Universal Free School Meals Policy and Childhood Obesity.

BACKGROUND AND OBJECTIVES: The Community Eligibility Provision (CEP), a universal free school meals policy, increases school meal participation by allowing schools in low-income areas to provide free breakfast and lunch to all students; however, its impact on obesity remains uncertain. The objective of this study is to estimate the association of CEP with child obesity. METHODS: School obesity prevalence was calculated using BMI measurements collected annually between 2013 and 2019 from students in California public schools in grades 5, 7, and 9. To estimate the association of CEP with obesity, we used a difference-in-differences approach for staggered policy adoption with an outcome regression model conditional on covariates, weighted by student population size. RESULTS: The analysis included 3531 CEP-eligible schools using school-level obesity prevalence calculated from 3 546 803 BMI measurements. At baseline, on average, 72% of students identified as Hispanic, 11% identified as white, 7% identified as Black, and 80% were eligible for free or reduced-price meals. Baseline obesity prevalence was 25%. Schools that participated in CEP were associated with a 0.60-percentage-point net decrease in obesity prevalence after policy adoption (95% confidence interval: -1.07 to -0.14 percentage points, P = .01) compared with eligible, nonparticipating schools, corresponding with a 2.4% relative reduction, given baseline prevalence. Meals served increased during this period in CEP-participating schools only. CONCLUSIONS: In a balanced sample of California schools, CEP participation was associated with a modest net decrease in obesity prevalence compared with eligible, nonparticipating schools. These findings add to the growing literature revealing potential benefits of universal free school meals for children's well-being.

Seattle's sweetened beverage tax implementation and changes in interior marketing displays.

Policymakers aim sugar-sweetened beverage (SSB) taxes at decreasing SSB consumption; however, little is known about their impact on beverage marketing in the retail environment. We assessed changes in interior marketing displays within large food stores before and after the implementation of Seattle's SSB tax. We used Poisson difference-in-difference (DID) models to estimate whether presence and variety of interior beverage marketing displays in Seattle changed from before to after the tax compared to displays in non-taxed comparison area stores, overall, and by beverage type. We found no significant changes in overall SSB or non-SSB interior marketing displays in Seattle versus the comparison area. There was less of an increase in displays for diet soda (DID 0.79, 90% CI 0.65, 0.97), and more of an increase in displays for diet energy drinks (DID 1.78, 90% CI 1.03, 3.09) in Seattle versus comparison area. There was mixed evidence that stores changed interior marketing displays in response to the SSB tax.

Costs, Reach, and Benefits of COVID-19 Pandemic Electronic Benefit Transfer and Grab-and-Go School Meals for Ensuring Youths' Access to Food During School Closures.

Importance: School meals are associated with improved nutrition and health for millions of US children, but school closures due to the COVID-19 pandemic disrupted children's access to school meals. Two policy approaches, the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases, and the grab-and-go meals program, which offered prepared meals from school kitchens at community distribution points, were activated to replace missed meals for children from low-income families; however, the extent to which these programs reached those who needed them and the programs' costs were unknown. Objective: To assess the proportion of eligible youths who were reached by P-EBT and grab-and-go meals, the amount of meals or benefits received, and the cost to implement each program. Design, Setting, and Participants: This cross-sectional study was conducted from March to June 2020. The study population was all US youths younger than 19 years, including US youths aged 6 to 18 years who were eligible to receive free or reduced-price meals (primary analysis sample). Exposures: Receipt of P-EBT or grab-and-go school meals. Main Outcomes and Measures: The main outcomes were the percentage of youths reached by P-EBT and grab-and-go school meals, mean benefit received per recipient, and mean cost, including implementation costs and time costs to families per meal distributed. Results: Among 30 million youths eligible for free or reduced-price meals, grab-and-go meals reached an estimated 8.0 million (27%) and P-EBT reached 26.9 million (89%). The grab-and-go school meals program distributed 429 million meals per month in spring 2020, and the P-EBT program distributed $3.2 billion in monthly cash benefits, equivalent to 1.1 billion meals. Among those receiving benefits, the mean monthly benefit was larger for grab-and-go school meals ($148; range across states, $44-$176) compared with P-EBT ($110; range across states, $55-$114). Costs per meal delivered were lower for P-EBT ($6.46; range across states, $6.41-$6.79) compared with grab-and-go school meals ($8.07; range across states, $2.97-$15.27). The P-EBT program had lower public sector implementation costs but higher uncompensated time costs to families (eg, preparation time for meals) compared with grab-and-go school meals. Conclusions and Relevance: In this economic evaluation, both the P-EBT and grab-and-go school meal programs supported youths' access to food in complementary ways when US schools were closed during the COVID-19 pandemic from March to June 2020.

Countermarketing About Fruit Drinks, Alone or With Water Promotion: A 2019 Randomized Controlled Trial in Latinx Parents.

Objectives. To test whether fruit drink countermarketing messages alone or combined with water promotion messages reduce Latinx parents' purchases of fruit drinks for children aged 0 to 5 years. Methods. We performed a 3-arm randomized controlled online trial enrolling 1628 Latinx parents in the United States during October and November 2019. We assessed the effect of culturally tailored fruit drink countermarketing messages (fruit drink‒only group), countermarketing and water promotion messages combined (combination group), or car-seat safety messages (control) delivered via Facebook groups for 6 weeks on parental beverage choices from a simulated online store. Results. The proportion of parents choosing fruit drinks decreased by 13.7 percentage points in the fruit drink‒only group (95% confidence interval [CI] = -20.0, -7.4; P < .001) and by 19.2 percentage points in the combination group (95% CI = -25.0, -13.4; P < .001) relative to control. Water selection increased in both groups. Conclusions. Fruit drink countermarketing messages, alone or combined with water promotion messages, significantly decreased parental selection of fruit drinks and increased water selection for their children. Public Health Implications. Countermarketing social media messages may be an effective and low-cost intervention for reducing parents' fruit drink purchases for their children. (Am J Public Health. 2021;111(11):1997-2007. https://doi.org/10.2105/AJPH.2021.306488).

Qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program.

BACKGROUND: Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State. OBJECTIVE: To better understand SNAP participants' experience, and to determine perceived impacts and consequences of the program. DESIGN: Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti. SETTING: Spokane, Seattle, and Yakima, Washington. PARTICIPANTS: Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington. ANALYSIS: Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers. RESULTS: Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive. CONCLUSION: Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Is the public sweet on sugary beverages? Social desirability bias and sweetened beverage taxes.

Social desirability bias has been documented in self-reported diet as well as in voting behavior, but not in regards to sweetened beverage consumption or sweetened beverage taxes. We find evidence that respondents in a mixed-mode opinion survey exhibit social desirability bias in both reported sweetened beverage consumption and beliefs about the health and economic benefits of sweetened beverage taxes. We do so in a study of 1704 adults residing in Seattle, Minneapolis, and the D.C. metro area. Phone respondents in our survey under-report sweetened beverage consumption by 0.63 beverages per week relative to web respondents (average web respondent consumption is 3.55 beverages per week). They also over-report their beliefs about the positive health and economic impacts of sweetened beverage taxes by 0.54 points in an 18-point index (average web respondent index score is 2.79). These differences are measured after we control for selection into survey mode by using matching methods, and we interpret them as occurring due to social desirability bias. In contrast to these findings, there is no modal difference in respondents' stated approval of sweetened beverage taxes, and so we conclude that this question is not subject to social desirability bias.

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax.

BACKGROUND: Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy. METHODS: In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01). RESULTS: A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances. CONCLUSIONS: A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Training High School Student "Citizen Scientists" to Document School Water Access: A Feasibility Study.

BACKGROUND: Youth water consumption is inadequate. Increasing adolescent water consumption could support decreased dental caries and body mass index (BMI). Most schools are required to provide free, potable water. However, there is evidence that schools' self-reported compliance data overestimate access to water in schools. We tested the feasibility of using student citizen scientists to collect high quality observational data about water sources in schools. METHODS: We trained 12 teams of high school students to use a validated photo-evidence protocol to photograph and submit data on water sources in elementary and secondary schools. We surveyed students and advisors to assess student learning, advisor burden, and project feasibility. RESULTS: Students submitted data for 325 water sources across 40 racially and economically diverse schools. We were able to use 99% of the student-submitted photographs to measure water source wear, cleanliness, accessibility, and flow. The majority of students (72%, N = 70) spent under 2 hours photographing each school. The majority of students and advisors felt the project was valuable and feasible. CONCLUSIONS: High school students can use a photographic method to collect data for analysis, and understand access to water in schools. This is a feasible, scalable, cost-effective method to gather valid water source data.

Casino Ownership and Health-Related Community Resources Among Native American Tribes in California.

INTRODUCTION: Casinos are significantly associated with improved health among some Native Americans living on tribal lands. An increase in health-related community resources related to tribal ownership of casinos may be one mechanism through which the health of Native Americans is improved. However, no studies have quantitatively assessed whether casinos are associated with having more community resources. METHODS: To investigate the association between casino ownership and health-related community resources among Native Americans, we surveyed 81 of California's 110 federally recognized tribes about casino ownership and health-related community resources during 2015 and 2016. We created a total health-related community resources score (maximum of 50 points) by grouping resources into 5 subdomains (community infrastructure, health care and education, social determinants, recreational infrastructure, and recreation programs), which we scored for a maximum of 10 points each and then summed. Casino ownership was our independent variable. We used adjusted linear regression models to test the association between casino ownership and health-related community resources. RESULTS: Half (49%) of the tribes surveyed owned a casino. Compared with tribes without casinos, tribes with casinos had higher total health-related community resource scores (ß = 5.09; 90% confidence interval [CI], 1.17-9.01). Casino-owning tribes had more resources related to community infrastructure (ß = 1.81; 90% CI, 0.81-2.80), social determinants of health (ß = 1.45; 90% CI, 0.24-2.67) and recreational infrastructure (ß = 1.08; 90% CI, 0.24-1.92) compared with tribes without casinos. CONCLUSIONS: Casino ownership is significantly associated with health-related community resources. Future research should assess whether community resources mediate the relationship between economic resources and health among Native Americans.

An Evaluation of Washington State SNAP-Ed Farmers' Market Initiatives and SNAP Participant Behaviors.

OBJECTIVE: To describe Supplemental Nutrition Assistance Program-Education (SNAP-Ed)-supported farmers' market (FM) access activities in Washington State communities and identify associations between participation in these activities and SNAP participants' FM shopping and fruit and vegetable consumption. DESIGN: Descriptive study; data included stakeholder interviews and surveys with FM managers and a stratified clustered random sample of SNAP participants. SETTING: Washington State. PARTICIPANTS: A total of 51 SNAP-Ed stakeholders, 400 SNAP participants, and 94 FM managers participated. MAIN OUTCOME MEASURE(S): Partnership measures and SNAP-Ed FM access activities; SNAP participants' participation in FM access activities, FM shopping frequency, and fruit and vegetable consumption. ANALYSIS: Thematic content analysis, descriptive statistics, and 0-inflated Poisson and ordinary least-squares regression models. RESULTS: A total of 343 FM access activities and strong multi-sector partnerships were identified. Fifty percent of SNAP participants shopped at an FM in the past year, and 30% at least monthly. The SNAP participants participating in FM access activities shopped at FMs more frequently (P=.005). The SNAP participants shopping at FMs ate fruit and vegetables more frequently than did non-FM shoppers (P<.001). CONCLUSIONS AND IMPLICATIONS: Through nutrition education and systems and environmental changes, Washington SNAP-Ed developed effective programming and multi-sector partnerships. These efforts are associated with SNAP participants' FM shopping and fruit and vegetable consumption.