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Heidi Blanck, MS, Ph. D Research and Surveillance Team Lead Division of Nutrition, Physical Heidi Blanck, MS, Ph. D Research and Surveillance Team Lead Division of Nutrition, Physical Activity and Obesity, NCCDPHP, CDC Fruit & Vegetable Nutrition Coordinator Call Fruit and Vegetable Surveillance April 7, 2009

DNPAO Goals • Increase health-related physical activity through population-based approaches. • Improve those aspects DNPAO Goals • Increase health-related physical activity through population-based approaches. • Improve those aspects of dietary quality most related to population burden of chronic disease and unhealthy child development. • Decrease prevalence of obesity through prevention of excess weight gain and maintenance of healthy weight loss.

Nutrition Targets • Increase the consumption of fruits and vegetables • Decrease the consumption Nutrition Targets • Increase the consumption of fruits and vegetables • Decrease the consumption of sugar-sweetened beverages • Reduce the consumption of high-energy-dense foods • Increase breastfeeding initiation, duration, and exclusivity

Fruit and Vegetable Focus Area • Influencing the influencers to make policy and environmental Fruit and Vegetable Focus Area • Influencing the influencers to make policy and environmental changes • • Why “influencing the influencers”? • • To impact 300 million Americans, we must work through others Expect multiplier effect Who are the “influencers”? • School administrators, employers, state legislatures, planning commissions, U. S. Congress, restaurant owners, retailers, grocery manufacturers

Fruit and Vegetable Objectives • • • Enhance state capacity to implement environmental and Fruit and Vegetable Objectives • • • Enhance state capacity to implement environmental and policy interventions Strengthen partnerships and advocacy efforts, strategies, and activities Identify, adapt, and/or develop surveillance systems to measure behavior, policy and environmental change Strengthen the science base related to environment and policy strategies and interventions Translate and disseminate effective/promising interventions Identify and reduce disparities related to access, availability, and consumption

F&V Objectives Identify, adapt, and/or develop surveillance systems to measure behavior, policy and environmental F&V Objectives Identify, adapt, and/or develop surveillance systems to measure behavior, policy and environmental change

F&V Surveillance • Surveillance across various levels of the SE model • Individual • F&V Surveillance • Surveillance across various levels of the SE model • Individual • FV Consumption • Physical environment • Workplace • Schools • Macro-level environments • Policy actions Story, M. , K. M. Kaphingst, et al. (2008). "Creating healthy food and eating environments: policy and environmental approaches. " Annual Rev Public Health 29: 253 -72, Figure 1.

Population-Based Surveillance: Individual F&V Data • Behavioral Risk Factor Surveillance System (BRFSS) – F&V Population-Based Surveillance: Individual F&V Data • Behavioral Risk Factor Surveillance System (BRFSS) – F&V in odd years (6 -item screener) • Youth Risk Behavioral Survey (YRBS) – Classroom survey of high school students, F&V in odd years

State-Based FV Surveillance Use of an Abbreviated FV frequency questionnaire • Measure FV intake State-Based FV Surveillance Use of an Abbreviated FV frequency questionnaire • Measure FV intake of populations to monitor local (state) and trends in consumption overtime • Evaluate interventions to promote fruit and vegetable consumption for the primary prevention of disease • Use data to leverage resources, target programs, change policy

BRFSS F&V Screener • BRFSS 6 -item F&V Frequency Screener • How often do BRFSS F&V Screener • BRFSS 6 -item F&V Frequency Screener • How often do you drink fruit juices such as orange, grapefruit, or tomato? • Not counting juice, how often do you eat fruit? • How often do you eat green salad? • How often do you eat potatoes not including French fries, fried potatoes, or potato chips? • How often do you eat carrots? • Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?

F&V Consumption Among Adults Cohen, Blanck et al. , MMWR, 2007 2005 BRFSS Data, F&V Consumption Among Adults Cohen, Blanck et al. , MMWR, 2007 2005 BRFSS Data, 50 States and D. C. Healthy People 2010 health objectives include • 75% the percentage of persons aged >2 y who eat at least 2 daily servings of fruit (objective 19 -5) • 33% ate fruit >=2 times/day • 50% the proportion of persons aged >2 y who eat at least 3 daily servings of vegetables, with at least one third being dark green or orange vegetables (objective 19 -6) • 27% ate vegetables >=3 times/day BOTH • 14% at both >=2 fruit/day and >=3 vegetables/day • 2008 BRFSS Conference, Blanck et al.

www. fruitsandveggiesmatter. gov www. fruitsandveggiesmatter. gov

BRFSS 2007 Adults consuming ≥ 2 Fruit BRFSS 2007 Adults consuming ≥ 2 Fruit

BRFSS 2007 Adults consuming ≥ 3 Vegetable BRFSS 2007 Adults consuming ≥ 3 Vegetable

BRFSS 2007 Adults consuming ≥ 2 Fruit & ≥ 3 Vegetable BRFSS 2007 Adults consuming ≥ 2 Fruit & ≥ 3 Vegetable

2007 Web F&V Data • • http: //www. fruitsandveggiesmatter. gov/ For Health Professionals section 2007 Web F&V Data • • http: //www. fruitsandveggiesmatter. gov/ For Health Professionals section • Research • 2007 Surveillance Data, BRFSS- Adults • National, State • By: Age, Sex, Race, Education, Income, BMI, physical activity • Compare State to State • Compare State to National • Compare multiple years of data (back to 1996)

2007 Web F&V Data • • http: //www. fruitsandveggiesmatter. gov/ For Health Professionals section 2007 Web F&V Data • • http: //www. fruitsandveggiesmatter. gov/ For Health Professionals section • Research • 2007 Surveillance Data, BRFSS- Adults • GIS Maps – from BRFSS site • State and MMSA • Metropolitan/Micropolitan Area Risk Trends (SMART) • Metropolitan/micropolitan statistical area (MMSA) 2000 Census. • MMSAs with at least 500 completed interviews

BRFSS F&V Screener • BRFSS 6 -item F&V Frequency Screener • How often do BRFSS F&V Screener • BRFSS 6 -item F&V Frequency Screener • How often do you drink fruit juices such as orange, grapefruit, or tomato? • Not counting juice, how often do you eat fruit? • How often do you eat green salad? • How often do you eat potatoes not including French fries, fried potatoes, or potato chips? • How often do you eat carrots? • Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?

BRFSS F&V Screener Strengths: • Short, moderate validity in most groups, lowest in Hispanic BRFSS F&V Screener Strengths: • Short, moderate validity in most groups, lowest in Hispanic mothers enrolled in WIC • Created in 1989: No change overtime has allowed trends Limitations: • • Lacks text about forms: Fresh, frozen, canned, as well as cooked versus raw forms Juice question does not specify 100% juice and thus lemonade and other fruit-flavored added sugar drinks (Hi-C, Sunny Delight) might be included Beans not included as vegetable (DG 2005) Frequency only, new recommendations in Cups

BRFSS F&V Revisions • • Catalogued concerns from state coordinators and CATI staff Adapted BRFSS F&V Revisions • • Catalogued concerns from state coordinators and CATI staff Adapted National Cancer Institute’s NHIS/CHIS questions, 8 item frequency screener 6 -item: Fruit juice, fruit, salad, potatoes (non-fried), beans/legumes, other vegetables – rotation core questions 2 -item: dark green, orange vegetables - state-added questions (stand alone) • Analyzed NHANES 2003 -04 24 -hour recall data on top F&V contributors among adults for example listings (Kimmons et al. , Submitted) • • Conducted two rounds of cognitive interviews, Fall 2007 Field Tested Telephone, Summer 2008

BRFSS F&V Pilot Plan • In 2009, MA, TX & WA are testing in BRFSS F&V Pilot Plan • In 2009, MA, TX & WA are testing in parallel with current screener, reliability via call-back • Working with NCI to estimate median portion size in CUPS by age/sex/race-ethnicity • • Allow states to determine proportion of adults meeting My. Pyramid individualized recommendations based on caloric needs, e. g. 2 cups fruit, 2. 5 cups vegetables 2010 BRFSS methodology (weighting changes and mixedmodes: telephone, call, mailed surveys) will break ability to assess trends Long Term Goal: 2011+, new F&V core module

Environmental Surveillance Data • • Perceptions of physical access and availability of healthy eating Environmental Surveillance Data • • Perceptions of physical access and availability of healthy eating (variety, forms, quality) • MESA Study, Massachusetts BRFSS, NY BRFSS, NC CHAMP Community checklists (Physical presence): • Farmer’s markets, grocery & food stores, restaurants (WI Tool) Consumer environment (What food is in the store; quality, amount, cost): • Nutrition Environment Measures Survey (NEMS), Thrifty Food Basket GIS, Spatial analysis • Census Tract level on presence of different types of grocery stores, produce markets, farmers’ markets for California www. cnngis. org • Organizational survey • School Health Policies and Programs Study (SHPPS) • ICMA survey (International City/County Management Association; NGO; local government organization) typically examines the services, practices, and policies of local governments.

Environmental Surveillance Data Compiling what researchers and practitioners are using for: • Perceptions of Environmental Surveillance Data Compiling what researchers and practitioners are using for: • Perceptions of physical access and availability of healthy eating (variety, forms, quality) • MESA Study, Massachusetts BRFSS, NY BRFSS, NC CHAMP • • Staff Member: Latetia Moore – [email protected] gov Please send any questions your state or community have been using to assess residents perceptions of food environment – Examples - It is difficult for me to buy high quality fruits and vegetables in my community? The cost of fruits and vegetables is too high? I make my family dinner most nights of the week; agree, disagree To get to the store I drive/take transit/hire a taxi/ask a friend for a ride

Environmental Surveillance Data Compiling what researchers and practitioners are using for: • Perceptions of Environmental Surveillance Data Compiling what researchers and practitioners are using for: • Perceptions of physical access and availability of healthy eating (variety, forms, quality) • • Staff Member: Latetia Moore – [email protected] gov Please send any questions your state or community have been using to assess residents perceptions of food environment – Goal: Create a module for states to use in their own surveys or as state-added questions for BRFSS in 2011 (next time the FV module is also asked)

F&V Surveillance • Surveillance across various levels of the SE model • Individual • F&V Surveillance • Surveillance across various levels of the SE model • Individual • FV Consumption • Physical environment • Workplace • Schools • Macro-level environments • Policy actions Story, M. , K. M. Kaphingst, et al. (2008). "Creating healthy food and eating environments: policy and environmental approaches. " Annual Rev Public Health 29: 253 -72, Figure 1.

Nutrition Policy Surveillance Data • DNPAO State Legislative Database: Nutrition and Physical activity (introduced, Nutrition Policy Surveillance Data • DNPAO State Legislative Database: Nutrition and Physical activity (introduced, enacted, pending) – http: //apps. nccd. cdc. gov/DNPALeg/index. asp • National Council of State Legislatures • National Association of Counties' Healthy Counties Database for model policies, programs and initiatives from counties nationwide. • National Association of State Boards of Education – Sample General School Health Policies to Encourage Healthy Eating and Physical Activity. • ENACT: Local policies reported at http: //www. preventioninstitute. org/sa/policies/ (note: please encourage your communities to go here and enter)

Nutrition Policy Surveillance Project • DNPAO State Legislative Database: Nutrition and Physical activity (introduced, Nutrition Policy Surveillance Project • DNPAO State Legislative Database: Nutrition and Physical activity (introduced, enacted, pending) – http: //apps. nccd. cdc. gov/DNPALeg/index. asp Sonia Kim, Ph. D SKIM [email protected] gov Postdoctoral Fellow, Nutrition Branch, DNPAO

Nutrition Policy Surveillance and Policy Analysis • Identify & Describe State legislation that can Nutrition Policy Surveillance and Policy Analysis • Identify & Describe State legislation that can improve access to affordable, high quality fruits and vegetables – Content areas, By state, by year • Evaluate policy language, content area in relation to action, enforcement, and impact • Compare states’ identified legislative behaviors to fruit and vegetable consumption • Disseminate “model” policy language for states, counties, cities

Nutrition Policy Surveillance and Policy Analysis • Identify & Describe State legislation that can Nutrition Policy Surveillance and Policy Analysis • Identify & Describe State legislation that can improve access to affordable, high quality fruits and vegetables – Content areas, By state, by year • Evaluate policy language, content area in relation to action and impact • Compare states’ identified legislative behaviors to fruit and vegetable consumption • Disseminate “model” policy language for states, counties, cities

Policy Search: Methods Sources • Division of Nutrition, Physical Activity and Obesity (DNPAO) State Policy Search: Methods Sources • Division of Nutrition, Physical Activity and Obesity (DNPAO) State Legislative database • National Conference for State Legislation (NCSL) website • Lexis-Nexis Legislative database (enacted bills) Check sources against Published compiled reports: Robert Wood Johnson Report on Child Obesity (2007) and Food Policy Council Report (2006)

http: //apps. nccd. cdc. gov/DNPALeg/ http: //apps. nccd. cdc. gov/DNPALeg/

State F&V/Nutrition Policies Community Related Studies, councils, or task Establish a commission, committee, council, State F&V/Nutrition Policies Community Related Studies, councils, or task Establish a commission, committee, council, task force, or forces study to address community food security. Farmers’ markets Support and make appropriations for farmers’ market initiatives. Local procurement preference Directs state agencies to procure state-grown food products whenever available. Agricultural land use Expands the duties of the Department of Agriculture regarding the preservation of viable farm land. Grocery and food stores Establishes a Healthy Food Retail fund to provide residents of underserved communities with retail food markets providing high quality fruits and vegetables.

State Bills n=315 Community TOTAL 315 BILLS State Bills n=315 Community TOTAL 315 BILLS

State FV Bills Over Time 149 125 27 14 State FV Bills Over Time 149 125 27 14

States that introduced FV legislation 2001 -2008 58 47 States that introduced FV legislation 2001 -2008 58 47

States that enacted FV legislation 2001 -2008 8 13 States that enacted FV legislation 2001 -2008 8 13

FV Policy – We’d like to know A) Have you been involved in providing FV Policy – We’d like to know A) Have you been involved in providing testimony on either food access, healthy food retail, food systems OR anything related to fruits and vegetables? B) Have you been involved in drafting legislation related to either food access, healthy food retail, food systems OR anything related to fruits and vegetables? C) Have you been involved in writing regulations related to either food access, healthy food retail, food systems OR anything related to fruits and vegetables? What was the process, were stakeholders consulted, and if so, who?

FV Policy – We’d like to know D) Have you done any work in FV Policy – We’d like to know D) Have you done any work in evaluating state legislation and/or regulations? E) Do you engage in information advocacy related to either food access, healthy food retail, food systems OR anything related to fruits and vegetables? F) Do you work with any advocacy groups related to either food access, healthy food retail, food systems OR anything related to fruits and vegetables? - If so, who? G) Have you written policy briefs related to either food access, healthy food retail, food systems OR anything related to fruits and vegetables? For what audience? (are they automatically for legislators? ) H) Are you part of a Food Policy Council? In what capacity? Have you worked with this group to inform policy, and if so, how?

FV Policy If you are interested discussing your role in FV policy please contact: FV Policy If you are interested discussing your role in FV policy please contact: Sonia Kim SKim [email protected] gov We would be very appreciative!

Health. Styles 2008 Consumer Opinion for Policy Change • How likely would you be Health. Styles 2008 Consumer Opinion for Policy Change • How likely would you be to support changes to local or state rules or policies that would do each of the following: • Create local community markets or farmers markets? • Create a program that helps small food stores have fresh fruits and vegetables? • Create community gardens or plots for raising fruits and vegetables? • Create farm-to-school programs to provide locally grown fruits and vegetables in schools for breakfast, lunch, and snacks? • Require city/county government agencies to favor the purchase of locally grown fruits and vegetables to serve in cafeterias and at meetings? Available Late Summer 2009 DNPAO Website

F&V Research and Surveillance Staff • • Heidi Blanck, Team Lead HBlanck@cdc. gov Sonia F&V Research and Surveillance Staff • • Heidi Blanck, Team Lead [email protected] gov Sonia Kim SKim [email protected] gov Latetia Moore [email protected] gov Kirsten Grimm • • Joel Kimmons Larry Grummer-Strawn, Branch Chief

THANK YOU! Questions? www. cdc. gov/nccdphp/dnpa www. fruitsandveggiesmatter. gov THANK YOU! Questions? www. cdc. gov/nccdphp/dnpa www. fruitsandveggiesmatter. gov