Sheila Fleischhacker

A systematic review of fast food access studies.

The frequent consumption of energy‐dense fast food is associated with increased body mass index. This systematic review aims to examine the methodology and current evidence on fast food access and its associations with outcomes. Six databases were searched using terms relating to fast food. Only peer‐reviewed studies published in English during a 10‐year period, with data collection and analysis regarding fast food access were included. Forty articles met the aforementioned criteria. Nearly half of the studies (nu2003=u200316) used their own set of features to define fast food. Studies predominantly examined the relationship between fast food access and socioeconomic factors (nu2003=u200321) and 76% indicated fast food restaurants were more prevalent in low‐income areas compared with middle‐ to higher‐income areas. Ten of 12 studies found fast food restaurants were more prevalent in areas with higher concentrations of ethnic minority groups in comparison with Caucasians. Six adult studies found higher body mass index was associated with living in areas with increased exposure to fast food; four studies, however, did not find associations. Further work is needed to understand if and how fast food access impacts dietary intake and health outcomes; and if fast food access has disparate socioeconomic, race/ethnicity and age associations.

Disaggregate Land Uses and Walking

BACKGROUNDnAlthough researchers have explored associations between mixed-use development and physical activity, few have examined the influence of specific land uses.nnnPURPOSEnThis study analyzes how the accessibility, intensity, and diversity of nonresidential land uses are related to walking for transportation.nnnMETHODSnMultinomial logistic regression was used to investigate associations between walking for transportation and neighborhood land uses in a choice-based sample of individuals (n=260) in Montgomery County MD. Land uses examined included banks, bus stops, fast-food restaurants, grocery stores, libraries, rail stations, offices, parks, recreation centers, non-fast-food restaurants, retail, schools, sports facilities, night uses, physical activity uses, and social uses. Exposure to these uses was measured as the street distance from participants homes to the closest instance of each land use (accessibility); the number of instances of each land use (intensity); and the number of different land uses (diversity). Data were collected from 2004-2006 and analyzed in 2009-2010.nnnRESULTSnAfter adjusting for individual-level characteristics, the distances to banks, bus stops, fast-food restaurants, grocery stores, rail stations, physical activity uses, recreational facilities, restaurants, social uses and sports facilities were associated negatively with transportation walking (ORs [95% CI] range from 0.01 [0.001, 0.11] to 0.91 [0.85, 0.97]). The intensities of bus stops, grocery stores, offices, and retail stores in participants neighborhoods were associated positively with transportation walking (ORs [95% CI] range from 1.05 [1.01, 1.08] to 5.42 [1.73, 17.01]). Land-use diversity also was associated positively with walking for transportation (ORs [95% CI] range from 1.39 [1.20, 1.59] to 1.69 [1.30, 2.20]).nnnCONCLUSIONSnThe accessibility and intensity of certain nonresidential land uses, along with land-use diversity, are positively associated with walking for transportation. A careful mix of land uses in a neighborhood can encourage physical activity.

Evidence for validity of five secondary data sources for enumerating retail food outlets in seven American Indian Communities in North Carolina

BackgroundMost studies on the local food environment have used secondary sources to describe the food environment, such as government food registries or commercial listings (e.g., Reference USA). Most of the studies exploring evidence for validity of secondary retail food data have used on-site verification and have not conducted analysis by data source (e.g., sensitivity of Reference USA) or by food outlet type (e.g., sensitivity of Reference USA for convenience stores). Few studies have explored the food environment in American Indian communities. To advance the science on measuring the food environment, we conducted direct, on-site observations of a wide range of food outlets in multiple American Indian communities, without a list guiding the field observations, and then compared our findings to several types of secondary data.MethodsFood outlets located within seven State Designated Tribal Statistical Areas in North Carolina (NC) were gathered from online Yellow Pages, Reference USA, Dun & Bradstreet, local health departments, and the NC Department of Agriculture and Consumer Services. All TIGER/Line 2009 roads (>1,500 miles) were driven in six of the more rural tribal areas and, for the largest tribe, all roads in two of its cities were driven. Sensitivity, positive predictive value, concordance, and kappa statistics were calculated to compare secondary data sources to primary data.Results699 food outlets were identified during primary data collection. Match rate for primary data and secondary data differed by type of food outlet observed, with the highest match rates found for grocery stores (97%), general merchandise stores (96%), and restaurants (91%). Reference USA exhibited almost perfect sensitivity (0.89). Local health department data had substantial sensitivity (0.66) and was almost perfect when focusing only on restaurants (0.91). Positive predictive value was substantial for Reference USA (0.67) and moderate for local health department data (0.49). Evidence for validity was comparatively lower for Dun & Bradstreet, online Yellow Pages, and the NC Department of Agriculture.ConclusionsSecondary data sources both over- and under-represented the food environment; they were particularly problematic for identifying convenience stores and specialty markets. More attention is needed to improve the validity of existing data sources, especially for rural local food environments.

Tools for Healthy Tribes: Improving Access to Healthy Foods in Indian Country

There is growing recognition that policymakers can promote access to healthy, affordable foods within neighborhoods, schools, childcare centers, and workplaces. Despite the disproportionate risk of obesity and type 2 diabetes among American Indian children and adults, comparatively little attention has been focused on the opportunities tribal policymakers have to implement policies or resolutions to promote access to healthy, affordable foods. This paper presents an approach for integrating formative research into an action-oriented strategy of developing and disseminating tribally led environmental and policy strategies to promote access to and consumption of healthy, affordable foods. This paper explains how the American Indian Healthy Eating Project evolved through five phases and discusses each phases essential steps involved, outcomes derived, and lessons learned. Using community-based participatory research and informed by the Social Cognitive Theory and ecologic frameworks, the American Indian Healthy Eating Project was started in fall 2008 and has evolved through five phases: (1) starting the conversation; (2) conducting multidisciplinary formative research; (3) strengthening partnerships and tailoring policy options; (4) disseminating community-generated ideas; and (5) accelerating action while fostering sustainability. Collectively, these phases helped develop and disseminate Tools for Healthy Tribes-a toolkit used to raise awareness among participating tribal policymakers of their opportunities to improve access to healthy, affordable foods. Formal and informal strategies can engage tribal leaders in the development of culturally appropriate and tribe-specific sustainable strategies to improve such access, as well as empower tribal leaders to leverage their authority toward raising a healthier generation of American Indian children.

Engaging tribal leaders in an American Indian healthy eating project through modified talking circles.

Frequently used in the American Indian (AI) community and proven to be a valuable tool in health research, a Talking Circle is a method used by a group to discuss a topic in an egalitarian and nonconfrontational manner. Using community-based participatory research, a modified Talking Circle format was developed for engaging tribal leaders in an American Indian Healthy Eating Project in North Carolina. The culturally informed formative research approach enabled us to garner project support from 7 tribes, as well as insights on developing planning and policy strategies to improve access to healthy eating within each of the participating communities.

Promoting physical activity among native american youth: A systematic review of the methodology and current evidence of physical activity interventions and community-wide initiatives

Promoting physical activity using environmental, policy, and systems approaches could potentially address persistent health disparities faced by American Indian and Alaska Native children and adolescents. To address research gaps and help inform tribally led community changes that promote physical activity, this review examined the methodology and current evidence of physical activity interventions and community-wide initiatives among Native youth. A keyword-guided search was conducted in multiple databases to identify peer-reviewed research articles that reported on physical activity among Native youth. Ultimately, 20 unique interventions (described in 76 articles) and 13 unique community-wide initiatives (described in 16 articles) met the study criteria. Four interventions noted positive changes in knowledge and attitude relating to physical activity but none of the interventions examined reported statistically significant improvements on weight-related outcomes. Only six interventions reported implementing environmental, policy, and system approaches relating to promoting physical activity and generally only shared anecdotal information about the approaches tried. Using community-based participatory research or tribally driven research models strengthened the tribal-research partnerships and improved the cultural and contextual sensitivity of the intervention or community-wide initiative. Few interventions or community-wide initiatives examined multi-level, multi-sector interventions to promote physical activity among Native youth, families, and communities. More research is needed to measure and monitor physical activity within this understudied, high risk group. Future research could also focus on the unique authority and opportunity of tribal leaders and other key stakeholders to use environmental, policy, and systems approaches to raise a healthier generation of Native youth.

Assessing Competencies for Obesity Prevention and Control

Because law has pervasive effects on the social and physical environment, a comprehensive strategy to prevent and control obesity must include a strategy that insures all relevant actors have adequate understanding of and “competency” in law. Competency in the use of laws and legal authorities is one of the four core elements of public health legal preparedness. Public health practitioners, legal counsel, health care providers and others need to be able to assess current and proposed laws on obesity risk factors and make effective use of laws as specific obesity prevention and control tools. This paper assesses public health legal competency from both sides: 1) the ability of public health and setting-specific actors to understand and apply relevant laws including knowledge of the consequences of action and inaction; and 2) the ability of policy makers and legal counsel to understand and take into account the potential obesogenic effects of their decisions.

Improving Legal Competencies for Obesity Prevention and Control

journal of law, medicine & ethics This paper is one of four interrelated papers resulting from the National Summit on Legal Preparedness for Obesity Prevention and Control (Summit) convened in June 2008 by the Centers for Disease Control and Prevention (CDC), the Robert Wood Johnson Foundation, and the American Society of Law, Medicine, & Ethics. Each of the papers deals with one of the four core elements of legal preparedness: (1) laws and legal authorities for public health practitioners; (2) legal competencies public health practitioners and legal and policy decision makers need for use of these laws and authorities; (3) crossdisciplinary and cross-jurisdiction coordination of law-based public health actions; and (4) information on public health law best practices. Collectively, they are referenced as the “white papers.” Our purpose is to offer action options that will help to improve the legal competencies of public health practitioners and policy decision makers with respect to drafting, interpreting, implementing, and enforcing laws and regulations that are relevant to the effective prevention and control of obesity. The accompanying assessment paper provided a foundation for this agenda by first establishing that legal competence for obesity prevention and control is important for both health professionals, who with proper training can effectively interject health considerations into decision-making processes, and non-health professionals involved with relevant policy and legal work, who with proper training can effectively incorporate health considerations into their decisions.1 The paper acknowledges apparent gaps in not only health professionals’ understanding of legal tools relevant to obesity but also policymakers’ recognition of how obesity relates to their decisions. In addition, this paper set forth specific competencies each of these two broad groups should have to strengthen their legal preparedness for obesity prevention and control. To improve these competencies within and among the relevant professionals in these two broad groups, our framework identifies critical knowledge, skills, values, analytical approaches, and communication strategies. We also suggest mechanisms by which public health professionals can interact with professionals