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Household food insecurity is not necessarily equally experienced by all household members, with mothers often changing their intake first when food resources are limited. The purpose of this study was to understand the association between maternal mental health and intrahousehold differences in food security statuses. A cross-sectional survey was administered to Virginia mothers with low income (August-October 2021), assessing validated measures of food security, mental and physical health and related factors. Participants ( n = 570) were grouped according to the food security status of adults and children within the household. Linear regression was used to assess the outcomes of interest by group and controlled for key demographic variables. Mothers in households with any food insecurity reported worse overall mental health and used 3-4 more food coping strategies than households experiencing food security ( p < 0.05). Only mothers in households where adults experienced food insecurity reported significantly greater anxiety and depressive symptoms (61.5 and 58.1, respectively) compared to households experiencing food security (55.7 and 52.4, p < 0.001). While any experience of household food insecurity is associated with worse maternal mental health, there were differences by the within-household food security status. Future research should explore screening measures that capture specific household members' food security to connect households with available resources.

Objective: To explore factors influencing the adoption of direct education programs and policy, systems, and environmental (PSE) change initiatives focused on physical activity for Supplemental Nutrition Assistance Program-eligible audiences by Virginia Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program-Education (SNAP-Ed) staff., Methods: Online survey with Expanded Food and Nutrition Education Program and SNAP-Ed peer (paraprofessional) educators (n = 28) and SNAP-Ed agents (master of science level) (n = 9) in Virginia. Descriptive statistics were computed for sociodemographic characteristics and responses to questions on the basis of Likert-type scales. Exploratory factor analyses were run to identify the underlying structures of the different variables., Results: The main factors for peer educators were related to substituting nutrition programs or content for physical activity programs. Other factors included staff qualifications and expectations about leading vs teaching physical activities. For PSEs, the top factors were the capacity to reach many community members, attract new partners and stakeholders, and personal interest in the PSE., Conclusions and Implications: The results provide insight into potential barriers and motivators for adopting physical activity education and PSEs within community-based initiatives and can be used to inform program planning and staff training. Additional research is warranted to examine other factors influencing the adoption and implementation of physical activity programs and PSEs., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Opioid use disorder is a leading public health issue in the USA, with complex drivers requiring a multi-level response. Rural communities are particularly affected by opioid misuse. Due to variability in local conditions and resources, they require community-specific responses. The aim of this study was to gain insight into the perceptions, knowledge, and experiences of members of a rural community impacted by the opioid crisis to inform the development of local strategies to address the crisis., Methods: Stakeholder focus groups were conducted by a participatory research team as part of a larger project using the Stakeholder Engagement in Question Development and Prioritization (SEED) Method., Results: Key findings from the focus groups included the importance of family dynamics and social networks as risk and resiliency factors, addressing hopelessness as a preventive strategy, the need for holistic approaches to treatment, childhood exposure resulting in intergenerational substance use, the needs of overburdened healthcare providers, the expansion of long-term rehabilitation programs, and the need for judicial reform towards those with opioid use disorder. Specific and well-defined strategies are needed for more comprehensive methods to address the complexity of opioid use disorder. Understanding factors that contribute to opioid use disorder in rural communities through a stakeholder engagement process should be the first responsive strategy in developing actions., Conclusion: This study shows that rural community stakeholders provide important perspectives that can be useful in solving the drug epidemic in their neighborhoods. Their understanding of the internal dynamics of the communities' needs offers a unique roadmap in which prioritized actions can be customized and adapted for improving health outcomes.

The purpose of this communication is to describe the preliminary evaluation of the Virginia Fresh Match (VFM) financial incentive program for fresh fruits and vegetables for Virginia Supplemental Nutrition Assistance Program shoppers and to determine if there were differences in incentive outcomes by race. In this cross-sectional study, a questionnaire was administered to shoppers using Virginia Fresh Match incentives at participating farmers markets and community-based food retail outlets. Repeated measures ANOVAs were used to detect differences in fruit and vegetable consumption between demographic groups over time. Chi-square tests were used to determine if there were associations between race and perceived impact of VFM incentives on making food last and the attribution of VFM incentives to changes in fruit and vegetable consumption frequency. Frequency of fruit and vegetable intake was significantly higher during VFM incentive use, with a difference of 1.17 ± 0.07 and 1.07 ± 0.07 on a Likert scale measure, respectively ( p ≤ 0.001). There were racial differences in assertions that VFM incentives helped food to last. VFM incentives were effective at increasing fruit and vegetable consumption, but racial differences should be considered in the administration of VFM to avoid reinforcing systems or approaches that may contribute to disparities in food access and food security.

Food insecurity, which disproportionately impacts mothers, can have chronic consequences on physical and mental health. There is a relationship between food insecurity and mental health, but the relationship’s mechanisms are unclear. This study aimed to understand how mental health outcomes differ by food insecurity severity and race among Virginia mothers. A cross-sectional survey employed previously validated food security status measures, physical and mental health, social support, and food coping strategies. Results were analyzed using descriptive statistics, Spearman’s rank-order correlations, linear regression, and chi-squared with effect sizes. Overall, respondents (n = 1029) reported worse mental health than the U.S. average (44.3 ± 10.1 and 50, respectively). There was a large effect of food security on mental health (d = 0.6), with worse mental health outcomes for mothers experiencing very low food security (VLFS) than low food security (LFS; p < 0.001). There was a small effect of race on mental health (φc = 0.02), with Black mothers having better mental health than White mothers (p < 0.001). Compared to mothers experiencing LFS, mothers experiencing VLFS had less social support (d = 0.5) and used more food coping strategies, especially financial strategies (d = −1.5; p < 0.001). This study suggests that food-insecure mothers experience stressors and lack adequate social support, which is even more distinct for mothers experiencing VLFS.

The δ 13 C value of blood is a novel proposed biomarker of added sugars (AS) intake. AS prediction equations using either a single- (δ 13 C) or dual-isotope model (δ 13 C and δ 15 N) were previously developed in an adult population with high AS intake living in southwest Virginia (reference group). The purpose of this investigation was to test the δ 13 C single- and δ 13 C and δ 15 N dual-isotope prediction equations for AS intake in adults with a lower mean AS intake and different demographic characteristics (test group). The blood samples for the reference ( n = 257 for single-isotope, n = 115 for dual-isotope) and test groups ( n = 56) were analyzed for δ 13 C and δ 15 N values using natural abundance stable isotope mass spectrometry and were compared to reported dietary AS intake. When the δ 13 C single-isotope equation was applied to the test group, predicted AS intake was not significantly different from reported AS intake (mean difference ± standard error = -3.6 ± 5.5 g, Z = -0.55, p = 0.51). When testing the dual-isotope equation, predicted AS was different from reported AS intake (mean difference ± SEM = 13.0 ± 5.4 g, Z = -2.95, p = 0.003). δ 13 C value was able to predict AS intake using a blood sample within this population subset. The single-isotope prediction equation may be an alternative method to assess AS intake and is more objective, cost-feasible, and efficient than traditional dietary assessment methods. However, more research is needed to assess this biomarker with rigorous study designs such as controlled feeding.

Introduction: Adult onset diabetes is a significant health issue in rural communities that are disproportionately suffering from the health, social and financial costs of the disease. Despite this, over half of rural counties in the USA lack access to diabetes self-management programs, which are effective at improving diabetes management. The Cooperative Extension System &#40;CES&#41; is a nationwide education network that provides research-based information and programs in nearly 3000 counties in the USA to improve the health and wellbeing of rural and urban communities. This study evaluated the implementation and outcomes of a lifestyle management program, Balanced Living with Diabetes (BLD) conducted by community-based educators who are part of the CES in rural Virginia, to address the gap in diabetes education in these communities. BLD is grounded in social cognitive theory and has shown efficacy to modify dietary and physical activity behaviors resulting in improved glycemic control in people with type 2 diabetes., Methods: The study evaluated the implementation and effectiveness of BLD programs conducted by the CES in 16 rural counties over 2 years. Program adoption, reach, context, and barriers and facilitators to implementation were evaluated through program outcome data and extension educator interviews. Program outcomes included change in weight, glycosylated hemoglobin (A1C), diabetes knowledge, self-management practices, diet and physical activity behaviors, and self-efficacy from baseline to 12-week assessment., Results: Extension educators conducted 30 programs, reaching 290 residents, with a 58% mean retention rate. The program resulted in a significant increase in diabetes and food knowledge, fruit, vegetable, and whole grain intake, use of the plate method, exercise, and diabetes management self-efficacy. A1C decreased significantly in participants with diabetes (mean reduction=0.345&plusmn;1.013; p=0.001). The program was conducted twice in 11 counties, and once in five counties. Barriers to program adoption in the five counties included limited community interest, competing program priorities of the extension educator, and loss of extension personnel to conduct the program. Participant communication materials and systems to enhance program sustainability were developed in response to educator feedback. Process evaluation indicated that the program was highly acceptable to extension educators and program participants., Conclusion: The CES is an effective network for implementation of diabetes lifestyle-management programs in underserved communities, and the BLD program is effective at increasing lifestyle behaviors and self-efficacy that improve glycemic control in people with type 2 diabetes. Collaboration by Virginia's CES with a variety of community partners, including healthcare and social service providers, increases the reach and sustainability of extension diabetes programs. The CES in the USA is well positioned to fill the gap in diabetes education in rural communities as part of a chronic care model.

Background: In 2015, the Partnership for a Healthier America launched the branded Fruits & Veggies (FNV) Campaign to apply a unique industry-inspired marketing approach to promote fruit and vegetable sales and intake to moms and teens in two US pilot markets: Fresno, California and Hampton Roads, Virginia. The aims of this cross-sectional study were to: 1) assess brand awareness and fruit- and vegetable-related outcomes among FNV Campaign target audiences in the California and Virginia market locations; and 2) examine whether reported awareness of the FNV Campaign was associated with differences in fruit- and vegetable-related cognitive and behavioral outcomes., Methods: Data for this cross-sectional study were collected using an online survey administered to a non-probability convenience sample (n = 1604; February-July 2017) of youth aged 14-20 years (n = 744) and moms aged 21-36 years (n = 860) in the two pilot markets. Descriptive statistics were computed and outcomes compared between unaware and aware respondents, controlling for sociodemographic covariates. Multivariate analysis of covariance (MANCOVA) was conducted to assess whether fruit- and vegetable-related attitude, belief, and encouragement outcomes differed by FNV Campaign awareness; logistic regression was used to examine associations between FNV brand awareness and dichotomous variables (fruit- and vegetable-related behavioral intentions, trying new fruits and vegetables); and ANCOVA was used to assess associations with daily fruit and vegetable intake frequency., Results: Approximately 20% (n = 315/1604) of respondents reported awareness of the FNV Campaign. Youth that reported awareness of the FNV Campaign (n = 167, 22.4%) had higher intentions to buy (p = 0.003) and eat (p = 0.009) fruits and vegetables than unaware respondents. Mothers that reported awareness of the FNV Campaign (n = 148, 17.2%) reported greater encouragement for friends and family to eat fruits and vegetables (p = 0.013) and were approximately 1.5 times more likely to report trying a new fruit or vegetable (p = 0.04) than mothers unaware of the Campaign. Daily fruit and vegetable intake frequency did not differ by Campaign awareness., Conclusions: FNV Campaign awareness was associated with limited but positive short- and intermediate-term cognitive and behavioral outcomes among target audience respondents. These findings can inform future research to enhance understanding and improve the FNV Campaign as it is expanded to new markets nationwide.

Purpose: United States Department of Agriculture Supplemental Nutrition Assistance Program (SNAP) participants use SNAP-authorized stores for dietary purchases. Relationships between obesity prevalence and access to grocery and varied nontraditional (eg, dollar, drug, and convenience) SNAP settings are underexplored. This research aimed to determine the association of a full range of SNAP-authorized stores with obesity prevalence in Virginia., Design: The SNAP Retailer Locator was used to cross-sectionally identify authorized stores, and county health ranking information was applied based on store location., Setting: Virginia, United States., Sample: The SNAP-authorized stores, classified among store categories: grocery or supermarket; drug; mass merchandiser; supercenter; convenience; dollar; club; other; nonfood store; farmers markets; and independent grocery stores., Measures: County-level obesity prevalence with income and rurality as potential confounders., Analysis: Multiple linear regression was used to determine associations between county-level adult obesity prevalence and available SNAP-authorized store formats ( P < .05 a priori)., Results: Store format was a predictor of obesity prevalence in Virginia in simple and adjusted models ( R 2 < .0001 and P < .0001 and R < .0001, respectively). Grocery store or supermarket access was associated with obesity. The SNAP-authorized convenience, dollar, and nonfood stores were associated with a 0.3, 0.5, and 1.3 increase in county obesity prevalence, respectively ( 2 = 0.434, P < .0001, respectively). Grocery store or supermarket access was associated with obesity. The SNAP-authorized convenience, dollar, and nonfood stores were associated with a 0.3, 0.5, and 1.3 increase in county obesity prevalence, respectively ( P < .05)., Conclusions: Research, practice, and health policy approaches to improve grocery, convenience, dollar, and restaurant or delivery service settings may favorably influence community obesity prevalence in Virginia.

Colorectal cancer is the third leading cause of cancer death in the USA, yet is highly preventable and detectable at an early stage through screening. Virginia Cooperative Extension (VCE) implemented a worksite colon cancer awareness program to increase colorectal cancer screening rates and preventive lifestyle behaviors among its employees. The Colon Cancer-Free Zone program is designed using best practice principles of worksite health programs and includes information sessions covering the topics of colorectal cancer, screening guidelines, insurance coverage, and preventive lifestyle behaviors. It is conducted in a campaign format that includes a strategic communication strategy targeting relevant screening barriers and facilitators, peer champions, and incentives. The program was implemented with VCE employees statewide utilizing a web-based system for the information sessions, and resulted in broad participation, a significant increase in screening self-efficacy (4.15 ± 0.64 vs 3.81 ± 0.76, ρ = 0.006), changes in diet and physical activity (50% and 40% of participants, respectively), and a 20.6% increase in the employee colorectal cancer screening rate. A Colon Cancer-Free Zone toolkit was developed for use by Extension Agents to implement the program at worksites in their service communities.

Objective: To examine public commitments for encouraging United States consumers to make healthy dietary purchases with their Supplemental Nutrition Assistance Program (SNAP) benefits among of prevalent SNAP-authorised retailers., Setting: National SNAP-authorised retail landscape in addition to stores located in California and Virginia, two states targetted for a Partnership for a Healthier America pilot social marketing campaign., Participants: SNAP-authorised retailers with the most store locations in selected settings., Design: A review of retailers' publicly available business information was conducted (November 2016-February 2017). Webpages and grey literature sources were accessed to identify corporate social responsibility (CSR) reports and commitments describing strategies to encourage healthy consumer purchases aligned with the 2015-2020 Dietary Guidelines for Americans. Evidence was organised using a marketing-mix and choice-architecture (MMCA) framework to characterise strategies used among eight possible types (i.e. place, profile, portion, pricing, promotion, priming, prompting and proximity)., Results: Of the SNAP-authorised retailers (n 38) reviewed, more than half (n 20; 52·6 %) provided no information in the public domain relevant to the research objective. Few retailers (n 8; 21·1 %) had relevant CSR information; grey literature sources (n 52 articles across seventeen retailers) were more commonly identified. SNAP-authorised retailers in majority committed to increasing the number of healthy products available for purchase (profile)., Conclusions: Substantial improvements are needed to enhance the capacity and commitments of SNAP-authorised retailers to use diverse strategies to promote healthy purchases among SNAP recipients. Future research could explore feasible approaches to improve dietary behaviours through sector changes via public-private partnerships, policy changes, or a combination of government regulatory and voluntary business actions.

Objective: To determine barriers, motivators, and perspectives regarding plate waste reduction of early adolescents., Design: Trained interviewers conducted audio-recorded individual interviews with adolescents., Setting: Elementary schools implementing the National School Lunch Program in Hawai'i, Montana, and Virginia., Participants: Early adolescents (n = 47, aged 9-13 years) from families receiving or eligible to receive Supplemental Nutrition Assistance Program benefits were recruited to participate., Phenomenon of Interest: Factors influencing plate waste among adolescents and potential plate waste reduction strategies., Analysis: Coders analyzed content and thematic data to identify code categories and themes., Results: Main barriers to reducing school lunch plate waste were unsupportive school policy, undesirable food quality, satiation, and social influences. Key motivators to reducing school lunch plate waste were supportive school policy, including allowing students to share food with peers and save food to eat later; and social influences. Participants found it acceptable to throw away disliked food and unacceptable to throw away wanted food; they perceived that their peers did not care whether food was thrown away; and they thought their parents disliked wasting food., Conclusion and Implications: Results suggest that several factors might allow for minimization of school lunch plate waste in the National School Lunch Program, including improvements in food quality, food policy, and social influences. Under these important themes, strategies to employ may include improving food preparation and taste, allocating more time for students to finish lunch, allowing students to self-select food lunch items, and permitting them to share and save their leftover food., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate differences in school breakfast participation and food waste in 1 school district before and after the adoption of Breakfast in the Classroom., Methods: Using a pretest-posttest design, participation and food waste were measured from 7 elementary schools in a rural area of southwest Virginia during the 2014-2015 school year. Participation and waste were measured on 4 days in each school (twice before and twice after Breakfast in the Classroom implementation) using the quarter-waste method., Results: Across all schools, food waste decreased from 43.0% to 38.5% with Breakfast in the Classroom, with significant decreases for entrée items, juice, and savory snack foods (P < .01). Fruit and cheese items generated the greatest amount of food waste at 58.2% and 49.0%, respectively., Conclusions and Implications: Breakfast in the Classroom may be an effective tool to decrease food waste while improving dietary intake. Future research is needed among more diverse populations., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objectives: This study examines the relationships among self-reported body mass index (BMI), weight perception, and weight intention of rural Appalachian middle school students in southwest Virginia where there are higher rates of health disparities influenced by culture, economic distress, and geographic barriers., Study Design: This was a cross-sectional observational study., Methods: Sixth and seventh grade students (n = 492) in seven, rural, southwest Appalachian Virginia middle schools participated in this study in the spring of 2015., Results: A relatively high percentage of students classified as overweight/obese based on self-reported BMI (n = 196, 39.8%), yet only 29.3% (n = 144) of students believed themselves to be overweight. More boys (48.3%) than girls (29.8%) were classified based on self-reported BMI to be overweight, yet 44.9% of girls indicated the desire to lose weight., Conclusions: Distinct differences between sexes were found, where more boys were classified as overweight/obese and more girls wanted to lose weight. Previous studies have shown that perspectives of overweight/obese differ in Appalachian communities. These results emphasize the need for both region-specific and sex-specific programs for healthy body weights particularly in rural Appalachian United States., (Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Although reducing sugar-sweetened beverage (SSB) intake is an important behavioral strategy to improve health, no known SSB-focused behavioral trial has examined maintenance of SSB behaviors after an initial reduction. Guided by the RE-AIM framework, this study examines 6-18 month and 0-18 month individual-level maintenance outcomes from an SSB reduction trial conducted in a medically-underserved, rural Appalachia region of Virginia. Reach and implementation indicators are also reported., Methods: Following completion of a 6-month, multi-component, behavioral RCT to reduce SSB intake (SIPsmartER condition vs. comparison condition), participants were further randomized to one of three 12-month maintenance conditions. Each condition included monthly telephone calls, but varied in mode and content: 1) interactive voice response (IVR) behavior support, 2) human-delivered behavior support, or 3) IVR control condition. Assessments included the Beverage Intake Questionnaire (BEVQ-15), weight, BMI, and quality of life. Call completion rates and costs were tracked. Analysis included descriptive statistics and multilevel mixed-effects linear regression models using intent-to-treat procedures., Results: Of 301 subjects enrolled in the 6-month RCT, 242 (80%) were randomized into the maintenance phase and 235 (78%) included in the analyses. SIPsmartER participants maintained significant 0-18 month decreases in SSB. For SSB, weight, BMI and quality of life, there were no significant 6-18 month changes among SIPsmartER participants, indicating post-program maintenance. The IVR-behavior participants reported greater reductions in SSB kcals/day during the 6-18 month maintenance phase, compared to the IVR control participants (- 98 SSB kcals/day, 95% CI = - 196, - 0.55, p < 0.05); yet the human-delivered behavior condition was not significantly different from either the IVR-behavior condition (27 SSB kcals/day, 95% CI = - 69, 125) or IVR control condition (- 70 SSB kcals/day, 95% CI = - 209, 64). Call completion rates were similar across maintenance conditions (4.2-4.6 out of 11 calls); however, loss to follow-up was greatest in the IVR control condition. Approximated costs of IVR and human-delivered calls were remarkably similar (i.e., $3.15/participant/month or $38/participant total for the 12-month maintenance phase), yet implications for scalability and sustainability differ., Conclusion: Overall, SIPsmartER participants maintained improvements in SSB behaviors. Using IVR to support SSB behaviors is effective and may offer advantages as a scalable maintenance strategy for real-world systems in rural regions to address excessive SSB consumption., Trial Registry: Clinicaltrials.gov; NCT02193009 ; Registered 11 July 2014. Retrospectively registered.

Purpose: To test the feasibility of Kids SIP smartER, a school-based intervention to reduce consumption of sugar-sweetened beverages (SSBs)., Design: Matched-contact randomized crossover study with mixed-methods analysis., Setting: One middle school in rural, Appalachian Virginia., Participants: Seventy-four sixth and seventh graders (5 classrooms) received Kids SIP smartER in random order over 2 intervention periods. Feasibility outcomes were assessed among 2 teachers., Intervention: Kids SIP smartER consisted of 6 lessons grounded in the Theory of Planned Behavior, media literacy, and public health literacy and aimed to improve individual SSB behaviors and understanding of media literacy and prevalent regional disparities. The matched-contact intervention promoted physical activity., Measures: Beverage Intake Questionnaire-15 (SSB consumption), validated theory questionnaires, feasibility questionnaires (student and teacher), student focus groups, teacher interviews, and process data (eg, attendance)., Analysis: Repeated measures analysis of variances across 3 time points, descriptive statistics, and deductive analysis of qualitative data., Results: During the first intervention period, students receiving Kids SIP smartER (n = 43) significantly reduced SSBs by 11 ounces/day ( P = .01) and improved media ( P < .001) and public health literacy ( P < .01) understanding; however, only media literacy showed between-group differences ( P < .01). Students and teachers found Kids SIP smartER acceptable, in-demand, practical, and implementable within existing resources., Conclusion: Kids SIP smartER is feasible in an underresourced, rural school setting. Results will inform further development and large-scale testing of Kids SIP smartER to reduce SSBs among rural adolescents.

Objective: To evaluate the reliability of the Market Basket Assessment Tool (MBAT) for assessing the availability of fruits and vegetables, low-fat or nonfat dairy and eggs, lean meats, whole-grain products, and seeds, beans, and nuts in Supplemental Nutrition Assistance Program-authorized retail environments., Methods: Different trained raters used the MBAT simultaneously at 14 retail environments to measure interrater reliability. Raters returned to 12 retail environments (85.7%) 1 week later to measure test-retest reliability. Data were analyzed using paired-sample t tests and correlations., Results: No significant differences were found for interrater reliability or test-retest reliability for individual categories (mean differences, 0.0 to 0.3 ± 0.2 points) or total score (mean difference, 0.5 ± 0.4 points and (mean differences, 0.0 to 0.3 ± 0.3 points) or total score (mean difference, 0.8 ± 0.4 points), respectively., Conclusions and Implications: Future steps include validation of the MBAT. A low-burden tool can facilitate evaluation of efforts to promote healthful foods in retail environments., (Copyright © 2018 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

In order to better assess non-nutritive sweetener (NNS) consumption, measurement tools with greater utility are needed. The objective of this investigation is to determine the reproducibility and validity of a newly developed NNS food frequency questionnaire (NNS-FFQ) that measures five types of NNS (saccharin, aspartame, acesulfame potassium, sucralose and erythritol). Adult participants ( n = 123, 56% female, 75% Caucasian, mean age = 36.8 ± 16.6) completed the NNS-FFQ twice and had 24-h dietary recalls three times over a two-week study period. Reproducibility between two administrations of the NNS-FFQ was assessed via Bland-Altman plots, Spearman's correlations ( r s ) and paired samples t -tests. Bland-Altman plots, Cohen's κ, Spearman's correlations ( r s ), and paired samples t -tests compared NNS intake between the two methods for validity. For reproducibility analyses, Bland-Altman analyses revealed agreement levels above the 95% acceptance level for total NNS (99.2%), erythritol (99.2%), and aspartame (96.7%). Agreement levels for acesulfame potassium (94.3%), saccharin (94.3%), and sucralose (94.3%) were slightly below the acceptable level. For validity analyses, Bland-Altman analyses revealed agreement levels above the 95% acceptance level for total NNS (95.1%), sucralose (95.9%), saccharin (95.9%), and erythritol (95.1%). Agreement levels for aspartame (94.3%) and acesulfame potassium (92.7%) were slightly below the acceptable level. Although less than desirable agreement was found between the methods for aspartame and acesulfame potassium, some variance was expected due to the habitual nature of the NNS-FFQ as compared to the recent intake reported by recalls. Within the context of this constraint, the NNS-FFQ demonstrates acceptable reproducibility and validity. The NNS-FFQ is a brief questionnaire that could be administered among diverse participants at the individual and population levels to measure habitual NNS intake., Competing Interests: The authors declare no conflict of interest.

Few data assessing non-nutritive sweetener (NNS) intake are available, especially within rural, health-disparate populations, where obesity and related co-morbidities are prevalent. The objective of this study is to characterize NNS intake for this population and examine the variance in demographics, cardio-metabolic outcomes, and dietary intake between NNS consumers and non-consumers. A cross-sectional sample ( n = 301) of Virginian adults from a randomized controlled trial (data collected from 2012 to 2014) targeting sugar-sweetened beverage (SSB) intake completed three 24-h dietary recalls, and demographics and cardio-metabolic measures were assessed. The frequency, types, and sources of NNS consumption were identified. Thirty-three percent of participants reported consuming NNS ( n = 100). Sucralose was the largest contributor of mean daily NNS intake by weight (mg), followed by aspartame, acesulfame potassium, and saccharin. NNS in tabletop sweeteners, diet tea, and diet soda were the top contributors to absolute NNS intake. The most frequently consumed NNS sources were diet sodas, juice drinks, and tabletop sweeteners. Although mean body mass index (BMI) was greater for NNS consumers, they demonstrated significantly lower food, beverage, and SSB caloric intake and energy density, and higher overall dietary quality. It remains unclear whether NNS use plays a role in exacerbating weight gain. NNS consumers in this sample may have switched from drinking predominantly SSB to drinking some NNS beverages in an effort to cope with weight gain. Future studies should explore motivations for NNS use across a variety of weight and health categories., Competing Interests: The authors declare no conflict of interest.

Parenting style influences a child's overall diet quality and establishes food preferences. Parenting style and "food rules" for children differ by eating at home or away from home. Eating meals away from home is increasing despite associations with consumption of unhealthy foods and higher weight status. The objective of the current study was to compare parenting practices and decision-making at restaurants versus at home. A mixed methods approach was utilized: facilitated, individual interviews to explore decision-making and parenting practices; written questionnaires for socio-demographic information; and body mass index. Summaries and emergent themes were generated based on examination of tapes and transcripts. Descriptive statistics were computed for questionnaire data. Twenty-five mothers of children of five to eight years who ate at restaurants at least two times per week participated. Mothers reported more permissive food rules at restaurants yet maintained higher behavioral expectations. Mothers were also more likely to make decisions about whether they eat out, where to eat, and children's meal selections than their children. The findings suggest that parenting practices toward overall behavior and food choices may differ at restaurants than at home, highlighting the importance of healthy menu options, further research, and educational strategies., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To assess differences, by health literacy status and behavioral condition, in participants' abilities to self-monitor behaviors accurately and recall key behavioral messages using data from a teach-back call., Design: Cross-sectional., Setting: Rural, southwestern Virginia., Participants: Adults (n = 301). The majority were female (81.1%), 31.9% had a high school education or less, 66.1% earned < $25,000/y, and 32.9% were low health literate., Intervention: First class session of 2 community-based behavioral interventions: SIPsmartER (reduce sugar-sweetened beverage intake) or MoveMore (increase physical activity)., Main Outcome Measures: Reported accuracy of behavioral diary completion, proportion of behavioral messages recalled during the first round of teach-back, and rounds of teach-back., Analysis: Descriptive statistics and generalized linear model., Results: Low health literate participants were significantly less accurate in diary completion (P < .001), recalled fewer behavioral messages correctly (P < .001), and needed more rounds of teach-back (P < .001) than high health literate participants. Compared with SIPsmartER participants, MoveMore participants more accurately completed diaries (P = .001) but recalled a lower proportion of behavioral messages correctly (P < .001) and required more rounds of teach-back (P < .001)., Conclusions and Implications: Health literacy status and behavioral target affect the ability to self-monitor and recall key concepts. Researchers should consider using teach-back early in the intervention to assess and reinforce participants' ability to self-monitor., (Copyright © 2016 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objective: Few published community garden studies have focused on low socio-economic youth living in public housing or used a community-based participatory research approach in conjunction with youth-focused community garden programmes. The objective of the present study was to evaluate the feasibility (i.e. demand, acceptability, implementation and limited-effectiveness testing) of a 10-week experiential theory-based gardening and nutrition education programme targeting youth living in public housing., Design: In this mixed-methods feasibility study, demand and acceptability were measured using a combination of pre- and post-programme surveys and interviews. Implementation was measured via field notes and attendance. Limited-effectiveness was measured quantitatively using a pre-post design and repeated-measures ANOVA tests., Setting: Two public housing sites in the Dan River Region of south central Virginia, USA., Subjects: Forty-three youth (primarily African American), twenty-five parents and two site leaders., Results: The positive demand and acceptability findings indicate the high potential of the programme to be used and be suitable for the youth, parents and site leaders. Field notes revealed numerous implementation facilitators and barriers. Youth weekly attendance averaged 4·6 of 10 sessions. Significant improvements (P<0·05) were found for some (e.g. fruit and vegetable asking self-efficacy, overall gardening knowledge, knowledge of MyPlate recommendations), but not all limited-effectiveness measures (e.g. willingness to try fruits and vegetables, fruit and vegetable eating self-efficacy)., Conclusions: This community-based participatory research study demonstrates numerous factors that supported and threatened the feasibility of a gardening and nutrition programme targeting youth in public housing. Lessons learned are being used to adapt and strengthen the programme for future efforts targeting fruit and vegetable behaviours.

The study objective was to examine the nutritional quality of competitive foods and beverages (foods and beverages from vending machines and à la carte foods) available to rural middle school students, before implementation of the US Department of Agriculture's Smart Snacks in School standards in July 2014. In spring 2014, we audited vending machines and à la carte cafeteria foods and beverages in 8 rural Appalachian middle schools in Virginia. Few schools had vending machines. Few à la carte and vending machine foods met Smart Snacks in School standards (36.5%); however, most beverages did (78.2%). The major challenges to meeting standards were fat and sodium content of foods. Most competitive foods (62.2%) did not meet new standards, and rural schools with limited resources will likely require assistance to fully comply.

Objective: Approximately 40% of children bring a packed lunch to school. Little is known about the quality of these lunches. This study examined the nutritional quality of packed lunches compared with school lunches for pre-kindergarten and kindergarten children after the implementation of 2012-2013 National School Lunch Program standards., Methods: The researchers collected observational data for packed and school lunches from 3 schools in rural Virginia for 5 consecutive school days and analyzed them for macro and micro nutrients., Results: Of the 1,314 observations collected; 42.8% were packed lunches (n = 562) and 57.2% were school lunches (n = 752). Energy, fat, saturated fat, sugar, vitamin C, and iron were significantly higher whereas protein, sodium, fiber, vitamin A, and calcium were significantly lower for packed lunches than school lunches., Conclusions and Implications: Packed lunches were of less nutritional quality than school lunches. Additional research is needed to explore factors related to choosing packed over school lunches., (Copyright © 2014 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objective: To explore Family Nutrition Program assistants' perception of farmers' markets and alternative agricultural practices for themselves and their clients., Methods: Cross-section design, survey of Virginia Expanded Food and Nutrition Education Program (NEP) and Supplemental Nutrition Assistance Program-Education Family Nutrition Program assistants (n = 52) working with limited-resource populations., Results: Twenty-one percent to 55% of FNP assistants valued alternative agricultural practices, and only 5% to 8% of FNP assistants perceived that their clients did so. Benefits to shopping at farmers' markets included supporting local economies, and food price, quality, and safety. Barriers included lack of transportation, location/convenience, hours, and food prices. Assistants rated the benefits to shopping at farmers' markets similarly for themselves and their clients, but rated many of the barriers to shopping at farmers' markets as significantly lower (P < .05) for themselves than for their clients., Conclusions and Implications: Future assistant trainings should address the connection between agriculture and health, and how to overcome barriers to shopping at farmers' markets for their clients., (Copyright © 2014 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Background: We hypothesized that the combination of nebivolol and lifestyle modification would reduce large artery stiffness in middle-aged and older hypertensive adults more than either intervention alone., Methods: To address this, 45 men and women (age 40-75 years) with stage I hypertension were randomized to receive either nebivolol (NB; forced titration to 10 mg OD; n = 15; age 57.2 ± 11.4 years; body mass index [BMI] 30.8 ± 5.8 kg/m(2)), lifestyle modification (LM; 5-10% weight loss via calorie restriction and physical activity; n = 15; age 52.7 ± 8.5 years; BMI 33.9 ± 7.2 kg/m(2)) or nebivolol plus lifestyle modification (NBLM; n = 15; age 58.9 ± 9.4 years; BMI 32.5 ± 4.9 kg/m(2)) for 12 weeks. β-stiffness index, a blood-pressure-independent measure of arterial stiffness, and arterial compliance were measured via high-resolution ultrasound and tonometry at baseline and after the 12-week intervention. There was no difference between groups in age, body weight or composition, blood pressure, or in β-stiffness index or arterial compliance at baseline (all p > 0.05)., Results: Following the 12-week intervention, body weight decreased ~5% (p < 0.05) in the LM and NBLM groups but did not change from baseline in the NB group (p > 0.05). Supine brachial and carotid systolic and diastolic blood pressure declined following treatment in each of the groups (p < 0.05). However, the magnitude of reduction was not different (p < 0.05) between groups. β-stiffness index declined (-2.03 ± 0.60, -1.87 ± 0.83 and -2.51 ± 0.90 U) and arterial compliance increased similarly (both p > 0.05) in the NB, LM and NBLM groups, respectively., Conclusion: In summary, our findings indicate that the combination of nebivolol and lifestyle modification reduced large artery stiffness to a similar degree as either intervention alone in middle-aged and older hypertensive adults.

Background: Public school policies related to physical activity and nutrition recently have become the focal point for policymakers to evaluate the effect of regulations on the childhood obesity epidemic. State school board associations have begun to provide school districts templates for wellness policies, and little research exists that evaluates the effect of a template on the strength and comprehensiveness of these policies., Purpose: To determine the strength and comprehensiveness of school wellness policies developed using a standard template when compared to those that do not., Methods: In 2011, a random sample of wellness policies from school districts in Virginia (ten locally developed wellness policies and ten template-based policies) was coded using a previously validated audit tool for strength and comprehensiveness. Data were reduced to a scale ranging from 0 to 1, with higher scores representing stronger and more-comprehensive policies, and compared using t-tests., Results: Overall, only 17% of school wellness policies met all federal requirements. On average, locally developed policies met five of six federal requirements, whereas VSBA policies met four of six, t(2, 21)=2.161, p<0.05. Both types of policies were ranked on a scale from 0 (weakest) to 1 (strongest); both types were weak (M=0.16±0.13) and only mildly comprehensive (M=0.37±0.16). There was a difference in policy comprehensiveness and strength between locally developed policies and template-based policies. Locally developed policies were stronger, t(2, 21)= -1.82, p<0.05, and more comprehensive, t(2, 21)= -2.5, p<0.05, than template-based policies., Conclusions: In this sample, locally developed policies were stronger than template-based policies. If replicated in large studies, these findings suggest that further research is needed about how best to support schools that wish to develop school wellness policies., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Despite recommendations, there have been few efforts to apply the community-based participatory research (CBPR) approach in the development, implementation, and evaluation of community gardens., Objectives: As guided by the CBPR approach and grounded in a social-ecological model and behavioral theory, the purpose of this mixed methods study was to understand opinions and interests in developing and implementing a community garden and to understand factors impacting fruit, vegetable, and gardening behaviors., Methods: Community and academic members collaborated to develop and execute this study. The qualitative phase- targeting regional key informants-was designed to elicit perceived benefits and challenges of community gardens at the environmental, community, and individual levels. The quantitative phase targeted low resourced youth and parents and included a variety of validated theory-based questionnaires to understand factors impacting fruit, vegetable, and gardening behaviors., Results: Major benefits of community gardens that emerged from the 10 qualitative interviews included increasing community cohesion and improving nutrition and physical activity factors. The quantitative phase included 87 youth and 67 parents. Across 16 items for fruits and vegetables, the average willingness to try was 1.32 (standard deviation [SD] = 0.40) on a 2-point scale. The majority of youth indicated they would work in a garden (n = 59; 68%) and eat food grown in their garden (n = 71; 82%). Among parents, gardening attitude, belief, and self-efficacy scores were all above average; however, gardening intentions were neutral., Conclusion: This research illustrates the successful partnering a community-academic team and has provided the partnership with a clearer lens to conceptualize and launch future regional community garden efforts.

Objective: To describe sugar-sweetened beverage (SSB) consumption and to establish psychometric properties and utility of a Theory of Planned Behavior (TPB) instrument for SSB consumption., Methods: This cross-sectional survey included 119 southwest Virginia participants. Most of the respondents were female (66%), white (89%), and had at least a high school education (79%), and their average age was 41.4 ± 13.5 years. A validated beverage questionnaire was used to measure SSB. Eleven TPB constructs were assessed with a 56-item instrument. Analyses included descriptive statistics, 1-way ANOVA, Cronbach α, and multiple regression., Results: Sugar-sweetened beverage intake averaged 457 ± 430 kcal/d. The TPB model provided a moderate explanation of SSB intake (R(2) = 0.38; F = 13.10, P < .01). Behavioral intentions had the strongest relationships with SSB consumption, followed by attitudes, perceived behavioral control, and subjective norms. The 6 belief constructs did not predict significant variance in the models., Conclusions and Implications: Future efforts to comprehensively develop and implement interventions guided by the TPB hold promise for reducing SSB intake., (Copyright © 2012 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objective: Compare the macronutrient content of children's meals sold by fast-food restaurants (FFR) and non-fast-food restaurants (NFF)., Design: All restaurants within the designated city limits were surveyed. Non-fast-food children's meals were purchased, weighed, and analyzed using nutrition software. All fast-food children's meals were recorded, with nutrient content information obtained from their respective commercial Web sites., Setting: Community in southeastern United States., Participants: 33 restaurants, 10 FFR and 23 NFF., Main Outcome Measure(s): Total weight, total calories, fat, saturated fat, protein, carbohydrates, and fiber., Analysis: Paired t tests, 1-way analysis of variance, and general linear model analyses., Results: Overall mean percentage of calories from fat for children's meals at FFR was 37.5%, and 40.5% at NFF. Significant differences (P < .01) existed between FFR and NFF, with FFR providing smaller servings, fewer calories, and less total fat, saturated fat, protein, carbohydrates, and fiber. When analyzing only with the highest calorie option side, controlling for portion size, no differences remained except saturated fat., Conclusions and Implications: Fast-food restaurants offered smaller children's portion sizes and lower-fat options. These results have implications for restaurants, parents, children, and nutrition educators.

By fall 2006 each school division participating in the National School Lunch Program was mandated to establish a local wellness policy. The study objective was to assess schools' plans for the policy, including goals for food, nutrition education, and physical activity and evaluation. Surveys were administered to 132 School Health Advisory Board coordinators in Virginia in early 2006; 92 (69.7%) responded. The findings highlight gaps toward meeting minimum requirements for the policy and give guidance on how nutrition educators and researchers can provide expertise to optimize the policy and document progress and impacts on children's health related to the policy.

Unlabelled: The SenseWear Armband (SWA; BodyMedia, Inc.), using multiple sensors, was designed to estimate energy expenditure (EE) in free-living individuals., Purpose: To examine the reliability and validity of the SWA during rest and exercise compared with indirect calorimetry (IC)., Methods: EE was assessed with SWA and IC in 13 males during two resting and one cycle ergometry (40 min at 60% VO2peak) sessions. In a second experiment, 20 adults walked on a treadmill for 30 min at three intensities (80.5 m x min, 0% grade; 107.3 m x min, 0% grade; 107.3 m x min, 5% grade) while IC and SWA measured EE., Results: At rest, no significant differences were found between EE measurements from the SWA (1.3 +/- 0.1 kcal x min) and IC (1.3 +/- 0.1 kcal x min), and the two methods were highly correlated (r = 0.76; P < 0.004). The SWA EE estimation was reliable when comparing the two resting visits (r = 0.93; P < 0.001). For the ergometer protocol, no significant differences were found between the SWA and IC measurements of EE early, mid, or late in exercise or for the total bout, although the measurements were poorly correlated (r = 0.03-0.12). The SWA EE estimate of walking increased with treadmill speed but not with incline. The SWA significantly overestimated (13-27%) the EE of walking with no grade (P < 0.02) and significantly underestimated (22%) EE on the 5% grade (P < 0.002). The SWA estimation of EE correlated moderately with IC (r = 0.47-0.69)., Conclusion: The SWA provided valid and reliable estimates of EE at rest and generated similar mean estimates of EE as IC on the ergometer; however, individual error was large. The SWA overestimated the EE of flat walking and underestimated inclined walking EE.