B'More Healthy Communities For Kids Research Articles

Monthly Food Spending and Consumption of Promoted Foods Among a Sample of Adults Living in Intervention Neighborhoods of the Baltimore Urban Food Distribution (BUD) Trial

ObjectivesIt is well documented that under-resourced residents living in Baltimore, Maryland face barriers to accessing healthy foods largely due to low availability in their neighborhoods coupled with a lack of transportation, among other factors. Previous (B’more Healthy Communities for Kids (BHCK)) and ongoing (Baltimore Urban food Distribution (BUD)) systems interventions have sought to provide multi-level solutions to challenges in the Baltimore food environment. Research suggests that food spending is related to diet, however, this study aims to better understand consumption of promoted foods across levels of food spending (low, medium, high spending) to identify points of focus and future directions for the BUD trial. MethodsExtant data from BHCK were collected from July 2013 to July 2014 using an Adult Impact Questionnaire (AIQ) and Food Frequency Questionnaire (FFQ). Baseline data collection for BUD is ongoing and expected to end in April 2022. BUD data collection instruments (AIQ, FFQ) were developed based on those used for BHCK. Participants include Baltimore residents aged 21 to 75 recruited to participate in BHCK or BUD. A model-building approach will be conducted using Stata to assess consumption of promoted foods (fruits, vegetables, whole grains, etc.) across levels of monthly food spending in a merged sample. ResultsAn initial analysis of BHCK data found that all monthly spending levels were significantly associated with lower than recommended daily fruit and vegetable intake (1.5 ± 1.1 (M ± SD) servings of fruit, 1.8 ± 1.7 servings of vegetables) regardless of demographics. We anticipate data from BUD will add to these results, further supporting the need to intervene and improve access to healthier foods for various socioeconomic groups living in Baltimore. We expect to examine similar associations across other food groups (whole grains, low-fat dairy, flavored water beverages) based on the BUD FFQ data. ConclusionsThe BUD intervention aims to increase access to and incentivize the purchase of healthier foods and beverages for customers who frequent participating corner stores. The findings from this study will help to inform strategies for increasing consumer purchasing power for certain desired foods via BUD, and to provide a starting point for a future planned clinical trial. Funding SourcesNHLBI, NIH, award number R34HL145368.

Exploring Store Owner and Consumer Preferences for Foods and Beverages to Be Stocked in Corner Stores Located in Under-Resourced Neighborhoods of Baltimore, Maryland

ObjectivesIn Baltimore, Maryland, there is a documented lack of accessible healthy foods in under-resourced neighborhood corner stores largely due to gaps in (1) supply-side food distribution and (2) demand-side understanding between store owners and consumers. The Baltimore Urban food Distribution (BUD) study is a systems intervention that leverages a mobile application (app) to address supply-side challenges. For the app to be sustainable, a crucial consideration must be the demand-side desire and appropriateness of available foods. Free-listing allows individuals to list all possible items within a specific domain and has been used successfully in Baltimore to assess desired foods. Therefore, this study seeks to identify corner store owners’ and consumers’ preferred foods for stocking and purchasing in corner stores participating in BUD by using free-listing. MethodsThe primary analysis will utilize BUD baseline data collected between January and April 2022 among corner store owners (n = 38) and consumers (n = 190) in East Baltimore. During in-depth interviews (IDIs), participants will be asked to name the top 5 foods/beverages they would like to see available on the BUD app for stocking or purchasing, followed by probing. Saliency analyses will be conducted using STATA v17 based on the order and frequency of answers given. Extant data from the previous B’more Healthy Communities for Kids (BHCK) trial will inform the primary analysis. ResultsIDIs with corner store owners who participated in BHCK revealed little perceived demand for healthy foods by consumers. However, consumer IDIs generally reported a desire for affordable, high-quality fresh fruits and vegetables in their local stores. Once data collection for BUD is complete, we expect to learn which specific foods and beverages are desirable and appropriate from both the corner store owner and consumer perspectives. ConclusionsFree-listing is a powerful tool for engaging participants in identifying salient foods that are both desirable and culturally appropriate for the target population. Findings from the present study will inform the larger BUD study in preparation for the promotion of certain healthier food items in Baltimore, and eventual scale-up of BUD to additional under-resourced urban settings nationwide. Funding SourcesNHLBI, NIH, award number R34HL145368.

Assessment of Healthy Food Availability and Promotion Among Baltimore, Maryland Corner Stores

ObjectivesUnder-resourced neighborhoods in Baltimore, Maryland tend to have low healthy food availability. Residents of these neighborhoods often frequent corner stores, which are ubiquitous and primarily stock energy-dense foods and sugar-sweetened beverages. The Baltimore Urban food Distribution (BUD) trial aims to improve access to healthy foods by corner store owners and their customers. As part of the baseline assessment of BUD, this study aims to (1) measure the pre-intervention availability of promoted foods and beverages (fruits, vegetables, whole grains, low-sugar beverages) at participating corner stores; and (2) describe current promotional strategies used by participating corner store owners for healthy foods and beverages. MethodsWe expect to have baseline data from 38 corner stores recruited to participate in BUD by April 2022. During data collection, trained researchers will conduct in-depth interviews and a Store Environmental Checklist based on similar tools used in the previous B’more Healthy Communities for Kids (BHCK) trial. Subsequently, corner store Healthy Food Availability Index (HFAI) scores will be analyzed quantitatively using Stata, and qualitative data regarding promotional strategies will be analyzed using Atlas.ti. ResultsAt the time BHCK was implemented, Baltimore corner stores had a low average HFAI score of 9.1 out of 28.5. Now, nearly a decade later, it is crucial to understand the current landscape of healthy food availability in order to inform the context in which BUD is intervening. Regarding promotional practices, we expect to see corner stores having a larger social media presence. A recent uptake of social media use among corner store owners could signify greater acceptance of technology, and a new medium for customer engagement and promotion of foods. Further quantitative and qualitative analyses will be completed by late Spring 2022. ConclusionsThe gap in healthy food availability among corner stores compared to supermarkets is well-documented, especially in under-resourced urban settings. Recent advances in the use of social media and greater acceptance of technology by small store owners is promising. Our findings here will help to inform the strategies undertaken by the BUD intervention in an upcoming randomized controlled trial. Funding SourcesNHLBI, NIH, award number R34HL145368.

Challenges and Lessons Learned from Multi-Level Multi-Component Interventions to Prevent and Reduce Childhood Obesity.

Multi-level multi-component (MLMC) strategies have been recommended to prevent and reduce childhood obesity, but results of such trials have been mixed. The present work discusses lessons learned from three recently completed MLMC interventions to inform future research and policy addressing childhood obesity. B’more Healthy Communities for Kids (BHCK), Children’s Healthy Living (CHL), and Health and Local Community (SoL) trials had distinct cultural contexts, global regions, and study designs, but intervened at multiple levels of the socioecological model with strategies that address multiple components of complex food and physical activity environments to prevent childhood obesity. We discuss four common themes: (i) How to engage with community partners and involve them in development of intervention and study design; (ii) build and maintain intervention intensity by creating mutual promotion and reinforcement of the intervention activities across the multiple levels and components; (iii) conduct process evaluation for monitoring, midcourse corrections, and to engage stakeholder groups; and (iv) sustaining MLMC interventions and its effect by developing enduring and systems focused collaborations. The paper expands on each of these themes with specific lessons learned and presents future directions for MLMC trials.

Process Evaluation and Lessons Learned From Engaging Local Policymakers in the B'More Healthy Communities for Kids Trial.

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Partnering with carryouts: implementation of a food environment intervention targeting youth obesity.

Youth obesity is a major public health problem in the United States, especially among urban-based, minority youth. The B'More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment, including carryouts, to increase access to and demand for healthy, affordable foods. The objective of this article is to describe the development and implementation of BHCK's carryout intervention. Process evaluation was conducted to assess intervention reach (number of interactions with youth and adults either in person or on social media), dose delivered (number of food samples and promotional materials distributed, social media posts and meetings with owners) and fidelity (availability of promoted items). Overall, the carryout intervention showed moderate to optimal reach, moderate to optimal dose delivered and moderate to optimal fidelity. These findings demonstrate a successfully implemented carryout intervention in a low-income urban setting. Lessons learned about new methods for engaging the community and increasing demand for healthy food can be used to inform future studies and programs to improve the food environment.

The Impact of a Multi-Level Multi-Component Childhood Obesity Prevention Intervention on Healthy Food Availability, Sales, and Purchasing in a Low-Income Urban Area.

The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

Impact of a Multi‐Level Multi‐Component Food Environment/Behavioral Intervention on Youth Leaders

IntroductionPeer‐led interventions may be an effective means of addressing the childhood obesity epidemic, particularly as part of multi‐level interventions. Thus, we aimed to expand and sustain the youth‐leader program for the second wave of the B'more Healthy Communities for Kids (BHCK) trial using a combined policy, systems and environmental (PSE) approach.MethodsOur PSE approach targeted children (10–14 years old); and BHCK youth‐leaders (n=14) in low‐income, predominately African American neighborhoods in Baltimore City. The youth‐leaders delivered nutrition education in recreation centers, community corner stores and carryouts, acted as spokesperson in BHCK social media, and implemented environmental changes at food stores and recreation centers to improve healthy food access. Nutrition interactive sessions (n=98) were evaluated through multiple process measures to ensure adequate reach, dose delivered, fidelity, selected impact measures to plan (quality), and reproducibility for sustainability of the youth‐leader programing. Youth‐leader skills, dietary intake, and shopping behaviors were measured at pre‐ and post‐intervention and compared to a similar‐age sample of youth who were not selected to deliver the program thus assigned to the comparison group. A difference‐in‐difference analysis assessed the impact of the program on BHCK youth‐leaders and their counterparts (n=14 intervention, 11 comparison) on frequency of purchasing of specific promoted foods, overall energy intake, fat intake and other indicators of dietary quality (FV servings), and Body Mass Index. Difference‐in‐difference analysis was also conducted to determine the impact of the intervention on dietary factors of a subsample of child participants (n=93) receiving the intervention.ResultsThe wave 2 BHCK youth‐leader program was delivered with moderate to high reach, dose, and moderate fidelity. An average of 9.5 children (10–14 years old) participated in each nutrition session. Overall, we distributed 1018 handouts and 312 recipe cards. We conducted 98 nutrition sessions and distributed 1080 giveaways. We observed significant improvements in outcome expectancies and leadership skills in the most highly involved youth leaders (p<0.05). Analysis of available data indicated that children receiving the intervention from the youth‐leaders showed a trend in decreased total calorie intake and dietary fat compared to comparison, although not statistically significant.ConclusionsThe wave‐2 youth‐leader program was successfully implemented in low‐income areas of Baltimore. Youth‐leaders appeared to benefit as part of multi‐level programs, with improved psychosocial factors and leadership skills. Sustainability of such complex programs remains a challenge that must be addressed through strong partnerships established at the beginning of PSE projects.Support or Funding InformationResearch reported in this publication was supported by the Northeast ‐ Regional Nutrition Education Center of Excellence, and the Global Obesity Prevention Center (GOPC) at Johns Hopkins, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Office of the Director, National Institutes of Health (OD) under award number U54HD070725. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AT is supported by a doctoral fellowship from CNPq (GDE: 249316/2013‐7).

Development and Implementation: B'More Healthy Communities for Kid's Store and Wholesaler Intervention.

Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B'More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community's access to healthy food. The objective of this article is to describe the development and implementation of BHCK's corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

Food insecurity, overweight and obesity among low-income African-American families in Baltimore City: associations with food-related perceptions.

To examine associations between food insecurity, excess body weight, psychosocial factors and food behaviours among low-income African-American families. Cross-sectional survey of participants in the baseline evaluation of the B'More Healthy Communities for Kids (BHCK) obesity prevention trial. We collected data on socio-economic factors, food source destinations, acquiring food, preparation methods, psychosocial factors, beliefs and attitudes, participation in food assistance programmes, anthropometry and food security. We used principal component analysis to identify patterns of food source destinations and logistic regression to examine associations. Fourteen low-income, predominantly African-American neighbourhoods in Baltimore City, MD, USA. Two hundred and ninety-eight adult caregiver-child (10-14 years old) dyads. Of households, 41·6 % had some level of food insecurity and 12·4 % experienced some level of hunger. Food-insecure participants with hunger were significantly more likely to be unemployed and to have lower incomes. We found high rates of excess body weight (overweight and obesity) among adults and children (82·8 % and 37·9 % among food insecure without hunger, 89·2 % and 45·9 % among food insecure with hunger, respectively), although there were no significant differences by food security status. Food source usage patterns, food acquisition, preparation, knowledge, self-efficacy and intentions did not differ by food security. Food security was associated with perceptions that healthy foods are affordable and convenient. Greater caregiver body satisfaction was associated with food insecurity and excess body weight. In this setting, obesity and food insecurity are major problems. For many food-insecure families, perceptions of healthy foods may serve as additional barriers to their purchase and consumption.

Process Evaluation Findings of B'More Healthy Communities for Kids: A Multi‐Level, Multi‐Component Obesity Prevention Program

B'More Healthy Communities for Kids (BHCK) is a multi‐level, multi‐component obesity prevention trial directed toward low‐income African American youth in Baltimore. BHCK works with small food stores, recreation centers, carryout restaurants, wholesalers, policymakers and families. Process evaluation is conducted by monitoring 88 implementation standards based on reach, dose delivered and fidelity. Guidelines rank each standard in terms of low, medium or high delivery. Here, we report on findings to date based on two feedback periods. Food store interactive sessions had low reach to the target audience (10‐14 year old youth) with 7.4 + 6.2 interactions/session compared to higher reach for adults (17.1 + 6.6). Dose delivered of food samples (28.5 + 14.4) and giveaways (16.2 + 6.2) distributed was medium to high. Carryout restaurant menu redesign obtained medium to high fidelity with 20% healthy side options and 10% healthy entrée options provided on posted menu boards. Recreation centers achieved high reach with 11.6 + 6.1 youth attending educational sessions. The agent‐based policy model (ABM) had low to medium reach with one local policymaker including the ABM on a formal agenda in the past year. Wholesalers obtained overall high fidelity by stocking food items that met BHCK nutrition guidelines. Social media and text messaging achieved high reach with 70% of BHCK‐enrolled families joining the program. Dose was high with an average of 3.2 text messages sent per week. These findings are used to monitor and modify components during the trial and to assess implementation quality post‐intervention.

B'More Healthy Communities for Kids: design of a multi-level intervention for obesity prevention for low-income African American children.

BackgroundChildhood obesity rates in the U.S. have reached epidemic proportions, and an urgent need remains to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component interventions are needed due to the multi-factorial nature of obesity, and its proven links to both the social and built environment. However, there are huge gaps in the literature related to doing these kinds of interventions among low-income, urban, minority groups.MethodsThe B’More Healthy Communities for Kids (BHCK) intervention is a multi-level, multi-component intervention, targeting low-income African American youth ages 10–14 and their families in Baltimore, Maryland. This intervention prevents childhood obesity by working at multiple levels of the food and social environments to increase access to, demand for, and consumption of healthier foods. BHCK works to create systems-level change by partnering with city policy-makers, multiple levels of the food environment (wholesalers, corner stores, carryout restaurants), and the social environment (peers and families). In addition, extensive evaluation will be conducted at each level of the intervention to assess intervention effectiveness via both process and impact measures.DiscussionThis project is novel in multiple ways, including: the inclusion of stakeholders at multiple levels (policy, institutional, and at multiple levels of the food system); that it uses novel computational modeling methodologies to engage policy makers and guide informed decisions of intervention effectiveness; it emphasizes both the built environment (intervening with food sources) and the social environment (intervening with families and peers). The design of the intervention and the evaluation plan of the BHCK project are documented here.Trial registrationNCT02181010 (July 2, 2014).

Development and piloting of a multi‐level obesity prevention program for low income African American children: The B’More Healthy Communities for Kids study (132.4)

Multi‐component interventions are needed in low income urban settings to address the complex environmental, economic, and social issues driving obesity. Low income neighborhoods in Baltimore can be described as “food swamps,” with few supermarkets and many small food outlets stocking unhealthy foods. After a decade of focused work in specific food source types (e.g. corner stores) in Baltimore, we are developing and implementing a multi‐level intervention to prevent childhood obesity. Substantial formative research has been conducted to develop the B’More Healthy Communities for Kids (BHCK) program, including in‐depth interviews (n=24) with children, parents and store owners, focus groups (n=4), and direct observations (n=7). We piloted structural incentives for small sources, a farm to store component, and a peer mentored cooking program. The BHCK program will be implemented at the policy, wholesaler, corner store, carryout, recreation center, family and individual levels. The program will use a four‐fold strategy to improve healthy eating behavior ‐ including environmental interventions to increase access to healthy foods, behavioral nudging to make choosing healthier options easier, interactive nutrition education opportunities to increase consumer demand, and policies (informed by systems models) to increase long‐term sustainability. Detailed process and impact evaluations will take place at each intervention level.Grant Funding Source: NIH U54