How does eligibility for GusNIP produce prescriptions relate to fruit and vegetable purchases and what factors shape the relationship? A protocol for a secondary analysis of nationally representative data in the USA

INTRODUCTION

US Department of Agriculture (USDA) Gus Schumacher Nutrition Incentive Programme (GusNIP) produce prescription programme (PPR) 'prescriptions' provide eligible participants with low income, risk for diet-related chronic disease and food insecurity a healthcare issued incentive to purchase lower to no cost fruits and vegetables (FVs). However, GusNIP requirements specify that PPR prescriptions can only be redeemed for fresh (not frozen, canned or dried) FVs. This requirement may prevent participants from fully engaging in or benefiting from GusNIP PPR, given communities with lower healthy food access may have reduced fresh FV accessibility.

METHODS AND ANALYSIS

We will use the nationally representative 2012-2013 National Household Food Acquisition and Purchase Survey (FoodAPS) and complementary FoodAPS Geography Component data in a secondary data analysis to examine how household GusNIP PPR eligibility relates to the quantity and variety of fresh, frozen, canned and dried FV purchases and to what extent individual, household and food environment factors shape the relationship. FoodAPS data include household food purchasing and acquisition information across a 7 day period from 14 317 individuals among 4826 households and was collected between April 2012 and January 2013. The FoodAPS Geography Component provides information about the local community/environment relative to FoodAPS households. This study will examine the correlation or association of selected variables between different quantities and varieties of fresh, frozen, canned and dried FVs, as well as correlations among multilevel predictors.

ETHICS AND DISSEMINATION

We are following data integrity standards as outlined by agreements with the USDA Economic Research Service. All results of analyses will undergo a thorough disclosure review to ensure no identifiable data are shared. Results will be disseminated to research, practice and policy communities using an Open Access peer-reviewed manuscript(s), scientific and practice presentations, and a public facing report and infographic.

Implementation of Food is Medicine Programs in Healthcare Settings: A Narrative Review

Food is Medicine (FIM) programs to improve the accessibility of fruits and vegetables (FVs) or other healthy foods among patients with low income and diet-related chronic diseases are promising to improve food and nutrition security in the United States (US). However, FIM programs are relatively new and implementation guidance for healthcare settings using an implementation science lens is lacking. We used a narrative review to describe the evidence base on barriers and facilitators to FIM program integration in US healthcare settings following the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework. Evidence surrounding the EPIS Inner Context was a focus, including constructs Leadership, Organizational Characteristics, Quality and Fidelity Monitoring and Support, Organizational Staffing Processes, and Individual Characteristics. Peer-reviewed and grey literature about barriers and facilitators to FIM programs were of interest, defined as programs that screen and refer eligible patients with diet-related chronic disease experiencing food insecurity to healthy, unprepared foods. Thirty-one sources were included in the narrative review, including 22 peer-reviewed articles, four reports, four toolkits, and one thesis. Twenty-eight sources (90%) described EPIS Inner Context facilitators and 26 sources (84%) described FIM program barriers. The most common barriers and facilitators to FIM programs were regarding Quality and Fidelity Monitoring and Support (e.g., use of electronic medical records for tracking and evaluation, strategies to support implementation) and Organizational Staffing Processes (e.g., clear delineation of staff roles and capacity); although, barriers and facilitators to FIM programs were identified among all EPIS Inner Context constructs. We synthesized barriers and facilitators to create an EPIS-informed implementation checklist for healthcare settings for use among healthcare organizations/providers, partner organizations, and technical assistance personnel. We discuss future directions to align FIM efforts with implementation science terminology and theories, models, and frameworks to improve the implementation evidence base and support FIM researchers and practitioners.

E-health Dietary Interventions for Participants of SNAP and WIC: A Systematic Review

The migration of federal assistance services to online platforms during the COVID-19 pandemic sparked interest in digital nutrition education for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs. With federal government investing in the modernization of the nutrition education components of both programs, there is a need to identify science-backed electronic health (e-health) dietary interventions to improve health outcomes in this population. Therefore, the objective of this systematic literature review was to summarize the effectiveness, acceptability, and feasibility of e-health dietary interventions among individuals participating in WIC or SNAP. Keyword searches were performed in Google Scholar, PubMed, and Science Direct. The search included peer-reviewed literature from 2014 to 2023 and a few articles offering context about interventions used long-term by the nutrition assistance programs. PRISMA guidelines were followed to conduct this systematic literature review, which resulted in 36 articles eligible for extraction. The studies evaluated e-health (52.8%), short message service/text messaging (27.8%), and smartphone application interventions (19.4%) delivered to WIC or SNAP participants. The interventions identified aimed to modify food choice, eating behavior, and dietary intake among SNAP participants, SNAP-eligible adults, and WIC participants. Most interventions were developed using content delivery and health behavior theoretical frameworks (77.8%) and evidence-based nutritional recommendations (59.3%). Review findings show a high level of acceptability and feasibility for e-health and mobile health dietary interventions among WIC and SNAP participants but varying levels of effectiveness. Level of engagement, dosage, retention, and adherence were strong predictors of positive dietary behavior change regardless of the mode of intervention delivery. Future studies need to prioritize health equity by recruiting samples representative of food nutrition assistance participants and addressing digital health literacy as a potential barrier to intervention effectiveness, as none of the present studies measured literacy among participants.

Implementation and Impact of Perinatal Food is Medicine Programs: A Qualitative Research Study

BACKGROUND

Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is medicine (FIM) programs, which integrate food into the healthcare system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited.

OBJECTIVE

The purpose of this study was to explore 1) perceptions of public health impacts of perinatal food is medicine programs from the perspectives of both program implementers and program supporters and 2) implementation strategies used to enhance program adoption, implementation, and maintenance.

DESIGN

Qualitative data were collected through semi-structured interviews. The interview guide was based on the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework.

PARTICIPANTS

/setting: Program implementers (n=16) and program supporters (n=20) were recruited across the United States through purposive sampling in 2022-2023.

ANALYSIS

Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner.

RESULTS

Interviews were completed with program implementers and program supporters and generated meaning units (N=1942) that were coded into themes aligned with each RE-AIM dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through healthcare systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies/laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes.

CONCLUSIONS

There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

Development of a Comprehensive Household Food Security Tool for Families with Young Children and/or Pregnant Women in High Income Countries

Despite increasing rates of food insecurity in high income countries, food insecurity and its related factors are inconsistently and inadequately assessed, especially among households with young children (0-6 years) and pregnant women. To fill this gap, researchers from the U.S. and Australia collaborated to develop a comprehensive household food security tool that includes the known determinants and outcomes of food insecurity among parents of young children and pregnant women. A five-stage mixed methods approach, including a scoping literature review, key informant interviews, establishing key measurement constructs, identifying items and scales to include, and conducting cognitive interviews, was taken to iteratively develop this new comprehensive tool. The resulting 78-item tool includes the four dimensions of food security (access, availability, utilization, and stability) along with known risk factors (economic, health, and social) and outcomes (mental and physical health and diet quality). The aim of this novel tool is to comprehensively characterize and assess the severity of determinants and outcomes of food insecurity experienced by households with young children and pregnant women.

Factors Associated with Food Insecurity among Pregnant Women and Caregivers of Children Aged 0-6 Years: A Scoping Review

With a global focus on improving maternal and child nutrition through the 2030 Sustainable Development Goals, it is important to understand food insecurity in pregnant women and families with young children, as food insecurity at these life stages can have ongoing negative health consequences. However, factors that influence food insecurity among this population group are not well understood. This scoping review investigates the factors that influence food insecurity among pregnant women and households with young children aged 0–6 years living in high-income countries. A scoping literature review was conducted using four electronic databases. The search combined terms relevant to: food security, determinants, pregnancy and family and high-income countries. Only full text and English language articles were included. The search identified 657 titles and abstracts; 29 articles were included in the review. A majority (70%) of the studies were conducted in the United States and were mostly either cross-sectional or secondary data analysis of existing population data. Factors associated with food insecurity were identified and grouped into 13 constructs. These included social, economic and health risk factors, food access and utilization factors and health and dietary outcomes. This scoping review identifies the factors associated with food insecurity among pregnant women and families with young children that could be used to better measure and understand food insecurity, which could assist in developing program and policy responses. This review also highlights the lack of literature from high-income countries outside the US.

Lessons learned from the initial 4 years of the SBM Mid-Career Leadership Institute

In 2015, the Society of Behavioral Medicine (SBM) created the Mid-Career Leadership Institute. The initial model that motivated the creation of the institute came from my participation in the Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) program, specifically designed to enhance the leadership skills of senior female faculty in the health sciences. My participation in ELAM was transformative. It led me to run for president of SBM in 2014, to consider how behavioral scientists could similarly benefit from mid-career leadership training, and ultimately to work with the SBM Executive Director, the SBM Leadership Institute Steering Committee, and leadership training professionals to launch the Leadership Institute in 2016. The overarching goal of the SBM Leadership Institute is to train mid-career behavioral scientists engaged in academic and health care settings to develop essential skills needed to navigate the unique challenges of mid-career. Central to this goal is a focus on integrating diversity, equity, and inclusion into their emerging leadership roles through participation in training exercises, lectures, and dynamic group discussions. To optimize the Leadership Institute experience, opportunities were developed, including mentoring from SBM seasoned members, peer mentoring through the creation of "learning communities," career coaching, and additional networking opportunities. The purpose of this brief commentary is to summarize lessons learned by highlighting program evaluation, describing key changes over the initial 4 years, and sharing future plans for leadership training.

Introduction to the Special Issue of the SBM Mid-Career Leadership Institute: leadership and behavioral medicine in context

In 2016, we established the year-long Society of Behavioral Medicine (SBM) Mid-Career Leadership Institute. Individuals are often selected for leadership positions without intentional training in needed leadership skills, including strategic planning, building collaborative teams, goal setting, negotiation, and communication. The purpose of the Leadership Institute is to: (a) provide opportunities for mid-career professionals to build and sustain their leadership capacity; (b) create cohorts of connected fellows in behavioral medicine fields, disciplines, and institutions, who can support one another throughout their professional careers; and (c) enhance specific skills needed to navigate the challenges of mid-career. Over the first 4 years of the Institute, 139 fellows have participated, representing 35 states. Most of the fellows hold PhDs (93%) as a terminal degree. This special issue is dedicated to the leadership experiences of fellows, faculty, senior SBM mentors, peer mentors, and executive coaches.

Changes in Consumption of Foods and Beverages With Added Sugars During the COVID-19 Pandemic Among US Adults

Objectives

To examine changes in intake of foods and beverages with added sugars during the COVID-19 pandemic among US adults to understand groups at risk for decreasing dietary quality.

Methods

We used SummerStyles data collected in June 2020 (3,916 US adults, ≥18 y). The outcome was the reported frequency of 1) consuming more unhealthy snacks and desserts including chips, cookies, and ice cream and 2) drinking more sugary drinks like regular soda, fruit drinks, sports/energy drinks, sweetened coffee/teas during the COVID-19 pandemic. Responses were categorized as Never/Rarely, Sometimes, or Often/Always. Exposure variables were sociodemographics, currently having children (<18 y), weight status, and Census regions. Multinomial regressions were used to estimate adjusted odds ratios (OR) for Sometimes or Often/Always consuming more unhealthy snacks/desserts (vs. Never/Rarely); and Sometimes or Often/Always more sugary drinks (vs. Never/Rarely).

Results

36% of adults reported Sometimes consuming more unhealthy snacks/desserts; 16% did so Often/Always. 22% of adults reported Sometimes drinking more sugary drinks; 10% did so Often/Always. Factors significantly associated with higher odds of reporting Often/Always consuming more unhealthy snacks/desserts were younger adults (OR range = 1.51–2.86 vs. adults ≥65 y), females (OR = 1.58), non-Hispanic (NH) Black (OR = 1.89 vs. NH White), lower household income (OR = 2.01 for < $35K vs. ≥$100K), and obesity (OR = 1.56 vs. underweight/healthy weight). Factors significantly associated with odds of Often/Always drinking more sugary drinks were being younger (OR range = 2.26–4.39 vs. adults ≥65 y), NH Black (OR = 3.25), Hispanic (OR = 1.75), NH other (OR = 2.41 vs. NH White), lower education (OR = 2.03 for ≤high school; OR = 1.80 for some college vs. college graduate), lower household income (OR range = 1.64–3.15 vs. ≥$100k), and obesity (OR = 1.61 vs. underweight/healthy weight).

Conclusions

Consuming more foods and beverages with added sugars during the pandemic was higher in younger adults, racial/ethnic minority groups, lower-income adults, and adults with obesity. Dietary changes such as these may impact metabolic health if continued long-term. Implementing strategies to ensure these dietary changes are not permanent may benefit future health.

Funding Sources

Solely for author's time from their institutions.

Characteristics Associated With Self-Reported Worry Among Adults About Food Availability and Food Safety During the COVID-19 Pandemic — United States, June 2020

Objectives

During the COVID-19 pandemic, U.S. retailers have reported few major, sustained disruptions in food availability (FA); the risk of contracting COVID-19 from eating or handling food is low. Some consumer food behaviors related to FA and food safety (FS), such as panic buying, stockpiling, bleaching food have occurred. During emergencies, assessing consumer nutrition beliefs and developing intervention can prevent unintended negative behaviors. We examined self-reported worry about FA and FS during the pandemic.

Methods

Survey data was collected online in June 2020 from a representative panel of US adults (n = 4,053). Outcome variables (worry about FA and FS) were assessed using collapsed response options (‘Worried at any level’ and ‘Not at all worried) to the question, “How worried are you and your household about each of the following as it

relates to the COVID-19 pandemic?” Multivariable logistic regression analyses were used to estimate adjusted odds ratios (aORs) for the associations between sociodemographic variables and worry about FA and FS.

Results

Over half of respondents reported worry about FA (58.3%) or FS (57.5%). The highest reported worry about FA were among those not employed (74%), those with household income ≤$34,999 (70%), Black adults (68%), adults aged 35–49 years (64%), those with a high school education or less (62%), and those in the South (61%). The highest reported worry about FS was among those not employed (78%), Black adults (73%), household income ≤$34,999 (74%), aged 35–49 years (61%), and those in the Northeast (61%). Compared with their respective referent groups, significantly higher worry for FA and FS respectively were found among lower income households (aOR [CI] = 1.76 [1.30–2.39]; 1.84 [1.35–2.51]), those who were unemployed (1.54 [1.05–2.28]; 1.90 [1.26–2.81]), non-Hispanic Black (1.55 [1.14–2.12]; 2.25 [1.65–3.07]), and Hispanic (1.39 [1.06–1.82]; 1.94 [1.46–2.56]).

Conclusions

Findings highlight the importance of strategies and communications that reduce fears and prevent unintended negative behaviors, and stress increasing consumer awareness of food access options during emergencies, including promotion of hunger safety net programs, especially among disproportionately affected groups.

Funding Sources

Solely for author's time from their institutions.

The intergenerational transmission of obesity: The role of time preferences and self-control

Previous research has found that impatient time preferences and self-control problems (present bias) are related to increased obesity risk. However, scant evidence exists pertaining to whether parents' impatience and self-control problems impact the obesity status of their children, too. Accordingly, we explore this study question among a large national sample of US adults and their children. Study results confirm previous findings indicating that intertemporal preferences are related to adults' obesity status. Moreover, these results extend the literature by finding that children of impatient or present-biased parents have a significantly higher likelihood of being obese, too. Specifically, parents' low levels of patience and present bias were each independently related to a five-percentage point increase in the likelihood of obesity of their children. These findings were more pronounced when all children were combined in analyses and for the first child; however, they varied for the second and third child. Thus, findings suggest that parents' time preferences and self-control problems likely affect not only their own weight status but that of their children.

Increasing access to healthful foods: a qualitative study with residents of low-income communities

BACKGROUND

Inadequate access to healthful foods has been identified as a significant barrier to healthful dietary behaviors among individuals who live in low-income communities. The purpose of this study was to gather low-income community members' opinions about their food purchasing choices and their perceptions of the most effective ways to increase access to healthful foods in their communities.

METHODS

Spanish and English focus groups were conducted in low-income, ethnically-diverse communities. Participants were asked about their knowledge, factors influencing their food purchasing decisions, and their perceptions regarding solutions to increase access to healthful foods.

RESULTS

A total of 148 people participated in 13 focus groups. The majority of participants were female and ethnically diverse (63% Hispanic, 17% African American, 16% Caucasian, and 4% “other”). More than 75% of the participants reported making less than $1999 USD per month. Participants reported high levels of knowledge and preference for healthful foods. The most important barriers influencing healthful shopping behaviors included high price of healthful food, inadequate geographical access to healthful food, poor quality of available healthful food, and lack of overall quality of the proximate retail stores. Suggested solutions to inadequate access included placement of new chain supermarkets in their communities. Strategies implemented in convenience stores were not seen as effective. Farmers’ markets, with specific stipulations, and community gardens were regarded as beneficial supplementary solutions.

CONCLUSION

The results from the focus groups provide important input from a needs assessment perspective from the community, identify gaps in access, and offer potential effective solutions to provide direction for the future.

It is better to be a fat ex-smoker than a thin smoker: findings from the 1997-2004 National Health Interview Survey-National Death Index linkage study

OBJECTIVE

The aim of this research was to compare the risk of all-cause mortality and mortality from all cancers combined, lung cancer, respiratory diseases, cardiovascular diseases and diabetes mellitus between normal-weight smokers and overweight or obese ex-smokers.

METHODS

Data were from 1997 to 2004 National Health Interview Survey (with response rates ranging from 70% to 80%) which were linked to records in the National Death Index. Mortality follow-up was through 31 December 2006. The sample was limited to normal-weight smokers and overweight/obese ex-smokers 25 years of age and older (n=52,819). HR from Cox regression was computed to represent mortality effect.

RESULTS

Results showed that in both women and men, normal-weight smokers, relative to overweight or obese ex-smokers, had a higher risk of mortality from all causes combined, all cancers combined, lung cancer, cardiovascular and respiratory diseases. Among women, there was no difference in mortality risk from diabetes mellitus between normal-weight smokers and overweight or obese ex-smokers. Among men, there was some evidence that the risk of mortality was higher in obese ex-smokers than normal-weight smokers.

CONCLUSIONS

This article concludes that, overall, mortality risk is smaller in overweight or obese ex-smokers than normal-weight smokers. Smoking cessation interventions can tailor messages that highlight the greater reduction in mortality associated with quitting, compared with potential weight gain.

Practicing what they preach: health behaviors of those who provide health advice to extensive social networks

As a way of identifying a conduit to disseminate health information, this study aims to explore health behaviors and attitudes of a unique group of extensively socially-networked individuals who regularly are asked for their health advice. Respondents from a population-based consumer opinion panel (n = 2,639) were categorized as "extensively socially-networked" (75+ friends and acquaintances, and almost daily giving friends advice on general issues) vs. "non-networked." The networked respondents were further divided into "health-networked" (regularly asked for health advice) versus "only-socially-networked" groups (asked for general advice, not health). Chi-square analyses, ANOVA tests, and multivariate regressions controlling for sociodemographic variables compared health behaviors and attitudes between groups. Results indicated that health-networked individuals reported more positive health behaviors (e.g., fruit and vegetable consumption) and attitudes than only-socially-networked and non-networked individuals. Future research is warranted to elucidate how providing health advice to a large network contributes to the positive health of health-networked individuals. Exploratory analyses revealed that doctors and health/fitness magazines were main sources of health and nutrition information for health-networked respondents. Through their advice and word-of-mouth, health-networked individuals have the potential to influence the health information of large groups of people and, therefore, may serve as valuable change agents to disseminate health and nutrition information.

Effects of the Sunny Days, Healthy Ways curriculum on students in grades 6 to 8

BACKGROUND

There are few effective sun-safety education programs for use in secondary schools. Project aims were to create a sun-safety curriculum for grades 6 to 8, and to test whether exposure to the curriculum would increase children's sun-protection behavior.

DESIGN

A pair-matched, group-randomized, pre--post test, controlled trial was performed with middle schools as the unit of randomization. Teachers implemented the six-unit sun-safety curriculum in 2001-2003, and analyses were performed in 2003-2004.

SETTING/PARTICIPANTS

A total of 2038 children from 30 middle schools in Colorado, New Mexico, and Arizona.

MAIN OUTCOME MEASURES

Self-reported sun-protection behavior using frequency ratings and diary.

RESULTS

Compared to control schools, children receiving the curriculum reported more frequent sun protection (p=0.0035), and a greater proportion wore long-sleeved shirts during recess (p<0.0001) and applied sunscreen (p<0.0001). Exposure to the curriculum improved knowledge (p<0.0001), decreased perceived barriers to using sunscreen (p=0.0046), enhanced self-efficacy expectations (p=0.0577) about sun safety, and reduced favorable attitudes toward sun tanning (p=0.0026 to <0.0001). In intent-to-treat analyses, the treatment effect was eliminated only under the most conservative assumptions about dropouts.

CONCLUSIONS

Educational approaches to sun safety in middle school may be effective for improving children's sun safety. Potential trial limitations include measuring short-term outcomes, focusing on young adolescents, using active parental consent, and testing in the American Southwest.

Gimme 5 fruit and vegetables for fun and health: process evaluation

Gimme 5 (Georgia) was a school-based nutrition education effectiveness trial to help fourth- and fifth-grade students eat more fruit, 100% juice, and vegetables (FJV). Process evaluation assessed fidelity of implementation, reach, and use of intervention materials and environmental mediators: teacher training, curriculum delivery, participation in family activities, attendance at evening point-of-purchase grocery store activities, and availability and accessibility of FJV at home. Approximately half of the curriculum activities were implemented in fourth and fifth grades. The lowest proportion completed were those most pertinent to behavior change. Eighty-seven percent of parents reported participating in homework activities with their fourth grader, 66% with fifth graders. Sixty-five percent of parents reported viewing a video with their child in both grades. Ten percent attended evening point-of-purchase grocery store activities. The low level of implementation and modest level of participation in family activities suggest that higher levels of behavior change may have occurred if exposure to the intervention had been higher.