Childhood eating practices are relevant to ultra-processed food consumption in adulthood: results from the Nutritionists’ Health Study

Abstract Studies on childhood feeding and current food consumption, according to the NOVA classification, in adults are scarce. The objective of this study was to evaluate the relationship between childhood dietary practices and the current consumption of different categories of processed foods in young adults using data from the Nutritionists’ Health Study (NutriHS) cohort. A cross-sectional analysis was performed using data of 392 on nutrition undergraduate students or nutritionists aged ≥18 years. Current food consumption was assessed using a food frequency questionnaire and the NOVA classification. The investigated childhood eating practices included fruit and vegetable intake, exclusive breastfeeding, and other breastfeeding practices. Participants breastfed with introduction of solid, semi-solid or soft foods before 6 months had higher current consumption of processed foods than those who were not breastfed (β = 4.30; 95% confidence interval [CI] = 0.56–8.04) and those who did not have the habits of eating fruits and vegetables during childhood consumed less unprocessed and minimally processed foods in adulthood than those who ate fruits and vegetables during infancy (β = −3.76; 95% CI = −0.82 to −6.70). Further, later introduction of infant formula or other types of milk between 3 and 5 months of age had a lower current consumption of ultra-processed foods than those fed infant formula or other types of milk before 1 month age of life (β = −3.09; 95% CI = −6.12 to −0.06). In conclusion, childhood feeding practices were linked to food consumption in adult life in NutriHS cohort, highlighting that the first 1000 days of life seems to impact on food choices during adulthood, with potential to protect against nutrition-related diseases later in life.

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Intakes of fruits, vegetables and carbohydrate and the risk of CVD

Public Health Nutrition ◽

10.1017/s1368980008002036 ◽

2009 ◽

Vol 12 (1) ◽

pp. 115-121 ◽

Cited By ~ 29

Author(s):

Kaumudi J Joshipura ◽

Hsin-Chia Hung ◽

Tricia Y Li ◽

Frank B Hu ◽

Eric B Rimm ◽

...

Keyword(s):

Fruits And Vegetables ◽

Proportional Hazards ◽

Vegetable Intake ◽

Cox Proportional Hazards ◽

Carbohydrate Intake ◽

Leafy Vegetables ◽

Health Study ◽

Fruit Intake ◽

Green Leafy Vegetables ◽

Low Carbohydrate

AbstractBackgroundLow-carbohydrate diets could lead to reduced fruit and vegetable intake, which may be protective against CVD. The role of carbohydrate intake in modifying the association between fruits and vegetables and CVD has not been evaluated.ObjectiveTo evaluate whether carbohydrate intake affects the association between fruits and vegetables and CVD.DesignWe included participants from two large prospective studies, the Nurses’ Health Study (NHS) and the Health Professionals’ Follow-Up Study (HPFS). We followed 70 870 eligible NHS females for 16 years and 38 918 eligible HPFS males for 14 years. Diet was assessed from an FFQ updated every 4 years. Our primary outcome was ischaemic CVD (fatal and non-fatal myocardial infarction and ischaemic stroke). We used Cox proportional hazards models to evaluate the relationship between fruits and vegetables and ischaemic CVD within groups with low, moderate or high carbohydrate intake.ResultsFruit intake was strongly related with carbohydrate intake, but vegetables showed a very small correlation. Vegetable intake showed stronger associations with ischaemic CVD among the low carbohydrate group (multivariate risk ratio (RR) = 0·82 for an increment of 3 servings/d; 95 % CI 0·68, 0·99); green leafy vegetables and carotene-rich fruits and vegetables followed a similar pattern. Total fruit intake was associated with a lower risk of ischaemic CVD only among participants with moderate carbohydrate intake (RR = 0·81 comparing extreme quintiles; 95 % CI 0·70, 0·94).ConclusionsTotal vegetables, green leafy vegetables and carotene-rich fruits and vegetables showed stronger associations with ischaemic CVD among the low carbohydrate group. No consistent trends were observed for fruit intake.

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Associations between Food Consumption Patterns and Chronic Diseases and Self-Reported Morbidities in 6 American Indian Communities

Current Developments in Nutrition ◽

10.1093/cdn/nzz067 ◽

2019 ◽

Vol 3 (Supplement_2) ◽

pp. 69-80

Author(s):

Felicia J Setiono ◽

Brittany Jock ◽

Angela Trude ◽

Caroline R Wensel ◽

Lisa Poirier ◽

...

Keyword(s):

Type 2 Diabetes ◽

American Indian ◽

Chronic Diseases ◽

Food Consumption ◽

Dietary Patterns ◽

Fruits And Vegetables ◽

Processed Foods ◽

Waist To Hip Ratio ◽

Fried Foods

ABSTRACT Background American Indian (AI) have the highest rates of diet-related chronic diseases in the country. Yet, the relation between dietary patterns and chronic diseases in this population has not been well explored. Objective We aimed to characterize common dietary patterns among adults from 6 AI communities (N = 580) and assess their relation with BMI, percentage body fat, waist-to-hip ratio, hypertension, and self-reported type 2 diabetes and cardiovascular disease. Methods We conducted a baseline assessment of an obesity prevention study (N = 580). Dietary intake data were collected using a modified Block FFQ. Exploratory factor analysis was used to characterize dietary patterns. We used multivariate linear and logistic regression analyses to assess associations between dietary patterns and health outcomes, controlling for age, sex, employment status, smoking status, geographic region, and energy intake. Results Five dietary patterns, explaining 81.8% of variance in reported food consumption, were identified: “meat and fried foods,” “processed foods,” “fruits and vegetables,” “sugary snacks,” and “meat alternatives and high-protein foods.” “Those with higher consumption of “meat and fried foods” were associated with higher mean waist-to-hip ratio (0.03; 95% CI: 0.01, 0.04), higher mean BMI (2.45 kg/m2; 95% CI: 0.83, 4.07), and increased odds of being overweight or obese (OR: 2.63; 95% CI: 1.10, 6.31) compared to those with lower consumption of “meat and fried foods.” Higher consumption of “processed foods” was associated with increased odds of self-reported type 2 diabetes (OR: 3.41; 95% CI: 1.31, 8.90). No protective effect of consumption of “fruits and vegetables” was observed, although average consumption was below national recommendation levels. Conclusions AI dietary patterns corroborate nutritional concerns previously reported among AI populations. Future interventions should discourage overconsumption of meat, fried foods, and processed foods, and promote consumption of fruits and vegetables to reduce chronic disease burden in this population.

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Fruit and Vegetable Consumption and the Incidence of Hypertension in Three Prospective Cohort Studies

Hypertension ◽

10.1161/hypertensionaha.115.06497 ◽

2016 ◽

Vol 67 (2) ◽

pp. 288-293 ◽

Cited By ~ 55

Author(s):

Lea Borgi ◽

Isao Muraki ◽

Ambika Satija ◽

Walter C. Willett ◽

Eric B. Rimm ◽

...

Keyword(s):

Fruits And Vegetables ◽

Vegetable Intake ◽

Vegetable Consumption ◽

Fruit And Vegetable Consumption ◽

Health Study ◽

Fruit Intake ◽

Fruit And Vegetable ◽

Hypertension Risk ◽

Hazard Ratios

Increased fruit and vegetable intake lowers blood pressure in short-term interventional studies. However, data on the association of long-term intake of fruits and vegetables with hypertension risk are scarce. We prospectively examined the independent association of whole fruit (excluding juices) and vegetable intake, as well as the change in consumption of whole fruits and vegetables, with incident hypertension in 3 large longitudinal cohort studies: Nurses’ Health Study (n=62 175), Nurses’ Health Study II (n=88 475), and Health Professionals Follow-up Study (n=36 803). We calculated hazard ratios and 95% confidence intervals for fruit and vegetable consumption while controlling for hypertension risk factors. Compared with participants whose consumption was ≤4 servings/week, the pooled hazard ratios among those whose intake was ≥4 servings/day were 0.92(0.87–0.97) for total whole fruit intake and 0.95(0.86–1.04) for total vegetable intake. Similarly, compared with participants who did not increase their fruit or vegetable consumption, the pooled hazard ratios for those whose intake increased by ≥7 servings/week were 0.94(0.90–0.97) for total whole fruit intake and 0.98(0.94–1.01) for total vegetable. Analyses of individual fruits and vegetables yielded different results. Consumption levels of ≥4 servings/week (as opposed to <1 serving/month) of broccoli, carrots, tofu or soybeans, raisins, and apples was associated with lower hypertension risk. In conclusion, our results suggest that greater long-term intake and increased consumption of whole fruits may reduce the risk of developing hypertension.

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Introdução de frutas e verduras na alimentação complementar de lactentes em Montes Claros, Minas Gerais

Archivos Latinoamericanos de Nutrición ◽

10.37527/2020.70.1.001 ◽

2020 ◽

Vol 70 (1) ◽

pp. 1-7

Author(s):

Camila de Jesus Santos ◽

Danielly Pereira Rocha ◽

Wanessa Casteluber Lopes ◽

Lucineia de Pinho

Keyword(s):

Food Consumption ◽

Fruits And Vegetables ◽

Vegetable Intake ◽

Family Health ◽

Cross Sectional Study ◽

Minas Gerais ◽

Food Record ◽

Cross Sectional ◽

Early Introduction ◽

Family Health Strategy

Esse trabalho teve como objetivo avaliar a introdução de frutas e verduras na alimentação complementar de lactentes. Trata-se de um estudo de corte transversal, realizado em 2015, envolvendo crianças com idade entre 0 a 24 meses de idade, que frequentam a Estratégia da Saúde da Família de Montes Claros, Minas Gerais. Avaliaram-se as características sociodemográficas e o consumo alimentar de frutas e verduras entre as crianças. Foi aplicado o questionário de frequência de consumo alimentar onde se perguntava em que idade se deu início a ingestão de frutas e verduras, além de aplicar também o recordatório alimentar para avaliar a presença ou ausência do consumo desses alimentos no dia anterior. Participaram deste estudo 545 crianças, sendo 53,9% do sexo masculino. Quanto à introdução de frutas e verduras, observou-se que 52,0% e 24,0% consumiram antes dos seis meses de idade, respectivamente. Neste estudo foi alta a prevalência da introdução precoce de frutas e verduras entre as crianças. This work aimed to evaluate the introduction of fruits and vegetables in the complementary feeding of infants. This is a cross-sectional study, carried out in 2015, involving children aged 0 to 24 months, who attend the Family Health Strategy of Montes Claros, Minas Gerais. Sociodemographic characteristics and food consumption of fruits and vegetables among children were evaluated. The food consumption frequency questionnaire was applied, asking at what age fruit and vegetable intake started, in addition to applying the food record to assess the presence or absence of consumption of these foods on the previous day. 545 children participated in this study, being 53.9% male. As for the introduction of fruits and vegetables, it was observed that 52.0% and 24.0% consumed before the age of six months, respectively. In this study, the prevalence of early introduction of fruits and vegetables was high among children

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Fruits and Vegetables Intake and Risk of Frailty in Women Aged 60 and Older (OR33-08-19)

Current Developments in Nutrition ◽

10.1093/cdn/nzz039.or33-08-19 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

Cited By ~ 1

Author(s):

Teresa Fung ◽

Ellen Stuijk ◽

Fernando Rodriguez-Artalejo ◽

Kaitlin Hagan ◽

Frank Hu ◽

...

Keyword(s):

Lower Risk ◽

Fruits And Vegetables ◽

Vegetable Intake ◽

Activity Level ◽

Leafy Vegetables ◽

Health Study ◽

Cox Models ◽

Funding Sources ◽

Fruits And Vegetables Intake

Abstract Objectives Prior research has suggested that the anti-oxidative, and anti-inflammatory potential of fruits and vegetables may reduce pre-mature aging. The purpose of this analysis is to prospectively examine the association between fruits and vegetables intake and incident frailty in older women. Methods 30,267 non-frail women aged 60+ from the Nurses’ Health Study were followed from 1990 to 2012. Frailty was defined as having at least three of the following five criteria from the FRAIL scale: fatigue, poor strength, low aerobic capacity, having ≥5 illnesses, and weight loss ≥5%. Fruits and vegetables intake were assessed from a food frequency questionnaire six times during follow-up and Cox models adjusting for potential confounders was used to estimate hazard ratios (HRs) and 95% confidence intervals for the association with incident frailty. Results 6888 incident frailty cases were accrued during follow-up. Total fruits and vegetable intake was associated with a lower risk of frailty (adjusted RR comparing 7+ servings/d vs <3d/ = 0.77, 95% CI = 0.69–0.85, p trend < 0.001). The RR for total vegetables intake comparing 5+/d vs <2/d was 0.85 (95% CI = 0.77–0.94, p trend = 0.009). The strongest association among vegetables groups was observed with leafy vegetables (RR for >1/d compared with <1/wk = 0.77, 95% CI = 0.68–0.88, p trend < 0.001) and yellow vegetables (RR = 0.85, 95% CI = 0.74–0.98, p trend = 0.002). RR total fruits intake, comparing 4+/d vs <1/d was 0.91 (95%CI = 0.80–1.04, p trend = 0.03). intake of 6/wk or more of apples and pears was associated with an RR of 0.87 (95% CI = 0.78–0.98, p trend < 0.001) compared with women who consumed <1/wk. These associations did not differ by BMI or physical activity level. Conclusions Higher fruits and vegetables intake was associated with a lower risk of frailty in this cohort of age 60+ U.S. women. Funding Sources Data collection for this analysis was funded by the National Institutes of Health.

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Fruit and vegetable intake and risk of frailty in women 60 years old or older

American Journal of Clinical Nutrition ◽

10.1093/ajcn/nqaa256 ◽

2020 ◽

Vol 112 (6) ◽

pp. 1540-1546 ◽

Cited By ~ 1

Author(s):

Teresa T Fung ◽

Ellen A Struijk ◽

Fernando Rodriguez-Artalejo ◽

Walter C Willett ◽

Esther Lopez-Garcia

Keyword(s):

Lower Risk ◽

Fruits And Vegetables ◽

Vegetable Intake ◽

Fruit And Vegetable Intake ◽

Health Study ◽

Inverse Association ◽

Fruit And Vegetable ◽

Cox Models ◽

Physically Active

ABSTRACT Background Prior research has suggested that the antioxidative and anti-inflammatory potential of fruits and vegetables may ameliorate aging-related frailty. Objective We sought to prospectively examine the association between fruit and vegetable intake and incident frailty in older women. Design We followed 78,366 nonfrail women aged ≥60 y from the Nurses’ Health Study from 1990 to 2014. In this analysis, the primary exposure was the intake of total fruits and vegetables, assessed with an FFQ administered 6 times during follow-up. Frailty was defined as having ≥3 of the following 5 criteria from the FRAIL scale: fatigue, poor strength, low aerobic capacity, having ≥5 illnesses, and ≥5% weight loss. Cox models adjusted for potential confounders were used to estimate HRs and 95% CIs for the association between fruit and vegetable intake and incident frailty. Results In total, 12,434 (15.9%) incident frailty cases were accrued during follow-up. Total fruit and vegetable intakes were associated with a lower risk of frailty (adjusted HR comparing 7+ servings/d compared with <3 servings/d: 0.92; 95% CI: 0.85, 0.99). The inverse association appeared to be stronger for those with physical activity above the median (P-interaction < 0.05). Among physically active women, compared with those who consumed <3 servings/d, the HR for 7+ servings/d was 0.68 (95% CI: 0.57, 0.81). Conclusion Higher fruit and vegetable intake was associated with a lower risk of frailty in this cohort of US women aged ≥60 y. Because of limited evidence on intakes of fruits and vegetables and the development of frailty, more data are needed to confirm our results.

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Complementary Feeding in Children From 9 to 24 Months in a Northeastern Brazilian Low-Income Urban Community

Current Developments in Nutrition ◽

10.1093/cdn/nzab046_095 ◽

2021 ◽

Vol 5 (Supplement_2) ◽

pp. 798-798

Author(s):

Eva Oliveira Andrade ◽

Amanda Rebouças ◽

Bruna Maciel

Keyword(s):

Low Income ◽

Complementary Feeding ◽

Dietary Diversity ◽

Urban Community ◽

Health Study ◽

Processed Foods ◽

Child Feeding ◽

Young Child Feeding ◽

Using Data ◽

Over Time

Abstract Objectives The study aimed to characterize complementary feeding of children aged 9 to 24 months in a Brazilian community. Methods Data from the Brazilian site of The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health study (MAL-ED), located in a low-income urban community (favela) in the city of Fortaleza, Ceará, were used. In the present analysis, food consumption of n = 233 children was analyzed at 9, 15, and 24 months of age, using data from the 24 h recalls. The infant and young child feeding practices were accessed by the WHO core indicators. Foods consumed were also categorized in unprocessed, minimally processed foods, processed foods, and ultra-processed food products. Results The number of breastfed children decreased over time, from 77.6% at 9 months to 55.0% at 15 months and 45.1% at 24 months. 88.6% of the children reached the minimum meal frequency at 9 months, 99.5% at 15 months, and 97% at 24 months. Dietary diversity was reached by 81.9%, 95.1%, and 98.2%of the children at 9, 15, and 24 months, respectively; and 74.6%, 95.1%, and 95.1% of the studied children reached the minimum acceptable diet at 9, 15, and 24 months, respectively. Unprocessed foods consumption reduced from 9 to 24 months of age [a median of 3.0 (1.0 – 4.0)/day at 9 months, 2.0 (1.0 – 5.0)/day at 15 months, and 2.0 (1.0 – 2.0)/day at 24 months, p < 0.0005]. Ultra-processed foods consumption increased over time (p < 0.0005), from 2.0 (1.0 – 2.0)/day at 9 months, to 2.0 (2.0 – 3.0)/day at 15 months, and 3.0 (2.0 – 3.0)/day at 24 months. Conclusions Most of the studied children presented adequate complementary feeding indicators. However, when observing the processing of the foods consumed, there was an increase in the consumption of ultra-processed foods and a decrease in unprocessed foods, which may be unfavorable to children's health. Funding Sources NIH grant OPP47075 and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil, Finance Code 001.

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Pesticide Residue Intake From Fruit and Vegetable Consumption and Risk of Uterine Fibroids

Current Developments in Nutrition ◽

10.1093/cdn/nzab053_026 ◽

2021 ◽

Vol 5 (Supplement_2) ◽

pp. 1033-1033

Author(s):

Nichole Garzia ◽

Colette Davis ◽

Kara Cushing-Haugen ◽

Kathryn Terry ◽

Yu-Han Chiu ◽

...

Keyword(s):

Pesticide Residue ◽

Pesticide Residues ◽

Fruits And Vegetables ◽

Vegetable Intake ◽

Vegetable Consumption ◽

Uterine Fibroids ◽

Dietary Factors ◽

Health Study ◽

Fruit And Vegetable ◽

Incident Cases

Abstract Objectives Dietary factors may play a role in uterine fibroids etiology due to their potential to modify endogenous hormones and their inflammatory effects – these processes may be influenced by food contaminants including pesticides. We sought to examine the association between pesticide residue intake from consumption of fruits and vegetables and risk of ultrasound or hysterectomy-confirmed fibroids. Methods A prospective cohort study using data collected from 52,982 premenopausal women from 1999–2009 in the Nurses’ Health Study II. Every four years, diet was assessed with a validated food frequency questionnaire. We classified fruits and vegetables into high- or low-pesticide-residues using a validated method based on surveillance data from the U.S. Department of Agriculture. Multivariable Cox proportional hazards models were used to calculate RR and 95% CIs for the association between high- and low-pesticide-residue fruit and vegetable intake and fibroids. Results During 10 years of follow-up (median age at baseline 42 years), 4,285 incident cases of ultrasound or hysterectomy-confirmed fibroids were reported. No association was observed between intake of high-pesticide-residue (RR for 5th vs 1st quintile = 0.91; 95% CI = 0.80–1.03; ptrend = 0.12) nor the low-pesticide-residue (RR for 5th vs 1st quintile = 1.01; 95% CI = 0.88–1.14; ptrend = 0.84) fruits and vegetables and fibroids. Conclusions No clear associations were observed between intake of high- or low-pesticide-residue fruits and vegetables and risk of uterine fibroids. These results suggest that pesticide residues on fruits and vegetables are not strong contributors to fibroid risk among women in their 30s, 40s, and 50s. Additional studies examining an exposure window more proximal to fibroid initiation among younger women and assessing class specific pesticides are needed. Funding Sources National Institutes of Health.

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The Effects of Different Kinds of Nutrition and Functional Foods on Multiple Sclerosis

Current Nutrition & Food Science ◽

10.2174/1573401316666200129115858 ◽

2020 ◽

Vol 16 (5) ◽

pp. 632-637

Author(s):

Masih Falahatian

Keyword(s):

Multiple Sclerosis ◽

Functional Foods ◽

Fruits And Vegetables ◽

Salt Intake ◽

Vegetable Intake ◽

Dietary Salt ◽

Negative Effects ◽

Dietary Salt Intake ◽

Neuroinflammatory Disease ◽

The Central Nervous System

It is an assumption that different kinds of nutrition, diet, and functional foods might have different positive or negative effects on multiple sclerosis (MS), a neuroinflammatory disease of the central nervous system (CNS). This brief paper involved a study on various kinds of nutrition including salt, fat, dairy, fruit, and vegetables. At the end of this study, appropriate diets were evaluated for MS patients. Based on previous studies both on animal models and on MS patients, excessive dietary salt intake and animal fat had worsening effects on MS patients but fruit and vegetable intake helped the remission of MS and decreased the risk of developing it. There were, of course, conflicting results in different studies over the role of some nutrition in MS and future studies on larger numbers of cases were required to collect reliable results. As a result, at the end of this study and based on literature, it is suggested that a diet should be programmed by nutritionists containing fewer salt, fat, and dairy intake and more fruits and vegetables for MS patients in order to better management of the disease.

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Awareness and outcomes of the fruits and veggies (FNV) campaign to promote fruit and vegetable consumption among targeted audiences in California and Virginia: a cross-sectional study

BMC Public Health ◽

10.1186/s12889-021-11055-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Tessa R. Englund ◽

Valisa E. Hedrick ◽

Sofía Rincón-Gallardo Patiño ◽

Lauren E. Kennedy ◽

Kathryn W. Hosig ◽

...

Keyword(s):

Fruits And Vegetables ◽

Vegetable Intake ◽

Behavioral Outcomes ◽

Cross Sectional Study ◽

Fruit And Vegetable Intake ◽

Brand Awareness ◽

Sectional Study ◽

Fruit And Vegetable ◽

Cross Sectional ◽

Convenience Sample

Abstract Background In 2015, the Partnership for a Healthier America launched the branded Fruits & Veggies (FNV) Campaign to apply a unique industry-inspired marketing approach to promote fruit and vegetable sales and intake to moms and teens in two US pilot markets: Fresno, California and Hampton Roads, Virginia. The aims of this cross-sectional study were to: 1) assess brand awareness and fruit- and vegetable-related outcomes among FNV Campaign target audiences in the California and Virginia market locations; and 2) examine whether reported awareness of the FNV Campaign was associated with differences in fruit- and vegetable-related cognitive and behavioral outcomes. Methods Data for this cross-sectional study were collected using an online survey administered to a non-probability convenience sample (n = 1604; February–July 2017) of youth aged 14–20 years (n = 744) and moms aged 21–36 years (n = 860) in the two pilot markets. Descriptive statistics were computed and outcomes compared between unaware and aware respondents, controlling for sociodemographic covariates. Multivariate analysis of covariance (MANCOVA) was conducted to assess whether fruit- and vegetable-related attitude, belief, and encouragement outcomes differed by FNV Campaign awareness; logistic regression was used to examine associations between FNV brand awareness and dichotomous variables (fruit- and vegetable-related behavioral intentions, trying new fruits and vegetables); and ANCOVA was used to assess associations with daily fruit and vegetable intake frequency. Results Approximately 20% (n = 315/1604) of respondents reported awareness of the FNV Campaign. Youth that reported awareness of the FNV Campaign (n = 167, 22.4%) had higher intentions to buy (p = 0.003) and eat (p = 0.009) fruits and vegetables than unaware respondents. Mothers that reported awareness of the FNV Campaign (n = 148, 17.2%) reported greater encouragement for friends and family to eat fruits and vegetables (p = 0.013) and were approximately 1.5 times more likely to report trying a new fruit or vegetable (p = 0.04) than mothers unaware of the Campaign. Daily fruit and vegetable intake frequency did not differ by Campaign awareness. Conclusions FNV Campaign awareness was associated with limited but positive short- and intermediate-term cognitive and behavioral outcomes among target audience respondents. These findings can inform future research to enhance understanding and improve the FNV Campaign as it is expanded to new markets nationwide.

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