Barriers to Equity in Nutritional Health for U.S. Children and Adolescents: A Review of the Literature

Following Through: The Impact of Culinary Medicine on Mediterranean Diet Uptake in Inflammatory Bowel Disease

BACKGROUND

The Mediterranean diet (MD) is recommended for all patients with inflammatory bowel disease (IBD) unless there is a specific contraindication. Culinary medicine has emerged as a method for improving dietary education. Patients and caregivers are often invested in making dietary changes to improve disease control. Here, we examine the dietary preferences of a group of young people with IBD and apply culinary medicine techniques with an in-person MD-focused cooking class.

METHODS

A survey evaluating dietary attitudes was sent to an IBD email listserv at our tertiary care center (n = 779). A validated questionnaire, the Mediterranean Diet Quality Index for Children and Adolescents was used to assess MD adherence. IBD dietitians customized 2 in-person MD-focused cooking classes, one for children 6 to 12 years of age (arm 1) and one for adolescents 13 to 17 years of age (arm 2). Baseline, 1-month follow-up, and 3-month follow-up surveys were completed.

RESULTS

There were 112 survey responses. Participants were 67.0% male with diagnosis of Crohn's disease (50.0%), ulcerative colitis (42.0%), or IBD unclassified (8.0%). Most were managed on advanced therapies (82.0%). Most reported making decisions about diet (82.0%) in order to help with IBD, had met with a dietitian (69.0%), and were interested in learning more about the MD (55.3%). MD scores were primarily in the average (49.5%) and poor (41.1%) diet categories. Only those eating together as a family 3 or more times per week or those who had met with a dietitian scored in the optimal diet category. The median MD score at baseline was 4.5, increasing to 6.0 at 1 month and 7.0 at 3 months postintervention. Almost all (90%) would recommend cooking classes to others. Common barriers to MD uptake included lack of knowledge about which foods to prepare, concern about taste, and time to prepare food.

CONCLUSIONS

This study showcases high patient and caregiver interest in dietary management of IBD and demonstrates efficacy of education via application of culinary medicine. Classes were well received by families and MD adherence scores increased postintervention. As patients with IBD and their families are often motivated to incorporate dietary therapy into their care, this work highlights the role of culinary medicine and value of future study.

How policy implementation shapes the impact of U.S. food assistance policies: the case study of the Child and Adult Care Food Program

Much of the chronic disease burden in the U.S. population can be traced to poor diet. There has been a sustained focus on influencing children's diets and encouraging healthier eating habits by changing policies for what foods and beverages can be served to children through large federally-funded nutrition assistance programs. Yet without attention to how nutrition policies are implemented, and the surrounding context for these policies, these policy changes may not have the intended results. In this perspective, we used Bullock et al.'s (2021) Process Model of Implementation from a Policy Perspective to analyze how the complexities of the implementation process of large-scale nutrition policies can dilute potential health outcomes. We examine the Child and Adult Care Food Program (CACFP), a federal program focused on supporting the provision of nutritious meals to over 4 million children attending childcare, as a case study. We examine how the larger societal contexts of food insecurity, attitudes towards the social safety net, and a fragmented childcare system interact with CACFP. We review the "policy package" of CACFP itself, in terms of its regulatory requirements, and the various federal, state, and local implementation agencies that shape CACFP's on-the-ground implementation. We then review the evidence for how each component of the CACFP policy implementation process impacts uptake, costs, feasibility, equity, and effectiveness at improving children's nutrition. Our case study demonstrates how public health researchers and practitioners must consider the complexities of policy implementation processes to ensure effective implementation of nutrition policies intended to improve population health.

Farm to school programs in low-income, high minority K-12 schools in New Jersey before and after implementation of the Healthy Hunger Free Kids Act

We analyzed the prevalence of farm to school (FTS) programs in K-12 schools in four low-income, high-minority cities in New Jersey before and after implementation of the Healthy Hunger-Free Kids Act (HHFKA), between school years 2010-11 and 2017-18. Multivariable logistic regression was used to model FTS participation and the prevalence of FTS before versus after HHFKA initiation. Schools showed a significant positive trend in FTS participation (OR 1.18; p=.010) over the study period. Nonetheless, 20% of schools participated in FTS for 3+ years over the eight-year study period. Findings underscore the importance of federal legislation in supporting child nutrition initiatives.

Implementation of Flexibilities to the National School Lunch and Breakfast Programs and Their Impact on Schools in Missouri

BACKGROUND

In 2018, the United States Department of Agriculture (USDA) issued flexibilities to the National School Lunch and Breakfast Programs, relaxing the nutrition standards for milk, whole grains, and sodium. This study examines the implementation decision-making among Missouri school food services and the impact of implementing these flexibilities on the meals served.

METHODS

We developed a survey using the Consolidated Framework of Implementation to determine schools' implementation of the flexibilities and factors related to implementation. To determine how the implementation of flexibilities affected participation, we merged the survey results with school-level meal county data from the Missouri Department of Elementary and Secondary Education. We used ordinary least squares regression to examine how flexibility adoption related to the number of meals served.

RESULTS

Most schools implemented the wheat, milk, and sodium flexibilities. Common reasons for implementation were increasing participation, meeting students' preferences, expanding menu variety, and saving money. The implementation of flexibilities was associated with more lunches and breakfasts being served per month, particularly among free and reduced-price meals.

CONCLUSIONS

Continued research is needed to determine how the increased uptake of school meals that do not fully meet dietary guidelines by low-income students results in inequities in health outcomes. The findings can inform the design and implementation of future policies, especially as new rules related to flexibility design are determined.

Costs, Reach, and Benefits of COVID-19 Pandemic Electronic Benefit Transfer and Grab-and-Go School Meals for Ensuring Youths' Access to Food During School Closures

IMPORTANCE

School meals are associated with improved nutrition and health for millions of US children, but school closures due to the COVID-19 pandemic disrupted children's access to school meals. Two policy approaches, the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases, and the grab-and-go meals program, which offered prepared meals from school kitchens at community distribution points, were activated to replace missed meals for children from low-income families; however, the extent to which these programs reached those who needed them and the programs' costs were unknown.

OBJECTIVE

To assess the proportion of eligible youths who were reached by P-EBT and grab-and-go meals, the amount of meals or benefits received, and the cost to implement each program.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted from March to June 2020. The study population was all US youths younger than 19 years, including US youths aged 6 to 18 years who were eligible to receive free or reduced-price meals (primary analysis sample).

EXPOSURES

Receipt of P-EBT or grab-and-go school meals.

MAIN OUTCOMES AND MEASURES

The main outcomes were the percentage of youths reached by P-EBT and grab-and-go school meals, mean benefit received per recipient, and mean cost, including implementation costs and time costs to families per meal distributed.

RESULTS

Among 30 million youths eligible for free or reduced-price meals, grab-and-go meals reached an estimated 8.0 million (27%) and P-EBT reached 26.9 million (89%). The grab-and-go school meals program distributed 429 million meals per month in spring 2020, and the P-EBT program distributed $3.2 billion in monthly cash benefits, equivalent to 1.1 billion meals. Among those receiving benefits, the mean monthly benefit was larger for grab-and-go school meals ($148; range across states, $44-$176) compared with P-EBT ($110; range across states, $55-$114). Costs per meal delivered were lower for P-EBT ($6.46; range across states, $6.41-$6.79) compared with grab-and-go school meals ($8.07; range across states, $2.97-$15.27). The P-EBT program had lower public sector implementation costs but higher uncompensated time costs to families (eg, preparation time for meals) compared with grab-and-go school meals.

CONCLUSIONS AND RELEVANCE

In this economic evaluation, both the P-EBT and grab-and-go school meal programs supported youths' access to food in complementary ways when US schools were closed during the COVID-19 pandemic from March to June 2020.

Methods for Assessing Willingness to Try and Vegetable Consumption among Children in Indigenous Early Childcare Settings: The FRESH Study

Food preferences begin in early childhood, and a child's willingness to try (WTT) new vegetables is an important determinant of vegetable intake. Young children living in rural communities are at increased risk for food insecurity, which may limit exposure to and consumption opportunities for vegetables. This manuscript describes the validation of the Farfan-Ramirez WTT (FR-WTT) measure using baseline data from the FRESH study, a gardening intervention for Native American families with preschool-aged children in Osage Nation, Oklahoma. Individually weighed vegetable containers were prepared with six types of vegetables and ranch dip. Researchers presented children (n = 164; M = 4.3 years, SD = 0.8) with these vegetables preceding a snack- or lunch time and recorded the child's FR-WTT for each vegetable using a 5-point scale, ranging from "did not remove food (0)" to "put food in mouth and swallowed (4)". After the presentation period, contents were re-weighed to calculate vegetable consumption. Household parents/guardians completed the Child Food Neophobia Scale (CFNS) for their child. FR-WTT scores were positively correlated with consumption weights of all vegetables (r = 0.7613, p < 0.0001) and each vegetable individually (r = 0.2016-0.7664). The total FR-WTT score was inversely correlated with the CFNS score (r = 0.3268, p < 0.0001). Sensitivity analyses demonstrated similar relationships by BMI, food security, and age. In conclusion, the FR-WTT is a valid method for assessing young children's vegetable eating behavior and intake.

Feeding Children and Maintaining Food Service Operations during COVID-19: A Mixed Methods Investigation of Implementation and Financial Challenges

The United States Department of Agriculture (USDA) National School Lunch and Breakfast Programs are critical for the health and food security of U.S. schoolchildren, but access to these programs was disrupted by COVID-19 pandemic-related school closures in spring 2020. While temporary policy changes to the programs enabled school food authorities (SFAs) to pivot towards distributing meals throughout their communities instead of within school buildings, SFAs faced complex challenges during COVID-19 with minimal external support. This mixed methods study investigates the implementation and financial challenges experienced by twelve of the largest urban SFAs in the U.S. during COVID-19. We conducted semi-structured interviews with SFA leaders and analyzed alongside quantitative financial data. We found that SFAs reconfigured their usual operations with nearly no preparation time while simultaneously trying to keep staff from contracting COVID-19, accommodate stakeholders with sometimes competing priorities, and remain financially solvent. Because student participation was much lower than during regular times, and revenue is tied to the number of meals served, SFAs saw drastic decreases in revenue even as they carried regular operating costs. For future crises, disaster preparedness plans that help SFAs better navigate the switch to financially viable community distribution methods are needed.

Body dissatisfaction and disordered eating are prevalent problems among U.S. young people from diverse socioeconomic backgrounds: Findings from the EAT 2010-2018 study

PURPOSE

Body dissatisfaction and disordered eating are linked to adverse health consequences. Research describing socioeconomic patterns in the prevalence of these problems is important for informing the design of health services and efforts to improve health equity.

METHODS

Population-based cohort study (EAT 2010-2018: Eating and Activity over Time) of socioeconomically and ethnically/racially diverse U.S. young people who completed surveys as adolescents in 2009-2010 (mean age = 14.5 years) and as emerging adults in 2018 (mean age = 22.0 years). Participants were recruited from 20 schools in Minneapolis-St. Paul, Minnesota. Household socioeconomic status was determined using adolescent report of parental education, employment, and public assistance benefits. Analyses were conducted using data from 1531 participants and regression models that accounted for repeated measures within individuals.

RESULTS

Among females, high body dissatisfaction and unhealthy weight control behaviors (e.g., skipping meals) were more prevalent and regular use of lifestyle weight management behaviors (e.g., exercise) was less prevalent in the low SES group as compared to the middle and/or upper SES groups (p ≤ .010). Among males, thinness-oriented dieting, unhealthy weight control behaviors, and extreme weight control behaviors (e.g., taking diet pills) were all more prevalent in the low SES group as compared to the middle and/or upper SES groups (p ≤ .010). Few differences were observed across SES groups in models that adjusted for ethnic/racial identity and body mass index.

CONCLUSIONS

There is a need for greater attention to the reach and relevance of efforts to prevent disordered eating and improve body satisfaction to ensure efforts benefit young people across SES groups.

Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.

Nutritional problems in childhood and adolescence: a narrative review of identified disparities

To inform programmes and policies that promote health equity, it is essential to monitor the distribution of nutritional problems among young individuals. Common nutritional problems include overall low diet quality, the underconsumption and overconsumption of certain dietary components, unhealthy meal and snack patterns, problematic feeding practices and disordered eating. The objective of the present narrative review was to summarise recent evidence of disparities among US children (2-19 years) according to age, sex, socio-economic status, ethnicity/race and rural-urban location. Searches in PubMed® and MEDLINE® were completed to identify peer-reviewed research studies published between January 2009 and January 2019. Findings from the ninety-nine reviewed studies indicate adolescent females, young individuals from lower socio-economic households and individuals who identify as non-Hispanic Black race are particularly vulnerable populations for whom targeted strategies should be developed to address evidence of increased risk with regards to multiple aspects of nutritional wellbeing. Limitations of the existing evidence relate to the accuracy of self-reported dietary data; the need for consistent definitions of disordered eating; the focus on individual dietary components v. patterns; the complexities of categorising socio-economic status, ethnicity/race, and rural and urban areas; and the cross-sectional, observational nature of most research designs. There is an urgent need for research to address these limitations and fill a large gap in evidence on rural-urban differences in nutritional problems. It will further be important for future studies to build greater understanding of how nutritional problems cluster among population groups.

Early maturity, shortened stature, and hardship: Can life-history trade-offs indicate social stratification and income inequality in the United States?

OBJECTIVE

Life-history strategies promote reproductive fitness and survival. Limited energy availability and competing energetic demands between life-history decisions may result in organismal trade-offs leading to selection for "optimal" traits that facilitate fitness and survival in present environmental conditions. Few life-history analyses have been conducted in food abundant/high resource human populations. Here, we use a life-history theory framework integrated with a biocultural approach to assess whether trade-offs between growth (height) and the onset of reproductive maturation (ages at menarche) were observed in a sample of adult women living in the United States.

METHODS

Adult women (18 years and older) from the National Health and Nutrition Examination Survey (NHANES) 2005 to 2006 were analyzed using complex survey regression to evaluate associations between ages at menarche, height, and biological, socio-economic, demographic, and anthropometric variables. Associations between stature, ages at menarche, and socio-economic status (household income and education level) suggest life-history trade-offs in this populations may be mitigated by access to resources and marginalization.

CONCLUSIONS

These study results have applied public health implications. We demonstrate that females who experience early menarche in the US population achieve short stature. Our study also demonstrates the need for implementing life-history analyses in Western affluent populations, where marginalization may result in life-history trade-offs.

Using repeated exposure through hands-on cooking to increase children's preferences for fruits and vegetables

Few children in the United States meet national fruit and vegetable intake recommendations, highlighting a need for interventions. Children's food preferences act as a barrier to fruit and vegetable consumption, but prior research has demonstrated that repeated taste exposures can increase children's acceptance of these foods. Prior research in this area has typically utilized controlled procedures in which children sample small tastes of target foods over repeated occasions. The primary aim of the present pilot study was to test whether children's preferences for target fruits and vegetables increased following repeated taste exposures to them through hands-on cooking in a community setting. Seventeen 6-to-8-year-old children participated in biweekly study sessions during six weeks of a summer camp serving lower-income families. Liking of (yummy, just OK, yucky) and rank-ordered preferences for nine fruits and vegetables were measured before and after exposure sessions (pre-test and post-test). Based on pre-test assessments, four relatively less liked foods (two fruits, two vegetables) were chosen to become target foods. Children were then exposed to target foods during nine hands-on cooking sessions; liking of target foods was also measured at a midpoint assessment. At each exposure session, children assisted with preparation of a different snack using a recipe involving target foods and then ate the prepared snack together. Preferences for target foods increased from pre-test (Median = 5.8) to post-test (Median = 5.5; p < 0.05). On average, the majority of children rated the prepared snacks favorably. Results from this pilot study demonstrate the potential of applying repeated exposure techniques via hands-on cooking in a community setting.

Examining Household Changes in Produce Purchases Among New Parents

OBJECTIVE

To measure whether parenthood is associated with changes in produce purchasing behavior, overall and stratified by income.

DESIGN

Retrospective examination of retail grocery purchases in the Nielsen Consumer Panel, a nationally representative sample of US households, 2007-2015.

PARTICIPANTS AND SETTING

A total of 21,939 households in the US, aged 25-49 years, observed ≤ 8 years; 508 households initiated parenthood during the study period.

MAIN OUTCOME MEASURE

Percentage of household grocery budget spent on produce each year.

ANALYSIS

Difference-in-differences design was used to measure change in the percentage of the grocery budget spent on produce after becoming a parent, relative to households that did not become parents, overall and stratified by income level. Ordinary least-squares regressions was used to adjust for confounders.

RESULTS

Percentage of the grocery budget spent on produce increased by 1.7 percentage points (15.7%) after initiating parenthood. Among higher-income households, produce purchases increased by 1.9 percentage points; no detectable change was found among low-income households.

CONCLUSIONS AND IMPLICATIONS

Initiation of parenthood increased grocery expenditures on produce. Because new parenthood is a critical time in a person's life, this behavior change could create the opportunity for interventions with long-term effects. However, heterogeneous impacts by income indicated that lower-income households need more support and reveal 1 mechanism for income-related disparities in childhood nutrition.

Disparities in food access around homes and schools for New York City children

Demographic and income disparities may impact food accessibility. Research has not yet well documented the precise location of healthy and unhealthy food resources around children's homes and schools. The objective of this study was to examine the food environment around homes and schools for all public school children, stratified by race/ethnicity and poverty status. This cross-sectional study linked data on the exact home and school addresses of a population-based sample of public school children in New York City from 2013 to all corner stores, supermarkets, fast-food restaurants, and wait-service restaurants. Two measures were created around these addresses for all children: 1) distance to the nearest outlet, and 2) count of outlets within 0.25 miles. The total analytic sample included 789,520 K-12 graders. The average age was 11.78 years (SD ± 4.0 years). Black, Hispanic, and Asian students live and attend schools closer to nearly all food outlet types than White students, regardless of poverty status. Among not low-income students, Black, Hispanic, and Asian students were closer from home and school to corner stores and supermarkets, and had more supermarkets around school than White students. The context in which children live matters, and more nuanced data is important for development of appropriate solutions for childhood obesity. Future research should examine disparities in the food environment in other geographies and by other demographic characteristics, and then link these differences to health outcomes like body mass index. These findings can be used to better understand disparities in food access and to help design policies intended to promote healthy eating among children.

Coping with Food Insecurity Among African American in Public-Sector Mental Health Services: A Qualitative Study

While there are high rates of food insecurity among individuals with serious mental illnesses, and among African Americans, there is very little research on the ways African Americans in public-sector mental health services cope with food insecurity. This research paper presents qualitative data from a mixed methods study on the prevalence and management of food insecurity among African Americans using public sector mental health services. We interviewed 21 people about their everyday experiences of food insecurity and strategies they used to cope. While participants reported experiencing high levels of food insecurity, they also described the use of communal strategies to help them cope, including sharing food and cooking meals jointly, which seemed to reduce the negative effects of living with high levels of food insecurity as well as a serious mental illness. Policy innovations like communal gardens and kitchens provided through public mental health services may be particularly helpful.

Who Values Gluten-Free? Dietary Intake, Behaviors, and Sociodemographic Characteristics of Young Adults Who Value Gluten-Free Food

BACKGROUND

Over the past decade, consumer demand for gluten-free products has increased, but little is known about the public health impact of and factors correlated with valuing gluten-free food.

OBJECTIVE

Describe the sociodemographic and behavioral characteristics of young adults valuing gluten-free as an important food attribute, and compare their dietary intake with other young adults.

DESIGN

Cross-sectional analysis of survey data collected in 2015 to 2016 as part of the fourth wave of the Project EAT (Eating and Activity in Teens and Young Adults) cohort study.

PARTICIPANTS/SETTING

Population-based sample of 1,819 young adults (25 to 36 years) (57% women, 69% white), initially recruited in Minneapolis-St Paul, MN, public middle and senior high schools.

MEASURES

Valuing gluten-free food, weight goals and weight control behaviors, food production values, eating behaviors, physical activity, and dietary intake.

STATISTICAL ANALYSES PERFORMED

Logistic regression models were used to investigate associations with potential correlates of valuing gluten-free food. For dietary intake, adjusted mean estimates were calculated for those who did and those who did not value gluten-free foods.

RESULTS

Approximately 13% of young adults valued gluten-free food, a characteristic most strongly related to valuing food production practices (eg, organic, locally grown); factors such as Nutrition Facts use and having a weight goal were also related to gluten-free food values. Valuing gluten-free food was related to engagement in both healthy behaviors (eg, eating breakfast daily, eating more fruits and vegetables) and unhealthy behaviors (eg, using diet pills to control weight).

CONCLUSIONS AND RELEVANCE

Young adults valuing gluten-free food generally engaged in healthier behaviors and had better dietary intake; of concern, they were also more likely to engage in unhealthy weight control behaviors. Valuing gluten-free food may be part of a cluster of behaviors representing an interest in making healthier food choices but may also be a marker for unhealthy weight preoccupation and behaviors.

A Low-Cost, Grab-and-Go Breakfast Intervention for Rural High School Students: Changes in School Breakfast Program Participation Among At-Risk Students in Minnesota

OBJECTIVE

Evaluate the impact of a grab-and-go component embedded within a larger intervention designed to promote School Breakfast Program (SBP) participation.

DESIGN

Secondary data analysis.

SETTING

Rural Minnesota high schools.

PARTICIPANTS

Eight schools were enrolled in the grab-and-go only intervention component. An at-risk sample of students (n = 364) who reported eating breakfast ≤3 d/wk at baseline was enrolled at these schools.

INTERVENTIONS

Grab-and-go style breakfast carts and policies were introduced to allow all students to eat outside the cafeteria.

MAIN OUTCOME MEASURES

Administrative records were used to determine percent SBP participation (proportion of non-absent days on which fully reimbursable meals were received) for each student and school-level averages.

ANALYSIS

Linear mixed models.

RESULTS

School-level increases in SBP participation from baseline to the school year of intervention implementation were observed for schools enrolled in the grab-and-go only component (13.0% to 22.6%). Student-level increases in SBP participation were observed among the at-risk sample (7.6% to 21.9%) and among subgroups defined by free- or reduced-price meal eligibility and ethnic or racial background. Participation in SBP increased among students eligible for free or reduced-price meals from 13.9% to 30.7% and among ineligible students from 4.3% to 17.2%.

CONCLUSIONS AND IMPLICATIONS

Increasing access to the SBP and social support for eating breakfast are effective promotion strategies.

Assessing the role of access and price on the consumption of fruits and vegetables across New York City using agent-based modeling

Most residents in New York City (NYC) do not consume sufficient fruits and vegetables every day. Difficulties with access and high prices of fruits and vegetables in some neighborhoods contribute to different consumption patterns across NYC neighborhoods. We developed an agent-based model (ABM) to predict dietary behaviors of individuals at the borough and neighborhood levels. Model parameters were estimated from the 2014 NYC Community Health Survey, United States Census data, and the literature. We simulated six hypothetical interventions designed to improve access and reduce the price of fruits and vegetables. We found that all interventions would lead to increases in fruit and vegetable consumption but the results vary substantially across boroughs and neighborhoods. For example, a 10% increase in the number of fruit/vegetable vendors combined with a 10% decrease in the prices of fruits and vegetables would lead to a median increase of 2.28% (range: 0.65%-4.92%) in the consumption of fruits and vegetables, depending on neighborhood. We also found that the impact of increasing the number of vendors on fruit/vegetable consumption is more pronounced in unhealthier local food environments while the impact of reducing prices on fruits/vegetable consumption is more pronounced in neighborhoods with low levels of education. An agent-based model of dietary behaviors that takes into account neighborhood context has the potential to inform how fruit/vegetable access and pricing strategies may specifically work in tandem to increase the consumption of fruits and vegetables at the local level.

Foods and Beverages Available at SNAP-Authorized Drugstores in Sections of North Carolina

OBJECTIVE

To assess healthy food availability in Supplemental Nutrition Assistance Program-authorized drugstores by store chain and neighborhood income level in 3 regions of North Carolina.

DESIGN

Cross-sectional, descriptive study.

SETTING

Twenty-five counties in North Carolina.

PARTICIPANTS

A total of 108 drugstores (36 CVS Health, 36 Rite Aid, and 36 Walgreens).

MAIN OUTCOME MEASURE(S)

Fifty foods and beverages offered at drugstores, categorized as healthier and less healthy.

ANALYSIS

Kruskal-Wallis tests were used to test differences in the availability of foods and beverages by chain and neighborhood income.

RESULTS

Of the 50 foods/beverages observed, 11 were available at all drugstores. Three of the 36 (8%) healthier items were available at all stores (100% fruit juice, water, and high-fiber cereal) whereas 8 of the 14 less healthy items (57%) were available at all stores (chips, sports drinks, energy drinks, regular soda, diet soda, sugar-sweetened beverages, beer, and wine). Only 3% of drugstores offered fresh vegetables and 4% offered fresh fruits. Less than 20% offered frozen chicken or beef. For 36 healthier foods, 11 differed by chain (28%); for less healthy foods 2 of 14 differed by chain (7%). Foods and beverages offered did not vary by neighborhood income.

CONCLUSIONS AND IMPLICATIONS

Although drugstores offer some healthier items, few offer fresh produce. As the drugstore industry changes, it is important for the nutrition community to study the impact of these changes on food purchasing behavior and ultimately health.

Disparities in Supports for Student Wellness Promotion Efforts Among Secondary Schools in Minnesota

BACKGROUND

We examined whether there are differences in the presence of supports for student wellness promotion (1) between schools in city, suburban and rural locations and, (2) among rural schools, according to distance from a metropolitan center.

METHODS

The analysis was conducted in a sample of 309 secondary schools using 2012 Minnesota School Health Profiles surveys and National Center for Educational Statistics Common Core Data. Scores for overall support addressed school health improvement coordination (range: 0-29), collaboration on health education activities (range: 0-5), and teachers' professional preparation (range: 0-7).

RESULTS

Mean overall scores for health improvement coordination (10.5 ± 7.3), collaboration on health education activities (3.0 ± 1.5) and professional preparation (4.0 ± 1.9) indicated supports are lacking in schools across city, suburban, and rural locations. Comparison of overall scores did not identify disparities; however, weaknesses and strengths of particular relevance for rural schools were identified in examining specific aspects of support. For example, the proportion of rural schools having a written school improvement plan was 54.8% compared to 84.6% of city schools and 64.3% of suburban schools (p = .01).

CONCLUSIONS

Tailored training and technical assistance are needed to better support schools in implementing recommended wellness policies and practices.

The Role of Assimilating to the US Culture and the Relationship Between Neighborhood Ethnic Composition and Dietary Intake Among Hispanic Youth

BACKGROUND

Dietary fiber and sugar intake have been shown to affect metabolic health in overweight Hispanic youth. Evidence on the influence of culture on fiber and sugar intake in Hispanic youth is limited.

METHODS

The associations among score for levels of assimilation, neighborhood ethnic characteristics, and daily total and added dietary sugar and dietary fiber intake were assessed using regression analyses.

RESULTS

One hundred twenty-four Hispanic youth (age = 13.6 ± 3.0, 106 female) were included. The proportion of Hispanic population in the neighborhood was positively associated with fiber intake (standardized β = 0.205, p < 0.01) and inversely associated with added (standardized β = -0.234, p < 0.01) and total sugar intake (standardized β = -0.229, p < 0.01). Youth's self-identified levels of assimilation inversely moderated (standardized β = -0.465, p = 0.036) the association between %HP and dietary fiber intake.

CONCLUSIONS

Hispanic youth residing in areas of that are predominantly populated with Hispanics may be protected from conforming to unhealthy dietary behaviors. This protective effect is weaker among Hispanic youth with higher level of assimilation.

Social Norms and the Consumption of Fruits and Vegetables across New York City Neighborhoods

Consumption of fruits and vegetables is associated with a lower risk of developing many chronic health conditions such as diabetes and cardiovascular disease. While five or more servings of fruits and vegetables per day are recommended, only 50 % of New York City (NYC) residents consume two or more servings per day. In addition, there is wide variation in dietary behaviors across different neighborhoods in NYC. Using a validated agent-based model and data from 34 NYC neighborhoods, we simulate how a mass media and nutrition education campaign strengthening positive social norms about food consumption may potentially increase the proportion of the population who consume two or more servings of fruits and vegetables per day in NYC. We found that the proposed intervention results in substantial increases in daily fruit and vegetable consumption, but the campaign may be less effective in neighborhoods with relatively low education levels or a relatively high proportion of male residents. A well-designed, validated agent-based model has the potential to provide insights on the impact of an intervention targeting social norms before it is implemented and shed light on the important neighborhood factors that may affect the efficacy of the intervention.

Exposing some important barriers to health care access in the rural USA

OBJECTIVES

To review research published before and after the passage of the Patient Protection and Affordable Care Act (2010) examining barriers in seeking or accessing health care in rural populations in the USA.

STUDY DESIGN

This literature review was based on a comprehensive search for all literature researching rural health care provision and access in the USA.

METHODS

Pubmed, Proquest Allied Nursing and Health Literature, National Rural Health Association (NRHA) Resource Center and Google Scholar databases were searched using the Medical Subject Headings (MeSH) 'Rural Health Services' and 'Rural Health.' MeSH subtitle headings used were 'USA,' 'utilization,' 'trends' and 'supply and distribution.' Keywords added to the search parameters were 'access,' 'rural' and 'health care.' Searches in Google Scholar employed the phrases 'health care disparities in the USA,' inequalities in 'health care in the USA,' 'health care in rural USA' and 'access to health care in rural USA.' After eliminating non-relevant articles, 34 articles were included.

RESULTS

Significant differences in health care access between rural and urban areas exist. Reluctance to seek health care in rural areas was based on cultural and financial constraints, often compounded by a scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services. Rural residents were found to have poorer health, with rural areas having difficulty in attracting and retaining physicians, and maintaining health services on a par with their urban counterparts.

CONCLUSIONS

Rural and urban health care disparities require an ongoing program of reform with the aim to improve the provision of services, promote recruitment, training and career development of rural health care professionals, increase comprehensive health insurance coverage and engage rural residents and healthcare providers in health promotion.

Dysbiotic drift: mental health, environmental grey space, and microbiota

Advances in research concerning the mental health implications of dietary patterns and select nutrients have been remarkable. At the same time, there have been rapid increases in the understanding of the ways in which non-pathogenic microbes can potentially influence many aspects of human health, including those in the mental realm. Discussions of nutrition and microbiota are often overlapping. A separate, yet equally connected, avenue of research is that related to natural (for example, green space) and built environments, and in particular, how they are connected to human cognition and behaviors. It is argued here that in Western industrial nations a ‘disparity of microbiota’ might be expected among the socioeconomically disadvantaged, those whom face more profound environmental forces. Many of the environmental forces pushing against the vulnerable are at the neighborhood level. Matching the developing microbiome research with existing environmental justice research suggests that grey space may promote dysbiosis by default. In addition, the influence of Westernized lifestyle patterns, and the marketing forces that drive unhealthy behaviors in deprived communities, might allow dysbiosis to be the norm rather than the exception in those already at high risk of depression, subthreshold (subsyndromal) conditions, and subpar mental health. If microbiota are indeed at the intersection of nutrition, environmental health, and lifestyle medicine (as these avenues pertain to mental health), then perhaps the rapidly evolving gut-brain-microbiota conversation needs to operate through a wider lens. In contrast to the more narrowly defined psychobiotic, the term eco-psychotropic is introduced.