Purpose: Women in the justice-involved system and in recovery for substance use disorders (SUD) are rapidly outpacing men. Since many applied programs are “gender-neutral”, meaning designed with men in mind, they seldom address why women use drugs and alcohol, how they manifest differently in their bodies, and how to reduce female recidivism. Gender-responsive education and treatment calls for an emphasis on the treatment needs of women based on these differences. The purpose of this study was to determine the effectiveness of a 10-week, gender-responsive health and nutrition education program, Healthy Steps to Freedom (HSF), on improving physical activity (PA) and nutrition-related behaviors and associations between weight concerns and drug reoccurrence for women in recovery. Methods: HSF was implemented in minimum- and maximum-security prison(s), as well as inpatient and outpatient treatment centers serving women with substance use. The Eating Attitudes Test (EAT-26), Binge Eating Scale (BES), Body Shape Questionnaire (BSQ), International Physical Activity Questionnaire (IPAQ), and a 12-item health behavior and thoughts survey (HBT) were used to assess eating pathology, body dissatisfaction, PA participation, and nutrition habits, respectively. Participants were also surveyed to assess concerns related to weight gain and relapse. Data were collected from 2014-2022. A paired t-test was used to identify significant differences in outcomes before- and after- the program. Results: All participants (n = 1986) had a history of substance use and 72% of them reported use of stimulants. The mean age of participants was 35 (± 9) years old, 78% were non-Hispanic White, and 5% were pregnant. After the program, there were significant improvements in eating attitudes (EAT-26) (t=4.623, p <.001, d=.157), binge eating behavior (BES) (t=3.821, p<.001, d=.128), body shape concerns (BSQ) (t=-12.566, p<.001, d=.396), nutrition behaviors (HBT) (t=-23.580, p<.001, d=.762) and PA MET minutes (IPAQ) (t=-8.345, p<.001, d=.280). Participants also indicated significantly less concern that weight gain could be a trigger for reoccurrence (t=-4.301, p<.001, d=.129). Conclusion: The HSF program improved nutrition-related behaviors, PA habits, and outcomes related to body dissatisfaction and eating pathology. SUD behavioral treatment programs for women should prioritize these health-related and psychosocial topics to improve health and reduce risk of relapse.

Impact of Three Non-Invasive Interventions on Online Food Purchases: A Randomized Controlled Trial of Nutri-Score Presence, Default Product Order and the Option to Filter or Order
Authors: E.Godden (Corresponding author, presenting author); L. Thornton;N. Dens

Purpose: The continuous growth in online grocery shopping presents a unique opportunity to introduce novel healthy eating interventions. By strategically modifying the design of digital shopping environments, we can influence consumer decision-making towards healthier choices. This study used a virtual online grocery store (VOS) to examine the extent to which three Nutri-Score related interventions influence consumers' food choices.
Methods: Following a fractional factorial design, 1184 Flemish participants were randomly assigned to combinations of three interventions (in total 7 conditions): Nutri-Score label presence (no/yes), default product order (alphabetically/by Nutri-Score) and options to filter and order products by healthiness (unavailable/available). Outcome measure were Food Standards Agency (FSA) score, proportion of products bought within each Nutri-Score category (A, B, C, D, and E), and expenditure within each category. Linear regressions and t-tests were employed for interval scaled outcomes and mixture models were used for composite data.
Results/findings: Nutri-Score presence increased the purchases of Nutri-Score A and B and decreased the purchases of Nutri-Score D and E, but did not affect the mean FSA. Changing the default order from alphabetically to healthiness reduced the mean FSA with 1.29 points (2.92 in combination with the other interventions), thus improving the nutritional quality of the shopping basket. It also increased the money spent on products with the healthier Nutri-Score categories A (€6.62) and B (€0.36), and reduced the money spent of products with less healthy Nutri-Score categories D (-€5.56) and E (-€1.26). In contrast, the options to filter and order the product assortment by healthiness were barely used (<10%) by the participants, and this intervention did not lead to large changes in mean FSA or food purchases.
Conclusions: The results suggest that the Nutri-Score FOP label holds promise for online grocery shopping, despite its original design for brick-and-mortar stores. More precisely the Nutri-score was found to affect the distribution of the purchases and expenditure over the five Nutri-Score categories, but not the mean FSA. When products were ordered by default to display healthier Nutri-Scores first, the healthiness of the shopping basket also increased. Validation of the results on real-life purchase data is warranted.

Purpose: Given the rise in diet-related diseases, nutritional guidance often prioritizes avoiding certain “negative” nutrients (e.g., fat, sugar, sodium) over seeking out foods high in “positive” nutrients, (e.g., fiber, potassium, iron). The objective of this study was to evaluate associations between attention to positive/negative nutrients and nutritional quality of food choices.
Methods: An online survey was completed by 1002 adult US residents to examine the relationship between the use of nutritional information and the healthfulness of ready-to-eat cereal choice. Respondents chose from 33 cereals displayed with nutritional information and price. Healthfulness was categorized by the guiding stars (GS) system, which ranges from zero (least healthy) to three (most healthy) stars based on the nutritional profile. After making a cereal choice, respondents answered survey questions about the use of nutritional and other information. The numbers of positive and negative nutrients each respondent considered during their food choice were calculated. Respondents were categorized into considering no nutrients (reference), more positive nutrients, more negative nutrients, or equal numbers of positive and negative nutrients (balanced). These categories were evaluated for their effects on GS rating of chosen cereals by ordinal logistic regression.
Results: In total, 386 respondents (39%) considered nutritional information during food choice. On average, 1.7 (95%CI=1.6-1.8) nutrients were considered per respondent, with 211 respondents considering more negative nutrients than positive; 87 considering more positive nutrients; and 88 considering balanced nutrients. Greater attention to positive or balanced nutrients increased the odds ratio of selecting a cereal with a higher GS rating 6.73 (CI=4.15-11.1) and 6.58 (CI=4.07-10.8) times, respectively, while respondents that considered mostly negative nutrients had a much lower odds ratio of selecting a cereal with a higher GS rating (2.92; CI=2.10-4.06) (linear hypothesis test of positive=negative, p=0.001; balanced=negative, p=0.002).
Conclusions: Although focusing on any nutritional information during cereal choice increased the healthiness of cereal choices (compared with none), focusing on positive or balanced nutrients increased the healthfulness of cereal choices much more than focusing on negative nutrients. This study suggests that focusing nutritional recommendations on positive nutrients, rather than focusing on nutrients to avoid, may be more effective at increasing nutritional quality.

Dose Response of Attendance to a Behavioral Intervention on Physical and Mental Health Outcomes in Recipe4Health

Marcela D. Radtke1,2* , June Tester3,4, Lan Xiao2, Ben Emmert-Aronson5, Elizabeth Markle5, Steven Chen6, Lisa Goldman Rosas2, 7, 8*

1 Propel Postdoctoral Research Fellow, Stanford University School of Medicine
2 Department of Epidemiology and Population Health, Stanford University School of Medicine
3 Osher Center for Integrative Medicine and Department of Family and Community Medicine, University of California, San Francisco School of Medicine
4 Department of Pediatrics, University of California, San Francisco
5 Open Source Wellness, Oakland, California
6 Community Health Center Network, San Leandro, California
7 Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine
8 Office of Community Engagement, Stanford University School of Medicine
*Corresponding authors: mdradtke@stanford.edu; lgrosas@stanford.edu

Purpose: Behavior change is an essential component to Food as Medicine programming to ensure health improvements are sustained following an acute dietary intervention. The objective of this secondary analysis was to determine whether the frequency of attendance to a behavioral intervention in Recipe4Health, a multicomponent Food as Medicine program, results in a dose response in patient physical and mental health outcomes.

Methods: A subset of patients experiencing a chronic disease and/or food insecurity were referred to a 16-week combined food and behavioral intervention. Along with weekly deliveries of vegetables and fruits (V/F), patients attended 16 sessions of an intensive behavioral lifestyle program that emphasized nutritious eating, physical activity, social connection, and stress reduction. Attendance was recorded on a per session basis and categorized into tertiles (<50%, 50–75%, 75%<). Outcome measures included V/F intake, physical activity, loneliness, depression, anxiety, and quality of life. Pre-post changes in health outcomes by attendance frequency were assessed using repeated measures linear mixed effects models with adjusting for the baseline value of outcome.

Results: A total of 199 participants completed the behavioral intervention, with low (n=72), moderate (n=60), and high (n=67) attendance. When comparing outcomes by attendance, participants with high attendance had significant improvements in daily cups of V/F (0.26 cups/day 95%CI: [0.02, 0.5]; p=0.03), physical activity (24.4 minutes/week [8.5, 40.4]; p<0.01), and depressive symptoms (PHQ9 score: -1.1 [-1.8, -0.4]; p<0.01) compared to participants with low attendance. When comparing high attendance to moderate, participants who attended >75% of sessions had significant improvements in the number of physically unhealthy days experienced (-2.4 [-4.2, -0.6]; p<0.01). When comparing moderate attendance to low, only the duration of physical activity was higher in the participants who attended 50–75% of sessions (15.1 minutes/week [1.1, 29.1]; p=0.03).

Conclusions: Participants who attended a majority of the behavioral intervention sessions had significant improvements in dietary intake, physical activity, and mental wellness compared to participants who attended more infrequently. Strategies to improve attendance, such as limiting barriers to participation and including culturally inclusive content, should be prioritized in Food as Medicine programming to maintain health outcomes in diverse populations across the lifespan.

Purpose: The health benefits of nature-based physical activity (PA) are well-established, including mental, physical, and social well-being. Recommended by health experts, programs such as Park Prescriptions and NatureRx encourage healthcare providers to prescribe nature-based PA for chronic disease prevention and treatment. Despite the effectiveness of these programs, patient PA counseling is underutilized. One reason is lack of healthcare provider education and training, particularly as part of their school curricula. The purpose of this study was to pilot and evaluate an applied nature-based experience and nature-based PA prescription counseling activity as part of educational curricula for future healthcare providers. Methods: In summer 2023, two waves of high school students attended a week-long university health professions exploration program. They participated in a 2-hour long applied session that included a 2-mile nature-based obstacle course, a discussion about the health benefits of nature-based PA, and a practical park prescription counseling activity. Activities were held outdoors at an adventure park. Students completed surveys before and after the session. Measures included demographics, Godin Leisure Time PA, exercise-induced feeling scale, stress, PA enjoyment, and interest in completing future outdoor PA. Students also rated session enjoyment (1-5 stars) and provided qualitative feedback. Results: Students (n=30) were mostly female (90%), 16.5±0.52 years old, physically active (96.7%), and typically spend at least 30+ minutes outside daily (86.7%). Example career interests included physician, physician assistant, nurse practitioner, RN, cardiologist, surgeon, and physical therapist. Students indicated significant increases in revitalization (p< 0.001) and interest in outdoor PA (p=0.046). Paired samples t-tests showed significant improvements in feeling good (p=0.024), positive engagement (p=0.012), revitalization (p=0.002) and decreased physical exhaustion (p=0.033). Average session rating was 4.5/5. Students commented, “I really enjoyed this activity”; “Not a big fan of activity, especially outside, but I do feel good about myself”; and “the course was so fun to do and made me feel good at the end”. Conclusions: Positive nature experiences may enhance future healthcare providers’ enthusiasm for recommending nature-based PA. Nature experiences and practicing park prescription counseling offer promising approaches to train the next generation of healthcare providers on the importance of nature-based PA for improved health.