When increasing vegetable production may worsen food availability gaps: A simulation model in India.

Translating agricultural productivity into food availability depends on food supply chains. Agricultural policy and research efforts promote increased horticultural crop production and yields, but the ability of low-resource food supply chains to handle increased volumes of perishable crops is not well understood. This study developed and used a discrete event simulation model to assess the impact of increased production of potato, onion, tomato, brinjal (eggplant), and cabbage on vegetable supply chains in Odisha, India. Odisha serves as an exemplar of vegetable supply chain challenges in many low-resource settings. Model results demonstrated that in response to increasing vegetable production 1.25-5x baseline amounts, demand fulfillment at the retail level fluctuated by + 3% to -4% from baseline; in other words, any improvements in vegetable availability for consumers were disproportionately low compared to the magnitude of increased production, and in some cases increased production worsened demand fulfillment. Increasing vegetable production led to disproportionately high rates of postharvest loss: for brinjal, for example, doubling agricultural production led to a 3% increase in demand fulfillment and a 19% increase in supply chain losses. The majority of postharvest losses occurred as vegetables accumulated and expired during wholesale-to-wholesale trade. In order to avoid inadvertently exacerbating postharvest losses, efforts to address food security through agriculture need to ensure that low-resource supply chains can handle increased productivity. Supply chain improvements should consider the constraints of different types of perishable vegetables, and they may need to go beyond structural improvements to include networks of communication and trade.

COVID-19, Climate Change, and Conflict in Honduras: A food system disruption analysis.

In Honduras, as in many settings between 2020 and 2022, food security was affected by the COVID-19 pandemic, climate change, and conflicts-what some refer to as "The Three Cs." These challenges have had overlapping impacts on food supply chains, food assistance programs, food prices, household purchasing power, physical access to food, and food acceptability. This article applies a food system disruption analysis-adapted from a fault tree analysis originally developed for a municipal context in the United States-to the context of Honduras to systematically examine how the Three Cs affected food availability, accessibility, and acceptability. This article demonstrates the value of approaching food security through a disruption analysis, especially for settings impacted by multiple, interconnected, ongoing crises.

Sustainable food systems and diets in dietetic training standards: an international content analysis.

BACKGROUND: Low professional confidence and perceived competence create tangible barriers to integrating sustainable food systems (SFS) and diets into dietetic practice. One opportunity to facilitate more systemic integration into dietetic education and training is to include these concepts in professional standards. To better understand the barrier of low professional confidence and perceived competence for engagement with SFS-related practice, the purpose of this research was to investigate dietetic training standards for SFS content and to highlight opportunities for growth within the profession. Questions posed by this research are: (1) how, if at all, are SFS and diets articulated in dietetic training standards, and (2) to what level of cognitive complexity? METHODS: A content analysis of dietetic training standards documents was conducted between 15 April and 15 September 2021. Search terms included 'sustain*' or 'sustainable', 'food systems' and/or 'diets'. Extracted data with applicable SFS content were analysed for level of cognitive complexity requirements. RESULTS: Of 47 National Dietetics Associations, researchers obtained 23 dietetic training standards documents, of which 16 included SFS-related content. The majority of documents used broad descriptors of the concepts, with little granularity and at a lower level of cognitive complexity. CONCLUSIONS: Adoption of more robust frameworks for sustainability with specific learning outcomes that can be adapted to regional contexts would strengthen higher education curricula and thus the profession's ability to contribute more meaningfully to SFSs and diets.

Food security and food access during the COVID-19 pandemic: Impacts, adaptations, and looking ahead.

The coronavirus disease 2019 (COVID-19) pandemic continues to alter US household food consumption and food spending. Although terminology used to describe food insecurity has varied during the COVID-19 pandemic, many reliable estimates illustrate a dramatic increase in food insecurity from approximately 10% of US households before the pandemic to 25%-30% of households during the pandemic, with an even higher prevalence reported by more vulnerable and socially disadvantaged populations. To address the increase in food and economic insecurity, food and nutrition assistance policies and programs made innovative and temporary changes, and enrollment in these programs generally increased. However, some changes to food, nutrition, and income assistance programs are now expiring or contracting even as food insecurity prevalence is again on the rise and elevated food and nutrition assistance needs are expected to persist based on historical patterns. American Society for Parenteral and Enteral Nutrition (ASPEN) practitioners can play an important role in identifying clients at elevated risk of food insecurity-related acute and chronic conditions and connecting high-risk clients to resources. ASPEN practitioners can contribute to the evidence base linking food insecurity and nutrition outcomes. ASPEN practitioners can also advocate for addressing the root social and structural determinants of food insecurity and for the continuation of effective food and nutrition policy changes and innovations.

Insights from Washington State's COVID-19 Response: A Mixed-Methods Evaluation of WIC Remote Services and Expanded Food Options Using the RE-AIM Framework.

BACKGROUND: In response to the COVID-19 pandemic, Washington State's Supplemental Nutrition Program for Women, Infants, and Children (WA WIC) adopted federal waivers to transition to remote service delivery for certification and education appointments. WA WIC also expanded the approved food list without using federal waivers, adding more than 600 new items to offset challenges participants experienced accessing foods in stores. OBJECTIVE: This study aimed to assess the reach and effectiveness of the programmatic changes instituted by WA WIC during the COVID-19 pandemic; the processes, facilitators, and challenges involved in their implementation; and considerations for their continuation in the future. DESIGN: A mixed-methods design, guided by the RE-AIM framework, including virtual, semi-structured focus groups and interviews with WA WIC staff and participants, and quantitative programmatic data from WIC agencies across the state. PARTICIPANTS/SETTING: This study included data from 52 state and local WIC staff and 40 WIC participants across the state of Washington and from various WA WIC programmatic records (2017-2021). The research team collected data and conducted analyses between January 2021 and August 2021. ANALYSIS: An inductive thematic analysis approach with Dedoose software was used to code qualitative data, generate themes, and interpret qualitative data. Descriptive statistics were calculated for quantitative programmatic data, including total participant count, percent increase and decrease in participation, percent of food benefits redeemed monthly, and appointment completion rates. RESULTS: All WA WIC participants (n = 125,279 in May 2020) experienced the programmatic changes. Participation increased by 2% from March to December 2020 after WA WIC adopted programmatic changes in response to the COVID-19 pandemic. Certification and nutrition education completion rates increased by 5% and 18% in a comparison of June 2019 with June 2020. Food benefit redemption also increased immediately after the food list was expanded in April 2020. Staff and participants were highly satisfied with remote service delivery, predominantly via the phone, and participants appreciated the expanded food options. Staff and participants want a remote service option to continue and suggested various changes to improve service quality. CONCLUSIONS: Participation in WIC and appointment completion rates increased after WA WIC implemented service changes in response to the COVID-19 pandemic. Staff and participants were highly satisfied with remote services, and both desire a continued hybrid model of remote and in-person WIC appointments. Some of the suggested changes to WIC, especially the continuation of remote services, would require federal policy change, and others could be implemented under existing federal regulations.

Leveraging Online Learning to Promote Systems Thinking for Sustainable Food Systems Training in Dietetics Education.

Educating and training a multisectoral food systems workforce is a critical part of developing sustainable, resilient, and healthy food and water systems. This paper shares perspectives from a working group of educators, learners, and food systems subject matter experts that collaborated over the course of a year to develop, pilot test, and evaluate two interactive webinar series with a multi-site cohort of dietetics interns and graduate students. The three-part webinar series format included a training webinar, a practice activity, and a synthesis webinar. In reflecting on the effectiveness of this format, we provide direct assessments of student learning from subject matter experts alongside indirect assessments from pre- and post-surveys fielded with learners. Learners who participated in an interactive webinar series demonstrated skills in several dimensions of systems thinking and gained confidence in food systems learning outcomes. Learners also shared valuable feedback on the opportunities and challenges of using online platforms for this experience. As online learning opportunities become more common, it will become increasingly important for educators to prioritize strategies that effectively equip students with the higher-order thinking skills, such as systems thinking, needed to address the complexities of sustainable food systems. The interactive webinar series format described here provides an opportunity to leverage didactic webinars in combination with interactive experiences that enable learners to deepen their knowledge through practice with peers and subject matter experts. Though this format was piloted within dietetics education programs, many of the lessons learned are transferable to other food systems educational contexts.

Inedible Food Waste Linked to Diet Quality and Food Spending in the Seattle Obesity Study SOS III.

Americans waste about a pound of food per day. Some of this is represented by inedible food waste at the household level. Our objective was to estimate inedible food waste in relation to diet quality and participant socio-economic status (SES). Seattle Obesity Study III participants (n = 747) completed the Fred Hutch Food Frequency Questionnaire (FFQ) and socio-demographic and food expenditure surveys. Education and geo-coded tax-parcel residential property values were measures of SES. Inedible food waste was calculated from diet records. Retail prices of FFQ component foods (n = 378) were used to estimate individual-level diet costs. The NOVA classification was used to identify ultra-processed foods. Multivariable linear regressions tested associations between inedible food waste, SES, food spending, Nutrient Rich Food (NRF9.3) and Healthy Eating Index (HEI-2015) scores. Inedible food waste was estimated at 78.7 g/d, mostly from unprocessed vegetables (32.8 g), fruit (30.5 g) and meat, poultry, and fish (15.4 g). Greater inedible food waste was associated with higher HEI-2015 and NRF9.3 scores, higher food expenditures and lower percent energy from ultra-processed foods. In multivariable models, more inedible food waste was associated with higher food expenditures, education and residential property values. Higher consumption of unprocessed foods were associated with more inedible food waste and higher diet costs. Geo-located estimates of inedible food waste can provide a proxy index of neighborhood diet quality.

"Maybe it's still good?" A qualitative study of factors influencing food waste and application of the E.P.A. Food recovery hierarchy in U.S. supermarkets.

About 31% of post-harvest food available for human consumption is lost or wasted annually in the United States. Roughly one third (43 billion lbs.) of food loss occurs in grocery and other retail food stores. Supermarkets engage in food waste reduction, rescue, and recycling strategies, but little is known about frontline workers' and department managers' perspectives on food discards and strategies to limit waste. We aimed to increase understanding of factors influencing grocery retail employees' food waste decision-making at the store level, and of the perspectives of those frontline supermarket workers and managers responsible for food waste prevention and mitigation. We conducted 20 qualitative semi-structured interviews and used thematic analysis to explore how grocery workers and managers view food waste decision drivers, and how these impact the feasibility and effectiveness of waste reduction and food rescue and recycling in their stores. Workers and managers report personalized discard decision-making and confusion between quality and safety indicators. Interviewees described in-store policies, resources and trainings as lacking or inconsistently applied, leading to variability in food waste prevention, rescue, and recycling. Overall, interview participants considered waste reduction strategies that rescue profitable goods more feasible than other food rescue and recycling efforts like donation and composting. Workers' and managers' perceptions of in-store food waste drivers and views on extant food waste prevention and mitigation efforts point to areas for future research and intervention.

The importance of food systems and the environment for nutrition.

Global and local food system transformation is necessary in order to ensure the delivery of healthy, safe, and nutritious foods in both sustainable and equitable ways. Food systems are complex entities that affect diets, human health, and a range of other outcomes including economic growth, natural resource and environmental resiliency, and sociocultural factors. However, food systems contribute to and are vulnerable to ongoing climate and environmental changes that threaten their sustainability. Although there has been increased focus on this topic in recent years, many gaps in our knowledge persist on the relation between environmental factors, food systems, and nutritional outcomes. In this article, we summarize this emerging field and describe what innovative nutrition research is needed in order to bring about food policy changes in the era of climate disruption and environmental degradation.

Academy of Nutrition and Dietetics: Revised 2020 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.

Current systems of food production and consumption are challenged by factors such as natural resource constraints, relative unaffordability of nutrient-dense foods, persistent social inequities, and high rates of diet-related disease. Registered dietitian nutritionists (RDNs) play a critical role in protecting the health of current and future populations by advancing sustainable, resilient, and healthy food and water systems. By definition, such systems can meet current dietary needs without jeopardizing the ability to meet the needs of future generations; can withstand or adapt to disturbances over time; and can equitably facilitate disease prevention and well-being for all individuals. This area of practice within nutrition and dietetics requires recognition of the complex interrelationships among indiviudal health and economic, environmental, and social domains of food and nutrition, and allows RDNs to bring unique expertise to diverse interprofessional teams. The Revised 2020 Standards of Professional Performance for RDNs (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems update the 2014 standards and cover the following 6 standards of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how the RDN can apply the principles of sustainable food systems to a variety of practice settings. The indicators describe 3 skill levels (ie, competent, proficient, and expert) for RDNs in this focus area.

Misunderstood food date labels and reported food discards: A survey of U.S. consumer attitudes and behaviors.

INTRODUCTION: Food date labels such as "best before" and "sell by" are largely unregulated in the United States (U.S.), although new voluntary standards are coming into effect. A U.S. consumer survey was performed in April 2016 to inform policy and education activities related to date labels. METHODS: The survey was administered online to a nationally representative sample of 1029 adults as part of a biweekly omnibus survey. Survey questions assessed the frequency of discarding food based on date labels by food type, interpretation of label language variations, and knowledge of whether date labels are currently regulated by the federal government. RESULTS: 84% of consumers discard food near the package date at least occasionally. Among date labels assessed, "best if used by" was most frequently perceived as communicating quality, and both "expires on" and "use by" as communicating safety. Over 1/3 of participants incorrectly thought that date labeling was federally regulated, and 26% more were unsure. Respondents ages 18-34 and those with misunderstanding about date labels reported discarding food based on label dates with significantly more frequency than others. CONCLUSIONS: Misunderstanding the meaning of food date labels is strongly associated with reports of more frequent food discards. This survey provides new and policy-relevant insights about how Americans use and perceive date labels, and about language used in labeling that may be most effective at communicating desired messages to consumers. As date labeling becomes standardized, this research underlines the need for a strong accompanying communications campaign, and highlights a particular need to reach those ages 18-34.

Estimated Cost to a Restaurant of a Foodborne Illness Outbreak.

OBJECTIVES: Although outbreaks of restaurant-associated foodborne illness occur periodically and make the news, a restaurant may not be aware of the cost of an outbreak. We estimated this cost under varying circumstances. METHODS: We developed a computational simulation model; scenarios varied outbreak size (5 to 250 people affected), pathogen (n = 15), type of dining establishment (fast food, fast casual, casual dining, and fine dining), lost revenue (ie, meals lost per illness), cost of lawsuits and legal fees, fines, and insurance premium increases. RESULTS: We estimated that the cost of a single foodborne illness outbreak ranged from $3968 to $1.9 million for a fast-food restaurant, $6330 to $2.1 million for a fast-casual restaurant, $8030 to $2.2 million for a casual-dining restaurant, and $8273 to $2.6 million for a fine-dining restaurant, varying from a 5-person outbreak, with no lost revenue, lawsuits, legal fees, or fines, to a 250-person outbreak, with high lost revenue (100 meals lost per illness), and a high amount of lawsuits and legal fees ($1 656 569) and fines ($100 000). This cost amounts to 10% to 5790% of a restaurant's annual marketing costs and 0.3% to 101% of annual profits and revenue. The biggest cost drivers were lawsuits and legal fees, outbreak size, and lost revenue. Pathogen type affected the cost by a maximum of $337 000, the difference between a Bacillus cereus outbreak (least costly) and a listeria outbreak (most costly). CONCLUSIONS: The cost of a single foodborne illness outbreak to a restaurant can be substantial and outweigh the typical costs of prevention and control measures. Our study can help decision makers determine investment and motivate research for infection-control measures in restaurant settings.

A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior.

OBJECTIVE: Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation. METHODS: Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched. RESULTS: Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings. CONCLUSIONS: Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.

Wasted Food, Wasted Nutrients: Nutrient Loss from Wasted Food in the United States and Comparison to Gaps in Dietary Intake.

BACKGROUND: Previous research has estimated that wasted food in the United States contains between 1,249 and 1,400 kcal per capita per day, but little is known about amounts of other nutrients embedded in the 31% to 40% of food that is wasted. OBJECTIVE: This research aimed to calculate the nutritional value of food wasted at the retail and consumer levels in the US food supply, and contextualize the amount of nutrient loss in terms of gaps between current and recommended intakes and estimated food recovery potential. DESIGN: Data from the National Nutrient Database for Standard Reference were used to calculate the nutritional value of retail- and consumer-level waste of 213 commodities in the US Department of Agriculture Loss-Adjusted Food Availability data series for 27 nutrients in 2012. RESULTS: Food wasted at the retail and consumer levels of the US food supply in 2012 contained 1,217 kcal, 33 g protein, 5.9 g dietary fiber, 1.7 µg vitamin D, 286 mg calcium, and 880 mg potassium per capita per day. Using dietary fiber as an example, 5.9 g dietary fiber is 23% of the Recommended Dietary Allowance for women. This is equivalent to the fiber Recommended Dietary Allowance for 74 million adult women. Adult women in 2012 underconsumed dietary fiber by 8.9 g/day, and the amount of wasted fiber is equivalent to this gap for 206.6 million adult women. CONCLUSIONS: This was the first study to document the loss of nutrients from wasted food in the US food supply, to our knowledge. Although only a portion of discarded food can realistically be made available for human consumption, efforts to redistribute surplus foods where appropriate and prevent food waste in the first place could increase the availability of nutrients for Americans, while saving money and natural resources.

Economic impact of thermostable vaccines.

BACKGROUND: While our previous work has shown that replacing existing vaccines with thermostable vaccines can relieve bottlenecks in vaccine supply chains and thus increase vaccine availability, the question remains whether this benefit would outweigh the additional cost of thermostable formulations. METHODS: Using HERMES simulation models of the vaccine supply chains for the Republic of Benin, the state of Bihar (India), and Niger, we simulated replacing different existing vaccines with thermostable formulations and determined the resulting clinical and economic impact. Costs measured included the costs of vaccines, logistics, and disease outcomes averted. RESULTS: Replacing a particular vaccine with a thermostable version yielded cost savings in many cases even when charging a price premium (two or three times the current vaccine price). For example, replacing the current pentavalent vaccine with a thermostable version without increasing the vaccine price saved from $366 to $10,945 per 100 members of the vaccine's target population. Doubling the vaccine price still resulted in cost savings that ranged from $300 to $10,706, and tripling the vaccine price resulted in cost savings from $234 to $10,468. As another example, a thermostable rotavirus vaccine (RV) at its current (year) price saved between $131 and $1065. Doubling and tripling the thermostable rotavirus price resulted in cost savings ranging from $102 to $936 and $73 to $808, respectively. Switching to thermostable formulations was highly cost-effective or cost-effective in most scenarios explored. CONCLUSION: Medical cost and productivity savings could outweigh even significant price premiums charged for thermostable formulations of vaccines, providing support for their use.

When are solar refrigerators less costly than on-grid refrigerators: A simulation modeling study.

BACKGROUND: Gavi recommends solar refrigerators for vaccine storage in areas with less than eight hours of electricity per day, and WHO guidelines are more conservative. The question remains: Can solar refrigerators provide value where electrical outages are less frequent? METHODS: Using a HERMES-generated computational model of the Mozambique routine immunization supply chain, we simulated the use of solar versus electric mains-powered refrigerators (hereafter referred to as "electric refrigerators") at different locations in the supply chain under various circumstances. RESULTS: At their current price premium, the annual cost of each solar refrigerator is 132% more than each electric refrigerator at the district level and 241% more at health facilities. Solar refrigerators provided savings over electric refrigerators when one-day electrical outages occurred more than five times per year at either the district level or the health facilities, even when the electric refrigerator holdover time exceeded the duration of the outage. Two-day outages occurring more than three times per year at the district level or more than twice per year at the health facilities also caused solar refrigerators to be cost saving. Lowering the annual cost of a solar refrigerator to 75% more than an electric refrigerator allowed solar refrigerators to be cost saving at either level when one-day outages occurred more than once per year, or when two-day outages occurred more than once per year at the district level or even once per year at the health facilities. CONCLUSION: Our study supports WHO and Gavi guidelines. In fact, solar refrigerators may provide savings in total cost per dose administered over electrical refrigerators when electrical outages are less frequent. Our study identified the frequency and duration at which electrical outages need to occur for solar refrigerators to provide savings in total cost per dose administered over electric refrigerators at different solar refrigerator prices.

A systems approach to obesity.

Obesity has become a truly global epidemic, affecting all age groups, all populations, and countries of all income levels. To date, existing policies and interventions have not reversed these trends, suggesting that innovative approaches are needed to transform obesity prevention and control. There are a number of indications that the obesity epidemic is a systems problem, as opposed to a simple problem with a linear cause-and-effect relationship. What may be needed to successfully address obesity is an approach that considers the entire system when making any important decision, observation, or change. A systems approach to obesity prevention and control has many benefits, including the potential to further understand indirect effects or to test policies virtually before implementing them in the real world. Discussed here are 5 key efforts to implement a systems approach for obesity prevention: 1) utilize more global approaches; 2) bring new experts from disciplines that do not traditionally work with obesity to share experiences and ideas with obesity experts; 3) utilize systems methods, such as systems mapping and modeling; 4) modify and combine traditional approaches to achieve a stronger systems orientation; and 5) bridge existing gaps between research, education, policy, and action. This article also provides an example of how a systems approach has been used to convene a multidisciplinary team and conduct systems mapping and modeling as part of an obesity prevention program in Baltimore, Maryland.