Making community-supported agriculture accessible to low-income families: Findings from the Farm Fresh Foods for Healthy Kids process evaluation

A randomized trial of Farm Fresh Foods for Healthy Kids (F3HK) was initiated across 4 states and 12 farms to test whether cost-offset community-supported agriculture (CO-CSA) could improve diet quality among children in low-income families. Intervention households purchased a 50% subsidized share of local produce and were invited to nine complimentary nutrition classes. The purpose of this study was to assess F3HK reach, dose, and fidelity via a mixed methods process evaluation. Screening and enrollment records indicated reach; study records and postlesson educator surveys tracked dose delivered; CSA pickup logs, lesson sign-in sheets, postseason participant surveys, and postlesson caregiver surveys assessed dose received; and coordinator audits and educator surveys tracked fidelity. Educator interviews contextualized findings. The results of this study were as follows. Reach: enrolled caregivers (n = 305) were older (p =. 005) than eligible nonenrollees (n = 243) and more likely to be female (p <. 001). Dose: mean CSA season was 21 weeks (interquartile range [IQR]: 19-23). Median CSA pickup was 88% of the weeks (IQR: 40-100). All sites offered each class at least once. Most adults (77%) and children (54%) attended at least one class; few attended all. Eighty-two percent of caregivers indicated that their household consumed most or all produce. Median lesson activity ratings were 5/5 ("very useful"). Fidelity: CSA locations functioned with integrity to project standards. Educators taught 92% of activities but frequently modified lesson order. This study demonstrates the feasibility of pairing a CO-CSA intervention with nutrition education across geographically dispersed sites. Greater integration of intervention elements and clearer allowance for site-level modifications, particularly for educational elements, may improve intervention dose and, ultimately, impact

Associations between shopping patterns, dietary behaviors, and Geographic Information System-assessed store accessibility among small food store customers

Objective: To examine associations between Geographic Information Systems (GIS)-assessed accessibility to small food stores, shopping patterns, and dietary behaviors among small food store customers. Design: Residential addresses and customer shopping patterns (frequency of shopping, previous purchase of fruits and vegetables) were gathered through customer intercept surveys. Addresses were geocoded and GIS-assessed distance and driving time from the participants' residence to the store were calculated. Dietary status and behaviors were assessed using an objective non-invasive measure of skin carotenoids, the National Cancer Institute Fruit and Vegetable Screener, and items to assess sugary beverage intake. Associations between distance and driving time, demographics, shopping frequency, prior reported purchase of fruits and vegetables at the store, and dietary behaviors were examined. Setting: Small food stores (n=22) across North Carolina. Participants: Cross-sectional convenience samples of English-speaking customers aged 18 or older (n=692). Results: Participants living closer to the small store had lower income and formal education were more likely to be Black, more likely to have previously bought fruits and vegetables at the store, and more frequently shopped at the store. In adjusted models, skin carotenoids (n=644) were positively associated with distance to the store from home in miles (p = 0.01). Conclusions: Customers who lived closer to the stores were more frequent shoppers and more likely to have previously purchased fruits and vegetables at the store yet had lower skin carotenoids. These results support continued efforts to examine how to increase the availability and promotion of healthful foods at small food retail stores

A modified choice experiment to examine willingness to participate in a Community Supported Agriculture (CSA) program among low-income parents

There is a need to improve geographical and financial access to healthy foods for limited resource populations in rural areas. Community Supported Agriculture (CSA) programs can improve access to healthy foods in rural and limited-resource populations. However, research is needed to discern the most appealing conditions for a CSA (e.g. price, frequency, food quantity) among rural, low-income customers. The goal of this study was to understand low-income consumers' preferences related to participation in a CSA program, considering price, frequency, food quantity and accessibility (e.g. distance) conditions. A modified exploratory choice experiment exercise was embedded within in-depth interviews to examine willingness to participate in CSA under a variety of conditions among 42 low-income adults with at least one child in the household in North Carolina, New York, Vermont and Washington. Willingness to participate in a CSA under each condition was summed and compared across conditions. Results were stratified by race, number of children and household members and McNemar's test and Student's t-test were used to examine differences in willingness between conditions. Salient quotes were extracted to support themes related to each condition. Our analysis suggests that the ideal CSA would be a full-sized share of eight to nine items of mixed variety, distributed every other week, priced at less than US$15, no more than 10 min further than the supermarket (SM) from their home and preferably less expensive but no more than 20% more expensive than SM prices. CSAs interested in reaching rural low-income populations may benefit from considering these consumer-level preferences

Examining the Association between Intervention-Related Changes in Diet, Physical Activity, and Weight as Moderated by the Food and Physical Activity Environments among Rural, Southern Adults

Background Few studies have been conducted in rural areas assessing the influence of community-level environmental factors on residents’ success improving lifestyle behaviors. Objective Our aim was to examine whether 6-month changes in diet, physical activity, and weight were moderated by the food and physical activity environment in a rural adult population receiving an intervention designed to improve diet and physical activity. Design We examined associations between self-reported and objectively measured changes in diet, physical activity, and weight, and perceived and objectively measured food and physical activity environments. Participants were followed for 6 months. Participants/setting Participants were enrolled in the Heart Healthy Lenoir Project, a lifestyle intervention study conducted in Lenoir County, located in rural southeastern North Carolina. Sample sizes ranged from 132 to 249, depending on the availability of the data. Intervention Participants received four counseling sessions that focused on healthy eating (adapted Mediterranean diet pattern) and increasing physical activity. Potential moderating factors Density of and distance to food and physical activity venues, modified food environment index, Walk Score, crime, and perceived nutrition and physical activity neighborhood barriers were the potential mediating factors. Outcome measures Diet quality, physical activity, and weight loss were the outcomes measured. Statistical analyses Statistical analyses included correlation and linear regression and controlling for potential confounders (baseline values of the dependent variables, age, race, education, and sex). Results In adjusted analysis, there was an inverse association between weight change and the food environment, suggesting that participants who lived in a less-healthy food environment lost more weight during the 6-month intervention period (P=0.01). Also, there was a positive association between self-reported physical activity and distance to private gyms (P=0.04) and an inverse association between private gym density and pedometer-measured steps (P=0.03), indicating that those who lived farther from gyms and in areas with lower density of gyms had greater increases in physical activity and steps, respectively. Conclusions Contrary to our hypotheses, results indicated that those living in less-favorable food and physical activity environments had greater improvements in diet, physical activity, and weight, compared to those living in more favorable environments. Additional research should be undertaken to address these paradoxical findings and, if confirmed, to better understand them

Fruit and vegetable intake assessed by repeat 24 h recalls, but not by a dietary screener, is associated with skin carotenoid measurements in children

Accurate measurement of fruit and vegetable (FV) intake is important for nutrition surveillance and evaluation of dietary interventions. We compared two tools for reporting FV intake to objective measurement of skin carotenoids among children. FV cups/day was assessed by repeated 24 h dietary recalls (24H FV) and the National Cancer Institute’s All-Day Fruit and Vegetable Screener (NCI FV). Skin carotenoids were measured by repeated resonance Raman spectroscopy (RRS) of the palm. FV cups were regressed on RRS scores in unadjusted, field-based, and research-setting models with covariates feasible in each scenario. Data were baseline values from children aged 2–12 years in low-income households enrolled in a healthy eating randomized trial in four U.S. states (n = 177). Twenty-four-hour FV cups were associated with skin carotenoids in all models (p < 0.001) but NCI FV cups were not. Predicted RRS scores for discrete 24H FV cups provide a guide to interpretation of RRS in children (2 cups FV intake ~36,000 RRS units), with the research-setting scenario generally providing the narrowest prediction range (+/−1924). When self-reported data are required, 24 h recalls are more accurate than NCI FV screener data; and, when limited time, resources, or literacy must be considered, RRS scores can be quickly obtained and easily interpreted

Snacking, sugar-sweetened beverage consumption and child obesity in low-income households

Purpose: Snacking contributes to one-quarter of children’s total daily energy intake in the USA, with many snack foods being nutrient-poor and energy-dense. Snacking and sugary beverage consumption have been identified as potential contributors to childhood overweight and obesity and may play a particularly important role among children from socioeconomically disadvantaged households that generally display higher rates of obesity. This exploratory study investigated associations between consumption of snack foods, sugar-sweetened beverages (SSB) and overweight and obesity in children from low-income households. Design/methodology/approach: Data from households that participated in a multi-state cost-offset (CO-CSA) community supported agriculture intervention in 2016 and 2017 (n = 305) were analyzed. Fixed effect regression models were used to estimate associations between child monthly consumption of salty snack foods; sweet snack foods and SSBs; and child weight status, accounting for demographic characteristics. Findings: No associations were found between snack or SSB consumption and child overweight. However, household income was significantly, negatively related to all three consumption variables (Salty snacks: ß = −0.09, SE = 0.04, p = 0.02; Sweet snacks: ß= −0.10, SE = 0.04, p = 0.01; SSB: ß= −0.21, SE = 0.05, p = 0.0001). The results suggest that household income may play an important role in children’s snacking and SSB behaviors among more disadvantaged households. Practical implications: Factors beyond snack food and SSB consumption should be explored to better understand childhood overweight and obesity, and to inform future obesity interventions. Originality/value: Socioeconomic disparities in childhood obesity are an ongoing policy-relevant issue within the USA and internationally. This study provides new information about child snacking behaviors in a unique, low-income population and contributes to the evidence base regarding the role household context in shaping child consumption behaviors

Assessing Preliminary Impact of the North Carolina Community Transformation Grant Project Farmers' Market Initiatives Among Rural Residents

Objective: Using the Social Determinants of Health as the study's theoretical underpinning, the authors examined the impact of the North Carolina Community Transformation Grant Project farmers' market initiatives on changes in awareness and use of farmers' markets, and fruit and vegetable consumption. Methods: During the farmers' market season, the researchers conducted a random digit-dial telephone survey among residents in 3 rural North Carolina counties to examine changes in farmers' market awareness, shopping, and fruit and vegetable consumption. They examined change over 1 year using t tests, chi-square tests, and propensity score matching. Results: In 1 county there were increases in farmers' market shopping and fruit and vegetable consumption, and in 1 county there were decreases in farmers' market shopping and fruit and vegetable consumption. Conclusions and Implications: The impact of farmers' market initiatives may be affected by county-specific socioeconomic contexts

Knowledge, attitudes, beliefs and behaviors regarding fruits and vegetables among cost-offset community-supported agriculture (csa) applicants, purchasers, and a comparison sample

Community-supported agriculture (CSA) participation has been associated with high fruit and vegetable (FV) consumption, which may be due to better access to FV for CSA purchasers, or to positive knowledge, attitudes, and beliefs (KAB) regarding healthy eating among CSA applicants. The objective of this study was to examine KAB and consumption, in association with application to a cost-offset CSA (CO-CSA) program, and with CO-CSA purchase among applicants. We conducted a cross-sectional survey of CO-CSA applicants and a comparison sample in August 2017. All respondents were English-reading adults with a child 2–12 years old and household income of < 185% of the federal poverty level. Among CO-CSA applicants, some were CO-CSA purchasers (n = 46) and some were not (n = 18). An online comparison sample met equivalent eligibility criteria, but had not participated in CSA for three years (n = 105). We compared CO-CSA applicants to the comparison sample, and compared purchasers and non-purchaser sub-groups, using Mann- Whitney U tests and chi-square analysis. CO-CSA applicants reported better knowledge, selfefficacy, home habits, and diet than the comparison sample. Among applicants, CO-CSA purchasers and non-purchasers had equivalent KAB, but children in purchaser households had higher FV consumption than in non-purchaser households (4.14 vs. 1.83 cups, P = 0.001). Future research should explore associations between CO-CSA participation and diet using experimental methods

The perceived influence of cost-offset community-supported agriculture on food access among low-income families

Objective To examine perspectives on food access among low-income families participating in a cost-offset community-supported agriculture (CO-CSA) programme.Design Farm Fresh Foods for Healthy Kids (F3HK) is a multicentre randomized intervention trial assessing the effect of CO-CSA on dietary intake and quality among children from low-income families. Focus groups were conducted at the end of the first CO-CSA season. Participants were interviewed about programme experiences, framed by five dimensions of food access: Availability, accessibility, affordability, acceptability and accommodation. Transcribed data were coded on these dimensions plus emergent themes.Setting Nine communities in the US states of New York, North Carolina, Washington and Vermont.Subjects Fifty-Three F3HK adults with children.Results CSA models were structured by partner farms. Produce quantity was abundant; however, availability was enhanced for participants who were able to select their own produce items. Flexible CSA pick-up times and locations made produce pick-up more accessible. Despite being affordable to most, payment timing was a barrier for some. Unfamiliar foods and quick spoilage hindered acceptability through challenging meal planning, despite accommodations that included preparation advice.Conclusions Although CO-CSA may facilitate increased access to fruits and vegetables for low-income families, perceptions of positive diet change may be limited by the ability to incorporate share pick-up into regular travel patterns and meal planning. Food waste concerns may be particularly acute for families with constrained resources. Future research should examine whether CO-CSA with flexible logistics and produce self-selection are sustainable for low-income families and CSA farms

Preferred Healthy Food Nudges, Food Store Environments, and Customer Dietary Practices in 2 Low-Income Southern Communities

Objective To examine how food store environments can promote healthful eating, including (1) preferences for a variety of behavioral economics strategies to promote healthful food purchases, and (2) the cross-sectional association between the primary food store where participants reported shopping, dietary behaviors, and body mass index. Methods Intercept survey participants (n = 342) from 2 midsized eastern North Carolina communities completed questionnaires regarding preferred behavioral economics strategies, the primary food store at which they shopped, and consumption of fruits, vegetables, and sugary beverages. Results Frequently selected behavioral economic strategies included: (1) a token and reward system for fruit and vegetable purchases; and (2) price discounts on healthful foods and beverages. There was a significant association between the primary food store and consumption of fruits and vegetables (P = .005) and sugary beverages (P = .02). Conclusions and Implications Future studies should examine associations between elements of the in-store food environment, purchases, and consumption