Higher rates of obesity and obesity-related chronic disease are prevalent in communities where there is limited access to affordable, healthy food. The B’More Healthy Communities for Kids (BHCK) trial worked at multiple levels of the food environment including food wholesalers and corner stores to improve the surrounding community’s access to healthy food. The objective of this article is to describe the development and implementation of BHCK’s corner store and wholesaler interventions through formal process evaluation. Researchers evaluated each level of the intervention to assess reach, dose delivered, and fidelity. Corner store and wholesaler reach, dose delivered, and fidelity were measured by number of interactions, promotional materials distributed, and maintenance of study materials, respectively. Overall, the corner store implementation showed moderate reach, dose delivered, and high fidelity. The wholesaler intervention was implemented with high reach, dose, and fidelity. The program held 355 corner store interactive sessions and had 9,347 community member interactions, 21% of which were with children between the ages of 10 and 14 years. There was a 15% increase in corner store promoted food stocking during Wave 1 and a 17% increase during Wave 2. These findings demonstrate a successfully implemented food retailer intervention in a low-income urban setting.

B'More Healthy Community for Kids (BHCK) is an ongoing multi-level intervention to prevent childhood obesity in African-American low-income neighborhoods in Baltimore city, MD. Although previous nutrition interventions involving peer mentoring of youth have been successful, there is a lack of studies evaluating the influence of cross-age peers within interventions targeting youth. This article evaluates the implementation of the BHCK intervention in recreation centers, and describes lessons learned. Sixteen youth leaders delivered bi-weekly, interactive sessions to 10- to 14-y olds. Dose, fidelity and reach are assessed, as is qualitative information regarding what worked well during sessions. Dose is operationalized as the number of interactive sessions, and taste tests, giveaways and handouts per session; fidelity as the number of youth leaders participating in the entire intervention and per session and reach as the number of interactions with the target population. Based on a priori set values, number of interactive sessions was high, and number of taste tests, giveaways and handouts was moderate to high (dose). The number of participating youth leaders was also high (fidelity). Of the 14 planned sessions, the intervention was implemented with high/moderate reach. Data suggest that working with cross-age peers is a promising nutritional intervention for recreation centers.

Peer-led interventions may be an effective means of addressing the childhood obesity epidemic; however, few studies have looked at the long-term sustainability of such programs. As part of a multilevel obesity prevention intervention, B’More Healthy Communities for Kids, 16 Baltimore college students were trained as youth-leaders (YLs) to deliver a skill-based nutrition curriculum to low-income African American children (10–14 years old). In April 2015, formative research was used to inform sustainability of the YL program in recreation centers. In-depth interviews were conducted with recreation center directors (n = 4) and the YLs (n = 16). Two focus groups were conducted with YLs (n = 7) and community youth-advocates (n = 10). Barriers to this program included difficulties with transportation, time constraints, and recruiting youth. Lessons learned indicated that improving trainings and incentives to youth were identified as essential strategies to foster continuity of the youth-led program and capacity building. High school students living close to the centers were identified as potential candidates to lead the program. Based on our findings, the initial intervention will be expanded into a sustainable model for implementation, using a train-the-trainer approach to empower community youth to be change agents of the food environment and role models.

BackgroundTo prevent obesity, it is important to assess dietary habits through self-reported energy intake (EI) in children. We investigated how EI is associated with body mass index and which elements of dietary habits and status are associated with EI among African-American (AA) children.MethodsWe assessed and included data from 218 10–14-year-old AA children in Baltimore, MD, USA. EI was calculated using a food frequency questionnaire. The basal metabolic rate (BMR) was used as the predicted minimal rate of energy expenditure of children. A fully adjusted multiple logistic regression was used to determine the prevalence of obesity (≥ 95th BMI-for-age percentile) among the quartiles of EI/BMR ratio using the third quartile for the reference. The differences in the age-adjusted mean EI/BMR among the categories of dietary habits, social support, and socio economic status were analyzed using a general linear model.ResultsChildren with the lowest EI/BMR had significantly higher adjusted odds ratio (aOR) of obesity as compared to those in the third quartile of EI/BMR (boys aOR 4.3; 95% confidence interval 1.08, 20 and girls aOR 4.1; 1.02, 21). In girls, the adjusted mean EI/BMR in the group that prepared food less than the means (3.8 times/week) was significantly lower than the group that prepared food over the means (P = 0.03). Further, the group that reported eating breakfast under 4 times/week indicated an adjusted mean EI/BMR lower than the group that ate breakfast over 5 times/week in both sexes.ConclusionsWhen EI was under-reported with reference to BMR, we may observe high prevalence of obesity. Further, food preparation by children and frequent consumption of breakfast may instill food cognition with usual dietary habits. Therefore, holistic assessments including dietary habits are required to examine self-reported food intake especially among overweight/obese children.

Multilevel, multicomponent (MLMC) interventions are needed to address the complex, multifactorial obesity epidemic. Such interventions work in several settings simultaneously, including schools, food stores, restaurants and households. However, limited work has been done to use MLMC program implementation data to guide program delivery. In July 2014, implementation of B'More Healthy Communities for Kids MLMC trial began. It's goal is to reduce obesity among low income African American youth (10‐14 years) by partnering with policymakers, wholesalers, small food stores, carryouts, recreation centers, and families through environmental change, education, structural incentives, and social media. Detailed process evaluation is conducted by regularly assessing 88 implementation standards for reach, dose delivered and fidelity. Every two months, the latest process data is reviewed to improve the program. For example, during the first review, reach to children during corner store intervention delivery periods did not meet the standard of 10 interactions/session (mean: 6.7, range: 0‐20). The # of new items stocked per food store was low. In a second review, reach to children during store interactive sessions increased (mean: 8.7). Additionally, recreation center session reach decreased from 15.7 to 7.6 interactions/session. These findings led to rescheduling intervention delivery times to when more youth were present, and increasing the duration of sessions. Detailed process evaluations using defined standards are essential for continuous improvement of MLMC intervention trials.

B'More Healthy Communities for Kids (BHCK) is a multi‐level, multi‐component obesity prevention trial directed toward low‐income African American youth in Baltimore. BHCK works with small food stores, recreation centers, carryout restaurants, wholesalers, policymakers and families. Process evaluation is conducted by monitoring 88 implementation standards based on reach, dose delivered and fidelity. Guidelines rank each standard in terms of low, medium or high delivery. Here, we report on findings to date based on two feedback periods. Food store interactive sessions had low reach to the target audience (10‐14 year old youth) with 7.4 + 6.2 interactions/session compared to higher reach for adults (17.1 + 6.6). Dose delivered of food samples (28.5 + 14.4) and giveaways (16.2 + 6.2) distributed was medium to high. Carryout restaurant menu redesign obtained medium to high fidelity with 20% healthy side options and 10% healthy entrée options provided on posted menu boards. Recreation centers achieved high reach with 11.6 + 6.1 youth attending educational sessions. The agent‐based policy model (ABM) had low to medium reach with one local policymaker including the ABM on a formal agenda in the past year. Wholesalers obtained overall high fidelity by stocking food items that met BHCK nutrition guidelines. Social media and text messaging achieved high reach with 70% of BHCK‐enrolled families joining the program. Dose was high with an average of 3.2 text messages sent per week. These findings are used to monitor and modify components during the trial and to assess implementation quality post‐intervention.

IntroductionPeer‐led interventions may be an effective means of addressing the childhood obesity epidemic, particularly as part of multi‐level interventions. Thus, we aimed to expand and sustain the youth‐leader program for the second wave of the B'more Healthy Communities for Kids (BHCK) trial using a combined policy, systems and environmental (PSE) approach.MethodsOur PSE approach targeted children (10–14 years old); and BHCK youth‐leaders (n=14) in low‐income, predominately African American neighborhoods in Baltimore City. The youth‐leaders delivered nutrition education in recreation centers, community corner stores and carryouts, acted as spokesperson in BHCK social media, and implemented environmental changes at food stores and recreation centers to improve healthy food access. Nutrition interactive sessions (n=98) were evaluated through multiple process measures to ensure adequate reach, dose delivered, fidelity, selected impact measures to plan (quality), and reproducibility for sustainability of the youth‐leader programing. Youth‐leader skills, dietary intake, and shopping behaviors were measured at pre‐ and post‐intervention and compared to a similar‐age sample of youth who were not selected to deliver the program thus assigned to the comparison group. A difference‐in‐difference analysis assessed the impact of the program on BHCK youth‐leaders and their counterparts (n=14 intervention, 11 comparison) on frequency of purchasing of specific promoted foods, overall energy intake, fat intake and other indicators of dietary quality (FV servings), and Body Mass Index. Difference‐in‐difference analysis was also conducted to determine the impact of the intervention on dietary factors of a subsample of child participants (n=93) receiving the intervention.ResultsThe wave 2 BHCK youth‐leader program was delivered with moderate to high reach, dose, and moderate fidelity. An average of 9.5 children (10–14 years old) participated in each nutrition session. Overall, we distributed 1018 handouts and 312 recipe cards. We conducted 98 nutrition sessions and distributed 1080 giveaways. We observed significant improvements in outcome expectancies and leadership skills in the most highly involved youth leaders (p<0.05). Analysis of available data indicated that children receiving the intervention from the youth‐leaders showed a trend in decreased total calorie intake and dietary fat compared to comparison, although not statistically significant.ConclusionsThe wave‐2 youth‐leader program was successfully implemented in low‐income areas of Baltimore. Youth‐leaders appeared to benefit as part of multi‐level programs, with improved psychosocial factors and leadership skills. Sustainability of such complex programs remains a challenge that must be addressed through strong partnerships established at the beginning of PSE projects.Support or Funding InformationResearch reported in this publication was supported by the Northeast ‐ Regional Nutrition Education Center of Excellence, and the Global Obesity Prevention Center (GOPC) at Johns Hopkins, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Office of the Director, National Institutes of Health (OD) under award number U54HD070725. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. AT is supported by a doctoral fellowship from CNPq (GDE: 249316/2013‐7).