Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
STUDY PROTOCOL
Open Access
B’More healthy communities for kids: design of a
multi-level intervention for obesity prevention for
low-income African American children
Joel Gittelsohn*, Elizabeth Anderson Steeves, Yeeli Mui, Anna Y Kharmats, Laura C Hopkins and Donna Dennis
Abstract
Background: Childhood obesity rates in the U.S. have reached epidemic proportions, and an urgent need remains
to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component interventions are
needed due to the multi-factorial nature of obesity, and its proven links to both the social and built environment.
However, there are huge gaps in the literature related to doing these kinds of interventions among low-income,
urban, minority groups.
Methods: The B’More Healthy Communities for Kids (BHCK) intervention is a multi-level, multi-component intervention,
targeting low-income African American youth ages 10–14 and their families in Baltimore, Maryland. This intervention
prevents childhood obesity by working at multiple levels of the food and social environments to increase access to,
demand for, and consumption of healthier foods. BHCK works to create systems-level change by partnering with city
policy-makers, multiple levels of the food environment (wholesalers, corner stores, carryout restaurants), and the social
environment (peers and families). In addition, extensive evaluation will be conducted at each level of the intervention
to assess intervention effectiveness via both process and impact measures.
Discussion: This project is novel in multiple ways, including: the inclusion of stakeholders at multiple levels
(policy, institutional, and at multiple levels of the food system); that it uses novel computational modeling methodologies
to engage policy makers and guide informed decisions of intervention effectiveness; it emphasizes both the built
environment (intervening with food sources) and the social environment (intervening with families and peers).
The design of the intervention and the evaluation plan of the BHCK project are documented here.
Trial registration: NCT02181010 (July 2, 2014).
Keywords: Obesity, Children, Urban, Multi-level interventions, Policy, Study design
Background
Currently, 35.0% of adults in the United States are obese
and 33.6% are overweight [1]. While US obesity rates
have leveled off in recent years [1], the high prevalence
of obesity remains a severe threat to the health of Americans. Simply stated, obesity is caused by an imbalance
in energy intake and expenditure; however, there are
multiple, complex factors that influence this equation.
The rise in obesity in the US has occurred too rapidly to
be primarily related to our biology [2], which has led scientists and practitioners to examine changes in the food
environment, policies, and production system as potential drivers [2,3]. Over the past 40 years the U.S. food
system and food environment has evolved to provide an
abundant supply of inexpensive, highly palatable, high
energy foods that are accessible, convenient, and heavily
marketed [3]. In this context, high obesity rates may be
viewed as a natural response to the environment [3].
The food environment may be defined as the types of
food sources that are accessible to an individual (such as
supermarkets, fast food restaurants, convenience stores,
school meal programs, etc.) and what consumers are exposed to in those environments (availability of healthy
* Correspondence: jgittel1@jhu.edu
Johns Hopkins Global Obesity Prevention Center, Johns Hopkins Bloomberg
School of Public Health, 615 North Wolfe St, Baltimore, MD 21205-2179, USA
© 2014 Gittelsohn et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
and unhealthy foods, prices, promotions/marketing, etc.)
[2,4]. A review of the literature by Larson and colleagues
[5] found that increased access to supermarkets was related to improvements in diet quality, fat intake, and
fruit and vegetable consumption in studies of both adults
and adolescents. Increased access to grocery stores is generally linked to reduced levels of obesity, whereas increased access to convenience stores, corner stores, and
fast food outlets is linked to increased obesity [5-9]. Additionally, low-income and minority neighborhoods have
disproportionately lower levels of access to healthier food
sources (i.e. supermarkets) and increased access to less
healthy food sources (i.e. fast food, convenience stores,
corner stores) [5,10-12], which may contribute to the disparities seen in obesity rates among groups.
Like many cities in the US, healthy foods and food
source availability is limited in low-income areas in
Baltimore [13-16]. These areas have few supermarkets,
but do have many small food sources including corner
stores, carry-out restaurants, and fast food restaurants
[13-15]. Corner stores in Baltimore have limited space
and stock primarily high fat and high added sugar
items [17]. Baltimore carry-outs primarily serve high
fat and high sugar foods [18]. In 2007, 32.7% of Baltimore
City adult residents were overweight and 35.0% were
obese [19]. These disparities can be attributed, in part, to
the poor community food environment.
It is clear that multi-level, multi-component interventions are needed to address the obesity epidemic, and
that this work needs to take place in low-resource settings. In the area of childhood obesity prevention, the
majority of work has taken place in schools – with limited impact [20]. In recent years, a number of trials have
combined school-based approaches with complementary
approaches in the community [21]. Shape Up Somerville
was one such successful approach. Using community
participatory approaches, Shape up Somerville was designed to prevent undesirable weight gain by intervening
within the before-, during-, and after-school environments of an elementary school child. Program development involved the engagement of various community
members, including school food service providers, beforeand after-school programs, restaurants, parents, children,
and others. As a result, the multi-component program led
to a decrease in BMI percentile among children [22]. Despite this success, fewer than half of the combined schoolcommunity intervention trials have successfully reduced
obesity in children. Some limitations of this previous work
include: lack of attention to policy, which is needed for
long-term sustainability and stakeholder buy-in; no systematic exploration of the potential for different intervention strategies to work alone and in combination; lack of
emphasis on the social environment as part of intervention strategies, weaknesses in the delivery of the
Page 2 of 9
intervention, such that intensity and exposure is limited,
and a near total lack of work on low income urban populations, where the risk for obesity and associated negative
outcomes is the greatest. New approaches are needed that
will work at multiple levels, combine multiple intervention
venues and strategies – and that address the significant
gaps presented above.
The B’More Healthy Communities for Kids (BHCK)
trial is a multi-level child obesity prevention intervention, supported as part of an U54 grant to the Johns
Hopkins Bloomberg School of Public Health to fund the
Johns Hopkins Global Obesity Prevention Center. The
BHCK intervention is guided by social cognitive theory
(SCT), social ecology, and systems theory [23-26]. SCT
and social ecology conceptualize the individual as nested
within broad social and environmental networks and
structures that impinge on their perceptions, outlooks, and
behaviors (Figure 1). Psychosocial factors (e.g. knowledge,
intentions and self-efficacy), social-environmental factors
(e.g. behavioral observations), and physical-environmental
factors (e.g. food availability, price) interact at various levels
to shape health outcomes [26-32]. According to systems
theory, this dynamic and complex system operates as one
whole interacting functional unit, in which information
and influences flow bi-directionally from one level to another. Policy, institutional, and behavioral strategies have
the potential to reach multiple levels of the food environment. The BHCK trial seeks to develop and test a series
of intervention strategies that will function at multiple
interacting levels, and will be implemented in collaboration with city officials, local wholesaler(s), and retail
food stores/carryouts. These strategies will improve the
healthy food supply chain for low-income communities.
Institutional level intervention components (e.g., wholesalers, retailers, recreation centers, and consumers) will
promote healthy dietary behaviors in order to influence
the household (e.g., food purchasing and preparation) and
individual food-related psychosocial factors and behaviors,
which will ultimately impact risk of obesity. Emphasis will
be placed on institutional and behavioral strategies, (e.g.,
retailer discounts, point of purchase promotions, and
health education), which will elicit change at each level.
Methods/design
The BHCK trial uses a group randomized study design,
where 30 low-income, geographic zones surrounding recreation centers have been selected to serve as either
intervention or comparison areas. All areas were required
to be predominantly low-income and African American.
Half of these zones have been randomized to intervention
(Healthy Eating Zones (HEZs)), while the other half have
been set to comparison (delayed intervention), in two
waves. The center point (recreation center) of all intervention and comparison zones must exceed one mile in
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
Page 3 of 9
Figure 1 B’More healthy communities for kids conceptual framework.
distance from each other, to reduce the potential for
contamination.
The research was approved by the Johns Hopkins
Bloomberg School of Public Health Institutional Review
Board. Written informed consent was obtained from all
adult participants for themselves, and for children. Written assent was obtained from all children who were part
of the evaluation sample.
Formative research
Extensive formative research was conducted to aid in
program planning and materials development. Methods
included in-depth interviews and focus groups with
youth and their adult caregivers, ground truthing of food
sources, and environmental scans of food availability. Indepth interviews with youth (ages 10–14) and their adult
caregivers were conducted to identify key areas for intervention, along selection of the most appropriate communication channels and messaging materials. Ground
truthing techniques were used to identify and map food
sources in each intervention and comparison neighborhood with over 300 unique food sources documented.
Selection of appropriate and acceptable foods to be
promote during the intervention is critical to the success
of this project. To select the food items that we will promote in the intervention, study staff observed inventory
at local wholesalers to identify availability of healthy and
affordable beverages, snacks, and grocery items. Four
child focus groups were conducted at Baltimore City recreation centers. Children were involved in the selection
of foods for promotion, and in communication material
pre-testing, to gauge which images, characters, slogans,
and messaging resonated.
Three additional focus groups were conducted with
adult caregivers to discuss media preferences for information dissemination, information needs, and to ascertain interest in cooking classes. During the final two
groups, parents were asked to provide feedback on draft
text-messages, and to discuss how frequently they would
like to receive the text-messages.
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
Participants and recruitment
The target group in the BHCK multi-level intervention
are low-income African American adolescents, ages 10–
14, and their adult caregivers. Recruitment will occur at
recreation centers and neighborhoods sites within each
zone. Interested parents/guardians and youth are screened
for eligibility prior to enrollment. Once a sample of 75
youth are screened as eligible in each of the HEZs, a sampling frame will be created for that HEZ. Among those recruited and screened, 24 dyads (comprised of a child and
adult pair) will be randomly selected in each neighborhood. If a randomly selected dyad was unable to complete
the interview, then the next eligible dyad will be chosen
from the recruitment list.
Intervention
The BHCK intervention will involve multiple components at many levels (Figure 1): policy, wholesalers, recreation centers, corner stores/carryouts and family/
parents. Each component of the BHCK program will
reinforce several other components – either by improving access or increasing demand.
Page 4 of 9
with policymakers. The model will be presented at regular meetings to solicit feedback and promote dialogue
about programs and policies of interest to stakeholders.
Activities of the workgroup, including the number of
attendees per meeting, the number of divisions represented at each meeting, suggested updates to the model
by stakeholders, requests to simulate program or policy
impact by stakeholders, etc. will be tracked to measure
progress of this intervention component (Table 1).
Wholesaler engagement and pricing strategies
Our work with wholesalers will aim to increase access to
healthier foods by small retail and prepared food sources
in the city, by increasing the stocking and sales of affordable healthy food options at local wholesalers that supply
corner stores and carryouts. BHCK will collaborate with
Table 1 Selected process evaluation measures and
minimum standards per intervention level
Intervention
level
Intervention component
Minimum
standards
for delivery
Policy
# of attendees/meeting
>25
# of different sectors represented/
meeting
>6
# ABM sub-groups formed/year
>2
# of food items that meets the
nutrition guidelines per phase
≥3
# wholesalers that provide discount
to BHCK intervention stores
2
% of shelf labels correctly placed
≥75%
Policy level approaches
The policy-level intervention component will bridge the
gap between research and policy by engaging with and
informing key Baltimore City stakeholders. The policy
work will strive to develop collaborations to sustain
BHCK program elements, and to contribute to policy to
improve the food environment. A working group of
nearly forty members was established in July 2013 with
representation from the Baltimore City Health Department,
City Council, Department of Planning, school food services, non-profit organizations, and academia. Quarterly
meetings and cross-sector communications with collaborators ensure engagement.
A key role of JHU will be the provision and development of the evidence base to support decision-making
and policy development by these entities. Unique to this
component will be the use of computational modeling to
simulate the potential impact of programs and policies
for reducing children’s obesity risk. Using agent-based
modeling [33], we have developed a virtual representation how low income Baltimore children behave in their
food environment, including dietary and physical activity
choices. Key institutions within this model (corner stores,
carryouts, recreation centers) can be impacted by different
intervention strategies. The model will serve three major
purposes as: 1) a novel tool to better understand the
dynamic nature of children and their food environment;
2) a low-cost approach to predict the impact of obesity
prevention programs and policies before investing in
implementation; and 3) a highly visual, interactive, and
intuitive platform to facilitate the exchange of ideas
Wholesaler
Recreation Center/ # of planned intervention sessions
Peer Leader
delivered by youth-leaders
Corner Store/
Carryout
≥75%
# of kid interactions per session at
the recreation center
≥12
# of NEW promoted foods stocked
per phase
≥4
# of kid interactions during interactive ≥20
session/store/phase
Family/SMS
messaging,
social media
# healthier options on menu
(designated by green leaf)/phase
≥4
# reduced price healthier options on
menu/phase
≥4
% families receiving invitation to join
SMS program
90%
% that join
40%
# SMS text messages sent to
participants/week
2
% text messages received
80%
% families that participate in one of
BHCK’s social media websites
50%
# posts/week on 1+ social media
websites
1
# goal-setting messages/week
1
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
two local wholesale distributors and a national club
store. These organizations have agreed to stock at least
one type/brand of the promoted food items for each
sub-phase of the program and to allow us to post the
BHCK logo sign on the shelves above or adjacent to the
promoted products. BHCK staff will visit these locations
once per month to assess the stocking of promoted foods
and to ensure that logo signs remain posted correctly.
Small store retailers often pay higher prices for (lowdemand) healthy foods than larger retailers due to their
lower inventory. Participating wholesalers have agreed to
provide discounts on select BHCK promoted food items
to participating small food sources. We will also provide
storeowners with gift cards from these businesses to use
to purchase an initial stock of the promoted items.
Expected benefits to participating wholesalers include
increased sales, potential new customers, and public recognition for their support of the project.
Recreation center activities and work with peer leaders
The BHCK study has used a participatory process with
community partners and young people from intervention
neighborhoods to develop the youth-leader intervention
including the youth-leader training materials, a curriculum
that will be delivered to recreation center youth, and messaging and promotional media (videos, posters). For youth in
the 10–14 year old age range, youth-leaders are seen as a
reliable, relatable and credible source of information [34].
We will train a cohort of 16 youth-leaders (local college
students, ages 18–22 years) to deliver a nutrition intervention to the target population of youth in the recreation
centers in each intervention neighborhood.
Youth-leaders who successfully complete the training
program will go on to deliver the curriculum to youth
in the recreation centers. The recreation center sessions
will involve a brief instructional period (5–15 minutes of
information giving) followed by interactive games, activities, taste tests, and cooking classes to reinforce promotional messages. These sessions will be delivered by the
youth-leaders bi-weekly with the support of project staff.
The topics, activities, and taste tests that occur in the recreation centers will mirror the topics and foods/beverages promoted in the store intervention.
Additionally, the youth-leaders’ roles will extend beyond the recreation centers and will cut across the intervention components, as they will also be involved in
delivering the intervention components in stores, via
promotional materials, and on social media. The youthleaders will partner with BHCK staff to deliver interactive
sessions in the corner stores, they will serve as models or
“spokespeople” for the program by having their images
featured on promotional materials (posters, Facebook
posts, tweets), and will generate and promote (by liking
and sharing) social media content for the intervention.
Page 5 of 9
Changing food access in corner stores/carryouts
At the food sources level, BHCK will aim to increase access to, and demand for healthier food options. A minimum of three food sources (at least two corner stores
and one carryout) will be recruited from each zone, located within a ½ mile radius of the recreation center.
The intervention components at the store level are
based on previous corner store [35-39] and carryout
[40-42] trials completed in Baltimore City, with additional innovative pieces.
At the small food source level, BHCK will begin with
a series of storeowner trainings which aim to improve
their knowledge of healthier food options and selfefficacy to be able to stock, prepare and sell their
foods. These trainings will be developed based on formative research [40-43], and will address the following
topics: 1) Introduction to B’More Healthy Communities
for Kids; 2) Customer Service Strategies for Success; 3) How
to Keep Your Food Safe, Fresh, and Healthy; 4) Business
Strategies for Success: How to Stock Healthier Foods; 5)
How to Get WIC in Your Store; and 6) Improving Your
Store Environment. Following completion of the trainings,
store owners may choose structural incentives to aid in
the stocking of healthier food items, i.e. a banana holder,
grill, or small produce refrigerator.
After completion of the training phase, the food promotion phases will begin, which include Smart Beverages,
Smart Snacks, and Smarter Cooking Methods. During
each phase, corner storeowners will be asked to stock
at least four new healthy food options. At the carryouts,
store owners will be asked to make the default beverage
option a healthier option (i.e. water with meal instead of
soda), provide healthier side dishes, engage in healthier
cooking methods, such as grilling, and create a healthy
combo meal on their menu. In order to create demand for
these foods and improve customers’ knowledge about the
foods, a messaging campaign, which was tested in focus
groups with adults and children, will be implemented
through posters, improved menu boards, shelf talkers, labels, and other signage. Interactive sessions, such as taste
tests or blind tasting challenges, will occur in each store at
least every other week. If stores successfully stock new,
healthy food options and allow the BHCK team to promote the foods with their stores throughout the phases,
the BHCK team will progressively deem each store a
Bronze, Silver, Gold, or Platinum Certified Healthy Store.
Family-level work and text messaging
Adult caregivers will receive bi-directional text-messages
(Textit, Inc. [44]), and have the option to select from
one of two frequencies of text-message delivery: twice a
week or three to five times a week. The campaign content will be modified over the course of the intervention
and will be tailored to each neighborhood. The first
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
message each week will encourage completion of an attainable and specific goal. For example, “Does ur child
have a sweet tooth? Try offering them granola bars or
fruit as an alternative to candy 1 time this week”. The
subsequent text-messages will offer support to help parents reach the goal, by highlighting discounts offered
on promoted products at local stores, or BHCK related
activities.
Social media websites such as Facebook, Twitter, and
Instagram will mirror the content of the text-messages.
Images will be added to the websites and interaction between parents will be encouraged. Participants will be
asked to share whether they were able to achieve weekly
goals and advise other parents. The websites will also be
used to link caregivers to outside resources available
through other organizations, (i.e. farmers markets that
accept Supplemental Nutrition Program Assistance benefits, cooking classes offered for adults through the
American Heart Association).
Page 6 of 9
Table 2 Impact evaluation components for the BHCK trial
per intervention level
Intervention
Level
Impact/outcome measures
Policy
% of action items achieved/year
# of health-related issues put on policymaker’s
agenda/year
# of health-related issues introduced by policymaker/
year
Wholesaler
% change in sales of promoted foods to BHCK corner
stores and carryouts
Recreation
Center
Corner Store/
Carryout
Measurements
The BHCK trial will be evaluated at each level (Table 2).
Process evaluation measures will assess reach, dose
delivered and fidelity of intervention implementation
(Table 1).
A sample of adult caregiver-child dyads (n = 24 dyads
per zone, 720 at baseline) will be surveyed pre- and
post-intervention to assess impact. The first section of
the adult instrument contains questions pertaining to
household size and composition, and use of community
recreation centers by children. Specific food sources visited for purchasing/getting foods and amount of money
spent at each source is recalled for the last 30 days. Frequency of purchase of 40+ non-prepared foods in the
last 30 days is recalled (fruits, vegetables, chips, soda,
chicken, etc.). The next section asks how many times a
meal was prepared for the household in the last 30 days,
and inquires about the top three most common preparation methods of seven types of foods (chicken, fish, potatoes, etc.). A series of self-efficacy questions assess
confidence in performing healthier behaviors along a 4
# of posters, shelf labels, shelf talkers, etc. seen by
BHCK participants (exposure)
# promoted foods purchased/consumed by BHCK
participants
# of giveaways received by BHCK participants
# units of promoted foods sold
Adult/household Household food purchasing (healthy and unhealthy
(SMS)
foods)
Healthiness of common methods of food preparation
Change in psychosocial factors (knowledge, self-efficacy,
intentions)
Comparison group (delayed Intervention)
The comparison areas will receive an abbreviated version of the BHCK intervention following completion of
the post-intervention evaluations.
Changes in recreation center policies regarding the
food environment
Changes in the recreation center food environment
(e.g., after-school snack program, concession stand
foods)
Standards for intervention delivery
Intervention implementation at each level will be monitored through ongoing process evaluation, with the intent to assure that set standards are being met (Table 1).
These standards are based on our review of the literature,
and on our previous experience with wholesaler, corner
stores, carryout and peer-led interventions.
% change in sales of promoted foods based on
collected sales data from wholesalers
Change in weight, BMI
Children and
Youth Leaders
Frequency of purchase of healthy and unhealthy foods
Healthiness of food preparation methods
Change in dietary patterns (e.g., total calories, total
fat, FV servings, HEI scores, etc.)
Change in psychosocial factors (knowledge, selfefficacy, intentions, outcome expectations)
Change in BMI percentile
point ordinal scale. Eight questions about behavioral intentions about food are asked (i.e., “The next time you
fried an egg, what would you use to fry it? a) Cooking
Spray; b) Oil; c) Butter, Margarine, Shortening, or Lard.”
Ten food-related knowledge questions are asked. The
next section asks a series of questions about health beliefs and attitudes using a Likert scale, i.e. “Health foods
are tasteless. Do you Strongly Disagree, Disagree, Undecided, Agree, or Strongly Agree?” Adult respondents
are questioned about their food assistance participation
and are asked to provide basic socioeconomic information (education level, income category). The last section
of the survey contains the 18 question USDA food security questionnaire [45].
The child interview consists of two instruments – the
Block Kids 2004 Food Frequency Questionnaire (FFQ)
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
and a Child Impact Questionnaire (CIQ). The Block
Kids 2004 FFQ instrument is a validated FFQ (Nutrition
Quest, Berkeley, CA) that asks about frequency and portion of consumption of 77 food items as is based on
NHANES 1998–2002 data [46]. The CIQ consists of 79
questions pertaining to demographics, food purchasing,
food preparation, intentions about food, outcome expectancies, self-efficacy, food knowledge, social support,
and breakfast consumption. Demographics including
age, birthdate, sex, race, and contact information are obtained. Specific food sources visited, number of times
patronized, and who the child most frequently shopped
within the last seven days is recalled. Frequency and location of purchase of 65+ non- prepared and prepared
food items is recalled for the last seven days (beverages,
fruits and vegetables, groceries, fast food, snacks, etc.).
The next section of the questionnaire assesses how often
a member of the household prepared food for the child
and how often the child prepared food for themselves in
the last seven days. If a child prepared food for themselves, information on types of food prepared and
methods of preparation utilized are collected. Twelve
questions about behavioral intentions about food are
asked (i.e. “If you wanted a snack, which would you
choose? a) Potato chips; b) Pretzels; c) Yogurt). Eleven
questions on both short-term and long-term outcome
expectancies related to consumption of healthy and unhealthy foods are asked (i.e. I would be healthier if I ate
French fries three times a week instead of eating French
fries seven days a week. Is this a) True; b) Mostly true;
c) Mostly false; or d) False). A series of twelve selfefficacy questions assess confidence in performing
healthier behaviors along a 4 point ordinal scale. Fourteen food-related knowledge questions are asked. The
survey contains two social support scales. The first scale
consists of seven questions that inquire whether the
child has someone in their life that would support
healthier food and physical activity habits, who that person is, and whether they are older, younger, or around
the same age as the child. The second social support
scale consists of fourteen questions and asks how often
the child’s parents and peers exhibit certain behaviors
that support healthy and unhealthy eating using a Likert
scale. The final section assesses frequency of breakfast
consumption and includes a 24-hour recall of breakfast
consumed the previous day. Anthropometric data
(height and weight) are collected from both the caregiver
and the child using a Seca 213 Portable Measuring Rod
stadiometer and a Tantia BF697W Duo Scale.
At the store-level, sales data will be collected in two
ways. Before, during and after the intervention, a BHCK
staff member will ask store owners approximately
monthly to recall sales of selected food items (promoted
and non-promoted foods) in the last 7 days.
Page 7 of 9
Additionally, some of the wholesalers with which we
partner will provide the BHCK team with specific sales
data from accounts (stores) throughout the intervention.
Wholesalers have agreed to provide sales data on promoted foods for BHCK participating corner stores
and carryouts.
Sample size and statistical methods
We used baseline data from our previous trial, Baltimore
Healthy Stores, regarding adult food purchasing to calculate sample size and study power to address the second
hypothesis. Based upon our sample size calculations, we
will need to have a sample size of 720 adult caretakerchild dyads (this is equivalent to 24 dyads from each HEZ)
for the intervention assessments. Assuming a 15-20%
drop-out after two years, this will leave us with a minimum of 600 adult caretaker-child dyad respondents postintervention. We will be able to detect a 4–6 point change
in our frequency of healthy food purchasing score, reflecting one healthy food purchased once a week.
For children participants in the dyads, sample size and
power for program impact on children’s diet was calculated using national data on low-income urban AA
youth diet. Within each selected household, we will randomly sample one child in the 10–14 year age range. Assuming 600 child respondents post-intervention, we will
be able to detect a 320–450 difference in caloric intake,
a difference of 12–15 g of fat intake and a difference of
1–1.5 percentage points in percent of energy from fat.
Discussion
To our knowledge, BHCK will be one of few multi-level,
multi-component obesity prevention intervention trials
working with urban, low-income, minority youth. First,
BHCK will be a unique trial that seeks to integrate
stakeholders at multiple critical levels: policy; food
supply (wholesalers); retail (corner stores, carryouts);
community (recreation centers); and individual (children
and caregivers). Second, policymakers and other key
stakeholders will be engaged with the research in a novel
manner using computational modeling. Our ability to
simulate the potential impact of programs and policies
within a virtual food environment will provide an
approachable and low-cost means to collaboratively explore ways to improve the food environment. Third,
multiple components of the food system will be targeted.
Not only do storeowners receive business and nutrition
training, but the program intervenes at the wholesale
level as well. Fourth, there will be an emphasis on social
aspects of the environment, operating at the individual
level – including text messaging with caregivers and delivery of nutrition interventions through incorporation
of youth-leaders to allow for enhanced social modeling
of desired eating behaviors. This will be one of the first
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
nutritionally related text messaging campaigns that will
target low-income participants, and incorporate information regarding participants’ local food environment.
Lastly, detailed process and impact evaluations will
occur at all intervention levels.
Researchers, public health officials, and policy makers
will have a significant interest in the results of the BHCK
intervention. Several leading organizations and scientists
have cited that multi-level, multi-component interventions are required to address the obesity epidemic in the
US, yet few of these large intervention trials have been
successfully completed. Trials such as BHCK are needed
to support this claim.
One powerful advantage of BHCK intervention, will be
that it will serve as a model of how to engage with city
policymakers to improve the food environment. Because
of its regular and prolonged engagement with policy
makers, the BHCK intervention will have the potential to
create long-term impact, and to be sustainable through
institutionalization of intervention components with the
largest impact into our partners in the Baltimore City
Health Department and city government.
Page 8 of 9
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Competing interests
The authors declare they have no competing interests.
Authors contribution
JG designed the study, developed the protocol and drafted the manuscript.
EAS participated in the design of the study, and developed and coordinated
the peer leader and recreation center components. YM participated in the
design of the study, and developed and coordinated the policy component.
AK participated in the design of the study, and developed and coordinated
the SMS messaging/family media components. LH participated in the design
of the study, and developed and coordinated the food source component.
DD participated in the design of the study, and developed and coordinated
the wholesaler component. All authors assisted in developing process and
impact evaluation tools related to their component. All authors read and
approved the final manuscript.
Acknowledgements
Grant Number U54HD070725 from the Eunice Kennedy Shriver National
Institute of Child Health & Human Development (NICHD). The project is
co-funded by the NICHD and the Office of Behavioral and Social Sciences
Research (OBSSR).
Received: 20 May 2014 Accepted: 3 September 2014
Published: 11 September 2014
References
1. Ogden CL, Carroll MD, Kit BK, Flegal KM: Prevalence of childhood and
adult obesity in the United States, 2011–2012. JAMA 2014, 311:806–814.
2. Sallis JF, Glanz K: Physical activity and food environments: solutions to
the obesity epidemic. Milbank Q 2009, 87:123–154.
3. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML,
Gortmaker SL: The global obesity pandemic: shaped by global drivers
and local environments. Lancet 2011, 378:804–814.
4. Glanz K, Sallis JF, Saelens BE, Frank LD: Healthy nutrition environments:
concepts and measures. Am J Heal Promot 2005, 19:330–333. ii.
5. Larson NI, Story MT, Nelson MC: Neighborhood environments: disparities
in access to healthy foods in the U.S. Am J Prev Med 2009, 36:74–81.
6. Morland KB, Evenson KR: Obesity prevalence and the local food
environment. Health Place 2009, 15:491–495.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Morland K, Diez Roux AV, Wing S: Supermarkets, other food stores, and
obesity: the atherosclerosis risk in communities study. Am J Prev Med
2006, 30:333–339.
Powell LM, Auld MC, Chaloupka FJ, O’Malley PM, Johnston LD: Associations
between access to food stores and adolescent body mass index. Am J
Prev Med 2007, 33(4 Suppl):S301–S307.
Gibson DM: The neighborhood food environment and adult weight
status: estimates from longitudinal data. Am J Public Health 2011,
101:71–78.
Powell LM, Slater S, Mirtcheva D, Bao Y, Chaloupka FJ: Food store
availability and neighborhood characteristics in the United States.
Prev Med (Baltim) 2007, 44:189–195.
Franco M, Diez Roux AV, Glass TA, Caballero B, Brancati FL: Neighborhood
characteristics and availability of healthy foods in Baltimore. Am J Prev
Med 2008, 35:561–567.
Gordon C, Purciel-Hill M, Ghai NR, Kaufman L, Graham R, Van Wye G:
Measuring food deserts in New York City’s low-income neighborhoods.
Health Place 2011, 17:696–700.
Steinberger J, Daniels SR: Obesity, insulin resistance, diabetes, and
cardiovascular risk in children: an American Heart Association scientific
statement from the Atherosclerosis, Hypertension, and Obesity in the
Young Committee (Council on Cardiovascular Disease in the Young)
and. Circulation 2003, 107:1448–1453.
Zenk SN, Schulz AJ, Israel BA, James SA, Bao S, Wilson ML: Fruit and
vegetable access differs by community racial composition and
socioeconomic position in Detroit, Michigan. Ethn Dis 2006, 16:275–280.
Daroszewski EB: Dietary fat consumption, readiness to change, and
ethnocultural association in midlife African American women. J Community
Health Nurs 2004, 21:63–75.
Powell LM, Zhao Z, Wang Y: Food prices and fruit and vegetable
consumption among young American adults. Health Place 2009,
15:1064–1070.
Casagrande SS, Wang Y, Anderson C, Gary TL: Have Americans increased
their fruit and vegetable intake? The trends between 1988 and 2002.
Am J Prev Med 2007, 32:257–263.
Zenk SN, Schulz AJ, Hollis-Neely T, Campbell RT, Holmes N, Watkins G,
Nwankwo R, Odoms-Young A: Fruit and vegetable intake in African
Americans income and store characteristics. Am J Prev Med 2005, 29:1–9.
Sharma S, Cao X, Arcan C, Mattingly M, Jennings S, Song H-J, Gittelsohn J:
Assessment of dietary intake in an inner-city African American
population and development of a quantitative food frequency
questionnaire to highlight foods and nutrients for a nutritional
invention. Int J Food Sci Nutr 2009, 60(Suppl 5):155–167.
Gittelsohn J, Kumar M: Preventing childhood obesity and diabetes: is it
time to move out of the school? Diabetes 2007, 76:485–495.
Gittelsohn J, Park S: School and Community-Based Interventions. In Pediatr
Obes Etiol Pathog Treat. Edited by Freemark M. New York, New York:
Humana Press; 2010:315–336.
Economos C, Hyatt R, Goldberg J, Must A, Naumova E, Collins J, Nelson M:
A community-based environmental change intervention reduces BMI
z-scores in children: Shape up Somerville first year results. Prev Med 2004,
2:S108–S136.
Sallis J, Cervero R, Ascher W, Henderson K, Kraft MK, Kerr J: An ecological
approach to creating active living communities. Annu Rev Public Health
2006, 27:297–322.
Bronfenbrenner U: Ecology of the Family as a Contect for Human
Development: Research Perspectives. Dev Psychol 1986, 22:723–742.
Bandura A: Social Foundations of Thought and Action a Social Cognitive
Theory. Prentice Hall: Engelwood, NJ; 1986.
Bandura A: Social Learning Theory. Prentice Hall: Engelwood, NJ; 1977.
Rimal R: Intergenerational transmission of health: the role of
intrapersonal, interpersonal, and communicative factors. Heal Ecuation
Behav 2003, 30:10–28.
Rimal R: Longitudinal influences of knowledge and self-efficacy on
exercise behavior: Tests of a mutual reinforcement model. J Heal Psychol
2001, 6(1):31–46.
McLeroy K, Bibeau D, Stechler A, Glanz K: An ecological perspective on
health promotion programs. Health Educ Q 1998, 15:351–377.
Kremers S, de Bruijn G-J, Visscher T, V MW, de Vries N, Brug J: Environmental
influences on energy balance-related behaviors: a dual-process view. Int J
Behav Nutr Phys Act 2006, 3:9.
Gittelsohn et al. BMC Public Health 2014, 14:942
http://www.biomedcentral.com/1471-2458/14/942
Page 9 of 9
31. Stokols D: Establishing and maintaining healthy environments: toward a
social ecology of health promotion. Am Psychol 1992, 47:6–22.
32. Cotterill R: Dynamic Explanations of Industry Structure and Performance.
2000:53.
33. Orr MG, Galea S, Riddle M, Kaplan GA: Reducing racial disparities in
obesity: simulating the effects of improved education and social
network influence on diet behavior. Ann Epidemiol 2014, 24(8):563–569.
34. Smith LH: Piloting the use of teen mentors to promote a healthy diet
and physical activity among children in Appalachia. J Spec Pediatr Nurs
2011, 16:16–26.
35. Gittelsohn J, Franceschini MCT, Rasooly IR, Ries AV, Ho LS, Pavlovich W,
Santos VT, Jennings SM, Frick KD: Understanding the Food Environment in
a Low-Income Urban Setting: Implications for Food Store Interventions.
J Hunger Environ Nutr 2008, 2:33–50.
36. Dodson JL, Hsiao Y-C, Kasat-Shors M, Murray L, Nguyen NK, Richards AK,
Gittelsohn J: Formative research for a healthy diet intervention among
inner-city adolescents: the importance of family, school and neighborhood
environment. Ecol Food Nutr 2001, 48:39–58.
37. Gittelsohn J, Song H-J, Suratkar S, Kumar MB, Henry EG, Sharma S, Mattingly
M, Anliker JA: An urban food store intervention positively affects foodrelated psychosocial variables and food behaviors. Health Educ Behav
2010, 37:390–402.
38. Song H-J, Gittelsohn J, Kim M, Suratkar S, Sharma S, Anliker J: A corner store
intervention in a low-income urban community is associated with
increased availability and sales of some healthy foods. Public Health Nutr
2009, 12:2060–2067.
39. Song H-J, Gittelsohn J, Anliker J, Sharma S, Suratkar S, Mattingly M, Kim MT:
Understanding a Key Feature of Urban Food Stores to Develop Nutrition
Intervention. J Hunger Environ Nutr 2012, 7:77–90.
40. Lee-Kwan SH, Goedkoop S, Yong R, Batorsky B, Hoffman V, Jeffries J,
Hamouda M, Gittelsohn J: Development and implementation of the
Baltimore healthy carry-outs feasibility trial: process evaluation results.
BMC Public Health 2013, 13:638.
41. Jeffries JK, Lee SH, Frick KD, Gittelsohn J: Preferences for healthy carryout
meals in low-income neighborhoods of Baltimore city. Health Promot
Pract 2013, 14:293–300.
42. Hoffman VA, Lee SH, Bleich SN, Goedkoop S, Gittelsohn J: Relationship
between BMI and food purchases in low-income, urban adult carry-out
customers. J Hunger Environ Nutr 2013, 8:533–545.
43. Lee-Kwan SH, Bleich SN, Kim H, Colantuoni E, Gittelsohn J: Environmental
Intervention in Carryout Restaurants Increases Sales of Healthy Menu
Items in a Low-Income Urban Setting. Am J Health Promot 2014,
[Epub ahead of print].
44. Pottier N: Newcomer E. TextIt: Kwizera N; 2014.
45. Bickel G, Nord M, Price C, Hamilton W, Cook J: Guide to Measuring
Household Food Security. Alexandria, Virginia: U.S. Department of Agriculture,
Food and Nutrition Service; 2000:1–76.
46. Cullen KW, Watson K, Zakeri I: Relative reliability and validity of the Block
Kids Questionnaire among youth aged 10 to 17 years. J Am Diet Assoc
2008, 108:862–866.
doi:10.1186/1471-2458-14-942
Cite this article as: Gittelsohn et al.: B’More healthy communities for
kids: design of a multi-level intervention for obesity prevention for
low-income African American children. BMC Public Health 2014 14:942.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color figure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit