Topics environment in urban settings: Changing the Food Environment - - PDF document

10/5/12 ¡ 1 ¡ Working to improve the food environment in urban settings: Findings, lessons learned and policy linkages

Joel Gittelsohn, PhD Betsy Anderson Steeves, MS, RD

Center for Human Nutrition Johns Hopkins Global Center on Childhood Obesity Johns Hopkins Bloomberg School of Public Health October 5, 2012

Topics

• Changing the Food Environment
• Baltimore

▫ Part 1. Working with small food stores ▫ Part 2. Working with prepared food sources ▫ Part 3. Multi-institutional interventions

• Summary and Lessons Learned

Policy Linkages

• Food availability associated with diet and higher

youth BMI (French 2001)

• Fewer supermarkets is associated with higher BMI

and chronic disease rates (Morland 2006; Bodor JN 2010)

• Distance of 1.76 miles or greater from home to

grocery store was a predictor of increased BMI

(Inagami et al 2006)

• More small stores and prepared food sources are

associated with higher BMI and chronic disease rates (Bodor JN 2010 Maddock, 2004)

3

Food Environment and Obesity

• Changing access to foods within retail food

stores & prepared food sources by:

▫ Decreasing availability of less healthy foods ▫ Increasing availability of healthy foods in small stores ▫ Changing the physical location of foods (e.g., store layout) ▫ Store renovations (e.g., adding refrigeration units for produce) ▫ Manipulating price

Ways to Change the Food Environment (1)

• Changing access to foods within

neighborhoods by:

▫ Building new supermarkets ▫ Developing farmer’s markets ▫ Improving transportation

• Changing setting for provision of

information (e.g., POP promotions)

Ways to Change the Food Environment (2)

• Policy

▫ Setting small store criteria/standards ▫ Menu labeling ▫ Rezoning ▫ Taxes (E.g., SSB tax)

• Work in multiple settings/ institutions at the

same time

▫ Integrating interventions in food stores, restaurants, schools, worksites, etc.

Ways to Change the Food Environment (3)

10/5/12 ¡ 2 ¡

• Other approaches:

▫ Improving food networks (distributors, producers, retailers) ▫ Improving local production (producers) ▫ Increasing nutrient content of foods (manufacturers) ▫ Changing packaging of foods (manufacturers)

Ways to Change the Food Environment (4)

Some questions

• Which approach most effective?
• Which combination of approaches are needed?
• How to develop/select approaches?
• Which approaches are more cost-effective – for

all stakeholders?

• How to enhance sustainability?

Example. Baltimore City Food Environment

Corner stores

Behind the glass

Part 1. Working in Small Stores Baltimore Healthy Stores

• East Baltimore:

intervention area

• West Baltimore:

comparison area

• Store sample

▫ 2 supermarkets/area ▫ 6-7 small stores/area

• Consumer sample

▫ ~87 respondents/area

Baltimore Baltimore

E E Y Y T T A A L L H H H H T T E E O O R R S S S S T T E E O O R R S S S S

10/5/12 ¡ 3 ¡ Key Issues from Interviews

• From Store Customers: “I would love to buy/eat

healthy foods but they are…”

▫ Too expensive ▫ Not available in the stores I shop in ▫ Are of poor quality in the stores I shop in

• From Store Owners/Managers: “I would love to

stock healthy foods but …”

▫ No one buys them ▫ The last time I stocked (xxxxx) it just sat on the shelves Top ten sources of energy, fat and sugar of low income African American adults in Baltimore (Sharma et al, 2009)

Food Item Energy (%) Food Item Fat (%) Food Item Sugar (%) Sodas 9.5 Chicken 12.1 Sodas 34.1 Chicken 8.2 Hot dogs, sausages 8.1 Sugary drinks (iced tea, punch) 15.2 Breads 6.0 Chips 6.3 Juices 9.0 Cake, donut and

• ther pastry

4.2 Meat dishes 5.2 Sugar and syrup 8.3 Sandwiches and burgers 4.0 Margarine and butter 5.2 Cake, pastry and donut 4.2 Sugary drinks 3.8 Cake, donut and

• ther pastry

5.1 Candies 4.1 Chips 3.7 Mayo, salad dressing, dips 4.9 Ice cream 3.2 Pasta dishes 3.3 Sandwiches and burgers 4.5 Cookies 2.5 Meat dishes 3.1 Cheese 4.3 Fruits 2.1 Candies 2.9 Eggs 4.0 Cereals 1.6 Total 48.7 Total 59.8 Total 84.3

Community workshops for planning

• 1-3 new foods per store per

phase

• Start with “low-hanging fruit”
• Incentives/Information

▫ Stocking guidelines ▫ Promotional materials to create demand ▫ Incentive card to wholesaler ▫ Provide small supply

Increasing supply: Corner stores stock healthier foods

Baltimore Baltimore

E E Y Y T T A A L L H H H H T T E E O O R R S S S S T T E E O O R R S S S S

Increasing Demand: Visual Materials Interactive Sessions in large and small food stores

10/5/12 ¡ 4 ¡

• Nutrition Education

Booklet (Korean)

Materials and training for Korean American store owners

l Cultural Guidelines

(Korean)

20 / 63

Impact o

• n S

Stocki king a and S Sales

Stocking Score (range 0-10) Sales Score (range 0-10) Intervention Comparison Significance Intervention Comparison Significance Baseline 5.9 ± 2.0 6.8 ± 1.6 NS 4.4 ± 1.8 5 ± 1.5 NS Post-phase 8.3 ± 1.0 6 ± 1.8 0.004 7.1 ± 2.0 5.8 ± 1.8 0.05 Post- intervention 7 ± 2.0 5.5 ± 1.5 0.009 6.4 ± 1.8 4.7 ± 1.5 0.003

Song et al, Public Health Nutrition, 2009

• N=85 respondents measured pre and post
• After adjustment for baseline value, age, sex and

SES:

▫ Significant impact on food preparation methods and frequency of purchase of promoted foods ▫ Positive trend for healthy food intentions

Consumer Results

Gittelsohn et al, Health Education and Behavior, 2009

Baltimore Food Policy Advisory Committee (Food PAC)

• Early 2009: Baltimore City Food Policy Task

Force develops report with recommendations

• Late 2009: Holly Freishtat, MS, CN, named

Baltimore City Food Policy Director

• Early 2010: Baltimore Food PAC forms, begins

to implement recommendations of the task force

Policy: Baltimore Cornerstore Criteria Program

• Phase 1: Pilot

▫ Work with 2-3 stores ▫ Star system for healthy stores ▫ Produce display or small store structural incentive (< $300) ▫ Promotional signage for healthy foods ▫ Monitored by BHCK study staff

• Phase 2: Optional criteria

▫ Same Phase 1, for up to 100 stores ▫ Monitored by City Health Department

• Phase 3: Legislation

▫ Same as Phase 1 and 2, for all small stores ▫ Increased fees for non-compliance ▫ Monitored by City Health Department

Part 2. Changing the prepared food source environment: Baltimore Healthy Carryouts

10/5/12 ¡ 5 ¡

Background: Prepared Food Consumption Patterns

• Americans spend nearly half of their food dollars

eating out (USDA 2011)

• One-third of daily caloric intake comes from foods

purchased and/or eaten away from home (Guthrie et al 2002)

• A large proportion (76.8%) of foods eaten away from

home consists of prepared foods purchased at fast food restaurants and carryouts (USDA 2011)

• Prepared foods are typically calorically dense and

higher in fat and are associated with increased BMI and weight gain (Pereira et al 2005, Duffey et al 2007, Beydoun et al 2011)

Prepared Food Sources in Baltimore

• A total of 144 Prepared Food Sources (PFSs ) were observed

(ground-truthing method) in low-income neighborhoods of Baltimore (Lee et al. 2010)

▫ 72% carryouts (n=104) ▫ 15% corner stores with deli/take-out ▫ 10% Fast food restaurants ▫ 5% Sit-down restaurants

Carryouts: Food establishments selling ready- to-eat food and beverage for off-premises consumption (Zoning Code of Baltimore City. 1-123.1 )

Average Monthly Expenditures by Food Sources in Baltimore

Fast food , $44 Covered market, $43 Sit-down restaurant, $48 Carryout, $153 Corner Store, $140 Supermarket , $274

Palmer et al 2007

Prepared food sources : $288

Exterior & Interior of Carryouts Baltimore Healthy Carryout Aims

• To develop, implement and evaluate a culturally

appropriate multi-component carryout intervention to reduce risk factors for diet-related chronic diseases in a low income urban setting

Ø Conduct formative research on the availability, pricing and consumption of carryout foods Ø Develop and test interventions Ø Develop and pilot instruments to assess the efficacy of environmental interventions in carryouts

Study Design: BHC Pilot Trial

▫ Matching variables : ethnicity, location, physical environment of the carry-out

Intervention group 1st generation Korean American owned carryouts (N=2) African American owned carryouts (N=2) Comparison group 1st generation Korean American owned carryouts (N=2) African American owned carryouts (N=2)

N= 4 N= 4

10/5/12 ¡ 6 ¡

Intervention Phases

• Phase 1: Modified Menu Boards & Menu

Labeling

• Phase 2: Healthy Sides & Beverages
• Phase 3: Affordable Healthy Combo Meals

Phase 1: Modified Menu Boards & Menu Labeling

• Owners were reluctant/

concerned about changing what they sell

• Many do not have

resources to change menu boards

• Allowed us to build

rapport/trust with

• wners

Phase 1: Modified Menu Boards & Menu Labeling

Before

Healthier options were highlighted with a leaf logo Healthier menu

• ptions were

also promoted with photos

Menu Analysis: Definition of Healthy Items

• Two Registered Dietitians reviewed the menu recipes &
• bserved cooking methods at baseline
• Calculated total calories and fat (g) using USDA

National Nutrient Database (db.nal.usda.gov)

▫ Healthy Entrée: <600kcal and <20g of fat ▫ Healthy Side dish: <200kcal

• Total of 47 healthy items & Total of 119 less-healthy

items

• Grilled chicken sandwich (350kcal, 15g fat)
• vs. Four fried chicken wings (780kcal, 52g fat)

Phase 2: Healthy Sides & Healthy Beverages

• Promoted currently available

healthy sides & beverages

– Collard greens, corn, salads, soups, water, diet soda, 100% fruit juice

• Introduced new healthy sides

– Yogurt, fresh fruits, fruit cups, baked chips

• Provided initial stocks of healthy

sides

Phase 3. Affordable Healthy Combo Meals

• Improving food preparation

methods

Ø Provide an indoor grill to implement grilled chicken

• Healthy combo meal promotion

with price reduction

Ø Owners agreed to reduce up to $2.50 per healthy combo meal without compensation Ø Combo meal with free baked chips

10/5/12 ¡ 7 ¡ Point-of-purchase posters Evaluation Method

• Weekly sales receipt collection

(February – September 2011, 32 weeks )

▫ Trained data collectors visited carryouts every week ▫ A total of 186,654 units of sales were collected

• One intervention carryout did not

follow the protocol - excluded from the analysis

Aggregate Variables

Healthy Items (H_itemj)

• Low-fat sandwiches

▫ Grilled chicken ▫ Turkey ….

• Sides

▫ Fresh fruits ▫ Salads ▫ Cooked greens….

Less-healthy Items LH_itemj)

• High-fat sandwiches

▫ Chicken fillet (deep-fried) ▫ Cheese fish fillet

• Sides

▫ French fries ▫ Western fries….

⨳Excluded beverages because often owners did not write down beverage-only sales to the receipts

Analysis

• Outcome variables

▫ Change in percentage of healthy item sales from baseline [(H_itemi / H_item0) - 1]*100

⨳ Example [(60 / 40 ) -1]*100 = 50% increase

▫ Change in the ratio of healthy to less-healthy item sales from baseline

(H_itemi / H_item0) (LH_itemj/ LH_item0)

• Independent t-test
• Paired t-test and ANOVA

Changes in percentage of healthy food sales from baseline by intervention phases

p<0.05, ***<0.001, Independent t-test comparing Intervention vs. Comparison H_item: Healthy item sales

Changes in the ratio of healthy to less-healthy items sales from baseline

* p<0.05, ***p<0.001 comparing intervention to comparison, independent t-test

abcDifferent lettered superscripts indicate significant differences (p<0.05) across intervention phases

H_item: Healthy item sales, LH_item: Less-healthy item sales

10/5/12 ¡ 8 ¡

Mean purchasing score by level of exposure, comparing respondents from intervention and comparison carryouts.

1 2 3 4 5 No Exposure Medium Exposure High Exposure

Comparison Intervention Comparison Intervention Comparison Intervention

Intervention vs Comparison

Purchasing Behavior by Exposure Level

Impact of Baltimore Healthy Carryouts exposure on

Purchasing Behavior (Random-effects logistic regression)

Strengths & Significance

• First prepared food source intervention in low-

income urban setting using quasi-experimental design with comparison group

• One of the first studies to look at sales patterns of

non-franchise fast food restaurants

• Future analyses: investigate sales in terms of gross

revenue & customer outcomes such as changes in food purchasing habits

Policy linkages

Part 3. Multi-institutional Approaches Baltimore Healthy Eating Zones Pilot

Nutritional Health of Baltimore Adolescents

• Among African American high school

students in Baltimore City:

▫ 20.3% are overweight ▫ 18.8% are obese

• AA youth in Baltimore tend to eat diets:

▫ High in sugary drinks and high fat foods ▫ Low in fruits, vegetables, and fiber

10/5/12 ¡ 9 ¡

Working with adolescents: Is it too late?

• Obesity literature leaning toward earlier and

earlier interventions

• Adolescent behavior change

Obesity Interventions for Youth: A History

• Clinical programs
• School-based programs
• Family-focused programs
• …but overweight and obesity in youth is still at

an all time high! We need to work in all of these areas: Multi-level interventions Baltimore Healthy Eating Zones Pilot

• Creation of “healthy eating zones” in and around

6 Baltimore recreation centers (with 6 comparison)

• Worked with corner stores and some carryouts
• Increasing availability of healthy foods
• Point of purchase signage
• Interactive sessions
• Peer educators
• Cooking classes for kids in recreation centers
• Recreation center staff training

Funded by RWJ HER, Round 2

Youth materials developed by Kids On The Hill Interactive activities in recreation centers

Early findings

• Intervention youth had greater exposure to the

intervention than comparison youth.

• Intervention youth significantly improved food-

related outcome expectancies (p=0.02) and knowledge (p<0.001).

10/5/12 ¡ 10 ¡

Early Findings: Impact on Obesity

By Direct Exposure By Intervention Changes in

• besity

Low Med High Sig. Comparison Intervention Sig.

BMI Percentile

(entire sample)

• 1.74

1.44

• 2.91

0.34 0.22

• 1.88

0.33

BMI Percentile

(Baseline BMI>85)

• 1.2
• 2.85
• 2.7

0.1

• 0.78
• 3.15

0.051

BMI Percentile

(Baseline BMI>85, Girls

• nly)
• 1.1

N/A

• 3.1

0.016

• 0.13
• 3.16

0.03

Program Population Reduced Significant Impacts Observed

Consumer psychosocial Consumer behavior Consumer diet/ BMI Store Marshall Islands Healthy Stores Pacific Islander adults Knowledge Healthy food purchasing N/A N/A Apache Healthy Stores American Indian adults Knowledge Healthy food purchasing Increased healthy foods, decreased unhealthy foods Increased stocking and sales Zhiwaa-penewin Akinomagewin First Nations adults Knowledge Healthy food purchasing ? Diet/ no impact BMI N/A Healthy Foods Hawaii (PI: R Novotny) Pacific Islander adults and children Caregiver knowledge Healthy food purchasing frequency trend Increased water , Total HEI score and HEI grain score / No impact BMI N/A Navajo Healthy Stores American Indian adults Self-efficacy Intentions Purchasing labeled foods ? Diet / Reduced BMI % No impact Baltimore Healthy Stores African American adults Intentions Healthy cooking methods, purchasing labeled foods ? Diet / N/A Increased stocking and sales Baltimore Healthy Eating Zones African American youth Intentions, self- efficacy No impact ? Diet / Reduced BMI %

• verwt youth

?

Summary of Healthy Stores Environmental Interventions: Results of Completed Trials

Summary and Lessons Learned

• Programs to implement mixed

environmental-behavioral change interventions have shown success in improving psychosocial factors, food- related behavior and in some instances

• besity in rural and urban settings
• Strong need to evaluate policies/programs

to improve the food environment

Summary and Lessons Learned

• Environmental interventions involve

developing relationships with communities and many key stakeholders over time

– Community engagement and planning – Multi-phase programs – Academic/university partner working with local agencies and policy makers

Summary and Lessons Learned

• Achieving adequate exposure is

critical in environmental interventions

▫ Many environmental interventions are not intensive ▫ Need to combine strategies that work with different stakeholders simultaneously

10/5/12 ¡ 11 ¡ Break

Next Steps of the Food Environment Work in Baltimore

• BHCK was recently

funded as part of the new Johns Hopkins Global Center on Childhood Obesity

• Project 2: Joel

Gittelsohn, PI

BHCK Topics

• Rationale
• Study aims
• Conceptual framework
• Levels of the BHCK intervention
• Formative research and planning of the BHCK

intervention

▫ Sub-studies for intervention development

• Study design
• Evaluation plan for BHCK

Primary Aims of BHCK

• Develop, implement and evaluate a community-

based obesity prevention program, operating at multiple levels of the Baltimore city food system

• Increase affordability, availability, purchase &

consumption of healthy foods

• Evaluate impact of the program on:

▫ a) healthy food pricing and availability ▫ b) adult food purchasing and preparation ▫ c) youth diet & psychosocial factors

Secondary Aims of BHCK

§ Demonstrate the cost-effectiveness of this approach § Contribute to development of GIS mapping system, which will be used to inform policymakers and develop future randomized controlled trials targeting this high-risk population. § Pilot a partnership between two local urban farms and neighboring cornerstores, aimed at increasing produce supply and access.

Multi-Level Approach using the Social Ecological Model

Image from: www.balancedweightmanagement.com

10/5/12 ¡ 12 ¡

Multi-Level Intervention Approaches

• Policy Level

▫ Create political partnerships ▫ Provide evidence to policy makers

• Environmental intervention to increase supply:

▫ Increased access (availability, price) ▫ Store upgrades (façade, healthier merchandise)

• Behavioral intervention to increase demand:

▫ Peer-led intervention ▫ Interactive sessions (taste testing, cooking demos, health education, giveaways) ▫ POP promotions (signage)

• Community area retail collaborations

▫ Bulk purchases by collaborating retailers ▫ Wholesaler/distributor discounts (key healthy foods)

BHCK Conceptual Framework

We’ve got everything, but…. Policy- Level Interventions Policy-Level Interventions

• Collaboration with Baltimore Food PAC

▫ Partnership with Holly Freischtat ▫ Regular reporting at Food PAC meetings

• Identification of a policy champion

▫ Legislative/ voting records of council members ▫ Committee appointments

• Adaption and adoption of program by city

government

▫ Formative interviews with policy makers

Identification of a Policy Champion

Red Bold: Identified potential policy champion (>= 5 sponsors ) Yellow Highlight: Person who introduced bill, resolution or informational hearing to city council.

Search terms: Youth, Obesity, Health, Recreation Center, Store

10/5/12 ¡ 13 ¡

Environmental/Community- Level Interventions

Environmental-Level

• What do you think of

when you think of food in Baltimore?

B’More Food! Environmental-Level

• Work with multiple players in the food system:

▫ Policy makers ▫ Wholesaler ▫ Corner stores/ Carry outs

• Creation of Healthy Eating Zones (HEZs)

Healthy Eating Zones

§ “Zones” are areas within ¼ mile of recreation centers or other community hub § Zones must be areas that are:

§ Majority African American § Low income (mean income <200% FPL) § Supermarket >1/2 mile away from rec center § Have >3-5 cornerstores and/or carryouts within ¼ mile of recreation center

10/5/12 ¡ 14 ¡ What’s going on in the recs?

• Closures
• Transition to community based organizations

▫ ROCACP ▫ Big Brothers Big Sisters ▫ Elev8 ▫ Youth Sports programs

10/5/12 ¡ 15 ¡

Participating Rec Centers for Wave 1

• 1. Bentalou
• 2. C.C. Jackson
• 3. Chick Webb
• 4. Coldstream
• 5. Collington Square
• 6. Edgewood
• 7. Ft. Worthington
• 8. Greenmount
• 9. J.E. Howard
• 10. Lillian Jones
• 11. Madison Square
• 12. Patapsco
• 13. Samuel Morse
• 14. Patterson Park

(pilot)

Alternative HEZ Hubs

• Rec Centers run by

alternative groups

• Other community

centers

• Feeding centers
• Churches

Wholesaler Level

• Where do corner stores & carry outs get their

food?

• They shop like we do!
• Wholesalers

Wholesaler Level

• Healthy foods can cost

more

• Small food sources don’t

have purchasing power of grocery stores

• Collective purchasing

power

▫ Reduced prices for store

• wners

▫ New customers for wholesaler

Corner Stores & Carry Outs

• 3-5 Food sources in each HEZ
• Stocking of healthier alternatives
• In-store promotions
• Changes in product placement
• Small structural changes/ improvements
• Point-of-purchase advertising

▫ Shelf labels, posters, displays

Sub-Study on the Food Environment

10/5/12 ¡ 16 ¡

Sub-Study: Getting Hyper-Local Produce into Corner Stores

Project leader: Kim Gudzune

Objective

• To ¡partner ¡two ¡local ¡urban ¡farms ¡with ¡two ¡local ¡

corner ¡stores ¡to ¡create ¡a ¡hyper-­‑local, ¡sustainable ¡ distribu4on ¡network ¡for ¡fresh ¡produce. ¡

▫ We ¡will ¡use ¡a ¡social ¡marke4ng ¡campaign ¡to ¡adverCse ¡ this ¡hyper-­‑local ¡produce ¡and ¡provide ¡educaConal ¡ materials ¡on ¡food ¡preparaCon. ¡ ¡ ▫ We ¡hypothesize ¡that ¡a ¡hyper-­‑local ¡produce ¡ distribuCon ¡network ¡will ¡be ¡feasible, ¡acceptable, ¡and ¡

• sustainable. ¡

Da Kao Market – Real Food Farm Da Kao Market Produce Display Da Kao Market Sales

Item ¡ Total ¡# ¡Sold ¡ Item ¡ Total ¡# ¡Sold ¡ Bell ¡peppers ¡ 4 ¡quarts ¡ Peaches ¡ 12 ¡ BuLernut ¡squash ¡ 1 ¡ Sweet ¡potato ¡greens ¡ 2 ¡ Cantaloupe ¡ 3 ¡ Swiss ¡chard ¡ 2 ¡ Cherry ¡tomatoes ¡ 3 ¡ Tomatoes ¡ 12 ¡ Cucumber ¡ 15 ¡ Watermelon ¡ 4 ¡ Eggplant ¡ 6 ¡ Yellow ¡squash ¡ 12 ¡ Okra ¡ 0 ¡ Zucchini ¡ 8 ¡

Number ¡of ¡Each ¡Item ¡Sold ¡during ¡Weeks ¡1-­‑3 ¡

Linden Market – Whitelock Farm

10/5/12 ¡ 17 ¡ Produce Displays in Linden Market Linden Market Sales

Item ¡ Total ¡# ¡Sold ¡ Item ¡ Total ¡# ¡Sold ¡ Apples ¡ 148 ¡ Green ¡onions ¡ 23 ¡bunches ¡ Beets ¡ 11 ¡bunches ¡ Okra ¡ 22 ¡pints ¡ Bell ¡peppers ¡ 31 ¡ Peaches ¡ 154 ¡ Carrots ¡ 4 ¡bunches ¡ Potatoes ¡ 10 ¡quarts ¡ Cherry ¡tomatoes ¡ 14 ¡pints ¡ Sweet ¡potatoes ¡ 8 ¡quarts ¡ Cucumber ¡ 36 ¡ Swiss ¡chard ¡ 13 ¡ Eggplant ¡ 46 ¡ Tomatoes ¡ 6 ¡ Garlic ¡ 2 ¡ Yellow ¡Squash ¡ 1 ¡

Number ¡of ¡Each ¡Item ¡Sold ¡during ¡Weeks ¡1-­‑7 ¡

Key Preliminary Results

• Designated and sufficient refrigeration space critical to

reduce spoilage

• Modification of usual farm strategies needed to increase

shelf life

• Strong community support essential for uptake and

sustained sales

• Residents appreciate convenience and quality, but

financial barriers still exist

• Continued marketing campaign needed to maintain sales

Household and Individual-Level Household and Individual Level

• Household

▫ Corner store/ Carryout in-store programming

• Individual (youth)

▫ Corner store/ Carryout in-store programming ▫ Peer-led intervention

– SMS Messaging

▫ Sub-study: photovoice

Why Peer-Leaders?

• Peer-led interventions are well established in other

disciplines, showing promise in nutrition interventions

• Behaviors similar to/influenced by peers

▫ Adolescents breakfast, fruit, vegetable, and dairy intakes appear to be linked to friends consumption (Bruening, 2012) ▫ Physical activity behaviors linked among girls (Koehly, 2009)

• Peer interventions

▫ Reduce passivity (Hamdan, 2005) ▫ May be more affective than adult led-interventions (Mellanby, 2005)

10/5/12 ¡ 18 ¡ Peer Interventions

• Peers as promoters
• Role(s) of peers:

▫ Creating and implementing promotions of low-fat cafeteria

• ptions, healthy behaviors(French, 2004; Bogart, 2011)

▫ Peers assisted in creating social media campaign, served as peer communicators, submitted media (DeBarr, 2009)

• Peers as teachers
• Role(s) of peers:

▫ Implement health curriculum (Lo, 2008; Smith 2011; Cawley 2011; Stock 2007;

Story 2002)

Lead class activities/discussions (Story 2002) ▫ Physical activity partners during/afterschool (Cawley 2011; Stock 2007) ▫ Lunch workshops/office hours (Cawley 2011)

Outcomes of Peer Interventions

▫ Increased sales of low-fat/healthy cafeteria foods

(French, 2004; Bogart, 2011)

▫ Decreased SSB consumption (in peer advocates)

(Bogart, 2011)

▫ Decrease in SSBs (Lo, 2008; Cawley 2011) ▫ Improvement in psychosocial factors( Smith 2011; Story 2002) ▫ Anthropometrics (Smith 2011; Stock 2007)

One step further: The novelty of BHCK

• School è Recreation Center
• Within the context of the large multi-level study

Intervention Materials Development

• Partnership with

New Lens to develop:

▫ Posters ▫ Videos ▫ Handouts ▫ Promotional items

Can we change “Hot Cheetos and Takis” to “Baked Cheetos and Bananas”?

• http://youtu.be/7YLy4j8EZIk

Discuss: Hot Cheetos & Takis

• Overall impressions
• What was affective about this video?
• Could healthier options be promoted in the same

way?

• Who do you think made this video?

10/5/12 ¡ 19 ¡

Example from Philly: Snack Smart Street Soldiers Comic Books

Formative Work Formative Work

• In-depth Interviews:

▫ Policy makers - 4 ▫ Wholesalers - 1 ▫ Store owners - 15 ▫ Caretakers – 9 ▫ Youth - 12

Kids & Caretakers: Emerging Themes

• Multiple meal opportunities
• Motivation for healthy eating
• Parenting styles, food rules

Multiple Meal Opportunities

• Kids have many opportunities to consume meals

and snacks, often at different locations

▫ Breakfast at home then at school ▫ Dinner at the rec and at grandmom’s house

• Caretakers often feed other children

▫ “I mean there’s things that we do in our neighborhood, we have friends that live across the street and down the street and sometimes the parents come out, like I do, and give the kids popsicles and stuff like that, or if their friends have candy in the house they share with them.” – female caretaker

Motivation for Healthy Eating

• Youth can cite many examples of reasons for healthy eating

▫ Growth, strength, health/disease prevention, avoiding teasing, avoiding weight gain, being able to be active – “You need to eat healthy because if you don’t, your body will not function right, and you’ll end up getting a disease. So you’re having a heart attack and you don’t want to have that because it’s not a good thing for you. And you don’t want to be like really, really short, you want to be like really, really, tall. Because some people get made fun of for being, like, extra short” – 12 y/o girl – ‘Cuz when they grow up and they keep eating that stuff, that’s not

• good. They could die from it…They could die from it it because

they might get really, really, really big.” – 10 year old girl

10/5/12 ¡ 20 ¡ Motivation for Healthy Eating

• Acknowledge the effects of food on the body, but this

may not translate into behaviors

▫ Interviewer: “You said water keeps you energized. How do you know that?” ▫ 13 y/o boy: “Because when I drink sodas I be drowsy and I don’t feel like doing nothing sometimes, but when I drink water, I’ll be up and running, playing and stuff.” ▫ 12 y/o boy: “I went to the store yesterday and I bought me four boxes of lemon, chewy lemon head chews and a bag of chewy candy, a whole bunch of candies, it made me tired. When I got home, it was, I was sleepy, I just went to sleep. I didn’t even want to go to sleep it just made me out.”

Parenting Styles, Food Rules

High Structure Low Structure High Nurturance Sensitive/Responsive: Authoritative Indulgent: Permissive Low Nurturance Controlling (forceful/restrictive): Authoritarian Uninvolved: Unengaged

Parenting Styles, Food Rules

• Variation in parenting styles

▫ “Interviewer: How do you decide what you’ll eat? 10 y/o girl: I’ll just tell my mom. She makes

• everything. Well she makes the same thing, but she’ll,

if either of my brother or my sisters don’t want the thing she’ll give them peanut butter and jelly sandwich.”

• Strategies for getting kids to eat healthy

▫ 12 y/o boy, referring to mother: “She just puts them vegetables in things, sometimes I may not even know they’re there til I’m done eating it…I’m like, mom what did you put in this? She said…some vegetables.”

Parenting Styles, Food Rules

• Few food rules used

▫ “I have to, if I drink juice first, I have to drink water right after it. And I have to have something green on my plate every time I eat a starch” – 11 y/

• girl
• Implementation of rules is loose

▫ “And I try not to make her, like eat [greens], because I know it’s good for her and she should be eating it, but I know when I was little I ate a lot of stuff, a lot of stuff I didn’t want to eat, but I was forced to eat it.” – father of a 10 y/o girl

Sub-study: Food in My Neighborhood: A photovoice project

• Small grant funded by the Urban Health

Institute

• Conducted in 2 intervention rec centers
• Purpose:

▫ To gain youth’s perspective on food environment ▫ To engage youth in change process ▫ To generate policy maker interest

Photovoice

• A series of educational and discussion sessions

with youth

▫ Welcome and introduction ▫ Photography lesson and discussion of photovoice assignment ▫ Review of photos and focus groups discussions, telling stories behind photos

10/5/12 ¡ 21 ¡ Photovoice Outcomes

• Displayed throughout the city
• Used in intervention materials

BHCK Study Design BHCK study design

• 30 recreation centers divided into 2 waves
• Randomized into round 1 and round 2 (delayed

intervention)

• 24 adolescent-adult caregiver dyads sampled per rec

center area (n=720 dyads)

• Dyads assessed at pre and post intervention
• Store, carryout, recreation center assessments at

baseline, interim, post-intervention and follow-up

BHCK Study Design Sample Selection

• Goal: Obtaining a random sample of dyads from

each HEZ

▫ Option 1: Enumerate houses in HEZs, door to door recruitment

– Time, costs, safety, feasibility

▫ Option 2: Creation of a sampling frame

Sampling Frame

• Children will be recruited and screened

▫ Rec centers ▫ Corner stores/ carryouts

• 24 children from each zone will be randomly

selected

▫ Invited to participate ▫ Obtain parental consent

10/5/12 ¡ 22 ¡ BHCK Evaluation Plan

• 720 children, aged 10 -14 years old

▫ 3 dietary recalls, psychosocial factors, food getting, food preparations, BMI, food source usage

• 720 adult caregivers

▫ Demographics, psychosocial factors, food getting, food preparation, food security, BMI, food source usage

But here’s a problem…

• Store addresses/ exact locations are unknown

▫ Customers usually recall food source location via description

• Customer use nicknames for stores

▫ Referred to by: storeowner’s name, physical characteristics, or random nicknames

• Frequent changes in store names/ownership
• How can you track exposure to food source

interventions if you don’t know which specific places people are getting food?

• Here’s our solution…

GIS Technology

• Food source location data

is collected via a 7” Lenovo tablet PC

• GIS information is entered
• n site at the food

source, including exact location coordinates

• Information is

downloaded to a database

• Databases will be

transferred back to tablet, and used for data collection

Ground Truthing of Food Source Information & Creating the Database

Entering food source information into tablet

10/5/12 ¡ 23 ¡ A complete food source entry Using the Database to Increase Accuracy of Food Source Data Collection Food Source Data Collection

Key descriptive terms can be used to search database and retrieve store images

• Store name
• Store address
• Food source type
• Store nicknames
• Cross streets
• Color of store front
• Types of food sold

Search results display photos of all stores that match participants descriptions

10/5/12 ¡ 24 ¡

• Identified store

can enlarged on tablet PC’s screen to confirm food source for increased accuracy

• Each store will be

given a unique ID number for use in recording food sources accessed

S t

• r

e I D : 6 3 4

Next Steps for BHCK

• Finishing formative research with

children and caretakers

• Pilot testing instruments at Patterson Park rec
• Recruiting youth (ages 10-14) from rec centers/

neighborhoods

• Conducting baseline interviews with children

and caretakers (approx. 24 dyads per rec center)

• Conducting Photovoice project
• Creating intervention materials and intervention

plan/curricula

What do you think?: Questions & Comments