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Grummon AH, Reimold AE, Hall MG. Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment. J Acad Nutr Diet 2022; 122:363-370.e6. [PMID: 34465443 PMCID: PMC9127741 DOI: 10.1016/j.jand.2021.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/14/2021] [Accepted: 07/20/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message. OBJECTIVES To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics. DESIGN Randomized experiment. PARTICIPANTS AND SETTING During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White). METHODS Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels. MAIN OUTCOME MEASURES Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish. STATISTICAL ANALYSES PERFORMED Ordinary least squares regression. RESULTS The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12). CONCLUSIONS San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.
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Farmer JE, Falk LW, Clark MJ, Mayfield WA, Green KK. Developmental Monitoring and Referral for Low-Income Children Served by WIC: Program Development and Implementation Outcomes. Matern Child Health J 2022; 26:230-241. [PMID: 34988863 PMCID: PMC10249725 DOI: 10.1007/s10995-021-03319-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop, implement, and assess implementation outcomes for a developmental monitoring and referral program for children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS Based on Centers for Disease Control and Prevention's Learn the Signs. Act Early. campaign, the program was developed and replicated in two phases at 20 demographically diverse WIC clinics in eastern Missouri. Parents were asked to complete developmental milestone checklists for their children, ages 2 months to 4 years, during WIC eligibility recertification visits; WIC staff referred children with potential concerns to their healthcare providers for developmental screening. WIC staff surveys and focus groups were used to assess initial implementation outcomes. RESULTS In both phases, all surveyed staff (n = 46) agreed the program was easy to use. Most (≥ 80%) agreed that checklists fit easily into clinic workflow and required ≤ 5 min to complete. Staff (≥ 55%) indicated using checklists with ≥ 75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During the second phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program. CONCLUSIONS Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support.
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Claiborne DM, Chen C, Zhang Q. Disparities in Caregiver-Reported Dental Cavities and Toothaches Among Children in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) Program. JOURNAL OF DENTAL HYGIENE : JDH 2022; 96:43-54. [PMID: 35190493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/02/2021] [Indexed: 06/14/2023]
Abstract
Purpose: Dental caries is prevalent among low-income and minority children despite oral health promotion programs. The purpose of this study was to examine disparities associated with caregiver-reported cavities and toothaches among children in the United States aged 2-4 years by their eligibility for and participation in the Special Supplemental Nutrition for Women, Infants, and Children (WIC) program.Methods: A secondary data analysis was performed using the 2016 National Survey of Children's Health (NSCH) data on children aged 2-4 years (n=7,719) with complete WIC participation information. Three groups were formed based on WIC eligibility and participation status: WIC participants, income-eligible non-participants, and higher-income non-participants. Caregiver-reported cavities and toothaches were compared by WIC eligibility and participation using chi-square tests and multivariate logistic regression analysis.Results: Among all children in the data set, 2,069 were WIC eligible, 49.8% of whom participated in WIC. Participants in WIC had higher reported cavities and toothaches (10.0% and 5.2%) than income-eligible, or higher-income non- WIC participating children (8.9% and 3.2%; 4.4% and 0.1%, respectively; p < 0.001). However, non-Hispanic, white WIC participants, had a higher proportion of reported cavities (14.0%) and toothaches (8.2%) than income-eligible non-participants (6.7% and 1.9%, respectively; p < 0.05). While non-Hispanic, black WIC participating children, had nearly 3.6 times more reported cavities than income-eligible nonparticipants (9.0% vs. 2.5%, p < 0.05).Conclusion: Caregiver-reported cavities and toothaches varied by sociodemographic characteristics within WIC participation and eligibility groups. These findings suggest that more research is warranted to explore factors that are contributing to oral health disparities associated with WIC eligibility and participation.
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Martin NM, Barnett DJ, Poirier L, Sundermeir SM, Reznar MM, Gittelsohn J. Moving Food Assistance into the Digital Age: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:1328. [PMID: 35162351 PMCID: PMC8835246 DOI: 10.3390/ijerph19031328] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/15/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
One of the most basic needs globally, food assistance refers to the multitude of programs, both governmental and non-governmental, to improve food access and consumption by food-insecure individuals and families. Despite the importance of digital and mobile Health (mHealth) strategies in food insecurity contexts, little is known about their specific use in food assistance programs. Therefore, the purpose of this study was to address that gap by conducting a scoping review of the literature. Keywords were defined within the concepts of food assistance and digital technology. The search included relevant peer-reviewed and grey literature from 2011 to 2021. Excluded articles related to agriculture and non-digital strategies. PRISMA guidelines were followed to perform a partnered, two-round scoping literature review. The final synthesis included 39 studies of which most (84.6%) were from the last five years and United States-based (93.2%). The top three types of articles or studies included text and opinion, qualitative research, and website, application, or model development (17.9%). The top three types of digital tools were websites (56.4%), smartphone applications (20.5%), and chatbots (5.1%). Nineteen digital features were identified as desirable. Most tools included just one or two features. The most popular feature to include was online shopping (n = 14), followed by inventory management, and client tracking. Digital tools for individual food assistance represent an opportunity for equitable and stable access to programs that can enhance or replace in-person services. While this review identified 39 tools, all are in early development and/or implementation stages. Review findings highlight an overall lack of these tools, an absence of user-centered design in their development, and a critical need for research on their effectiveness globally. Further analysis and testing of current digital tool usage and interventions examining the health and food security impacts of such tools should be explored in future studies, including in the context of pandemics, where digital tools allow for help from a distance.
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Bari MDA, Khan GD, He B, Yoshida Y. The impact of unconditional cash and food assistance on contraceptive expenditure of rural households in Coastal Bangladesh: Evidence from fuzzy RDD. PLoS One 2022; 17:e0262031. [PMID: 35061751 PMCID: PMC8782502 DOI: 10.1371/journal.pone.0262031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
This study investigates the impact of unconditional cash and food (UCF) assistance on the monthly contraceptive expenditure of rural households in coastal Bangladesh using a fuzzy regression discontinuity design (RDD). Eligibility for UCF assistance was based on the running variable of land ownership in acres. We used eligibility as an instrumental variable to estimate the local average treatment effect of UCF assistance on contraceptive expenditures. The results show that UCF assistance results in increases in monthly contraceptive expenditures.
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Hanson KL, Meng X, Volpe LC, Jilcott Pitts S, Bravo Y, Tiffany J, Seguin-Fowler RA. Farmers’ Market Nutrition Program Educational Events Are Broadly Accepted and May Increase Knowledge, Self-Efficacy and Behavioral Intentions. Nutrients 2022; 14:nu14030436. [PMID: 35276793 PMCID: PMC8840006 DOI: 10.3390/nu14030436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 02/05/2023] Open
Abstract
The Farmers’ Market Nutrition Program (FMNP) in the U.S. provides coupons for the purchase of fruit and vegetables (FV) to pregnant women and children enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and to income-eligible adults 60+ years of age. The New York State FMNP Education Event Guide was developed to support cooperative extension educators in providing information, food tastings, and cooking demonstrations at farmers’ markets (FM) to encourage consumption of FV. This paper describes implementation at seven FM in New York City, and shopping and eating behaviors in a cross-sectional survey of FM shoppers (n = 377). Three of nine lessons were implemented more than once, typically with food sampling (78.9%). FM shoppers were primarily women (81.5%), racially diverse (30.5% Black, 23.1% White), frequent shoppers (2.4 times/month), and had high FV consumption (2.24 cups fruit; 2.44 cups vegetables daily). Most FM shoppers participated in the FM education event (84%), and participants and non-participants had equivalent shopping and eating behaviors. More than 70% of FM education participants believed that the event positively impacted their knowledge, self-efficacy, and behavioral intentions. FMNP education events at FM were broadly accepted by FM shoppers of all characteristics, and may improve knowledge, self-efficacy, and behavioral intention.
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Shroba J, Das R, Bilaver L, Vincent E, Brown E, Polk B, Ramos A, Russell AF, Bird JA, Ciaccio CE, Lanser BJ, Mudd K, Sood A, Vickery BP, Gupta R. Food Insecurity in the Food Allergic Population: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:81-90. [PMID: 34862158 DOI: 10.1016/j.jaip.2021.10.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 12/13/2022]
Abstract
Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.
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Adeyemi OJ, Stullken JD, Baah EG, Olagbemiro N, Huber LR. An Assessment of the Relationship of SNAP and Anemia Among School-Aged Children and Adolescents Living in Households With Food Insecurity. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580211067498. [PMID: 35199589 PMCID: PMC8883399 DOI: 10.1177/00469580211067498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children in food-insecure households have an increased risk of anemia. Participation in Supplemental Nutrition Assistance Programs (SNAP) has several benefits. However, it is unknown if it ameliorates anemia among school-aged children and adolescents living in food-insecure households. This study aims to assess the association of SNAP participation and anemia among children and adolescents living in households experiencing food insecurity. The sample population (n = 1635), aged 6 to 18 years, were pooled from the 2003–2014 National Health and Nutrition Examination Survey (NHANES). The exposure of interest was self-reported household SNAP participation. The outcome variable was the presence or absence of anemia, classified using the blood hematocrit concentration values. Survey weighted logistic regression was performed to calculate the odds ratio (OR) and 95% Confidence Interval (CI) of the association between participation in SNAP and anemia in food-insecure children. We found that over 80% of anemic children and adolescents, living in food-insecure households, participated in SNAP, while 63% of non-anemic children and adolescents, living in food-insecure households participated in SNAP (p = .007). Among children living in food-insecure households, SNAP participants had 3-fold increased odds of anemia compared to those who do not participate in SNAP, after adjusting for confounders (OR = 3.33, 95% CI: 1.25–8.88). In this study, SNAP participation was associated with increased odds of anemia in children and adolescents living in food-insecure households. Additional research is needed to assess if these unexpected findings are related to the adequacy of SNAP, affordability, and accessibility to healthy foods, or the household and individual food preferences in food-insecure households.
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Byker Shanks C, Vanderwood K, Grocke M, Johnson N, Larison L, Wytcherley B, Yaroch AL. The UnProcessed Pantry Project (UP3): A Community-Based Intervention Aimed to Reduce Ultra-Processed Food Intake Among Food Pantry Clients. FAMILY & COMMUNITY HEALTH 2022; 45:23-33. [PMID: 34783688 PMCID: PMC8604383 DOI: 10.1097/fch.0000000000000310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Low-income populations are more likely to experience food and nutrition insecurity and suffer a greater burden of noncommunicable disease than the general population. The UnProcessed Pantry Project (UP3) is an intervention aimed to reduce ultra-processed food availability and consumption of food pantry clients accessing the emergency food system. The pilot study included nutrition education, food boxes, and social support for 16 weeks at 2 food pantries. Data collection included the ASA24 dietary recall to calculate Healthy Eating Index-2015 (HEI-2015) scores, biomarkers (hemoglobin A1c, total cholesterol, blood pressure, waist circumference, body mass index [BMI]), and a demographic and psychosocial survey. Dietary quality among 43 participants significantly (P < .05) improved as measured by the HEI-2015 for total HEI-2015, whole grains, total protein foods, and added sugars scores. BMI, total cholesterol, and waist circumference also significantly improved across study participants. Findings indicate that the emergency food system may be an effective access point to apply frameworks including UP3 to address ultra-processed food consumption, dietary quality, and noncommunicable chronic disease risk among food-insecure populations. Programs and policies that limit the amount of ultra-processed food in the emergency food system should be further tested and could be efficacious in addressing inequities among vulnerable populations.
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Czarnik M, Hamner HC, Moore LV. Food Preparation Practices for Infants Aged From 7 to 13 Months. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2022; 54:28-35. [PMID: 34598893 PMCID: PMC10898497 DOI: 10.1016/j.jneb.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To examine infant food preparation practices at age 7, 9, 11, and 13 months overall and by sociodemographic characteristics. DESIGN Data from a longitudinal study from the US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study-2 (ITFPS-2) were used. PARTICIPANTS A sample of 1,904 infants (970 males and 934 females) enrolled in WIC who had been introduced to solid foods and were consuming food prepared at home. MAIN OUTCOME MEASURES Food preparation practices included pureeing, mashing, chopping/dicing, and prechewing. Estimates were provided overall and by sociodemographics. ANALYSIS Prevalence estimates were calculated for each survey month overall and by sociodemographics. Chi-square tests for independence were used to test for differences. RESULTS Food preparation practices changed as infants aged. Pureeing and mashing were common in month 7 (57.8% and 59.6%, respectively), but chopping/dicing were the most prevalent by month 13 (85.4%). Food preparation practices did not vary by education status, but statistical differences were consistently observed by race and ethnicity and inconsistently observed by maternal age at birth. CONCLUSIONS AND IMPLICATIONS Exposing children to a range of food textures at an appropriate age is important for developmental progress. Continued culturally relevant efforts by WIC educators and health care providers can emphasize the importance of early experiences with food textures.
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Kelly C, Maytag A, Allen M, Ross C. Results of an Initiative Supporting Community-Based Organizations and Health Care Clinics to Assist Individuals With Enrolling in SNAP. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:E56-E61. [PMID: 33208716 DOI: 10.1097/phh.0000000000001208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Only 58% of eligible Coloradans are enrolled in the Supplemental Nutrition Assistance Program (SNAP). In recent years, more community-based organizations (CBOs) and health care clinics are incorporating screening for social needs into their workflows. PROGRAM Seven Colorado-based CBOs and 3 clinics received funding (2016-2018) to screen for food insecurity (FI) and provide SNAP application assistance to their clients and patients. IMPLEMENTATION Funded agencies were required to implement strategies focused on particular populations or settings based on Food Research and Action Center recommendations. EVALUATION A 5-part care cascade from screening to SNAP enrollment was conceptualized to guide the evaluation. Funded CBOs and clinics were asked to submit de-identified individual-level data to the evaluation team (number and characteristics of individuals screened, screening results, interest in receiving assistance, submitted application, enrolled in SNAP). The purpose of the evaluation was to assess the proportion of individuals CBOs and clinics screen for FI and assist with completing a SNAP application and describe the characteristics of individuals who are not interested in receiving assistance to complete a SNAP application and the characteristics of individuals who enroll in SNAP. RESULTS Thirty-five percent of individuals who reported FI participated in the care cascade and enrolled in SNAP. CBOs assisted a greater proportion of food-insecure individuals (55%) than clinics (22%) (P < .001). Males, adults 40 years or older, rural residents, and African Americans were more likely to be interested in receiving assistance, and adults 40 years or older, rural residents, and American Indians/Alaska Natives were more likely to enroll in SNAP. DISCUSSION CBOs were more successful in assisting individuals along the care cascade than clinics. Certain subpopulations are more likely to be interested in receiving assistance and enrolling in SNAP. These findings can be used by public health practitioners to plan interventions to increase enrollment in SNAP.
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Parnham J, Millett C, Chang K, Laverty AA, von Hinke S, Pearson-Stuttard J, Vamos EP. Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom? BMC Public Health 2021; 21:2220. [PMID: 34915897 PMCID: PMC8680244 DOI: 10.1186/s12889-021-12222-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/11/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Healthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK. METHODS Cross-sectional analyses of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n = 4869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households). RESULTS Of 876 eligible households, 54% participated in Healthy Start. No statistically significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV. CONCLUSION This study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may help to improve programme performance and counteract the harmful effects of poverty on diet.
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Caldwell JI, Kuo T, Shah-Patel D, Cohen DA. Health Behavior Changes Among Adults in the Supplemental Nutrition Assistance Program Education, Los Angeles County, California. Prev Chronic Dis 2021; 18:E102. [PMID: 34914578 PMCID: PMC8718123 DOI: 10.5888/pcd18.210221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES The Supplemental Nutrition Assistance Program Education (SNAP-Ed), the educational branch of SNAP, can play an important role in improving dietary outcomes, eliminating food insecurity, and preventing chronic disease among low-income populations. This study examined the effects of local SNAP-Ed efforts on self-reported health behaviors and body mass index (BMI) over a 1-year period, using data collected from intercept surveys of program-eligible adults. INTERVENTION APPROACH From 2016 to 2020, the Los Angeles County Department of Public Health partnered with 24 community-based organizations to provide nutrition education and to implement policy, systems, and environmental changes in the community. EVALUATION METHODS A cross-sectional survey was conducted in 2018 and repeated in 2019 to measure 6 outcomes describing population-level changes in health behaviors and BMI. The study recruited 4 samples: 2 samples from outside selected supermarkets (2018, n = 2,098; 2019, n = 2,323) and 2 samples from participants at SNAP-Ed class sites (2018, n = 651; 2019, n = 569). RESULTS While study results showed an increase in consumption of fruits and vegetables and in vigorous physical activity, they also showed an increase in BMI and high consumption of unhealthy foods. Participating in SNAP-Ed classes was positively associated with several health behaviors but no change in BMI. Participants who experienced food insecurity had worse health behavior outcomes than those who did not experience this condition. IMPLICATIONS FOR PUBLIC HEALTH SNAP-Ed interventions appear to have a favorable effect on fruit and vegetable consumption, but increases in BMI suggest that unhealthy food consumption is abundant and may be counteracting the benefits gained from eating more fruits and vegetables. Future efforts should take these results into consideration and optimize enrollment in nutrition assistance programs. These efforts should include coordinating with local programs to increase healthy food access for at-risk low-income populations in Los Angeles County.
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Quinn EL, Ortiz K, Titzer L, Houston-Shimizu B, Jones-Smith J. Healthy Food Environments in Food Pantries: Lessons Learned from a Sodium Reduction Intervention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:13206. [PMID: 34948815 PMCID: PMC8701667 DOI: 10.3390/ijerph182413206] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/06/2021] [Accepted: 12/11/2021] [Indexed: 11/16/2022]
Abstract
In the United States, food pantries increasingly serve as regular food sources for low income households experiencing high rates of chronic disease, including hypertension. Sodium consumption is a modifiable risk factor for hypertension, so pantry customers would benefit from access to low-sodium foods. Pantry customers often experience difficulty acquiring healthy foods, however; little is known about pantry foods' sodium content specifically. This study assesses the sodium content of pantry foods and lessons learned from an adaptable intervention to support pantries in adopting policies and environmental changes to make healthy, lower-sodium foods appealing and accessible. We conducted sodium assessments of food at 13 food pantries, tracked implementation of intervention strategies, and interviewed 10 pantry directors. More than half of food items in 11 categories met sodium standards for foods to be chosen "often". Pantry directors reported valuing the intervention approach and implemented six of nine behavioral economics strategies, especially those targeting the visibility and convenience of foods, along with layout changes and expanded customer choice. One pantry adopted an agency-specific nutrition policy and 12 adopted a coalition-level policy. Results can inform intervention efforts to make available healthy options appealing and easy to select while also improving the customer experience in food pantries.
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Williams BD, Sisson SB, Stinner EL, Hetrick HN, Dunlap M, Graef-Downard J, Eliot K, Finnell K, Salvatore AL. Quality of Nutrition Environments, Menus and Foods Served, and Food Program Achievement in Oklahoma Family Child Care Homes. Nutrients 2021; 13:4483. [PMID: 34960034 PMCID: PMC8704456 DOI: 10.3390/nu13124483] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 02/02/2023] Open
Abstract
Child care environments foster children's healthy eating habits by providing exposure to healthy foods and feeding practices. We assessed the healthfulness of nutrition environments, menu/meal quality, and the achievement of Child and Adult Care Food Program (CACFP) guidelines and best practices in Oklahoma CACFP-enrolled family child care homes (FCCHs) (n = 51). Two-day classroom observations were conducted. Healthfulness of classroom nutrition environments was assessed using the Environment and Policy Assessment and Observation (EPAO). Foods served to and consumed by children were quantified using the Dietary Observations in Child Care (DOCC) tool. Nutrient analysis was performed to determine total energy for foods listed on menus, served to, and consumed by children. Menu and meal food variety and CACFP Guideline Achievement Scores were determined. Average nutrition environment score was 11.7 ± 1.2 (61.5% of maximum possible score). Energy (kcals) from menus and consumed by children was insufficient to meet two-thirds of their daily reference intake. Children were exposed to 1.7 vegetables and 1.3 fruits per meal. CACFP Guideline Achievement Scores were 66.3% ± 7.8 for menus and 59.3% ± 7.6 for mealtimes. Similar to previous research, our findings indicate a need for improved FCCH nutrition practices. Tailored interventions for FCCHs are needed.
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Fung GJ, Jefferies LK, Call MAL, Eggett DL, Richards R. Comparison of Emergency Preparedness Practices between Food Assistance Program Participants and Non-Participants in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182412937. [PMID: 34948550 PMCID: PMC8702057 DOI: 10.3390/ijerph182412937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022]
Abstract
Background: Previous research has suggested many households are meeting the Federal Emergency Management Agency’s 3-day emergency food and water storage recommendations. The impact of limited economic household resources on emergency preparedness practices related to food and water is uncertain. The purpose of this study was to compare emergency preparedness practices in households participating in United States’ food assistance programs with households not participating in these programs. Methods: A convenience sample of adults (n = 572) completed an online Qualtrics survey. Descriptive statistics, chi-square statistics, and independent t-tests were used to measure differences between households participating in food assistance programs vs. non-participating households. Results: Most households participating in food assistance programs felt prepared to provide household members with food and water during an emergency, which did not significantly differ from non-participating households. Households using food assistance programs had less accessible cash but had similar foods on-hand for an emergency compared to non-participating households. However, they more frequently reported having baby formula/food and less frequently reported having vitamin/mineral supplements compared to non-participating households. Conclusions: Food assistance programs may be effective in providing enough food and water to help low-income families be prepared for an emergency.
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Cardarelli KM, DeWitt E, Gillespie R, Graham RH, Norman-Burgdolf H, Mullins JT. Policy Implications of the COVID-19 Pandemic on Food Insecurity in Rural America: Evidence from Appalachia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312792. [PMID: 34886518 PMCID: PMC8657698 DOI: 10.3390/ijerph182312792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 01/04/2023]
Abstract
Rural communities are disproportionally affected by food insecurity, making them vulnerable to the consequences of supply disruptions caused by the COVID-19 pandemic. While access to food was initially diminished due to food supply disruptions, little is known about the mechanisms through which federal emergency assistance programs impacted food access in rural populations. Through a series of five focus groups in spring 2021, we examined the impact of the COVID-19 pandemic on food access in a rural Appalachian community in Kentucky. Data were analyzed using a Grounded Theory Approach. Findings revealed the following four primary themes: food scarcity in grocery stores; expanded federal food assistance; expanded community food resources; and expanded home gardening. Participants provided details regarding the way increased federal assistance, especially expanded benefits within the Supplemental Nutrition Assistance Program, allowed them to purchase greater quantities of nutritious food. This study unveils the specific impacts of the COVID-19 pandemic on one rural population, including the influence of some social determinants of health on food insecurity. Policymakers and stakeholders should recognize the layered protection of multiple federal emergency assistance programs against food insecurity and the potential for long-term population health promotion in rural areas.
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268
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Valluri S, Mason SM, Peterson HH, French SA, Harnack LJ. The impact of financial incentives and restrictions on cyclical food expenditures among low-income households receiving nutrition assistance: a randomized controlled trial. Int J Behav Nutr Phys Act 2021; 18:157. [PMID: 34863192 PMCID: PMC8642917 DOI: 10.1186/s12966-021-01223-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/10/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Supplemental Nutrition Assistance Program (SNAP) is the largest anti-hunger program in the United States. Two proposed interventions to encourage healthier food expenditures among SNAP participants have generated significant debate: financial incentives for fruits and vegetables, and restrictions on foods high in added sugar. To date, however, no study has assessed the impact of these interventions on the benefit cycle, a pattern of rapid depletion of SNAP benefits that has been linked to worsening nutrition and health outcomes over the benefit month. METHODS Low-income households not currently enrolled in SNAP (n = 249) received benefits every 4 weeks for 12 weeks on a study-specific benefit card. Households were randomized to one of four study arms: 1) incentive (30% incentive for fruits and vegetables purchased with study benefits), 2) restriction (not allowed to buy sugar-sweetened beverages, sweet baked goods, or candy using study benefits), 3) incentive plus restriction, or 4) control (no incentive or restriction). Weekly household food expenditures were evaluated using generalized estimating equations. RESULTS Compared to the control group, financial incentives increased fruit and vegetable purchases, but only in the first 2 weeks after benefit disbursement. Restrictions decreased expenditures on foods high in added sugar throughout the benefit month, but the magnitude of the impact decreased as the month progressed. Notably, restrictions mitigated cyclical expenditures. CONCLUSIONS Policies to improve nutrition outcomes among SNAP participants should consider including targeted interventions in the second half of the month to address the benefit cycle and attendant nutrition outcomes. TRIAL REGISTRATION ClinicalTrial.gov, NCT02643576 . Retrospectively registered December 22, 2014.
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269
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Miller DP, Morrissey TW. SNAP participation and the health and health care utilisation of low-income adults and children. Public Health Nutr 2021; 24:6543-6554. [PMID: 34482850 PMCID: PMC11148611 DOI: 10.1017/s1368980021003815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This article examined whether participation in the Supplemental Nutrition Assistance Program (SNAP) produced changes to adult and child health and health care utilisation during a period of economic recession. DESIGN Instrumental variables analysis relying on variation in state SNAP policies to isolate exogenous variation in household SNAP participation. SETTING Nationally representative data on child and adult health from the 2008 to 2013 National Health Interview Survey. PARTICIPANTS Participants were 92 237 adults and 45 469 children who were either eligible for SNAP based on household income and state eligibility rules or were low income but not eligible for SNAP benefits. RESULTS For adults, SNAP participation increased the probability of reporting very good or excellent health, and for both adults and children, reduced needing but having to go without dental care or eyeglasses. The size of these benefits was especially pronounced for children. However, SNAP participation increased the probability of needing but not being able to afford prescription medicine, and increased psychological distress for adults and behavioural problems for children under age 10. CONCLUSIONS SNAP's benefits for adult health and improved access to dental and vision care for adults and children suggest benefits from the program's expansions during the current COVID-induced crisis. Predicted negative effects of SNAP participation suggest the need for attention to program and benefit structure to avoid harm and the need for continued research to explore the causal effects of program participation.
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Molitor F, Doerr C, Kehl S. Unemployment, SNAP Enrollment, and Food Insecurity Before and After California's COVID-19 Shutdown. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2021; 53:1055-1059. [PMID: 34895558 PMCID: PMC8761532 DOI: 10.1016/j.jneb.2021.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To examine whether the decrease in very low food security (VLFS) observed in California shortly after California's coronavirus disease (COVID-19) shutdown remained throughout Federal Fiscal Year (FFY) 2020. To investigate associations among unemployment, Supplemental Nutrition Assistance Program (SNAP) enrollment, and VLFS across FFY 2020. METHODS Telephone interview responses from mothers from randomly sampled households from low-income areas throughout California to the 6-item US Department of Agriculture Food Security Survey Module identified VLFS families. Logistic regression examined VLFS rates before vs after California's COVID-19 shutdown, with race/ethnicity, age, and education as covariates. Pearson correlations were calculated for unemployment, SNAP enrollment, and VLFS. RESULTS Most (66.4%) of the 2,682 mothers were Latina. VLFS declined from 19.3% before to 14.5% after California's COVID-19 shutdown (adjusted odds ratio, 0.705; P = 0.002). The correlation for unemployment and SNAP household participation was 0.854 (P = 0.007), and for SNAP participation and VLFS was -0.869 (P = 0.005). CONCLUSIONS AND IMPLICATIONS Publicly-funded assistance programs may lower food insecurity, even during a time of increased economic hardship. Examining the specific factors responsible for the observed decline in VLFS has merit. Whether VLFS remains below the rate observed before California's COVID-19 shutdown is worthy of ongoing study.
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Schneider KR, Oslund J, Liu T. Impact of the community eligibility provision program on school meal participation in Texas. Public Health Nutr 2021; 24:6534-6542. [PMID: 34462037 PMCID: PMC11148575 DOI: 10.1017/s1368980021003712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To estimate the impact of opting into the community eligibility provision (CEP) on school meal participation among students in Texas. DESIGN A quasi-experimental design using a two-way fixed effects panel difference-in-difference model and the variation in adoption timing to estimate the impact of opting into CEP on student breakfast and lunch participation in eligible, ever-adopting schools. SETTING All public and charter K-12 schools in Texas participating in national school meals (breakfast and/or lunch) from 2013 to 2019 who are eligible for the CEP program in at least 1 year and choose to opt into the program in at least 1 year (n 2797 unique schools and 16 103 school-years). PARTICIPANTS School-level administrative data from the Texas Department of Agriculture on meal counts, enrollment and summary characteristics of students merged with district-level educational and socio-demographic data from the Texas Education Authority. RESULTS We find opting into CEP increased school breakfast participation by 4·59 percentage points (P < 0·001) and lunch participation by 4·32 percentage points (P < 0·001), on average. The effect is slightly larger (4·64 and 4·61, respectively) and still statistically significant when excluding summer months. CONCLUSION Our findings suggest that opting into CEP modestly increases school meal participation in Texas, with a similar impact on breakfast and lunch.
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Saxe-Custack A, LaChance J, Hanna-Attisha M, Goldsworthy M, Ceja T. Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2021; 53:1060-1065. [PMID: 34479817 DOI: 10.1016/j.jneb.2021.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/23/2021] [Accepted: 06/27/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Examine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7-18 years) receiving free/reduced-price school meals. METHODS Cross-sectional study. Caregiver-child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants. RESULTS Among 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44). CONCLUSIONS AND IMPLICATIONS In this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.
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Boys KA, Haynes-Maslow L, McGuirt JT, Ammerman AS, Van Fleet EE, Johnson NS, Kelley CJ, Donadio VE, Fleischhacker SE, Truesdale KP, Bell RA, Jilcott Pitts SB. Perceived barriers and facilitators to participating in the North Carolina Healthy Food Small Retailer Program: a mixed-methods examination considering investment effectiveness. Public Health Nutr 2021; 24:6555-6565. [PMID: 34509178 PMCID: PMC11148602 DOI: 10.1017/s1368980021003955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The North Carolina Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP. DESIGN The current analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches, including monthly financial reports and activity forms, and end-of-programme evaluations were collected from participating HFSRP storeowners. SETTING Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP. PARTICIPANTS Owners of corner stores participating in the HFSRP. RESULTS All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to programme administration and support. Specific suggestions included additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements and a more efficient process of delivering and maintaining equipment. CONCLUSIONS All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.
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Borger C, Paolicelli C, Ritchie L, Whaley SE, DeMatteis J, Sun B, Zimmerman TP, Reat A, Dixit-Joshi S. Shifts in Sources of Food but Stable Nutritional Outcomes among Children in the Early Months of the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312626. [PMID: 34886351 PMCID: PMC8656921 DOI: 10.3390/ijerph182312626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022]
Abstract
Early in the COVID-19 pandemic, the U.S. Department of Agriculture (USDA), State governments, and school districts took unprecedented steps to mitigate the pandemic’s impact on students’ nutrition. To examine the effect of emergency responses on 6-year-old children’s nutritional outcomes, this study analyzed longitudinal data from a national study of children’s feeding practices, the Special Supplemental Nutrition Program for Women, Infants, and Children—Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2). Findings include no differences in food insecurity prevalence; however, there were shifts in sources of food, with children in the post-COVID-emergency-declaration (post-ED) group consuming more dietary energy from stores and community food programs and less from restaurants and schools than children in the pre-COVID-emergency-declaration (pre-ED) group (p < 0.01 for all comparisons). Examination of within-person mean differences in 2015 Healthy Eating Index scores and nutrient intakes between ages 5 and 6 years revealed few statistically significant differences between the two groups: children in the post-ED group consumed slightly fewer vegetables (p = 0.02) and less sodium (p = 0.01) than their pre-ED peers. Findings suggest emergency efforts to maintain children’s nutrition were largely successful in the early months of the pandemic. Research is needed to understand the mechanisms by which emergency efforts contributed to these findings.
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Budd Nugent N, Byker Shanks C, Seligman HK, Fricke H, Parks CA, Stotz S, Yaroch AL. Accelerating Evaluation of Financial Incentives for Fruits and Vegetables: A Case for Shared Measures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212140. [PMID: 34831902 PMCID: PMC8621044 DOI: 10.3390/ijerph182212140] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022]
Abstract
Food insecurity, or lack of consistent access to enough food, is associated with low intakes of fruits and vegetables (FVs) and higher risk of chronic diseases and disproportionately affects populations with low income. Financial incentives for FVs are supported by the 2018 Farm Bill and United States (U.S.) Department of Agriculture’s Gus Schumacher Nutrition Incentive Program (GusNIP) and aim to increase dietary quality and food security among households participating in the Supplemental Nutrition Assistance Program (SNAP) and with low income. Currently, there is no shared evaluation model for the hundreds of financial incentive projects across the U.S. Despite the fact that a majority of these projects are federally funded and united as a cohort of grantees through GusNIP, it is unclear which models and attributes have the greatest public health impact. We explore the evaluation of financial incentives in the U.S. to demonstrate the need for shared measurement in the future. We describe the process of the GusNIP NTAE, a federally supported initiative, to identify and develop shared measurement to be able to determine the potential impact of financial incentives in the U.S. This commentary discusses the rationale, considerations, and next steps for establishing shared evaluation measures for financial incentives for FVs, to accelerate our understanding of impact, and support evidence-based policymaking.
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