SNAP and Cardiometabolic Risk in Youth.

Increasing numbers of children and adolescents have unhealthy cardiometabolic risk factors and show signs of developing metabolic syndrome (MetS). Low-income populations tend to have higher levels of risk factors associated with MetS. The Supplemental Nutrition Assistance Program (SNAP) has the potential to reduce poverty and food insecurity, but little is known about how the program affects MetS. We examine the relationship between SNAP and the cardiometabolic risk factors in children and adolescents using regression discontinuity to control for unobserved differences between participants and nonparticipants. We find that SNAP-eligible youth who experience food insecurity have significantly healthier outcomes compared to food-insecure youth just over the income-eligibility threshold. Our findings suggest that SNAP may be most beneficial to the most disadvantaged households. Policy makers should consider the broad range of potential health benefits of SNAP.

Age of Bottle Cessation and BMI-for-Age Percentile among Children Aged Thirty-Six Months Participating in WIC.

Background: Children's age at bottle weaning typically ranges from 12 to 24 months. The recommended age of bottle weaning varies. The American Academy of Pediatrics recommends weaning by 12 months; The American Academy of Pediatric Dentistry recommends 12-15 months; The US Department of Agriculture recommends 18 months. Prolonged bottle use is associated with dental caries, iron-deficiency anemia, and child overweight or obesity. We examined factors associated with age of bottle cessation, and the association between age of bottle cessation and BMI-for-age percentile at age 36 months among Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants. Methods: Data were from the WIC Infant and Toddler Feeding Practices Study-2 (ITFPS-2). The ITFPS-2, a longitudinal study of WIC participants (mothers and their children) began in 2013. We used Cox proportional hazards models to identify factors associated with bottle cessation and multivariate linear regression to examine the association between age of bottle cessation and BMI. Results: About 34% of children used a bottle longer than 12 months, and 13% longer than 18 months. Bottle cessation at older ages was associated with Hispanic ethnicity, multiparity, low income, low education, higher caregiver weight, and not initiating breastfeeding. The adjusted children's BMI-for-age percentile at age 36 months increased by 0.47 for each additional month of bottle use. Conclusion: Prolonged bottle use was associated with increased children's BMI-for-age percentile. Future research is warranted to determine the optimal age to recommend bottle cessation for WIC participants.

Factors Associated with the Initiation of Added Sugar among Low-Income Young Children Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children in the US.

Added sugar intake at a young age is associated with chronic diseases including cardiovascular diseases, asthma, elevated blood pressure, and overweight. The Dietary Guidelines for Americans 2020-2025 and the American Heart Association recommend delaying the introduction of added sugar until age 2. The aims of this study were to identify the timing of added sugar initiation; factors associated with added sugar initiation; and the top five added sugar foods and beverages consumed by infants and children at three age ranges (<7 months, 8-13 months, and 14-24 months). Data were from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study-2, a longitudinal, national population of WIC participants enrolled in WIC eligible clinics (n = 3835). The Cox proportional hazards model was used to examine the factors associated with introducing added sugar. About 25% of children were given added sugar at or before 7 months. Contributing factors were caregivers' race/ethnicity, education, employment, weight status, parity, child sex, and premature birth (all p < 0.05). The top added sugar foods consumed between 1-24 months were cereal, crackers, apple sauce, dessert, yogurt, sweetened beverages, syrup and preserves, and cookies. Further research to examine the impact of early initiation of added sugar on health outcomes and taste preferences is warranted.

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.

An Increase in SNAP Benefits Did Not Impact Food Security or Diet Quality in Youth.

BACKGROUND: Low diet quality during childhood and adolescence is associated with adverse health outcomes later in life. Diet quality is generally poor in American youth, particularly in youth of low socioeconomic status. The Supplemental Nutrition Assistance Program (SNAP) is the primary safety net to help low-income households afford a healthy diet. Yet self-selection into the program creates challenges in estimating the relationship between SNAP and diet outcomes. OBJECTIVE: This study examined how the increase in SNAP benefits during the American Recovery and Reinvestment Act (ARRA) affected food security and diet quality in low-income youth. DESIGN: This analysis used a difference-in-differences design and data from the National Health and Nutrition Examination Survey 2007-2008 to 2011-2012 waves. PARTICIPANTS/SETTING: The sample included children and adolescents aged 2 to 18 years with household income ≤250% of the Federal Poverty Line. Food security and diet outcomes in SNAP-eligible youth (n = 2,797) were examined, with children in nearly SNAP-eligible households serving as a comparison group (n = 1,169). The diet quality analysis stratified the sample by age range. MAIN OUTCOME MEASURES: The study assessed food security and 6 dietary outcomes: 2 nutrients (sodium and fiber), 3 food categories (fruit, vegetables, and sugar-sweetened beverages), and 1 measure of overall diet quality (Healthy Eating Index 2010). STATISTICAL ANALYSIS PERFORMED: Logistic regression and linear regression were used to estimate the relationship between SNAP eligibility and child food security and diet. RESULTS: In unadjusted analysis, approximately 64% of SNAP-eligible children were food secure before ARRA and 73% were food secure while ARRA was in effect. Using logistic regression in a difference-in-differences framework, the ARRA SNAP benefit increase was not significantly associated with food security (odds ratio 1.37, P = 0.43). Diet quality of SNAP-eligible children was low, scoring a 46 out of 100 on the Healthy Eating Index 2010. Measures of diet quality did not significantly change from the pre-ARRA period to the ARRA period; this did not differ by age range. CONCLUSIONS: The increase in SNAP benefits during ARRA did not significantly impact food security or diet quality in low-income children and adolescents. Additional research to better understand how SNAP benefits impact dietary choice is warranted.

Black-white disparities in alcohol consumption trends among women in the United States, 1990-2015.

Alcohol consumption has more adverse consequences among African American women than among white women. Yet little is known about trends in alcohol consumption among African American women. Using the National Survey on Drug Use and Health, we examined trends in alcohol consumption among African American (n = 4,079) and white (n = 17,512) women, 1990-2015. We calculated population prevalence and used the Cochrane-Armitage test to examine trends, controlling for sociodemographic factors. In adjusted analyses, binge consumption increased for African American and white women; not consuming alcohol decreased among African Americans (all p < 0.05). Results highlight the need for culturally sensitive prevention and intervention strategies.

Increasing Access to WIC through Discount Variety Stores: Findings from Qualitative Research.

BACKGROUND: Many low-income neighborhoods do not include a full-service grocery store. In these communities, discount variety stores (DVS) can be convenient points of food access. However, no identified DVS are authorized to accept Special Supplemental Nutrition Program for Women, Infants, and Children Program (WIC) benefits. OBJECTIVE: One national DVS retailer implemented WIC in 10 stores located in low-income communities in North Carolina over a 10-month pilot period to assess WIC feasibility. METHODS: To better understand the facilitators and barriers to WIC implementation from the perspective of DVS staff, we analyzed 36 in-depth interviews with employees of this DVS chain at corporate, manager, and store clerk levels. RESULTS: Most participants provided positive feedback about implementing and offering WIC. Many store employees had personal experience participating in WIC, which increased their understanding of the WIC shopping experience. Store staff's prior WIC participation and customers' proximity to DVS locations were facilitators to implementation. Primary barriers included limited choice of store products for customers, complicated or unclear labeling of WIC products, and difficulty training employees to process WIC vouchers. CONCLUSIONS: These findings suggest that whereas most employees viewed WIC positively, barriers related to product selection and training must be addressed. Notably, North Carolina's recent change to an electronic system to process WIC transactions requires minimal manual employee training and should address several barriers to implementation. However, the computer system upgrades necessary to accept electronic WIC transactions may be a barrier for DVS to continued WIC acceptance. Future research is needed to evaluate implementation of electronic WIC transactions in DVS.

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) authorization of discount variety stores: leveraging the private sector to modestly increase availability of healthy foods.

BACKGROUND: Many lower-income communities in the United States lack a full-line grocery store. There is evidence that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) increases the availability of healthy foods in stores. One national discount variety store chain (DVS) that is often located in low-income neighborhoods became an authorized WIC vendor in 8 pilot stores. OBJECTIVES: The objective of this study was to evaluate how implementing WIC in DVS pilot stores affected sales of healthy, WIC-eligible foods. METHODS: We used DVS sales data and difference-in-differences regression to evaluate how WIC authorization affected sales of WIC-eligible foods in 8 DVS pilot stores, compared with 8 matched comparison stores. RESULTS: DVS added 18 new WIC-approved foods to become an authorized vendor. Results indicate that becoming a WIC vendor significantly increased sales of healthy, WIC-eligible foods that DVS carried before authorization. WIC implementation in DVS led to a 31-unit increase in sales of the original WIC foods per week on average (P < 0.01). Lower socioeconomic status, assessed using a summary measure, is associated with increased sales of WIC foods. Yet sales of non-WIC eligible foods (e.g., salty snack foods, candy bars, soda, and processed meats) were not affected by WIC authorization. CONCLUSIONS: Encouraging DVS stores to become WIC-authorized vendors has the potential to modestly increase DVS sales and the availability of healthy foods in low-income neighborhoods. If WIC authorization is financially viable for small-format variety stores, encouraging similar small-format variety stores to become WIC-authorized has the potential to improve food access.

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.

Is having any prenatal care associated with lower infant mortality in West Africa? Evidence from the Demographic and Health Surveys.

Although developing countries may find it difficult to provide adequate prenatal care, it is likely that they can provide at least some. We examined associations of prenatal care with infant mortality in West Africa. We used data from the Demographic and Health Surveys (n = 57,322) and proportional hazards regression models to estimate the risk of infant mortality. Having any prenatal care was associated with lower infant mortality risk in all but the poorest wealth quintile, with 56% lower risk in the wealthiest quintile (95% confidence interval [CI] 0.28-0.69). Even limited prenatal care may significantly reduce infant mortality in developing countries.

Accessibility Landscapes of Supplemental Nutrition Assistance Program-Authorized Stores.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States. Participants receive electronic benefits that are redeemable at a variety of food stores. Previous research notes that low-income neighborhoods often lack supermarkets with high-quality, affordable food. OBJECTIVE: The first aim of this study was to explore the number and spatial distribution of SNAP stores by type and to assess how SNAP benefit redemption is linked to store type in North Carolina in 2015. The second aim was to compare the demographics of populations living in areas with a high concentration of SNAP participants vs areas with a lower concentration of SNAP participants. The third aim was to test for disparities in the availability of and access to SNAP-authorized stores in areas with high vs low concentration of SNAP participants stratified by rural/urban status. DESIGN: US Department of Agriculture and US Census data were used to explore the spatial distribution of SNAP stores at the census block group level utilizing a Geographic Information System. PARTICIPANTS: The 9,556 North Carolina SNAP stores in 2015 categorized into full-variety and limited-variety stores. OUTCOME MEASURES: Proximity to limited-variety SNAP food stores and full-variety SNAP food stores within access range (1 mile in urban areas and 10 miles in rural areas). STATISTICAL ANALYSES: Wilcoxon rank sum and χ2 tests are used to compare the distance to and concentration of SNAP stores by rurality and SNAP participant concentration at census block group scale. RESULTS: Among the SNAP stores in North Carolina, 83% are limited-variety stores and 17% are full-variety stores. There are disparities in the demographics of individuals living in census block groups with a high proportion of SNAP participants compared to census block groups with a lower proportion of SNAP participants. More households in higher SNAP participant census block groups were non-white, did not have a car, and had children compared to census block groups with lower SNAP participation. Residents in high SNAP participant census block groups typically had access to 0 full-variety stores and 4 limited-variety stores in urban areas and 3 full-variety stores and 17 limited-variety stores in rural areas. CONCLUSIONS: SNAP participant access to a variety of stores should be considered when approving food stores for SNAP authorization. More research is essential to disentangle the relationship between access to SNAP store type and SNAP food choice and to estimate geographical disparities.

Foods and Beverages Available at SNAP-Authorized Drugstores in Sections of North Carolina.

OBJECTIVE: To assess healthy food availability in Supplemental Nutrition Assistance Program-authorized drugstores by store chain and neighborhood income level in 3 regions of North Carolina. DESIGN: Cross-sectional, descriptive study. SETTING: Twenty-five counties in North Carolina. PARTICIPANTS: A total of 108 drugstores (36 CVS Health, 36 Rite Aid, and 36 Walgreens). MAIN OUTCOME MEASURE(S): Fifty foods and beverages offered at drugstores, categorized as healthier and less healthy. ANALYSIS: Kruskal-Wallis tests were used to test differences in the availability of foods and beverages by chain and neighborhood income. RESULTS: Of the 50 foods/beverages observed, 11 were available at all drugstores. Three of the 36 (8%) healthier items were available at all stores (100% fruit juice, water, and high-fiber cereal) whereas 8 of the 14 less healthy items (57%) were available at all stores (chips, sports drinks, energy drinks, regular soda, diet soda, sugar-sweetened beverages, beer, and wine). Only 3% of drugstores offered fresh vegetables and 4% offered fresh fruits. Less than 20% offered frozen chicken or beef. For 36 healthier foods, 11 differed by chain (28%); for less healthy foods 2 of 14 differed by chain (7%). Foods and beverages offered did not vary by neighborhood income. CONCLUSIONS AND IMPLICATIONS: Although drugstores offer some healthier items, few offer fresh produce. As the drugstore industry changes, it is important for the nutrition community to study the impact of these changes on food purchasing behavior and ultimately health.

Associations of government health expenditures, the supply of health care professionals, and country literacy with prenatal care use in ten West African countries.

Social and health care context may influence prenatal care use. We studied associations of government health expenditures, supply of health care professionals, and country literacy rates with prenatal care use in ten West African countries, controlling for individual factors. We used data from Demographic and Health Surveys (n = 58,512) and random effect logistic regression models to estimate the likelihood of having any prenatal care and adequate prenatal care. Each percentage increase in the literacy rate was associated with 4% higher odds of having adequate prenatal care (p = .029). Higher literacy rates among women may help to promote adequate prenatal care.

Association of type of birth attendant and place of delivery on infant mortality in sub-Saharan Africa.

OBJECTIVE: To examine the association between type of birth attendant and place of delivery, and infant mortality (IM). METHODS: This cross-sectional study used self-reported data from the Demographic Health Surveys for women in Ghana, Kenya, and Sierra Leone. Logistic regression estimated odds ratios (ORs) and95% confidence intervals. RESULTS: In Ghana and Sierra Leone, odds of IM were higher for women who delivered at a health facility versus women who delivered at a household residence (OR=3.18, 95% confidence interval, CI: 1.29-7.83, p=0.01 and OR=1.62, 95% CI: 1.15-2.28, p=0.01, respectively). Compared to the use of health professionals, the use of birth attendants for assistance with delivery was not significantly associated with IM for women in Ghana or Sierra Leone (OR=2.17, 95% CI: 0.83-5.69, p=0.12 and OR=1.25, 95% CI: 0.92-1.70, p=0.15, respectively). In Kenya, odds of IM, though nonsignificant, were lower for women who used birth attendants than those who used health professionals to assist with delivery (OR=0.85, 95% CI: 0.51-1.41, p=0.46), and higher with delivery at a health facility versus a household residence (OR=1.29, 95% CI: 0.81-2.03, p=0.28). CONCLUSIONS: Women in Ghana and Sierra Leone who delivered at a health facility had statistically significant increased odds of IM. Birth attendant type-IM associations were not statistically significant.Future research should consider culturally-sensitive interventions to improve maternal health and help reduce IM.

Associations of Household Wealth and Individual Literacy with Prenatal Care in Ten West African Countries.

Objective To examine associations of household wealth and individual literacy with prenatal care in West Africa. Methods Data on women with recent births in Benin, Burkina Faso, Ghana, Guinea, Liberia, Mali, Nigeria, Niger, Senegal and Sierra Leone were obtained from 2006 to 2010 Demographic and Health Surveys (n = 58,512). Separate logistic regressions estimated associations of literacy and wealth quintiles with prenatal care, controlling for age, parity, marital status, rural/urban residence, religion, multiple births, pregnancy wantedness, and the woman's involvement in decision-making at home. Any prenatal care was defined by ≥1 prenatal care visit. Adequate prenatal care was defined as at least four prenatal care visits beginning in the first trimester, at least one with a skilled provider. Results Seventy-eight percent of women had any prenatal care; 23 % had adequate care. Women who were not literate had lower odds of having any prenatal care (odds ratio, OR 0.29; 95 % confidence interval, CI 0.26-0.33) and lower odds of adequate care (OR 0.73, CI 0.68-0.78). Women in the poorest wealth quintile were substantially less likely to have any prenatal care than women in the wealthiest quintile (OR 0.24, CI 0.11-0.18), and less likely to have adequate care (OR 0.31, CI 0.27-0.35). Conclusions for Practice A substantial percentage of women in West Africa have no prenatal care. Few have adequate care. Illiteracy and poverty are important risk factors for having little or no prenatal care. Increasing education for girls, promoting culturally appropriate messages about prenatal care, and building trust in providers may increase prenatal care.

Availability of Foods and Beverages in Supplemental Nutrition Assistance Program-Authorized Dollar Stores in a Region of North Carolina.

BACKGROUND: There are >25,000 Supplemental Nutrition Assistance Program (SNAP)-authorized dollar stores throughout the United States; many are located in lower-income neighborhoods and provide an accessible food and beverage source for area residents. OBJECTIVE: The purpose of this research was to determine the percent of food deserts within 16 counties in North Carolina that include a SNAP dollar store; examine the types of foods and beverages at SNAP dollar stores in these counties; test whether the foods and beverages offered vary by SNAP dollar store chain; and test whether the foods and beverages available differ by rural and urban location. DESIGN: This cross-sectional study used a combination of publicly available data and primary data to investigate the research questions. Secondary data sources were obtained from the US Department of Agriculture's SNAP retailer locator, the US Census, and the US Department of Agriculture's Food Access Research Atlas. Availability of foods and beverages was assessed among a sample of 90 SNAP dollar stores in 16 counties in southern and western sections of North Carolina. Data were collected in June 2014. RESULTS: About half (52%) of the food deserts in the research area included a SNAP dollar store. Most of the sampled stores sold healthier food staples, such as frozen meats, brown rice, 100% whole-wheat bread, and dried beans. None of the stores sold fresh fruits or vegetables. Some of the foods and beverages offered (eg, frozen fruit, frozen unseasoned vegetables, nonfat or low-fat milk, frozen ground beef) varied by SNAP dollar store chain. The foods and beverages offered did not differ by rural or urban county location. CONCLUSIONS: SNAP dollar stores offer a number of healthy food staples; however, they do not sell fresh fruits or vegetables. Further food environment research should include dollar stores.

Is breakfast skipping associated with physical activity among U.S. adolescents? A cross-sectional study of adolescents aged 12-19 years, National Health and Nutrition Examination Survey (NHANES).

OBJECTIVE: To examine the association between breakfast skipping and physical activity among US adolescents aged 12-19 years. DESIGN: A cross-sectional study of nationally representative 2007-2008 National Health and Nutrition Examination Survey (NHANES) data. SETTING: Breakfast skipping was assessed by two 24 h dietary recalls. Physical activity was self-reported by participants and classified based on meeting national recommendations for physical activity for the appropriate age group. Multiple logistic regression analysis was used to model the association between breakfast skipping and physical activity while controlling for confounders. SUBJECTS: A total of 936 adolescents aged 12-19 years in the USA. RESULTS: After adjusting for family income, there was no association between breakfast skipping and meeting physical activity guidelines for age among adolescents aged 12-19 years (OR = 0.95, 95% CI 0.56, 1.32). CONCLUSIONS: Findings from the study differ from previous research findings on breakfast skipping and physical activity. Therefore, further research that uses large, nationally representative US samples and national recommended guidelines for physical activity is needed.

Understanding characteristics of families who buy local produce.

OBJECTIVE: To examine individual characteristics associated with local produce purchasing among North Carolina families with children. DESIGN: Cross-sectional analysis using data from the 2008 North Carolina Child Health Assessment and Monitoring Program (NC CHAMP), a representative sample of adults who have land-line telephones. SETTING: North Carolina. PARTICIPANTS: Families with children who participated in the NC CHAMP (n = 2,932). MAIN OUTCOME MEASURE: Frequency of buying local produce from local vendors in the past year. ANALYSIS: Bivariate and multivariate zero-inflated negative binomial regression identified characteristics associated with not buying local produce and, among those who purchased local produce, the frequency of purchasing. RESULTS: About half of families reported buying local produce on average once a month during the past year. In adjusted results, buying local produce was more likely among white families, lower income families, families living in rural areas, families with children who ate 5 or more servings of fruits and vegetables per day, and families with children in poor health. CONCLUSIONS AND IMPLICATIONS: Findings suggest that it may be useful for dietitians and health promotion professionals to assess the availability of local produce in urban areas and to focus interventions to promote local produce purchases among black families.

Medical home and pediatric primary care utilization among children with special health care needs.

INTRODUCTION: The medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs. METHOD: Survey logistic regression was used to analyze the relationship. RESULTS: When CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits. DISCUSSION: By controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.