A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.

BACKGROUND: The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month. DESIGN: These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC. PARTICIPANTS/SETTING: Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed. MAIN OUTCOME MEASURES: Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category. STATISTICAL ANALYSES PERFORMED: For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month. RESULTS: On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only. CONCLUSIONS: Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

Caregiver Perspectives on Underutilization of WIC: A Qualitative Study.

OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC. METHODS: In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research. RESULTS: Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others. CONCLUSIONS: Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

Participant Perceptions of a Free Fresh Produce Market at a Health Center.

OBJECTIVE: To examine participant perceptions of a free, monthly produce market at a health center in Massachusetts. DESIGN: Participants were recruited at a produce market between June 2019 and January 2020 and engaged in a 30-65-minute focus group (n = 3 English language; n = 2 Spanish; n = 2 Arabic) conducted by trained facilitators using a semistructured guide. PARTICIPANTS: Adults (n = 49) who had attended the market at least twice in the previous 6 months. MAIN OUTCOME MEASURES: Participant-reported facilitators, barriers, perceived benefits, and opportunities for improvement. ANALYSIS: Conventional content analysis. RESULTS: Reported facilitators included accessibility (eg, convenient location and timing), program experience (eg, positive volunteer interactions), and characteristics of goods and services (eg, acceptable variety of produce). Barriers fell under similar themes and included transportation challenges, poor weather, and insufficient quantity of produce for larger households. Participants perceived the market as improving diet and finances and offered suggestions for improvement: distributing nonproduce foods (eg, meat) or nonfood items (eg, toiletries) and augmenting existing initiatives aimed to help attendees make use of the produce (eg, handing out recipe cards). CONCLUSIONS AND IMPLICATIONS: The produce market was widely accepted, and targeted areas for improvement were identified. Findings may improve existing and future charitable produce markets among diverse populations.

Decreasing Trends in Heavy Sugar-Sweetened Beverage Consumption in the United States, 2003 to 2016.

BACKGROUND: Although previous studies have documented declines in intake from sugar-sweetened beverages (SSB) in the United States, it is important to examine whether heavy SSB intake (≥500 kcal/day) is decreasing in parallel. Examining the intake patterns of heavy SSB consumers is imperative because these individuals face the greatest health risks and thus may benefit the most from targeted policy and programmatic efforts to reduce intake. OBJECTIVE: To provide the most recent national estimates for trends in heavy SSB intake among children and adults in the United States between 2003-2004 and 2015-2016, to examine whether these trends differ by sociodemographic characteristics, and to describe where SSB are acquired and consumed by the heaviest SSB consumers. DESIGN: Trend analyses of demographic and 24-hour dietary recall data in the 2003-2004 to 2015-2016 National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: Participants were 21,783 children (aged 2 to 19 years) and 32,355 adults (aged ≥20 years). MAIN OUTCOME MEASURES: Heavy SSB intake (≥500 kcal/day). STATISTICAL ANALYSIS: Survey-weighted logistic regression was used to estimate the proportion of heavy SSB consumers, overall and by age group, race/ethnicity, sex, and income status (lower income = <130% Federal Poverty Level). Proportions were used to summarize where SSB are most often acquired and consumed. RESULTS: Between 2003-2004 and 2015-2016, the prevalence of heavy SSB intake declined significantly among children (10.9% to 3.3%) and adults (12.7% to 9.1%). For children, these declines were observed across age group, sex, family income status, and most races/ethnicities. For adults, these significant declines were observed among 20- to 39-year olds, most races/ethnicities, and higher-income adults. However, there was a significant increase in heavy SSB intake among adults aged ≥60 years and no significant change among 40- to 59-year olds and non-Mexican Hispanic adults. The majority of energy intake from SSB consumed by heavy SSB drinkers was from products acquired from stores and was consumed at home. CONCLUSIONS: Heavy SSB intake is declining, but attention must be paid to certain subgroups with high intake for whom trends are not decreasing, particularly 40- to 59-year olds and non-Mexican Hispanic adults.

Strengthening the Public Health Impacts of the Supplemental Nutrition Assistance Program Through Policy.

The US Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) is the cornerstone of the US nutrition safety net. Each month, SNAP provides assistance to 40 million low-income Americans-nearly half of them children. A number of changes could strengthen the public health impacts of SNAP. This review first presents a framework describing the mechanisms through which SNAP policy can influence public health, particularly by affecting the food security, the diet quality, and, subsequently, the health of SNAP participants. We then discusspolicy opportunities with the greatest potential to strengthen the public health impacts of SNAP, organized into three areas: (a) food production and distribution, (b) benefit allocation, and (c) eligibility and enrollment. For each section, we describe current policy and limitations of the status quo, suggest evidence-based opportunities for policy change to improve public health, and identify important areas for future research.

Understanding price incentives to upsize combination meals at large US fast-food restaurants.

OBJECTIVE: To understand price incentives to upsize combination meals at fast-food restaurants by comparing the calories (i.e. kilocalories; 1 kcal = 4·184 kJ) per dollar of default combination meals (as advertised on the menu) with a higher-calorie version (created using realistic consumer additions and portion-size changes). DESIGN: Combination meals (lunch/dinner: n 258, breakfast: n 68, children's: n 34) and their prices were identified from online menus; corresponding nutrition information for each menu item was obtained from a restaurant nutrition database (MenuStat). Linear models were used to examine the difference in total calories per dollar between default and higher-calorie combination meals, overall and by restaurant. SETTING: Ten large fast-food chain restaurants located in the fifteen most populous US cities in 2017-2018. PARTICIPANTS: None. RESULTS: There were significantly more calories per dollar in higher-calorie v. default combination meals for lunch/dinner (default: 577 kJ (138 kcal)/dollar, higher-calorie: 707 kJ (169 kcal)/dollar, difference: 130 kJ (31 kcal)/dollar, P < 0·001) and breakfast (default: 536 kJ (128 kcal)/dollar, higher-calorie: 607 kJ (145 kcal)/dollar, difference: 71 kJ (17 kcal)/dollar, P = 0·009). Results for children's meals were in the same direction but were not statistically significant (default: 536 kJ (128 kcal)/dollar, higher-calorie: 741 kJ (177 kcal)/dollar, difference: 205 kJ (49 kcal)/dollar, P = 0·053). Across restaurants, the percentage change in calories per dollar for higher-calorie v. default combination meals ranged from 0·1 % (Dunkin' Donuts) to 55·0 % (Subway). CONCLUSIONS: Higher-calorie combination meals in fast-food restaurants offer significantly more calories per dollar compared with default combination meals, suggesting there is a strong financial incentive for consumers to 'upsize' their orders. Future research should test price incentives for lower-calorie options to promote healthier restaurant choices.

Sugary Drink Consumption Among Children by Supplemental Nutrition Assistance Program Status.

INTRODUCTION: The Supplemental Nutrition Assistance Program is the largest U.S. federally funded nutrition assistance program, providing food assistance to more than 40 million low-income Americans, half of whom are children. This paper examines trends in sugar-sweetened beverage consumption among U.S. children and adolescents by Supplemental Nutrition Assistance Program participation status. METHODS: Dietary data from 15,645 participants (aged 2-19 years) were obtained from the 2003-2014 National Health and Nutrition Examination surveys. Supplemental Nutrition Assistance Program participation was categorized as: Supplemental Nutrition Assistance Program participant, income-eligible nonparticipant, lower income-ineligible nonparticipant, and higher income-ineligible nonparticipant. Survey-weighted logistic regressions estimated predicted probabilities of daily sugar-sweetened beverage consumption, and negative binomial regressions estimated predicted per capita daily consumption of sugar-sweetened beverage calories. Data were analyzed in 2019. RESULTS: From 2003 to 2014, there were significant declines across all Supplemental Nutrition Assistance Program participation categories for sugar-sweetened beverage consumption (participants: 84.2% to 75.6%, p=0.009; income-eligible nonparticipants: 85.8% to 67.5%, p=0.004; lower income-ineligible nonparticipants: 84.3% to 70.6%, p=0.026; higher income-ineligible nonparticipants: 82.2% to 67.7%, p=0.001) and per capita daily sugar-sweetened beverage calories (participants: 267 to 182 kilocalories, p<0.001; income-eligible nonparticipants: 269 to 168 kilocalories, p<0.001; lower income-ineligible nonparticipants: 249 to 178 kilocalories, p=0.008; higher income-ineligible nonparticipants: 244 to 161 kilocalories, p<0.001). Per capita sports/energy drink consumption increased among Supplemental Nutrition Assistance Program participants (2 to 15 kilocalories, p=0.007). CONCLUSIONS: Sugar-sweetened beverage consumption has declined for children and adolescents in all Supplemental Nutrition Assistance Program participation categories, but current levels remain high. There were fewer favorable trends over time for consumption of sugar-sweetened beverage subtypes among Supplemental Nutrition Assistance Program participants relative to other participant categories.

Implementation of a Rooftop Farm Integrated With a Teaching Kitchen and Preventive Food Pantry in a Hospital Setting.

Safety-net hospitals serving populations with disproportionately high levels of poverty, food insecurity, and chronic disease can utilize innovative strategies to improve the health and environment of their communities. Boston Medical Center in Boston, Massachusetts, constructed an on-site rooftop farm to provide fresh produce for the hospital's preventive food pantry, teaching kitchen, cafeterias, and inpatient meal services. This novel model can be replicated by other organizations aiming to alleviate food insecurity, encourage healthy eating, and promote environmental sustainability.

Trends in Energy Drink Consumption Among U.S. Adolescents and Adults, 2003-2016.

INTRODUCTION: Energy drinks refer to non-alcoholic beverages that contain caffeine, amino acids, herbs, and vitamins. Although energy drinks are marketed to reduce fatigue and improve physical/mental performance, frequent consumption of these beverages has been linked to negative health consequences. The purpose of this study is to provide timely, national estimates of the percentage of energy drink consumers in the U.S. and to analyze trends in energy drink intake between 2003 and 2016. METHODS: A total of 9,911 adolescents (aged 12-19 years); 12,103 young adults (aged 20-39 years); and 11,245 middle-aged adults (aged 40-59 years) were assessed using dietary data from the 2003-2016 National Health and Nutrition Examination Surveys. For each age group (adolescents, young adults, and middle-aged adults), logistic regression was used to estimate the proportion of energy drink consumers, and negative binomial regression was used to estimate per capita energy drink consumption, adjusting for covariates. Differences in total caffeine intake between energy drink consumers and non-consumers were examined by pooling all survey years together and using negative binomial regression. Analyses were conducted in 2018. RESULTS: From 2003 to 2016, the prevalence of energy drink consumption increased significantly for adolescents (0.2% to 1.4%, p=0.028); young adults (0.5% to 5.5%, p<0.001); and middle-aged adults (0.0% to 1.2%, p=0.006). Per capita consumption of energy drinks increased significantly from 2003 to 2016 only for young adults (1.1 to 9.7 calories, p<0.001). Pooled across years, energy drink consumers had significantly higher total caffeine intake compared with non-consumers for adolescents (227.0 mg vs 52.1 mg, p<0.001); young adults (278.7 mg vs 135.3 mg, p<0.001); and middle-aged adults (348.8 mg vs 219.0 mg, p<0.001). CONCLUSIONS: These findings indicate that consumption of energy drinks has grown substantially and that these drinks are a major source of caffeine among those who consume them.

Strategies to reduce sugar-sweetened beverage consumption and increase water access and intake among young children: perspectives from expert stakeholders.

OBJECTIVES: To summarize stakeholder recommendations and ratings of strategies to reduce sugar-sweetened beverage (SSB) consumption and increase water access and intake among young children (0-5 years). DESIGN: Two online surveys: survey 1 asked respondents to recommend novel and innovative strategies to promote healthy beverage behaviour; survey 2 asked respondents to rank each of these strategies on five domains (overall importance, feasibility, effectiveness, reach, health equity). Open-ended questions were coded and analysed for thematic content. SETTING: Using a snowball sampling approach, respondents were invited to complete the survey through an email invitation or an anonymous listserv link. Of the individuals who received a private email invitation, 24 % completed survey 1 and 29 % completed survey 2. SUBJECTS: Survey 1 (n 276) and survey 2 (n 182) included expert stakeholders who work on issues related to SSB and water consumption. RESULTS: Six overarching strategies emerged to change beverage consumption behaviours (survey 1): education; campaigns and contests; marketing and advertising; price changes; physical access; and improving the capacity of settings to promote healthy beverages. Labelling and sugar reduction (e.g. reformulation) were recommended as strategies to reduce SSB consumption, while water testing and remediation emerged as a strategy to promote water intake. Stakeholders most frequently recommended (survey 1) and provided higher ratings (survey 2) to strategies that used policy, systems and/or environmental changes. CONCLUSIONS: The present study is the first to assess stakeholder opinions on strategies to promote healthy beverage consumption. This knowledge is key for understanding where stakeholders believe resources can be best utilized.

100% Juice, Fruit, and Vegetable Intake Among Children in the Special Supplemental Nutrition Program for Women, Infants, and Children and Nonparticipants.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides monthly food packages to low-income children (aged 1-4 years) in the U.S., including 128 ounces of 100% fruit juice and an $8 cash value voucher for purchasing fruits and vegetables. The fruit juice allowance translates to 71%-107% of the maximum intake recommended by the American Academy of Pediatrics (4-6 ounces/day). Careful examination of WIC food package allocations is necessary because overconsumption of fruit juice among young children has been linked to weight gain and juice lacks important nutrients found in whole fruit (e.g., fiber). METHODS: A total of 1,576 children aged 2-4 years were assessed using the 2009-2014 National Health and Nutrition Examination Surveys. Multiple linear regressions were conducted in 2017 to analyze the association between WIC program participation and intake of 100% fruit juice, whole fruits, and vegetables. Logistic regression was used to examine the association between WIC program participation and the odds of exceeding the American Academy of Pediatrics maximum intake for juice. RESULTS: Adjusting for child and parent/caregiver characteristics, WIC participants consumed significantly more 100% fruit juice (ß=0.22 cup equivalents/day, 95% CI=0.04, 0.40) compared with income-eligible nonparticipants, but not more whole fruits or total vegetables. WIC participants had 1.51-times greater odds (95% CI=1.06, 2.14) of exceeding the age-specific American Academy of Pediatrics maximum intake for juice compared with income-eligible nonparticipants. CONCLUSIONS: These findings support recommendations to reduce 100% fruit juice allowances in the WIC program and reallocate those funds to the cash value voucher to increase whole fruit and vegetable consumption.