The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

Background The Intervention Nurses Start Infant Growing on Healthy Trajectories (INSIGHT) study's responsive parenting (RP) intervention, initiated in early infancy, prevented the use of nonresponsive, controlling feeding practices and promoted use of structure-based feeding among first-time parents compared with controls. Objectives We sought to examine the spillover effect of the RP intervention on maternal feeding practices with their secondborn (SB) infants enrolled in an observational-only study, SIBSIGHT, and to test the moderating effect of spacing of births. Methods SB infants of mothers participating in the INSIGHT study were enrolled into the observation-only ancillary study, SIBSIGHT. SBs were healthy singleton infants ≥36 weeks of gestation. Infant feeding practices (i.e., food to soothe, structure vs. control-based practices) were assessed using validated questionnaires: Babies Need Soothing Questionnaire, Infant Feeding Styles Questionnaire, and the Structure and Control in Parent Feeding Questionnaire. Results SBs (n = 117 [RP: 57, control: 60]; 43% male) were delivered 2.5 ± 0.8 y after firstborns (FBs). At age 1 y, the Structure and Control in Parent Feeding Questionnaire revealed that the mothers in the RP group used more consistent feeding routines (4.19 [0.43] compared with 3.77 [0.62], P = 0.0006, Cohen's D: 0.69) compared with control group mothers. From the Infant Feeding Styles Questionnaire, RP group mothers also used less nonresponsive, controlling feeding practices such as pressuring their SB infant to finish (1.81 [0.52] compared with 2.24 [0.68], P = 0.001, Cohen's D: 0.68) compared with controls. In contrast to our hypotheses, no differences were detected in bottle-feeding practices such as putting to bed with a bottle/sippy cup or adding cereal to the bottle, despite observing study group differences in FBs. Spacing of births did not moderate intervention effects. Conclusions RP guidance given to mothers of FBs may prevent the use of some nonresponsive, controlling feeding practices while establishing consistent feeding routines in subsequent siblings.

B'More Healthy Communities for Kids was a multi-level, multi-component obesity prevention intervention to improve access, demand and consumption of healthier foods and beverages in 28 low-income neighborhoods in Baltimore City, MD. Process evaluation assesses the implementation of an intervention and monitor progress. To the best of our knowledge, little detailed process data from multi-level obesity prevention trials have been published. Implementation of each intervention component (wholesaler, recreation center, carryout restaurant, corner store, policy and social media/text messaging) was classified as high, medium or low according to set standards. The wholesaler component achieved high implementation for reach, dose delivered and fidelity. Recreation center and carryout restaurant components achieved medium reach, dose delivered and fidelity. Corner stores achieved medium reach and dose delivered and high fidelity. The policy component achieved high reach and medium dose delivered and fidelity. Social media/text messaging achieved medium reach and high dose delivered and fidelity. Overall, study reach and dose delivered achieved a high implementation level, whereas fidelity achieved a medium level. Varying levels of implementation may have balanced the performance of an intervention component for each process evaluation construct. This detailed process evaluation of the B'More Healthy Communities for Kids allowed the assessment of implementation successes, failures and challenges of each intervention component.

Partnerships linking researchers to the policymaking process can be effective in increasing communication and supporting health policy. However, these policy partnerships rarely conduct process evaluation. The Policy Working Group (Policy WG) was the policy-level intervention of the multilevel B'More Healthy Communities for Kids (BHCK) trial. The group sought to align interests of local policymakers, inform local food and nutrition policy, introduce policymakers to a new simulation modeling, and sustain intervention levels of BHCK. We conducted an evaluation on the Policy WG between July 2013 and May 2016. We evaluated process indicators for reach, dose-delivered, and fidelity and developed a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The policy intervention was implemented with high reach and dose-delivered. Fidelity measures improved from moderate to nearly high over time. The number of health-related issues on policymakers' agenda increased from 50% in the first 2 years to 150% of the high standard in Year 3. SWOT analysis integrated a stakeholder feedback survey to consider areas of strength, weakness, opportunity, and threats. Although the fidelity of the modeling was low at 37% of the high standard, stakeholders indicated that the simulation modeling should be a primary purpose for policy intervention. Results demonstrate that process evaluation and SWOT analysis is useful for tracking the progress of policy interventions in multilevel trials and can be used to monitor the progress of building partnerships with policymakers.

Computational simulation models have potential to inform childhood obesity prevention efforts. To guide their future use in obesity prevention policies and programs, we assessed Baltimore City policymakers' perceptions of computational simulation models. Our research team conducted 15 in-depth interviews with stakeholders (policymakers in government and non-profit sectors), then transcribed and coded them for analysis. We learned that informants had limited understanding of computational simulation modeling. Although they did not understand how the model was developed, they perceived the tool to be useful when applying for grants, adding to the evidence base for decision-making, piloting programs and policies, and visualizing data. Their concerns included quality and relevance of data used to support the model. Key recommendations for model design included a visual display with explanations to facilitate understanding and a formal method for gathering feedback during model development.

Studies from diverse cultures report mixed results in the relationship between birth order and risk for obesity. Explanations may thus lie in the postnatal period when growth is shaped by the family environment, including parental feeding practices, which may be affected by siblings. Consistent with a family systems perspective, we describe two processes that may explain birth order effects on parental feeding practices and child outcomes: learned experience and resource dilution. Parents learn from experience when earlier-born children influence their parents’ knowledge, expectations, and behavior toward later-born siblings through their behaviors and characteristics—which can have both positive and negative implications. Resource dilution is a process whereby the birth of each child limits the time, attention and other resources parents have to devote to any one of their children. The goal of this review is to provide a theoretical basis for examining potential sibling influences on parental responsive feeding toward developing recommendations for future research and practice aimed at preventing obesity throughout family systems.

We sought to understand Baltimore corner store owners’ awareness of and readiness for the then-approved Supplemental Nutrition Assistance Program depth of stock requirements and assess potential barriers and solutions. In-depth interviews and stocking observations were conducted in 17 corner stores in low-income food deserts of Baltimore City. Corner store owners conveyed little to no awareness of the pending depth of stock changes. Only two stores were currently ready for the requirements. Low customer demand, high amounts of potential spoilage, and unfair pricing at the wholesaler were identified by store owners as barriers to stocking required foods.

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