Thomas C. Keyserling

Farmers’ market use is associated with fruit and vegetable consumption in diverse southern rural communities

BackgroundWhile farmers’ markets are a potential strategy to increase access to fruits and vegetables in rural areas, more information is needed regarding use of farmers’ markets among rural residents. Thus, this study’s purpose was to examine (1) socio-demographic characteristics of participants; (2) barriers and facilitators to farmers’ market shopping in southern rural communities; and (3) associations between farmers’ market use with fruit and vegetable consumption and body mass index (BMI).MethodsCross-sectional surveys were conducted with a purposive sample of farmers’ market customers and a representative sample of primary household food shoppers in eastern North Carolina (NC) and the Appalachian region of Kentucky (KY). Customers were interviewed using an intercept survey instrument at farmers’ markets. Representative samples of primary food shoppers were identified via random digit dial (RDD) cellular phone and landline methods in counties that had at least one farmers’ market. All questionnaires assessed socio-demographic characteristics, food shopping patterns, barriers to and facilitators of farmers’ market shopping, fruit and vegetable consumption and self-reported height and weight. The main outcome measures were fruit and vegetable consumption and BMI. Descriptive statistics were used to examine socio-demographic characteristics, food shopping patterns, and barriers and facilitators to farmers’ market shopping. Linear regression analyses were used to examine associations between farmers’ market use with fruit and vegetable consumption and BMI, controlling for age, race, education, and gender.ResultsAmong farmers’ market customers, 44% and 55% (NC and KY customers, respectively) reported shopping at a farmers’ market at least weekly, compared to 16% and 18% of NC and KY RDD respondents. Frequently reported barriers to farmers’ market shopping were market days and hours, “only come when I need something”, extreme weather, and market location. Among the KY farmers’ market customers and NC and KY RDD respondents, fruit and vegetable consumption was positively associated with use of farmers’ markets. There were no associations between use of farmers’ markets and BMI.ConclusionsFruit and vegetable consumption was associated with farmers’ market shopping. Thus, farmers’ markets may be a viable method to increase population-level produce consumption.

A Randomized Trial of a Church-Based Diabetes Self-management Program for African Americans With Type 2 Diabetes

Purpose This study developed and tested a culturally appropriate, church-based intervention to improve diabetes self-management. Research Design and Methods This was a randomized trial conducted at 24 African American churches in central North Carolina. Churches were randomized to receive the special intervention (SI; 13 churches, 117 participants) or the minimal intervention (MI; 11 churches, 84 participants). The SI included an 8-month intensive phase, consisting of 1 individual counseling visit, 12 group sessions, monthly phone contacts, and 3 encouragement postcards, followed by a 4-month reinforcement phase including monthly phone contacts. The MI received standard educational pamphlets by mail. Outcomes were assessed at 8 and 12 months; the primary outcome was comparison of 8-month A1C levels. Results At baseline, the mean age was 59 years, A1C 7.8%, and body mass index 35.0 kg/m2; 64% of participants were female. For the 174 (87%) participants returning for 8-month measures, mean A1C (adjusted for baseline and group randomization) was 7.4% for SI and 7.8% for MI, with a difference of 0.4% (95% confidence interval [CI], 0.1-0.6, P = .009). In a larger model adjusting for additional variables, the difference was 0.5% (95% CI, 0.2-0.7, P < .001). At 12 months, the difference between groups was not significant. Diabetes knowledge and diabetes-related quality of life significantly improved in the SI group compared with the MI group. Among SI participants completing an acceptability questionnaire, intervention components and materials were rated as highly acceptable. Conclusions The church-based intervention was well received by participants and improved short-term metabolic control.

Trust, Benefit, Satisfaction, and Burden: A Randomized Controlled Trial to Reduce Cancer Risk Through African- American Churches

BACKGROUND: Community-based participatory research (CBPR) approaches that actively engage communities in a study are assumed to lead to relevant findings, trusting relationships, and greater satisfaction with the research process.OBJECTIVE: To examine community members’ perceptions of trust, benefit, satisfaction, and burden associated with their participation.DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial tested a cancer prevention intervention in members of African-American churches. Data were collected at baseline and 1-year follow-up.MEASUREMENTS: Subscales measured perception of trust in the research project and the project team, benefit from involvement with the project, satisfaction with the project and the team, and perception of burden associated with participation.MAIN RESULTS: Overall, we found high levels of trust, perceived benefit, and satisfaction, and low perceived burden among community members in Partnership to Reach African Americans to Increase Smart Eating. In bivariate analyses, participants in the intervention group reported more perceived benefit and trust (P<.05). Participants in smaller churches reported more benefit, satisfaction and trust, while participants from churches without recent health activities perceived greater benefit, greater satisfaction, and lower burden with the project and the team (P<.05). Participants whose pastors had less educational attainment noted higher benefit and satisfaction; those whose pastors were making personal lifestyle changes noted higher benefit and satisfaction, but also reported higher burden (P<.05).CONCLUSIONS: A randomized clinical trial designed with a CBPR approach was associated with high levels of trust and a perceived benefit of satisfaction with the research process. Understanding variations in responses to a research partnership will be helpful in guiding the design and implementation of future CBPR efforts.

Confidence of Graduating Internal Medicine Residents to Perform Ambulatory Procedures

AbstractOBJECTIVE: To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations. DESIGN: Self-administered descriptive survey. SETTING: Internal medicine training programs associated with 9 medical schools in the eastern United States. PARTICIPANTS: Graduating residents (N=128); response rate, 60%. MEASUREMENTS AND MAIN RESULTS: The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency; simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures. CONCLUSIONS: Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.

A randomized controlled trial of a public health nurse directed treatment program for rural patients with high blood cholesterol.

BACKGROUND Many rural residents do not have access to high-quality nutrition counseling for high blood cholesterol. The objective of this study was to assess the effectiveness of an intervention program designed to facilitate dietary counseling for hypercholesterolemia by rural public health nurses. METHODS Eight health departments (216 participants) were randomized to give the special intervention (SI) and nine (252 participants) to give the minimal intervention (MI). The SI consisted of three individual diet counseling sessions given by a public health nurse, using a structured dietary intervention (Food for Heart Program), referral to a nutritionist if lipid goals were not achieved at 3-month follow-up, and a reinforcement phone call and newsletters. Diet was assessed by the Dietary Risk Assessment (DRA), a validated food frequency questionnaire, at baseline, 3-, and 12-month follow-up; blood lipids and weight were assessed at baseline, 3-, 6-, and 12-month follow-up. RESULTS Participants were largely female (71%), older (mean age 55), and white (80%). At 3-month follow-up, the average reduction (indicating dietary improvement) in total Dietary Risk Assessment score was 3.7 units greater in the SI group (95% confidence interval [CI] 1.9 to 5.5, P = 0.0006), while both groups experienced a similar reduction in blood cholesterol, 14.1 mg/dL (0.37 mmol/L) for SI and 14.5 mg/dL (0.38 mmol/L) for minimal intervention group (difference -0.4 mg/dL [-0.010 mmol/L], 95% CI -12.5 to 11.7 [-0.32 to 0.30], P = 0.9). At 12-month follow-up, the reduction in total Dietary Risk Assessment score was 2.1 units greater in the SI group (95% CI 0.8 to 3.5, P = 0.005), while the reduction in blood cholesterol was similar in both groups, 18.4 mg/dL (0.48 mmol/L) for SI and 15.6 mg/dL (0.40 mmol/L) for minimal intervention group (difference 2.8 mg/dL [0.07 mmol/L], 95% CI -7.5 to 13.1 [-0.19 to 0.34], P = 0.6). During follow-up, weight loss was greater in the SI group; the difference between groups was statistically significant at 3 (1.9 lb [0.86 kg], 95% CI 0.3 to 3.4 [0.14 to 1.55], P = 0.022) and 6 months (2.1 lb [0.95 kg], 95% CI 0.1 to 4.1 [0.04 to 1.86], P = 0.04). At 12 months, the difference was not significant (1.6 lb [0.73 kg], 95% CI -0.05 to 3.7 [-0.02 to 1.68], P = 0.13). CONCLUSIONS Improvement in self-reported dietary intake was significantly greater in the SI group, while reduction in blood cholesterol was similar in both groups.

Associations between access to farmers’ markets and supermarkets, shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, USA

OBJECTIVE We examined associations between access to food venues (farmers’ markets and supermarkets), shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, U.S.A. DESIGN Access to food venues was measured using a Geographic Information System incorporating distance, seasonality and business hours, to quantify access to farmers’ markets. Produce consumption was assessed by self-report of eating five or more fruits and vegetables daily. BMI and blood pressure were assessed by clinical measurements. Poisson regression with robust variance was used for dichotomous outcomes and multiple linear regression was used for continuous outcomes. As the study occurred in a university town and university students are likely to have different shopping patterns from non-students, we stratified analyses by student status. SETTING Eastern North Carolina. SUBJECTS Low-income women of reproductive age (18–44 years) with valid address information accessing family planning services at a local health department (n 400). RESULTS Over a quarter reported ever shopping at farmers’ markets (114/400). A larger percentage of women who shopped at farmers’ markets consumed five or more fruits and vegetables daily (42.1%) than those who did not (24.0%; P < 0.001). The mean objectively measured distance to the farmers’ markets where women reported shopping was 11.4 (SD 9.0) km (7.1 (SD 5.6) miles), while the mean distance to the farmers’ market closest to the residence was 4.0 (SD 3.7) km (2.5 (SD 2.3) miles). CONCLUSIONS Among non-students, those who shopped at farmers’ markets were more likely to consume five or more servings of fruits and vegetables daily. Future research should further explore potential health benefits of farmers’ markets.

A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies

BackgroundEfficacious strategies for the primary prevention of coronary heart disease (CHD) are underused, and, when used, have low adherence. Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice.MethodsWe conducted a randomized trial of a CHD prevention intervention (including a computerized decision aid and automated tailored adherence messages) at one university general internal medicine practice. After obtaining informed consent and collecting baseline data, we randomized patients (men and women age 40-79 with no prior history of cardiovascular disease) to either the intervention or usual care. We then saw them for two additional study visits over 3 months. For intervention participants, we administered the decision aid at the primary study visit (1 week after baseline visit) and then mailed 3 tailored adherence reminders at 2, 4, and 6 weeks. We assessed our outcomes (including the predicted likelihood of angina, myocardial infarction, and CHD death over 10 years (CHD risk) and self-reported adherence) between groups at 3 month follow-up. Data collection occurred from June 2007 through December 2009. All study procedures were IRB approved.ResultsWe randomized 160 eligible patients (81 intervention; 79 control) and followed 96% to study conclusion. Mean predicted CHD risk at baseline was 11.3%. The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points (95% CI 8% to 42%), with the biggest effect for aspirin. It also changed predicted CHD risk by -1.1% (95% CI -0.16% to -2%), with a larger effect in a pre-specified subgroup of high risk patients.ConclusionA computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk.Clinical trials registration numberClinicalTrials.gov: NCT00494052

Randomized trial of a behavioral weight loss intervention for low-income women: the Weight Wise Program.

Low‐income women in the United States have the highest rates of obesity, yet they are seldom included in weight loss trials. To address this research gap, components of two evidence‐based weight loss interventions were adapted to create a 16‐week intervention for low‐income women (Weight Wise Program), which was evaluated in a randomized trial with the primary outcome of weight loss at 5‐month follow‐up. Participants were low‐income women (40–64 years) with a BMI of 25–45. Of 143 participants, 72 were randomized to the Weight Wise Program (WWP) and 71 to the Control Group (CG). Five‐month follow‐up data were obtained from 64 (89%) WWP and 62 (87%) CG participants. With baseline values carried forward for missing data, WWP participants had a weight change of −3.7 kg compared to 0.7 kg in the CG (4.4 kg difference, 95% confidence interval (CI), 3.2–5.5, P < 0.001). For systolic blood pressure (SBP), change in the WWP was −6.5 mm Hg compared to −0.4 mm Hg among controls (6.2 mm Hg difference, 95% CI, 1.7–10.6, P = 0.007); for diastolic BP (DBP), changes were −4.1 mm Hg for WWP compared to −1.3 mm Hg for controls (2.8 mm Hg difference, 95% CI, 0.0–5.5, P = 0.05). Of the 72 WWP participants, 64, 47, and 19% lost at least 3, 5, and 7% of their initial body weight, respectively. In conclusion, the WWP was associated with statistically significant and clinically important short‐term weight loss.

Confidence of Academic General Internists and Family Physicians to Teach Ambulatory Procedures

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures.DESIGN: Mailed survey.SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states.PARTICIPANTS: Convenience sample of full-time teaching faculty.MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians’ confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year.CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

The Praise! Project: A Church-Based Nutrition Intervention Designed for Cultural Appropriateness, Sustainability, and Diffusion

Cancer prevention research has inadequately reached the African American community despite a higher risk for cancer and many other chronic diseases. Reasons for this failure include historical mistrust of research and medical institutions; lack of culturally relevant interventions; and a failure to design and implement interventions that “give back” to the community. The Partnership to Reach African Americans to Increase Smart Eating (PRAISE!) project is a National Cancer Institute-funded study that developed and tested a nutrition intervention program in partnership with African American churches. Sixty churches and over 1300 individuals participated in this 5 year randomized controlled trial. In this article, the authors describe the design and implementation of the PRAISE! intervention, building on the strengths of the African American church to create a community-university partnership to enhance cultural relevance of the intervention and foster the potential for long term sustainability and diffusion in the African American community.