Association of the Healthy, Hunger-Free Kids Act With Dietary Quality Among Children in the US National School Lunch Program.

Importance: The Healthy, Hunger-Free Kids Act of 2010, implemented nationwide in 2012, was intended to improve the nutritional quality of meals served in the National School Lunch Program (NSLP). Objective: To assess whether there was an association between the Healthy, Hunger-Free Kids Act of 2010 and dietary quality of lunch for students participating in the NSLP, stratified by income. Design, Setting, Participants: Serial cross-sectional study design, using National Health and Nutrition Examination Survey (NHANES) data from 2007-2008, 2009-2010, 2013-2014, and 2015-2016, of students who were surveyed in the NHANES and were attending schools participating in the NSLP. Individuals who were aged 5 to 18 years, in kindergarten through 12th grade, enrolled in a school that served school lunch, and had a reliable weekday dietary recall were included. Exposures: The Healthy, Hunger-Free Kids Act of 2010 (prepolicy period: 2007-2010; postpolicy period: 2013-2016), with participation in the NSLP estimated based on an algorithm. Main Outcomes and Measures: The primary outcome was dietary quality of intake for lunch, measured by the Healthy Eating Index-2010 (HEI-2010) score (range, 0-100; 0 indicates a diet with no adherence to the 2010 Dietary Guidelines for Americans and 100 indicates a diet with complete adherence to the guidelines). Results: Among 6389 students included in the surveys (mean age, 11.7 [95% CI, 11.6-11.9] years; 3145 [50%] female students; 1880 [56%] were non-Hispanic white), 32% were low-income, 12% were low-middle-income, and 56% were middle-high-income students. A total of 2472 (39%) were participants in the NSLP. Among low-income students, the adjusted mean prepolicy HEI-2010 score was 42.7 and the postpolicy score was 54.6 among NSLP participants and the adjusted mean prepolicy score was 34.8 and postpolicy score was 34.1 among NSLP nonparticipants (difference in differences, 12.6 [95% CI, 8.9-16.3]). Among low-middle-income students, the adjusted mean prepolicy HEI-2010 score was 40.4 and postpolicy score was 54.8 among NSLP participants and the adjusted mean prepolicy score was 34.2 and postpolicy score was 36.1 among NSLP nonparticipants (difference in differences, 12.4 [95% CI, 4.9-19.9]). Among middle-high-income students, the adjusted mean HEI-2010 prepolicy score was 42.7 and postpolicy score 55.5 for NSLP participants and the adjusted mean prepolicy score was 38.9 and prepolicy score was 43.6 for NSLP nonparticipants (difference in differences, 8.1 [95% CI, 4.2-12.0]). Conclusions and Relevance: In a serial cross-sectional study of students, the Healthy, Hunger-Free Kids Act of 2010 was associated with better changes in dietary quality for lunch among presumed low-income, low-middle-income, and middle-high-income participants in the NSLP compared with nonparticipants.

The Effects of SNAP Work Requirements in Reducing Participation and Benefits From 2013 to 2017.

Objectives. To assess the effects of work requirements for able-bodied adults without dependents in the Supplemental Nutrition Assistance Program (SNAP).Methods. We used changes in waivers of work requirements to assess the impact of requiring work on the number of SNAP participants and benefit levels in 2410 US counties from 2013 to 2017 using 2-way fixed effects models.Results. Adoption of work requirements was followed by reductions of 3.0% in total SNAP participation, 4.5% in SNAP households, and 3.8% in SNAP benefit dollars, after controlling for the unemployment, poverty, and Medicaid expansions. Because able-bodied adults without dependents comprise 8% to 9% of all SNAP participants, our findings indicate that work requirements caused more than one third of able-bodied adults without dependents to lose benefits.Conclusions. Expansions of work requirements caused about 600 000 participants to lose SNAP benefits from 2013 to 2017 and caused a reduction of about $2.5 billion in federal SNAP benefits in 2017. The losses occurred rapidly, beginning a few months after work requirements were imposed.Public Health Implications. SNAP work requirements rapidly reduce caseloads and benefits, reducing food and health access. Effects on participation could be similar for work requirements in Medicaid or other programs.

The Supplemental Nutrition Assistance Program (SNAP): History, Politics, and Public Health Implications.

This commentary introduces a special section of AJPH on the Supplemental Nutrition Assistance Program (SNAP), the US government's largest antihunger program and third-largest antipoverty program. SNAP demonstrably lifts adults, children, and families out of poverty, thereby constituting a vital component of this nation's public health safety net.Despite its well-documented benefits, SNAP is under political and budgetary siege, mainly from congressional representatives and lobbying groups opposed to a federal role in welfare. In part, SNAP is protected from total annihilation by its unusual authorizing legislation-the Farm Bill.This commentary provides a brief overview of the political history of SNAP and its Farm Bill location as background to the deeper analyses provided in this series of articles.

Supplemental Nutrition Assistance Program Data: Why Disclosure Is Needed.

The Supplemental Nutrition Assistance Program (SNAP) provides funding to low-income households to purchase food at participating stores. The goals of the program include reducing hunger, improving nutrition, and strengthening the US food system. These are interrelated, as food access and choice depend on availability.SNAP generates data that could be useful for program evaluation and evidence-based policymaking to reach public health goals. However, the US Department of Agriculture (USDA) does not collect or disclose all SNAP-related data. In particular, the USDA does not systematically collect food expenditure data, and although it does collect transaction (sales) and redemption data (the amount retailers are reimbursed through SNAP), it does not release these data at the store level.In 2018, Congress quietly changed the law to prohibit the USDA from disclosing store-level transaction and redemption data, and in 2019, the US Supreme Court blocked disclosure of these data. These federal proceedings can inform the outcome of additional efforts to disclose SNAP-related data, as well as future research and policy evaluation to support improved public health outcomes for SNAP beneficiaries.

Adoption and Design of Emerging Dietary Policies to Improve Cardiometabolic Health in the US.

PURPOSE OF REVIEW: Suboptimal diet is a leading cause of cardiometabolic disease and economic burdens. Evidence-based dietary policies within 5 domains-food prices, reformulation, marketing, labeling, and government food assistance programs-appear promising at improving cardiometabolic health. Yet, the extent of new dietary policy adoption in the US and key elements crucial to define in designing such policies are not well established. We created an inventory of recent US dietary policy cases aiming to improve cardiometabolic health and assessed the extent of their proposal and adoption at federal, state, local, and tribal levels; and categorized and characterized the key elements in their policy design. RECENT FINDINGS: Recent federal dietary policies adopted to improve cardiometabolic health include reformulation (trans-fat elimination), marketing (mass-media campaigns to increase fruits and vegetables), labeling (Nutrition Facts Panel updates, menu calorie labeling), and food assistance programs (financial incentives for fruits and vegetables in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infant and Children (WIC) program). Federal voluntary guidelines have been proposed for sodium reformulation and food marketing to children. Recent state proposals included sugar-sweetened beverage (SSB) taxes, marketing restrictions, and SNAP restrictions, but few were enacted. Local efforts varied significantly, with certain localities consistently leading in the proposal or adoption of relevant policies. Across all jurisdictions, most commonly selected dietary targets included fruits and vegetables, SSBs, trans-fat, added sugar, sodium, and calories; other healthy (e.g., nuts) or unhealthy (e.g., processed meats) factors were largely not addressed. Key policy elements to define in designing these policies included those common across domains (e.g., level of government, target population, dietary target, dietary definition, implementation mechanism), and domain-specific (e.g., media channels for food marketing domain) or policy-specific (e.g., earmarking for taxes) elements. Characteristics of certain elements were similarly defined (e.g., fruit and vegetable definition, warning language used in SSB warning labels), while others varied across cases within a policy (e.g., tax base for SSB taxes). Several key elements were not always sufficiently characterized in government documents, and dietary target selections and definitions did not consistently align with the evidence-base. These findings highlight recent action on dietary policies to improve cardiometabolic health in the US; and key elements necessary to design such policies.

Using a trauma-informed policy approach to create a resilient urban food system.

OBJECTIVE: Food insecurity is associated with toxic stress and adverse long-term physical and mental health outcomes. It can be experienced chronically and also triggered or exacerbated by natural and human-made hazards that destabilize the food system. The Baltimore Food System Resilience Advisory Report was created to strengthen the resilience of the city's food system and improve short- and long-term food security. Recognizing food insecurity as a form of trauma, the report was developed using the principles of trauma-informed social policy. In the present paper, we examine how the report applied trauma-informed principles to policy development, discuss the challenges and benefits of using a trauma-informed approach, and provide recommendations for others seeking to create trauma-informed food policy. DESIGN: Report recommendations were developed based on: semi-structured interviews with food system stakeholders; input from community members at outreach events; a literature review; Geographic Information System mapping; and other analyses. The present paper explores findings from the stakeholder interviews. SETTING: Baltimore, Maryland, USA. SUBJECTS: Baltimore food system stakeholders stratified by two informant categories: organizations focused on promoting food access (n 13) and community leaders (n 12). RESULTS: Stakeholder interviews informed the recommendations included in the report and supported the idea that chronic and acute food insecurity are experienced as trauma in the Baltimore community. CONCLUSIONS: Applying a trauma-informed approach to the development of the Baltimore Food System Resilience Advisory Report contributed to policy recommendations that were community-informed and designed to lessen the traumatic impact of food insecurity.

Reducing US cardiovascular disease burden and disparities through national and targeted dietary policies: A modelling study.

BACKGROUND: Large socio-economic disparities exist in US dietary habits and cardiovascular disease (CVD) mortality. While economic incentives have demonstrated success in improving dietary choices, the quantitative impact of different dietary policies on CVD disparities is not well established. We aimed to quantify and compare the potential effects on total CVD mortality and disparities of specific dietary policies to increase fruit and vegetable (F&V) consumption and reduce sugar-sweetened beverage (SSB) consumption in the US. METHODS AND FINDINGS: Using the US IMPACT Food Policy Model and probabilistic sensitivity analyses, we estimated and compared the reductions in CVD mortality and socio-economic disparities in the US population potentially achievable from 2015 to 2030 with specific dietary policy scenarios: (a) a national mass media campaign (MMC) aimed to increase consumption of F&Vs and reduce consumption of SSBs, (b) a national fiscal policy to tax SSBs to increase prices by 10%, (c) a national fiscal policy to subsidise F&Vs to reduce prices by 10%, and (d) a targeted policy to subsidise F&Vs to reduce prices by 30% among Supplemental Nutrition Assistance Program (SNAP) participants only. We also evaluated a combined policy approach, combining all of the above policies. Data sources included the Surveillance, Epidemiology, and End Results Program, National Vital Statistics System, National Health and Nutrition Examination Survey, and published meta-analyses. Among the individual policy scenarios, a national 10% F&V subsidy was projected to be most beneficial, potentially resulting in approximately 150,500 (95% uncertainty interval [UI] 141,400-158,500) CVD deaths prevented or postponed (DPPs) by 2030 in the US. This far exceeds the approximately 35,100 (95% UI 31,700-37,500) DPPs potentially attributable to a 30% F&V subsidy targeting SNAP participants, the approximately 25,800 (95% UI 24,300-28,500) DPPs for a 1-y MMC, or the approximately 31,000 (95% UI 26,800-35,300) DPPs for a 10% SSB tax. Neither the MMC nor the individual national economic policies would significantly reduce CVD socio-economic disparities. However, the SNAP-targeted intervention might potentially reduce CVD disparities between SNAP participants and SNAP-ineligible individuals, by approximately 8% (10 DPPs per 100,000 population). The combined policy approach might save more lives than any single policy studied (approximately 230,000 DPPs by 2030) while also significantly reducing disparities, by approximately 6% (7 DPPs per 100,000 population). Limitations include our effect estimates in the model; these estimates use interventional and prospective observational studies (not exclusively randomised controlled trials). They are thus imperfect and should be interpreted as the best available evidence. Another key limitation is that we considered only CVD outcomes; the policies we explored would undoubtedly have additional beneficial effects upon other diseases. Further, we did not model or compare the cost-effectiveness of each proposed policy. CONCLUSIONS: Fiscal strategies targeting diet might substantially reduce CVD burdens. A national 10% F&V subsidy would save by far the most lives, while a 30% F&V subsidy targeting SNAP participants would most reduce socio-economic disparities. A combined policy would have the greatest overall impact on both mortality and socio-economic disparities.

Protecting progress against childhood obesity--the National School Lunch Program.

Two years after their implementation, new school-nutrition standards are at risk. In response to complaints about food waste and difficulties in meeting certain goals, among other issues, lawmakers have proposed granting schools waivers if they are losing revenue.

Economics and obesity policy.

This paper elucidates the challenges surrounding the economics of some popular obesity-related policy proposals. Solid economic justifications for anti-obesity policies are often lacking, and evidence suggests policies like fat and soda taxes or restrictions on food stamp spending are unlikely to substantively affect obesity prevalence. In short, many of the same factors that make obesity such a complicated and multifaceted issue extend to the economic analysis of public health policies.

Availability of Low-Fat Milk and Produce in Small and Mid-Sized Grocery Stores After 2014 WIC Final Rule Changes, Tennessee.

INTRODUCTION: The 2007 Interim Rule mandated changes to food packages in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for implementation by 2009. The 2014 Final Rule required additional changes, including increasing the cash value voucher for fruits and vegetables from $6 to $8 for children by June 2014, and allowing only low-fat (1%) or nonfat milk for mothers and children aged 2 to 4 years by October 2014. This study evaluated the effect of the 2014 Final Rule changes on the food environment of small and mid-sized WIC-authorized grocery stores. METHODS: We analyzed secondary data using a natural experimental design to compare the percentage of shelf space for low-fat and nonfat milk and the number of fresh fruit and vegetable varieties in stock before and after the changes. We collected observational data on 18 small and mid-sized WIC-authorized grocery stores in Nashville, Tennessee, using the Nutrition Environment Measures in Store tool in March 2014 and February 2016. RESULTS: The mean percentage of shelf space occupied by low-fat and nonfat milk increased from 2.5% to 14.4% (P = .003), primarily because of an increase in the proportion of low-fat milk (P = .001). The mean number of fresh fruit and vegetable varieties increased from 24.3 to 27.7 (P = .01), with a significant increase for vegetables (P = .008) but not fruit. CONCLUSION: Availability of low-fat milk and variety of fresh vegetables increased after the Final Rule changes in the observed stores. Future research should examine outcomes in other cities.

Child Nutrition Programs: Flexibilities for Milk, Whole Grains, and Sodium Requirements. Interim final rule.

This interim final rule extends through school year 2018-2019 three menu planning flexibilities currently available to many Child Nutrition Program operators, giving them near-term certainty about Program requirements and more local control to serve nutritious and appealing meals to millions of children nationwide. These flexibilities include: Providing operators the option to offer flavored, low-fat (1 percent fat) milk in the Child Nutrition Programs; extending the State agencies' option to allow individual school food authorities to include grains that are not whole grain-rich in the weekly menu offered under the National School Lunch Program (NSLP) and School Breakfast Program (SBP); and retaining Sodium Target 1 in the NSLP and SBP. This interim final rule addresses significant challenges faced by local operators regarding milk, whole grains and sodium requirements and their impact on food development and reformulation, menu planning, and school food service procurement and contract decisions. The comments from the public on the long-term availability of these three flexibilities will help inform the development of a final rule, which is expected to be published in fall 2018 and implemented in school year 2019-2020.

Delivering Improved Nutrition: Dairy Ingredients in Food Aid Products.

The United States has a long history of food assistance for humanitarian need. The Food for Peace Act of 1954 established the United States' permanent food assistance program which has fed over 3 billion people in 150 countries worldwide through thousands of partner organizations. In 60 years, the program has evolved and will continue to do so. Recently, the program has gone from a focus on quantity of food shipped to quality food assistance from improved products, programs, and processes to effectively meet the needs of different vulnerable groups. The current debate focuses on the appropriateness of using fortified blended foods to prevent and treat malnutrition during the first 1000 days of life. Dairy ingredients have been at the center of this debate; they were included initially in fortified blended, removed in the 1980s, and now reincorporated into fortified therapeutic and supplemental foods. Improved quality food baskets and effective nutrition programming to prevent and treat malnutrition were developed through multisectoral collaboration between government and nongovernment organizations. The US Agency for International Development has focused on improving nutrition through development programs often tied to health, education, and agriculture. The years since 2008 have been a particularly intense period for improvement. The Food Aid Quality Review was established to update current food aid programming products, program implementation, cost-effectiveness, and interagency processes. Trials are underway to harmonize the areas of multisectoral nutrition programming and gather more evidence on the effects of dairy ingredients in food aid products.

Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Implementation of Electronic Benefit Transfer-Related Provisions. Final rule.

This final rule considers public comments submitted in response to the proposed rule published February 28, 2013 and implements the provisions set forth in the Healthy, Hunger-Free Kids Act of 2010 related to electronic benefit transfer (EBT) for the WIC Program (also referred to herein as ``the Program''). The HHFKA amended provisions of the Child Nutrition Act of 1966 (CNA) and was enacted on December 13, 2010. EBT provisions of the HHFKA and other EBT implementation requirements included in this final rule are: A definition of EBT; a mandate that all WIC State agencies implement EBT delivery method by October 1, 2020; system management and reporting requirements; revisions to current provisions that prohibit imposition of costs on vendors; a requirement for the Secretary of Agriculture to establish minimum lane equipage standards; a requirement for the Secretary of Agriculture to establish technical standards and operating rules; and a requirement that State agencies use the National Universal Product Code (NUPC) database.

National School Lunch Program and School Breakfast Program: Eliminating Applications Through Community Eligibility as Required by the Healthy, Hunger-Free Kids Act of 2010. Final rule.

This final rule establishes requirements for State agencies, local educational agencies, and schools operating the Community Eligibility Provision, a reimbursement option that allows the service of school meals to all children at no-cost in high poverty schools without collecting household applications. By eliminating the household application process and streamlining meal counting and claiming procedures through the Community Eligibility Provision, local educational agencies may substantially reduce administrative burden related to operating the National School Lunch and School Breakfast Programs. This rule codifies many requirements that were implemented through policy guidance following enactment of the Healthy, Hunger-Free Kids Act of 2010, as well as provisions of the proposed rule. These requirements will result in consistent, national implementation of the Community Eligibility Provision.

Supplemental Nutrition Assistance Program: Nutrition Education and Obesity Prevention Grant Program. Final rule.

This rule adopts the interim rule implementing the Supplemental Nutrition Assistance Program (SNAP) nutrition education and obesity prevention grant program with changes as provided in this rule. This rule also amends SNAP regulations to implement section 28 of the Food and Nutrition Act (FNA) of 2008, as added by section 241 of the Healthy, Hunger-Free Kids Act (HHFKA) of 2010, to award grants to States for provision of nutrition education and obesity prevention programs. These programs provide services for eligible individuals that promote healthy food choices consistent with the current Dietary Guidelines for Americans (DGAs). The rule provides State agencies with requirements for implementing section 28, including the grant award process and describes the process for allocating the Federal grant funding for each State's approved SNAP-Ed plan authorized under the FNA to carry out nutrition education and obesity prevention services each fiscal year. This final rule also implements section 4028 of the Agricultural Act of 2014 (Farm Bill of 2014), which authorizes physical activity promotion in addition to promotion of healthy food choices as part of this nutrition education and obesity prevention program.

Implications of the Supplemental Nutrition Assistance Program Tax Exemption on Sugar-Sweetened Beverage Taxes.

US state and local governments are debating sugar-sweetened beverage excise taxes to support public health. A related issue is whether such taxes would apply to beverage purchases made by Supplemental Nutrition Assistance Program (SNAP) participants. Federal law proscribes states from collecting excise taxes on SNAP purchases, but the law is confined to taxes at the point of sale. I provide legal analysis and recommendations for policymakers to enact taxes that are not subject to the SNAP tax exemption to potentially deter consumption by all consumers.