Relation between the Supplemental Nutritional Assistance Program cycle and dietary quality in low-income African Americans in Baltimore, Maryland

Pediatric produce prescription initiatives in the U.S.: a scoping review

BACKGROUND

To describe pediatric Produce Prescription (PRx) interventions and their study designs, outcomes, and opportunities for future research.

METHODS

A scoping review framework was used to describe PRx interventions published between January 2000 and September 2023. Articles from online databases were uploaded into Covidence. Data on study characteristics, outcomes of interest (health, food insecurity (FI), nutritional and culinary efficacy, and fruit and vegetable (F/V) consumption), and feasibility were extracted. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment.

RESULTS

19 articles met inclusion criteria. Ten studies were quantitative, five were qualitative, and four used mixed-methods. Interventions included food vouchers (n = 14) or food box/pantries (n = 5). Four studies allowed food items in addition to F/Vs. Six studies measured changes in FI and five reported a statistically significant decrease. Seven studies measured changes in F/V consumption and five reported a statistically significant increase. One study reported a statistically significant reduction in child BMI z-score. Most studies reported high feasibility. Few studies used high-quality methods.

CONCLUSIONS

Pediatric PRx interventions show promising potential to reduce FI and improve diet quality and health-related outcomes. Future studies should utilize rigorous study designs and validated assessment tools to understand the impact of pediatric PRx on health.

IMPACT

This work offers a summary of programmatic outcomes including retention, redemption, incentives, nutrition education, study design and quality limitations to help inform future work. We found positive impacts of pediatric produce prescriptions (PRx) on FI, F/V consumption, and nutritional knowledge and culinary skills. More high-quality, rigorous studies are needed to understand the best delivery and design of PRx and their impact on child behavior and health outcomes. This work provides support for the need for rigorous studies and the potential for PRx to play a role in multi-pronged strategies that address pediatric FI and diet-related disease.

Narrative review: food as medicine across the pediatric age continuum

PURPOSE OF REVIEW

Poor diet and food insecurity contribute to the dramatic rise in diet-related chronic disease and increasing cost of healthcare. The Food as Medicine (FAM) framework describes food-based interventions designed to prevent, manage, and treat diet-related diseases. However, FAM interventions have not been widely implemented or evaluated in pediatric populations, so critical questions remain about their optimal delivery and design, efficacy, and funding opportunities. We have reviewed the recent literature and offer insights into potential funding and implementation strategies for pediatric healthcare providers.

RECENT FINDINGS

Data from adult and population-level interventions provide evidence that FAM interventions positively impact diet quality, food security, health outcomes, and healthcare utilization and cost in adults and households with children. Evidence from recent pediatric-based FAM interventions and population data from recent changes to federal nutrition programs support the use of food-based interventions to improve child diet quality, food insecurity, and potentially impact long-term health and healthcare utilization and cost.

SUMMARY

Applying the entire spectrum of evidence-based FAM interventions in pediatric settings from prenatal to adolescent stages will offer the greatest opportunity to ensure all children have access to enough healthful food so they can achieve their highest potential in life.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state

INTRODUCTION

There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children.

MATERIALS AND METHODS

Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects.

RESULTS

Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33).

CONCLUSIONS

Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Food insecurity among African Americans in the United States: A scoping review

In 2019, the estimated prevalence of food insecurity for Black non-Hispanic households was higher than the national average due to health disparities exacerbated by forms of racial discrimination. During the COVID-19 pandemic, Black households have experienced higher rates of food insecurity when compared to other populations in the United States. The primary objectives of this review were to identify which risk factors have been investigated for an association with food insecurity, describe how food insecurity is measured across studies that have evaluated this outcome among African Americans, and determine which dimensions of food security (food accessibility, availability, and utilization) are captured by risk factors studied by authors. Food insecurity related studies were identified through a search of Google Scholar, PubMed, CINAHL Plus, MEDLINE®, PsycINFO, Health Source: Nursing/Academic Edition, and Web of Science™ (Clarivate), on May 20, 2021. Eligible studies were primary research studies, with a concurrent comparison group, published in English between 1995 and 2021. Ninety-eight relevant studies were included for data charting with 37 unique measurement tools, 115 risk factors, and 93 possible consequences of food insecurity identified. Few studies examined factors linked to racial discrimination, behaviour, or risk factors that mapped to the food availability dimension of food security. Infrequently studied factors, such as lifetime racial discrimination, socioeconomic status (SES), and income insecurity need further investigation while frequently studied factors such as age, education, race/ethnicity, and gender need to be summarized using a systematic review approach so that risk factor impact can be better assessed. Risk factors linked to racial discrimination and food insecurity need to be better understood in order to minimize health disparities among African American adults during the COVID-19 pandemic and beyond.

The impact of financial incentives and restrictions on cyclical food expenditures among low-income households receiving nutrition assistance: a randomized controlled trial

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) is the largest anti-hunger program in the United States. Two proposed interventions to encourage healthier food expenditures among SNAP participants have generated significant debate: financial incentives for fruits and vegetables, and restrictions on foods high in added sugar. To date, however, no study has assessed the impact of these interventions on the benefit cycle, a pattern of rapid depletion of SNAP benefits that has been linked to worsening nutrition and health outcomes over the benefit month.

METHODS

Low-income households not currently enrolled in SNAP (n = 249) received benefits every 4 weeks for 12 weeks on a study-specific benefit card. Households were randomized to one of four study arms: 1) incentive (30% incentive for fruits and vegetables purchased with study benefits), 2) restriction (not allowed to buy sugar-sweetened beverages, sweet baked goods, or candy using study benefits), 3) incentive plus restriction, or 4) control (no incentive or restriction). Weekly household food expenditures were evaluated using generalized estimating equations.

RESULTS

Compared to the control group, financial incentives increased fruit and vegetable purchases, but only in the first 2 weeks after benefit disbursement. Restrictions decreased expenditures on foods high in added sugar throughout the benefit month, but the magnitude of the impact decreased as the month progressed. Notably, restrictions mitigated cyclical expenditures.

CONCLUSIONS

Policies to improve nutrition outcomes among SNAP participants should consider including targeted interventions in the second half of the month to address the benefit cycle and attendant nutrition outcomes.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT02643576 . Retrospectively registered December 22, 2014.

The Relationship between Household SNAP Participation, Parent Feeding Styles, and Child Eating Behaviors

This cross-sectional analysis of the Minnesota Now Everybody Together for Amazing Healthful Kids (NET-Works) study evaluated whether SNAP participation was associated with specific parental feeding styles and child eating behaviors. Associations between parent-reported feeding styles and child eating behaviors and SNAP participation were examined using multiple linear regression analyses and responses from 534 parent/child dyads (49.1% female children, 91.7% female parents). SNAP participation was not associated with specific feeding styles or child eating behaviors when adjusting for food insecurity, timing in SNAP cycle, and other covariates in this large, ethnically and racially diverse sample of predominantly mothers and preschool-aged children. Other factors, such as food insecurity, not SNAP participation, may influence parental feeding and child eating behaviors, and screening by health care providers is recommended.

Do additional SNAP benefits matter for child weight?: Evidence from the 2009 benefit increase

We know that youth who live in low-income households tend to have lower nutritional health outcomes-including higher rates of obesity-when compared to their higher-income counterparts. The Supplemental Nutrition Assistance Program (SNAP) is the largest U.S. federal nutrition program and has been found to improve food security and to serve as an income support. It is less clear how SNAP may affect obesity in low-income youth. From a policy perspective, it is essential to understand how the largest federal nutrition assistance program influences the health of children and adolescents. We use the exogenous increase in SNAP benefits that was a part of the American Recovery and Reinvestment Act (ARRA) to identify how a change in benefits is linked with obesity in youth. We find evidence that the ARRA increase in SNAP benefits is associated with healthier weight outcomes in three of the four age groups examined. SNAP-eligible toddlers are less likely to be overweight and adolescents are less likely to be obese. These findings can help policy makers understand how additional SNAP benefits from the Families First Coronavirus Response Act may influence weight outcomes in children and adolescents.

Associations between shopper impulsivity and cyclical food purchasing: Results from a prospective trial of low-income households receiving monthly benefits

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. Proposed interventions targeting the benefit cycle often focus on impulsive decision-making. However, it remains unclear whether shopper impulsivity is associated with food purchasing behavior. Using data from a prospective trial, we evaluate whether shopper impulsivity is associated with food purchasing behavior before and after households receive nutrition assistance. In this study, 249 low-income households in the Minneapolis-St. Paul, Minnesota, metropolitan area received monthly benefits for three months. Overall impulsivity and impulsivity subtraits of the primary shopper was assessed using the Barratt Impulsiveness Scale-11. Both total food expenditures and expenditures for two specific categories (fruits and vegetables, and foods high in added sugar) were evaluated. Generalized estimating equations were used to model household expenditures as a function of week since benefit distribution, impulsivity, and their interaction. Results showed that during the benefit period, food expenditures were cyclical and patterned by impulsivity. Shoppers with greater overall impulsivity spent $40.62 more in week 1 (p < 0.001). While more impulsive shoppers spent more on foods high in added sugar throughout the month (p < 0.05 for all weeks), no patterns were observed for fruits and vegetables. These findings suggest that greater impulsivity exacerbates cyclical food purchasing behavior. The impact of shopper impulsivity is especially notable for expenditures on foods high in added sugar. SNAP educational interventions to mitigate the benefit cycle may be strengthened by focusing on more impulsive shoppers and on strategies to reduce impulsive purchases of foods high in added sugar.

Trends in cyclical food expenditures among low-income households receiving monthly nutrition assistance: results from a prospective study

OBJECTIVE

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics.

DESIGN

Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means.

SETTING

Minneapolis-St. Paul, Minnesota, metropolitan area.

PARTICIPANTS

Low-income households (n 249) enrolled May 2013-August 2015.

RESULTS

Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households.

CONCLUSIONS

Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

All Children Thrive: Integration of Nutrition and Early Childhood Development

Building on the successes of child survival, we review the evidence needed to ensure both that children who survive also thrive and that recommendations promote equity, with no child left behind. To illustrate the critical roles played by nutrition and child development, we revise the Conceptual Framework for the Causes of Malnutrition and Death and the Nurturing Care Framework to create the Conceptual Framework of All Children Surviving and Thriving. The revised framework highlights the goals of child growth and development, supported by health, nutrition, learning, responsive caregiving, and security and safety. We review the challenges posed by undernutrition, stunting, micronutrient deficiencies, overweight, and children not reaching their developmental potential. Although integrated nutrition-childhood development interventions have shown promising effects, most have not been implemented at scale. Implementation science that investigates how and why integrated interventions work in real life, along with the acceptability, feasibility, cost, coverage, and sustainability of the interventions, is needed to ensure equity for all children thriving.

Effects Of Alternative Food Voucher Delivery Strategies On Nutrition Among Low-Income Adults

Nutrition assistance programs are the subject of ongoing policy debates. Two proposals remain uninformed by existing evidence: whether restricting benefits to allow only fruit and vegetable purchases improves overall dietary intake, and whether more frequent distribution of benefits (weekly versus monthly) induces more fruit and vegetable consumption and less purchasing of calorie-dense foods. In a community-based trial, we randomly assigned participants to receive food vouchers that differed in what foods could be purchased (fruit and vegetables only or any foods) and in distribution schedule (in weekly or monthly installments, holding total monthly value constant). The use of vouchers for fruit and vegetables only did not yield significantly greater improvements than the unrestricted voucher did in terms of fruit and vegetable consumption or Healthy Eating Index (HEI) score. Weekly vouchers also failed to yield significantly greater improvements than monthly vouchers did. Proposed policies to make assistance more restricted or more frequent, while holding benefit value constant, might not improve nutrition among low-income Americans.

The Supplemental Nutrition Assistance Program and Child Weight Status: A Review

CONTEXT

The Supplemental Nutrition Assistance Program (SNAP) is a food assistance program that helps Americans afford a healthy diet. However, its influence on children's weight status is unclear. This review examined the evidence of the relationship between SNAP participation and child weight.

EVIDENCE ACQUISITION

The following databases were searched: PubMed, EconLit, Web of Science, and the U.S. Department of Agriculture Economic Research Service. The last search was performed in October 2018. This systematic review gives a narrative synthesis of included studies.

EVIDENCE SYNTHESIS

Twenty-three studies that examined the weight outcomes of children aged 2-18 years and SNAP participation were included. Eleven studies found no significant relationship between SNAP and child weight outcomes. Nine found that SNAP participation was associated with increased weight outcomes in certain subpopulations, and four found that SNAP was linked to a predicted decrease in weight outcomes in some subpopulations. However, many of these studies did not address a key methodologic challenge: self-selection. Of those that did, five found that SNAP participation was associated with an increased risk of being overweight and elevated weight in certain subpopulations.

CONCLUSIONS

SNAP participation may help boys maintain a healthy body weight but can be a contributing factor in being overweight or obese in girls who are long-term participants, or who are already overweight. Food security and participation in multiple food assistance programs may be important modifiers. These findings are relevant to policymakers who are considering reducing SNAP funding or restructuring the program. Further research that utilizes strong designs is needed.

Chronic disease self-management within the monthly benefit cycle of the Supplemental Nutrition Assistance Program

OBJECTIVE

The present study explored chronic disease management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, PA, USA.

DESIGN

In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households.

SETTING

Interviews and surveys were conducted in a clinical setting at Children's Hospital of Philadelphia, at participants' homes, and in food procurement settings including grocery stores, food pantries and soup kitchens.

PARTICIPANTS

Eighteen adults who received SNAP; five with a diet-related chronic condition, five managing the chronic condition of a family member and thirteen with overweight or obesity.

RESULTS

All households had at least one member with a chronic disease or condition. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programmes, often had negative impacts on chronic disease self-management.

CONCLUSIONS

Drawing from nearly 50 h of in-depth qualitative interviews with SNAP participants, the study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations.

Food Insecurity is Associated with Maladaptive Eating Behaviors and Objectively Measured Overeating

OBJECTIVE

The association between food insecurity and obesity may be partially explained by overeating in response to unpredictable food availability cycles. The aim of this study was to measure objective food intake in food-insecure individuals.

METHODS

Eighty-two volunteers (53 m; BMI 29 ± 7; 38 ± 12 years) were admitted to our inpatient Clinical Research Unit and completed the Food Security Short Form, Three-Factor Eating Questionnaire, Gormally Binge Eating Scale, and body composition assessment (dual-energy x-ray absorptiometry). After 5 days of a weight-maintaining diet, participants self-selected food from an ad libitum vending machine paradigm for 3 days. Mean daily intake (kilocalories), macronutrient intake, and percentage of weight-maintaining energy needs (%WMEN) were calculated.

RESULTS

Based on Food Security Short Form cutoffs, food-insecure participants (n = 46; 56%) had higher body weight (P = 0.04), fat-free mass (P = 0.05), disinhibition (P = 0.008), hunger (P = 0.02), and binge-eating scores (P = 0.02) but not cognitive restraint (P = 0.37) compared with food-secure individuals. They overate more kilocalories (P = 0.001), %WMEN (P = 0.003), fat (P = 0.003), and carbohydrates (P = 0.004) during the vending machine paradigm, continued to increase their hourly rate of kilocalories (group × time; β = 37.7 cumulative kcal/h; P < 0.0001), and ate more total kilocalories across the 72 hours (β = 47.09 kcal/h; P = 0.003).

CONCLUSIONS

Food insecurity may amplify susceptibility to weight gain via overeating during times of unlimited food access.

Association of Grocery Expenditure Relative to Thrifty Food Plan Cost with Diet Quality of Women Participating in the Supplemental Nutrition Assistance Program

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States. Allotment of SNAP benefits is based on the Thrifty Food Plan (TFP), which is designed to achieve a nutritious diet at a minimal cost. Although low-income households do not meet the TFP cost for total groceries, the impact on diet quality is not known.

OBJECTIVE

The objective of this research is to determine the relationship of TFP-adjusted total grocery and SNAP-related expenditures with diet quality of women participating in SNAP.

DESIGN

In this observational study, participants were administered a demographics questionnaire, food frequency questionnaire, and United States adult food security module. Participants were also instructed to save grocery receipts for 1 month. Total and SNAP-related grocery expenditures and TFP cost for each household were determined. The Healthy Eating Index-2010 was used as a measure of diet quality.

PARTICIPANTS/SETTING

A total of 217 women from low-income housing and neighborhood centers in central Texas were enrolled from January through December 2015. Eligibility criteria included participation in SNAP; age 18 to 50 years; and Hispanic, non-Hispanic black, or non-Hispanic white race/ethnicity. Fifty-eight women were lost during follow-up. Data from 15 participants were excluded as a result of reporting of implausible caloric intakes or incomplete collection of receipts, thereby resulting in a final sample of 144.

MAIN OUTCOME MEASURES

Food group and nutrient intake and diet quality were the main outcome measures of the study.

STATISTICAL ANALYSIS

Multiple linear regression analyses determined the association of TFP-adjusted total grocery and SNAP benefit expenditure with food group intake and diet quality. Independent-samples t test and one-way analysis of variance were used to determine differences in ratio of spending to TFP cost by demographic characteristics.

RESULTS

The mean ratio of total grocery expenditure to TFP cost was 0.74. Total and SNAP benefit expenditures relative to TFP cost were positively related to fruit and vegetable intake (P<0.01) and diet quality (P<0.05). Ratio of grocery spending to TFP costs did not differ based on food security status.

CONCLUSIONS

The results of this study indicate inadequate grocery spending among SNAP households relative to recommended TFP cost, which in turn was associated with poorer diet quality in women.

Diet Quality Over the Monthly Supplemental Nutrition Assistance Program Cycle

INTRODUCTION

Supplemental Nutrition Assistance Program (SNAP) benefits, which are distributed monthly, help low-income families put food on their tables. Both food spending and caloric intake among recipients decrease over the month following benefit receipt. This pattern, termed the "SNAP-cycle," has serious implications for health and food security of low-income households. To understand better the SNAP-cycle, this study explored (1) differences in diet quality between SNAP and non-SNAP households and (2) the association between the SNAP-cycle and diet quality.

METHODS

Multivariate linear regression with SNAP households in the U.S. Department of Agriculture's Food Acquisition and Purchase Survey to evaluate changes in diet quality as time from SNAP distribution increased. Diet quality of food purchases was measured by Healthy Eating Index-2010 total and component scores. Data were collected 2012-2013 and analyzed 2016-2017.

RESULTS

Overall dietary quality was low throughout the SNAP-cycle (n=1,377, mean Healthy Eating Index 46.14 of 100). SNAP households had significantly lower Healthy Eating Index scores compared with eligible and ineligible nonparticipants (p<0.05). After controlling for covariates, households in the final 10 days of the benefit cycle had Healthy Eating Index-2010 total scores 2.95 points lower than all other SNAP households (p=0.02). Significant declines in Healthy Eating Index fruit and vegetable scores contributed to worsening diet quality over the SNAP-cycle.

CONCLUSIONS

This study provides evidence of low dietary quality throughout the SNAP-cycle with significantly lower Healthy Eating Index scores in the final 10 days of the benefit month. This suggests less healthy purchasing occurs when resources are diminished, but overall that current SNAP levels are insufficient to consistently purchase foods according to dietary guidelines.

Monthly Variations in Dietary Intake of Women Participating in the Supplemental Nutrition Assistance Program

BACKGROUND

Households participating in the Supplemental Nutrition Assistance Program (SNAP) have been shown to spend the majority of their program benefits within the first 3 days of receipt. Hence, it is important to investigate dietary intakes of SNAP participants based on time since receipt of benefits.

OBJECTIVE

The objectives of this study were to investigate the dietary intake of women participating in SNAP over 1 month and to compare diet quality between food secure and food insecure women using two indices.

DESIGN

A longitudinal design was used to examine monthly dietary intake of women in SNAP. Participants were measured for height and weight. A demographics questionnaire and a food frequency questionnaire (FFQ) based on a reference period of 1 week were administered. The FFQ was completed four times, with an interval of 1 week, so that it reflected the diets of participants during weeks 1, 2, 3, and 4 of benefit receipt. Participants also completed the US adult food security module. The Healthy Eating Index-2010 and the Dietary Guidelines Adherence Index 2015 were used to assess diet quality.

PARTICIPANTS/SETTING

A total of 217 women were recruited from low-income housing and neighborhood centers in Central Texas from January to December 2015. Women enrolled in SNAP, aged 18 to 50 years, and of Hispanic, African-American, and white race or ethnicity participated in the study. Fifty-eight women were lost during follow-up. Data from eight participants was excluded due to reporting of implausible caloric intakes, thereby resulting in a final sample of 151.

MAIN OUTCOME MEASURES

Food group, nutrient intake, and diet quality were the main outcome measures of the study.

STATISTICAL ANALYSIS

A mixed linear model was conducted using week since receipt of benefits as the independent variable and food group, nutrient intake, and diet quality as the dependent variables. An analysis of variance was conducted to determine differences in diet quality based on food security status for each week of the monthly SNAP cycle.

RESULTS

A significant decrease in daily intakes of fruits, vegetables, dairy, and diet quality was observed over the month (P<0.05, with Bonferroni adjustment). Food secure women had higher diet quality than those with very low food security (P<0.05, with Bonferroni adjustment). However, a decline in diet quality was observed in all groups of women, classified according to food security status.

CONCLUSIONS

These results show that dietary intake of SNAP participants varies based on time since receipt of benefits.

Food insecurity, diet quality and body mass index of women participating in the Supplemental Nutrition Assistance Program: The role of intrapersonal, home environment, community and social factors

Obesity is a public health problem that disproportionately affects low-income populations. Moreover, participation in Supplemental Nutrition Assistance Program (SNAP) has been associated with obesity among low-income women. The goal of this study was to determine the impact of intrapersonal, home environment, community and social factors on diet quality and body mass index (BMI) of low-income women participating in SNAP. This study also aimed to examine the role of these factors in mediating the relationship between food insecurity and diet quality, and BMI. A total of 152 women receiving SNAP benefits were recruited from low-income neighborhood centers and housing communities, and administered a demographics questionnaire, the United States adult food security scale, food frequency questionnaire, and multi-dimensional home environment scale (MHES). They also were measured for height and weight to calculate BMI. The Dietary Guidelines Adherence Index 2015 was used to measure diet quality. Regression analyses were conducted to determine the MHES subscales that were significant predictors of diet quality and BMI. The Preacher and Hayes mediation model was used to evaluate the mediation of the relationship between food insecurity and diet quality, and BMI by the MHES. Emotional eating resistance and favorable social eating behaviors were positively associated with diet quality; whereas emotional eating resistance, lower availability of unhealthy food at home, neighborhood safety and favorable social eating behaviors were inversely associated with BMI in women participating in SNAP. The MHES significantly mediated the relationship between food insecurity and BMI. These results emphasize the importance of intrapersonal, home environment, community and social factors in mediating the relationship between food insecurity and BMI in low-income women.

Farmers' Market Utilization among Supplemental Nutrition Assistance Program Recipients in New Orleans, Louisiana: Preliminary Findings

Objective

Farmers' markets are increasingly being promoted as a means to provide fresh produce to poor and underserved communities. However, farmers' market (FM) use remains low among low-income patrons. The purpose of our study was to examine FM awareness and use, grocery shopping behaviors, and internet use among Supplemental Nutrition Assistance Program (SNAP) recipients.

Design

A descriptive analysis of preliminary data was performed to evaluate quantitative baseline data among SNAP recipients between June and August 2016 in New Orleans, Louisiana (N=51). Data were collected via a 42-item online survey that included demographics, internet use, FM awareness and use, health information seeking behaviors and fruit and vegetable purchasing behaviors.

Results

Less than half of the survey respondents (n=24) had ever been to a FM. Local grocery stores and Wal-Mart were most used for purchasing fruits and vegetables (88% and 84%, respectively). The most common sources of healthy eating information were Women, Infants and Children (WIC) and the internet, frequently accessed via smartphones. More than 80% of participants were not aware that local FMs accepted electronic benefit transfer payments as a form of payment.

Conclusion

These results support the incorporation of promotional methodology that combines internet-based mobile technology and existing services (eg, WIC) as a viable strategy to improve farmers' market use among low-income populations. As most participants were not aware that participating FMs accept electronic benefit transfer payments, this fact should be emphasized in promotional material.

Securing a Stop to the Summer Setback: Policy Considerations in the Future Expansion of the Summer Electronic Benefit Transfer for Children

The Summer Electronic Benefits Transfer for Children (SEBTC) has been proposed as a solution to address the problem of child food security during the summer. Initial SEBTC findings from a demonstration project show promise and the federal government has approved substantial funding for its continuation. This report reviews empirical assessments of SEBTC and Electronic Benefits Transfer research, and presents policy considerations in the program's future expansion.

Application of Noninferiority Tests to Examine the Food Insecurity-Obesity Relationship in Children

This study applies non-inferiority testing to assess the relationship between child weight and food security status in a sample of 808 children between 3 and 5 years old who were attending an urban, state-funded preschool program. Most families were African American (72.3%). Analyses were conducted using non-inferiority testing to evaluate the overweight-food security association. Odds of being overweight in the Food Insecure (FI) group were .643 (95% CI .525 to .788) while odds from the Food Secure (FS) group were .570 (95% CI .464 to .697), OR=1.127 (P=.004). These findings held across sub-groups of gender, race, and family conflict. Children whose parent indicated education beyond high school showed a reversal with FI odds of overweight less than FS odds (OR=.663). As illustrated in this study, non-inferiority testing provides an alternative analytic approach to examining the association between FI and weight in children.

The Relationship between Food Insecurity, Dietary Patterns, and Obesity

Food insecurity is a major public health concern, and refers to the uncertainty, lack of, or inability to acquire nutritious food in a safe and socially acceptable manner. Food insecurity has been associated with obesity and unhealthy dietary patterns, both of which can have negative health consequences. A review of the current literature revealed an adverse association between food insecurity and dietary patterns is well supported. The association between food insecurity and obesity is strongest for women, with results for men and children being mixed. Evidence for long-term effects is limited due to a lack of longitudinal studies. Results from interventional studies have mostly yielded mixed results, and it is presently unclear how to best help food insecure individuals improve diet and weight.

Household food insecurity as a determinant of overweight and obesity among low-income Hispanic subgroups: Data from the 2011-2012 California Health Interview Survey

An estimated 78% of Hispanics in the United States (US) are overweight or obese. Household food insecurity, a condition of limited or uncertain access to adequate food, has been associated with obesity rates among Hispanic adults in the US. However, the Hispanic group is multi-ethnic and therefore associations between obesity and food insecurity may not be constant across Hispanic country of origin subgroups. This study sought to determine if the association between obesity and food insecurity among Hispanics is modified by Hispanic ancestry across low-income (≤200% of poverty level) adults living in California. Data are from the cross-sectional 2011-12 California Health Interview Survey (n = 5498). Rates of overweight or obesity (BMI ≥ 25), Calfresh receipt (California's Supplemental Nutrition Assistance Program), and acculturation were examined for differences across subgroups. Weighted multiple logistic regressions examined if household food insecurity was significantly associated with overweight or obesity and modified by country of origin after controlling for age, education, marital status, country of birth (US vs. outside of US), language spoken at home, and Calfresh receipt (P < .05). Significant differences across subgroups existed for prevalence of overweight or obesity, food security, Calfresh receipt, country of birth, and language spoken at home. Results from the adjusted logistic regression models found that food insecurity was significantly associated with overweight or obesity among Mexican-American women (β (SE) = 0.22 (0.09), p = .014), but not Mexican-American men or Non-Mexican groups, suggesting Hispanic subgroups behave differently in their association between food insecurity and obesity. By highlighting these factors, we can promote targeted obesity prevention interventions, which may contribute to more effective behavior change and reduced chronic disease risk in this population.

Food insecurity, overweight and obesity among low-income African-American families in Baltimore City: associations with food-related perceptions

OBJECTIVE

To examine associations between food insecurity, excess body weight, psychosocial factors and food behaviours among low-income African-American families.

DESIGN

Cross-sectional survey of participants in the baseline evaluation of the B'More Healthy Communities for Kids (BHCK) obesity prevention trial. We collected data on socio-economic factors, food source destinations, acquiring food, preparation methods, psychosocial factors, beliefs and attitudes, participation in food assistance programmes, anthropometry and food security. We used principal component analysis to identify patterns of food source destinations and logistic regression to examine associations.

SETTING

Fourteen low-income, predominantly African-American neighbourhoods in Baltimore City, MD, USA.

SUBJECTS

Two hundred and ninety-eight adult caregiver-child (10-14 years old) dyads.

RESULTS

Of households, 41·6 % had some level of food insecurity and 12·4 % experienced some level of hunger. Food-insecure participants with hunger were significantly more likely to be unemployed and to have lower incomes. We found high rates of excess body weight (overweight and obesity) among adults and children (82·8 % and 37·9 % among food insecure without hunger, 89·2 % and 45·9 % among food insecure with hunger, respectively), although there were no significant differences by food security status. Food source usage patterns, food acquisition, preparation, knowledge, self-efficacy and intentions did not differ by food security. Food security was associated with perceptions that healthy foods are affordable and convenient. Greater caregiver body satisfaction was associated with food insecurity and excess body weight.

CONCLUSIONS

In this setting, obesity and food insecurity are major problems. For many food-insecure families, perceptions of healthy foods may serve as additional barriers to their purchase and consumption.

B'More Healthy: Retail Rewards--design of a multi-level communications and pricing intervention to improve the food environment in Baltimore City

BACKGROUND

Low-income black residents of Baltimore City have disproportionately higher rates of obesity and chronic disease than other Maryland residents. Increasing the availability and affordability of healthy food are key strategies to improve the food environment and can lead to healthier diets. This paper describes B'More Healthy: Retail Rewards (BHRR), an intervention that tests the effectiveness of performance-based pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers.

METHODS/DESIGN

BHRR is 2x2 factorial design randomized controlled trial. Fifteen regular customers recruited from each of 24 participating corner stores in Baltimore City were enrolled. Food stores were randomized to 1) pricing intervention, 2) communications intervention, 3) combined intervention, or 4) control. Pricing stores were given a 10-30% price discount on selected healthier food items, such as fresh fruits, frozen vegetables, and baked chips, at the point of purchase from two food wholesale stores during the 6-month trial. Storeowners agreed to pass on the discount to the consumer to increase demand for healthy food. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Primary outcome measures include consumer food purchasing and associated psychosocial variables. Secondary outcome measures include consumer food consumption, store sales, and associated storeowner psychosocial factors. Process evaluation was monitored throughout the trial at wholesaler, small store, and consumer levels.

DISCUSSION

This is the first study to test the impact of performance-based pricing and communications incentives in small food stores, an innovative strategy to encourage local wholesalers and storeowners to share responsibility in creating a healthier food supply by stocking, promoting, and reducing costs of healthier foods in their stores. Local food wholesalers were involved in a top-down, participatory approach to develop and implement an effective and sustainable program. This study will provide evidence on the effectiveness of price incentives and health communications, separately and combined, among a low-income urban U.S.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02279849 (2/18/2014).

Forefronts in portion size. An overview and synthesis of a roundtable discussion

Establishing eating habits in early life that include appropriate portion sizes of foods which are nutrient dense and low in energy density is considered important in the prevention of obesity in children. This special supplement presents the proceedings of a symposium focusing on advances in scientific understanding of the development of healthy food portion sizes in children and their families. Recent basic research highlights individual differences in children's responsiveness to portion size as well as potential mechanisms of portion size effects. Quantitative approaches highlight the influence of maternal serving in determining intake, while qualitative approaches seek to elaborate caregiver decisions around child portion sizes at meals and snacks. Family-based environmental interventions for child weight control involving food portion size are outlined. An overview of the overarching issues and roundtable discussion on the forefronts of portion size research are presented as well as policy considerations to promote healthy portion control.