Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic.

OBJECTIVE: This study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic. DESIGN: Weekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes. SETTING: North Carolina large chain grocery stores. PARTICIPANTS: Large chain grocery store/SNAP shoppers. INTERVENTION: Rural/urban status of the stores and COVID-19 pandemic onset. MAIN OUTCOME MEASURES: Share of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM). ANALYSIS: Multivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors. RESULTS: We did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (-0.43%) and less healthful food (-1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05). CONCLUSIONS AND IMPLICATIONS: Urban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.

Estimating the Effects of COVID-19 on WIC Participant Food Purchases

Background: Emergency changes to food assistance programs can prevent widening nutrition disparities during societal shocks such as pandemics. Understanding whether and how COVID altered the nutritional quality of food assistance program participant food purchases can inform future emergency food response policies. We described the relationship between the shock of COVID and Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) participant food purchases. Methods: We used a longitudinal dataset from October 2019 to December 2020 of transaction data from a large grocery store chain with 496 stores in North Carolina. This dataset includes all items purchased and payment type(s) used in transactions. WIC participants were identified by using WIC as a payment type. Our sample includes >1.2 million shopper-month observations from 187,005 unique WIC shoppers. We grouped food items into nutritionally relevant food groups. We used fixed effects models adjusted for time-varying covariates with a variable for pre/post March 2020 interacted with a linear time trend. We used robust standard errors. Outcomes were calories/shopper/day and share (%) of total calories purchased from each food group. Results: Among WIC shoppers, mean calories per day from fruits, vegetables, nuts and legumes (FVNL) were higher after March 2020 (+7.2 kcal/day);however, the share of total calories purchased from FVNL decreased (-0.6%) (both p<0.01). Similar trends were observed for FVNL without added salt, sugar, or fat. Mean calories per day from sugar-sweetened beverages (SSB) were higher after March 2020 (+37.4 kcal/day), as was the share of total calories purchased from SSBs (+0.5%) (both p<0.01). The calories per day from junk foods increased after March 2020 (+60.1 kcal/day, p<0.01) and the share of total calories from junk foods remained stable at about 25% of total calories purchased. Conclusions: Understanding how purchasing patterns shift during societal shocks is important in designing emergency food policies that reduce existing diet-related disease disparities. Emergency food policies that support nutrient-dense food groups may be particularly needed under these conditions.

Utilizing the Increased WIC Cash Value Benefit for Fruits and Vegetables: A Qualitative Study

Background: Addressing disparities in fruit and vegetable (FV) consumption in childhood is important for chronic disease prevention. During COVID, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) increased the Cash Value Benefit (CVB) for FV by ~$25/person/month. Our objectives were to understand barriers and facilitators to participants' uptake of this policy change and whether and how it influenced WIC households' FV consumption. Methods: We conducted 10 virtual focus groups with WIC participants (n=56) in North Carolina in March 2022. Sampled participants represented two subgroups: (1) rural WIC participants (5 focus groups) (2) urban/suburban (5 focus groups). We used a semi-structured focus group guide to assess perceptions and awareness of the CVB change, barriers to using CVB, and perceived influence of the CVB change on FV consumption. Focus groups were recorded, transcribed, and open-coded. We used thematic analysis informed by social constructionist grounded theory to uncover consistencies within and between sampled groups. Results: Participants expressed favorable perceptions of the CVB increase and felt CVB was one of the most valued parts of the WIC food package. Participants stated the pre-COVID CVB amount was insufficient. Barriers to utilizing the increased CVB were finding WIC-eligible FV in stores, insufficient supply of appealing FV, and preferred stores for FV not accepting WIC. Facilitators were household preferences for FV and the variety of FV that can be purchased with the CVB. Many participants felt the CVB increase allowed them and their children to eat a wider variety of FV, serve FV more often, and worry less about food waste associated with trying new FV. Conclusions: The CVB increase was positively perceived by WIC participants in North Carolina and may reduce FV intake disparities, but barriers to CVB and WIC benefit utilization must be addressed. This study can inform future efforts to improve the WIC food package and access to FV.

Grocery Purchase Changes Were Associated With A North Carolina COVID-19 Food Assistance Incentive Program.

Many low-income Americans experience food insecurity, which may have been exacerbated by economic instability during the early stages of the COVID-19 pandemic in 2020. In this study we assessed the impact of Healthy Helping, a short-term fruit and vegetable incentive program aimed at alleviating food insecurity and improving diet quality for Supplemental Nutrition Assistance Program participants, on grocery purchases, using transaction data from a large supermarket chain in North Carolina. We compared Healthy Helping participants' purchases of key food groups before and during the program with purchases by control shoppers participating in federal food assistance programs during the same period. Healthy Helping enrollment was associated with a $26.95 increase in monthly spending on fruit, vegetables, nuts, and legumes-an increase of 2.5 grams of fiber per 1,000 kilocalories purchased-and other shifts in the composition of food purchases, relative to control shoppers. These findings suggest that the program increased healthy food purchases while also increasing dollar sales at participating retailers. On average, participants did not use the full benefit; future research should explore factors associated with non- or underuse of benefits, to inform program design and outreach.

Preventing Non-Communicable Diseases Using Pricing Policies: Lessons for the United States from Global Experiences and Local Pilots

Preventing non-communicable diseases (NCDs) in an effective and sustainable way will require forward-looking policy solutions that can address multiple objectives. This was true pre–COVID-19 and is even more true now. There are already examples from across the globe and within the United States that show how these may be possible. Although there are still many unknowns around how the design, targeting, level, sequencing, integration, and implementation of fiscal policies together can maximize their NCD prevention potential, there is already clear evidence that health taxes and particularly sugar-sweetened beverage (SSB) taxes are cost-effective. Nonetheless, policies alone may not succeed. Political will to prioritize well-being, protections against industry interference, and public buy-in are necessary. If those elements align, pricing policies that consider the context in question can be designed and implemented to achieve several goals around reducing consumption of unhealthy SSBs and foods, narrowing existing nutritional and health disparities, encouraging economic and social development. The US and its local and state jurisdictions should consider these pricing policy issues and their contexts carefully, in collaboration with community partners and researchers, to design multi-duty actions and to be prepared for future windows of opportunities to open for policy passage and implementation.

Prevalence and demographic correlates of online grocery shopping: results from a nationally representative survey during the COVID-19 pandemic.

OBJECTIVE: To estimate the prevalence of online grocery shopping in a nationally representative sample and describe demographic correlates with online grocery shopping. DESIGN: The Nielsen COVID-19 Shopper Behavior Survey was administered to a subset of Nielsen National Consumer Panel participants in July 2020. We used survey weighted-multivariable logistic regression to examine demographic correlates of having ever online grocery shopped. SETTING: Online survey. PARTICIPANTS: 18 598 Nielsen National Consumer Panel participants in the USA. RESULTS: Thirty-nine percent of respondents had purchased groceries online, and among prior purchasers, 89 % indicated that they would continue to online grocery shop in the next month. Canned/packaged foods were the most shopped for grocery category online, followed by beverages, fresh foods and lastly frozen foods. In adjusted analyses, younger respondents (39 years or less) were more likely (47 %) to have ever shopped for groceries online than older age groups (40-54 years, 55-64 years and 65+ years) (29 %, 22 % and 23 %, respectively, all P < 0·001). Those with greater than a college degree were more likely to have ever grocery shopped online (45 %) than respondents with some college education (39 %) and with a high school education or less (32 %) (both P < 0·001). Having children, having a higher income and experiencing food insecurity, particularly among higher income food-insecure households, were also associated with a higher probability of prior online grocery shopping. CONCLUSIONS: The COVID-19 pandemic accelerated the transition to online grocery shopping. Future research should explore the nutrition implications of online grocery shopping.

"I Think That's the Most Beneficial Change That WIC Has Made in a Really Long Time": Perceptions and Awareness of an Increase in the WIC Cash Value Benefit.

During the COVID-19 pandemic, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Cash Value Benefit (CVB) for fruits and vegetables increased by roughly USD 25/month/person. We sought to understand WIC participant perceptions of this change and barriers and facilitators to using the CVB. We conducted 10 virtual focus groups (5 rural, 5 urban/suburban) with WIC participants (n = 55) in North Carolina in March 2022. Focus groups were recorded and transcribed. We open-coded the content and used thematic analysis to uncover consistencies within and between sampled groups. Participants expressed favorable perceptions of the CVB increase and stated the pre-pandemic CVB amount was insufficient. Barriers to using the increased CVB were identifying WIC-approved fruits and vegetables in stores and insufficient supply of fruits and vegetables. Barriers were more pronounced in rural groups. Facilitators of CVB use were existing household preferences for fruits and vegetables and the variety of products that can be purchased with CVB relative to other components of the WIC food package. Participants felt the CVB increase allowed their families to eat a wider variety of fruits and vegetables. The CVB increase may improve fruit and vegetable intake, particularly if made permanent, but barriers to CVB and WIC benefit use may limit the potential impact.

Estimating the Effects of COVID-19 on WIC Participant Food Purchases

Objectives Emergency changes to food assistance programs such as WIC can prevent widening nutritional disparities during societal shocks such as pandemics. However, to understand the potential impact of emergency policy changes, it is first essential to understand whether COVID altered the nutritional quality of WIC participant food purchases. We describe the relationship between the societal shock induced by COVID and WIC participant food purchases. Methods We used a longitudinal dataset from October 2019 to December 2020 of loyalty-card linked food purchasing data from a large grocery store chain in North Carolina with 496 stores in 86 counties. This dataset includes all items purchased and tender type(s) used in transactions. WIC participants are identified by using WIC tender types. Our sample includes about one million loyalty card shoppers in a typical month, about 10% of whom are WIC participants. Food items have been grouped into nutritionally relevant food groups. To control for seasonality, we compared mean calories purchased per shopper per day for all food groups in the same 3-month period pre-COVID (Oct-Dec 2019) and during COVID (Oct 2020-Dec 2020) among WIC shoppers and non-WIC shoppers using t-tests and unadjusted difference-in-difference (DID) models. Results Mean calories purchased from all food groups increased in both WIC and non-WIC shoppers during COVID (all p < 0.01). WIC shoppers purchased more calories from all food groups than non-WIC shoppers both pre-COVID and during COVID (all p < 0.01). Comparing pre-COVID to during COVID purchases, WIC shoppers’ total purchases increased by 294 calories per day, compared to non-WIC shoppers which increased by 197 calories per day. Increases in purchases of all food groups during COVID were similar except for the junk food and sugar sweetened beverage groups which increased more among WIC shoppers (59 and 26 calories per day, respectively) than non-WIC shoppers (36 and 13 calories per day, respectively). Future analyses will adjust for potential confounders and incorporate propensity score weighting. Conclusions Understanding how food purchasing patterns shift in response to societal shocks is vital for ensuring future emergency food response efforts improve existing diet-related disparities. Funding Sources National Institutes of Health.

South Africa's Health Promotion Levy: Excise tax findings and equity potential.

In 2016, the South African government proposed a 20% sugar-sweetened beverage (SSB) tax. Protracted consultations with beverage manufacturers and the sugar industry followed. This resulted in a lower sugar-based beverage tax, the Health Promotion Levy (HPL), of approximately 10% coming into effect in April 2018. We provide a synthesis of findings until April 2021. Studies show that despite the lower rate, purchases of unhealthy SSBs and sugar intake consumption from SSBs fell. There were greater reductions in SSB purchases among both lower socioeconomic groups and in subpopulations with higher SSB consumption. These subpopulations bear larger burdens from obesity and related diseases, suggesting that this policy improves health equity. The current COVID-19 pandemic has impacted food and nutritional security. Increased pandemic mortality among people with obesity, diabetes, and hypertension highlight the importance of intersectoral public health disease-prevention policies like the HPL, which should be strengthened.