Emily H. Morgan

Can nutrition be promoted through agriculture-led food price policies? A systematic review

Objective To systematically review the available evidence on whether national or international agricultural policies that directly affect the price of food influence the prevalence rates of undernutrition or nutrition-related chronic disease in children and adults. Design Systematic review. Setting Global. Search strategy We systematically searched five databases for published literature (MEDLINE, EconLit, Agricola, AgEcon Search, Scopus) and systematically browsed other databases and relevant organisational websites for unpublished literature. Reference lists of included publications were hand-searched for additional relevant studies. We included studies that evaluated or simulated the effects of national or international food-price-related agricultural policies on nutrition outcomes reporting data collected after 1990 and published in English. Primary and secondary outcomes Prevalence rates of undernutrition (measured with anthropometry or clinical deficiencies) and overnutrition (obesity and nutrition-related chronic diseases including cancer, heart disease and diabetes). Results We identified a total of four relevant reports; two ex post evaluations and two ex ante simulations. A study from India reported on the undernutrition rates in children, and the other three studies from Egypt, the Netherlands and the USA reported on the nutrition-related chronic disease outcomes in adults. Two of the studies assessed the impact of policies that subsidised the price of agricultural outputs and two focused on public food distribution policies. The limited evidence base provided some support for the notion that agricultural policies that change the prices of foods at a national level can have an effect on population-level nutrition and health outcomes. Conclusions A systematic review of the available literature suggests that there is a paucity of robust direct evidence on the impact of agricultural price policies on nutrition and health.

Dietary Intake and Cardiometabolic Risk in Ethnically Diverse Urban Schoolchildren

Dietary factors vary widely among ethnic groups. However, the effect of specific nutrients on cardiometabolic risk is not well understood, especially in children. Four dietary factors known to influence cardiometabolic risk (ie, carbohydrate, saturated, monounsaturated, and polyunsaturated fat intake) were assessed by the Block Kids 2004 Food Frequency Questionnaire in a cross-sectional sample of racially diverse fourth- through eighth-grade students (n=148) in a Boston-area school district studied between January and April 2010. Fasting total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL) cholesterol, triglyceride, C-reactive protein (CRP), and interleukin-6 (IL-6) levels, and body mass index z scores were measured. Differences in dietary factors and cardiometabolic risk factors were examined among the following racial/ethnic groups: white (39%), Hispanic (32%), black (8%), Asian (10%), and multiracial/other (11%). In bivariate analyses, total, saturated, and polyunsaturated fat intakes differed by race/ethnicity (P<0.05), with white and black children reporting saturated fat intakes above the recommended level. Forty-seven percent of children had at least one suboptimal cardiometabolic risk factor. HDL cholesterol, triglyceride, and IL-6 concentrations differed by race/ethnicity (P<0.05, P<0.01, and P<0.01, respectively), with Hispanics having low HDL cholesterol levels and high triglyceride levels, whereas Asians had high IL-6 levels. In multivariate analyses controlling for demographic characteristics, none of the dietary factors examined explained racial/ethnic differences in lipid profiles or inflammatory markers. Body mass index z score was associated with lower HDL cholesterol, higher triglyceride, higher CRP, and higher IL-6 levels (P<0.0001). Further research is warranted to determine the influence of dietary recommendations at a young age among different racial/ethnic groups on cardiometabolic health.

Rural food and physical activity assessment using an electronic tablet- based application, New York, 2013-2014

Introduction A community’s built environment can influence health behaviors. Rural populations experience significant health disparities, yet built environment studies in these settings are limited. We used an electronic tablet-based community assessment tool to conduct built environment audits in rural settings. The primary objective of this qualitative study was to evaluate the usefulness of the tool in identifying barriers and facilitators to healthy eating and active living. The second objective was to understand resident perspectives on community features and opportunities for improvement. Methods Participants were recruited from 4 rural communities in New York State. Using the tool, participants completed 2 audits, which consisted of taking pictures and recording audio narratives about community features perceived as assets or barriers to healthy eating and active living. Follow-up focus groups explored the audit experience, data captured, and opportunities for change. Results Twenty-four adults (mean age, 69.4 y [standard deviation, 13.2 y]), 6 per community, participated in the study. The most frequently captured features related to active living were related to roads, sidewalks, and walkable destinations. Restaurants, nontraditional food stores, and supermarkets were identified in the food environment in relation to the cost, quality, and selection of healthy foods available. In general, participants found the assessment tool to be simple and enjoyable to use. Conclusion An electronic tablet–based tool can be used to assess rural food and physical activity environments and may be useful in identifying and prioritizing resident-led change initiatives. This resident-led assessment approach may also be helpful for informing and evaluating rural community-based interventions.

Factors influencing fruit and vegetable intake among urban Fijians: A qualitative study

Low fruit and vegetable intake is an important risk factor for micronutrient deficiencies and non-communicable diseases, but many people worldwide, including most Fijians, eat less than the World Health Organization recommended amount. The present qualitative study explores factors that influence fruit and vegetable intake among 57 urban Fijians (50 women, 7 men) of indigenous Fijian (iTaukei) and South Asian (Indian) descent. Eight focus group discussions were held in and around Suva, Fijis capital and largest urban area, which explored motivation for eating fruit and vegetables, understandings of links to health and disease, availability and sources, determinants of product choice, and preferred ways of preparing and eating fruit and vegetables. Data were analysed using thematic content analysis. Regardless of ethnicity, participants indicated that they enjoyed and valued eating fruit and vegetables, were aware of the health benefits, and had confidence in their cooking skills. In both cultures, fruit and vegetables were essential components of traditional diets. However, increasing preferences for processed and imported foods, and inconsistent availability and affordability of high-quality, low-priced, fresh produce, were identified as important barriers. The findings indicate that efforts to improve fruit and vegetable intake in urban Fijians should target the stability of the domestic fruit and vegetable supply and access.

3rd Annual Conference of the Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH), Developing methods in agriculture and health research, London, 13-14 June 2013

Agriculture and health interact in complex ways via food systems and nutrition, creating positive and negative synergies, which differ according to economic, political and environmental contexts, but particularly affecting the lives of vulnerable populations in low-income countries. Research in these subjects has historically proceeded in relative isolation, with different disciplines applying distinct methods to generate knowledge and inform sector-based policy and practice. This segregated working is not beneficial if research is to inform the design and implementation of programs and policies that aim to fully and sustainably address the nexus of agriculture and health. Encouragingly, policy and programmatic initiatives, as well as research endeavours, have been increasingly attentive to the linkage of agriculture and health as a method for improving nutritional status and health (Masset et al. 2012). More and better multi-sectoral action will be necessary, however, to reduce the harms and enhance the benefits of the agriculture-health relationship, and research increasingly needs to engage with this complex picture if findings are to remain relevant to policy and practice. In response to this interdisciplinary challenge, the Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH) was established in 2010 with a grant from the Leverhulme Trust to develop “unifying approaches and methodologies for understanding the relationship between agricultural production and population health, and the factors which drive them both”an agri-health research agenda (www.lcirah.ac.uk). Since its inception, LCIRAH has hosted three international conferences endeavouring to bring together experts from different sectors to share perspectives and explore integrated inter-disciplinary approaches to global agri-health challenges. In 2011, the first conference, organised with the International Food Policy Research Institute (IFPRI), had a strong focus on agri-health metrics, with scholars presenting work on ways in which metrics and methods can cross disciplines to fill knowledge gaps. The conference found a potentially huge benefit in promoting the understanding and utilization of different methods across disciplines to move the agri-health research agenda forward. The second conference, in 2012, J. Harris :M. Bruce : E. Cavatorta : L. Cornelsen :B. Hasler : R. Green : E. H.Morgan : S. Stevano :H. L.Walls :K. Cunningham Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH), London, UK

A qualitative study of factors related to cardiometabolic risk in rural men

BackgroundRural men are known to have poor health behaviors, which contribute to their elevated burden of cardiometabolic disorders in the United States. Although regular physical activity, healthy eating, and avoiding tobacco can reduce cardiometabolic risk, little is known about how to engage rural men in health promotion programs. To bridge this gap in evidence, we investigate knowledge of modifiable cardiometabolic risk factors among rural men in the western United States, identify their concerns related to heart health and motivation to reduce risk, and explore individual, social, and community-level influences on heart-healthy behaviors, specifically diet, physical activity, and tobacco use.MethodsWe conducted seven focus groups with 54 sedentary, overweight/obese men (mean body mass index [BMI] = 31.3 ± 4.6) aged 43–88 residing in government-designated “medically underserved” rural Montana towns in September and October 2014. All sessions were audio-recorded and transcribed verbatim. Transcripts were coded and analyzed thematically using Nvivo software. Participants also completed a brief questionnaire about personal characteristics and health behaviors. These data were explored descriptively.ResultsDespite being classified as overweight/obese and sedentary, no participants reported to be in poor health. Many men described health relative to self-reliance and the ability to participate in outdoor recreation; concern with health appeared to be related to age. Participants were generally knowledgeable of heart-healthy behaviors, but many felt fatalistic about their own risk. Catalysts for behavior change included a serious medical event in the household and desire to reduce aging-associated functional decline. Barriers to adopting and maintaining healthy eating and physical activity habits and abstaining from tobacco included normative beliefs around masculinity and individual liberty, the limited social universe of small towns, winter weather, time constraints, and preferences for unhealthy foods. Facilitators included behavioral self-monitoring, exercising with a partner, and opportunities for preferred activities, such as hunting and team sports.ConclusionsThese findings provide important insight about influences on rural men’s health behaviors and provide guidance for possible intervention strategies to promote cardiometabolic health.Trial registrationClinicalTrials.gov NCT02499731. Registered 1 July 2015.

Adults and children in low-income households that participate in cost-offset community supported agriculture have high fruit and vegetable consumption

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

4th Annual Conference of the Leverhulme Centre for Integrative Research on Agriculture and Health (LCIRAH), Agri-food policy and governance for nutrition and health, London, 3–4 June 2014

The agricultural sector is essential to human nutrition and health, but agricultural and food systems do not always contribute to positive nutritional outcomes. Given the global challenges such as fluctuating food prices, the slowdown of growth in agricultural productivity, food and nutrition insecurity, and attendant health problems of underweight, micronutrient deficiencies, overweight and obesity, and diet-related non-communicable diseases (DR-NCDs), there is an urgent need for effective interventions to make agriculture and food systems more “nutrition-sensitive” (Ruel and Alderman 2013). This requires strong governance, including institutional structures, and appropriate multiand cross-sectorial policymaking. However, our understanding of the diverse impacts, both positive and negative, of governance and policy on nutrition and health remains limited. Rarely is the evidence that has been collected about individual policy outcomes collated and analyzed together, with an overarching aim to improve governance in mind. Agri-health researchers have started to identify this gap and address the need for greater policy research (Hawkes et al. 2013). The core conceptual issues in current agriculture and health (agri-health) research relate to both specific topics and the methods used to pursue research regarding these topics. Questions central to agricultural and health research are: how agricultural production and food systems help mitigate the persistent public health problem of childhood under-nutrition as well as how they contribute to the prevention of obesity and NCDs (Gillespie et al. 2013; Hawkes 2007; Hawkes et al. 2012; Ruel and Alderman 2013). To address these topics there is a need for new and innovative research methods and thus both evidence of agri-health linkages and ways to further investigate these linkages are growing. Since 2011, LCIRAH has addressed the aforementioned core conceptual issues in agri-health research by hosting an annual international conference that has established itself as an important forum for bringing together researchers from around the world to examine critical issues in agriculture and health (Fig. 1) (Harris et al. 2013) With greater attention to agri-health as a research discipline and the inherent inextricable linkages between agriculture, food systems, nutrition and health the need to focus on related governance and policy issues has become more evident. This is clear from the novel methods proposed by public health experts to improve and increase the monitoring of agriculture and food policies to benefit public health (Swinburn et al. 2013); as well as from new initiatives to create interdisciplinary dialogue among the scientific, political and private sectors on the future of sustainable food systems (Fondazione Barilla Center for Food and Nutrition 2014; Stordalen Foundation & R. Kanter (*) :G. F. Augusto :H. L. Walls : S. Cuevas : A. Flores-Martinez : E. H. Morgan :M. Tak : F. Picchioni Leverhulme Centre for Integrative Research on Agriculture and Health – LCIRAH, LIDC, 36 Gordon Square, London WC1H 0PD, UK e-mail: rkanter1@jhu.edu

Environmental Influences on Physical Activity among Rural Adults in Montana, United States: Views from Built Environment Audits, Resident Focus Groups, and Key Informant Interviews

Rural populations in the United States have lower physical activity levels and are at a higher risk of being overweight and suffering from obesity than their urban counterparts. This paper aimed to understand the environmental factors that influence physical activity among rural adults in Montana. Eight built environment audits, 15 resident focus groups, and 24 key informant interviews were conducted between August and December 2014. Themes were triangulated and summarized into five categories of environmental factors: built, social, organizational, policy, and natural environments. Although the existence of active living features was documented by environmental audits, residents and key informants agreed that additional indoor recreation facilities and more well-maintained and conveniently located options were needed. Residents and key informants also agreed on the importance of age-specific, well-promoted, and structured physical activity programs, offered in socially supportive environments, as facilitators to physical activity. Key informants, however, noted that funding constraints and limited political will were barriers to developing these opportunities. Since building new recreational facilities and structures to support active transportation pose resource challenges, especially for rural communities, our results suggest that enhancing existing features, making small improvements, and involving stakeholders in the city planning process would be more fruitful to build momentum towards larger changes.

Analyzing food value chains for nutrition goals

ABSTRACT First proposed in 2010, the use of ‘value chain analysis’ to identify opportunities for targeted nutrition interventions in food systems is still an emerging method. This review explores and summarizes the application of value chain analysis to nutrition and from this provides five insights into how to more effectively conduct value chain analysis for nutrition: 1) use a consumer perspective to inform selection of foods and chains; 2) consider the research question, available resources, and the type of chain; 3) situate consumer research at the center of the analysis; 4) assess economic trade-offs; and 5) pay attention to governance and stakeholders’ capacity for and incentives to change.