Small Improvements in an Urban Food Environment Resulted in No Changes in Diet Among Residents

Community Investments and Diet-Related Outcomes: A Longitudinal Study of Residents of Two Urban Neighborhoods

INTRODUCTION

Investments in historically oppressed neighborhoods through food retail, housing, and commercial development are hypothesized to improve residents' health, nutrition, and perceptions of their neighborhood as a place to live. Although place-based development (e.g., housing, retail, business assistance) is happening in many communities, there is little evidence of the long-term correlates of multiple investments such as health and nutrition among residents.

METHODS

A quasi-experimental longitudinal study was conducted using a cohort of randomly sampled households in two low-income, predominantly African American neighborhoods in Pittsburgh, PA, with surveys assessing residents' food insecurity, perception of their neighborhood as a place to live, perception of access to healthy foods, and dietary outcomes in 2011 and seven years later (2018), with an interim assessment in 2014. Analyses conducted in 2022 compared changes among residents of one neighborhood which had 2.6 times the investments over a 7-year period with changes among residents of a socio-demographically similar neighborhood that received fewer investments.

RESULTS

It was found that residents in the neighborhood receiving substantial investments demonstrated statistically significant improvements in neighborhood satisfaction (12.6% improvement compared with a 2.2% decrease) and perceived access to healthy food (52% improvement compared with 18.2% improvement), and marginally significant change in food security (14% compared with 4.8% improvement) compared with residents in the neighborhood receiving fewer investments.

CONCLUSIONS

Multiple place-based investments in neighborhoods can potentially induce positive change for residents in health and nutrition outcomes.

Effect of mobile food environments on fast food visits

Poor diets are a leading cause of morbidity and mortality. Exposure to low-quality food environments saturated with fast food outlets is hypothesized to negatively impact diet. However, food environment research has predominantly focused on static food environments around home neighborhoods and generated mixed findings. In this work, we leverage population-scale mobility data in the U.S. to examine 62M people's visits to food outlets and evaluate how food choice is influenced by the food environments people are exposed to as they move through their daily routines. We find that a 10% increase in exposure to fast food outlets in mobile environments increases individuals' odds of visitation by 20%. Using our results, we simulate multiple policy strategies for intervening on food environments to reduce fast-food outlet visits. This analysis suggests that optimal interventions are informed by spatial, temporal, and behavioral features and could have 2x to 4x larger effect than traditional interventions focused on home food environments.

Impact of the Neighborhood Food Environment on Dietary Intake and Obesity: a Review of the Recent Literature

PURPOSE OF REVIEW

The built environment impacts obesogenic behaviors and in turn body weight outcomes. This review summarizes recent research demonstrating environmental impacts on dietary intake and obesity with a specific focus on the neighborhood food environment.

RECENT FINDINGS

In the previous five years, an abundance of reviews and research studies have been undertaken to elucidate how the neighborhood food environment impacts diet and obesity. This includes studies using primary data collection and secondary data analyses in various populations across the globe. Taken together, current research presents mixed evidence on the impact of the neighborhood food environment on both dietary intake and obesity. While there is some evidence that certain features of the neighborhood food environment influence health behaviors and outcomes in particular populations, it is imperative to acknowledge the complexity of how neighborhood features interact and constantly evolve when considering place-based influences on health behaviors and outcomes.

Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic

OBJECTIVE

This study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic.

DESIGN

Weekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes.

SETTING

North Carolina large chain grocery stores.

PARTICIPANTS

Large chain grocery store/SNAP shoppers.

INTERVENTION

Rural/urban status of the stores and COVID-19 pandemic onset.

MAIN OUTCOME MEASURES

Share of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM).

ANALYSIS

Multivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors.

RESULTS

We did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (-0.43%) and less healthful food (-1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Urban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.

Association Between a Policy to Subsidize Supermarkets in Underserved Areas and Childhood Obesity Risk

IMPORTANCE

The establishment and renovation of supermarkets may promote healthy diet practices among youth by increasing retail infrastructure for fresh foods.

OBJECTIVE

To estimate the association between the Food Retail Expansion to Support Health (FRESH) program and the weight status of children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Using a difference-in-differences (DiD) design and including 12 months before and after a FRESH supermarket opened, data were analyzed for residentially stable public school students in kindergarten through 12th grade with objectively measured height and weight data from the academic years 2009 through 2016. Of the 8 FRESH-subsidized supermarkets in residential neighborhoods in New York City, New York, 5 were new and 3 were renovation projects between December 2011 and June 2014. Data were analyzed from June 2021 to January 2022.

INTERVENTIONS

The treatment group included students who resided within 0.50 miles of a FRESH-subsidized supermarket and had at least 1 body mass index (BMI) measurement within 12 months before and 3 to 12 months after the month a FRESH supermarket opened (n = 22 712 student-year observations). A 2-stage matching-weighting approach was used to construct a control group of students who resided more than 0.50 miles from a FRESH supermarket in a FRESH-eligible area (n = 86 744 student-year observations).

MAIN OUTCOMES AND MEASURES

BMI z score was calculated using objectively measured height and weight data from FITNESSGRAM, an annual, school-based, standardized fitness assessment of every New York City public school student. Obesity was defined as 95th percentile or greater of the BMI z score using Centers for Disease Control and Prevention growth charts.

RESULTS

The treatment group in the analytic sample had 11 356 students (22 712 student-year observations), and the control group had 43 372 students (86 744 student-year observations). The students were predominately Black (18.8%) and Hispanic and Latino (68.5%) and eligible for free or reduced-priced lunch (84.6%). There was a significant decrease in BMI z score among students who resided within 0.50 miles of a FRESH supermarket (vs control group students) in the 3- to 12-month follow-up period (DiD, -0.04; 95% CI, -0.06 to -0.02). This was true for those exposed to supermarkets that were either new (DiD, -0.07; 95% CI, -0.11 to -0.03) or renovated (DiD, -0.03; 95% CI, -0.06 to -0.01). A statistically significant decrease was also observed in the likelihood of obesity (DiD, -0.01; 95% CI, -0.02 to -0.002).

CONCLUSIONS AND RELEVANCE

Government-subsidized supermarkets may contribute to a small decrease in obesity risk among children residing near those supermarkets, if part of a comprehensive policy approach.

Food system dynamics structuring nutrition equity in racialized urban neighborhoods

BACKGROUND

The food system is a social determinant of health and a leverage point for reducing diet-related racial inequities. Yet, food system interventions have not resulted in sustained improvement in dietary outcomes for underrepresented minorities living in neighborhoods with a history of disinvestment. Research is needed to illuminate the dynamics structuring food systems in racialized neighborhoods to inform intervention development.

OBJECTIVES

To conduct participatory research examining the complexity and inequity of food systems in historically redlined neighborhoods to identify feedback mechanisms to leverage in efforts to transform system outcomes for racial equity.

METHODS

We conducted a mixed-methods study in Cleveland, Ohio, USA from 2018 to 2021 using participatory system dynamic modeling with 30 academic and community partners, in-depth qualitative interviews with 22 key stakeholders, and public convenings with 250 local food policy council affiliates. Data were synthesized into causal loop diagrams depicting feedback mechanisms reinforcing or balancing neighborhood-level food system dynamics.

RESULTS

We identified 10 feedback mechanisms structuring nutrition equity, which was identified as a meta-goal for food systems in racialized neighborhoods. Feedback mechanisms were organized in 3 domains: 1) meeting basic food needs with dignity (i.e., side hustle, government benefits, emergency food assistance, stigma, and stereotypes); 2) local food supply and demand dynamics (i.e., healthy food retail, job security, food culture, and norms); and 3) community empowerment and food sovereignty (i.e., community power, urban agriculture, risk of gentrification). Five exogenous factors moderate feedback dynamics: neighborhood crisis, neighborhood investments, household costs, government benefit funding, and voter participation.

CONCLUSIONS

We identified nutrition equity as an overarching goal for local food systems, which reflects a state of having freedom, agency, and dignity in food traditions resulting in people and communities healthy in body, mind, and spirit. It is a transformative goal designed to spur system-level interventions that further racial equity through improved local food system dynamics.

Improving Local Food Systems through the Coordination of Agriculture Supply Chain Actors

A local food system is an alternative food network that shortens and more effectively structures the supply chain system. An intermediary actor functioning as an aggregator is needed in the local food system. The food hub is one such intermediary actor with an essential role in strengthening the local food system and increasing the competence of small farmers to compete with large-scale food distribution. Many studies have been conducted on the effectiveness and efficiency of food hubs; however, changing the supply chain system to one that is based on a local food system is challenging. This study aims to build a conceptual model that describes the activities and coordination of the actors involved in a food hub to achieve a local food system. In this study, a soft system methodology and case study approach are used to answer the research question. The results show that two transformations are needed to achieve a local food system: changing the supply chain system to one that is shorter and more structured and increasing quality consistency. Recommendations are presented in the form of a series of human activity systems to achieve transformations. Human activities to achieve a shorter and structured supply chain involve building cooperation, operating operational activities to add value, product identification, promotion, and developing fair-trade contracts. Human activities required to achieve transformation of increasing quality consistency include identifying high-demand customer requirements, forecasting, scheduling planting, and harvesting, improving training, cooperating with research institutions, farmer assistance, and quality inspection.

Food environments and obesity: A geospatial analysis of the South Asia Biobank, income and sex inequalities

Introduction

In low-middle income countries (LMICs) the role of food environments on obesity has been understudied. We address this gap by 1) examining the effect of food environments on adults’ body size (BMI, waist circumference) and obesity; 2) measuring the heterogeneity of such effects by income and sex.

Methods

This cross-sectional study analysed South Asia Biobank surveillance and environment mapping data for 12,167 adults collected between 2018 and 2020 from 33 surveillance sites in Bangladesh and Sri Lanka. Individual-level data (demographic, socio-economic, and health characteristics) were combined with exposure to healthy and unhealthy food environments measured with geolocations of food outlets (obtained through ground-truth surveys) within 300 m buffer zones around participants' homes. Multivariate regression models were used to assess association of exposure to healthy and unhealthy food environments on waist circumference, BMI, and probability of obesity for the total sample and stratified by sex and income.

Findings

The presence of a higher share of supermarkets in the neighbourhood was associated with a reduction in body size (BMI, β = - 3∙23; p < 0∙0001, and waist circumference, β = −5∙99; p = 0∙0212) and obesity (Average Marginal Effect (AME): −0∙18; p = 0∙0009). High share of fast-food restaurants in the neighbourhood was not significantly associated with body size, but it significantly increased the probability of obesity measured by BMI (AME: 0∙09; p = 0∙0234) and waist circumference (AME: 0∙21; p = 0∙0021). These effects were stronger among females and low-income individuals.

Interpretation

The results suggest the availability of fast-food outlets influences obesity, especially among female and lower-income groups. The availability of supermarkets is associated with reduced body size and obesity, but their effects do not outweigh the role of fast-food outlets. Policies should target food environments to promote better diets and reduce obesity.

•

Healthy and unhealthy food environments in LMICs are significantly associated with BMI, waist circumference and obesity.

•

There is social inequality in this effect as female and low-income individuals are most affected.

•

Low-middle income countries show similar trends in obesity prevalence as high-income countries.

Prevalence, Knowledge and Potential Determinants of COVID-19 Vaccine Acceptability Among University Students in the United Arab Emirates: Findings and Implications

Objective

To evaluate the prevalence, knowledge, attitude and acceptance of the COVID-19 vaccines and related factors among university students in the United Arab Emirates.

Methods

Analytical cross-sectional study undertaken among a convenient sample of medical and non-medical colleges of Ajman University using a self-administrated questionnaire. The questionnaire included demographic data as well as assessing knowledge of COVID-19, attitudes and acceptance of COVID-19 vaccines.

Results

A total of 467 students participated in the study and completed the questionnaire. A total of 181 (38.8%) participants reported that they have been vaccinated against COVID-19 virus, principally with the Sinopharm vaccine (84%). Vaccination against the COVID-19 virus was less prevalent among Arabic nationalities compared to other nationalities, but more prevalent among students from health science colleges compared to those from non-health science colleges. The acceptance rate of COVID-19 vaccine among study participants was 56.3%, exacerbated by worries regarding unforeseen problems (65.5%, 306), general mistrust (47.3%, 221) and unforeseen impacts (35.1%, 164). The average knowledge score was 60.1%, with 142 (30.4%) having poor knowledge, 127 (27.2%) acceptable knowledge and 198 (42.4%) good knowledge. There were common misconceptions about symptoms including nausea and diarrhoea, as well as the route of transmission, with half believing antibiotics are effective treatment.

Conclusion

There was variable knowledge of COVID-19 among students. Misconceptions need addressing going forward. To enhance COVID-19 vaccination uptake in the country and worldwide, health education targeting diverse sociodemographic categories should be prioritized.

Fixes that Fail: A system archetype for examining racialized structures within the food system

Access to fresh and healthy food within a neighborhood has been identified as a social mechanism contributing to community health. Grounded in the understanding that challenges related to equity within a food system are both structural and systemic, our research demonstrates how systems thinking can further understandings of food system complexity. Within systems thinking, we provide an illustration of how system archetypes offer an analytic tool for examining complex community issues. We map semi-structured interview data from community stakeholders (N = 22) to the "Fixes that Fail" system archetype to illuminate systemic challenges, such as incarceration and poverty, that structure food system inequity in urban communities. Within our research, the "Fixes that Fail" archetype provided a narrative interpretive tool for unveiling complexity within the food system and interdependencies with racialized systems such as criminal justice and labor markets. This system archetype provided an accessible approach for generating narratives about systemic complexity, the production of inequity through racialized forces, and opportunities for transformation.

Local Value Chain Models of Healthy Food Access: A Qualitative Study of Two Approaches

Food value chains are increasingly recognized as more equitable alternatives to traditional supply chains and may represent a novel mechanism to achieve health equity at the local level. Country Fresh Stops (CFS) and Donation Station (DS) are two complementary programs that are part of a more robust value chain designed to support local agriculture in Appalachia Ohio. As the first study of these programs in the peer-reviewed literature, the objectives were to identify factors that facilitate or hinder the implementation of these two local value chain models of healthy food access and to identify the perceived impacts from the perspective of the sites implementing them. In-depth, semi-structured interviews were conducted with CFS (n = 7) and DS (n = 10) site representatives in January 2020. Template analysis was used to identify themes through a priori and inductive codes. Participants identified two primary facilitators: support from partner organizations and on-site program stewardship. Produce (and program) seasonality and mitigating food waste were the most cited challenges. Despite challenges, both CFS and DS sites perceive the models to be successful efforts for supporting the local economy, achieving organizational missions, and providing consumers with greater access to locally grown produce. These innovative programs demonstrate good feasibility, but long-term sustainability and impacts on other key stakeholders merit further investigation.

Elevated Dietary Inflammation Among Supplemental Nutrition Assistance Program Recipients Provides Targets for Precision Public Health Intervention

INTRODUCTION

The Supplemental Nutrition Assistance Program was designed to prevent food insecurity among low-income Americans and has been linked to improvements in pregnancy health, long-term child development, and criminal recidivism. However, the pursuit of food security does not ensure nutritional sufficiency, and the program has not improved diet quality or cardiometabolic mortality (i.e., heart disease, stroke, diabetes). In this study, longitudinal cohort data are used to identify by Supplemental Nutrition Assistance Program status the proinflammatory characteristics that predispose to chronic disease.

METHODS

Between 2015 and 2018, annual 24-hour dietary recalls were conducted with 409 residents from low-income, urban neighborhoods in Columbus and Cleveland, Ohio (statistical analysis started in 2019). The Dietary Inflammatory Index was calculated. It provides empirically validated estimates of the internal inflammation that each diet should produce; higher Dietary Inflammatory Index scores have been associated with elevated inflammatory biomarkers. Finally, associations between Supplemental Nutrition Assistance Program and Dietary Inflammatory Index were evaluated, and dietary components that differed by Supplemental Nutrition Assistance Program status were identified.

RESULTS

Supplemental Nutrition Assistance Program recipients had higher Dietary Inflammatory Index scores (+0.40, 95% CI=0.09, 0.70) and a consistently lower intake of 4 anti-inflammatory nutrients (dietary fiber, β-carotene, magnesium, vitamin E) than nonrecipients. Vitamin D intake did not differ by Supplemental Nutrition Assistance Program status but was well below the Recommended Daily Allowance in this sample.

CONCLUSIONS

Supplemental Nutrition Assistance Program recipients had elevated Dietary Inflammatory Index scores, implying higher diet-driven inflammation. This was due, in part, to low intake of 4 anti-inflammatory food components, which were higher yet still nutritionally insufficient among nonrecipients. Findings highlight specific nutritional targets for improving public health through dietary change.

Identification of factors related to food insecurity and the implications for social determinants of health screenings

Background

Food insecurity and other social determinants of health are increasingly being measured at routine health care visits. Understanding the needs and behaviors of individuals or families who screen positive for food insecurity may inform the types of resources they need. The goal of this research was to identify modifiable characteristics related to endorsement of two food insecurity screener questions to better understand the resources necessary to improve outcomes.

Methods

Analysis was conducted focusing on cross-sectional survey data collected in 2015–2016 from participants (N = 442) living in urban neighborhoods in Ohio with limited access to grocery stores. Food insecurity was assessed by the endorsement of at least one of two items. These were used to categorize participants into two groups: food insecure(N = 252) or food secure (N = 190). Using logistic regression, we estimated the association between several variables and the food insecure classification.

Results

Those that used their own car when shopping for food had lower odds of reporting food insecurity, as did those with affirmative attitudes related to the convenience of shopping for and ease of eating healthy foods. As shopping frequency increased, the odds of food insecurity increased. Food insecurity also increased with experience of a significant life event within the past 12 months. There was an 81% increase in the odds of reporting food insecurity among participants who received Supplemental Nutrition Assistance Program benefits compared to those not receiving Supplemental Nutrition Assistance Program benefits.

Conclusions

Along with referrals to SNAP, clinicians can further address screening-identified food insecurity through provision of transportation supports and linkages to other social services while collaborating on community initiatives to promote convenient and easy access to healthy foods. The needs and behaviors associated with screens indicating food insecurity also have implications for impacting other SDH, and thus, health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11465-6.

Racialized Experiences Differentiate Food Security Among African American Adults

BACKGROUND

Patterns of food security persistently vary by race, yet limited research has examined how community-specific experiences of race and racism are associated with nutritional outcomes.

OBJECTIVES

This analysis describes a novel approach for classifying experiences of race and racism and explores the relationship between identified classes and measures of food security and diet quality.

METHODS

Cross-sectional self-reported survey data from 306 African American adults living in two urban midwestern cities were collected in 2017-2018. Measures of racialized experiences assessed consciousness of race, perceived discrimination, and health effects of perceived discrimination. Food security was measured with a six-item screener and diet quality with the Healthy Eating Index-2010. Latent class analysis was used to generate racialized classes. Bivariate analyses were conducted to examine differences in class membership by sociodemographics and nutrition outcomes.

RESULTS

Participants were majority women who were receiving Supplemental Nutrition Assistance Program benefits. Three racialized classes were identified: Class 1 reported few racialized experiences (42.8% of the sample), Class 2 was racially conscious with few experiences of discrimination (45.1%), and Class 3 was both racially conscious and affected by racialized actions (12.1%). Racialized classes were significantly different in mean household income, level of education, home ownership, and job loss in the past year. Class 3 was the least represented among those that were food secure and the most represented among those that were very low food secure. There were no differences by class in Healthy Eating Index-2010 scores.

DISCUSSION

Findings offer an innovative method for measuring exposures to racism and for assessing its relationship to food security. Findings highlight heterogeneity of racialized experiences in similar contexts as well as potential root cause targets such as wages, education, home ownership, and employment that may be modulated to mitigate the effects of racism on food insecurity.

COVID-19 vaccine hesitancy: a survey in a population highly compliant to common vaccinations

Vaccination is a key protective factor against COVID-19. Some vaccines have already received emergency authorization from Health Agencies, but growing skepticism and vaccine hesitancy will probably affect COVID-19 vaccination campaigns. In the attempt to shed light on this issue, we conducted an online survey in a population of parents referring to 4 pediatric practices in Naples, Italy in whom we evaluated potential vaccine acceptability in relation to socio-demographic characteristics, perception of personal health and of the impact of COVID-19, and attitudes toward general vaccination practices. Vaccination rates were analyzed also in the corresponding pediatric population.Almost 27% of participants declared they were in favor of vaccinations, and in fact real life vaccination rates in children exceeded the national mean. Only 26.5% of respondents declared they would receive COVID-19 vaccine. Vaccine refusal was attributed to safety concerns in 76% of parents. Specific vaccine attributes further reduced the acceptance rate. Female gender, younger age and lower education level were associated with non-adherence to vaccination. Among extrinsic factors of COVID-19 vaccination, only information from National Health Authorities was significantly associated to vaccine acceptance.The rate of potential COVID-19 vaccine acceptability was very poor in our population of parents. Vaccine hesitancy was mainly due to safety concerns. Demographic and educational factors were correlated to vaccine acceptability. Health education and communication strategies are needed to achieve large-scale vaccine acceptability and finally herd immunity.

A relational approach to evaluate food environments finds that the proximate food environment matters for those who use it

Using a relational approach, this study investigates whether shopping close to home moderates the relationship between the proximate food environment and diet. To address this question, we develop the proximate food retail quality (PFRQ) score, an inverse-distance weighted measure of all food retailers within a resident's neighborhood that incorporates audit data of each food retailer. This study relies on data collected through 24-h dietary recalls and psychosocial surveys administered to 449 adults in two socioeconomically matched neighborhoods. Food retailer audits collected data on the availability, price, and quality of healthful foods. Seventy-one percent of study participants report conducting at least 50% of their food shopping within approximately one mile of their home. Household income and education are associated with likelihood to shop close to home, while access to a personal vehicle is not. Finally, results suggest that, for residents who shop primarily close to home, a one unit increase in proximate food retail environment score is associated with a 17.2-point increase in HEI-2010 score, a measure of overall diet quality that ranges from zero to 100. This study suggests that the food environment matters for those who use it and that a low-quality proximate food environment can amplify individual disadvantage.

Food security moderates relationship between perceived food environment and diet quality among adults in communities with low access to healthy food retail

OBJECTIVE

To examine the relationship between food security status, diet quality measured using Healthy Eating Index-2010 (HEI-2010) scores, demographics and the following factors: perceptions of healthy food availability, healthy eating identity and perceived control of healthy eating.

DESIGN

A cross-sectional study in 2016-2017 using three 24-h dietary recalls and one psychosocial survey.

SETTING

Two urban communities in Cleveland and Columbus, Ohio, USA, with low access to healthy food retailers.

PARTICIPANTS

Primary food shoppers living in the targeted geographic areas (N 450).

RESULTS

Our results indicated that high school graduates had lower HEI-2010 scores compared with participants who had some college education or more (β = -2·77, P = 0·02). Participants receiving Supplemental Nutrition Assistance Program (SNAP) benefits had lower HEI-2010 scores (β = -2·69, P = 0·03). Healthy eating identity was associated with higher HEI-2010 scores (β = 1·85, P = 0·004). Food security status moderated the relationship between perception of healthy food availability and HEI-2010 scores. Among participants with very low food security (VLFS), greater perceptions of healthy food availability were associated with higher HEI-2010 scores (β = 3·25, P = 0·03), compared with food secure participants. Only 14 % of VLFS participants used a personal vehicle as transportation to their primary food shopping store.

CONCLUSIONS

Findings offer targets for future intervention development and evaluation to promote community nutrition. These targets include strategies to improve the value of SNAP benefits, promote access to quality education, increase transportation options to healthy food retailers and develop nutrition programming to promote healthy eating identity.