The Benefits and Challenges of Providing School Meals during the First Year of California's Universal School Meal Policy as Reported by School Foodservice Professionals.

States in the U.S. are newly implementing universal school meal (USM) policies, yet little is known about the facilitators of their success and the challenges they confront. This study evaluated the challenges and facilitators faced by school food authorities (SFAs) implementing California's universal school meal (USM) policy during its inaugural year (2022-2023) using an online survey. In March 2023, 430 SFAs reported many benefits, including increased meal participation (64.2% of SFAs) and revenues (65.7%), reduced meal debt (41.8%) and stigma (30.9%), and improved meal quality (44.3%) and staff salaries (36.9%). Reported challenges include product/ingredient availability (80.9%), staffing shortages (77.0%), vendor/distributor logistics issues (75.9%), and administrative burden (74.9%). Top facilitators included state funding (78.2%) and increased federal reimbursement (77.2%). SFAs with fewer students eligible for free or reduced-price meals (as opposed to SFAs with more) reported greater increases in meal participation and reductions in stigma but also more administrative burdens. Larger SFAs reported greater increases in revenues, staff salaries, and improvements in meal quality than smaller SFAs but also more challenges. Overall, California's USM policy has enhanced student access to healthy meals while mitigating social and financial barriers. Understanding California's experience can inform other jurisdictions considering or implementing similar policies.

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools.

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain.

Importance: Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases. Objective: To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets. Design, Setting, and Participants: This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022. Intervention: Implementation of calorie labeling of prepared foods in April 2017. Main Outcomes and Measures: Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses). Results: Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%). Conclusions and Relevance: In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

Calorie Labeling and Product Reformulation: A Longitudinal Analysis of Supermarket-Prepared Foods.

INTRODUCTION: The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017. METHODS: The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace. RESULTS: Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items. CONCLUSIONS: Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake.

Comparing shopper characteristics by online grocery ordering use among households in low-income communities in Maine.

OBJECTIVE: Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations - especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store. DESIGN: We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store). SETTING: Two Maine supermarkets. PARTICIPANTS: 863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials. RESULTS: Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30-39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186-300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online. CONCLUSIONS: In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.

Supermarket Purchases Over the Supplemental Nutrition Assistance Program Benefit Month: A Comparison Between Participants and Nonparticipants.

INTRODUCTION: The Supplemental Nutrition Assistance Program provides financial assistance for food and beverage purchases to approximately 1 in 7 Americans, with benefits distributed once monthly. Most Supplemental Nutrition Assistance Program benefits are spent early in the month, leading to decreased caloric intake later in the month. The effects of this early benefit depletion on the types of foods and beverages purchased over the course of the month is unclear. METHODS: Using individually tracked sales data from 950 participants enrolled in 2 supermarket-based RCTs in Maine (October 2015-April 2016 and October 2016-June 2017), purchases of selected food categories by Supplemental Nutrition Assistance Program participants (n=248) versus nonparticipants (n=702) in the first 2 weeks compared with the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month were examined. Analyses were completed in 2019. RESULTS: For Supplemental Nutrition Assistance Program participants, adjusted mean food spending decreased 37% from the first 2 weeks to the last 2 weeks of the Supplemental Nutrition Assistance Program benefit month (p<0.0001) compared with a 3% decrease (p=0.02) for nonparticipants. The decline in spending by Supplemental Nutrition Assistance Program participants occurred in all examined categories: vegetables (-25%), fruits (-27%), sugar-sweetened beverages (-30%), red meat (-37%), convenience foods (-40%), and poultry (-48%). Difference-in-difference estimators comparing Supplemental Nutrition Assistance Program participants with nonparticipants were statistically significant (p<0.05) for all examined categories. CONCLUSIONS: In the second half of the Supplemental Nutrition Assistance Program benefit month, individuals reduced purchases of all examined categories. More research is needed to understand the impact of these fluctuations in spending patterns on the dietary quality of Supplemental Nutrition Assistance Program participants.

Financial Incentives Increase Purchases Of Fruit And Vegetables Among Lower-Income Households With Children.

The high cost of fruit and vegetables can be a barrier to healthy eating, particularly among lower-income households with children. We examined the effects of a financial incentive on purchases at a single supermarket by primary shoppers from low-income households who had at least one child. Participation in an in-store Cooking Matters event was requested for incentivized subjects but optional for their nonincentivized controls. The sample included but was not limited to Supplemental Nutrition Assistance Program participants. Compared to the controls, incentivized shoppers-who were given an immediate 50 percent discount on qualifying fruit and vegetables-increased weekly spending on those items by 27 percent; this change was for fresh produce. There was no change in purchases of frozen and canned produce or unhealthful foods. Estimated annual average daily consumption of fruit and vegetables by the incentivized shoppers and by one designated child per incentivized household did not change. Attendance at Cooking Matters events was low. These findings support financial incentive programs to increase fruit and vegetable purchasing but suggest that effective complementary approaches are needed to improve diet quality.

Cost-Effectiveness Analysis and Stakeholder Evaluation of 2 Obesity Prevention Policies in Maine, US.

OBJECTIVE: To evaluate the potential cost-effectiveness of and stakeholder perspectives on a sugar-sweetened beverage (SSB) excise tax and a Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSB purchases in Maine, US. DESIGN: A cost-effectiveness simulation model combined with stakeholder interviews. SETTING: Maine, US. PARTICIPANTS: Microsimulation of the Maine population in 2015 and interviews with stakeholders (n = 14). Study conducted from 2013 to 2017. MAIN OUTCOME MEASURES: Health care cost savings, net costs, and quality-adjusted life-years (QALYs) from 2017 to 2027. Stakeholder positions on policies. Retail SSB cost and implementation cost data were collected. ANALYSIS: Childhood Obesity Intervention Cost-Effectiveness Study project microsimulation model with uncertainty analysis to estimate cost-effectiveness. Thematic stakeholder interview coding. RESULTS: Over 10 years, the SSB and SNAP policies were projected to reduce health care costs by $78.3 million (95% uncertainty interval [UI], $31.7 million-$185 million) and $15.3 million (95% UI, $8.32 million-$23.9 million), respectively. The SSB and SNAP policies were projected to save 3,560 QALYs (95% UI, 1,447-8,361) and 749 QALYs (95% UI, 415-1,168), respectively. Stakeholders were more supportive of SSB taxes than the SNAP policy because of equity concerns associated with the SNAP policy. CONCLUSIONS AND IMPLICATIONS: Cost-effectiveness analysis provided evidence of potential health improvement and cost savings to state-level stakeholders weighing broader implementation considerations.

Make It Fresh, for Less! A Supermarket Meal Bundling and Electronic Reminder Intervention to Promote Healthy Purchases Among Families With Children.

OBJECTIVE: To evaluate the effects of a supermarket meal bundling and electronic reminder intervention on food choices of families with children. DESIGN: Quasi-experimental (meal bundling) and randomized, controlled trial (electronic reminders). SETTING: Large supermarket in Maine during 40-week baseline and 16-week intervention periods in 2015-2016. PARTICIPANTS: English-speaking adults living with at least 1 child aged ≤18 years (n = 300) with 25% of households participating in the Supplemental Nutrition Assistance Program. INTERVENTION(S): (1) Four bundles of ingredients needed to make 8 low-cost healthful meals were promoted in the store through displays and point-of-purchase messaging for 4 weeks each; (2) weekly electronic messages based on principles from behavioral psychology were sent to study participants reminding them to look for meal bundles in the store. MAIN OUTCOME MEASURES: (1) Difference in storewide sales and individual purchases of bundled items (measured using supermarket loyalty card data) from baseline to intervention in intervention vs control groups. ANALYSIS: Regressions controlling for total food spending and accounting for repeated measures. RESULTS: There were no differences in spending on bundled items resulting from the meal bundling intervention or the electronic reminders. CONCLUSIONS AND IMPLICATIONS: Overall, there was little impact of healthful meal bundles and electronic reminders on storewide sales or purchases of promoted items in a large supermarket.

What factors influence ultra-processed food purchases and consumption in households with children? A comparison between participants and non-participants in the Supplemental Nutrition Assistance Program (SNAP).

Ultra-processed foods are industrially formulated products that are convenient, highly-palatable, and contain few whole ingredients. While popular among US households regardless of SES, these foods constitute a relatively large proportion of grocery spending among low-income households participating in the Supplemental Nutrition Assistance Program (SNAP). Little is understood about the perceived factors influencing selection and consumption of these foods, particularly among households with children participating in SNAP. We conducted 5 focus groups with 45 parents of children under 18 years of age living in a low-income area of a Northeastern state. We conducted inductive-deductive thematic analysis to identify emergent themes and to identify similarities and differences by self-reported SNAP participation. Six themes related to ultra-processed food decision-making emerged, which were grouped into primarily rational or primarily intuitive processes. Rational decisions included concerns about the product's healthfulness, environmental sustainability, and desirable traits, which were each weighed against product cost when deciding between similar products. Intuitive themes included retailer marketing, household norms, and individual affective biases. The family social and emotional context and parenting practices were identified as important influences on preparation and consumption of ultra-processed foods. Differences between SNAP participants and non-participants emerged. SNAP participants selected ultra-processed foods because of their familiarity and long shelf-life -- attributes that mitigated fear of wasting money on foods that may be rejected by children or spoil quickly. Some SNAP participants purchased ultra-processed foods at the beginning of the monthly benefit cycle and stored them in anticipation of food scarcity at the end of the month. These findings underscore the distinct role of ultra-processed foods in meal planning and budgeting and the importance of rational considerations that particularly affect food choices of households participating in SNAP.

A Supermarket Double-Dollar Incentive Program Increases Purchases of Fresh Fruits and Vegetables Among Low-Income Families With Children: The Healthy Double Study.

OBJECTIVE: To carry out a pilot study to determine whether a supermarket double-dollar fruit and vegetable (F&V) incentive increases F&V purchases among low-income families. DESIGN: Randomized controlled design. Purchases were tracked using a loyalty card that provided participants with a 5% discount on all purchases during a 3-month baseline period followed by the 4-month intervention. SETTING: A supermarket in a low-income rural Maine community. PARTICIPANTS: A total of 401 low-income and Supplemental Nutrition Assistance Program (SNAP) supermarket customers. INTERVENTION: Same-day coupon at checkout for half-off eligible fresh, frozen, or canned F&V over 4 months. MAIN OUTCOME MEASURE: Weekly spending in dollars on eligible F&V. ANALYSIS: A linear model with random intercepts accounted for repeated transactions by individuals to estimate change in F&V spending per week from baseline to intervention. Secondary analyses examined changes among SNAP-eligible participants. RESULTS: Coupons were redeemed among 53% of eligible baskets. Total weekly F&V spending increased in the intervention arm compared with control ($1.83; 95% confidence interval [CI], $0.29 to $3.88). The largest increase was for fresh F&V ($1.97; 95% CI, $0.49 to $3.44). Secondary analyses revealed greater increases in F&V spending among SNAP-eligible participants who redeemed coupons ($5.14; 95% CI, $1.93 to $8.34) than among non-SNAP eligible participants who redeemed coupons ($3.88; 95% CI, $1.67 to $6.08). CONCLUSIONS AND IMPLICATIONS: A double-dollar pricing incentive increased F&V spending in a low-income community despite the moderate uptake of the coupon redemption. Customers who were eligible for SNAP saw the greatest F&V spending increases. Financial incentives for F&V are an effective strategy for food assistance programs to increase healthy purchases and improve dietary intake in low-income families.

Transactions at a Northeastern Supermarket Chain: Differences by Supplemental Nutrition Assistance Program Use.

INTRODUCTION: Although one in seven Americans receives Supplemental Nutrition Assistance Program (SNAP) benefits, little is known about how these benefits for food are spent because individual-level sales data are not publicly available. The purpose of this study is to compare transactions made with and without SNAP benefits at a large regional supermarket chain. METHODS: Sales data were obtained from a large supermarket chain in the Northeastern U.S. for a period of 2 years (April 2012-April 2014). Multivariate multiple regression models were used to quantify relative differences in dollars spent on 31 predefined SNAP-eligible food categories. Analyses were completed in 2016. RESULTS: Transactions with SNAP benefit use included higher spending on less healthful food categories, including sugar-sweetened beverages ($1.08), red meat ($1.55), and convenience foods ($1.34), and lower spending on more healthful food categories, such as fruits (-$1.51), vegetables (-$1.35), and poultry (-$1.25) compared to transactions without SNAP benefit use. CONCLUSIONS: These findings provide objective data to compare purchases made with and without SNAP benefits. Next steps should be to test proposed SNAP modifications to determine whether they would have the intended effect of promoting healthier purchasing patterns among SNAP beneficiaries.

Investigating How to Align Schools' Marketing Environments With Federal Standards for Competitive Foods.

BACKGROUND: Limiting food and beverage marketing to children is a promising approach to influence children's nutrition behavior. School-based marketing influences nutrition behavior and studies have consistently found marketing for nonnutritious foods and beverages in schools. No studies have examined the resources necessary to align school marketing environments with federal school nutrition standards. The purpose of this study was to determine how to improve school marketing environments so that they align with new federal competitive food nutrition standards. METHODS: We assessed food marketing environments in 3 Portland, Maine schools using the Food and Beverage Marketing Survey (FBMS) and provided technical assistance to bring their marketing environments into conformity with the federal competitive food regulations, tracking resources and strategies for marketing removal. RESULTS: Noncompliant marketing was significantly reduced pre- to postintervention. Intervention strategies were facilitated by the School Health Coordinator and school-based wellness teams. CONCLUSIONS: Low monetary resources were required to remove marketing not compliant with federal nutrition standards for foods sold in schools. Several key challenges remain to sustain efforts. This study provides timely information for policymakers to support crafting policies that address the realities of school nutrition environments and universal enforcement challenges.