Fruit and vegetable intake among participants in a District of Columbia farmers’ market incentive programme

Relationships among Local Agricultural Product Purchases, Self-Cooked Meal Consumption, and Healthy Eating Habits: A Cross-Sectional Study in a Town in Gunma, Japan

This study examined whether the frequency of purchasing local agricultural products and the intake frequency of self-cooked meals were related to healthy eating habits. A cross-sectional study was conducted using anonymized data from the “Survey on health promotion and food-and-nutritional education” conducted in 2021 in Tamamura, Gunma, Japan, targeting residents aged 20–65. Logistic regression analyses were conducted using the purchasing frequency of local agricultural products (often/sometimes/rarely) and the intake frequency of self-cooked meals (almost every day/not every day) as independent variables. The dependent variables were the frequencies of breakfast (every day/not every day), balanced meal (two times/day or more/fewer than two times/day), and vegetable intake (two times/day or more/fewer than two times/day). The purchasing frequency of local agricultural products was positively related to the frequency of balanced meal and vegetable intake. Additionally, the intake frequency of self-cooked meals was positively related to the frequencies of breakfast, balanced meal, and vegetable intake. In conclusion, significant positive relationships of the purchasing frequency of local agricultural products and the intake frequency of self-cooked meals with healthy eating habits were confirmed.

Farmers' Market Incentives for Low-Income Families: Who Uses, How Much, and Why

INTRODUCTION

Focusing on participation and utilization, this research helps to assess the potential impact and contributions of farmers' market incentive programs, often seen as means for improving nutrition and preventing disease among low-income families.

METHODS

Evaluating the largest farmers' market incentive program in the U.S. (California Market Match), this study used (1) 3 administrative databases (n=1,469, 6,799, and 30,506), (2) a participant survey (n=2,723), and (3) longitudinal interviews (n=163) with active and former participants. Quantitative data were analyzed with contingency tables and multiple regression. Qualitative data were coded into analytically significant themes. Data were collected in 2015-2018 and analyzed in 2018-2021.

RESULTS

Participation was typically low and varied across localities (3.7%-19.8% of eligible families in a sample of ZIP codes). According to administrative records, market visits by participants in 2 California regions averaged 2.18 and 3.12 per season. However, 77.1% of participants in the shopper survey indicated that they were repeat customers, and 51.0% indicated that they were regular utilizers. Deterrents to utilization included perceptions of inconvenience and high prices but not availability of produce in the community or travel time to markets. Utilization was most frequent among Asian shoppers and residents of Southern California outside Los Angeles County.

CONCLUSIONS

Farmers' market incentive programs such as Market Match appear likely to benefit population health through a core of committed shoppers. Improvement in participation and utilization may be attained through a better understanding of the communities that the markets are intended to serve.

Comparison of Fruit and Vegetable Prices between Farmers' Markets and Supermarkets: Implications for Fruit and Vegetable Incentive Programs for Food Assistance Program Participants

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers' markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers' markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers' market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers' markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Healthy Food Prescription Programs and their Impact on Dietary Behavior and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis

The enormous burden of diet-related chronic diseases has prompted interest in healthy food prescription programs. Yet, the impact of such programs remains unclear. The aim of this study was to conduct a systematic review of healthy food prescription programs and evaluate their impact on dietary behavior and cardiometabolic parameters by meta-analysis. A systematic search was carried out in Medline, Embase, Scopus, and Cochrane Central Register of Controlled Trials databases since their inception to 3 January, 2020 without language restriction. A systematic search of interventional studies investigating the effect of healthy food prescription on diet quality and/or cardiometabolic risk factors including BMI, systolic (SBP) and diastolic blood pressure (DBP), glycated hemoglobin (HbA1c), or blood lipids was carried out. Thirteen studies were identified for inclusion, most of which were quasi-experimental (pre/post) interventions without a control group (n = 9). Pooled estimates revealed a 22% (95% CI: 12, 32; n = 5 studies, n = 1039 participants; I2 = 97%) increase in fruit and vegetable consumption, corresponding to 0.8 higher daily servings (95% CI: 0.2, 1.4; I2 = 96%). BMI decreased by 0.6 kg/m2 (95% CI: 0.2, 1.1; I2 = 6.4%) and HbA1c by 0.8% (95% CI: 0.1, 1.6; I2 = 92%). No significant change was observed in other cardiometabolic parameters. These findings should be interpreted with caution in light of considerable heterogeneity, methodological limitations of the included studies, and moderate to very low certainty of evidence. Our results support the need for well-designed, large, randomized controlled trials in various settings to further establish the efficacy of healthy food prescription programs on diet quality and cardiometabolic health.

Reducing food insecurity and improving fruit and vegetable intake through a nutrition incentive program in Michigan, USA

Background

Nutrition incentive (NI) programs increase the purchase of fruits and vegetables (FVs) among low-income participants. Double Up Food Bucks (DUFB) is a robust statewide NI program in the United States. The purpose of this paper is to report findings from DUFB in Michigan describing the factors related to FV intake (FVI) and food insecurity among participants in a NI program.

Methods

We administered a repeated cross-sectional survey with a convenience sample of DUFB participants at farmers markets and grocery stores (over the 2016, 2017, 2018 seasons). The survey was conducted online via paper-pencil. Descriptive statistics were calculated for all variables. A logistic regression model estimated household food insecurity and a linear regression estimated FVI with DUFB use/perceptions, sociodemographics, and health status as independent variables (significance level = p < 0.05).

Results

Descriptive results revealed that participants that completed surveys at grocery stores tended to be more racially-ethnically diverse and younger than participants that completed surveys at farmers markets. Participants with lower length of time participating in DUFB (i.e., lower dose) (p < 0.001), greater FV purchases (p < 0.05), and lower perceived health status (p < 0.001) tended to report being food insecure more frequently. Participants with increased length of time participating in DUFB (p < 0.05), greater FV purchases (p < 0.001), being male (p < 0.01), and greater perceived health status (p < 0.001) tended to report higher levels of FVI more frequently.

Conclusions

Longer participation in DUFB leads to improved outcomes with FVI and food security, suggesting that NI programs do have the intended positive impact they were designed to achieve.

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Low income populations carry a larger burden of obesity, food insecurity, and chronic disease.

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Nutrition incentive programs were developed to address affordability barriers to healthy eating among SNAP participants.

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Participants at grocery stores tended to be more racially-ethnically diverse and younger than participants at farmers markets.

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Participants with longer time in the program reported greater FVI and higher levels of food security.

Higher Fruit and Vegetable Intake Is Associated with Participation in the Double Up Food Bucks (DUFB) Program

Incentivizing fruit and vegetable (F&V) purchases may help address barriers to healthy eating among populations with low income. In a repeated measures natural experiment study, we examined whether participation in the Double Up Food Bucks (DUFB) program increased F&V consumption among Supplemental Nutrition Assistance Program (SNAP) recipients. Two hundred and twelve participants recruited at baseline through telephone calls were informed about the availability of DUFB at their local farmers’ market (FM). F&V consumption frequency and DUFB use were obtained at baseline, mid FM, and end of FM season approximately 5 months later. Participants (N = 212) were primarily white (76.4%) women (77.3%) with an average age of 43.5 years. Only 34 participants opted to use the DUFB program. A linear mixed model showed a significant main effect of DUFB use (p = 0.001) and of time (p = 0.002), with a decrease in F&V intake over time. Compared to non-users, DUFB users had a significantly higher F&V consumption at baseline and midpoint (p = 0.02 and p = 0.02, respectively). F&V consumption was associated with participation in the DUFB program and higher F&V consumption frequency was observed prior to program use among program participants. Future interventions that specifically target SNAP recipients with low F&V intake to use the DUFB program are needed.

Markets in Municipal Code: The Case of Michigan Cities

Food’s place on the urban, municipal agenda has become an increasing focus in the emergent fields of food policy and food planning, whose leaders argue that food needs to be more explicitly added to the urban agenda. Yet, public food markets are a food system activity that municipal governments have been long engaged in. Reports from leading health, planning, and food organizations assert that farmers markets—the dominant form of public retail food markets in the US today—should be explicitly included in zoning and other municipal codes to ensure that they can be created and sustained. Despite their popularity as a local sustainable food system and healthy food access strategy, it is unclear whether markets have been codified through municipalities’ planning and policy instruments, and research has largely not addressed this topic. This study aims to elicit whether markets have been codified into law, focusing on US municipal charters, codes and zoning ordinances, using Michigan, an upper Midwest state, as a case. After analyzing municipal documents to determine whether and where markets have been codified into law in ninety Michigan cities, this study concludes that markets are highly underrepresented in municipal policy, rarely defined in code, and mostly absent from zoning ordinances, even among those cities with currently operating markets. Market presence in code is, however, associated with the presence of historically operated markets. These findings raise questions about why markets are missing from codified food policy and what risks this poses to the future of markets. They also highlight the need to better document the market sector and underline the importance of including historic perspectives when examining the efficacy of current food policy efforts.

Double Up Food Bucks: A Qualitative Evaluation of Usage, Impact, Barriers, and Facilitators

OBJECTIVE

Evaluate implementation of a farmers market-based fruit and vegetable incentive program.

DESIGN

Four focus groups and 6 interviews with program participants from April through November 2017.

SETTING

Double Up Food Bucks (DUFB) program in Western New York.

PARTICIPANTS

Western New York DUFB program participants.

PHENOMENON OF INTEREST

Customer DUFB usage, how DUFB affects purchasing, and program barriers or facilitators.

ANALYSIS

Two independent researchers coded focus group and interview transcripts. Researchers summarized codes as themes and selected illustrative quotes.

RESULTS

Participants (n = 36) were mostly female (75%); 69.4% reported a household income less than $20,000. They reported taking home and consuming more fruits and vegetables because of DUFB, almost always earning the maximum amount of DUFB and saving DUFB for later use. Barriers to using DUFB included limited hours and locations, running out of tokens, poor access to farmers market, and limited stocking. Participants recommended improved program communication, more venues, and convenient schedules to facilitate program use.

CONCLUSIONS AND IMPLICATIONS

Findings indicated that incentive programs increased fruit and vegetable consumption and purchasing among those who use them, however barriers to using incentives still existed. To improve the participant experience, program administrators should implement technology-based systems, provide robust communication, and offer incentives at varied locations and times.

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.

Participant Perceptions of the Double Up Food Bucks Program at Oregon Farmers' Markets

OBJECTIVE

To explore perceptions of program impact among Double Up Food Bucks participants in Oregon.

METHODS

Data were collected from 1,223 Double Up Food Bucks participants at 42 Oregon farmers' markets. Chi-square tests of independence and logistic regressions were used to examine associations among key variables.

RESULTS

Most participants reported buying more fruits and vegetables (FVs) (91.0%), trying new FV types (82.2%), eating less processed food (69.8%), having more food available at home (81.1%), and perceiving improvements in health (87.9%). Perceptions of affordability were higher among younger adults (P < 0.001) and households with 3-5 people (P = 0.02), with children (P < 0.001), and without chronic disease (P = 0.003). Perceptions of increased FV purchases were higher in households with children (P = 0.009) and reported overall health improvements were higher among non-White participants (P = 0.04). Perceptions of increased FV purchases and affordability were associated with other positive program outcomes.

CONCLUSIONS AND IMPLICATIONS

Participants may perceive barriers to purchasing FVs from farmers' markets, which are not fully addressed by the increased purchasing power from a FV incentive. Targeted redesign, outreach, and education may improve program experiences among groups with less positive perceptions. Further research to identify explanations for variation in program experience is needed.

Incentivizing Supplemental Nutrition Assistance Program Purchases with Fresh Produce in Corner Stores to Reduce Food Inequity in Underserved Areas of Washington DC

Purpose: Maintaining a healthy eating pattern plays a key role in ensuring optimal health outcomes, yet, in areas considered “food deserts” and lower-income neighborhoods where the accessibility of healthy foods and beverages is limited, the pursuit of adequate nutrient intake is rendered cumbersome. This pilot program aims to improve access to healthful foods by supporting corner stores in stocking and promoting the purchase of produce.

Methods: DC Central Kitchen's Healthy Corners program in Washington, DC piloted a nutrition incentive model in 17 corner stores that were upgraded to stock an increased variety and quantity of fresh produce. This program, entitled “5-for-5,” provided a $5 coupon toward the purchase of fresh produce to Supplemental Nutrition Assistance Program (SNAP) shoppers making a qualifying purchase of $5 or more with SNAP benefits.

Results: Evaluation based on store owner buy-in and customer intercept surveys indicated overall satisfaction in program offerings with 77% of SNAP shoppers polled indicating an increase in produce consumption as a direct result of the program. Coupon distribution data indicated that in the 5-for-5 program's first year, 76.5% of all 57,989 distributed coupons were redeemed, amounting to $221,770 worth of incentivized fresh produce sales.

Conclusion: The results of the incentive program were promising with increases in the amount of produce purchased as a result of the program. Lessons learned concerning the use of a financial incentive to encourage the purchase of produce at corner stores is explored, as well as the feasibility of the corner store as a sustainable venue to increase produce consumption in underserved communities.

Fruit and Vegetable Incentive Programs for Supplemental Nutrition Assistance Program (SNAP) Participants: A Scoping Review of Program Structure

The low intake of fruits/vegetables (FV) by Supplemental Nutrition Assistance Program (SNAP) participants is a persistent public health challenge. Fruit and vegetable incentive programs use inducements to encourage FV purchases. The purpose of this scoping review is to identify structural factors in FV incentive programs that may impact program effectiveness, including (i.) differences in recruitment/eligibility, (ii.) incentive delivery and timing, (iii.) incentive value, (iv.) eligible foods, and (v.) retail venue. Additionally, the FV incentive program impact on FV purchase and/or consumption is summarized. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, a search of four bibliographic databases resulted in the identification of 45 publications for consideration; 19 of which met the pre-determined inclusion criteria for full-length publications employing a quasi-experimental design and focused on verified, current SNAP participants. The data capturing study objective, study design, sample size, incentive program structure characteristics (participant eligibility and recruitment, delivery and timing of incentive, foods eligible for incentive redemption, type of retail venue), and study outcomes related to FV purchases/consumption were entered in a standardized chart. Eleven of the 19 studies had enrollment processes to receive the incentive, and most studies (17/19) provided the incentive in the form of a token, coupon, or voucher. The value of the incentives varied, but was usually offered as a match. Incentives were typically redeemable only for FV, although three studies required an FV purchase to trigger the delivery of an incentive for any SNAP-eligible food. Finally, most studies (16/19) were conducted at farmers’ markets. Eighteen of the 19 studies reported a positive impact on participant purchase and/or consumption of FV. Overall, this scoping review provides insights intended to inform the design, implementation, and evaluation of future FV incentive programs targeting SNAP participants; and demonstrates the potential effectiveness of FV incentive programs for increasing FV purchase and consumption among vulnerable populations.

Manager Perspectives on Implementation of a Farmers' Market Incentive Program in Maryland

OBJECTIVE

A growing number of farmers' markets offer incentive programs to increase access to fresh produce in low-income communities and support local farmers, yet program implementation has not been widely studied. This qualitative study explored market manager perspectives on implementing a Maryland statewide farmers' market incentive program.

DESIGN

Semistructured interviews with market managers.

SETTING

Participating farmers' markets across Maryland.

PARTICIPANTS

Managers of participating farmers' markets (n = 19).

PHENOMENON OF INTEREST

Barriers and facilitators to program implementation and recommendations for improvement.

ANALYSIS

Interviews were analyzed using a phronetic iterative approach and themes were organized using an adapted version of a multilevel implementation framework.

RESULTS

Managers reported overall favorable attitudes toward the incentive program. They identified barriers to implementation such as vendor buy-in and funding uncertainties, facilitators such as private fund-raising and local champions, and opportunities for improvement such as strengthening promotion and increasing the use of technology to reduce the data collection burden.

CONCLUSIONS AND IMPLICATIONS

Managers identified implementation barriers (eg, customer confusion) and facilitators (eg, ease of staff training) that may be shared by other incentive programs. Based on these findings, barriers and recommendations may be addressed through collaborative problem-solving with managers, vendors, and customers, and facilitators can be amplified broadly. Future research is warranted to explore incentive program implementation in other settings.

Double Up Food Bucks Participation is Associated with Increased Fruit and Vegetable Consumption and Food Security Among Low-Income Adults

OBJECTIVE

To evaluate the effect of the Utah Double Up Food Bucks (DUFB) program on fruit and vegetable (F&V) intake and food security status among Supplemental Nutrition Assistance Program (SNAP) recipients.

METHODS

Data were collected in 2015, using a before-and-after study design. At the farmers' market, a convenience sample of SNAP recipients was recruited for a survey and a 4-week telephone follow-up survey. Differences between the 2 surveys in food security and F&V intake were tested using the Wilcoxon signed-rank test.

RESULTS

Follow-up surveys were completed with 138 (40%) of the 339 baseline participants. Median F&V consumption increased from 2.82 times per day to 3.29 times per day (median, interquartile range 1.48-3.99 and 3.28-5.02, respectively, P = .002). The percentage of DUFB participants who were food secure increased by 15% (P = .001).

CONCLUSIONS AND IMPLICATIONS

The present results add to the growing literature indicating farmers' market incentives are associated with increased F&V consumption and decreased food insecurity. Although more research is needed, farmers' market incentives may be an effective area of policy intervention.

Association between Spatial Access to Food Outlets, Frequency of Grocery Shopping, and Objectively-Assessed and Self-Reported Fruit and Vegetable Consumption

Because supermarkets are a critical part of the community food environment, the purpose of this paper is to examine the association between accessibility to the supermarket where participants were surveyed, frequency of shopping at the supermarket, and self-reported and objectively-assessed fruit and vegetable consumption. Accessibility was assessed using Geographic Information Systems (GIS) measured distance and multiple versions of the modified Retail Food Environment Index (mRFEI), including a localized road network buffer version. Frequency of shopping was assessed using self-report. The National Cancer Institute Fruit and Vegetable screener was used to calculate daily servings of fruits and vegetables. Skin carotenoids were assessed using the "Veggie Meter™" which utilizes reflection spectroscopy to non-invasively assess skin carotenoids as an objective measure of fruit and vegetable consumption. Bivariate and multivariable statistics were used to examine the associations in RStudio. There was a positive association between skin carotenoids and the Special Supplemental Nutrition Program for Women Infants and Children (WIC) and mRFEI scores, suggesting that WIC participation and a healthier food environment were associated with objectively-assessed fruit and vegetable consumption (skin carotenoids). Future research should examine these associations using longitudinal study designs and larger sample sizes.