Food systems and health systems are interdependent. Historically, however, strategies that focused on the development of these systems evolved in isolation from one another. Non-communicable diseases such as type 2 diabetes have an etiology that is strongly linked to food systems. Type 2 diabetes is taking an ever-increasing toll on health, and health systems, globally, and in Canada. In response, health professional organizations propose an advocacy approach to improve food system characteristics linked to the development of diabetes. Opportunities for, and barriers to, such initiatives have not yet been examined in the health geography literature. The primary objective of this dissertation is to contribute to the development of a framework for action for nutrition educators working in rural areas to use to promote local sustainable food systems. The ultimate objective is to improve the diet, and by extension, the health of those suffering from type 2 diabetes. As part of the research approach, a gendered analysis was employed for the following reasons: First, labour around food production, food procurement and food preparation and health care work is provided predominantly by women. Second, there is a gendered profile of pattern of illness and access to care for people with type 2 diabetes. The research methodology was comprised of a case study and mixed methods approach. Nineteen communities in southwestern Ontario were selected for inclusion in the case study using criteria based on the Rurality Index of Ontario. Data were collected through extensive literature reviews, 34 semi-structured interviews with health professionals, a survey of 24 people afflicted with type 2 diabetes and ‘in situ’ observations. Analysis of the findings using grounded theory techniques, such as iterative coding, revealed barriers to, and opportunities for, supporting local sustainable food systems by area health professionals working at local, regional and national scales. This thesis provides important information about gender roles, community capacity, sense of community, and health professional training that should be considered in the development of policies to promote local sustainable food systems.

The prevalence of obesity is rising in the United States and one factor that contributes to it is the lack of cooking at home and planning out meals. Since text messaging is now a main avenue of communication, it could be used to motivate people to plan out their meals and cook at home instead of consuming fast food. Current research on how weekly nudges might relate to peoples’ goals about meal preparation and dietary intake is very limited. The purpose of this study was to examine if sending weekly nudges, focusing on specific dietary goals, improves meal planning and dietary intake in an online meal planning group. A Facebook group was used to send weekly nudges to the participants throughout six weeks. It was found that meal planning appears to have a significant effect on meal preparation at home and thus may help improve dietary intake. The results found can also be utilized in other aspects of leading to healthier lifestyles and motivation-need situations such as weight loss.

Studies have shown that many low-income and disadvantaged Americans have a poor diet quality, which increases obesity and chronic disease risk. According to the Massachusetts Department of Public Health, education and income levels of Springfield residents are well below state averages, and racial diversity in Springfield has increased significantly over the past few decades. Springfield’s demographics increase the risk of health disparities in the community, and higher rates of diabetes, heart disease, and obesity are seen in Springfield. To promote healthy eating behaviors among Springfield residents, Mason Square Health Task Force (MSHTF), a Live Well Springfield (LWS) partner, created a 6-session nutrition curriculum, entitled The MENU Program. The goal was to increase overall health awareness and healthy eating behaviors among residents in communities that are being targeted by the LWS initiative. Topics of the The MENU Program included MyPlate guidelines and label reading, budget shopping and cooking, healthy restaurant choices, diet and chronic disease, and food justice. The objective of this study was to evaluate The MENU Program to assess its strengths, weaknesses, and effectiveness using both quantitative and qualitative data from surveys, process evaluation, and facilitator observations. There were two phases of this study: Phase 1 was the evaluation of the pilot program delivered to a group of senior women recruited through the Dunbar YMCA; Phase 2 evaluated the second offering of the curriculum to Mason Square residents enrolled in the Task Force Fit Challenge. All participants responded positively to The MENU Program sessions and positive changes were seen in knowledge, attitudes, and behaviors after both Phases. Participant-perceived useful material included handouts, group discussions, and hands-on activities. Observational data supports the usefulness of group discussion over lecture-based teaching methods. This study supports the use of The MENU Program as an effective community education program for Springfield, MA. It has the potential to positively influence residents’ diet quality and nutrition-related behaviors through improved nutrition knowledge and attitudes.

High fruit and vegetable (FV) intake is associated with healthy weights and decreased risk of chronic disease. Yet, adolescent FV intakes fall below national recommendations. Few studies involve racial/ethnic minority adolescents in formative research, despite their increased risk of poor FV intake. Consequently, the purpose of this study was to describe the type and frequency of FV intake of urban multicultural young adolescents, and to examine their attitudes and beliefs towards increased consumption of FV. A convenience sample (n=79) of racially diverse (e.g., 31% Hispanic/Latino, 27.4% Black/African American) grade seven students, participated in our study comprised of a self-administered survey with culturally adapted FV food frequency questionnaire (FVFFQ) and focus group discussions. The FVFFQ revealed that hand fruit was the most highly consumed fruit among our students, while consumption of vegetables was more evenly distributed. Preferred FV among racial/ethnic population groups ranged with Hispanic/Latino identifying citrus, leafy green vegetables preferred by Black/African American, tropical fruit by Asian and Whites reporting cooked vegetables. Availability of preferred vegetables as school significantly influenced vegetable intake (p=0.038). Family attitudes towards vegetables also influenced student FV behaviors (diet diversity (DD) score, p=0.008; FV self-efficacy scores, p=0.019). The median DD score (73%) indicated moderate compliance with national FV intake recommendations among students with red, orange, and ‘other’ vegetables requiring the most improvement in intake. Focus group discussions revealed important barriers to FV intake, including a preference for consuming ‘junk food’ for snacks over FV, a lack of availability of preferred vegetables at school, and parental financial constraints, which limited availability of preferred produce at homes. Students’ suggested strategies to motivate increased FV intake included greater incentives and modeling from parents, improved recipes and taste tests for vegetables served at school and greater availability of culturally diverse produce represented in school menu. Students emphasized social media for FV promotion targeted at adolescents. Overall, our findings suggest young adolescents are open to increased FV intake, but require a supportive home and school environment, with access to cultural and preferred produce; students indicated a keen interest in involvement with FV promotion initiatives undertaken in their school.

The nutritional status of children is declining as evidenced by the steady rise in childhood obesity rates over the last three decades. Consuming five servings of fruit and vegetables (FV) daily has shown to help with weight maintenance, but children are consuming far less than the recommended servings. This study was designed to test the efficacy of a sensory-focused multi-component school-based program at increasing vegetable intake among fifth-graders. Classroom, family, and community components allowed children to explore thirteen target vegetables with their senses including taste. Vegetable consumption was measured by digitalized observations of lunchtime vegetable selection and consumption. Vegetable acceptance was evaluated using a selfadministered survey assessing attitude and behaviors related to vegetable consumption. Measures were assessed at multiple time points and compared between the intervention school and a comparison school matched for demographic similarities. Parental consent was obtained for 136 fifth-graders to participate in the multicomponent study and 114 were included in the plate waste study. Data were collected over six days of plate waste observations including two phases: the control phase (CP) and the target vegetable phase (TVP) where target vegetables were served in addition to the regular lunch vegetables. Differences in mean vegetables taken and consumed during each phase of the plate waste study were analyzed using analysis of variance (ANOVA) and paired sample t-tests. When fried potatoes were included as a vegetable in the analysis, the comparison school took (P < 0.001) and consumed (P < 0.001) significantly more vegetables than the intervention school. There were no significant differences in vegetables taken (P < 0.258) and consumed (P < 0.217) when fried potatoes were excluded. Self-administered surveys were analyzed using the Fisher’s exact test and ANOVA. Significantly more children at the intervention school compared to the comparison school reported ever eating bell peppers, butternut squash, and cucumbers. The findings of this study do not show significant differences in vegetable consumption when the intervention school is compared to the comparison school, but do show a small trend toward increased acceptance of target vegetables. Future studies should evaluate a larger sample size with increased frequency of taste testing opportunities.

Subclinical vitamin A deficiency was assessed in 65 Hispanic children attending four migrant Head Start programs in Utah. Subjects aged 2 to 6 years (median 3 years 10 months) were examined for evidence of vitamin A deficiency by conjunctival impression cytology. Biochemical indices for serum vitamin A, retinol-binding protein, zinc, and iron were performed. Of eight children (12.5%) with subclinical vitamin A deficiency, one child had a marginal serum vitamin A of 11 μg/dl. Retinol-binding protein concentrations were significantly lower in two subjects with abnormal conjunctival impression cytology. Serum zinc, which when low can mimic signs of ocular vitamin A lesions, was normal for all 65 subjects. Fifteen children (23%) had iron-deficiency anemia. Logistic regression was the central method of analysis used in this study. The results of the statistical analyses indicated there was a correlation value (0.31) between abnormal conjunctival impression cytology and serum vitamin A, which supports the hypothesis that abnormal conjunctiva! impression cytology is concurrent with decreased serum vitamin A. Assessment of vitamin A status of Hispanic migrant children by impression cytology was effective in identifying children at risk for hypovitaminosis A. Beyond vitamin A's role in vision and maintenance of epithelium, it is also required for growth and hematopoiesis. The children of migrant workers may be suffering physiologically important consequences of vitamin A and iron deficiency that can be prevented by screening with biochemical and histological testing. Nutrition intervention for deficient children is warranted.

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Children's energy consumption is outweighing their energy expenditure, increasing the risk for childhood obesity. While pediatric obesity continues to be a problem in America, the data are clear that those of low socioeconomic status are especially at risk for weight gain. The purpose of this study was to evaluate if a healthy lifestyle program could affect participants' diet and physical activity behavior. A program was planned and conducted using the curriculum from the "We Can" program established by the National Heart, Lung, and Blood Institute. Residents of the Jefferson City Housing Authority were asked to participate. No resident attended or completed the healthy lifestyle program. Follow-up focus groups with stakeholders and potential participants showed that lack of motivation was the greatest barrier to participation. Further investigation is needed to determine a more suitable venue to educate at-risk populations regarding the risk associated with pediatric obesity.

Background: Malnutrition can affect the body composition changes that occur in healthy pregnancy, resulting in adverse effects to both the mother and infant. Supplementary foods with high quality protein may result in more favorable changes in lean mass and fat mass in pregnant malnourished women. Objective: To retrospectively assess changes in body composition in moderately malnourished pregnant Malawian women in response to one of three nutritional interventions. Methods: Height, weight, MUAC, and TSF were measured in pregnant women with MUAC >20.6 cm and19) were compared using ANOVA. If differences were detected, differences between groups were tested using the Tukey HSD test (continuous) or Chi-squared test (categorical). Longitudinal changes were also measured using mixed model analysis of variance. Results: At baseline, women had small MUACs and low fat stores, but high muscle mass. Overall, women had significantly larger MUACs at the end of follow up than at baseline, except in adolescents in CSB-IFA and CSB-UNIMMAP. Women overall had significantly larger AMA at the end of enrollment than at baseline, with mature women in the RUSF group experiencing the largest increase compared to adolescents in RUSF and all women in CSB-UNIMMAP and CSB-IFA. On average, AMA was between the 50th-75th percentiles compared to women in the western world, indicating maintenance of muscle mass despite moderate malnutrition. TSF and AFA were both low in all age groups, falling below the 5th percentile for mature women and below the 10th percentile in adolescents compared to women in the Western world. There was no difference in birth weight across intervention groups. Among births that occurred during the rainy season, every cm of MUAC at the end of enrollment resulted in a 0.29 cm greater birth length. Conclusions: Overall, women improved their nutritional status but did not recover from moderate malnutrition over the course of enrollment. MUAC and BMI were the strongest predictors of birth weight, highlighting the contribution of overall nutritional status to birth outcomes. Women had high muscle mass relative to fat stores, with women in the RUSF group experiencing the largest accrual in muscle. More accurate and objective methods to measure body composition could provide greater detail about changes in body composition over the course of pregnancy in response to supplementary foods.

The study conducted in the rural area of the province of Imbabura included a total of 518 families that when compared with the estimated sample of 96%, 42.7 % corresponding to the indigenous ethnic group, 28.15% to Black and 25% to mixed-race ethnic groups, these differences of involvement between ethnic groups is due to the fact that the indigenous population is greater than the two remaining populations. Of the 518 families studied they were able to obtain a total of 794 children younger than 5, in which 48.5% pertaining to the male sex and 51.4% to the female sex. In linking the number of participating families and the number of children studied we were able to find that mothers have 1 to 2 children younger than the age of 5 in every family. In evaluating the nutritional state of the 794 studied children, 47.09% were found to have global malnutrition (P/E), 67.26% presented a chronic malnutrition that is to say a lower height for their age, whereas 13.97% presented an acute malnutrition, a percentage that doesn’t attract attention due to what I have already noted previously with children presenting low height and weight for their age when using the indicated weight/height, the nutritional state of the children is appropriate. The nutritional state of children under the age of 5, by considering the indicators of weight/age and height/age, identified the indigenous ethnicity having major problems of malnutrition (54% and 80.97%) respectively, while the two remaining ethnic groups have presented similar percentages. The opposite occurs with the indicator of weight/height, which detected that the Black ethnic group presented a major nutritional deterioration (24%) unlike the other two ethnic groups, we believe that this difference is due to indigenous children presenting a diminished height, consequently when we use the indicator of weight/height, an adequate weight for height is presented. According to the magnitude of diarrheal processes we find that 28.34% of children presented EDA, the indigenous ethnicity being that with the highest percentage (12.84%) in relation to the other two ethnic groups. According to the severity of the diarrheal processes, light EDA presents the highest percentage with 62.67%, with the indigenous ethnicity being affected the most, moderate EDA presents a 34.22% similarly affecting the indigenous ethnicity and severe EDA presents a 3.11% with the mixed-race ethnicity being the most affected. Relating the nutritional state with acute diarrheal illnesses, considering the indicators of weight/age and height/age, we find that the indigenous population is mostly affected in nutritional state as well as in the presence of EDA. Malnourished children present a higher number of diarrheal processes. Considering the indicator of weight/height, diarrhea is more frequent in children with a normal nutritional state, with the Black ethnicity that which presents the greater percentage of EDA in normal and malnourished children. For this reason, it is urgent that national programs of health and alimentation are defined and implemented in order to combat the nutritional problem and ensure an adequate supply of food for the whole population, improving the conditions of health and environmental sanitation in order to reduce the high rates of malnutrition, diarrhea and acute respiratory infections.