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Voices for Food was a longitudinal community, food pantry-based intervention informed by the social ecological model, and designed to improve food security, dietary intake, and quality among clients, which was carried out in 24 rural food pantries across 6 Midwestern states.Our objective was to evaluate changes in adult food security, dietary intake, and quality from baseline (2014) to follow-up (2016), and to assess the role of adult food security on dietary outcomes.A multistate, longitudinal, quasi-experimental intervention with matched treatment and comparison design was used to evaluate treatment vs comparison group changes over time and changes in both groups over time.Adult food pantry clients (n = 617) completed a demographic food security survey, and up to three 24-hour dietary recalls at baseline (n = 590) and follow-up (n = 160).Community coaching served as the experimental component, which only "treatment" communities received, and a food council guide and food pantry toolkit were provided to both "treatment" and matched "comparison" communities.Change in adult food security status, mean usual intakes of nutrients and food groups, and Healthy Eating Index-2010 scores were the main outcome measures.Linear mixed models estimated changes in outcomes by intervention group and by adult food security status over time.Improvements in adult food security score (-0.7 ± 0.3; P = .01), Healthy Eating Index-2010 total score (4.2 ± 1.1; Plt; .0001), and empty calories component score (3.4 ± 0.5; Plt;.0001) from baseline to follow-up were observed in treatment and comparison groups, but no statistically significant changes were found for adult food security status, dietary quality, and usual intakes of nutrients and food groups between the 2 groups over time. The intervention effect on dietary quality and usual intake changes over time by adult food security status were also not observed.Food pantry clients in treatment and comparison groups had higher food security and dietary quality at the follow-up evaluation of the Voices for Food intervention trial compared with baseline, despite the lack of difference among the groups as a result of the experimental coaching component.

To understand how families receiving benefits from the Supplemental Nutrition Assistance Program (SNAP) conceptualize healthy eating and its relationship to child development.This study is a secondary analysis of in-depth, in-home qualitative interviews. 30 caregivers with children between the ages of 4 and 10 years old participating in SNAP in Baltimore, MD, were asked about food purchasing resources and strategies. Two independent coders re-analyzed primary data using an iterative process to identify a priori themes related to caregivers' conceptualization of healthy eating and emergent themes related to the ways families use SNAP benefits. Themes were identified via content analysis and revised until consensus was reached.Participants demonstrated knowledge of nutritious food groups, specific unhealthy nutrients, and the importance of food in managing chronic conditions. However, the importance of nutrition was balanced with the need for ready-made foods that children could safely prepare on their own, shelf stable goods, and low-cost foods. Emergent themes identified caregivers' views of health-related impacts of food beyond nutrition, including the role of food as: a parenting tool to support child socialization and development, a means of creating experiences unique to childhood, and a mechanism for promoting family cohesion.This study suggests families receiving SNAP use benefits to best serve children's well-being while conceptualizing the child health benefits of food as extending beyond nutrition. Future policy interventions aimed at optimizing SNAP should address the potential for nutrition assistance to foster positive child social and emotional development among low-income families while meeting nutritional needs.

To describe state agencies' implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.Qualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.Twenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.Four focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, EmploymentTraining, and Outreach) supervisors (n = 62).Supplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.Thematic analysis using a phronetic iterative approach.Six primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Supplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition assistance program supporting low-income families, serves half of United States–born infants, most of whom are issued infant formula by age 2 mo. Obesity prevalence is high among children of low-income households, particularly formula-fed children. OBJECTIVES: This study was conducted to determine whether glucose-based lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with increased obesity risk compared with non-CSSFs that are lactose based. DESIGN: WIC administrative data on infant formula issuance and child weights and lengths were collected prospectively in Southern California between 2012 and 2020. Included children stopped breastfeeding by 3 mo, were issued cow’s milk–based formula through 12 mo, and were enrolled through the final year of WIC eligibility at age 4 y ( n = 15,246). CSSF issuance was assessed continuously (range 0–13 mo) and dichotomously (any, none). Poisson and linear risk regression with robust SE estimates generated risk ratios (RRs), risk differences, and CIs for child obesity [BMI for age (in kg/m (2)) ≥95th percentile]. RESULTS: Any CSSF was issued to 23% of children, and 25% were obese at age 4 y. Children with any CSSF issuance had 10% higher obesity risk (RR: 1.10; 95% CI: 1.02, 1.20) than children with no CSSF issuance at age 2 y. Associations remained significant through age 4 y (RR: 1.07; 95% CI: 1.01,1.14), independent of maternal weight status, total formula issued and breastfeeding duration, and were not modified by child race or sex. Obesity risk increased with additional mo of CSSF exposure, reaching 16% higher risk (RR: 1.16; 95% CI: 1.05, 1.28) at age 2 y for children with 12 mo of CSSF. CONCLUSIONS: CSSF issuance is associated with increased obesity risk in the first 5 y life in a dose dependent manner, independently of maternal weight status, breastfeeding duration, and total formula issuance.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional assistance to low-income women and children in the United States. The WIC food package was revised to align more closely to dietary recommendations in October 2009. The revised package included more fruits, vegetables, whole grains, and low-fat milk.The objective of this study was to examine the association of the revised WIC package with anemia indicators and iron intake in children.A quasi-experimental difference-in-difference design compared anemia and iron intake variables between WIC (n = 1497 and n = 1626 for anemia and iron intake variables, respectively) and WIC-eligible nonparticipating children (n = 1183 and n = 1322 for anemia and iron intake variables, respectively), aged 2-5 y, before and after the 2009 revisions. The NHANES 2003-2008 and 2011-2018 data represented the period pre- and post-2009 revisions, respectively.The 2009 package revisions were significantly associated with reduced probability of anemia (-4.3% points; 95% CI: -7.5, -1.1% points) and nonthalassemic microcytic anemia (-1.7% points; 95% CI: -3.3, -0.1% points) in children from WIC-participating households. The revised WIC package also was significantly related to higher nutrient adequacy ratio (0.04; 95% CI: 0.02, 0.07) and greater probability of meeting the RDA (12.1% points; 95% CI: 3.2, 21.0% points) for iron among WIC participants.This study found that the WIC 2009 revisions were associated with lower probability of nonthalassemic microcytic anemia and better adequacy of dietary iron intake, thereby suggesting the beneficial impact of WIC revisions on iron deficiency anemia in children. The current study findings suggest that nutritional policies could play a crucial role in supporting the health of vulnerable children in the United States.

Describe how a multiyear, mixed-methods evaluation informed the evolution of a healthy eating and physical activity social marketing campaign.Focus groups, A/B survey to test messages and images, telephone interviews (2019) with local programmers, and an annual outcome survey.Statewide through multiple channels: billboards, transit signs, social media, website, and program resources like banners and posters.Supplemental Nutrition Assistance Program-Education eligible adults, focusing on mothers and caregivers.Healthy Choices Catch On originally launched in 2006 and has since evolved.Fruit and vegetable consumption, physical activity, and campaign recall.Univariate descriptive statistics and multivariate, weighted linear regression modeling. Interview transcriptions were analyzed for common themes.The multiyear evaluation demonstrated a steady increase in campaign exposure from 2013 to 2017, followed by a decline when new messages and images were introduced in 2018 and 2020. People with greater exposure to messages were more likely to eat more fruits and vegetables and be physically active.Using a combination of evaluation methods can help inform campaign design and evolution while also demonstrating reach and impact.

The Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch Program; and Special Supplemental Nutrition Program for Women, Infants, and Children reduce food insecurity for millions of Americans with lower incomes. However, critics have questioned whether they increase obesity. This study examined whether program participation was associated with BMI z-score from kindergarten to fifth grade.Data from 4,457 primary-grade students whose household incomes were equal to or below 200% of the federal poverty level from kindergarten to fifth grade as part of the Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 were analyzed. Marginal structural models with inverse probability of treatment/censoring weights were used to estimate associations between Supplemental Nutrition Assistance Program/Free and Reduced Priced Lunch participation over time and fifth-grade BMI z-score, accounting for lost-to-follow-up and time-varying confounders. Weighted generalized estimating equations were used to examine associations between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trends. All analyses incorporated sampling weights. The Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 data were collected from 2010-2016; analyses were conducted in 2021 and 2022.At baseline, 2,419 (54.3%) respondents participated in the Supplemental Nutrition Assistance Program, 3,993 (89.6%) participated in Free/Reduced Priced Lunch, and 3,755 (84.2%) reported past participation in the Special Supplemental Nutrition Program for Women, Infants, and Children. No associations were found between any program and fifth-grade BMI z-score or between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trend.Previous findings of relationships between program participation and BMI may have been because of weaker study designs and uncontrolled confounding. Participation in the Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch; and Special Supplemental Nutrition Program for Women, Infants, and Children was not associated with increased risk of childhood obesity in this recently conducted longitudinal study.

To examine whether duration of participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and early feeding practices are associated with the likelihood of meeting the Dietary Guidelines for Americans (DGA) recommendation for added sugars (AS) at age 3 years.Using data from the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2), logistic regression assessed associations between WIC participation patterns, early feeding practices, and whether 3-year-olds met the AS recommendation.Children introduced to sugar-sweetened beverages (SSBs) in their first year were about half (adjusted odds ratio, 0.65; P0.01) as likely to meet the recommendation as those not exposed in their first 2 years. First-year-only WIC participation (adjusted odds ratio, 0.61; P0.04) also increased the risk of excessive consumption compared with children who participated in their third year.Duration of WIC participation is inversely associated with young children's AS intakes. Public health efforts to reduce WIC attrition and enhance education efforts focused on delaying sugar-sweetened beverage introduction are supported.

BACKGROUND: Ultra-processed foods contribute to risks of obesity and cardiometabolic disease, and higher intakes have been observed in low-income populations in the United States. Consumption of ultra-processed foods may be particularly higher among individuals experiencing food insecurity and participating in the Supplemental Nutrition Assistance Program (SNAP). OBJECTIVES: Using data from the 2007–2016 NHANES, we examined the associations between food insecurity, SNAP participation, and ultra-processed food consumption. METHODS: The study population comprised 9190 adults, aged 20–65 y, with incomes ≤300% of the federal poverty level (FPL). Food insecurity was assessed using the Household Food Security Survey Module and SNAP participation over the past 12 mo was self-reported. Dietary intake was measured from two 24-h dietary recalls. Ultra-processed food consumption (percentage of total energy intake) was defined using the NOVA food classification system. Linear regression models were used to examine the associations between food insecurity, SNAP participation, and ultra-processed food consumption, adjusting for sociodemographic and health characteristics. RESULTS: More severe food insecurity was associated with higher intakes of ultra-processed foods (P-trend = 0.003). The adjusted means of ultra-processed food intake ranged from 52.6% for adults with high food security to 55.7% for adults with very low food security. SNAP participation was also associated with higher intakes of ultra-processed foods (adjusted mean: 54.7%), compared with income-eligible participants (adjusted mean: 53.0%). Furthermore, the association between food insecurity and ultra-processed foods was modified by SNAP participation (P-interaction = 0.02). Among income-eligible nonparticipants and income-ineligible nonparticipants, more severe food insecurity was associated with higher consumption of ultra-processed foods. Among SNAP participants, the association between food insecurity and consumption of ultra-processed foods was nonsignificant. CONCLUSION: In a nationally representative sample of adults, food insecurity and SNAP participation were both associated with higher levels of ultra-processed food consumption.

To identify effective practices for assisting college students with Supplemental Nutrition Assistance Program (SNAP) applications and explore challenges in student SNAP enrollment.In-depth interviews with key informants on experiences assisting college students with SNAP applications.University of California campuses.Twenty-one key informants, including staff from the University of California on-campus Basic Needs Centers, campus financial aid offices, county agencies, and food banks.Facilitators and barriers of college student SNAP enrollment.Transcripts were coded to identify emerging themes.Two of the most frequently mentioned facilitators were county staff presence on campus for application assistance and a strong relationship between campus staff and the county SNAP agency. A common barrier was inconsistent student SNAP eligibility information and procedures across county offices.Federal coordination with state agencies on student SNAP policy is much needed. This approach could help to eliminate heterogeneous interpretations of student exemptions across counties and between county staff. Future research is warranted to identify policy leverage points at the county, state, and federal levels, such as eliminating the student rule, to ensure equitable access to SNAP among college students.

Objective To assess facilitators and barriers to participation in the Child and Adult Care Food Program (CACFP) and estimate foregone federal funds because of CACFP underuse. Methods An online survey of food service practices and experiences with CACFP among Connecticut-based licensed child care centers (n = 231). Results Serving meals and the center's nonprofit status predicted CACFP participation. The most common challenge among participants was collecting family income eligibility. Streamlining paperwork (mentioned by 44% of respondents) and funding for nonfood, administrative costs (40%) were recommended facilitators to increase CACFP uptake. Nonparticipating centers had limited knowledge about the program and its eligibility. Foregone federal funding due to CACFP underuse among eligible Connecticut centers was estimated at $30.7 million in 2019, suggesting that 20,300 young children from low-income areas missed out on CACFP-subsidized food. Conclusions and Implications Improving knowledge about CACFP and reducing participation burdens through additional funding and technical assistance can help expand the program to support child nutrition.

Background The food system is a social determinant of health and 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. Objective 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 2018-21 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 three 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.

OBJECTIVE: To understand the perspectives of food bank clients affected by type 2 diabetes (T2DM). DESIGN: Semi-structured in-depth interviews conducted with food bank clients. SETTING: Arizona regional food bank. PARTICIPANTS: Twenty English- and Spanish-speaking food bank clients with T2DM or living with a person with T2DM, 45–83-years-old, majority female, Hispanic, and food insecure. PHENOMENON OF INTEREST: Food bank utilization and preferences, and how these related to T2DM management. ANALYSIS: A hybrid thematic analysis combining inductive and deductive reasoning. RESULTS: Three organizing themes emerged from the analysis. First, use of food assistance was influenced by food preferences and ability to pair with existing household foods. Second, desired support included fresh fruits and vegetables, meat, oats, oil, and herbs, and recipes, cooking demonstrations, and social support. Third, factors influencing T2DM management were lack of financial resources, low motivation, insufficient nutrition knowledge, low medication adherence, and multiple co-morbidities. Participants also expressed resilience and interest in improving T2DM management. CONCLUSIONS AND IMPLICATIONS: Among a predominantly Hispanic food bank sample, produce and protein-rich foods, nutrition and culinary education, and social support were components of a supportive food bank experience and should be considered when designing food-based interventions for T2DM management for food insecure persons.

BACKGROUND Over the past 2 decades there has been an increased emphasis on added sugars intake in the Dietary Guidelines for Americans (DGA), which has been accompanied by policies and interventions aimed at reducing intakes, particularly among children, adolescents and teens. OBJECTIVE The present study provides a comprehensive time trends analysis of added sugars intake and contributing sources in the diets of U.S. children, adolescents and teens (2-18 y) from 2001-2018, focusing on variations according to sociodemographic factors (age, sex, race and ethnicity, income), food assistance and health-related factors (physical activity, body weight status). METHODS Data from 9 consecutive 2-y cycles of the National Health and Nutrition Examination Survey (NHANES) were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001-2018 for the overall age group (2-18 y) and for 2 age subgroups (2-8 and 9-18 y). Trends were also examined on subsamples stratified by sex, race and ethnicity (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White), income (household poverty income ratio), food assistance, physical activity and body weight status. RESULTS From 2001-2018, added sugars intake decreased significantly (P

Background Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. Objective Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa’s Medicaid expansion population. Design We conducted a cross-sectional telephone survey between March and May of 2019. Participants Our sample was drawn from Medicaid members enrolled in Iowa’s expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. Main outcome measure Our main outcome was whether a respondent’s household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. Statistical analyses performed We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. Results The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. Conclusions Our findings show that food insecurity is prevalent in Iowa’s Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. Abbreviations Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP)

To examine the association between elevated maternal postpartum depression symptoms and select targets of nutrition education within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), including infant feeding beliefs, feeding practices, and dietary intake choices.Longitudinal analysis of secondary data from the WIC Infant and Toddler Feeding Practices Study-2.Eighty WIC sites.The WIC Infant and Toddler Feeding Practices Study-2 participants interviewed through 13 months postpartum (n = 1,851).Latent factor variables for infant feeding beliefs, feeding practices, and dietary intake choices.Confirmatory factor analysis using structural equation modeling; multivariable linear regression models.Biological mothers with elevated postpartum depression symptoms engaged in significantly less optimal feeding practices than biological mothers with fewer symptoms of depression, in multivariable analyses controlling for sociodemographic variables (β = -0.26; P = 0.02). Maternal depression symptoms were not significantly associated with infant feeding beliefs or dietary intake choices.Maternal depression symptoms are specifically associated with infant feeding practices. The Special Supplemental Nutrition Program for Women, Infants, and Children could consider screening for depressive symptoms and referring mothers for treatment. For mothers with elevated depression symptoms, nutrition education may need greater emphasis on healthy and safe feeding practices.

Background In Pakistan, the prevalence of stunting among children under-five years has remained above WHO critical thresholds (≥30%) over the last two decades. Objective We hypothesized that an unconditional cash transfer (UCT) combined with lipid-based nutrient supplement (LNS) and/or social and behavior change communication (SBCC) will prevent stunting among children 6-23 months of age. Design This was a four-arm, community-based cluster randomized controlled trial conducted in the district of Rahim Yar Khan, Pakistan. A total of 1729 children (UCT n = 434); (UCT+SBCC n = 433); (UCT+LNS n = 430) and (UCT+LNS+SBCC n = 432) were enrolled at 6 months of age and measured monthly for 18 months until the age of 24 months. Results At 24 months of age, children who received UCT+LNS (rate ratio [RR], 0.85 [95% CI 0.74, 0.97]; P = 0.015); and UCT+LNS+SBCC (RR, 0.86 [95% CI 0.77, 0.96]; P = 0.007) had significantly lower risk of being stunted as compared to the UCT arm. No significant difference was noted among children who received UCT+SBCC (RR, 1.03 [95% CI 0.91, 1.16]; P = 0.675) in the risk of being stunted as compared to the UCT arm. The pooled prevalence of stunting among children 6-23 months was 41.7%, 44.8%, 38.5% and 39.3% in UCT, UCT+SBCC, UCT+LNS and UCT+LNS+SBCC, respectively. In pairwise comparisons, a significant impact on stunting among children in UCT+LNS (P = 0.029) and UCT+LNS+SBCC (P = Conclusions UCT combined with LNS and UCT+LNS+SBCC were effective in reducing the prevalence of stunting among children aged 6-23 months in marginalized populations. UCT+SBCC was not effective in reducing the child stunting prevalence.Clinical trial registration number: ClinicalTrials.gov NCT03299218.

Background The Community Eligibility Provision (CEP) allows high-poverty schools participating in US Department of Agriculture meal programs to offer universal free school meals. Emerging evidence suggests benefits of CEP for student meal participation, behavior, and academic performance. Although CEP became available nationwide in 2014, in school year 2019–2020, one third of eligible schools were not participating. Objective This study evaluates which school, district, and state factors are associated with CEP participation. Design Cross-sectional study comparing CEP-participating with eligible nonparticipating schools to assess the relationship between CEP participation and school, district, and state factors. Participants US public schools eligible for CEP in school year 2017–2018 (n = 42,813). Main Outcome Measures CEP participation. Statistical Analyses Performed Penalized regression variable selection methods to determine which factors contribute information to the model. Generalized logistic regression to predict odds of CEP participation unadjusted and adjusted for each factor in the full sample and in stratified analyses by whether a state was part of the CEP phase-in period (early vs late implementing states). Results In the full sample, adjusted odds of CEP participation were greater in states where CEP had been available longer (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.34, 1.67). In late implementing states, adjusted odds of CEP participation were higher in schools with more students directly certified for free meals (OR in schools with 80%–89% vs 30%–39% directly certified: 19.32; 95% CI, 12.98, 28.76), Title I schools (OR, 1.85; 95% CI, 1.55, 2.21), and urban schools (OR suburban vs urban, 0.46; 95% CI, 0.36, 0.59). Differences by school level, enrollment, district size, student race/ethnicity, and geographic region also existed. Conclusions Findings may help advocates, state agencies, and policymakers understand potential barriers to adoption and guide research exploring effective strategies to promote uptake. Future research should use qualitative and longitudinal designs to explore barriers to adoption, including cost and state and local policies.

Food allergies affect 32 million Americans. Restricted diets due to food allergies can be difficult to maintain especially when the household is food insecure. Food insecurity is defined as the inability to acquire food for household members due to insufficient money or resources for food. The COVID-19 pandemic has caused many people to face food insecurity for the first time with Latinx, Native American, and Black communities disproportionately affected. Because of the increase in food insecurity, this work group developed a survey regarding food insecurity screening. This survey was sent out to a random sample of American Academy of Allergy Asthma & Immunology members to assess food insecurity knowledge and practices. The majority of survey participants did not routinely screen their patients for food insecurity. The biggest barrier identified to screening was lack of knowledge of how to perform a screen and resources available when a patient screened positive. This work group report provides guidance on how to implement and perform a food insecurity screen, including federal resources and assistance programs.

Objectives To examine whether the decrease in very low food security (VLFS) observed in California shortly after California's coronavirus disease (COVID-19) shutdown remained throughout Federal Fiscal Year (FFY) 2020. To investigate associations among unemployment, Supplemental Nutrition Assistance Program (SNAP) enrollment, and VLFS across FFY 2020. Methods Telephone interview responses from mothers from randomly sampled households from low-income areas throughout California to the 6-item US Department of Agriculture Food Security Survey Module identified VLFS families. Logistic regression examined VLFS rates before vs after California's COVID-19 shutdown, with race/ethnicity, age, and education as covariates. Pearson correlations were calculated for unemployment, SNAP enrollment, and VLFS. Results Most (66.4%) of the 2,682 mothers were Latina. VLFS declined from 19.3% before to 14.5% after California's COVID-19 shutdown (adjusted odds ratio, 0.705; P = 0.002). The correlation for unemployment and SNAP household participation was 0.854 (P = 0.007), and for SNAP participation and VLFS was −0.869 (P = 0.005). Conclusions and Implications Publicly-funded assistance programs may lower food insecurity, even during a time of increased economic hardship. Examining the specific factors responsible for the observed decline in VLFS has merit. Whether VLFS remains below the rate observed before California's COVID-19 shutdown is worthy of ongoing study.

Among US households with children, 14% are food insecure. Household food insecurity (FI) is associated with poorer health outcomes and increased hospital admissions. There is less known about caregivers' ability to obtain adequate food during hospitalization (inpatient FI).We conducted a mixed methods study of primary caregivers of hospitalized children 0 to 18 years. A modified US Household Food Security Survey was used to identify inpatient FI. Associated factors were identified using logistic regression adjusted for covariables. Caregiver semistructured interviews were conducted to elicit perceptions on food accessibility and effects of and solutions for inpatient FI.The prevalence of inpatient FI was 43%. Household FI was present in 38% of families. Inpatient FI was associated with household FI (P.01). In multivariable analysis, odds of inpatient FI were increased among caregivers with annual household income$30,000 (adjusted odds ratio [aOR] 2.14), public transportation use (aOR 6.33), living30 miles from the hospital (aOR 2.80), self-rated fair/poor health (aOR 3.31), maternity leave (aOR 4.75), and past/current Supplemental Nutrition Assistance Program benefit utilization (aOR 2.52). Qualitative analysis identified barriers to food access, such as lack of affordable options, and found that caregivers made sacrifices for their hospitalized child, including skipping meals. Caregivers viewed their presence at their child's bedside and personal nourishment as important factors affecting their child's care.Inpatient FI may affect a significant proportion of hospitalized children's caregivers. Pediatric hospitals should ensure that caregivers have access to food in order to fully engage in their child's care.

Objective Examine the association between the timing of sugar-sweetened beverages (SSBs) and 100% juice introduction with subsequent diet quality at age 3 years. Design Secondary analysis of a publicly available, national longitudinal dataset. Participants A total of 2,218 children from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Main Outcome Measure Dietary intakes were assessed using a 24-hour dietary recall completed by caregivers of children aged 3 years. Diet quality was assessed using the Healthy Eating Index Score-2015 (HEI-2015). Analysis Linear regression was used to assess the relationship between the timing of introduction to 100% juice and SSBs with HEI-2015. Adjustments were made for child- and maternal-related factors. Results Delayed introduction of SSBs during the first 2 years of life was associated with an increased HEI-2015 score. In adjusted analyses, for every 1-month delay in the introduction, there was a 0.09-point increase (95% confidence interval, 0.04–0.13) in the HEI-2015 score at 3 years. Conclusions and Implications Earlier introduction to SSBs may be associated with subsequent lower diet quality in WIC participants. This association may be driven by total fruit, whole grains, and added sugars HEI component scores. Further research is needed to support changes to existing WIC nutrition practices regarding SSBs and 100% juice.

Introduction Although sugar-sweetened beverage (SSB) consumption is associated with Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation, no national studies have examined the interplay between these programs. This study compares children's sugar-sweetened beverage consumption across households enrolled in one, both, or neither program. Methods A total of 4 waves (2009–2010 to 2015–2016) of the National Health and Nutrition Examination Survey were combined to obtain a sample of 4,772 children aged 0–19 years living in households eligible for both SNAP and WIC (households with income ≤130% of the Federal Poverty Level). Children were grouped as living in 4 household types: SNAP only; WIC only; SNAP + WIC; and neither program. Beverages with any added sugars were classified as SSBs. Two-part regression models examined the adjusted association between SSB consumption and program participation. Analyses were conducted in 2020. Results Compared with the SNAP‒only group, children in all other household types had lower odds of SSB consumption (AOR=0.44, p=0.002 for WIC only; AOR=0.69, p=0.020 for SNAP + WIC; AOR=0.61, p=0.025 for neither program). The lower probability of SSB consumption for children from WIC‒participating households was mostly driven by children aged 0–5 years, with the differences weakening for children aged 6–12 years and completely disappearing for those aged 12–19 years. No significant differences were observed for the amount of added sugar consumed by SSB consumers. Conclusions Household WIC participation—whether jointly with SNAP or alone—may confer protection against SSB consumption. Unlike SNAP, WIC, by design, provides participating households with more information and opportunities to access and consume healthier diets. Understanding how SNAP and WIC interact can help policymakers improve the design and nutritional benefit of the U.S. food safety net.

Background Food shopping frequency may be an important modifiable factor related to increasing fruit and vegetable (FV) intake. Because of mixed findings of individual studies of shopping frequency, a systematic review is needed to examine findings across studies and store types. Objective To conduct a systematic review of articles examining the relationship between frequency of food shopping and FV intake including examination of participation in federal nutrition assistance programs on FV intake, if reported. Methods A search, guided by the Preferred Reported Items for Systematic Reviews and Metanalyses, using terms related to FV consumption and food shopping across 4 online databases, was conducted. Studies conducted in the US and published through October, 2020, included adults, and had a cross-sectional, longitudinal, cohort, or randomized study design were eligible for inclusion. Results Twenty-four articles were included. The majority of studies found at least 1 positive finding between the frequency of food shopping and FV intake, indicating that as the frequency of food shopping increased, FV intake increased. In studies with 100% participation in government/federal nutrition assistance programs, participation was associated with FV intake. Studies that included participation as a subset found participation not associated with FV intake. Implications for Future Research and Practice The frequency of shopping may be modifiable to increase FV intake. Experimental research is needed to test the directionality and causality of the relationship. Federal nutrition assistance programs may be a logical place to test the relationship through the adjustment of fund disbursements.

Objective To assess the readiness of health clinics to implement nutrition support strategies in partnership with the Supplemental Nutrition Assistance Program Education (SNAP-Ed) program. Design Qualitative study using semistructured interviews. Setting South Carolina. Participants A convenience sample of key informants (n = 26) from health clinics (n = 15) interested in partnering with the SNAP-Ed program. Phenomenon of Interest Health clinic readiness to implement nutrition supports, including motivation, current capacities, and capacity-building needs. Analysis Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed descriptively and thematically. Results Clinics were most interested in implementing food insecurity screenings and making referrals to resources for accessing nutritious foods and produce prescription programs. Motivation was largely driven by a commitment to prevent chronic disease and on the basis of past success implementing a healthy eating strategy. A wide range of current capacities and capacity-building needs to implement strategies of interest were identified. Conclusions and Implications Findings suggest the readiness of some clinics to partner with SNAP-Ed to implement nutrition support strategies and identifies early insights on areas practitioners might need to engage clinics in for capacity-building. Some implementers might need further training before having their own capacity to support clinics in the wide range of nutrition support strategies included, which could be explored in future studies.

Background Despite the promise of farm-to-institution interventions for addressing limited vegetable access as a barrier to intake, programs designed for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are lacking. As such, little is known about the implementation of, and mechanisms of action through which, farm-to-WIC interventions affect vegetable intake and participant satisfaction with such programs. Objective To examine whether a farm-to-WIC intervention to promote vegetable intake was implemented as intended, differences between participants who received the intervention relative to those in a usual-care control group in intermediate outcomes of vegetable-related knowledge, attitudes, and behaviors, and secondary outcomes of physical activity and weight status; and participant satisfaction with the intervention. Design A process evaluation encompassing descriptive and comparative analyses of implementation fidelity logs and survey data collected as part of a pilot study was conducted. Participants/setting The setting was a large, New Jersey-based, urban WIC agency. Recruited between June 3 and August 1, 2019 through 3 of the agency’s 17 sites (1 intervention and 2 control sites), participants were 297 primarily Hispanic adults (160 enrolled at the intervention site and 137 at control sites). Intervention The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers’ market, field trips to an area farmers’ market, telephone coaching and support, and recipe demonstrations and tastings. Main outcome measures Primary outcomes were vegetable intake (measured via self-report and objectively using dermal carotenoids as a biomarker of intake) and the redemption of vouchers provided by WIC for fruit and vegetable purchases at farmers’ markets (measured objectively using data provided by WIC). For the process evaluation, logs were used to document program activities. Vegetable-related knowledge, attitudes, and behaviors, physical activity, and satisfaction with the intervention were assessed with participant questionnaires. Weight status was assessed with direct measures of height and weight. Data were collected at baseline and at mid- and post-intervention (3 and 6 months post-baseline, respectively). Statistical analyses performed Descriptive statistics were used to characterize implementation fidelity. Associations between intermediate and secondary outcomes and vegetable intake were examined at baseline with Pearson correlations. Post-baseline between-group differences in the outcomes were examined with linear mixed-effects models adjusted for baseline values and covariates. Satisfaction with the intervention was assessed with inferential and thematic analyses. Results Post-intervention, measures of vegetable intake were higher in the intervention relative to the control study group. Receipt of the intervention was also associated with a greater likelihood of voucher redemption. Nearly all participants (≥94%) received the intervention as intended at the WIC-based farmers’ market; smaller percentages completed 1 or more planned trips to the area farmers’ market (28%) and telephone coaching and support calls (88%). Although most intermediate and secondary outcomes were associated with measures of vegetable intake at baseline, the variables did not differ between study groups post-intervention. Mean satisfaction ratings were ≥6.8 on a 7-point scale. Recipe demonstrations, learning about vegetables, field trips, and the rapport with staff were liked most about the program. Although adding days and times for field trips was suggested, limited market days and hours of operation limited the ability to do so. Conclusions Preliminary data highlight the promise of this well-received intervention. Intermediate outcome findings suggest that other potential intervention mechanisms of action should be considered in future large-scale trials of this program. Broad-scale initiatives are needed to improve access to farmers’ markets in underserved communities.

Objective To examine the relationship between WICShopper application (app) usage and full redemption of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefits. Design A cross-sectional study. Setting West Virginia WIC program. Participants A total of 23,050 West Virginia WIC households in 2019. Main Outcome Measures Full redemptions were defined as the redemption rate of ≥ 90% for a given food benefit. Analysis App/non-app users were defined as households with someone using/not using the WICShopper app. Multivariate logistic regressions were applied. To address the potential self-selection bias in app usage, the propensity score (PS) of app usage was estimated. The regressions were rerun with the balanced sample by matching the PS. Results With PS matching, the prevalence of full redemption at the household level was 7.2% for app users vs 4.7% for nonapp users (odds ratio, 1.64; 95% confidence interval, 1.40–1.92; P Conclusions and Implications Use of the WICShopper app was associated with a higher prevalence of full redemptions in most food benefits after controlling the self-selection bias.

Background Factors that influence breastfeeding initiation and duration have been well established; however, there is limited understanding of in-hospital exclusive breastfeeding (EBF), which is critical for establishing breastfeeding. Grady Memorial Hospital, which serves a high proportion of participants receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and racial/ethnic minorities, had an in-hospital EBF rate in 2018 by the Joint Commission’s definition of 29% and sought contextualized evidence on how to best support breastfeeding mothers. Objective The objectives were to (1) identify facilitators and barriers to in-hospital EBF and (2) explore breastfeeding support available from key stakeholders across the social-ecological model. Design In-depth, semistructured interviews were conducted and analyzed using thematic analysis. Participants The sample included a total of 38 purposively sampled participants from Grady Memorial Hospital (10 EBF mothers, 10 non-EBF, and 18 key stakeholders such as clinicians, community organizations’ staff, and administrators). Results Key themes included that maternal perception of inadequate milk supply was a barrier to in-hospital EBF at the intrapersonal level. At the interpersonal level, a personable and individualized approach to breastfeeding counseling may be most effective in supporting EBF. At the institutional level, key determinants of EBF were gaps in prenatal breastfeeding education, limited time to provide comprehensive prenatal education to high-risk patients, and practical help with latching and positioning. Community-level WIC services were perceived as a facilitator due to the additional benefits provided for EBF mothers; however, the distribution of WIC vouchers for formula to mothers while they are in the hospital undermines the promotion of EBF. Cultural norms and a diverse patient population were reported as barriers to providing support at the macrosystem level. Conclusion Multipronged approaches that span the social-ecological model may be required to support early EBF in hospital settings.

Objective To assess changes in food pantries’ consumer nutrition environment (CNE) after the provision of technical assistance. Design Pre-post study with 2 phases. Setting Staff completed observational assessments using the Nutrition Environment Food Pantry Assessment Tool (NEFPAT) at food pantries in an initial pilot phase. Then, staff conducted NEFPAT observations at pantries in Illinois statewide. Participants In the pilot phase, 6 staff assessed 28 pantries. In the statewide phase, 35 staff assessed 119 pantries. Intervention After completing an initial NEFPAT at each pantry, technical assistance was provided by staff to support changes in the pantries’ CNE before another NEFPAT observation was completed. Main Outcome Measure Changes in the CNE, as assessed with the NEFPAT, when comparing preassessment and postassessment. Analysis Score differences were evaluated with paired t tests. Results In the pilot phase, among 23 pantries with preassessment and postassessment data, 2 objectives on the NEFPAT observation increased significantly. In the statewide phase, among 66 pantries with preassessment and postassessment data, most NEFPAT objectives and the overall NEFPAT score (22.12 ± 8.16 vs 28.20 ± 7.14, P Conclusions and Implications Technical assistance provided by Supplemental Nutrition Assistance Program Education implementing staff were related to improvements in the CNE of food pantries in Illinois. Future work should evaluate the association of these CNE changes with changes in behavior among pantry patrons.

Background School nutrition programs mitigate child food insecurity across the United States. With the onset of the coronavirus disease 2019 (COVID-19) pandemic, kindergarten through grade 12 physical school campuses closed, which led to those programs transitioning to emergency feeding. The Sendai Framework for Disaster Risk Reduction has 4 action priorities that guided the assessment of school nutrition employees’ emergency response during the COVID-19 pandemic. Objective Our aim was to explore the experience of school nutrition employees as they provided emergency feeding services during the COVID-19 pandemic and evaluate their actions based on the Sendai Framework for Disaster Risk Reduction . Design A qualitative study with semi-structured interviews (n = 34) was conducted via videoconferencing software. A purposive sample of school nutrition employees across all 7 US Department of Agriculture regions who were involved in the COVID-19 emergency feeding response participated during April and May 2020. Participants/setting School nutrition employees were selected randomly for participation from those indicating willingness to be interviewed during their participation in a related survey. Recruitment continued until all 7 US Department of Agriculture regions were represented. Participants held various roles, ranging from state agency leaders to front-line supervisors, although most were district-level directors or assistant directors. Analysis Data were analyzed using a phenomenological qualitative analytic approach. Results Four themes emerged. First, participants described the progression of the initial shock associated with the pandemic and service disruption, the flexibility they practiced, and the development of new routines. Second, keeping people (children, coworkers, and the community) safe was highlighted. The next theme captured participants’ feeling that they came “out of the shadows” as communities and stakeholders recognized their important contribution to children’s food security. Finally, they shared insight on communication and accountability during the emergency feeding response. Conclusions These programs demonstrated flexibility, resilience, and commitment to children during this crisis. As the pandemic continues and future disasters are considered, school nutrition programs and leaders can use the Sendai Framework for Disaster Risk Reduction’s “build back better” concept to refine disaster preparedness plans and advocate for changes that will continue to combat child food insecurity in the United States.

Objective To review the effect of the Expanded Food and Nutrition Education Program (EFNEP) in changing nutrition-related outcomes. Methods Relevant research conducted before December 2020 was identified using PubMed, Web of Science, Google Scholar, and the EFNEP Research Database. The methodological quality of each eligible study was assessed. Results Of the 406 studies found, 30 were eligible; 26 studies were on EFNEP, and 4 included both EFNEP and Supplemental Nutrition Assistance Program Nutrition Education (SNAP-Ed). The sample sizes ranged from 35 to 122,961. Outcome measures included consumption of food groups, nutrients, other nutrition-related behaviors, and food security. At least 1 immediate behavior change (P Discussion This review found a consistent, immediate improvement in nutrition behaviors after program participation but poor retention over time. Overall, variation in programming and outcome measures, incomplete reporting, and generally low study quality by modern standards precluded strong conclusions. Implications for Research and Practice This review identified the need for control groups, improved reporting of program protocols, theory-based curriculum, and measurement of long-term outcomes.

Background Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State. Objective To better understand SNAP participants’ experience, and to determine perceived impacts and consequences of the program. Design Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti. Setting Spokane, Seattle, and Yakima, Washington. Participants Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington. Analysis Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers. Results Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive. Conclusion Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Objective The objective of this study was to assess the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants’ perceptions about ordering WIC groceries online. Methods Qualitative semistructured interviews were conducted with 24 WIC participants in East Tennessee from May to October 2019. Interviews were transcribed verbatim and analyzed using a grounded theory approach. Results Participants were interested in online ordering and spoke favorably about delivery and pickup options. Participants were willing to pay $2–5 to order online, though they were more willing to pay for a home or curbside delivery than an in-store pickup. Participants suggested additional ways to integrate technology into WIC food retail operations, such as providing benefit balances via text message and developing a mobile phone application for Tennessee WIC. Conclusions and Implications Findings can inform pilot tests for WIC online ordering.

Background Aging populations in the United States exhibit high rates of food insecurity and chronic illness. Few studies have explored the neighborhood-level drivers of food insecurity among such populations, and how they intersect with experiences of aging. Objective The aim of this study was to explore how aging women experience food insecurity in the United States, and the neighborhood-level factors that influence these experiences. Design Semistructured qualitative interviews were conducted to elicit participants’ perceptions of how their neighborhood influenced their experiences with food security and aging. Participants/setting Thirty-eight food-insecure women aged 50 years and older were purposively sampled from the Northern California, Georgia, and North Carolina sites of the Women’s Interagency Human Immunodeficiency Virus Study. Interviews were conducted between November 2017 and July 2018 at the three Women’s Interagency Human Immunodeficiency Virus Study sites. Statistical analysis Three researchers thematically analyzed the data using an inductive–deductive approach. Results Participants described neighborhood-level drivers of food insecurity that centered around three themes: accessibility of food from traditional food stores, the role of food aid institutions, and the intersection of aging with the food environment. Participants explained that food insecurity was related to limited access to food stores largely due to long distances and poor public transportation in Georgia and North Carolina, and high food prices in Northern California. Most participants described being dependent on food aid programs, but found this difficult due to poor quality food and long wait times. Aging-related issues emerged as a cross-cutting theme, with fatigue, poor strength, and chronic illness amplifying barriers to accessing food. Conclusions Findings from this study reveal the structural barriers that aging women face in accessing healthy food within their neighborhoods, and how experiences with aging and chronic illnesses exacerbate these barriers. Although future programs should address common neighborhood-level barriers such as the accessibility and affordability of healthy foods, they should also be tailored to aging women and the local context.

To examine the mediating effects of food resource management skills (FRM) on the relationship between participation in a Supplemental Nutrition Assistance Program Education (SNAP-Ed) nutrition education program and diet quality.Secondary analysis of data from a propensity score-matched sample of participants (n = 396) and nonparticipants (n = 111) in a SNAP-Ed nutrition education program.Independent-samples t tests were used to compare entry, exit, and gain scores in FRM and diet quality between participants and nonparticipants. Structural equation modeling was used to examine direct and mediated relationships among participation, FRM, and diet quality.Food resource management was measured as a summated rating scale, and diet quality measured as Healthy Eating Index and program participation.Mediated effect of FRM on the relationship between participation in a SNAP-Ed program and diet quality was statistically significant (P0.01). The effect size for the mediation effect indicated that about 70% of program participation on diet quality was transferred by FRM skills. The hypothesized model had acceptable fit indices as model χParticipation in a SNAP-Ed program enhanced participants' FRM, which in turn enhanced their diet quality.

Evaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures.Pre-post quasi-experimental study design.Farmers markets and grocery stores in states with FINI projects.A total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer.Awareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures.Ordinary least squares intent-to-treat regression model using lagged dependent variable model framework.Awareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups-increases ranged from $9 to $15 (P0.05).Point-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.

Objective Provide the first baseline census of Supplemental Nutrition Assistance Program Education (SNAP-Ed) state implementing agencies’ (SIAs) intent to use and evaluate 51 indicators described in the SNAP-Ed Evaluation Framework. Methods A cross-sectional study design was used to administer electronic surveys to 124 SIAs who received SNAP-Ed funding in 2017. Descriptive statistics were used to analyze the results. Results Of 51 indicators, SIAs reported their intent to impact an average of 19 indicators and evaluate an average of 12. More SIAs reported the intention to impact indicators at the individual (59%) and environmental levels (48%), compared with the sectors of influence (20%) and population levels (30%) of the framework. In addition, more SIAs intended to impact and evaluate short- or medium-term indicators, compared with long-term indicators. Conclusions and Implications These findings illustrate the progress made toward aggregating metrics to measure the collective impact of SNAP-Ed.

Objectives (1) To describe facilitators and barriers to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food shopping via electronic benefits transfer (eWIC) compared with paper vouchers. (2) To explore suggestions that WIC participants had for modifying the program to enhance their overall WIC experience. Design Qualitative, semistructured, in-depth interviews. Setting WIC participants in East Tennessee. Participants Twenty-four primary food shoppers of WIC-participating households aged at least 18 years were recruited using a purposive sampling strategy. Phenomenon of Interest Perceived facilitators and barriers to use of eWIC as compared with paper vouchers. Analysis Interview transcripts were analyzed using a grounded theory approach to identify emergent themes. Results Participants identified several ways eWIC has improved their food shopping experience, including ad hoc redemption of WIC benefits and a quicker, more discrete checkout. Participants’ chief complaint about eWIC was transaction errors at checkout. Participants identified other barriers to shopping for WIC foods that cannot be addressed by the card alone, such as difficulty identifying WIC items in-store. Participants reported changes to their benefit tracking behaviors and provided suggestions to improve WIC further. Conclusions and Implications The transition to eWIC was viewed favorably among WIC participants, although participants identified a need for additional support in addressing transaction errors. This finding presents an opportunity to modify messages delivered to WIC participants by WIC nutrition educators and enhance collaboration between WIC agencies, retailers, and e-commerce technology providers.

Objectives To model the potential impact on obesity of removing butter, cheese, and sugar subsidies in the Canary Islands. Methods A simulation model was applied based on a local data set of subsidies and retail prices (2007-2016), data on own-price elasticity estimates, and representative nutritional and health surveys. We estimated marginal obesity prevalence and population attributable fraction to assess the potential impact of the butter, cheese, and sugar subsidies intervention. Results The intervention was predicted to avoid 10 363 obese adults over the study period, because of the reduction of the obesity prevalence by -0.7 percentage points. Overall, the predicted effect was largest in elderly and male groups, although females with a low socioeconomic status experienced the greatest decrease in the prevalence. The population attributable fraction predicted that 4.0% of population with obesity were attributable to the existence of these subsidies. Conclusions This analysis provides policy makers with the predicted impact on obesity of the butter, cheese, and sugar subsidies disposal, enabling them to incorporate this health impact into decision making across policy areas in the economic and health field. This study aims to model the potential impact on obesity of removing industrial subsidies for butter, cheese and sugar in the Canary Islands.

Introduction Children enrolled in the Supplemental Nutrition Assistance Program are at higher risk of poor diet, including higher intake of sugar-sweetened beverages than non–Supplemental Nutrition Assistance Program participants. This study aims to identify the impact of restricting sugar-sweetened beverage purchases with Supplemental Nutrition Assistance Program benefits on children's consumption and health. Methods Using Supplemental Nutrition Assistance Program participation and dietary data of children (aged 2–19 years) in the National Health and Nutrition Examination Survey (2009–2016), a microsimulation model was constructed to assess expected changes in daily sugar-sweetened beverage consumption, total calorie intake, BMI, incidence of dental caries, and obesity prevalence of 2019 U.S. children over a 10-year period, incorporating differences in food consumption and disease risks between the Supplemental Nutrition Assistance Program and the general U.S. populations. Sensitivity analyses were conducted with various food substitution patterns and Supplemental Nutrition Assistance Program participation characteristics. Analysis was performed in 2019. Results Sugar-sweetened beverage restriction in the Supplemental Nutrition Assistance Program was estimated to reduce daily sugar-sweetened beverage intake by 112.5 g/person (95% CI= −115.9, −109.2), which was estimated to decrease the number of decayed teeth by 0.53/person (95% CI= −0.55, −0.51), an 8.0% decline from the baseline. If sugar-sweetened beverages were substituted with fruit juice and milk, the restriction would be expected to reduce daily total calorie intake by 39.2 kcal/person (95% CI= −39.8, −38.7), resulting 2.6 kg/m2 (95% CI= −2.9, −2.4) decrease in BMI and a 6.2 percentage point (95% CI= −6.5, −5.8) decrease in obesity prevalence among Supplemental Nutrition Assistance Program participants. Estimated changes in total calorie intake and obesity were subject to food substitution patterns. Conclusions Restricting sugar-sweetened beverage purchases in Supplemental Nutrition Assistance Program could promote a healthier diet and significantly lower the incidence of dental caries and potentially obesity prevalence in children.

Objective Identify factors associated with caregivers’ intention to keep their child enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program until age 5 years. Methods Baseline data from a longitudinal questionnaire aiming to assess the impact of a statewide intervention to increase WIC retention in Illinois were analyzed in 2018. Data on sociodemographics and household characteristics were collected in 2015 from 174 caregiver/child dyads. Logistic regression was used to identify factors associated with caregivers’ intention to keep their child enrolled in WIC until age 5 years (ie, intention). Results A total of 66% of caregivers stated they were very likely to keep their child enrolled in the WIC program. Breastfeeding and homeownership status were associated with 58% (P =.03) and 72% (P =.02) lower odds of intention among caregivers, respectively. Conclusions and Implications Significant inverse associations among breastfeeding, homeownership, and intention support the need for tailoring state-level WIC retention efforts to specific population characteristics and health behaviors.

Background Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting. Objectives We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC). Methods We conducted a 4-arm, cluster-randomized, controlled trial (2010–2012). Clusters were defined as “collines” (communities). Impact was estimated using repeated cross-sectional data (n = ∼2620 children in each round). Treatment arms received household and individual (mother or child in the first 1000 days) food rations (corn-soy blend and micronutrient-fortified vegetable oil) from pregnancy to 24 months (T24 arm), from pregnancy to 18 months (T18), or from birth to 24 months (TNFP). All beneficiaries received the same BCC for the first 1000 days. The control arm received no rations or BCC. Results Wasting (weight-for-length Z-score

The Virginia 365 Project1 aimed to address a serious problem—food insecurity among children—through a rigorous evaluation of a deeply intuitive theory of change: that food insecurity is about not having enough food, so providing additional food will reduce food insecurity. To improve access and take-up and reduce stigma, Virginia 365 universally distributed free food to children and families in low-income schools, using afterschool suppers and sending home food backpacks for the weekends—strategies that have become increasingly popular in schools across the country. Counter to hypotheses, the evaluation of Virginia 365 found that the intervention led to higher food insecurity among households, adults, and children, with the only positive outcome being that prevalence of very low food security among children (VLFS-C) was lower in the intervention condition than in the control condition.

Background Food pantries have the potential to improve the quality of clients’ diets. Objective This study evaluated the relationship between the quality of the mix of foods in pantry inventories and client food bags (separately), as assessed by the Healthy Eating Index-2010 (HEI-2010), with client diet quality and how these relationships varied by food security status. Design This cross-sectional, secondary analysis used baseline data from the Voices for Food intervention study (Clinical Trial Registry: NCT03566095 ). A demographic questionnaire, the US Household Food Security Survey Module, and up to three 24-hour dietary recalls on nonconsecutive days, including weekdays and weekends, were collected. Foods available in pantry inventories and distributed in client food bags were recorded at one time point during baseline data collection. Participants and setting A convenience sample of adult food pantry clients (N = 575) from 24 rural, food pantries in the US Midwest was recruited from August to November 2014. Main outcome measures Pantry inventories, client food bags, and client diets were scored using the HEI-2010. Main outcomes were client HEI-2010 scores. Statistical analyses performed Linear regression models estimated associations between HEI-2010 total and component scores for pantry inventories and client food bags (in separate models) and the corresponding scores for client dietary intake. The interaction of client food security status, and potential pantry- and client-level confounders, was considered. Results Client food bag HEI-2010 scores were positively associated with client diet scores for total vegetables, greens and beans, and total fruit components, whereas pantry inventory HEI-2010 scores were negatively associated with client diet scores for total fruit, total protein foods, and seafood and plant proteins components. Client food bag whole-grains scores were more strongly associated with very low food secure compared with food secure client diet scores (all P values Conclusions The quality of client food bags, but not of pantry inventories, was positively associated with client diet quality in a rural sample in the US Midwest.

Background To reduce childhood hunger, the US Department of Agriculture funded a set of demonstration projects, including the Nevada Healthy, Hunger-Free Kids (HHFK) project. Objective The study objective was to test whether the Nevada HHFK project reduced child food insecurity (FI-C) among low-income households with young children. Design Households were randomly assigned to treatment and control groups, with outcomes measured using household surveys and administrative data. Survey data were collected at baseline (n=3,088) and follow-up (n=2,074) 8 to 12 months into the project. Participants/setting Eligible households in Las Vegas, NV, had children under age 5 years, received Supplemental Nutrition Assistance Program (SNAP) benefits, and had incomes below 75% of the federal poverty level. Intervention Between June 2016 and May 2017, treatment households on SNAP received an additional $40 in monthly SNAP benefits per child under age 5 years. Main outcome measures Key outcomes included FI-C (primary), food security among adults and households, and food expenditures (secondary). Statistical analyses performed Differences between the treatment and control groups were estimated by a logistic regression model and controlling for baseline characteristics. Analyses were also performed on socioeconomic subgroups. Results The Nevada HHFK project did not reduce FI-C (treatment=31.2%, control=30.6%; P=0.620), very low food security among children (P=0.915), or food insecurity among adults (P=0.925). The project increased households’ monthly food expenditures (including SNAP and out-of-pocket food purchases) by $23 (P Conclusions A demonstration project to reduce FI-C by increasing SNAP benefits to Las Vegas households with young children and very low income did not reduce FI-C or other food-insecurity measures. This finding runs counter to prior research showing that SNAP and similar forms of food assistance have reduced food insecurity. This project was implemented during a period of substantial economic growth in Las Vegas. Future research should explore the role of the economic context, children’s ages, and household income in determining how increases in SNAP benefits affect food insecurity. ClinicalTrials.gov identifier NCT 04253743 ( http://www.clinicaltrials.gov ) Funding/Support This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

Poor diet quality among children can lead to poor health, development, and academic achievement. Child nutrition assistance programs aim to improve diet quality among children.This study tested the impact of the Packed Promise intervention on diet quality among low-income children in Chickasaw Nation territory.This study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control districts.Household data were collected at baseline (n = 2,859) and follow-up (n = 2,852) in 12 rural Oklahoma counties.Packed Promise treatment households chose from 5 types of home-delivered food boxes that contained nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables.Key outcomes included children's daily consumed amounts of fruits and vegetables, whole grains, and added sugars collected by a dietary screener questionnaire. Other outcomes included food shopping frequency, type of grocery store used, distance traveled from home to grocery stores, and the number of weekly family dinners. All outcomes in this article are secondary to the study's primary outcome-food insecurity among children.Differences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics and population-based average portion sizes.Children's mean daily consumption of fruits and vegetables combined was about 2.35-cup equivalents in the treatment group and 2.25-cup equivalents in the control group (P0.001). Mean consumption of whole grains was 0.73-ounce equivalents in the treatment group compared with 0.67-ounce equivalents in the control group (P0.001). Other outcomes were not statistically significant.Packed Promise led to significant but small improvements in children's daily consumption of fruits and vegetables and whole grains. Several factors, including household participation levels in Packed Promise, may have moderated the size of impacts.This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

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.

BACKGROUND The prevalence of stunting in central rural Malawi is ∼50%, which prompted a multipronged nutrition program in 1 district from 2014 to 2016. The program distributed a daily, fortified, small-quantity lipid-based nutritional supplement, providing 110 kcal and 2.6 g of protein to children aged 6-23 mo, and behavior change messages around optimal infant and young child feeding (IYCF) and water, sanitation, and hygiene. OBJECTIVES Our objective was to perform an impact evaluation of the program using a neighboring district as comparison. METHODS Using a quasi-experimental study design, with cross-sectional baseline (January-March, 2014; n = 2404) and endline (January-March, 2017; n = 2453) surveys, we evaluated the program's impact using a neighboring district as comparison. Impact on stunting was estimated using propensity score weighted difference-in-differences regression analyses to account for baseline differences between districts. RESULTS No differences in mean length-for-age z-score or prevalence of stunting were found at endline. However, mean weight, weight-for-length z-score, and mid-upper arm circumference were higher at endline by 150 g, 0.22, and 0.19 cm, respectively, in the program compared with the comparison district (all P