Uriyoán Colón-Ramos

Background: Food swamps, which have a high density of outlets selling unhealthy food relative to healthier options, are a major driver of diet-related disparities in urban communities. However, no validated food swamp measurement tools exist at the neighborhood level. Methods: We developed the Food Swamp Environment Audit Tool (FS-EAT) using community-based participatory research. FS-EAT includes 19 items as-sessing street-level food outlet types, accessibility features, food marketing, pricing, social features, and store-level information and food availability. Reliability and validity testing were performed using stakeholder surveys and feedback from the community advisory board (CAB). We compared secondary National Establishment Time Series (NETS) 2020 with FS-EAT food store data using positive predictive values and sensitivity scores. We computed Spearman's rank correlation coefficients to measure the alignment between block group-level food swamp and non-food swamp classifications, comparing FS-EAT data with NETS 2020 data. Results: Interrater reliability was strong (κ = 0.82), and 80% of stakeholders rated FS-EAT items as relevant/extremely relevant. CAB members con-firmed that FS-EAT maps aligned better with lived experiences than the secondary NETS data. GIS analyses showed that FS-EAT maps captured more accurate and timely food swamp exposure compared to NETS. When validated against the NETS 2020 business list, the FS-EAT demonstrated an overall sensitivity of 45.3% and a PPV of 68.2%. We con-firmed fewer than half of NETS-listed outlets through FS-EAT ground observation, yet more than two-thirds of audit-identified stores were also present in the NETS database. Sensitivity was highest for convenience stores (74.4%) and lowest for limited-service restaurants (29.2%). Resident perceptions were moderately correlated with FS-EAT scores (r = 0.5). While both sources agreed on the food swamp classification in 18 block groups, 15 block groups (38.5%) were classified as food swamps by the FS-EAT audit data but as non-food swamps by the NETS data. Discussion: The FS-EAT tool captures nuanced features needed to assess the level of neighborhood food swamp exposure and contributes a systematic, cost-effective way to identify neighborhood-level food swamps.

Objective: Half of people living in the USA do not consume tap water. Surveys have assessed perceptions of water and water utilities, but less is known about how these perceptions relate to the preference for tap or bottled water. The present analysis examined whether beliefs about tap water and the water utility were associated with drinking water preferences. Design: In a cross-sectional survey, six water beliefs were measured: trust in tap water, the water utility, and the local government; perceived safety and quality of tap water; and awareness that the water utility frequently tests tap water. Regression models adjusted for sociodemographic characteristics were used to estimate the odds of preferring tap over bottled water dependent on respondents’ beliefs about their tap water. Setting: Virginia, USA. Participants: Adults aged 18 years and older ( n 808). Results: More than two-thirds of respondents had positive beliefs about their tap water, but only 54 % reported tap as their preferred drinking water source. All water beliefs, except for awareness of the frequency of water testing, were associated with higher odds of preferring tap water over bottled (adjusted OR range: 1·56–3·2). Conclusions: Our findings suggest that favourable tap water beliefs may be necessary, but not sufficient, to motivate people to drink from the tap. There remains a critical need for future research to bridge the gap between tap water perceptions and consumption, which should include enhancing the trustworthiness of tap water and the water utility as well as improving consumers’ perceptions of water quality and safety.

Objective: To describe Brazilian parents’ perceptions of non-sugar sweeteners (NSS) in beverages consumed by children and their preferences for NSS front-of-package labels (FOPLs). Design: A qualitative-driven mixed-methods embedded design was used. Seven focus groups with parents of children explored perceptions of NSS. Thematic analysis was conducted on transcripts. Participants also completed a closed-ended survey assessing familiarity with NSS-containing beverages, ability to identify NSS on labels, and perceptions of NSS FOPLs. Survey responses were summarized using descriptive statistics. Setting: Public and private schools and early childhood education centers in urban areas of two municipalities in the State of São Paulo, Brazil. Participants: Forty parents of children aged 2-5 and 6-11, across seven focus groups. Results: About 35% of participants reported their children consumed at least one NSS-containing beverage weekly in the past month; 17% reported daily consumption. Parents expressed a preference for natural products and confusion over the term “edulcorantes” (Portuguese for NSS). They shared concerns about health effects of both sugar and NSS, particularly for children. NSS were seen as acceptable in specific cases, such as diabetes. Most parents supported FOPL like Mexico’s, stating “not recommended for children.” In the survey, 85% correctly identified beverages with NSS, but 82% misclassified non-NSS ingredients (e.g., sugar syrup, caramel) as NSS. The Mexico-style FOPL was preferred by 95%, who found it helpful and easy to understand. Conclusions: An FOPL clearly indicating NSS presence, especially one recommending against consumption by children, may help parents make informed choices and reduce children’s intake of NSS-containing beverages.

Objective: This study aimed to develop a shared understanding about the drivers of nutrition security in Puerto Rico (PR) from the collective perspective of multi-sector stakeholders in the agri-food, environmental and the health/disease systems. Design: A participatory community-based system dynamics approach (group model building) engaged stakeholders during one 4-h workshop March 2023 (followed by two 2.5-h member checking sessions). Setting: San Juan, PR. Participants: Stakeholders (n 22) in PR representing the agri-food, environmental and health/disease systems from multiple sectors (commercial food retail and technology, food production, public servants, academia and civil society) participated in the workshop. Results: Stakeholders collectively framed nutrition security as an outcome of six interconnected subsystems exacerbated by climate change: (1) governance and public policy; (2) demographic change and rural disinvestment; (3) climate change and adaptive capacity; (4) local food production economy; (5) food culture; and (6) nutrition security and health. Stakeholders identified leverage points mostly focused on strengthening information flow within and across subsystems and expanding cross-sectoral collaboration (systems structures and elements). We identified three paradigms that have the potential to transform the system structure and function: ecological conscience, traditional and healthy food culture, and social cohesion. Conclusions: These findings deepened the collective understanding of systemic interdependencies that drive nutrition security as stakeholders identified locally feasible leverage points.

Background: High dietary quality can protect against diet-related chronic diseases. In the United States, racial and ethnic minorities and those with lower incomes consistently exhibit lower dietary quality. Independently-owned restaurants are a common prepared food source in minority low-income communities, but there are significant knowledge gaps on how to work with these restaurants to offer healthy food, due to underlying and dynamic complexities associated with providing healthy food options.Methods: The Focus on Restaurant Engagement to Strengthen Health (FRESH) study addresses this complex problem by leveraging systems science approaches to work with independently-owned restaurants. FRESH has two interrelated objectives: (1) to test impact on regular customer dietary quality via a multisite cluster randomized controlled trial in two low-income urban areas (Baltimore and the Washington DC metropolitan area), and (2) to use systems science approaches to develop, parameterize, and calibrate a simulation model. The intervention is theory-and practice-based, comprising three phases: restaurant engagement, low-sugar beverages and healthy meals. The FRESH intervention will be implemented for 12 months in a total of 24 intervention and 24 comparison restaurants. The study is powered to detect a 5-point change in the Healthy Eating Index (HEI) score of regular customers, which would signify a meaningful shift toward healthier eating patterns.Discussion: The FRESH study will test a novel, multilevel, multisite intervention that aims to improve access to healthier prepared food options among small, independently-owned restaurants located in under-resourced settings. The design of the FRESH intervention and its evaluation are described, as well as plans for the development of a system dynamics simulation model for policymakers and other stakeholders to virtually test future restaurant-based interventions.Clinical trial registration: https://clinicaltrials.gov, identifier, NCT05869149.

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers’ acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore’s IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.

Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders’ leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment.