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Differences in the prevalence of obesity are generally associated with disparities in the food environment which partially determine diet quality. In this research, I examine the relationship between the local food environment and the consumption of fruit and vegetables among individuals living in the Mississippi Delta region using survey and store availability data for individuals living in seven counties with the highest obesity rates in the state. An ordered probit model with an endogenous covariate is used to assess the marginal effect of food environment variables on the frequency of fruit or vegetable consumption. I find that longer distance traveled to the nearest full-service grocery store is associated with lower frequency of vegetable consumption, while access to public transportation is generally associated with a higher frequency of consumption. Insights from this study could prove helpful for health officials and policymakers tasked with designing and implementing localized interventions that improve the food environment and increase healthy food access.

Seventy five percent of older adults are affected by multiple chronic diseases. Consuming a high quality diet consisting of fruits, vegetables, whole grains, and lean protein assists with chronic disease prevention and management. Healthful food availability is a major determinant of individual eating behaviors. The purpose of the current study was to describe the types, variety, and density of food outlets and to estimate access to a high quality diet for older adults in an urban setting. The Community Nutrition Environment Evaluation Data System (C-NEEDS) survey and restaurant menus were used to determine availability of healthful food in thirteen neighborhoods in Springfield, Massachusetts. A "Dietary Guidelines for Americans Adherence Index Food Environment" (DGAIFE) algorithm was created to estimate access to a high quality diet based on the stores and restaurants within the study area. Environmental characteristics that are recognized as facilitators or barriers to a high quality diet were added to the DGAIFE algorithm to calculate a "Dietary Guidelines for Americans Adherence Index Food Environment plus Environmental Characteristics" (DGAIFEC) score. The DGAIFE and DGAIFEC score ranges for all study areas were 1.53-2.25 and 1.38-2.50, respectively (possible range 1.00 higher to 5.00 lower access). Access to a high quality diet is within reach but not equal across the thirteen study areas. The findings can be used by Registered Dietitians to guide clients to make healthful food choices in urban neighborhoods and provides information to improve public health policy to increase access to healthful foods.

In an effort to begin filling a gap in the scientific literature about community-based food systems and promote food environment changes to increase dietary quality, this dissertation focuses on community-based food systems research with two different populations: Head Start families in southwest Virginia and Heifer International Alternative Spring Break (ASB) college student participants at Virginia Tech. Fresh Produce, Fresh Start (FPFS) tested the effectiveness of a local, fresh fruit and vegetable delivery program on dietary intake and purchasing patterns of Head Start families. FPFS utilized a one-group double pre-test post-test was conduced on two occasions at each of the two sites. Measures collected included: food-use questionnaire, height and weight, food security questionnaire, 24-hour recall, program process evaluation, and food receipts. Fifty-one of 67 (76%) of eligible participants were recruited. For dietary recalls completed (n = 29, 57%), significant increases were found in intake of vitamin A, vitamin C, fiber, vegetable, and fruit and vegetable (FV) servings combined, based upon paired t-tests (p <.05). Based on receipt data (n = 22, 43%), the proportion of fresh produce purchases significantly increased for both number of items and monetary costs, based upon a Wilcoxon Signed-Ranks Test (p < .05). A second study was conducted to examine the impacts of the Heifer Alternative Spring Break (ASB) programs on Virginia Tech student's attitudes, motivations, diet, and behaviors regarding community-based food systems before and after a one-week intensive program. The design was quasi-experimental, using a one-group pre-test, post-test, and follow-up. Participants completed questionnaires, dietary recalls, and journals. Forty-three of 43 (100%) of eligible participants enrolled in the study. Although increases in local and organic foods were observed, there were no significant changes in dietary quality. The intervention showed significant increases in local and organic food consumption for individuals that consumed less than 50% of their calories from local and organic foods at baseline based upon a paired t-test (p < .05). The findings from these studies offer evidence of the capacity for community-based food systems to change dietary patterns, across different populations. / Ph. D.

Philosophiae Doctor - PhD / Type 2 diabetes mellitus (T2DM) and pre-diabetes contribute increasingly to the global burden of disease. Along with other behavioural risk factors, diet plays a key role in the onset and management of the disease, in turn largely determined by what foods are immediately accessible in local food environments. With this in mind, this thesis aims to answer the research question: What role do local food environments play in promoting or inhibiting access to healthy foods as part of the self - management of T2DM in urban and rural communities in South Africa, and what can be learned from an international perspective? Specific research objectives include, to: 1. Understand the current national-level policy context with regard to the observed rise in NCDs, their proximal determinants (specifically an observed change in diet patterns), and contributing environmental factors; 2. Identify the current food-related environmental factors associated with the onset and/or management of T2DM in an urban and a rural setting (as well as in four additional international settings in order to provide an international perspective); 3. Explore community perspectives of the role the local food environment plays in the self-management of T2DM in an urban and a rural setting; and, consequently 4. Recommend intervention- and/or policy-related actions that can be implemented based on study findings. A review of the literature and relevant policies was conducted towards achieving the first research objective. Quantitative data were systematically collected at an urban and rural site in South Africa through the creation of an ‘environmental profile’ in an attempt to achieve the second objective – comparable urban and rural data was also collected as part of a larger study at two other international sites (Kampala, Uganda and Stockholm, Sweden) to provide an international perspective. Included in the third objective is the collection of qualitative data through a community based participatory research method at the same urban and rural sites in South Africa. Finally, intervention and/or policy-related recommendations are developed based on study findings and in consultation with relevant stakeholders through interviews. / 2018-12-14

<p>Infant and young child feeding practices are suboptimal in Tanzania, but optimal nutrition during the first two years of life is critical for development. At this age, behaviors of caregivers determine children’s diets, but few studies quantify how fathers or couples jointly influence child feeding. We investigate how men and women shape the family food environment to determine children’s diets in rural Mara, Tanzania. This mixed methods study used quantitative baseline data from the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov Identifier: NCT03759821), including 960 rural households with both parents and a young child. Logistic and linear mixed effects regressions examined associations between parental determinants and exclusive breastfeeding (n=189) and child dietary diversity over one day and one week (n=764 children 6-23 months; n=597 children 9-23 months). Parental determinants measured knowledge of breastfeeding and complementary feeding, self-efficacy on provision of diverse or nutritious diets, workload away from home, social support, household savings, and couples’ communication and decision-making, indicating women’s empowerment. Qualitative data drew from formative research (July-August 2018) conducted with parents of children aged 0-36 months, including eight focus group discussions (FGDs) with mothers and fathers (four FGDs each, 31 and 30 participants, respectively). FGDs were transcribed, translated, quality checked, and coded to identify key themes. The odds of exclusive breastfeeding decreased with mothers’ higher workload away from home and increased with mothers’ reports of more frequent couples’ communication over household decisions. Higher child dietary diversity was linked to mothers’ reports of higher knowledge of nutritious foods, higher social support, and higher couples’ communication frequency and quality. Generally, fathers’ determinants were not associated with children’s diets. Qualitative findings indicated that knowledge of exclusive breastfeeding was common, but challenges of perceived breastmilk insufficiency, women’s workload, and concerns about breastmilk quality led to early introduction of complementary foods. Affordability was a common challenge to appropriate complementary feeding, while couples’ decision-making dynamics and attitudes and beliefs about foods had the potential to be both enablers and barriers. Interventions must improve nutrition knowledge and social support, and they must empower women through joint decision-making and more gender-equitable workloads between parents to enable optimal child diets. </p>

Home availability of both healthful and unhealthful foods may influence consumption among rural adolescent populations. In conjunction, the availability of food in an individual’s local food environment has the potential to significantly impact what is procured for the home and eaten away from the home. The purpose of this study was to determine how in-store food availability and parental purchases influences home availability and, ultimately, dietary intake among adolescents. This study measured perceived home availability, using the University of Minnesota Project EAT Survey, and dietary intake, using the NHANES Dietary Screener Questionnaire, of (n=28) adolescent participants in two Kentucky counties during 2013. Availability of food in local stores was measured using the Nutrition Environment Measures Survey in Stores (NEM-S). The results of multiple linear regression analysis suggest that overall store availability does not significantly impact parental purchases. However, in-store availability of specific unhealthy food categories, such as snacks, junk food, candy, and pop, was associated with increased parental purchases of similar unwholesome items and a greater predicted intake of sugar. Therefore, it may be beneficial to develop interventions aimed at decreasing the availability of unhealthy food items in stores in order to improve diet quality among rural adolescents.

The aims of this research were to 1) demonstrate the validity of using a personally-worn micro-camcorder (PWMC) method to assess in-store parent-child food-purchasing interactions and environmental factors related to these behaviors; 2) examine the relationship between child at-home TV-exposure, home food availability/accessibility, parent dietary modeling, and child-feeding style with the healthfulness of child in-store food purchasing requests; and 3) examine the relationship between parent weight status, parent diet quality, food purchasing intentions, perceived relative cost of healthy food, and the use of nutrition facts labels with the healthfulness of parent responses to child in-store food purchasing requests. A total sample of 40 parent-child dyads completed the study. Parents were a mean age of 36.5 years (±6.3), and children were a mean age of 3.8 years (±1.1). Dyads were met at their usual grocery store and shopping time. Children wore a micro-camcorder or eButton on a hat to capture what they saw. Parents also completed a questionnaire about nutrition behaviors and the home food environment based on validated questions from the literature. Coded personally worn micro-camcorder (PWMC) data were highly correlated (rho = 0.345-0.911, p<0.01) with in-person observational data for assessing in-store behavioral and environmental factors, and the method demonstrated a high degree of reliability for assessing purchasing decisions compared to receipt data (Cohen's kappa = 0.787). Also, inter-rater reliability for assessing environmental/behavioral variables ranged from moderate to almost perfect (Cohen's kappa = 0.466-0.937). Children whose parents reported high levels of unhealthy dietary modeling had lower odds of a food request being healthy (OR=0.50, P=0.021), and having parents who report non-directive child-feeding had increased odds of a request being healthy (OR=1.66, P=0.028). Healthy weight parents were more likely to make healthy responses to child food purchasing requests than overweight/obese parents (OR=2.06, P=0.022). Behavioral interventions that seek to improve the healthfulness of food purchasing in families with young children should include components to promote non-directive feeding styles, discourage unhealthful dietary modeling, provide additional resources to target overweight/obese parents' responses to child requests, and use the PWMC method for efficient measurement of these behaviors. / text

Introdução: O consumo adequado de frutas, verduras e legumes (FVL) durante a gestação apresenta impacto positivo sobre a saúde da mulher e da criança. Os fatores ambientais associados ao comportamento alimentar vêm recebendo destaque no âmbito da saúde pública por afetar diretamente a saúde dos indivíduos. Entretanto, desconhecemos a existência de estudos que investigaram a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes. Objetivo: Verificar a reprodutibilidade de um questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes (manuscrito 1) e avaliar a relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2). Metodologia: O estudo de reprodutibilidade (manuscrito 1) foi conduzido em 2010 entre 48 gestantes usuárias do serviço público de saúde de Ribeirão Preto, SP. O questionário é composto por 12 questões de múltipla escolha que incluem a percepção do ambiente alimentar e para o consumo de frutas e hortaliças. Para verificação da reprodutibilidade, o questionário foi aplicado em duplicata, com intervalo entre 15 e 45 dias. A concordância entre as respostas foi avaliada por meio do teste de Kappa ponderado ou Kappa. A relação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças em gestantes (manuscrito 2) foi avaliada empregando-se os dados de um estudo transversal, conduzido em 2012, entre 282 gestantes adultas. O consumo de FVL foi avaliado por meio de um questionário de freqüência alimentar (QFA) , e dois recordatórios de 24 horas. O Multiple Source Method foi utilizado para estimar o consumo usual de FVL. A percepção do ambiente alimentar foi avaliada mediante a aplicação de questionário estruturado. Para a investigação da relação entre a as variáveis da percepção do ambiente alimentar e consumo adequado de FVL (400g/dia), modelos de regressão logística [OR (95% IC)] foram empregados ajustados por escolaridade, idade e classe econômica das gestantes. Resultados: No manuscrito 1, verificou-se a reprodutibilidade do questionário sobre a percepção do ambiente alimentar e para o consumo de frutas e hortaliças em gestantes. Concordância forte (Kappa entre 0,6 e 0,79) para: número de refeições ao dia, hábito de se alimentar no local de trabalho, distância entre a residência e local de aquisição de FVL e qualidade de FVL no local de aquisição. Concordância moderada (Kappa entre 0,4 e 0,59): hábito de se alimentar fora do domicílio, em restaurantes do tipo self-service ou por quilo, em lanchonetes, se adquire alimentos em mercearias, lojas de conveniência ou padaria, motivo da escolha do local para aquisição de FVL, variedade de FVL no local de aquisição e apoio familiar para ter uma alimentação saudável. Concordância fraca (Kappa entre 0,2-0,39): freqüência em que faz refeições na casa de amigos/ parentes, freqüência em que adquire alimentos em supermercados e varejão ou feira livre e percepção em relação ao preço de FVL. As questões que obtiveram concordância fraca foram reformuladas previamente a sua utilização. No manuscrito 2 observou-se que 35% das mulheres estudadas reportaram o Resumo consumo adequado de frutas e hortaliças durante a gestação, não encontrando uma associação direta entre a percepção do ambiente alimentar e o consumo adequado de frutas e hortaliças entre elas. Entretanto, as gestantes que relataram ter o hábito de fazer quatro ou mais refeições ao dia apresentaram maior chance de consumir a quantidade adequada de furtas e hortaliças quando comparadas àquelas que relataram menor número de refeições ao dia [OR 2.01 (95% IC 1.03, 3.91) p 0.04]. Da mesma forma, as mulheres que referiram o hábito de comprar FVL em varejão ou feira livre apresentaram maior chance de atingir a recomendação de frutas e hortaliças, independente de idade, escolaridade e classe socioeconômica [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusão: O questionário sobre a percepção do ambiente alimentar e para o consumo de FVL apresentou boa precisão entre gestantes. Não houve associação entre a percepção do ambiente alimentar e o consumo de frutas e hortaliças entre as gestantes estudadas. / Introduction: The adequate intake of fruits and vegetables (FV) during pregnancy has a positive impact on the health of women and children. Environmental factors associated with eating behavior have received attention in the context of public health by directly affecting individuals health. However, unaware of the existence of studies that investigated the relationship between self perceived food environment and fruit and vegetable intake in pregnant women. Objective: To evaluate the reliability of a self perceived questionnaerie about the food environment and for the consumption of fruit and vegetable in pregnant women (manuscript 1). To evaluate the relationship between self perceived food environment and the adequate consumption of fruits and vegetables in pregnant women (manuscript 2). Methods: The study was conducted in 2010 among 48 pregnant women attended by the public health service of Ribeirão Preto, SP. The questionnaire consists of 12 multiple choice questions which include the perception of the food environment and consumption of FV. To investigate the reproducibility of the questionnaire, it was administered twice, between 15 and 45 days apart. The agreement between the responses was assessed using the Kappa or Kappa weighted (manuscript 1). A cross-sectional study was conducted in 2012 among 282 adult pregnant women. Fruit and vegetable intake during pregnancy was assessed by a food frequency questionnaire, and 2 dietary recalls. The Multiple Source Method approach was applied to estimate usual FV intake. Self perceived food environment was assessed by a structured questionnaire. For the present analysis, we examined the association of self perceived food environment and the adequate intake of fruit and vegetable (400g/daily) in logistic regression models [OR (95% CI)], adjusted by maternal age, socioeconomic class, and educational level (manuscript 2). Results: Manuscript 1 describes the reliability of a self perceived questionnaire about the food environment and for the consumption of fruits and vegetables in pregnant women. There was strong agreement (Kappa: 0,6 to 0,79) for: meals per day, habit of eating at work, distance between the residence and places to purchase fruit and vegetable, quality of fruit and vegetable at the purchase place. Moderate agreement (Kappa 0,4 to 0,59): habit of eating out of home, habit of eating in self service restaurant, habit of eating in fast food restaurant, purchase food at grocery stores, convenience stores or bakery, variety of fruits and vegetables available and family support for healthy eating. Weak agreement (Kappa 0,2 to 0,39): habit of eating in friends or family house, purchase food at supermarket or FV specialized food market and perception of FV price. All the questions that had weak agreement were reformulated prior to use it. The manuscript 2 showed that 35% of the women intervied reported adequate intake of FV during pregnancy, with no association between self perceived food environment and adequate FV intake. However, a higher meal frequency was associated with a better chance of daily adequate intake of fruit and vegetable [OR 2.01 (95% CI 1.03, 3.91) p 0.04]. Moreover, the habit of buying fruit and vegetable in Abstract specialized food market was associated with the daily intake of 400g of fruit and vegetable [OR 1.68 (IC95% 1.01, 2.80) p 0.05]. Conclusion: The questionnaire of the perceived food environment and for the consumption of fruits and vegetables showed good precision among pregnant women. No association between self-perceived food environment and the adequate intake of FV among pregnant women was found.

Introdução: Um ambiente obesogênico pode ser definido como \"a soma de influências, oportunidades ou condições que o ambiente tem na promoção da obesidade\", onde o consumo de alimentos de risco é estimulado em detrimento do consumo de alimentos de proteção. Atualmente, o excesso de peso apresenta-se como um problema de saúde pública, sendo a dieta inadequada um fator modificável para seu desenvolvimento. As frutas e hortaliças desenvolvem um papel fundamental na prevenção do excesso de peso, uma vez que apresentam baixa densidade energética, são fontes de proteínas vegetais e micronutrientes considerados protetores, além de serem ricos em fibras, aumentando a sensação de saciedade. Objetivo: Investigar a associação entre excesso de peso, consumo de frutas e hortaliças por adolescentes e ambiente alimentar local em São Paulo. Métodos: Foram utilizados dados do Inquérito de Saúde de São Paulo 2015, o qual é um estudo transversal de base populacional com amostragem probabilística de residentes em domicílios permanentes no município. Os dados foram coletados por meio de um questionário estruturado e dois recordatórios alimentares de 24 horas. O estado nutricional foi avaliado pelo Índice de Massa Corporal classificado em sem excesso de peso (percentil <85) e com excesso de peso (percentil >=85) de acordo com a Organização Mundial da Saúde. Os dados de ambiente alimentar foram obtidos do Cadastro Municipal de Vigilância Sanitária e da Secretaria Municipal de Trabalho e Empreendedorismo. Buffers (áreas de influência) de 500, 1000 e 1500 metros foram criados para avaliar a presença dos estabelecimentos ao redor das residências dos adolescentes participantes do estudo. A fim de verificar a associação entre ambiente alimentar, consumo de frutas e hortaliças e excesso de peso foram elaborados modelos de regressão logística multinível, ajustados por potenciais cofundidores. A análise dos dados foi realizada no programa Stata 13.0, considerando nível de significância de 5%. Resultados: Os adolescentes apresentaram baixo consumo de frutas e hortaliças, uma vez que apenas 6,1% consumiram a quantidade recomendada pela Organização Mundial da Saúde. Além disso, 29,6% apresentaram excesso de peso. A maioria dos adolescentes possuía mercados, supermercados e mercearias (85,5%), restaurantes (75,6%) e feiras-livres e sacolões (50,6%) em torno da residência, mas não apresentava restaurantes fast-foods (93,9%), padarias e cafeterias (89,5%), e pizzarias (76,8%). A presença de uma feira-livre na zona mais próxima dos domicílios (500 m) e maior renda familiar foram associadas ao maior consumo de frutas e hortaliças. A presença de restaurantes de fast-foods no buffer de 500 metros em torno da residência foi positivamente associada ao excesso de peso. Conclusão: Esses resultados sugerem que o ambiente alimentar em São Paulo pode ser um fator importante em relação ao consumo alimentar e, consequentemente, ao excesso de peso em adolescentes da cidade. Dessa forma, é necessário intensificar políticas de educação alimentar e nutricional, redução de preços de alimentos protetores e manutenção de ambientes alimentares saudáveis. / Introduction: An obesogenic environment can be defined as \"the sum of influences, opportunities or conditions that the environment has in the promotion of obesity\", where the consumption of risky foods is stimulated to the detriment of protective foods consumption. Currently, overweight presents as a public health problem, and inadequate diet is a modifiable factor for its development. Fruits and vegetables play a key role in the prevention of overweight, since they have low energetic density, are sources of vegetable proteins and micronutrients considered protective, besides being rich in fibers, increasing the feeling of satiety. Objective: To investigate the association between overweight, fruit and vegetable consumption by adolescents and the local food environment in São Paulo. Methods: Data from the 2015 Health Survey of São Paulo were used, which is a cross-sectional population-based study with probabilistic sampling of residents in permanent households in the municipality. Data were collected through a structured questionnaire and two 24h dietary recall. The nutritional status was evaluated by the Body Mass Index classified as non-overweight (percentile <85) and overweight (percentile >=85) according to the World Health Organization. Food environment data were obtained from the Municipal Register Sanitary Surveillance and the Municipal Department of Labor and Entrepreneurship. Buffers (areas of influence) of 500, 1000 and 1500 meters were created to evaluate the presence of establishments around the adolescent\'s residences participating in the study. To verify the association between food environment, consumption of fruits and vegetables and overweight, multilevel logistic regression models were developed, adjusted by potential co-founders. Data analysis was performed in Stata 13.0 program, considering a significance level of 5%. Results: The adolescents presented low consumption of fruits and vegetables, since only 6.1% consumed the amount recommended by the World Health Organization. In addition, 29.6% were overweight. Most of the adolescents had markets, supermarkets and grocery stores (85.5%), restaurants (75.6%), and street markets and fruit and vegetable stands (50.6%) around the residence but did not present fast-food restaurants (93,9%), bakeries and coffee shops (89.5%), and pizzerias (76.8%). The presence of a street market in the area closest to the households (500 m) and higher family income was associated with higher consumption of fruits and vegetables. The presence of fast-food restaurants in the 500 meters buffer around the residence was positively associated with being overweight. Conclusion: These results suggest that the food environment in São Paulo may be an important factor in relation to food consumption and, consequently, to overweight in adolescents in the city. Thus, it is necessary to intensify policies of food and nutritional education, reduction of protective foods prices and maintenance of healthy food environments.