STATEMENT OF THE PROBLEM

Excessive weight gain is associated with increased risk of developing many serious diseases, including cardiovascular disease, hypertension, and type 2 diabetes. Despite extensive efforts to promote weight management, these efforts only reach a small proportion of the population at risk and even effective programs promoting individual behavior change may have limited effectiveness in environments that promote weight gain. Furthermore, there are limited validated tools used to effectively assess the perception of the environment in which these individuals live. Using the ecological perspective to understand how different factors interact to influence food and physical activity behaviors, we can inform more tailored interventions that lead to lasting behavior change. Therefore research is needed to elucidate the combination of individual and environmental factors associated with unhealthy weight gain among our targeted population of young adults, including those in under-represented, low-income communities. Participants in this multi-state research group have applied theory-based behavioral constructs to design intervention programs to promote healthful eating and exercise behaviors in young adults with a goal of preventing unhealthy weight gain. Although these programs have been effective in improving dietary behavior, they did not prevent weight gain. Obesity currently affects 17 percent of children and adolescents and greater than 30% of adults in the United States [1]. The socio-ecological framework is designed to account for the multiple societal levels that influence food and physical activity choices because the individual is studied in the context of interpersonal identity and support, organizations, community and public policy. Using the socio-ecological model to understand how different factors interact to influence food and physical activity behaviors is an important approach to understanding behavior change in this population. The previous five years of this multi-state research have been devoted to the development, validation and refinement of tools designed to: 1) evaluate the healthfulness of the environment, 2) evaluate the perceptions of the target community of the healthfulness of the environment, and 3) define the relationship between environmental and behavioral factors that influence excessive weight gain. The purpose of this renewal is to implement a newly developed model with consideration of cross-sector collaborations and to capture sustainability of change in environments, behavior and perception on college campuses and in low-income communities. Additionally, there will be continued effort on environment and behavioral instrument development, refinement, validation, and translation for under-represented or non-represented settings (e.g. low income communities who qualify for food assistance), as well as continued exploration of mechanisms of interaction between lifestyle behaviors and environmental factors in influencing healthy behaviors and health status of young adults using previous and ongoing work. This approach aligns with the U.S. Department of Agriculture’s focus on policy, systems, and environmental (PSE) approaches that address the outer levels of the socio-ecological model. It is also the intention of the PSE approach to supplement individual, group, and community-based educational strategies used by nutrition and physical activity educators in a multi-component program delivery model. It is argued that education in combination with PSE is more effective in tackling the prevention of overweight and obesity.

ISSUES AND JUSTIFICATION

Importance of work on college campuses. Since the numbers of young adults attending college has been increasing over the last 15 years [2] many young adults can be reached by targeting college campuses. Based on 2012 data, 41% of 18-24 year olds are enrolled in American colleges or universities [3]. College students need health and nutrition information because they are in a transitional period of life, often referred to as “emerging adulthood.”[4] As they grow in independence, they shift their support systems, expand those who are influential in their lives and form their own individual health behavior patterns [5] which set the stage for their future lives and health status. When their health choices include poor dietary and physical activity choices, excessive weight gain may be the consequence. Nelson and colleagues found that on average, during the first three to four months of college, undergraduate students gained 1.5 – 6.8 pounds, so that by the end of the first semester, the proportion of overweight or obese students had doubled. Arnold and colleagues reported that nearly one-third of college students are considered overweight or obese [6]. It was reported some years ago, that being mildly or moderately overweight at age 20-22 years is linked with substantial incidence of obesity by age 35-37 years [7, 8]. College campuses, as microcosms of larger communities, provide excellent environments for making and/or advocating for changes in policies and function to support healthful lifestyles of young adults. The efficacy of diet, exercise, behavior change and environmental supports for healthful lifestyles and obesity prevention in this population group has yet to be demonstrated. Translating tools for under-represented or non-represented settings. Low-income audiences (those eligible for or on food assistance-related programs) are especially at risk for obesity because of extra barriers to adopting a healthful lifestyle and the strain on household resources. Various risk factors contribute to this increased risk for obesity, including limited access to healthful foods at an affordable cost, less money to spend on food, fewer opportunities to be physically active, more stressful life situations, and greater exposure to the marketing of nutrient-poor foods [9]. Based on the REACH U.S. Risk Factor Survey of approximately 30 communities in the United States, residents in mostly minority communities continue to have greater barriers to health-care access, greater risks for, and burden of, disease compared with the general population living in the same county or state, as well as, lower socioeconomic status [10]. Validated tools are needed to evaluate the food environment in low- income communities as part of a needs assessment for interventions designed to address obesity. Glanz and colleagues [11-15] published a series of articles on what is known about assessing the physical activity and food environments of communities. They called for combined approaches for effective research and policy efforts and the importance of community partnerships, as in community-based participatory research. Integrating Extension and Research. This multistate team, since its inception in 1990, has been composed of faculty bridging Extension and research with a strong focus on behavior change and nutrition education intervention. Extension provides non-formal education and learning activities to people throughout the country. It emphasizes taking knowledge gained through research and education and bringing it directly to the people to create positive changes. Young adults, 18-24, have been the focus, primarily those in college, because of their vulnerability due to life changes and independent decision-making, which sets the stage for their own health and the health of current and future generations. From 2001-2005, this Extension-Research team used the Transtheoretical Model/Stages of Change to tailor educational materials to increase fruit and vegetable intake in low-income young adults [16]. The partnership has continued through two USDA funded projects, iCook: A 4-H Program to Promote Culinary Skills and Family Meals for Obesity Prevention, 2012-2017 [17], based in the Social Cognitive Theory, and the more recent “Get Fruved”: a peer-led, train-the-trainer social marketing intervention to increase fruit and vegetable intake and prevent childhood obesity, 2014-2019 [18], based in social marketing. Both of these projects are using community-based participatory research principles to foster Extension and target population partnerships. This multistate team recognizes the need for environmental changes to support tailored behavior change, and over the last five years, has been developing and testing tools to measure environmental supports for healthful lifestyle on college campuses. This work, aligning with the U.S. Department of Agriculture’s focus on policy, systems and environmental (PSE) change strategies, leads naturally to communities outside college campuses, and specifically to target populations of under-represented, low-income audiences who are at increased risk for unhealthful lifestyles, food insecurity, and reliance on assistance programs. Policy, Systems, and Environmental (PSE) Change Strategies. Strategies and interventions designed with policy, system, and environmental approaches support the individual by facilitating healthful options. These approaches have become the hallmark of multi-level interventions. The Centers for Disease Control and Prevention (CDC) and the Institute of Medicine believe that these strategies will have a much broader population impact and be less costly, more sustainable, and less prone to stigmatize individuals who are overweight or obese than programs focused on individual behavior change [19]. PSE strategies are intended to supplement individual, group, and community-based educational strategies used by nutrition and physical activity educators in a multi-component program delivery model. Education combined with PSE is more effective than either strategy alone for preventing overweight and obesity [20]. Environmental Factors and Obesity. The impact of the built environment on risk for obesity is pervasive in the obesity literature. The built environment encompasses a variety of components including, but not limited to, neighborhood walkability, access to parks, safety, cleanliness, and traffic flow [21]. These factors influence the ability and desire for people to be physically active. A review by Renalds et al. identified factors of the built environment that influenced physical activity [21]. More lights, fewer intersections and traffic, and better scenery all encouraged physical activity, while poor security and poor neighborhood maintenance discouraged physical activity. The authors concluded that neighborhoods that encouraged walking had more physically active residents with lower incidence of overweight. Many researchers have reported a positive association between some aspect of the built environment and obesity [22-25], possibly because of barriers to physical activity. In their review on obesity and the built environment, Booth et al. noted that biological, psychological, behavioral, and social factors do not fully account for the current obesity epidemic, which provides support for the evaluation of the effect of the built environment [23]. Increasing the ability for neighborhoods to promote physical activity may translate into a reduced risk for obesity but may be a challenge in socially disadvantaged neighborhoods where physical activity is lower for a variety of reasons [26-28]. More affluent neighborhoods tend to have higher levels of physical activity, which may provide more protection against certain diseases in these communities [28]. Currently there are few published studies documenting the effect a change in the built environment has had on the community. McCreedy and Leslie described a city-wide initiative in Orlando, Florida, called Get Active Orlando that brought together a multidisciplinary team of community partners passionate about changing the culture of their city to encourage physical activity [29]. With a grant from the Robert Wood Johnson’s “Active Living by Design” initiative, researchers designed and implemented a community-wide campaign that encouraged healthful lifestyle changes. After establishing baseline data by surveying their target low socioeconomic status neighborhood, researchers developed programs designed to increase physical activity such as bike giveaways, safe bike rides, free bike repair, a senior walking program, and a community garden. These programs were successful in getting the community involved and physically active. The program successes have led to policy changes for development projects in the community intended to make the city more active. Their website (www.getactiveorlando.com) provides information as well as a Design Standards Checklist to be used by developers to promote physical activity in developments. A similar program in Somerville, Massachusetts, described by Burke et al, also achieved positive results [30]. Although it is premature to determine if changes in the built environment will lead to a decrease in obesity, Orlando and Somerville can serve as models for community promotion of physical activity for the health benefit of residents. Another environmental factor is the food environment. According to Hill and Peters (1998) “one way in which the current environment promotes obesity is by providing more frequent opportunities for the consumption of large quantities of food. A variety of highly palatable, inexpensive foods is available nearly everywhere” [31]. A cross-sectional survey of rural adults indicated that frequency of eating at establishments that promote excessive food consumption such as buffets, cafeterias and fast food was positively associated with obesity [32]. Young adults in the Coronary Artery Risk Development in Young Adults (CARDIA) study who ate at fast food restaurants more than twice a week had a significantly higher weight gain during the 15 year study period than those who ate fast food less than once a week [33]. Despite these findings, Giskes and colleagues reported insufficient evidence to support an association between fast food consumption and obesity based on their 2007 review of literature, and stated that more studies are needed [34]. Upscale of Approach from Young Adult Population. Identifying evidence-based approaches and programs at a targeted, local level that can be scaled-up and adapted for diverse populations is necessary to win the war against obesity. Using previous work completed by this multistate team, a new model will be tested to capture the sustainability of our work. In Objective 1, we will forecast and capture the upscale evolvement of the programs we implement and the community impact via a dissemination and implementation model called eB4CAST (evidence-Based Forecasting). This model, adapted from the RE-AIM model [35], incorporates cross-sector engagement to capture the cultivating change in behavior and the environment. To support further scaling-up of our approach our multistate team will capture data that demonstrates trends in positive impact generated by sustainable community capacity-building and empowerment. Benefits of this project. This proposed research will reach young adults on college campuses and in low-income communities by using the socio-ecological model to ultimately impact policies, systems, and environments that will improve health and well-being. Research investigators will continue to work side-by-side as partners with young adults in diverse populations to understand, develop, create, and tailor interventions. Grant funding will be pursued for this research, as well as smaller state/local-specific projects. The ultimate outcome of this work will be tailored intervention strategies and environmental support approaches that meet audience needs in their acquisition of healthful eating behavior to prevent excessive weight gain. The collective power of the multiple states collaborating throughout the entire participatory process will significantly contribute to the understanding of how to best meet the needs of the priority population as they strive to prevent weight gain and adopt healthful habits. The outcomes from this work address health promotion priorities of USDA and other agencies such as National Institutes of Health and the Institute of Medicine. Need for cooperative work. Because of the multidimensional etiology of obesity and the equally multidimensional intervention designs needed to reduce incidence of obesity, significant large-scale progress toward weight management is unlikely to be achieved by a single investigator or University location, as acknowledged by the National Institutes of Health. Thus, a multi-state research team approach will increase diversity of expertise, environmental locations, and population demographics. The procedures outlined in this proposal require an enormous amount of work and a diverse set of research skills, all factors that this research team can provide. Furthermore, the limitations of previous studies on how environmental factors affect diet quality and health have suffered from regional bias that restricts ability to generalize findings. By using multiple communities to address specific objectives, this research team will be able to not only increase the power of analyses, but also enhance applicability of the findings and resolve regional disparities. This effective collaborative research relationship is demonstrated through a strong publication record with multiple authors from different institutions. This multi-state research team has a strong record of collaborative research (NC200, NC219, NC219R, NC1028, and NC1193 multi-state research) that will allow diversity needs to be met. Additionally, this research collaborative has successfully secured USDA grant funding, including an Initiative for Future Agriculture and Food Systems (IFAFS) grant, two National Research Initiative (NRI) grants and two Agriculture and Food Research Initiative (AFRI) grants.