Nationwide expansion of a financial incentive program on fruit and vegetable purchases among Supplemental Nutrition Assistance Program participants: A cost-effectiveness analysis

Household Food Insecurity and Maternal-Toddler Fruit and Vegetable Dietary Concordance

OBJECTIVE

To examine whether prenatal or concurrent household food insecurity influences associations between maternal and toddler fruit and vegetable (FV) intake.

DESIGN

Application of a life-course framework to an analysis of a longitudinal dataset.

SETTING

Early childhood obesity prevention program at a New York City public hospital.

PARTICIPANTS

One-hundred and fifty-six maternal-toddler dyads self-identifying as Hispanic or Latino.

VARIABLES MEASURED

Maternal and toddler FV intake was measured using Centers for Disease Control and Prevention dietary measures when toddlers were aged 19 months. Household food insecurity (measured prenatally and concurrently at 19 months) was measured using the US Department of Agriculture Food Security Module.

ANALYSIS

Regression analyses assessed associations between adequate maternal FV intake and toddler FV intake. Interaction terms tested whether prenatal or concurrent household food insecurity moderated this association.

RESULTS

Adequate maternal FV intake was associated with increased toddler FV intake (B = 6.2 times/wk, 95% confidence interval, 2.0-10.5, P = 0.004). Prenatal household food insecurity was associated with decreased toddler FV intake (B = -6.3 times/wk, 95% confidence interval, -11.67 to -0.9, P = 0.02). There was a significant interaction between the level of maternal-toddler FV association (concordance or similarity in FV intake between mothers and toddlers) and the presence of food insecurity such that maternal-toddler FV association was greater when prenatal household food insecurity was not present (B = -11.6, P = 0.04).

CONCLUSIONS AND IMPLICATIONS

Strategies to increase FV intake across the life course could examine how the timing of household food insecurity may affect intergenerational maternal-child transmission of dietary practices.

Which Program Implementation Factors Lead to more Fruit and Vegetable Purchases? An Exploratory Analysis of Nutrition Incentive Programs across the United States

Background

Nutrition incentive (NI) programs help low-income households better afford fruits and vegetables (FVs) by providing incentives to spend on FVs (e.g., spend $10 to receive an additional $10 for FVs). NI programs are heterogeneous in programmatic implementation and operate in food retail outlets, including brick-and-mortar and farm-direct sites.

Objective

This study aimed to explore NI program implementation factors and the amount of incentives redeemed.

Methods

A total of 28 NI projects across the United States including 487 brick-and-mortar and 1078 farm-direct sites reported data between 2020 and 2021. Descriptive statistics and linear regression analyses (outcome: incentives redeemed) were applied.

Results

Traditional brick-and-mortar stores had 0.48 times the incentives redeemed compared with small brick-and-mortar stores. At brick-and-mortar sites, automatic discounts had 3.47 times the incentives redeemed compared with physical discounts; and auxiliary services and marketing led to greater redemption. Farm-direct sites using multilingual and direct promotional marketing had greater incentives redeemed.

Conclusions

To our knowledge, this is the first national study to focus on NI program implementation across sites nationwide. Factors identified can help inform future programming and research.

The health and economic benefits of sugar taxation and vegetables and fruit subsidy scenarios in Canada

A tax on sugar-sweetened beverages (SSB) has been implemented in various jurisdictions. Though research confirmed this tax to reduce sugar consumption and to prevent chronic diseases, it also revealed concerns: one concern relates to the small proportion of sugar in the diet coming from SSBs; and another concern relates to the disproportional tax burden to low-income groups. To inform public health decision makers on alternatives, we examined three 'real world' taxation and subsidy scenarios in Canada: 1) a CAD$0.75/100 g tax on SSBs; 2) a CAD$0.75/100 g tax on free sugar in all foods; and 3) a 20% subsidy on vegetables and fruit (V&F). Using national survey data and a proportional multi-state life table-based Markov model, we simulated the changes in disability-adjusted life years, healthcare costs, tax revenue, intervention costs, and incremental cost-effectiveness ratio for five income quintiles after implementing the three scenarios, over a lifetime of the 2015 Canadian adult population. The first, second and third scenario would prevent 28,921, 262,348 and 551 cases of type 2 diabetes, respectively. They would avert 752,353, 12,167,113, and 29,447 disability-adjusted life years and save CAD$12,942 million, 149,927 million, and 442 million in health care costs, respectively, over a lifetime. Combining the second and third scenarios would lead to the largest health and economic benefits. Although the lowest income quintile would bear a higher sugar tax burden (0.81% of income, CAD$120/person/year), this would be compensated by a coinciding subsidy on V&F (1.30% of income, CAD$194/person/year). These findings support policies that include a tax on all free sugar in foods and a subsidy on V&F as an effective means to reduce chronic diseases and health care costs. Although the sugar tax was financially regressive, the V&F subsidy could compensate for the tax burden of the disadvantaged groups and improve health and economic equity.

Exploring the impacts of a fresh produce market program: a realist economic evaluation

OBJECTIVE

To determine the contexts under which a fresh food market program is cost-effective in improving dignified access to nutritious food for food-insecure individuals.

METHODS

A realist economic evaluation was employed. Purported cost related theories about how the program may function, known as context-mechanism-outcome configurations were developed. In-depth interviews with key stakeholders (program developers, funder, local food relief agencies, volunteers) involved in the program (n=19) as well Photovoice with focus groups with market attendees (n=8) were conducted and coded for contexts, mechanisms and outcomes. A cost-effectiveness analysis of the program was calculated whereby the cost inputs associated with operating the program were compared to the quantity and value of produce distributed. Alternative cost scenarios were evaluated in a sensitivity analysis. The cost-effectiveness analysis was used together with qualitative data to refine theory.

RESULTS

Food insecure individuals attending a partnership fresh food market with a small fee, experienced improved, yet infrequent access to nutritious food through community connections and support a more dignified, viable access to fresh nutritious food.

CONCLUSIONS

Food relief should consider alternative models.

IMPLICATIONS FOR PUBLIC HEALTH

More dignified food relief programs that support local connections may be part of the solution to addressing food insecurity.

A systematic review of the impact of food security governance measures as simulated in modelling studies

To effectively address food security, we need tools that assess governance measures (for example, strategic storage reserves, cash transfers or trade regulations) ex ante. Simulation models can estimate the impact of such measures via scenarios with differently governed food systems. On the basis of a systematic review of 110 simulation studies published over 2000-2021, we examined how food security governance has been represented, and identified needs for future simulation model development. We found that studies commonly used agent-based, system dynamics, and computable general equilibrium models; tended to be production, trade or consumption centric; assessed the impact of a wide variety of mostly treasure- or authority-based measures; and applied diverse food security indicators, mostly of access or availability. We also identified blind spots (for example, simulation of nodal measures) and proposed how to address these blind spots (for example, telecoupling) and to make food security governance simulation studies fit for meta-analyses (for example, harmonizing food security indicators for comparison).

How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change

Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition-related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that promote equitable access to FVs. The United States Department of Agriculture’s Gus Schumacher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nutrition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community economic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program.

Religion and Food Insecurity in the Time of COVID-19: Food Sovereignty for a Healthier Future

The COVID-19 pandemic has exposed and amplified food insecurity in marginalized communities of color, revealing systemic health and socioeconomic inequalities. Given the role that religious organizations play in building social capital, disseminating information to local communities, and facilitating the distribution of basic necessities such as food, they are integrally involved in short- and long-term solutions to food insecurity. Yet, literature on the role of religious institutions for mitigating food insecurity is limited. The literature related to methods and means by which religious organizations engage community efforts to mitigate food security as well as studies in food sovereignty will be reviewed.

Simulation Modeling for the Economic Evaluation of Population-Based Dietary Policies: A Systematic Scoping Review

Simulation modeling can be useful to estimate the long-term health and economic impacts of population-based dietary policies. We conducted a systematic scoping review following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guideline to map and critically appraise economic evaluations of population-based dietary policies using simulation models. We searched Medline, Embase, and EconLit for studies published in English after 2005. Modeling studies were mapped based on model type, dietary policy, and nutritional target, and modeled risk factor-outcome pathways were analyzed. We included 56 studies comprising 136 model applications evaluating dietary policies in 21 countries. The policies most often assessed were reformulation (34/136), taxation (27/136), and labeling (20/136); the most common targets were salt/sodium (60/136), sugar-sweetened beverages (31/136), and fruit and vegetables (15/136). Model types included Markov-type (35/56), microsimulation (11/56), and comparative risk assessment (7/56) models. Overall, the key diet-related risk factors and health outcomes were modeled, but only 1 study included overall diet quality as a risk factor. Information about validation was only reported in 19 of 56 studies and few studies (14/56) analyzed the equity impacts of policies. Commonly included cost components were health sector (52/56) and public sector implementation costs (35/56), as opposed to private sector (18/56), lost productivity (11/56), and informal care costs (3/56). Most dietary policies (103/136) were evaluated as cost-saving independent of the applied costing perspective. An analysis of the main limitations reported by authors revealed that model validity, uncertainty of dietary effect estimates, and long-term intervention assumptions necessitate a careful interpretation of results. In conclusion, simulation modeling is widely applied in the economic evaluation of population-based dietary policies but rarely takes dietary complexity and the equity dimensions of policies into account. To increase relevance for policymakers and support diet-related disease prevention, economic effects beyond the health sector should be considered, and transparent conduct and reporting of model validation should be improved.

Retail Nutrition Programs and Outcomes: An Evidence Analysis Center Scoping Review

As nutrition-related diseases contribute to rising health care costs, food retail settings are providing a unique opportunity for registered dietitian nutritionists (RDNs) to address the nutritional needs of consumers. Food as Medicine interventions play a role in preventing and/or managing many chronic conditions that drive health care costs. The objective of this scoping review was to identify and characterize literature examining Food as Medicine interventions within food retail settings and across consumer demographics. An electronic literature search of 8 databases identified 11,404 relevant articles. Results from the searches were screened against inclusion criteria, and intervention effectiveness was assessed for the following outcomes: improvement in health outcomes and cost-effectiveness. One-hundred and eighty-six papers and 25 systematic reviews met inclusion criteria. Five categories surfaced as single interventions: prescription programs, incentive programs, medically tailored nutrition, path-to-purchase marketing, and personalized nutrition education. Multiple combinations of intervention categories, reporting of health outcomes (nutritional quality of shopping purchases, eating habits, biometric measures), and cost-effectiveness (store sales, health care dollar savings) also emerged. The intervention categories that produced both improved health outcomes and cost-effectiveness included a combination of incentive programs, personalized nutrition education, and path-to-purchase marketing. Food as Medicine interventions in the food retail setting can aid consumers in navigating health through diet and nutrition by encompassing the following strategic focus areas: promotion of health and well-being, managing chronic disease, and improving food security. Food retailers should consider the target population and desired focus areas and should engage registered dietitian nutritionists when developing Food as Medicine interventions.

A Qualitative Evaluation of Double Up Food Bucks Farmers' Market Incentive Program Access

OBJECTIVE

Explore factors affecting access to and use of Double Up Food Bucks (DUFB), a farmers' market program that doubles Supplemental Nutrition Assistance Program benefits for use toward the purchase of fruits and vegetables (FV).

DESIGN

Focus groups.

SETTING

Metro and nonmetro counties in Utah and western Upstate New York.

PARTICIPANTS

Nine groups composed of 62 low-income adults (3-9/group).

PHENOMENA OF INTEREST

Satisfaction with, barriers to, and facilitators of program use; suggestions for improvement.

ANALYSIS

Transcribed verbatim and coded thematically in NVivo 11 software according to template analysis.

RESULTS

Program satisfaction was high and driven by FV affordability, perceived support of local farmers, positive market experiences, and high-quality FV. Primary barriers to using DUFB were lack of program information and inconvenient accessibility. Insufficient program communication was a consistent problem that elicited numerous suggestions regarding expansion of program marketing. Emergent topics included issues related to the token-based administration of DUFB and debate regarding stigma experienced during DUFB participation.

CONCLUSIONS AND IMPLICATIONS

Results suggest that although DUFB elicits many points of satisfaction among users, program reach may be limited owing to insufficient program marketing. Even among satisfied users, discussion of barriers was extensive, indicating that program reach and impact may be bolstered by efforts to improve program accessibility.

Grocery Stores Are Not Associated with More Healthful Food for Participants in the Supplemental Nutrition Assistance Program

BACKGROUND

Despite interventions to improve the nutrition of grocery store purchases, also referred to as at-home (AH) foods, by participants in the Supplemental Nutrition Program (SNAP), little is known about what proportion of participants' intake is from AH foods and how the dietary quality of AH food compares with participants' away-from-home (AFH) food. Although recent research indicates SNAP participants have dietary quality that is slightly worse than that of income-eligible nonparticipants, it is unknown whether this is attributable to AH or AFH consumption.

OBJECTIVE

The objective of this study is to examine differences in self-reported dietary intake by food source for SNAP participants compared with income-eligible nonparticipants using 2011-2014 data from the National Health and Nutrition Examination Survey (NHANES).

DESIGN

This study included data from the NHANES, a cross-sectional, nationally representative survey of the United States population.

STUDY PARTICIPANTS

This study included 2,523 adults with low incomes (≤130% of the federal poverty level) in NHANES (2011-2014).

MAIN OUTCOME MEASURES

Self-reported intake of calories, solid fats, added sugars, and servings of nonstarchy vegetables, whole fruits, and whole grains was assessed by food source in SNAP participants and income-eligible nonparticipants.

STATISTICAL ANALYSIS

Multivariate linear regression was used for each outcome, controlling for relevant sociodemographic characteristics. Data were stratified by food source, including grocery stores, sit-down restaurants, and fast food.

RESULTS

SNAP participants had a higher intake of solid fats and added sugar from AH foods than nonparticipants. Added sugar from AH food accounted for 15.3% of total calories consumed by SNAP participants, compared with 11.8% for nonparticipants (P<0.001). SNAP participants consumed fewer calories from sit-down restaurants, but both groups consumed similar amounts of calories from fast food. Consumption of nonstarchy vegetables, whole fruits, and whole grains was low for both groups.

CONCLUSIONS

SNAP participants had poorer diet quality from consumption of AH food than did nonparticipants. Future research should focus on interventions to improve the healthfulness of grocery store purchases as a mechanism to improve dietary quality of SNAP participants.

Interventions targeting diet quality of Supplemental Nutrition Assistance Program (SNAP) participants: A scoping review

The national Supplemental Nutrition Assistance program (SNAP) has been successful in reducing food insecurity among low-income Americans. However, the program has also been criticized as unhealthy food choices, and rates of diet-related chronic diseases remain high among SNAP beneficiaries. Recently, several multi-component interventions have targeted SNAP beneficiaries, aiming to improve how benefits are utilized to support a healthful diet. The aim of this scoping review is to examine the breadth of published interventions that have targeted SNAP beneficiaries, and their reported impact on diet and nutrition related outcomes. Using key search terms, a literature search of government and peer review databases was conducted. Twelve unique interventions were identified and categorized based on the type of intervention delivered: 1) monetary incentives 2) nutrition education, and 3) combined nutrition education plus monetary incentives. Across all interventions, monetary interventions showed modest improvements in reported fruit and vegetable intake among SNAP beneficiaries. While nutrition education interventions showed improvement in psychosocial correlates of diet, changes in dietary intake were inconsistent. Combination programs demonstrated the strongest improvements in dietary change among beneficiaries. Variability in types of outcomes measured limits comparability of findings across studies, and our findings calls for further evaluation in this area. This scoping review suggests using financial incentives combined with nutrition education may be effective in improving dietary intake among SNAP beneficiaries. Future research should integrate more robust study designs and consider multiple levels of intervention to effectively change beneficiary habits and in turn, reduce diet related disease in this population.

Pricing Strategies to Encourage Availability, Purchase, and Consumption of Healthy Foods and Beverages: A Systematic Review

Introduction

Food pricing policies to promote healthy diets, such as taxes, price manipulations, and food subsidies, have been tested in different settings. However, little consensus exists about the effect of these policies on the availability of healthy and unhealthy foods, on what foods consumers buy, or on the impact of food purchases on consumer health outcomes. We conducted a systematic review of studies of the effect of food-pricing interventions on retail sales and on consumer purchasing and consumption of healthy foods and beverages.

Methods

We used MEDLINE, Embase, PsycINFO, Web of Science, ClinicalTrials.gov, and the Cochrane Library to conduct a systematic search for peer-reviewed articles related to studies of food pricing policies. We selected articles that were published in English from January 2000 through December 2016 on the following types of studies: 1) real-world experimental studies (randomized controlled trials, quasi-experimental studies, and natural experiments); 2) population studies of people or retail stores in middle-income and high-income countries; 3) pricing interventions alone or in combination with other strategies (price promotions, coupons, taxes, or cash-back rebates), excluding studies of vending-machine or online sales; and 4) outcomes studies at the retail (stocking, sales) and consumer (purchasing, consumption) levels. We selected 65 articles representing 30 studies for review.

Results

Sixteen pricing intervention studies that sought to improve access to healthy food and beverage options reported increased stocking and sales of promoted food items. Most studies (n = 23) reported improvement in the purchasing and consumption of healthy foods or beverages or decreased purchasing and consumption of unhealthy foods or beverages. Most studies assessed promotions of fresh fruits and vegetables (n = 20); however, these foods may be hard to source, have high perishability, and raise concerns about safety and handling. Few of the pricing studies we reviewed discouraged purchasing and consumption of unhealthy foods (n = 6). Many studies we reviewed had limitations, including lack of formative research, process evaluation, or psychosocial and health assessments of the intervention’s impact; short intervention duration; or no assessment of food substitutions or the effects of pricing interventions on food purchasing and diets.

Conclusion

Pricing interventions generally increased stocking, sales, purchasing, and consumption of promoted foods and beverages. Additional studies are needed to differentiate the potential impact of selected pricing strategies and policies over others.

Inclusion of equity in economic analyses of public health policies: systematic review and future directions

OBJECTIVES

To assess current approaches to inclusion of equity in economic analysis of public health interventions and to recommend best approaches and future directions.

METHODS

We conducted a systematic review of studies that have used socioeconomic position (SEP) in cost-effectiveness analyses. Studies were identified using MedLine, EconLit and HEED and were evaluated based on their SEP specific inputs and methods of quantification of the health and financial inequalities.

RESULTS

Twenty-nine relevant studies were identified. The majority of studies comparing two or more interventions left interpretation of the size of the health and financial inequality differences to the reader. Newer approaches include: i) use of health inequality measures to quantify health inequalities; ii) inclusion of financial impacts, such as out-of-pocket expenditures; and iii) use of equity weights. The challenge with these approaches is presenting results that policy makers can easily interpret.

CONCLUSIONS

Using CEA techniques to generate new information about the health equity implications of alternative policy options has not been widely used, but should be considered to inform future decision making. Implications for public health: Inclusion of equity in economic analysis would facilitate a more nuanced comparison of interventions in relation to efficiency, equity and financial impact.

Shopping pattern and food purchase differences among Supplemental Nutrition Assistance Program (SNAP) households and Non-supplemental Nutrition Assistance Program households in the United States

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SNAP households are influenced by proximity to stores in predicting store choice.

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Store choice among SNAP households predicted beverage purchases.

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SNAP households are more likely to purchase sugar-sweetened beverages at supercenters and convenience stores.

Cost Effectiveness of Subsidizing Fruit and Vegetable Purchases Through the Supplemental Nutrition Assistance Program

INTRODUCTION

A diet high in fruits and vegetables (FV) is associated with reduced risk of chronic disease. One strategy to incentivize FV consumption among low-income households is to make them more affordable through the Supplemental Nutrition Assistance Program (SNAP). This study aims to identify the cost effectiveness of subsidizing FV purchases among the one in seven Americans who participate in SNAP.

METHODS

A cost-effectiveness analysis was conducted from a societal perspective to estimate lifetime costs and health gains associated with subsidizing FV purchases. A stochastic microsimulation model of obesity, type 2 diabetes, myocardial infarction, and stroke in the 2015 U.S. population was used. Model parameters were based on nationally representative SNAP participation and dietary consumption data from the National Health and Nutrition Examination Survey (2003-2012), and data from a randomized trial of FV subsidies among SNAP users.

RESULTS

Despite cycling of participants in and out of SNAP, expanding an FV subsidy nationwide through SNAP would be expected to reduce incidence of type 2 diabetes by 1.7% (95% CI=1.2, 2.2), myocardial infarction by 1.4% (95% CI=0.9, 1.9), stroke by 1.2% (95% CI=0.8, 1.6), and obesity by 0.2% (95% CI=0.1, 0.3), and be cost saving from a societal perspective. The saved costs would be largely attributable to long-term reductions in type 2 diabetes and cardiovascular diseases.

CONCLUSIONS

The model suggests nationwide SNAP FV subsidies would reduce chronic disease morbidity, mortality, and costs over long time horizons that are unlikely to be observed in short-term community-based trials.

Rebates to Incentivize Healthy Nutrition Choices in the Supplemental Nutrition Assistance Program

Price incentives, or rebates, have been proposed as one promising strategy for improving diet quality among Supplemental Nutrition Assistance Program participants. This paper explores the existing evidence on effectiveness of rebates in this program. In particular, this paper considers findings from a recent RCT of Supplemental Nutrition Assistance Program rebates, the U.S. Department of Agriculture Healthy Incentives Pilot, in the context of the broader literature on rebate strategies. The paper concludes that rebates have a moderate impact on food intake, at moderate cost relative to alternative interventions. There is further evidence that implicit promotional effects may contribute to impacts of rebate interventions, beyond the impacts of price effects alone. However, existing studies on complementary effects of explicit promotion have been limited by relatively small sample sizes and correspondingly low power to detect differences. This appears to be a promising area for future research.

Food Costs Are Higher in Counties With Poor Health Rankings

BACKGROUND

Poor dietary habits are associated with higher rates of cardiovascular disease. However, the cost of foods associated with lower risk of cardiovascular disease can be a significant barrier to healthy eating.

OBJECTIVE

The aim of this study is to determine whether food prices per serving differed across Kentucky counties based on health ranking and overall nutritional quality.

METHODS

Fifteen counties were randomly selected based on County Health Ranking. Overall Nutritional Quality Index and cost of 75 foods were assessed in all 15 counties in the same week. A generalized estimating equations model and post hoc analyses were used to assess differences in food cost by nutritional quality and health ranking.

RESULTS

Food prices were significantly less in the most healthy counties compared with the least healthy (Z = 3.8; P < .001; $0.08 per serving). Prices were also significantly higher in least healthy counties (tertile 3) compared with moderately healthy counties (tertile 2) (Z = 2.3; P = .024; $0.05 per serving).

CONCLUSIONS

Disproportionately higher food costs are associated with poor health outcomes in Kentucky counties. Community-based interventions can potentially improve access to affordable healthy foods. Current supplemental nutritional policies do not address disparate food costs. Health professionals should advocate for policy changes that are reflective of these food cost disparities.