Supplemental nutrition assistance program participation and sugar-sweetened beverage consumption, overall and by source

Online retail nudges to help parents with lower-income choose healthy beverages for their children: A randomized clinical trial

BACKGROUND

Nudges offer a promising tool to reduce sugary drink intake among children who are most at risk for diet-related disease.

OBJECTIVE

To examine the impact of online store nudges on purchases of sugary drinks for children in lower-income households.

METHODS

Caregivers with lower-income were recruited to an online shopping experiment and instructed to spend $10-$30 on three beverages for their child aged 1-5 years. Participants were randomized to navigate an online supermarket in its standard version (n = 1106) or a version with nudges (n = 1135), including a product placement nudge (i.e. placing healthy beverages in prominent positions) and a swap nudge (i.e. offering a swap of water, plain milk and/or 100% fruit juice upon selection of sugary drinks).

RESULTS

On average, participants purchased 1887 (SD = 2113) and 620 (SD = 1528) calories from sugary drinks per basket in the control and experimental conditions, respectively. Model-based results indicate that those in the experimental condition purchased 1267 (95% CI: 1419, 1114) fewer calories from sugary drinks, and fewer grams of total sugar (β = -253.5 g (95% CI: -286.3, -220.6)) and added sugar (β = -287.8 g (95% CI: -323.1, -252.5)) purchased from sugary drinks.

CONCLUSION

Nudges may be an effective, acceptable, scalable strategy for leading caregivers in lower-income households to purchase fewer sugary drinks for their children.

Importance of Nutrition Security to CVD Prevention Efforts in the USA

PURPOSE OF REVIEW

The importance of addressing nutrition security for the primary and secondary prevention of cardiovascular disease (CVD) in the USA is reviewed by describing the relationships between food security, diet quality, and CVD risk along with the ability of governmental, community, and healthcare policies and interventions to address nutrition security.

RECENT FINDINGS

Existing safety net programs have shown to be effective at improving food security and diet quality and reducing risk for CVD, but continued efforts to increase reach and improve standards are needed. Adoption of policies, healthcare initiatives, and community- and individual-level interventions addressing the nutritional intake of socioeconomically disadvantaged populations may also lessen CVD burden, but scaling interventions remains a key challenge. Research suggests simultaneously addressing food security and diet quality is feasible and could help reduce socioeconomic disparities in CVD morbidity and mortality. Intervening at multiple levels among high-risk groups should be a priority.

Factors Influencing the Sugar-Sweetened Beverage Intake of Caregivers of Adolescents in Appalachia

OBJECTIVE

To identify factors that influence the sugar-sweetened beverage (SSB) intake of caregivers of middle school-aged adolescents.

DESIGN

Cross-sectional.

SETTING

Southwestern Virginia, US, part of Central Appalachia.

PARTICIPANTS

Caregivers (n = 362) of adolescents enrolled in the Kids SIPsmartER trial. Participants were mostly female (91%) and non-Hispanic White (96%), and 21% received Supplemental Nutrition Assistance Program (SNAP) benefits.

MAIN OUTCOME MEASURES

Caregiver daily SSB intake and demographics, personal-level, interpersonal-level, and environmental-level determinants.

ANALYSIS

Descriptive statistics, 1-way ANOVA, and stepwise regression.

RESULTS

On average, caregivers consumed 25.7 (SD, 33.2) fluid ounces of SSB per day. In the final model, which included all variables, age (β = -0.41; P < 0.05), receiving SNAP benefits (β = 14.19; P ≤ 0.01), behavioral intentions (β = -5.48; P ≤ 0.001), affective attitudes (β = -2.15, P < 0.05), perceptions of whether their adolescent frequently consumes high amounts of SSB (β = 1.92; P ≤ 0.001), and home availability (β = 7.43; P ≤ 0.01) were significantly associated with SSB intake.

CONCLUSIONS AND IMPLICATIONS

Caregivers of Appalachian middle school students are high SSB consumers. Findings highlight the importance of implementing behavioral interventions for caregivers of adolescents that target multiple levels of influence, including demographic, personal-level, interpersonal-level, and environmental-level factors. Interventions may be particularly important for communities and groups with higher SSB intakes, such as those in Appalachia and who receive SNAP benefits.

A rapid review of stocking and marketing practices used to sell sugar-sweetened beverages in U.S. food stores

Sugar-sweetened beverages (SSBs) are a primary source of added sugars in the American diet. Habitual SSB consumption is associated with obesity and noncommunicable disease and is one factor contributing to U.S. health disparities. Public health responses to address marketing-mix and choice-architecture (MMCA) strategies used to sell SSB products may be required. Thus, our goal was to identify original research about stocking and marketing practices used to sell SSB in U.S. food stores. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the World Health Organization (WHO) protocol for rapid reviewing. We searched six databases and Google Scholar using key terms focused on store type and SSB products. We characterized results using an MMCA framework with categories place, profile, portion, pricing, promotion, priming or prompting, and proximity. Our search resulted in the identification of 29 articles. Most results focused on profile (e.g., SSB availability) (n = 13), pricing (e.g., SSB prices or discounts) (n = 13), or promotion (e.g., SSB advertisements) (n = 13) strategies. We found some evidence of targeted MMCA practices toward at-risk consumers and differences by store format, such as increased SSB prominence among supermarkets. The potential for systematic variations in MMCA strategies used to sell SSB requires more research. We discuss implications for public health, health equity, and environmental sustainability.

Consumption of sugar-sweetened beverages and obesity in SNAP-eligible children and adolescents

BACKGROUND

Low-income individuals who are eligible for nutrition assistance have been shown to consume a larger portion of their daily calories from beverages with added sugar. We examined the association between Supplemental Nutrition Assistance Program (SNAP) participation and self-reported sugar sweetened beverage (SSB) consumption as well as the association between self-reported consumption of SSBs and overweight/obesity in low-income children.

DESIGN

Cross-sectional analysis of 1455 SNAP-eligible U.S. children, ages 2-17, who completed a questionnaire and physical examination during the 2009-2010 National Health and Nutrition Examination Survey (NHANES).

RESULTS

SNAP-eligible children who received SNAP in the last month were more likely to drink soda in the last month [76.0% (2.2)] than those who did not receive benefits [70.5% (2.8)]. These children were also more likely to drink fruit drinks [74.8% (1.6) vs. 69.3% (3.1)]. Among youth in households receiving SNAP benefits, soda consumption in the past month was associated with a greater risk of obesity, particularly Hispanic youth [OR=1.93 (1.07, 3.50), p=0.0314] aged 2-5 [OR=2.71 (1.29, 5.69), p=0.0114]. Additionally, among youth in households receiving SNAP benefits, male children who consumed sugar-sweetened fruit drinks in the past month were significantly more likely to be overweight [3.13 (1.12, 8.73), p=0.0315] as compared to male peers who did not consume any sugar sweetened fruit drinks.

CONCLUSION

Among youth, SNAP recipients drink more SSBs than their eligible non-recipient peers. Our results indicate that certain populations of children receiving SNAP benefits and consuming SSBs are more likely to be overweight or obese when compared to their peers who receive SNAP benefits but do not consume SSBs.

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.

Characteristics Associated with Household Purchases of Sugar-Sweetened Beverages in US Restaurants

OBJECTIVE

This study aimed to describe beverages purchased in restaurants among a nationally representative sample of US households.

METHODS

Data were obtained from the US Department of Agriculture National Household Food Acquisition and Purchase Survey, 2012 to 2013. Survey-weighted multiple regressions assessed correlates of purchasing a sugar-sweetened beverage (SSB), purchasing a low-calorie beverage, and per capita beverage calories and grams of sugar among purchases from US restaurants (n = 14,669).

RESULTS

Dining at a top fast-food chain (odds ratio = 1.9 [95% CI = 1.6, 2.3] vs. small chain or independent restaurants) and ordering a combination meal (2.8 [1.3, 3.3]) or from the kids' menu (2.1 [1.2, 3.4]) were positively associated with purchasing an SSB. Age (young adult and adolescent vs. older adult; 0.7 [0.5, 0.9] and 0.4 [0.3, 0.7], respectively), race (Black vs. White; 0.4 [0.3, 0.6]), ethnicity (Hispanic vs. non-Hispanic; 0.8 [0.6, 0.9]), and household food security (very low vs. high; 0.7 [0.5, 0.8]) were associated with purchasing a low-calorie beverage. Caloric beverage purchases contained the most calories and grams of sugar per capita when purchased by Hispanic and non-Hispanic Black adolescents.

CONCLUSIONS

US households purchase a considerable amount of SSBs from the nation's largest chain restaurants, particularly when combination meals or kids' menu items are ordered, and there are disparities by age, race/ethnicity, and household food security.

Dietary Intake Changes in Response to a Sugar-Sweetened Beverage Reduction Trial for Various Supplemental Nutrition Assistance Program (SNAP) Eligibility Groups

OBJECTIVE

To examine dietary intake differences resulting from a sugar-sweetened beverage reduction intervention by 3 Supplemental Nutrition Assistance Program (SNAP) participation groups: SNAP participants (n = 56), income-eligible nonparticipants (n = 30), and income-ineligible nonparticipants (n = 60).

METHODS

Adults in southwest Virginia were enrolled in a 6-month behavioral trial. The researchers collected SNAP enrollment status and 3 24-hour dietary recalls at baseline and 6 months. Repeated-measures ANOVAs were used to assess differences in dietary intake among SNAP participation groups.

RESULTS

No significant group × time differences were found for energy density, Healthy Eating Index scores, Healthy Beverage Index scores, or intake of total calories, added sugars, and sugar-sweetened beverages. However, several within-group improvements were noted: income-ineligible nonparticipants and SNAP participants improved in more areas compared with income-eligible nonparticipants, including intake of total calories, added sugars, and sugar-sweetened beverages.

CONCLUSIONS AND IMPLICATIONS

This exploratory analysis suggests that the overall effectiveness of a sugar-sweetened beverage intake reduction intervention was not influenced by SNAP eligibility and participation status, because there were no significant group by time differences over the intervention. It is important to recognize for future programs that different approaches to improving dietary intake may be needed to match the characteristics of this audience better. This may be accomplished by attempting to decrease the disparity gap between income-eligible nonparticipants and those receiving SNAP or who are income ineligible through the use of programs such as SIPsmartER.

Methods for Evaluating Natural Experiments in Obesity: A Systematic Review

BACKGROUND

Given the obesity pandemic, rigorous methodological approaches, including natural experiments, are needed.

PURPOSE

To identify studies that report effects of programs, policies, or built environment changes on obesity prevention and control and to describe their methods.

DATA SOURCES

PubMed, CINAHL, PsycINFO, and EconLit (January 2000 to August 2017).

STUDY SELECTION

Natural experiments and experimental studies evaluating a program, policy, or built environment change in U.S. or non-U.S. populations by using measures of obesity or obesity-related health behaviors.

DATA EXTRACTION

2 reviewers serially extracted data on study design, population characteristics, data sources and linkages, measures, and analytic methods and independently evaluated risk of bias.

DATA SYNTHESIS

294 studies (188 U.S., 106 non-U.S.) were identified, including 156 natural experiments (53%), 118 experimental studies (40%), and 20 (7%) with unclear study design. Studies used 106 (71 U.S., 35 non-U.S.) data systems; 37% of the U.S. data systems were linked to another data source. For outcomes, 112 studies reported childhood weight and 32 adult weight; 152 had physical activity and 148 had dietary measures. For analysis, natural experiments most commonly used cross-sectional comparisons of exposed and unexposed groups (n = 55 [35%]). Most natural experiments had a high risk of bias, and 63% had weak handling of withdrawals and dropouts.

LIMITATION

Outcomes restricted to obesity measures and health behaviors; inconsistent or unclear descriptions of natural experiment designs; and imperfect methods for assessing risk of bias in natural experiments.

CONCLUSION

Many methodologically diverse natural experiments and experimental studies were identified that reported effects of U.S. and non-U.S. programs, policies, or built environment changes on obesity prevention and control. The findings reinforce the need for methodological and analytic advances that would strengthen evaluations of obesity prevention and control initiatives.

PRIMARY FUNDING SOURCE

National Institutes of Health, Office of Disease Prevention, and Agency for Healthcare Research and Quality. (PROSPERO: CRD42017055750).

Trends and Disparities in Diet Quality Among US Adults by Supplemental Nutrition Assistance Program Participation Status

IMPORTANCE

Unhealthful diet is a top contributor to chronic diseases in the United States. There are growing concerns about disparities in diet among US adults, especially for those who participate in the Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program. It remains unclear how these disparities may have changed over time.

OBJECTIVE

To assess whether disparities in key food groups and nutrients according to participation and eligibility for SNAP have persisted, improved, or worsened over time among US adults.

DESIGN SETTING AND PARTICIPANTS

This survey study examined a nationally representative sample of 38 696 adults aged 20 years or older: 6162 SNAP participants, 6692 income-eligible nonparticipants, and 25 842 higher-income individuals from 8 cycles of the National Health and Nutrition Examination Survey (1999-2014). Data analysis was conducted between January 1, 2017, and December 31, 2017.

EXPOSURES

Survey-weighted, energy-adjusted diet by SNAP participation status.

MAIN OUTCOMES AND MEASURES

Mean diet scores and proportions of US adults meeting poor, intermediate, or ideal diet scores based on the American Heart Association (AHA) 2020 Strategic Impact Goals for diet, including 8 components (fruits and vegetables; whole grains; fish and shellfish; sugar-sweetened beverages; sodium; nuts, seeds, and legumes; processed meats; and saturated fat).

RESULTS

The survey included 38 696 respondents (20 062 female [51.9%]; 18 386 non-Hispanic white [69.8%]; mean [SD] age, 46.8 [14.8] years). Participants of SNAP were younger (mean [SD] age, 41.4 [15.6] years) than income-eligible nonparticipants (mean [SD] age, 44.9 [19.6] years) or higher-income individuals (mean [SD] age, 47.8 [13.6] years); more likely to be female (3552 of 6162 [58.6%] vs 3504 of 6692 [54.8%] and 13 006 of 25 842 [50.4%], respectively); and less likely to be non-Hispanic white (2062 of 6162 [48.2%] vs 2594 of 6692 [56.0%] and 13 712 of 25 842 [75.8%], respectively). From surveys conducted in 2003 and 2004 to those conducted in 2013 and 2014, SNAP participants had less improvement in AHA diet scores than both income-eligible nonparticipants and higher-income individuals (change in mean score = 0.57 [95% CI, -2.18 to 0.33] vs 2.56 [95% CI, 0.36-4.76] and 3.84 [95% CI, 2.39-5.29], respectively; P = .04 for interaction). Disparities persisted for most foods and nutrients and worsened for processed meats, added sugars, and nuts and seeds. In 2013 to 2014, a higher proportion of SNAP participants had poor diet scores compared with income-eligible nonparticipants and higher-income individuals (461 of 950 [53.5%] vs 247 of 690 [38.0%] and 773 of 2797 [28.7%]; P < .001 for difference), and a lower proportion had intermediate diet scores (477 of 950 [45.3%] vs 428 of 690 [59.8%] and 1933 of 2797 [68.7%]; P < .001 for difference). The proportion of participants with ideal diet scores was low in all 3 groups (12 of 950 [1.3%] vs 15 of 690 [2.2%] and 91 of 2797 [2.6%]; P = .26 for difference).

CONCLUSIONS AND RELEVANCE

Dietary disparities persisted or worsened for most dietary components among US adults. Despite improvement in some dietary components, SNAP participants still do not meet the AHA goals for a healthful diet.

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.