Objective To evaluate potential mediators of weight loss in the Strong Hearts, Health Communities-2.0 (SHHC-2.0) trial. Design Community-randomized trial (intervention vs delayed intervention). Outcomes were evaluated at baseline and postintervention. Setting Eleven rural, medically-underserved communities Participants Women (n = 182), mean age 57.2 years, 97.6% White, non-Hispanic. Intervention Classes delivered 2 times/wk for 24 weeks, targeting diet and physical activity behaviors. Main Outcomes Measures Dependent variable: weight; mediators: diet and physical activity behaviors, and related psychosocial factors. Analysis Mixed linear regressions evaluated the effect of mediators on weight loss. Results Significant mediators included dietary behaviors (Rapid Eating Assessment for Participants-Short; 31.8%; P = 0.03), healthy eating attitudes (23.0%; P = 0.03), and dietary cognitive restraint (29.8%; P = 0.01). Physical activity did not mediate weight loss; however, a worsening in attitudes toward exercise was a mediator of weight loss (22.6%; P = 0.01). Social support for diet and physical activity was unchanged in the intervention group and did not mediate weight loss effects. Conclusions and implications Healthy eating attitudes and dietary cognitive restraint represent important targets for future behavioral interventions for weight loss. Hypothesized mediators found to be nonsignificant (i.e., social support) represent opportunities for future intervention optimization.

Abstract Background Rural United States communities often experience disproportionate burdens of obesity, cardiovascular disease, diabetes, and premature mortality. Built environment constraints, including limited sidewalks, recreation facilities, and access to nutritious foods, may restrict opportunities for adoption and maintenance of healthy eating and physical activity behaviors. Civic engagement approaches empower residents to assess community needs, develop action plans, and implement policy, systems, and environmental (PSE) strategies. However, few randomized trials have examined implementation of PSE strategies and their impacts in rural adult populations. This study evaluated implementation of Cooperative Extension-led Change Club (CC) community project action plans aimed at facilitating PSE change in six rural and micropolitan Texas and New York intervention communities. Presently, we document implementation outcomes and identify factors that may have influenced implementation using the Consolidated Framework for Implementation Research (CFIR). Methods CCs followed a 24-module curriculum facilitated by trained Extension educators. Approved action plans were provided with seed money to target diet and physical activity PSE changes. Implementation outcomes regarding the action plans were tracked through educator reports, interviews, and proposals. CFIR factors were assessed during the early stages of action plan implementation using interviews with educators and participant residents. Results All six intervention communities implemented action plans, most of which had multiple components. Each prioritized environmental changes and most focused on addressing physical activity. Implementation timing and continuity varied, influenced by external factors such as weather and local approvals. CFIR analysis identified beliefs about feasibility, stakeholder engagement, and group decision-making as key factors influencing implementation. Conclusions Rural CCs successfully launched a variety of built environment initiatives. This implementation evaluation highlights pathways and barriers related to scaling rural civic engagement strategies. Trial registration Clinical Trial #NCT05002660 (August 2021).

PurposeTo examine multiple implementations of the Change Club (CC) curriculum.ApproachCompiled information about studies that used the CC curriculum.SettingTen research studies using the CC curriculum.InterventionCivic engagement policy, systems, and environmental change (PSE) curriculum, in which small groups follow a stepwise process to change physical activity- and/or food-related aspects of their community.MethodReviewed study records to describe multiple implementations of the CC curriculum.ResultsThe studies varied in terms of U.S. region, inclusion criteria, number of CC members, duration, and outcomes measured. Curriculum implementation varied, with session lengths varying from 30 minutes to multiple hours. Some studies included other interventions such as walking clubs. Across the 10 studies, there were 62 CCs, with seed monies ranging from $600 to $5000. The majority of CCs were facilitated by a USDA Cooperative Extension agent; 95% of CCs successfully completed a PSE project. Sixty-one percent of projects included physical activity elements only.ConclusionKey recommendations include the importance of involving stakeholders, encouraging positive CC group dynamics, ensuring CC members understand the time and effort of PSE projects, identifying and cultivating facilitators that have capacity and can transition the project to group members, completing CC modules in a short period of time to retain members, and including group members who have existing community connections.Clinical Trial #sNCT05002660, NCT05677906, NCT05867433.

OBJECTIVE:This study aimed to conduct cost analysis (CA) and cost-effectiveness analysis (CEA) of Strong Hearts, Healthy Communities (SHHC) implemented in two randomized trials. METHODS:Women with obesity or women who were sedentary with overweight who were ≥ 40 years old from rural medically underserved towns were randomized to SHHC intervention or control. CA calculated total and per participant costs and opportunity costs. CEA compared incremental costs to incremental outcome changes. Quality-adjusted life year (QALY) CEA compared incremental costs and effectiveness of a national SHHC intervention for a hypothetical cohort of 2.2 million women. RESULTS:SHHC-1.0 resource cost was $775/participant and SHHC-2.0 was $747. The incremental cost-effectiveness ratio from the payer's perspective for SHHC-1.0 was $346/kg weight loss and $187 and $155 for SHHC-2.0 at 24 and 48 weeks, respectively. Over a 10-year horizon, to avert QALYs lost, SHHC-1.0 was estimated to cost $238,271 from the societal perspective and $62,646 from the health care sector perspective. For SHHC-2.0, the corresponding numbers were $214,257 and $67,747 at 24 weeks and $94,395 and $11,341 at 48 weeks. CONCLUSIONS:SHHC-2.0 compared favorably to SHHC-1.0 and could be cost-effective for longer-term effects. Results can help guide policy makers' decisions on larger-scale community-based obesity and cardiovascular disease prevention interventions. TRIAL REGISTRATION:ClinicalTrials.gov identifier NCT03059472.

Objective Assess relationships between diet quality and healthy eating motivation, confidence, social support, and food environment. Methods The study sample of a community-randomized controlled intervention trial responded at baseline to sociodemographic, diet, diet-related psychosocial factor (motivation, confidence, social support), and environment (healthy food availability, food shopping motivation) questions. Linear regression was used to analyze cross-sectional associations between dietary intake (diet quality, fruit and vegetable, fiber, ultraprocessed food) and psychosocial and environmental factors. Results Data from 2420 rural adults were analyzed. Psychosocial factors were positively associated with fruit and vegetable and fiber consumption and diet quality. Psychosocial factors were negatively associated with ultraprocessed food consumption frequency, except for social support from friends. Fruit and vegetable availability was positively associated with fruit and vegetable and fiber consumption and overall diet quality. Food shopping motivation was positively associated with fruit and vegetable intake and overall diet quality. Conclusions and Implications These findings contribute insights into ways psychosocial and environmental factors influence diet quality within rural studies.

BACKGROUND:Psychosocial and built environment (BE) factors can influence physical activity (PA). Objectives were to assess whether psychosocial or BE variables were associated with PA and whether associations differed by sociodemographic characteristics in rural communities. METHODS:The sample included 2215 adults enrolled in a healthy lifestyle intervention cluster-randomized trial. Sociodemographic variables included age, sex, race/ethnicity, education, and income. Health variables included general health status and body mass index. PA was assessed using the International Physical Activity Questionnaire-long form. Metabolic Equivalent-minutes per week were calculated for total PA, moderate and vigorous PA, and walking. Psychosocial (exercise attitudes, exercise confidence, social support for PA from family/friends) and BE variables (walking environment, sidewalks, street shoulders, community safety, community aesthetic quality) were assessed via questionnaire. Linear regressions modeled bivariate associations between PA and PA context variables. Multivariate regression models evaluated whether sociodemographic or health variables modified relationships between PA and PA context variables. RESULTS:All psychosocial measures were positively associated with all measures of PA. Walking environment and community safety were the only BE measures associated with all measures of PA. Being an older adult (65+) had significantly greater effects on exercise attitudes, exercise confidence, and social support from friends on walking. Education and income did not consistently moderate associations between psychosocial factors and any measure of PA. CONCLUSIONS:Future studies should confirm whether psychosocial characteristics are associated with PA in other populations and explore how these effects are moderated by sociodemographic characteristics. Further research is needed on the role of the environment in influencing PA in rural communities.

Abstract Background Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cardiovascular disease prevention program that was effective in improving physical activity and nutrition behaviors and clinical outcomes among women in 11 rural New York, USA towns. This study evaluated the delivery of SHHC-2.0 to prepare the intervention for further dissemination. Methods This process evaluation was guided by the Medical Research Council recommendations and engaged program leaders and participants (i.e., women over age 40) using quantitative and qualitative methods. The quantitative evaluation included examination of enrollment and retention data, a participant survey, and a fidelity checklist completed after classes. Descriptive and comparative statistics were used to assess implementation measures: program reach, participant attendance, dose delivered, program length, perceived effectiveness, fidelity, and participant satisfaction. The qualitative evaluation included focus groups (n = 13) and interviews (n = 4) using semi-structured guides; audio was recorded and transcripts were deductively coded and analyzed using directed content analysis and iterative categorization approaches. Comparisons across towns and between intervention and waitlist control groups were explored. Results Average reach within towns was 7.5% of the eligible population (range 0.7-15.7%). Average attendance was 59.8% of sessions (range 42.0-77.4%). Average dose delivered by leaders was 86.4% of curriculum components (range 73.5-95.2%). Average session length was 51.8 ± 4.8 min across 48 sessions. Leaders’ perceived effectiveness rating averaged 4.1 ± 0.3 out of 5. Fidelity to curricular components was 81.8% (range 67.4-93.2%). Participants reported being “more than satisfied” with the overall program (88.8%) and the health benefits they obtained (72.9%). Qualitative analysis revealed that participants: (1) gained new knowledge and enjoyable experiences; (2) perceived improvements in their physical activity, nutrition, and/or health; (3) continued to face some barriers to physical activity and healthy eating, with those relating to social support being reduced; and (4) rated leaders and the group structure highly, with mixed opinions on the research elements. Conclusions SHHC-2.0 had broad reach, was largely delivered as intended, and participants expressed high levels of satisfaction with the program and its health benefits. Our findings expand on best practices for implementing cardiovascular disease prevention programs in rural communities. Clinical trials Registration www.clinicaltrials.gov #NCT03059472.

Objective: To better understand how the public defines 'healthy' foods and to determine whether the public considers sustainability, implicitly and explicitly, in the context of healthy eating.Design: We conducted a content analysis of public comments submitted to the US FDA in 2016 and 2017 in response to an invitation for feedback on use of the term 'healthy' on food labels. The analysis explored the ways in which commenters' definitions of 'healthy' aligned with the 2015-2020 Dietary Guidelines for Americans and whether their definitions considered sustainability.Setting: The US Government's Regulations.gov website.Participants: All 1125 unique comments from individuals and organisations.Results: Commenters' definitions of 'healthy' generally mirrored the recommendations that the Dietary Guidelines for Americans put forth to promote a 'healthy eating pattern'. Commenters emphasised the healthfulness of fruit, vegetables, whole grains, fish and other minimally processed foods and the need to limit added sugars, sodium, saturated and trans fats and other ingredients sometimes added during processing. One-third of comments (n 374) incorporated at least one dimension of sustainability, mainly the environmental dimension. Commenters who mentioned environmental considerations primarily expressed concerns about synthetic chemicals and genetic modification. Less than 20 % of comments discussed social or economic dimensions of sustainability, and less than 3 % of comments (n 30) used the word 'sustainability' explicitly.Conclusions: This novel analysis provides new information about the public's perceptions of 'healthy' foods relative to nutrition and sustainability considerations. The findings can be used to advance policy discussions regarding nutrition labelling and guidance.

BACKGROUND:Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating. OBJECTIVES:This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program. METHODS:A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models. RESULTS:At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating). CONCLUSIONS:SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www. CLINICALTRIALS:gov as NCT03059472.

Background: Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact. Methods: A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance. Results: Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: −3.15 kg [95% CI, −4.98 to −1.32]; P =0.008) and several secondary clinical (eg, waist circumference: −3.02 cm [−5.31 to −0.73], P =0.010; systolic blood pressure: −6.64 mmHg [−12.67 to −0.62], P =0.031; percent body fat: −2.32% [−3.40 to −1.24]; P <0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks. Conclusions: This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03059472.

Background Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial . Methods Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women ( n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect. Results Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P < 0.001) and at 24 weeks (increase of 6.4 min per day; P = 0.011). Self-reported total MET minutes per week also increased: at 12 weeks (increase of 725.8, P = 0.003) and 24 weeks (increase of 955.9, P = 0.002). Several of the psychosocial variables also showed significant positive changes. Conclusions The SHHC-2.0 intervention successfully increased physical activity level and related outcome measures. Modifications made based upon in-depth process evaluation from SHHC-1.0 appear to have been effective in increasing physical activity in this at-risk population. Trial registration Clinicaltrials.gov: NCT03059472. Registered 23 February 2017.

Observational evidence suggests that higher physical activity is associated with slower kidney function decline; however, to our knowledge, no large trial has evaluated whether activity and exercise can ameliorate kidney function decline in older adults.To evaluate whether a moderate-intensity exercise intervention can affect the rate of estimated glomerular filtration rate per cystatin C (eGFRCysC) change in older adults.This ancillary analysis of the Lifestyle Interventions and Independence For Elders randomized clinical trial enrolled 1199 community-dwelling, sedentary adults aged 70 to 89 years with mobility limitations and available blood specimens. The original trial was conducted across 8 academic centers in the US from February 2010 through December 2013. Data for this study were analyzed from March 29, 2021, to February 28, 2022.Structured, 2-year, partially supervised, moderate-intensity physical activity and exercise (strength, flexibility) intervention compared with a health education control intervention with 2-year follow-up. Physical activity was measured by step count and minutes of moderate-intensity activity using accelerometers.The primary outcome was change in eGFRCysC. Rapid eGFRCysC decline was defined by the high tertile threshold of 6.7%/y.Among the 1199 participants in the analysis, the mean (SD) age was 78.9 (5.2) years, and 800 (66.7%) were women. At baseline, the 2 groups were well balanced by age, comorbidity, and baseline eGFRCysC. The physical activity and exercise intervention resulted in statistically significantly lower decline in eGFRCysC over 2 years compared with the health education arm (mean difference, 0.96 mL/min/1.73 m2; 95% CI, 0.02-1.91 mL/min/1.73 m2) and lower odds of rapid eGFRCysC decline (odds ratio, 0.79; 95% CI, 0.65-0.97).Results of this ancillary analysis of a randomized clinical trial showed that when compared with health education, a physical activity and exercise intervention slowed the rate of decline in eGFRCysC among community-dwelling sedentary older adults. Clinicians should consider targeted recommendation of physical activity and moderate-intensity exercise for older adults as a treatment to slow decline in eGFRCysC.ClinicalTrials.gov Identifier: NCT01072500.

IntroductionMost children do not meet the recommendations for school-time and daily moderate-to-vigorous physical activity, with significant demographic disparities and declines over the elementary school years. Investigators examined the impact of Fueling Learning through Exercise study school-based physical activity programs on school-time and total daily moderate-to-vigorous physical activity among lower-income school children.Design, Participants, and InterventionUrban elementary schools (N=18) were cluster randomized to 100 Mile Club, Just Move, or control. Data collection and analyses occurred from 2015 to 2019 among third- and fourth-grade school children (N=1,008) across 2 academic years.Main outcome measuresStudent's moderate-to-vigorous physical activity was measured by 7-day accelerometry (Actigraph GT3X+) at baseline (before intervention), midpoint (6 months), and endpoint (18 months). Mixed-effects linear regression models examined program impact on school-time and daily moderate-to-vigorous physical activity, adjusting for clustering, demographics, weight status, free/reduced-price lunch eligibility, school physical activity environment, wear time, and weather. Program reach by sex, weight status, race/ethnicity, and baseline activity levels was explored.ResultsOf the 979 participants analyzed (aged 8.7 [SD=0.7] years, 44% male, 60% non-White, 40% overweight/obese, 55% eligible for free/reduced-price lunch), 8.4% (18.2 [SD=7.9] minutes per day) and 19.8% (45.6 [SD=19.4] minutes per day) fulfilled the 30-minute school-time and 60-minute daily moderate-to-vigorous physical activity recommendations at baseline, respectively. Overall, daily moderate-to-vigorous physical activity decreased from baseline to 18 months (p<0.001, −5.3 minutes, 95% CI= −8.2, −2.4) with no effect of programming. However, for school-time moderate-to-vigorous physical activity, intervention schools maintained school-time moderate-to-vigorous physical activity across the 2 academic years, whereas school-time moderate-to-vigorous physical activity decreased in control schools (p=0.004, −2.3 minutes, 95% CI= −4.3, −0.4). Program reach on school-time moderate-to-vigorous physical activity appeared equitable by sex and weight status but was different by race/ethnicity (p<0.001).ConclusionsTwo different school-based physical activity programs were effective in preventing the decline in school-time moderate-to-vigorous physical activity that is typical across the elementary years, with similar reach by sex and weight status. Multiple opportunities for physical activity during school are needed to promote meeting school-time moderate-to-vigorous physical activity recommendations among diverse children.Trial registrationThis study is registered at www.clinicaltrials.gov NCT02810834.

Context: Volunteer-led out-of-school-time (OST) programs, such as 4-H, scouting, and youth sports, reach a large population of children and are positioned to offer opportunities for healthy eating. However, cost is a barrier to providing healthy snacks such as fruits and vegetables (FVs) during OST. Objective: Offering discounts through grocery store partnerships has shown promise in addressing this barrier in structured, staff-led after-school programs. We tested this model in volunteer-led OST programs and evaluated it using mixed methods. Design/Setting: The Snack It Up (SIU) intervention was designed to promote FV snacks to volunteer-led OST programs through weekly $5 grocery store discounts. Participation was limited to 1 leader per program. Participants: Thirty-five of 36 recruited OST program leaders completed the study; 16 were enrolled in SIU and 19 in a comparison group. Main Outcome Measures: We assessed the following: (1) discount redemption among SIU leaders; (2) snacks served by SIU and comparison group leaders via photographs from 3 to 4 OST program sessions during SIU implementation; and (3) SIU leader perspectives using key informant interviews before and after implementation. Results: SIU leaders saved an average of $48.75 on FV snacks throughout the intervention ($2.90 per week, more than one-fifth of typical self-reported spending on snacks). SIU leaders also served a greater frequency (100% of sessions vs 75%,P< .001) and variety of FVs (an average of 3.5 types per session vs 1.3,P< .001) and fewer salty/sweet snacks (0.0 vs 1.3 types per session,P< .001) than those in the comparison group and expressed positive impressions of SIU. Conclusions: Partnerships between OST programs and grocery stores are a promising avenue for promoting healthier snacks during OST.

INTRODUCTION:Rural women have higher rates of cardiovascular disease than their nonrural counterparts, partially because of their social and environmental contexts. The study objective is to test a refined version of the multilevel Strong Hearts, Healthy Communities intervention, which used extensive process and outcome evaluation data from the original randomized trial to optimize effectiveness as measured by improved Simple 7 score, a composite measure of cardiovascular disease risk.STUDY DESIGN:The intervention was implemented in a 6-month, delayed intervention, community-randomized trial; control participants received the program following 24-week outcome assessment. The study was conducted in 2017-2018; data analysis occurred in 2018-2019.SETTING/PARTICIPANTS:The study was conducted in 11 rural, medically underserved towns in New York. Participants were women aged ≥40 years who were either (1) obese or (2) overweight and sedentary.INTERVENTION:The intervention group received 24 weeks of hour-long, twice-weekly classes including strength training, aerobic exercise, and skill-based nutrition- and health-related education, as well as civic engagement activities focused on healthy food and physical activity environments.MAIN OUTCOME MEASURES:Measures included weight and height; blood pressure; blood cholesterol; blood glucose; and self-reported smoking, diet, and physical activity behaviors. Individual Simple 7 components were examined, and mixed linear regression analyses were used to examine change in Simple 7 score.RESULTS:A total of 182 participants were randomized. Compared with control participants, the intervention group had greater improvements in Simple 7 score (difference=1.03, 95% CI=0.44, 1.61, p<0.001) and 3 of the Simple 7 components (physical activity, healthy diet score, and BMI).CONCLUSIONS:These findings highlight the importance of rigorously evaluating programs in real-world community settings and, when appropriate, revising and retesting interventions to optimize dissemination potential.TRIAL REGISTRATION:This study is registered at www.clinicaltrials.gov NCT03059472.

The National Institute of Food and Agriculture, US Department of Agriculture and the Agricultural Research Service.

BACKGROUND:Rural midlife and older women have high rates of cardiovascular disease (CVD) risk factors and lower access to healthy living resources. The Strong Hearts, Healthy Communities (SHHC) intervention, tailored to the needs of rural women, demonstrated effectiveness on many outcomes. The purpose of the Strong Hearts for New York (SHNY) study is to evaluate the efficacy of an enhanced version of the curriculum (SHHC-2.0). METHODS:SHNY is a randomized controlled efficacy intervention, comparing participants receiving the SHHC-2.0 curriculum with a delayed intervention control group. SHHC, informed by formative research, includes core elements from three evidence-based programs. Changes based on extensive outcome and process evaluation data were made to create SHHC-2.0. Classes will meet twice weekly for 24 weeks and include individual, social, and environmental components. Overweight women age 40 and over will be recruited from 11 rural, medically underserved communities in New York; data will be collected at baseline and 12, 24, 36, and 48 weeks across individual, social, and environmental levels. Primary outcome is body weight. Secondary outcomes include Simple 7 (composite CVD risk score), anthropometric, physiologic, biochemical, physical activity, and dietary intake measures; healthy eating and exercise self-efficacy and attitudes; and self-efficacy of the social network of participants. DISCUSSION:The aims of this study are to evaluate the efficacy of the enhanced SHHC-2.0 program for participants, changes among participants' social networks, and the difference in outcomes when participants are and are not provided with technological tools (Fitbit and body composition scale).

Purpose The purposes of these analyses were to determine whether Strong Hearts, Healthy Communities (SHHC), a multilevel, cardiovascular disease risk reduction program for overweight, sedentary rural women aged 40 or older, led to improved functional fitness, and if changes in fitness accounted for weight loss associated with program participation. Methods Sixteen rural communities were randomized to receive the SHHC intervention or a control program. Both programs involved groups of 12-16 participants. The SHHC program met 1 hour twice a week for 24 weeks where participants engaged in aerobic exercise and progressive strength training. Program content addressed diet and social and environmental influences on heart-healthy behavior. The control group met 1 hour each month for 6 months, covering current dietary and physical activity recommendations. Objective measures of functional fitness included the 30-second arm curl, 30-second chair stand, and 2-minute step test. Self-reported functional fitness was measured by the Physical Functioning Subscale of the MOS Short Form-36 (SF-36 PF). Findings The SHHC program was associated with increased strength and endurance, as represented by greater improvement in the chair stand and step test; and with increased physical function, as represented by the SF-36 PF. Adjustment for change in aerobic endurance, as measured by the step test, accounted for two-thirds of the intervention effect on weight loss at the end of the intervention. Conclusions SHHC participants experienced improved performance on objective measures of functional fitness and self-reported measures of physical function, and changes in weight were partially accounted for by changes in aerobic fitness.

Abstract Background Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities. Methods Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect. Results At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027). Conclusions Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change. Trial registration clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.

Little is known about the relationship between perceived and objective measures of the built environment and physical activity behavior among rural populations. Within the context of a lifestyle-change intervention trial for rural women, Strong Hearts, Healthy Communities (SHHC), we examined: (1) if Walk Score (WS), an objective built environment measure, was associated with perceived built environment (PBE); (2) if WS and PBE were associated with moderate-to-vigorous physical activity (MVPA); and (3) if MVPA changes were modified by WS and/or PBE. Accelerometers and questionnaires were used to collect MVPA and PBE. Bivariate analyses and linear mixed models were used for statistical analyses. We found that WS was positively associated with perceived proximity to destinations (p < 0.001) and street shoulder availability (p = 0.001). MVPA was generally not associated with WS or PBE. Compared to controls, intervention group participants increased MVPA if they lived in communities with the lowest WS (WS = 0), fewer perceived walkable destinations, or extremely safe perceived traffic (all p < 0.05). Findings suggest that WS appears to be a relevant indicator of walkable amenities in rural towns; results also suggest that the SHHC intervention likely helped rural women with the greatest dearth of built environment assets to improve MVPA.