Background. Rural schoolchildren outpace their urban counterparts in obesity and diet-related chronic disease rates. Educating students on nutrition basics may help reduce these health burdens in this focus population. Rural schoolteachers are ideally positioned to teach students about nutrition; however, to teach nutrition, one must first understand basic nutrition concepts. The nutrition literacy and knowledge of rural schoolteachers, as well as strategies to and barriers for integrating nutrition into rural classrooms, are understudied. Examining these topics may provide a deeper understanding of nutrition education in rural schools. Methods. Data were collected via an online survey of K-12 teachers (n = 153) from seven Midwestern rural school districts. This survey collected data on nutrition literacy, nutrition knowledge, and preferred methods for implementing nutrition education into current curricula. Descriptive statistics were reported; associations between nutrition literacy and knowledge were examined. Results. Nutrition literacy levels were borderline low (mean score 45.7 out of 64). Nutrition knowledge and literacy were associated (p < .001). Most teachers (n = 108, 70%) were/may be willing to change lessons to incorporate nutrition information, with hands-on and group activities being preferred strategies. Barriers to including nutrition information into curricula included lack of time, knowledge, and resources. Most teachers reported little support from administration for promoting nutrition in the classroom. Discussion. Implementing nutrition education into teachers' continuing education requirements may provide a means of improving teacher nutrition literacy and knowledge. Support from both state-level and local administration could benefit both nutrition knowledge acquisition by schoolteachers and implementation of nutrition education throughout the curriculum.

The current study explored teacher and principal familiarity with school wellness polices in primary schools, including who serves on school wellness committees, and who should implement and enforce wellness policies in the school. An electronic survey guided by the Health Promoting Schools framework was administered from February to May 2020 to teachers and principals from one urban and one suburban school district in the Midwestern United States. There were 450 participants; response rates were 28% (urban), 33% (suburban), and 51% (school principals). Only 41.7% of the aggregate participant pool were familiar with their wellness policy. Participants were more familiar in the suburban compared to the urban district (χ2 = 68.2, p-value ≤ 0.001). Teachers/health teachers, nurses, and principals were most likely to be on wellness committees, and the most preferred wellness champions were teachers, nurses, and food service staff. Teachers and nurses are integral to school wellness and health education as part of multiple systems that can promote school health. The Health Promoting Schools framework is useful for guiding examinations to improve understanding of school wellness within school communities.

Geriatric patients with complex health care needs can benefit from interprofessional (IP) care; however, a major gap in health professional education is determining how to prepare future providers for IP collaboration. Effective IP team behavior assessment tools are needed to teach, implement, and evaluate IP practice skills. After review of IP evaluation tools, the Standardized Patient Encounter Evaluation Rubric (SPEER) was created to evaluate team dynamics in IP practice sites. Independent sample t-tests between faculty and learner SPEER scores showed learners scored themselves 15 points higher than their faculty scores (p < .001). Cronbach's a showed high internal consistency (a = 0.91). Paired t-tests found that learners identified improvements in the team's ability to address the patient's education needs and to allow the patients to voice their expectations. Faculty identified improvements in the teams' ability to make recommendations. Faculty evaluations of learner teams showed improvements in raw ratings on all but two items. Qualitative data analysis for emergent themes showed learners desired team functioning feedback and how teamwork could improve to provide optimal IP care. In conclusion, the SPEER can help faculty and learners identify growth in their teams' ability to perform key IP skills in clinical sites.

Objective: To examine teachers' familiarity and use of MyPlate, including barriers to using it. Methods: Twenty kindergarten through grade 12 teachers were recruited from 1 urban and suburban school district in the Midwest to participate in virtual focus groups regarding familiarity, use, and barriers to MyPlate. A basic descriptive qualitative approach with thematic analysis was guided by systems thinking. Common categories were coded and agreed on by the authors. Results: Findings included main categories of individual awareness, use in curriculum, and appropriate fa-cilitators of MyPlate. Awareness and use of MyPlate were mixed. Teachers integrated MyPlate in math, his-tory, and other subjects. Barriers included packed curriculum and cultural issues. The facilitators of MyPlate mentioned were health or physical education teachers. Conclusions and Implications: Online focus groups successfully collected formative data on teachers' perspectives toward MyPlate. The technology could be used in future similar research. Enhanced teacher training may improve the integration of MyPlate into schools. School teachers identified major barriers to MyPlate in the classroom, including lack of time and resources. There was mixed feedback on how MyPlate and nutrition may be used in school curricula. Enhanced teacher training may improve the integration of MyPlate into schools.

Aerobic exercise reduces risk for breast cancer and recurrence and promotes visceral adipose tissue (VAT) loss in obesity. However, few breast cancer survivors achieve recommended levels of moderate to vigorous physical activity (MVPA) without supervision. In a two-cohort study, feasibility of 12 weeks of partially supervised exercise was started concomitantly with caloric restriction and effects on body composition and systemic risk biomarkers were explored. In total, 22 obese postmenopausal sedentary women (including 18 breast cancer survivors) with median age of 60 and BMI of 37 kg/m2 were enrolled. Using personal trainers twice weekly at area YMCAs, MVPA was escalated to ≥200 min/week over 9 weeks. For cohort 2, maintenance of effect was assessed when study provided trainer services were stopped but monitoring, group counseling sessions, and access to the exercise facility were continued. Median post-escalation MVPA was 219 min/week with median 12-week mass and VAT loss of 8 and 19%. MVPA was associated with VAT loss which was associated with improved adiponectin:leptin ratio. In total, 9/11 of cohort-2 women continued the behavioral intervention for another 12 weeks without trainers. High MVPA continued with median 24-week mass and VAT loss of 12 and 29%. This intervention should be further studied in obese sedentary women.

Objectives Nutrition literacy examines the intersection of nutrition knowledge and skills; however, no evidence shows interventions tailored to nutrition literacy deficits affect diet behaviors. This study examined the effects of nutrition interventions tailored to individual nutrition literacy deficits on improving diet-related behaviors. Methods Five outpatient clinics were randomized to 2 arms. The nutrition literacy and diet behaviors of patients were assessed before intervention with a dietitian and again 1 month later. Intervention-arm dietitians received patient nutrition literacy levels and tailored interventions toward nutrition literacy weaknesses. Differences in diet behaviors between arms were analyzed using Mann-Whitney U-tests and within-arms using Wilcoxon signed-rank tests. Results Intervention-arm patients improved 10 of 25 measured diet behaviors; control-arm patients improved 6 behaviors. Similarly, intervention-arm patients reported increased green vegetable consumption from baseline to follow-up (z = 2.00; P = 0.04). Conclusions and Implications Nutrition interventions tailored toward nutrition literacy deficits may play an important role in improving patient diet behaviors.

ObjectiveDietitians play key roles in collaborative practice; however, little evidence exists on the effects minimal interprofessional education (IPE) experience may play in improving collaborative behaviors amongst dietetics interns.Use of Theory or ResearchIPE involves healthcare students from multiple disciplines learning together as part of professional training. The goal of IPE is to nurture collaborative behaviors amongst healthcare professionals once they enter the workforce.Target AudienceDietetic interns.Course/Curriculum DescriptionInterns attended 2, half-day clinical rotations at an IPE-focused geriatric general practice clinic, on separate weeks, as part of their internships. A 10-minute PowerPoint presentation on clinic expectations was viewed prior to the first week of rotations. Trained preceptors directly observed interns' interactions with patients and other health professions, with debriefing/coaching provided after every rotation.Evaluation MethodsCollaborative behaviors for all interns (n = 42) were assessed by 1 trained preceptor using the Individual Teamwork Observation and Feedback Tool (iTOFT), a validated tool used to measure 11 interprofessional collaborative behaviors. Behaviors were scored as 0=not applicable to this activity, 1=beginner, 2=meets expectations, and 3=exemplary. Differences in score between weekly iTOFT collaborative behaviors were analyzed using Wilcoxon signed rank tests for related samples, while differences between weekly mean iTOFT scores were analyzed using paired-samples t-tests.ResultsInterns improved in all 11 iTOFT collaborative behaviors from Week 1 to Week 2 (P < 0.01 for all behaviors, respectively). Mean iTOFT scores improved from Week 1 to Week 2 (20.60 vs 25.43, P < 0.001).ConclusionDietetic interns improved significantly in collaborative behaviors, with little previous IPE experience. These findings highlight the positive effects minimal experience in IPE settings may have on improving collaborative behaviors. Dietitians play key roles in collaborative practice; however, little evidence exists on the effects minimal interprofessional education (IPE) experience may play in improving collaborative behaviors amongst dietetics interns. IPE involves healthcare students from multiple disciplines learning together as part of professional training. The goal of IPE is to nurture collaborative behaviors amongst healthcare professionals once they enter the workforce. Dietetic interns. Interns attended 2, half-day clinical rotations at an IPE-focused geriatric general practice clinic, on separate weeks, as part of their internships. A 10-minute PowerPoint presentation on clinic expectations was viewed prior to the first week of rotations. Trained preceptors directly observed interns' interactions with patients and other health professions, with debriefing/coaching provided after every rotation. Collaborative behaviors for all interns (n = 42) were assessed by 1 trained preceptor using the Individual Teamwork Observation and Feedback Tool (iTOFT), a validated tool used to measure 11 interprofessional collaborative behaviors. Behaviors were scored as 0=not applicable to this activity, 1=beginner, 2=meets expectations, and 3=exemplary. Differences in score between weekly iTOFT collaborative behaviors were analyzed using Wilcoxon signed rank tests for related samples, while differences between weekly mean iTOFT scores were analyzed using paired-samples t-tests. Interns improved in all 11 iTOFT collaborative behaviors from Week 1 to Week 2 (P < 0.01 for all behaviors, respectively). Mean iTOFT scores improved from Week 1 to Week 2 (20.60 vs 25.43, P < 0.001). Dietetic interns improved significantly in collaborative behaviors, with little previous IPE experience. These findings highlight the positive effects minimal experience in IPE settings may have on improving collaborative behaviors.

Obesity and poor diet quality (DQ) are associated with increased risk of morbidity/mortality among breast cancer survivors. This study explored DQ changes during a weight loss maintenance intervention in a cohort of rural female breast cancer survivors (n = 131) who lost ≥ 5% body weight in a weight loss intervention. Previous analyses demonstrated significant DQ improvements during weight loss. DQ was calculated using the alternate Healthy Eating Index (aHEI)-2010. Differences in scores across time for the cohort and between those that maintained weight loss within 5% (low regainers) and those that regained > 5% (high regainers) were analyzed by linear mixed models. Significant improvements in aHEI total score were observed from baseline (M = 52.3 ± 11) to 6 months (M = 60.7 ± 8; p < 0.001); these improvements were sustained from 6 to 18 months (M = 58.4 ± 11; p = 0.16). Total aHEI-2010 score at 18 months was higher in low regainers, compared with high regainers (60.7 vs. 56.0, p = 0.03), with healthier component scores for red meat (p = 0.01) and fruit (p = 0.04), and a trend for a healthier score for sugar-sweetened beverages (p = 0.08). Overall DQ improvements made during a weight loss intervention for rural breast cancer survivors were sustained during a weight loss maintenance intervention; this intervention was effective in helping low regainers maintain healthier scores in fruit, red meat, and sugar-sweetened beverage components. Maintaining higher DQ may help breast cancer survivors maintain weight loss, thereby reducing risk of breast cancer recurrence and premature death from comorbidities.

Nutrition literacy is the capacity to apply nutrition information to dietary choices and is associated with diet quality. Understanding patient nutrition literacy deficits may help dietitians provide a more patient-centered intervention and improve patient satisfaction with their nutrition care. This pilot study examined the effects of nutrition literacy assessments on patient satisfaction. Participants (n = 89) were patients scheduled for an appointment with an outpatient dietitian. All participants completed the validated Nutrition Literacy Assessment Instrument (NLit) prior to their visit with a dietitian. Intervention-arm dietitians accessed patient NLit results to focus interventions towards individual nutrition literacy deficits. Control-arm dietitians did not access NLit results and provided traditional interventions. All participants returned one month later to retake the NLit and a modified version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, a patient-centered satisfaction survey developed by the Agency for Healthcare Research and Quality (AHRQ). Correlations were used to examine relationships between patient satisfaction and baseline NLit scores, change in NLit scores, and randomization. Bootstrapped multiple linear regression models were used to examine relationships between patient satisfaction, changes in NLit score, and sociodemographic variables. Mean patient satisfaction score for the cohort was 9.01 (10-point scale). Patient satisfaction was correlated with improvements in NLit score (Spearman's r = 0.265, P = 0.012). Partial correlations showed a positive relationship between changes in NLit score and patient satisfaction (r = 0.302, P = 0.006) when controlling for randomization, age, sex, education, income, and ethnicity. Regression models showed a positive association between patient satisfaction and change in NLit score (adjusted r2 = 0.087, P = 0.036). Improved nutrition literacy may improve patient satisfaction. Nutrition literacy assessments may aid dietitians to focus nutrition interventions, individualizing nutrition education, and improve patient satisfaction. This work was supported by a CTSA grant from NCATS and the School of Health Professions.

BackgroundNutrition literacy is a unique subset of health literacy, a leading predictor of poor health outcomes. Understanding a patient's nutrition literacy may help dietitians provide interventions tailored to a patient's nutrition knowledge weaknesses. While tools exist to evaluate nutrition literacy, it is unclear whether dietitians currently assess patients for nutrition literacy.ObjectiveTo examine nutrition literacy assessment among practicing outpatient dietitians, barriers to implementing a nutrition literacy survey into clinical practice, and possible solutions to these barriers.Study Design, Settings, ParticipantsSemi-structured interviews, divided into four sampling frames, with dietitians (n = 28) from multiple outpatient settings were conducted across two Midwestern states. Similar interviews were conducted with outpatient clinic managers (n = 7), providing a wider viewpoint.Measurable Outcome/AnalysisQuestions addressed clinic work flow, assessing nutrition literacy, and barriers to implementing a survey into practice. All interviews were transcribed, coded, and analyzed by trained study personnel.ResultsAll dietitians stated they use no nutrition literacy assessment tools in clinical practice; subjective assessments are used. Barriers to survey implementation included time to complete the survey (79%/n = 22 of interviewees), logistics in administering the survey (75%/n = 21), patient motivation (75%/n = 21), literacy levels of patients (54%/n = 15), and clinic staff support (32/n = 9). Clinic managers stated barriers to survey implementation included patient motivation (86%/n = 6), devoting staff to a non-revenue generating task (71%/n = 5), logistics in administering the survey (71%/n = 5), and time to complete the survey (57%/n = 4). Solutions include survey administration prior to the patient's appointment (79% of dietitians/n = 22, 86% of managers/n = 6), motivating patients to complete the survey prior to their visit (29%/n = 8, 100%/n = 7), and reducing survey length (21%/n = 6, 43%/n = 3).ConclusionWhile multiple barriers to evaluating nutrition literacy in clinical settings exist, potential solutions to these barriers exist. Further research on the implementation of nutrition literacy assessment in the outpatient clinic setting is needed. Nutrition literacy is a unique subset of health literacy, a leading predictor of poor health outcomes. Understanding a patient's nutrition literacy may help dietitians provide interventions tailored to a patient's nutrition knowledge weaknesses. While tools exist to evaluate nutrition literacy, it is unclear whether dietitians currently assess patients for nutrition literacy. To examine nutrition literacy assessment among practicing outpatient dietitians, barriers to implementing a nutrition literacy survey into clinical practice, and possible solutions to these barriers. Semi-structured interviews, divided into four sampling frames, with dietitians (n = 28) from multiple outpatient settings were conducted across two Midwestern states. Similar interviews were conducted with outpatient clinic managers (n = 7), providing a wider viewpoint. Questions addressed clinic work flow, assessing nutrition literacy, and barriers to implementing a survey into practice. All interviews were transcribed, coded, and analyzed by trained study personnel. All dietitians stated they use no nutrition literacy assessment tools in clinical practice; subjective assessments are used. Barriers to survey implementation included time to complete the survey (79%/n = 22 of interviewees), logistics in administering the survey (75%/n = 21), patient motivation (75%/n = 21), literacy levels of patients (54%/n = 15), and clinic staff support (32/n = 9). Clinic managers stated barriers to survey implementation included patient motivation (86%/n = 6), devoting staff to a non-revenue generating task (71%/n = 5), logistics in administering the survey (71%/n = 5), and time to complete the survey (57%/n = 4). Solutions include survey administration prior to the patient's appointment (79% of dietitians/n = 22, 86% of managers/n = 6), motivating patients to complete the survey prior to their visit (29%/n = 8, 100%/n = 7), and reducing survey length (21%/n = 6, 43%/n = 3). While multiple barriers to evaluating nutrition literacy in clinical settings exist, potential solutions to these barriers exist. Further research on the implementation of nutrition literacy assessment in the outpatient clinic setting is needed.