Angela Trude

Barriers to and Facilitators of Stocking Healthy Food Options: Viewpoints of Baltimore City Small Storeowners

ABSTRACT Receptivity to strategies to improve the food environment by increasing access to healthier foods in small food stores is underexplored. We conducted 20 in-depth interviews with small storeowners of different ethnic backgrounds as part of a small-store intervention trial. Store owners perceived barriers and facilitators to purchase, stock, and promote healthy foods. Barriers mentioned included customer preferences for higher fat and sweeter taste and for lower prices; lower wholesaler availability of healthy food; and customers’ lack of interest in health. Most store owners thought positively of taste tests, free samples, and communication interventions. However, they varied in terms of their expectations of the effect of these strategies on customers’ healthy food purchases. The findings reported add to the limited data on motivating and working with small-store owners in low-income urban settings.

Patterns of Food Consumption are Associated with Obesity, Self-Reported Diabetes and Cardiovascular Disease in Five American Indian Communities

The relationship between dietary patterns and chronic disease is underexplored in indigenous populations. We assessed diets of 424 American Indian (AI) adults living in 5 rural AI communities. We identified four food patterns. Increased prevalence for cardiovascular disease was highly associated with the consumption of unhealthy snacks and high fat–food patterns (OR 3.6, CI = 1.06, 12.3; and OR 6.0, CI = 1.63, 22.1), respectively. Moreover, the food-consumption pattern appeared to be different by community setting (p < .05). We recommend culturally appropriate community-intervention programs to promote healthy behavior and to prevent diet-related chronic diseases in this high-risk population.

Diabetes and obesity prevention: Changing the food environment in low-income settings

Innovative approaches are needed to impact obesity and other diet-related chronic diseases, including interventions at the environmental and policy levels. Such interventions are promising due to their wide reach. This article reports on 10 multilevel community trials that the present authors either led (n = 8) or played a substantial role in developing (n = 2) in low-income minority settings in the United States and other countries that test interventions to improve the food environment, support policy, and reduce the risk for developing obesity and other diet-related chronic diseases. All studies examined change from pre- to postintervention and included a comparison group. The results show the trials had consistent positive effects on consumer psychosocial factors, food purchasing, food preparation, and diet, and, in some instances, obesity. Recently, a multilevel, multicomponent intervention was implemented in the city of Baltimore that promises to impact obesity in children, and, potentially, diabetes and related chronic diseases among adults. Based on the results of these trials, this article offers a series of recommendations to contribute to the prevention of chronic disease in Mexico. Further work is needed to disseminate, expand, and sustain these initiatives at the city, state, and federal levels.

Development and Implementation: B’More Healthy Communities for Kid’s Store and Wholesaler Intervention

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B’More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community’s access to healthy food. The objective of this article is to describe the development and implementation of BHCK’s corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

The Impact of a Multi-Level Multi-Component Childhood Obesity Prevention Intervention on Healthy Food Availability, Sales, and Purchasing in a Low-Income Urban Area

The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

A Youth-Leader Program in Baltimore City Recreation Centers: Lessons Learned and Applications:

Peer-led interventions may be an effective means of addressing the childhood obesity epidemic; however, few studies have looked at the long-term sustainability of such programs. As part of a multilevel obesity prevention intervention, B’More Healthy Communities for Kids, 16 Baltimore college students were trained as youth-leaders (YLs) to deliver a skill-based nutrition curriculum to low-income African American children (10-14 years old). In April 2015, formative research was used to inform sustainability of the YL program in recreation centers. In-depth interviews were conducted with recreation center directors (n = 4) and the YLs (n = 16). Two focus groups were conducted with YLs (n = 7) and community youth-advocates (n = 10). Barriers to this program included difficulties with transportation, time constraints, and recruiting youth. Lessons learned indicated that improving trainings and incentives to youth were identified as essential strategies to foster continuity of the youth-led program and capacity building. High school students living close to the centers were identified as potential candidates to lead the program. Based on our findings, the initial intervention will be expanded into a sustainable model for implementation, using a train-the-trainer approach to empower community youth to be change agents of the food environment and role models.

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review

Introduction Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages. Methods We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review. Results Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention’s impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets. Conclusion Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

Environmental interventions for obesity and chronic disease prevention

Innovative approaches are needed to impact obesity and other diet-related chronic diseases, including tested interventions at the environmental and policy levels. We have conducted multi-level community trials in low-income minority settings in the United States and other countries that test interventions to improve the food environment, support policy, and reduce the risk for developing obesity and other diet-related chronic diseases. All studies have examined change from pre- to post-study, comparing an intervention with a comparison group. Our results have shown consistent positive effects of these trials on consumer psychosocial factors, food purchasing, food preparation and diet, and, in some instances, obesity. We have recently implemented a systems science model to support programs and policies to improve urban food environments. Environmental interventions are a promising approach for addressing the global obesity epidemic due to their wide reach. Further work is needed to disseminate, expand and sustain these initiatives through policy at the city, state and federal levels.

Implementation of Text-Messaging and Social Media Strategies in a Multilevel Childhood Obesity Prevention Intervention: Process Evaluation Results:

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 <50%, medium as 50% to 99%, high as ≥100% of the high standard for each measure. Reach, dose delivered, and fidelity were assessed via web-based analytic tools. Between waves, social media implementation improved from low-moderate to high reach, dose delivered, and fidelity. Text messaging increased from moderate to high in reach and dose delivered, fidelity decreased from high to moderate. Data were used to monitor and revise the BHCK intervention throughout implementation. Our model for evaluating text messaging–based and social media–based interventions may be applicable to other settings.

Psychosocial Determinants of Food Acquisition and Preparation in Low-Income, Urban African American Households

Background. Psychosocial factors are important determinants of health behaviors and diet-related outcomes, yet relatively little work has explored their relation to food-purchasing and preparation behaviors in low-income populations. Aim. To evaluate the psychosocial factors associated with food-related behaviors. Methods. Cross-sectional data collected from 465 low-income African American adult caregivers in the baseline evaluation of the B’more Healthy Communities for Kids obesity prevention trial. Questionnaires were used to assess household sociodemographic characteristics, food sources frequently used, and food preparation and food acquisition behaviors. Multiple linear regression models explored the associations between caregiver psychosocial variables and food-related behaviors, controlling for caregivers’ age, sex, household income, household size, and food assistance participation. Results. Caregivers purchased prepared food at carry-outs on average 3.8 times (standard deviation [SD] = 4.6) within 30 days. Less healthy foods were acquired 2 times more frequently than healthier foods (p < .001). Higher food-related behavioral intention and self-efficacy scores were positively associated with healthier food acquisition (β = 0.7; 95% confidence interval [CI] [0.09, 1.4]; β = 0.04; 95% CI [0.02, 0.06]) and negatively associated with frequency of purchasing at prepared food sources (β = −0.4; 95% CI [−0.6, −0.2]; β = −0.5; 95% CI [−0.7, −0.3]), respectively. Higher nutrition knowledge was associated with lower frequency of purchasing food at prepared food venues (β = −0.7; 95% CI: [−1.2, −0.2]). Discussion. Our findings indicate a positive association between psychosocial determinants and healthier food acquisition and food preparation behaviors. Conclusion. Interventions that affect psychosocial factors (i.e., food-related behavioral intentions and self-efficacy) may have the potential to increase healthier food preparation and food-purchasing practices among low-income African American families.