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Precise dietary assessment is critical for accurate exposure classification in nutritional research, typically aimed at understanding how diet relates to health. Dietary supplement (DS) use is widespread and represents a considerable source of nutrients. However, few studies have compared the best methods to measure DSs. Our literature review on the relative validity and reproducibility of DS instruments in the United States [e.g., product inventories, questionnaires, and 24-h dietary recalls (24HR)] identified five studies that examined validity ( n = 5) and/or reproducibility ( n = 4). No gold standard reference method exists for validating DS use; thus, each study's investigators chose the reference instrument used to measure validity. Self-administered questionnaires agreed well with 24HR and inventory methods when comparing the prevalence of commonly used DSs. The inventory method captured nutrient amounts more accurately than the other methods. Reproducibility (over 3 months to 2.4 years) of prevalence of use estimates on the questionnaires was acceptable for common DSs. Given the limited body of research on measurement error in DS assessment, only tentative conclusions on these DS instruments can be drawn at present. Further research is critical to advancing knowledge in DS assessment for research and monitoring purposes. Expected final online publication date for the Annual Review of Nutrition, Volume 43 is August 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Objective:Subsidised or cost-offset community-supported agriculture (CO-CSA) connects farms directly to low-income households and can improve fruit and vegetable intake. This analysis identifies factors associated with participation in CO-CSA.Design:Farm Fresh Foods for Healthy Kids (F3HK) provided a half-price, summer CO-CSA plus healthy eating classes to low-income households with children. Community characteristics (population, socio-demographics and health statistics) and CO-CSA operational practices (share sizes, pick up sites, payment options and produce selection) are described and associations with participation levels are examined.Setting:Ten communities in New York (NY), North Carolina (NC), Vermont and Washington states in USA.Participants:Caregiver–child dyads enrolled in spring 2016 or 2017.Results:Residents of micropolitan communities had more education and less poverty than in small towns. The one rural location (NC2) had the fewest college graduates (10 %) and most poverty (23 %) and poor health statistics. Most F3HK participants were white, except in NC where 45·2 % were African American. CO-CSA participation varied significantly across communities from 33 % (NC2) to 89 % (NY1) of weeks picked up. Most CO-CSA farms offered multiple share sizes (69·2 %) and participation was higher than when not offered (76·8 % v. 57·7 % of weeks); whereas 53·8 % offered a community pick up location, and participation in these communities was lower than elsewhere (64·7 % v. 78·2 % of weeks).Conclusion:CO-CSA programmes should consider offering a choice of share sizes and innovate to address potential barriers such as rural location and limited education and income among residents. Future research is needed to better understand barriers to participation, particularly among participants utilising community pick up locations.

Community-supported agriculture (CSA) is an alternative food marketing model in which community members subscribe to receive regular shares of a farm's harvest. Although CSA has the potential to improve access to fresh produce, certain features of CSA membership may prohibit low-income families from participating. A ‘cost-offset’ CSA (CO-CSA) model provides low-income families with purchasing support with the goal of making CSA more affordable. As a first step toward understanding the potential of CO-CSA to improve access to healthy foods among low-income households, we interviewed 24 CSA farmers and 20 full-pay CSA members about their experiences and perceptions of the cost-offset model and specific mechanisms for offsetting the cost of CSA. Audio recordings were transcribed verbatim and coded using a thematic approach. Ensuring that healthy food was accessible to everyone, regardless of income level, was a major theme expressed by both farmers and members. In general, CSA farmers and CSA members favored member donations over other mechanisms for funding the CO-CSA. The potential time burden that could affect CSA farmers when administering a cost-offset was a commonly-mentioned barrier. Future research should investigate various CO-CSA operational models in order to determine which models are most economically viable and sustainable.

Objective:To examine cross-sectional associations between farmers’ market shopping behaviours and objectively measured and self-reported fruit and vegetable (FV) intake among rural North Carolina (NC) and New York City (NYC) shoppers.Design:Cross-sectional intercept surveys were used to assess self-reported FV intake and three measures of farmers’ market shopping behaviour: (1) frequency of purchasing FV; (2) variety of FV purchased and (3) dollars spent on FV. Skin carotenoids, a non-invasive biomarker for FV intake, were objectively measured using pressure-mediated reflection spectroscopy. Associations between farmers’ market shopping behaviours and FV intake were examined using regression models that controlled for demographic variables (e.g. age, sex, race, smoking status, education, income and state).Setting:Farmers’ markets (n 17 markets) in rural NC and NYC.Participants:A convenience sample of 645 farmers’ market shoppers.Results:Farmers’ market shoppers in NYC purchased a greater variety of FV and had higher skin carotenoid scores compared with shoppers in rural NC. Among all shoppers, there was a positive, statistically significant association between self-reported frequency of shopping at farmers’ markets and self-reported as well as objectively assessed FV intake. The variety of FV purchased and farmers’ market spending on FV also were positively associated with self-reported FV intake, but not skin carotenoids.Conclusion:Those who shop for FV more frequently at a farmers’ markets, purchase a greater variety of FV and spend more money on FV have higher self-reported, and in some cases higher objectively measured FV intake. Further research is needed to understand these associations and test causality.

BACKGROUND Glucose variability increases cardiometabolic disease risk. While many factors can influence glucose levels, postprandial glucose response is the primary driver of glucose variability. Furthermore, affect may directly and indirectly impact glucose variability through its effect on eating behavior. Continuous glucose monitors (CGMs) facilitate the real-time evaluation of blood glucose, and ecological momentary assessment (EMA) can be used to assess affect in real time. Together, data collected from these sources provide the opportunity to further understand the role of affect in glucose levels. OBJECTIVE This paper presents the protocol for a study that aims to (1) evaluate the feasibility and acceptability of using CGMs along with EMA in nondiabetic populations and (2) examine the bidirectional relationship between affect and glucose in nondiabetic adults with overweight or obesity using a CGM and EMA. METHODS Eligibility criteria for the study include participants (1) aged 18 to 65 years old, (2) with a BMI of ≥25 kg/m2, (3) who are able to read and write in English, and (4) who own a smartphone. Individuals will be excluded if they (1) have type 1 or 2 diabetes or have any other condition that requires glucose monitoring, (2) are pregnant, (3) use any medications that have the potential to alter blood glucose levels or interfere with the glucose sensing process, or (4) have a diagnosed gastrointestinal condition or eating disorder. In a 14-day observational study, participants will wear a FreeStyle Libre Pro CGM sensor (Abbott) and will receive mobile phone–based EMA prompts 6 times per day (randomly within six 2-hour windows between 8 AM and 8 PM) to assess positive and negative affect. Participants will also wear a Fitbit Inspire 2 (Fitbit) to continuously monitor physical activity and sleep, which will be included as covariates in the analysis. Multilevel linear regression models will be used to evaluate the acute relationship between glucose level and affect. RESULTS Recruitment started in October 2022 and is expected to be completed in March 2023. We will aim to recruit 100 participants. As of December 12, 2022, a total of 39 participants have been enrolled. CONCLUSIONS The results of this study will further elucidate the role of affect in glucose variability. By identifying affective states that may lead to glucose excursions, our findings could inform just-in-time behavioral interventions by indicating opportunities for intervention delivery. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/45104

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

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.

Some farmers are offering subsidized or “cost-offset” community supported agriculture (CO-CSA) shares as a strategy to counter market saturation and improve low-income families’ access to fresh local foods. However, little is known about farmers’ experiences with this model, particularly in regard to the balance between additional resources required for adoption and subsequent contributions to farm revenue. As part of the Farm Fresh Foods for Healthy Kids Study of the impact of a CO-CSA on dietary behaviors in low-income families, we conducted qualitative interviews with 12 farmers across four states after the first and the third years of CO-CSA implementation. We explored these data to understand what accommodations farmers provided to low-income families, the benefits and challenges of implementing the CO-CSA model, and farmers’ perceptions of its impact on cash flow and profitability. We found that farmers selected pick-up locations that met CO-CSA members’ needs, were responsive to members’ food preferences in selecting CSA contents, and allowed for late payments and pickups, though sometimes this placed an additional burden on farmers’ time and resources. Additionally, weekly payment transactions led to increased recordkeeping. Despite its challenges, most farmers said CO-CSA adoption was a worthwhile addition to their business model. Expanding food access through this mechanism may become more sustainable with the additional support of innovative policies like eased land-use restrictions, operational models, and community strategies to fund and operate CO-CSA programs. This is an area ripe for future research, as there is little documentation on both single farm and multifarm CO-CSA operations.

Purpose Snacking contributes to one-quarter of children’s total daily energy intake in the USA, with many snack foods being nutrient-poor and energy-dense. Snacking and sugary beverage consumption have been identified as potential contributors to childhood overweight and obesity and may play a particularly important role among children from socioeconomically disadvantaged households that generally display higher rates of obesity. This exploratory study investigated associations between consumption of snack foods, sugar-sweetened beverages (SSB) and overweight and obesity in children from low-income households. Design/methodology/approach Data from households that participated in a multi-state cost-offset (CO-CSA) community supported agriculture intervention in 2016 and 2017 (n = 305) were analyzed. Fixed effect regression models were used to estimate associations between child monthly consumption of salty snack foods; sweet snack foods and SSBs; and child weight status, accounting for demographic characteristics. Findings No associations were found between snack or SSB consumption and child overweight. However, household income was significantly, negatively related to all three consumption variables (Salty snacks: ß = −0.09, SE = 0.04, p = 0.02; Sweet snacks: ß= −0.10, SE = 0.04, p = 0.01; SSB: ß= −0.21, SE = 0.05, p = 0.0001). The results suggest that household income may play an important role in children’s snacking and SSB behaviors among more disadvantaged households. Practical implications Factors beyond snack food and SSB consumption should be explored to better understand childhood overweight and obesity, and to inform future obesity interventions. Originality/value Socioeconomic disparities in childhood obesity are an ongoing policy-relevant issue within the USA and internationally. This study provides new information about child snacking behaviors in a unique, low-income population and contributes to the evidence base regarding the role household context in shaping child consumption behaviors.

Purpose The present study aimed to evaluate the implementation of a civic engagement curriculum (HEART Club) designed to catalyze positive environmental change in rural communities. Design The HEART Club curriculum was integrated into a six-month community-based health behavior intervention to reduce cardiovascular disease risk. Setting Participants were recruited from eight rural towns in Montana and New York. Subjects 101 midlife and older women. Intervention Participants worked to address an issue related to their local food or physical activity environment and establish progress monitoring benchmarks. Method Evaluation components included after-class surveys, program leader interviews ( n = 15), participant focus groups ( n = 8), and post-intervention surveys. Results Intervention sites reported high fidelity (78%) to the curriculum. Average attendance was 69% and program classes were rated as highly effective (4.1 out of 5). Despite positive participant feedback, low readiness for civic engagement and insufficient time were implementation challenges. The majority of HEART Club groups had accomplished two or more benchmarks post-intervention. Facilitators of progress included community support, effective leadership, and collective effort. Participants also indicated that trying to affect community change while simultaneously making personal health improvements likely stalled initial progress. Conclusion These findings highlight the potential and challenges associated with civic engagement within the context of rural lifestyle interventions. Future implementation efforts should focus on reframing civic engagement as an approach to support and maintain behavior change.

Background Glucose variability increases cardiometabolic disease risk. While many factors can influence glucose levels, postprandial glucose response is the primary driver of glucose variability. Furthermore, affect may directly and indirectly impact glucose variability through its effect on eating behavior. Continuous glucose monitors (CGMs) facilitate the real-time evaluation of blood glucose, and ecological momentary assessment (EMA) can be used to assess affect in real time. Together, data collected from these sources provide the opportunity to further understand the role of affect in glucose levels. Objective This paper presents the protocol for a study that aims to (1) evaluate the feasibility and acceptability of using CGMs along with EMA in nondiabetic populations and (2) examine the bidirectional relationship between affect and glucose in nondiabetic adults with overweight or obesity using a CGM and EMA. Methods Eligibility criteria for the study include participants (1) aged 18 to 65 years old, (2) with a BMI of ≥25 kg/m2, (3) who are able to read and write in English, and (4) who own a smartphone. Individuals will be excluded if they (1) have type 1 or 2 diabetes or have any other condition that requires glucose monitoring, (2) are pregnant, (3) use any medications that have the potential to alter blood glucose levels or interfere with the glucose sensing process, or (4) have a diagnosed gastrointestinal condition or eating disorder. In a 14-day observational study, participants will wear a FreeStyle Libre Pro CGM sensor (Abbott) and will receive mobile phone–based EMA prompts 6 times per day (randomly within six 2-hour windows between 8 AM and 8 PM) to assess positive and negative affect. Participants will also wear a Fitbit Inspire 2 (Fitbit) to continuously monitor physical activity and sleep, which will be included as covariates in the analysis. Multilevel linear regression models will be used to evaluate the acute relationship between glucose level and affect. Results Recruitment started in October 2022 and is expected to be completed in March 2023. We will aim to recruit 100 participants. As of December 12, 2022, a total of 39 participants have been enrolled. Conclusions The results of this study will further elucidate the role of affect in glucose variability. By identifying affective states that may lead to glucose excursions, our findings could inform just-in-time behavioral interventions by indicating opportunities for intervention delivery. International Registered Report Identifier (IRRID) DERR1-10.2196/45104

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.

To improve low-income families’ access to fresh local produce, some farmers offer subsidized or “cost-offset” community supported agriculture (CO-CSA) shares. We evaluated a structured planning and implementation process conducted during the final intervention year of the Farm Fresh Foods for Healthy Kids (F3HK) study, which aimed to help participating farmers (N=12) to sustain a CO-CSA program after study funding ended. The process included training webinars, planning tools to develop CO-CSA continuation funding and recruitment strategies, regional coach­ing teams to provide technical assistance, and peri­odic group conference calls to facilitate shared learning among F3HK farmers. Our evaluation explored the content of farmers’ CO-CSA contin­u­ation plans, their experiences during implementa­tion, their opinions about the planning process, and their future plans regarding their CO-CSA. We found that F3HK farmers used diverse methods to plan, recruit, and raise funds, with each farm adapt­ing strategies to fit their local conditions and farm business. Many farmers found success with word-of-mouth advertising and CSA member donations. Yet lack of farm resources—time, money, and ex­pertise—was a continual barrier to moving for­ward. As with full price CSAs, reciprocity was a key factor: farmers needed to consider the needs and preferences of low-income consumers, and CO-CSA members needed to understand their financial responsibility to the farmer. In general, F3HK farmers appreciated the continuation planning pro­cess, but expressed a desire for more technical assistance with grant writing. Farmers were com­mitted to the success of the CO-CSA continuation planning process, and most intended to continue the CO-CSA the following year.

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.

Objective Explore factors affecting access to and use of Double Up Food Bucks (DUFB), a farmers’ market program that doubles Supplemental Nutrition Assistance Program benefits for use toward the purchase of fruits and vegetables (FV). Design Focus groups. Setting Metro and nonmetro counties in Utah and western Upstate New York. Participants Nine groups composed of 62 low-income adults (3–9/group). Phenomena of Interest Satisfaction with, barriers to, and facilitators of program use; suggestions for improvement. Analysis Transcribed verbatim and coded thematically in NVivo 11 software according to template analysis. Results Program satisfaction was high and driven by FV affordability, perceived support of local farmers, positive market experiences, and high-quality FV. Primary barriers to using DUFB were lack of program information and inconvenient accessibility. Insufficient program communication was a consistent problem that elicited numerous suggestions regarding expansion of program marketing. Emergent topics included issues related to the token-based administration of DUFB and debate regarding stigma experienced during DUFB participation. Conclusions and Implications Results suggest that although DUFB elicits many points of satisfaction among users, program reach may be limited owing to insufficient program marketing. Even among satisfied users, discussion of barriers was extensive, indicating that program reach and impact may be bolstered by efforts to improve program accessibility.

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.