Impact of Supplemental Nutrition Assistance Program Benefit Reduction or Loss on Food-at-Home Acquisitions and Community Food Program Use

Since Supplemental Nutrition Assistance Program (SNAP) benefits are vital for food-at-home (FAH) acquisitions among participating families, changes in participation or benefit amounts may impact FAH purchase and use of community-based food programs (CFP). The association of the loss of or a reduction in SNAP benefits with FAH acquisitions and CFP use was assessed using 2012–2013 National Household Food Acquisition and Purchase Survey data. Households with incomes equal to or below 130% of the Federal Poverty Level were categorized as (1) current SNAP households, (2) households with benefit loss in the preceding year, or (3) households with benefit loss for more than a year. Current SNAP households were classified as receiving (1) lesser-than-usual benefits or (2) usual benefits. Regression analyses examined associations of the loss of or a reduction in benefits with the Healthy Eating Index-2015 (HEI-2015) scores of FAH purchases and CFP use. Benefit loss in the preceding year was related to a lower total HEI-2015 score for FAH acquisitions, whereas benefit reduction was associated with lower green/bean and added sugar scores and increased CFP use. This study suggests that the loss of or a reduction in SNAP benefits may adversely impact the quality of FAH purchases. The findings also suggest that efforts enhancing the nutrition environment of community food sources could support healthy food acquisition by families experiencing benefit reduction.

More Frequent Food Shopping May Promote Fruit and Vegetable Intake: A Systematic Review

BACKGROUND

Food shopping frequency may be an important modifiable factor related to increasing fruit and vegetable (FV) intake. Because of mixed findings of individual studies of shopping frequency, a systematic review is needed to examine findings across studies and store types.

OBJECTIVE

To conduct a systematic review of articles examining the relationship between frequency of food shopping and FV intake including examination of participation in federal nutrition assistance programs on FV intake, if reported.

METHODS

A search, guided by the Preferred Reported Items for Systematic Reviews and Metanalyses, using terms related to FV consumption and food shopping across 4 online databases, was conducted. Studies conducted in the US and published through October, 2020, included adults, and had a cross-sectional, longitudinal, cohort, or randomized study design were eligible for inclusion.

RESULTS

Twenty-four articles were included. The majority of studies found at least 1 positive finding between the frequency of food shopping and FV intake, indicating that as the frequency of food shopping increased, FV intake increased. In studies with 100% participation in government/federal nutrition assistance programs, participation was associated with FV intake. Studies that included participation as a subset found participation not associated with FV intake.

IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE

The frequency of shopping may be modifiable to increase FV intake. Experimental research is needed to test the directionality and causality of the relationship. Federal nutrition assistance programs may be a logical place to test the relationship through the adjustment of fund disbursements.

Earlier Introduction to Sugar-Sweetened Beverages Associated With Lower Diet Quality Among WIC Children at Age 3 Years

OBJECTIVE

Examine the association between the timing of sugar-sweetened beverages (SSBs) and 100% juice introduction with subsequent diet quality at age 3 years.

DESIGN

Secondary analysis of a publicly available, national longitudinal dataset.

PARTICIPANTS

A total of 2,218 children from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

MAIN OUTCOME MEASURE

Dietary intakes were assessed using a 24-hour dietary recall completed by caregivers of children aged 3 years. Diet quality was assessed using the Healthy Eating Index Score-2015 (HEI-2015).

ANALYSIS

Linear regression was used to assess the relationship between the timing of introduction to 100% juice and SSBs with HEI-2015. Adjustments were made for child- and maternal-related factors.

RESULTS

Delayed introduction of SSBs during the first 2 years of life was associated with an increased HEI-2015 score. In adjusted analyses, for every 1-month delay in the introduction, there was a 0.09-point increase (95% confidence interval, 0.04-0.13) in the HEI-2015 score at 3 years.

CONCLUSIONS AND IMPLICATIONS

Earlier introduction to SSBs may be associated with subsequent lower diet quality in WIC participants. This association may be driven by total fruit, whole grains, and added sugars HEI component scores. Further research is needed to support changes to existing WIC nutrition practices regarding SSBs and 100% juice.

Nationwide Assessment of SNAP Online Purchasing Pilot State Communication Efforts During the COVID-19 Pandemic

OBJECTIVE

To conduct a nationwide assessment of communication by participating states and Washington DC about the Supplemental Nutrition Assistance Program (SNAP) Online Purchasing Pilot expansion.

DESIGN

Systematic coding of official communication from state and DC SNAP administrating agencies.

PARTICIPANTS

Forty-six states and DC approved to participate in the pilot as of October 2020 (n = 47). Data were collected from official SNAP administrating agency websites, state press releases, and state emergency coronavirus disease 2019 websites.

VARIABLES MEASURED

Four domains were collected from communication materials: (1) program information, (2) retailer information, (3) health and nutrition information, and (4) communication accessibility.

ANALYSIS

Qualitative content analysis, descriptive statistics.

RESULTS

Thirty-four (72%) states issued an official press release about the pilot that was easily accessible through online searches (15 available in multiple languages), 21 (45%) included information on their SNAP agency website, and 15 (32%) included information on their official coronavirus disease 2019 website. Most states identified authorized retailers (n = 37; 79%), provided information about pickup/delivery (n = 31; 66%), and stated the SNAP online start date (n = 29; 62%). About a quarter of states (n = 12; 26%) provided information about nutrition and health.

CONCLUSIONS AND IMPLICATIONS

State communication about the SNAP online pilot mostly focused on basic program and retailer information and included limited information about nutrition and health.

Nutrition Supports Deconstructed and Disrupted: An Evaluation of a Multilevel School-Based Intervention during the Time of COVID

The Best Food Forward (BFF) project aims to provide multiple nutrition supports and interventions to improve family food security (FS) and health outcomes associated with FS within two metropolitan school districts. A quasi-experimental time-series design guided a multilevel evaluation for BFF through surveys, biometric screenings, focus groups, and observations among a random sample of caregiver-child dyads. FS, utilization of school meal programs, and nutrition behaviors were observed and analyzed at three time points: preintervention, postintervention pre-COVID-19, and postintervention post-COVID-19. Participants included 122 parents and 162 youth. Families reported (1) an income less than $35,000 annually (48.8%) and (2) a COVID-19-related job loss (36.9%). Parents used Supplemental Nutrition Assistance Programs or Women, Infants, Children benefits prior to (51.1%) and following COVID-19 (50.0%). No significant differences in FS were found. RM-ANOVA indicated an increase in breakfast consumption at home and a decrease in use of the school breakfast program (F(1.78, 74) = 19.64, p < 0.001, partial η² = 0.21) and school lunch program (F(1.51, 74) = 23.30, p < 0.001, partial η² = 0.24). Rates of FS and eating behaviors did not change significantly over time. Correlations of program usage and eating behaviors demonstrate the importance of promoting participation in school meal programs. BFF may have prevented significant decreases in FS during COVID-19.

Exploring Perceived Importance of a Novel Emergency Food Program during COVID-19 and Program Recipient Characteristics

Following rising unemployment rates and consequent loss of income due to COVID-19, many people have been seeking meal assistance. This study examines the impact of a community-based free meal distribution program during the pandemic in Kentucky, reviewing characteristics of recipients of the program. Demographics, health behaviors, food insecure classification, and rating of importance of the meal program were collected. Qualitative feedback on the impact of the program was collected via open response. Of the 92 participants using the meal service, the cohort was female, Black, 43 years of age (43.5 ± 15.0 years), with a household income under 30,000 USD before COVID, decreased income since COVID, and were food insecure. Recipients rated the importance of the service as 8.7 ± 1.8 (of 10), and those with children indicated the importance as 4.2 ± 1.1 (of 5). Qualitative data on program importance highlighted four response categories including "changed habits", "mental wellbeing", "provided resources", and "other". In response to the COVID-19 pandemic, many individuals have struggled. Meal assistance programs are a fundamental asset in the community that have seen marketed demand since COVID-19. Collaboration with, and evaluation of, meal assistance programs can be valuable for continued programmatic funding support.

Did School Meal Programs and SNAP Participation Improve Diet Quality of US Children from Low-Income Households: Evidence from NHANES 2013-2014?

Nutrition assistance programs such as school meals and the Supplemental Nutrition Assistance Program (SNAP) are designed to provide a safety net for the dietary intake of children from low-income families. However, compared with eligible non-participants, the relationship of diet quality with school meals only and school meals + SNAP is not well understood. The objectives of the study include: (1) To explore whether and to what extent nutrition assistance program participation (school meals only and school meals + SNAP) is related to diet quality; and (2) to examine the differences of diet quality between participating in school meals only, school meals + SNAP, or non-participation among American children. Children aged 5 to 18 years old from income eligible households who participated in the 2013-2014 National Health and Nutrition Examination Survey (NHANES) were included in this cross-sectional study (n = 1425). Diet quality was measured using the Healthy Eating Index (HEI)-2015 and its 13 subcomponents. A Rao-Scott Chi-square test, propensity scores approach, and Analysis of Covariance were performed. Covariates included age, sex, race/ethnicity, weight status, and family monthly poverty index. SAS survey procedures were used to incorporate the appropriate sample design weights. Participation in school meals + SNAP was not associated with higher diet quality compared to eligible non-participants or school meals-only participants. Participation in school meals + SNAP improved the intake of total dairy, but not added sugars or total vegetables compared to school meals only. Overall, school meal + SNAP participation did not significantly improve the overall diet quality of children in low-income households relative to comparable non-participants.

A Community-Based Approach to Integrating Socio, Cultural and Environmental Contexts in the Development of a Food Database for Indigenous and Rural Populations: The Case of the Batwa and Bakiga in South-Western Uganda

Comprehensive food lists and databases are a critical input for programs aiming to alleviate undernutrition. However, standard methods for developing them may produce databases that are irrelevant for marginalised groups where nutritional needs are highest. Our study provides a method for identifying critical contextual information required to build relevant food lists for Indigenous populations. For our study, we used mixed-methods study design with a community-based approach. Between July and October 2019, we interviewed 74 participants among Batwa and Bakiga communities in south-western Uganda. We conducted focus groups discussions (FGDs), individual dietary surveys and markets and shops assessment. Locally validated information on foods consumed among Indigenous populations can provide results that differ from foods listed in the national food composition tables; in fact, the construction of food lists is influenced by multiple factors such as food culture and meaning of food, environmental changes, dietary transition, and social context. Without using a community-based approach to understanding socio-environmental contexts, we would have missed 33 commonly consumed recipes and foods, and we would not have known the variety of ingredients’ quantity in each recipe, and traditional foraged foods. The food culture, food systems and nutrition of Indigenous and vulnerable communities are unique, and need to be considered when developing food lists.

Health Clinic Readiness to Implement Nutrition Supports in Partnership With SNAP-Ed

OBJECTIVE

To assess the readiness of health clinics to implement nutrition support strategies in partnership with the Supplemental Nutrition Assistance Program Education (SNAP-Ed) program.

DESIGN

Qualitative study using semistructured interviews.

SETTING

South Carolina.

PARTICIPANTS

A convenience sample of key informants (n = 26) from health clinics (n = 15) interested in partnering with the SNAP-Ed program.

PHENOMENON OF INTEREST

Health clinic readiness to implement nutrition supports, including motivation, current capacities, and capacity-building needs.

ANALYSIS

Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed descriptively and thematically.

RESULTS

Clinics were most interested in implementing food insecurity screenings and making referrals to resources for accessing nutritious foods and produce prescription programs. Motivation was largely driven by a commitment to prevent chronic disease and on the basis of past success implementing a healthy eating strategy. A wide range of current capacities and capacity-building needs to implement strategies of interest were identified.

CONCLUSIONS AND IMPLICATIONS

Findings suggest the readiness of some clinics to partner with SNAP-Ed to implement nutrition support strategies and identifies early insights on areas practitioners might need to engage clinics in for capacity-building. Some implementers might need further training before having their own capacity to support clinics in the wide range of nutrition support strategies included, which could be explored in future studies.

Comparing shopper characteristics by online grocery ordering use among households in low-income communities in Maine

OBJECTIVE

Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations - especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store.

DESIGN

We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store).

SETTING

Two Maine supermarkets.

PARTICIPANTS

863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials.

RESULTS

Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30-39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186-300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online.

CONCLUSIONS

In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.

Food Shopping Frequency of Rural Tennessee Adults With Comparisons by Federal Nutrition Assistance Participation

OBJECTIVE

To describe food shopping frequency across 7 store types in a rural context and compare food shopping frequency between federal nutrition assistance recipients and nonrecipients.

METHODS

This cross-sectional study was conducted at county fairs in rural Tennessee.

RESULTS

Reported overall mean food shopping frequency was 18.4 (SD, 13.9) times in the past 30 days. A mean of 3.1 (SD, 1.2) store types were visited, with supermarkets, convenience stores, and dollar stores the most frequented stores. Federal nutrition assistance program recipients shopped significantly less frequently than nonrecipients for overall shopping frequency (P = 0.02), supermarkets (P = 0.02), and farmers' markets (P = 0.04).

CONCLUSIONS AND IMPLICATIONS

Educating and counseling individuals on how food shopping frequency may promote nutrition and health may be important. Federal nutrition assistance programs that distribute benefits monthly may impact food shopping frequency.

Food pantries select healthier foods after nutrition information is available on their food bank's ordering platform

OBJECTIVE

In the USA, community-based food pantries provide free groceries to people struggling with food insecurity. Many pantries obtain food from regional food banks using an online shopping platform. A food bank introduced a visible nutrition rank (i.e. green, yellow or red) onto its platform. The hypothesis was that pantry orders would increase for the healthiest options (green) and decrease for the least healthy options (red).

DESIGN

Interrupted time series (ITS) analysis of a natural experiment. Monthly data included nutrition ranks of available inventory and itemised records of all products ordered during the 15-month baseline period and 14-month intervention.

SETTING

A New England food bank.

PARTICIPANTS

The twenty-five largest food pantries in the network based on pounds of food ordered.

RESULTS

Descriptive analyses of 63 922 pantry ordering records before and after the visible ranks identified an increase in the proportion of green items ordered (39·3-45·4 %) and a decrease in the proportion of red items ordered (10·5-5·1 %). ITS analyses controlling for monthly changes in inventory available and pantry variables indicated that average monthly orders of green items increased by 1286 pounds (P < 0·001) and red orders decreased by 631 pounds (P = 0·045). Among the largest changes were increases in orders of fresh produce, brown rice, low-fat dairy and low-fat meats and decreases in orders of sugary juice drinks, canned fruit with added sugar, higher fat dairy and higher fat meats.

CONCLUSIONS

This promising practice can support system-wide efforts to promote healthier foods within the food banking network.

WIC Participants' Perceptions of COVID-19-Related Changes to WIC Recertification and Service Delivery

Many Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics implemented alternatives to in-person service delivery in response to the COVID-19 pandemic, including virtual visits and electronic document sharing. The objective of this cross-sectional study was to describe WIC participants’ experiences with remote service delivery and recertification during the pandemic. Participants included mothers and infants who participated in a WIC-based intervention between June 2019-August 2020. All participants (N = 246) were invited to complete a follow-up survey between November 2020-February 2021; 185 mothers completed the survey. The survey assessed sociodemographics, employment, food security, experiences with remote WIC recertification and service delivery, and experiences with obtaining WIC foods during the pandemic. Average age for mothers was 29.2 ± 6.3 years and for infants was 17.7  ± .2 months; 80% (n = 147) identified as Hispanic. Approximately 34% (n = 62) of participants reported very low or low food security and 40% (n = 64) had difficulties buying WIC foods during the pandemic. Among participants who recalled providing documentation of income and address virtually, the majority felt comfortable providing information via email (60%) and text messaging (72%). Participants reported high levels of satisfaction with remote methods of service delivery, as well as overall satisfaction with the WIC program during the pandemic. While ~ 25% of study participants preferred for all WIC services to remain remote, 75% still desired at least some in-person contact with WIC staff after the pandemic. In conclusion, remote methods of WIC service delivery addressed existing barriers to WIC participation and were well-received by study participants.

Between- and within-Group Differences in Fruit and Vegetable Purchases, Consumption, and BMI among Hispanic Farmers' Market Shoppers Who Use SNAP

(1) Background: Despite considerable efforts to increase farmers' market access (FM) and improve household fruit and vegetable (FV) purchasing in low-income communities, little is known about the FV purchasing and consumption characteristics of low-income Hispanic farmers' market shoppers. (2) Methods: A secondary analysis of baseline data from a farmers' market study conducted between 2015 and 2017 (n = 2825) was performed. Participants who also received supplemental nutrition assistance program (SNAP) completed a 31-item online survey assessing demographics, health characteristics, and FV purchasing and consumption habits. Descriptive statistics and bivariate analyses were used to assess between- and within-group differences amongst Hispanic and non-Hispanic households. Regression analyses were used to examine associations among BMI, FV purchasing and consumption, and household size for Hispanic and non-Hispanic households as well as for Hispanic subgroups. (3) Results: The sample included 515 Hispanic and 2310 non-Hispanic SNAP-using FM shoppers in 13 states. Despite experiencing significantly higher food insecurity (89% vs. 81%, non-Hispanic), Hispanic shoppers consumed similar amounts of FV (3.04 cups/day) and spent less doing so. Significant subgroup differences were identified for FV purchasing. (4) Conclusions: Findings emphasize the importance of food insecurity and household size in FV interventions and underscore the capacity of Hispanic families to maintain FV consumption.

COVID-19-associated school closures and related efforts to sustain education and subsidized meal programs, United States, February 18-June 30, 2020

Pre-emptive school closures are frontline community mitigation measures recommended by the US Centers for Disease Control and Prevention (CDC) for implementation during severe pandemics. This study describes the spatiotemporal patterns of publicly announced school closures implemented in response to the coronavirus disease 2019 (COVID-19) pandemic and assesses how public K-12 districts adjusted their methods of education delivery and provision of subsidized meals. During February 18–June 30, 2020, we used daily systematic media searches to identify publicly announced COVID-19–related school closures lasting ≥1 day in the United States (US). We also collected statewide school closure policies from state government websites. Data on distance learning and subsidized meal programs were collected from a stratified sample of 600 school districts. The first COVID-19–associated school closure occurred on February 27, 2020 in Washington state. By March 30, 2020, all but one US public school districts were closed, representing the first-ever nearly synchronous nationwide closure of public K-12 schools in the US. Approximately 100,000 public schools were closed for ≥8 weeks because of COVID-19, affecting >50 million K-12 students. Of 600 districts sampled, the vast majority offered distance learning (91.0%) and continued provision of subsidized meal programs (78.8%) during the closures. Despite the sudden and prolonged nature of COVID-19–associated school closures, schools demonstrated flexibility by implementing distance learning and alternate methods to continue subsidized meal programs.

Investigating the short and long-term effects of "nutritional-score" pricing on food pantry selections

Approximately one out of ten households in the U.S. experienced food insecurity in 2019 (U. S. Department of Agriculture, 2020). Food pantries have taken on an important role in helping those with both short term and persistent food insecurity. As pantries are increasingly being arranged to allow clients to choose their own food, the question of how to encourage healthy choices is becoming an important topic for discussion. The Des Moines Area Religious Council (DMARC) implemented a "Nutritional-Score" program on September 1, 2017 as an experiment aimed at answering the above question. This program essentially changes the budgets of food pantry clients to make healthier choices cheaper and less healthy choices more expensive. We perform a Bayesian analysis using a zero-inflated Poisson (ZIP) model to help describe the effects of this program on the frequency with which clients choose less healthy items. We find evidence that the Nutritional-score program had a positive effect on the probability of rejecting less healthy items in the short and long term.

App Usage Associated With Full Redemption of WIC Food Benefits: A Propensity Score Approach

OBJECTIVE

To examine the relationship between WICShopper application (app) usage and full redemption of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefits.

DESIGN

A cross-sectional study.

SETTING

West Virginia WIC program.

PARTICIPANTS

A total of 23,050 West Virginia WIC households in 2019.

MAIN OUTCOME MEASURES

Full redemptions were defined as the redemption rate of ≥ 90% for a given food benefit.

ANALYSIS

App/non-app users were defined as households with someone using/not using the WICShopper app. Multivariate logistic regressions were applied. To address the potential self-selection bias in app usage, the propensity score (PS) of app usage was estimated. The regressions were rerun with the balanced sample by matching the PS.

RESULTS

With PS matching, the prevalence of full redemption at the household level was 7.2% for app users vs 4.7% for nonapp users (odds ratio, 1.64; 95% confidence interval, 1.40-1.92; P < 0.001). App users had a higher prevalence of full redemption in most food categories, even with PS matching.

CONCLUSIONS AND IMPLICATIONS

Use of the WICShopper app was associated with a higher prevalence of full redemptions in most food benefits after controlling the self-selection bias.

Technical Assistance is Related to Improvements in the Food Pantry Consumer Nutrition Environment

OBJECTIVE

To assess changes in food pantries' consumer nutrition environment (CNE) after the provision of technical assistance.

DESIGN

Pre-post study with 2 phases.

SETTING

Staff completed observational assessments using the Nutrition Environment Food Pantry Assessment Tool (NEFPAT) at food pantries in an initial pilot phase. Then, staff conducted NEFPAT observations at pantries in Illinois statewide.

PARTICIPANTS

In the pilot phase, 6 staff assessed 28 pantries. In the statewide phase, 35 staff assessed 119 pantries.

INTERVENTION

After completing an initial NEFPAT at each pantry, technical assistance was provided by staff to support changes in the pantries' CNE before another NEFPAT observation was completed.

MAIN OUTCOME MEASURE

Changes in the CNE, as assessed with the NEFPAT, when comparing preassessment and postassessment.

ANALYSIS

Score differences were evaluated with paired t tests.

RESULTS

In the pilot phase, among 23 pantries with preassessment and postassessment data, 2 objectives on the NEFPAT observation increased significantly. In the statewide phase, among 66 pantries with preassessment and postassessment data, most NEFPAT objectives and the overall NEFPAT score (22.12 ± 8.16 vs 28.20 ± 7.14, P < 0.001) significantly increased.

CONCLUSIONS AND IMPLICATIONS

Technical assistance provided by Supplemental Nutrition Assistance Program Education implementing staff were related to improvements in the CNE of food pantries in Illinois. Future work should evaluate the association of these CNE changes with changes in behavior among pantry patrons.

Understanding patterns of food insecurity and family well-being amid the COVID-19 pandemic using daily surveys

This paper investigates economic and psychological hardship during the COVID-19 pandemic among a diverse sample (61% Latinx; 16% White; 9% Black; 14% mixed/other race) of socioeconomically disadvantaged parents (90% mothers; mean age = 35 years) and their elementary school-aged children (ages 4-11; 49% female) in rural Pennsylvania (N = 272). Families participating in a local food assistance program reported on food insecurity (FI) and parent and child mood and behavior daily from January to May 2020. Longitudinal models revealed that FI, negative parent and child mood, and child misbehavior significantly increased when schools closed; only FI and parent depression later decreased. FI decreased most among those who received the local food assistance program; Supplemental Nutrition Assistance Program receipt uniquely predicted decreases in child FI.

Readiness of SNAP-Ed Implementers to Incorporate Policy, Systems, and Environmental Approaches into Programming

OBJECTIVE

To identify the readiness of Supplemental Nutrition Assistance Program Education (SNAP-Ed) implementers to facilitate policy, systems, and environmental (PSE) changes in conjunction with delivering direct nutrition education.

DESIGN

Qualitative study using semistructured interviews.

SETTING

A southeastern state.

PARTICIPANTS

Purposive sample of SNAP-Ed staff (n = 19) from state implementing agencies (n = 3) in 1 state.

PHENOMENON OF INTEREST

Readiness using the validated framework: readiness equals motivation coupled with general-capacities and innovation-specific capacities (R = MC²).

ANALYSIS

Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using an iterative approach to the analysis via emergent coding and constant comparison.

RESULTS

Although a general sense of motivation is present among implementers to meet the new federal guidelines, nutrition education is still prioritized. General capacity for SNAP-Ed implementers, comprised communication, training, and funding and staffing, was limited. Innovation-specific capacities around the implementation of PSEs revealed limited knowledge, experience, and resources among most implementers.

CONCLUSIONS AND IMPLICATIONS

Identifying the nuanced and interrelated aspects of motivation and capacity of SNAP-Ed implementers to incorporate PSEs into their direct education interventions could inform tailored strategies for increasing readiness, such as through training, reallocation of resources, or program restructuring.

Supplemental nutrition assistance program 2009 expansion and cardiometabolic markers among low-income adults

A 2009 Supplemental Nutrition Assistance Program (SNAP) policy change that expanded eligibility and increased benefit amounts has been associated with reduced food insecurity. This study tests the hypothesis that the SNAP policy change corresponds with improved stress- and nutrition-sensitive cardiometabolic markers. This study included non-pregnant participants aged 18-59 with annual family incomes ≤185% of the federal poverty guideline from the repeated cross-sectional NHANES study. Those living in SNAP eligible households (income ≤130% of the poverty guideline) were compared to those who were likely non-eligible (income 131%-≤185%). Difference-in-differences analyses compared hemoglobin A1c (%), CRP (mg/dL), total cholesterol (mg/dL), LDL (mg/dL) and waist circumference (cm) across groups before (2007-2008) and after (2009-2010) the SNAP policy change. Sampling weights were applied. Adjusting for demographic, socioeconomic, household and health factors, there were statistically significant difference-in-differences estimates for hemoglobin A1c (p = 0.003, n = 3723) and total cholesterol (p = 0.028, n = 3710). SNAP eligible adults had no difference in hemoglobin A1c after the policy change and, among those less than 40 years of age, 5 mg/dL lower total cholesterol levels whereas likely non-SNAP eligible adults had 0.14% higher hemoglobin A1c and no difference in total cholesterol after the policy change. The 2009 SNAP expansion was associated with improved nutrition-sensitive cardiometabolic markers in SNAP-eligible adults. This study found less of an upward trend in hemoglobin A1c levels for young and middle aged adults and decreased total cholesterol for young adults. These results highlight the potential role of SNAP to prevent costly chronic conditions among low-income U.S. adults.

Changes in High Weight-for-Length among Infants Enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children during 2010-2018

Background: Infants and young children with high weight-for-length are at increased risk for obesity in later life. This study describes prevalence of high weight-for-length and examines changes during 2010-2018 among 11,366,755 infants and young children 3-23 months of age in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods: Children's weights and lengths were measured. High weight-for-length was defined as ≥2 standard deviations above sex and age-specific median on World Health Organization growth charts. Adjusted prevalence differences (APDs) between years were calculated as 100 times marginal effects from logistic regression models. APD was statistically significant if 95% confidence interval did not include 0. Results: Adjusted prevalence of high weight-for-length decreased from 2010 to 2014, and leveled off through 2018 overall, in boys and girls, those 6-11 and 18-23 months of age, and non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders. For 12-17 months old and American Indian/Alaska Native infants and young children, adjusted prevalence decreased from 2010 to 2014, and then increased slightly through 2018. Among 56 WIC state or territorial agencies, 33 had significant decreases between 2010 and 2018, whereas 8 had significant increases. Between 2014 and 2018, prevalence decreased significantly in 12 agencies and increased significantly in 23. Conclusions: The results indicate overall declines in prevalence of high weight-for-length from 2010 to 2018, with a prevalence stabilization since 2014. Continued surveillance is needed. Obesity prevention strategies in WIC and multiple settings are important for ensuring healthy child growth.

A novel intervention combining supplementary food and infection control measures to improve birth outcomes in undernourished pregnant women in Sierra Leone: A randomized, controlled clinical effectiveness trial

BACKGROUND

Innovations for undernourished pregnant women that improve newborn survival and anthropometry are needed to achieve the Sustainable Development Goals 1 and 3. This study tested the hypothesis that a combination of a nutritious supplementary food and several proven chemotherapeutic interventions to control common infections would increase newborn weight and length in undernourished pregnant women.

METHODS AND FINDINGS

This was a prospective, randomized, controlled clinical effectiveness trial of a ready-to-use supplementary food (RUSF) plus anti-infective therapies compared to standard therapy in undernourished pregnant women in rural Sierra Leone. Women with a mid-upper arm circumference (MUAC) ≤23.0 cm presenting for antenatal care at one of 43 government health clinics in Western Rural Area and Pujehun districts were eligible for participation. Standard of care included a blended corn/soy flour and intermittent preventive treatment for malaria in pregnancy (IPTp). The intervention replaced the blended flour with RUSF and added azithromycin and testing and treatment for vaginal dysbiosis. Since the study involved different foods and testing procedures for the intervention and control groups, no one except the authors conducting the data analyses were blinded. The primary outcome was birth length. Secondary outcomes included maternal weight gain, birth weight, and neonatal survival. Follow-up continued until 6 months postpartum. Modified intention to treat analyses was undertaken. Participants were enrolled and followed up from February 2017 until February 2020. Of the 1,489 women enrolled, 752 were allocated to the intervention and 737 to the standard of care. The median age of these women was 19.5 years, of which 42% were primigravid. Twenty-nine women receiving the intervention and 42 women receiving the standard of care were lost to follow-up before pregnancy outcomes were obtained. There were 687 singleton live births in the intervention group and 657 in the standard of care group. Newborns receiving the intervention were 0.3 cm longer (95% confidence interval (CI) 0.09 to 0.6; p = 0.007) and weighed 70 g more (95% CI 20 to 120; p = 0.005) than those receiving the standard of care. Those women receiving the intervention had greater weekly weight gain (mean difference 40 g; 95% CI 9.70 to 71.0, p = 0.010) than those receiving the standard of care. There were fewer neonatal deaths in the intervention (n = 13; 1.9%) than in the standard of care (n = 28; 4.3%) group (difference 2.4%; 95% CI 0.3 to 4.4), (HR 0.62 95% CI 0.41 to 0.94, p = 0.026). No differences in adverse events or symptoms between the groups was found, and no serious adverse events occurred. Key limitations of the study are lack of gestational age estimates and unblinded administration of the intervention.

CONCLUSIONS

In this study, we observed that the addition of RUSF, azithromycin, more frequent IPTp, and testing/treatment for vaginal dysbiosis in undernourished pregnant women resulted in modest improvements in anthropometric status of mother and child at birth, and a reduction in neonatal death. Implementation of this combined intervention in rural, equatorial Africa may well be an important, practical measure to reduce infant mortality in this context.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079388.