. 0, max. 34 items per week), and unhealthier food purchasing 4.6 (+ 3.7; 0–19 items per week). Mean intake at baseline for kcal from SSB was 176 (+ 189.1) and 153 (+ 142.5), and % of calories from sweets (i.e. cookies, cakes, pies, donuts, candy, ice cream, sweetened cereals, and chocolate beverages) was 15.9 (+ 9.7) and 15.9 (+ 7.7) in comparison and intervention youth, respectively. Intervention youth increased healthier foods and beverages purchases by 1.4 more items per week than comparison youth (β = 1.4; 95% CI: 0.1; 2.8). After the intervention, there was a 3.5% decrease in kcal from sweets for older intervention youth, compared to the control group (β = − 3.5; 95% CI: -7.76; − 0.05). No impact was seen on SSB consumption. Conclusion BHCK successfully increased healthier food purchasing variety in youth, and decreased % calories from sweet snacks in older youth. Multilevel, multicomponent environmental childhood obesity programs are a promising strategy to improve eating behaviors among low-income urban youth. Trial registration NCT02181010 (July 2, 2014, retrospectively registered).

Abstract Background For community interventions to be effective in real-world conditions, participants need to have sufficient exposure to the intervention. It is unclear how the dose and intensity of the intervention differ among study participants in low-income areas. We aimed to understand patterns of exposure to different components of a multi-level multi-component obesity prevention program to inform our future impact analyses. Methods B’more Healthy Communities for Kids (BHCK) was a community-randomized controlled trial implemented in 28 low-income zones in Baltimore in two rounds (waves). Exposure to three different intervention components (corner store/carryout restaurants, social media/text messaging, and youth-led nutrition education) was assessed via post-intervention interviews with 385 low-income urban youths and their caregivers. Exposure scores were generated based on self-reported viewing of BHCK materials (posters, handouts, educational displays, and social media posts) and participating in activities, including taste tests during the intervention. For each intervention component, points were assigned for exposure to study materials and activities, then scaled (0–1 range), yielding an overall BHCK exposure score [youths: mean 1.1 (range 0–7.6 points); caregivers: 1.1 (0–6.7), possible highest score: 13]. Ordered logit regression analyses were used to investigate correlates of youths’ and caregivers’ exposure level (quartile of exposure). Results Mean intervention exposure scores were significantly higher for intervention than comparison youths (mean 1.6 vs 0.5, p

Psychosocial factors may influence consumption patterns of sweet snacks and sugar sweetened beverages (SSB), which are potential risk factors for obesity among African American (AA) adolescents. We used multivariable linear and logistic regression models to examine cross-sectional associations among psychosocial factors, sweet snacks and SSB consumption, and BMI z-scores in 437 AA adolescents aged 9–14 years living in low-income neighborhoods in Baltimore City, U.S.A. Mean caloric intake from sugar was 130.64 ± 88.37 kcal. Higher sweet snacks consumption was significantly associated with lower self-efficacy (adjusted Odds Ratio (aOR) = 0.81; 95% CI = 0.71 to 0.93) and lower food intentions scores (0.43; 0.30 to 0.61). Higher SSB consumption was associated with lower outcome expectancies (aOR = 0.98; 95% CI = 0.96–0.99), lower self-efficacy (0.98; 0.96 to 0.99), and lower food intentions (0.91; 0.87 to 0.95). No significant association was found between SSB and sweet snacks consumption and weight status. Psychosocial factors may play a role in sugar consumption behaviors among AA adolescents in low-income neighborhoods. Further studies are needed to improve our understanding of causal mechanisms of this association.

The prevalence of stunting in young Indonesian children is the highest among countries belonging to the Association of Southeast Asian Nations (ASEAN). Breastfed children are reported to grow better than non-breastfed. The present study examined the protective effect of exclusive breastfeeding against stunting in children under two years old (CU2) and its interaction with monthly household expenditure. Secondary analyses were conducted based on a 2012 cross-sectional study including 408 children aged 6–24 months and their caregivers from 14 villages in rural Eastern Indonesia. Data on breastfeeding history, childcare, and household expenditures were collected using structured questionnaires. Focus Group Discussions (FGDs) were conducted in each village (n = 14). Nearly two-thirds (61%) of caregivers who identified as the biological mother exclusively breastfed their child at 6 months. Exclusively-breastfed CU2 from poorer households were 20% less likely to be stunted than their non-exclusively-breastfed peers. Further, exclusively-breastfed CU2 from wealthier households were 50% less likely to be stunted than non-exclusively-breastfed CU2 from poorer households. FGDs revealed that some mothers were unaware of the importance of recommended breastfeeding practices. Exclusive breastfeeding may protect low-income children against stunting. Health promotion to improve caregiver motivation to exclusively breastfeed is critical in the present setting and beyond.

Policy interventions to improve food access and address the obesity epidemic among disadvantaged populations are becoming more common throughout the United States. In Baltimore MD, corner stores are a frequently used source of food for low-income populations, but these stores often do not provide a range of affordable healthy foods. This research study aimed to assist city policy makers as they considered implementing a Staple Food Ordinance (SFO) that would require small stores to provide a range and depth of stock of healthy foods. A System Dynamics (SD) model was built to simulate the complex Baltimore food environment and produce optimal values for key decision variables in SFO planning. A web-based application was created for users to access this model to optimize future SFOs, and to test out different options. Four versions of potential SFOs were simulated using this application and the advantages and drawbacks of each SFO are discussed based on the simulation results. These simulations show that a well-designed SFO has the potential to reduce staple food costs, increase corner store profits, reduce food waste, and expand the market for heathy staple foods.

(1) Background: The present study aimed to investigate the association between home-related factors, community environmental factors, and sugar-sweetened beverages (SSBs) intake among Northeastern Chinese children. (2) Methods: Cross-sectional. Children with complete data were included in the analysis (n = 901). A questionnaire modified according to BEVQ-15 measured the intake of SSBs. Logistic regression was applied to determine the factors associated with the consumption of SSBs. IBM SPSS Statistics 23.0 was applied to perform all statistical analyses. (3) Results: The mean total amount of SSBs consumed on a weekly basis was 2214.04 ± 2188.62 mL. Children’s weekly pocket money, frequency of SSBs purchase, SSBs availability at home, the number of accessible supermarkets, and frequency of weekly visits to convenience stores were all found to be associated with a high intake of SSBs among all children. Among children of normal weight, the findings indicated that weekly pocket money, SSBs availability at home, and number of accessible supermarkets were associated with a high SSBs intake. At the same time, frequency of SSBs purchase, mother’s SSBs intake, and frequency of weekly visits to convenience stores were associated with a high SSBs intake among children with obesity. (4) Conclusions: Given the potential negative health effects of high SSBs intake, it is crucial to pay attention to home-related factors and community environment.

Abstract Background Obesity and other nutrition-related chronic disease rates are high in American Indian (AI) populations, and an urgent need exists to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component (MLMC) interventions are needed, but there are significant knowledge gaps on how to deliver these types of interventions in low-income rural AI communities. Methods OPREVENT2 is a MLMC intervention targeting AI adults living in six rural reservations in New Mexico and Wisconsin. Aiming to prevent and reduce obesity in adults by working at multiple levels of the food and physical activity (PA) environments, OPREVENT2 focuses on evidence-based strategies known to increase access to, demand for, and consumption of healthier foods and beverages, and increase worksite and home-based opportunities for PA. OPREVENT2 works to create systems-level change by partnering with tribal stakeholders, multiple levels of the food and PA environment (food stores, worksites, schools), and the social environment (children as change agents, families, social media). Extensive evaluation will be conducted at each level of the intervention to assess effectiveness via process and impact measures. Discussion Novel aspects of OPREVENT2 include: active engagement with stakeholders at many levels (policy, institutional, and at multiple levels of the food and PA system); use of community-based strategies to engage policymakers and other key stakeholders (community workshops, action committees); emphasis on both the built environment (intervening with retail food sources) and the social environment. This paper describes the design of the intervention and the evaluation plan of the OPREVENT2. Trial registration Clinical Trial Registration: NCT02803853 (June 10, 2016)

Introduction Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs. Methods We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports. We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies. Results The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps. Conclusions We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community-based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime.

Background: Sub-optimal vitamin D status is common worldwide and the condition may be associated with increased risk for various chronic diseases. In particular, low vitamin D status is highly prevalent in indigenous communities in Canada, although limited data are available on the determinants of serum 25-hydroxyvitamin D (25(OH)D) concentrations in this population. The relationship between traditional food consumption and vitamin D status has not been well documented. Objective: To investigate the determinants of serum 25(OH)D status in a First Nations community in Ontario, Canada, with a focus on the role of traditional food consumption and activities. Methods: A cross-sectional analysis was conducted within the Sandy Lake Health and Diabetes Project (2003–2005). A total of 445 participants (>12 years of age) were assessed for serum 25(OH)D status, anthropometric and lifestyle variables, including traditional and non-traditional dietary practices and activities. Diet patterns were identified using factor analysis, and multivariate linear regression analysis was used to analyse the determinants of 25(OH)D concentrations. Results: Mean serum 25(OH)D concentrations were 22.1 nmol/L (16.9, 29.9 nmol/L) in men and 20.5 nmol/L (16.0, 27.3 nmol/L) in women. Multivariate determinants of higher serum 25(OH)D included higher consumption of traditional and healthier market foods, higher wild fish consumption, male gender, spring/summer season of blood collection and more frequent physical activity. Significant negative determinants included hours of TV/day, higher BMI and higher consumption of unhealthy market foods. Conclusions: Traditional food consumption contributed independently to higher 25(OH)D concentrations in a First Nations community with a high prevalence of sub-optimal vitamin D status.

Abstract Background Childhood obesity, one of the greatest challenges to public health, disproportionately affects low-income urban minority populations. Fruits and vegetables (FV) are nutrient dense foods that may be inversely associated with excessive weight gain. We aimed to identify the individual characteristic, psychosocial, and household factors influencing FV and fiber consumption in low-income African-American (AA) youth in Baltimore, MD. Methods Cross-sectional analysis of data collected from 285 low-income AA caregiver-youth (age range: 10–14 y) dyads participating in the baseline evaluation of the B’More Healthy Communities for Kids obesity prevention trial. The Kid's Block FFQ was used to estimate daily intakes of FV (including 100 % fruit juice) and dietary fiber. Questionnaires were used to assess household socio-demographics, caregiver and youth food purchasing and preparation behavior, and youth psychosocial information. Ordered logit regression analyses were conducted to examine psychosocial and food-related behavior associated with FV and dietary fiber intake (quartile of intake) controlling for youth age, sex, BMI percentile, total calorie intake and household income. Results On average, youth consumed 1.5 ± 1.1 (M ± SD) servings of fruit, 1.8 ± 1.7 serving of vegetables, and 15.3 ± 10.9 g of fiber/day. There were no differences by gender, age or household income. Greater youth’s healthy eating intentions and self-efficacy scores were associated with greater odds ratio for higher intake of FV and fiber (Intention: ORfruit 1.22; 95 % CI: 1.06–1.41, ORvegetable 1.31; 1.15–1.51 and ORfiber 1.46; 1.23–1.74, Self-efficacy: ORfruit 1.07; 1.03–1.12, ORvegetable 1.04; 1.01–1.09, ORfiber 1.10; 1.04–1.16). Youth receiving free/low-cost breakfast were more than twice as likely to have higher fiber intake than those who did not receive free breakfast (OR 2.7; 1.10; 6.9). In addition, youth shopping more frequently at supermarkets were more likely to have greater vegetable and fiber intake (OR 1.26; 1.06–1.50; OR 1.28; 1.03–1.58, respectively). Also, youth with parents who shopped more frequently at fast-food stores had 7 % lower odds for higher vegetable intake (95 % CI: 0.88–0.99). Conclusion In this study, both, youth and household factors were associated with youth FV and fiber intake, underscoring the need for a multi-level approach to increasing youths’ diet quality. These results will inform and shape an effective intervention program for improving youth dietary intakes.

Abstract Background Three decades ago, casino gaming on sovereign American Indian lands was legalized with differential economic and social implications. While casinos have improved the incomes of tribal communities, there have been both positive and negative findings in relation to health impacts. We sought to understand the perceived pathways by which casinos impact individual and community health through voices of the community. Methods We conducted semi-structured, interviews with tribal leaders (n =12) and tribal members (n =24) from tribal communities (n = 23) representing different regions of California. We inductively analyzed textual data drawing from Grounded Theory, first using line-by-line coding to identify analytic categories from emergent themes in consideration of the study objective. Then, focused codes were applied to identify salient themes, which we represented through exemplar quotes and an overall conceptual framework. Data were managed and coded using Dedoose software. Results American Indian-owned casinos are perceived to influence the health of tribal communities through three pathways: 1) improving the tribal economy 2) altering the built environment, and 3) disrupting the the social landscape. Forming these pathways are a series of interrelated health determinants. Improvement of the tribal economy, through both job creation for tribal members and improved tribal cash flow, was perceived by participants to both influence health. Specifically, improved cash flow has resulted in new wellness programs, community centers, places for recreation, and improved social services. Higher disposable incomes have led to better financial stability, increased access to healthy food, and more opportunities for physical activity. Yet, higher disposable incomes were perceived to also contribute to negative health behaviors, most notably increased drug and alcohol abuse. Casinos were also perceived to alter built environments, resulting in increased availability and access to unhealthy food. And to a lesser extent, they were perceived to disrupt the social landscape of communities with impacts on tribal community value systems. Conclusions Casino environments improve economic conditions of tribal communities, but present important social and public health challenges. Policy makers at federal, state, and tribal levels should consider the perceptions of tribal members and leaders when determining policies in light of casino development.

The nutrition transition in low-middle income countries is marked by rising intakes of highly caloric, low nutrient-dense (junk) foods, decreasing intakes of fruits and vegetables, and sedentary behavior. The objective of this study was to explore interactions among fruit-and-vegetable intake, junk food energy intake, sedentary behavior, and obesity in Indonesian children. We conducted this school-based, case-control study in 2013 in Yogyakarta Special Province, Indonesia. The cases were 244 obese children aged 7−12 years having a BMI ≥95th percentile of an age- and sex-specific distribution from the Centers for Disease Control and Prevention. The controls (n = 244) were classroom-matched children with a BMI

Social media and text messaging show promise as public health interventions, but little evaluation of implementation exists. The B’more Healthy Communities for Kids (BHCK) was a multilevel, multicomponent (wholesalers, food stores, recreation centers) childhood obesity prevention trial that included social media and text-messaging components. The BHCK was implemented in 28 low-income areas of Baltimore City, Maryland, in 2 waves. The texting intervention targeted 241 low-income African American caregivers (of 283), who received 3 texts/week reinforcing key messages, providing nutrition information, and weekly goals. Regular posting on social media platforms (Facebook, Instagram, Twitter) targeted community members and local stakeholders. High implementation standards were set a priori (57 for social media, 11 for texting), with low implementation defined as

Background Globally, secondhand tobacco smoke causes over 365,000 deaths each year. To fulfill their obligations under the WHO Framework Convention on Tobacco Control, low- and middle-income countries (LMICs) are increasingly enacting smoke-free laws covering public places. These policies have proven effective in high-income countries, but some LMICs have struggled to implement smoke-free laws and attain compliance. We present a systematic review and a research agenda for improving implementation of smoke-free laws in LMICs. Methods We conducted a systematic review of the literature on implementation of smoke-free laws in LMICs through January 2017. The search of 10 databases yielded 3,894 unique articles, which reduced to 1,409 after title screening, 236 after abstract screening, and 66 after full text review. We also reviewed reports from WHO and international tobacco control NGOs and citations in sources. The total number of sources that met inclusion criteria was 131. We analyzed these materials for common themes. Results We found that many of the health and economic aspects of smoke-free laws in high-income countries carry over to LMICs: the tobacco industry aggressively opposes smoke-free laws, there are commonalities in lessons learned in implementing laws across various LMICs, and a number of obstacles to successful implementation are faced in LMICs, especially in terms of resources and political will. Conclusions Based on these findings and our own experience in the field, we suggest four central topics on which research is urgently needed: (1) determining the most efficient methods of working with limited resources; (2) learning how to increase political will among political leaders and enforcement officers; (3) finding methods for increasing public compliance in settings where laws have already been passed but not achieved success; and, (4) understanding the social and behavioral processes underlying smoke-free laws. Investigation into these topics can inform more effective implementation of smoke-free laws in LMICs.

Obesity has become a significant problem for developing countries, including Indonesia. High duration of sedentary activity and high intake of unhealthy foods were associated with high risk of overweight and obesity. The objective of this study was to compare the distributions of sedentary activity and dietary behavior with overweight/obesity risks between urban and rural areas among children and adolescents aged 10−18 years in Indonesia. This is a cross-sectional study. Data from a national survey in 33 Indonesian provinces (Basic Health Research /Riskesdas 2013) were analyzed. Multiple logistic regression models were used to calculate the odds ratio (OR) adjusted with all variables, such as age, gender, residency, education level, physical activity, and food intake. An urban−rural residence difference was found in the factors related to obesity. Daily caffeinated soft drinks and energy drinks consumption (OR = 1.12, 95% CI: 1.01−1.23) were related to risk of overweight and obesity in urban areas. Daily grilled foods (OR = 1.32, 95% CI: 1.22−1.42) and salty food (OR = 1.09, 95% CI: 1.04−1.15) consumption were significantly associated with obesity in rural areas but not in urban areas. Furthermore, sedentary activity was correlated with overweight and obesity among those who lived in urban and rural areas. Our findings suggest that education, environmental, and policy interventions may need to specifically target urban settings, where access is high to a wide range of processed and traditional high-sugar, high-fat snack foods and beverages.

To prevent obesity, it is important to assess dietary habits through self-reported energy intake (EI) in children. We investigated how EI is associated with body mass index and which elements of dietary habits and status are associated with EI among African-American (AA) children.We assessed and included data from 218 10-14-year-old AA children in Baltimore, MD, USA. EI was calculated using a food frequency questionnaire. The basal metabolic rate (BMR) was used as the predicted minimal rate of energy expenditure of children. A fully adjusted multiple logistic regression was used to determine the prevalence of obesity (≥ 95th BMI-for-age percentile) among the quartiles of EI/BMR ratio using the third quartile for the reference. The differences in the age-adjusted mean EI/BMR among the categories of dietary habits, social support, and socio economic status were analyzed using a general linear model.Children with the lowest EI/BMR had significantly higher adjusted odds ratio (aOR) of obesity as compared to those in the third quartile of EI/BMR (boys aOR 4.3; 95% confidence interval 1.08, 20 and girls aOR 4.1; 1.02, 21). In girls, the adjusted mean EI/BMR in the group that prepared food less than the means (3.8 times/week) was significantly lower than the group that prepared food over the means (P = 0.03). Further, the group that reported eating breakfast under 4 times/week indicated an adjusted mean EI/BMR lower than the group that ate breakfast over 5 times/week in both sexes.When EI was under-reported with reference to BMR, we may observe high prevalence of obesity. Further, food preparation by children and frequent consumption of breakfast may instill food cognition with usual dietary habits. Therefore, holistic assessments including dietary habits are required to examine self-reported food intake especially among overweight/obese children.

Objective. A pediatric office-based intervention was implemented following a randomized, controlled design, aimed at improving child feeding practices and growth patterns and ultimately reducing risk for overweight and obesity later in life. Methods. Four clinics (232 infants) were randomized to control or intervention (I), the latter delivered by health care provider at each of 7–9 well-baby visits over 2 years, using a previously developed program (Growing Leaps and Bounds) that included verbal, visual, and text advice and information for parents. Results. The I group offered significantly less soda p=0.006, sweetened tea p=0.01, punch p=0.02 and/or cow’s milk p=0.001 to infants and delayed the introduction of drink/food other than breast milk p