Geographical patterns of implementing a government subsidy program: implications for health outcomes and nutrient intake in Iran.

Introduction: The lack of access to a diverse and nutritious diet has significant health consequences worldwide. Governments have employed various policy mechanisms to ensure access, but their success varies. Method: In this study, the impact of changes in food assistance policy on food prices and nutrient security in different provinces of Iran, a sanctioned country, was investigated using statistical and econometric models. Results: Both the old and new policies were broad in scope, providing subsidized food or cash payments to the entire population. However, the implementation of these policies led to an increase in the market price of food items, resulting in a decline in the intake of essential nutrients. Particularly, the policy that shifted food assistance from commodity subsidies to direct cash payments reduced the price sensitivity of consumers. Consequently, the intake of key nutrients such as Vitamin C and Vitamin A, which are often constrained by their high prices, decreased. To improve the diets of marginalized populations, it is more effective to target subsidies towards specific nutrient groups and disadvantaged populations, with a particular focus on food groups that provide essential nutrients like Vitamin A and Vitamin C in rural areas of Iran. Discussion: More targeted food assistance policies, tailored to the specific context of each province and income level, are more likely to yield positive nutritional outcomes with minimal impact on food prices.

Multiple micronutrient supplementation cost-benefit tool for informing maternal nutrition policy and investment decisions.

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision-making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost-benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost-benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost-effectiveness and benefit-cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost-benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost-effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit-cost ratio ranges from US$ 41-US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user-friendly design, open access availability, and online data-driven analytics, the MMS cost-benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence-based analyses to inform policy-decision and investments towards the scale-up of MMS for pregnant women globally.

Recomendações para o fortalecimento da atenção nutricional na APS

No Brasil, a alimentação é um direito constitucional, reconhecido como determinante e condicionante da saúde, que deve ser assegurado por meio de políticas públicas). A Lei Orgânica da Saúde determina que cabe à direção nacional do Sistema Único de Saúde (SUS) formular, avaliar e apoiar políticas de alimentação e nutrição; e inclui a Vigilância Alimentar e Nutricional (VAN) no rol de Vigilâncias em Saúde. Assim, a Política Nacional de Alimentação e Nutrição (PNAN), desde 1999, estabelece diretrizes para organização das ações de Alimentação e Nutrição (A&N) no SUS, e desde sua atualização em 2011, tem como propósito a melhoria das condições de alimentação, nutrição e saúde da população brasileira, com vistas à garantia da Segurança Alimentar e Nutricional. A atenção nutricional é compreendida como um conjunto de cuidados relativos à A&N voltados à promoção e proteção da saúde, prevenção, diagnóstico e tratamento de agravos, que devem estar associados às demais ações de atenção à saúde do SUS, para indivíduos, famílias e comunidades, contribuindo para a conformação de uma rede integrada, resolutiva e humanizada de cuidados. A prioridade da organização dessas ações deve estar no âmbito da Atenção Primária à Saúde (APS) por seu papel estratégico como porta de entrada e coordenação do cuidado em saúde.

A demanda por novas práticas de atenção nutricional do SUS

Ciclo de debates da Política Nacional de Alimentação e Nutrição. A demanda por novas práticas de atenção nutricional do SUS.

Política nacional de alimentação e nutrição no Brasil: 20 anos de história

Ciclo de Debates da Política Nacional de Alimentação e Nutrição (PNAN) 09 de setembro, 05 e 21 de outubro, 18 de novembro e 09 de dezembro de 2021

The Potential for Healthy Checkout Policies to Advance Nutrition Equity.

BACKGROUND: As the only place in a store where all customers must pass through and wait, the checkout lane may be particularly influential over consumer purchases. Because most foods and beverages sold at checkout are unhealthy (e.g., candy, sweets, sugar-sweetened beverages, and salty snacks), policymakers and advocates have expressed growing interest in healthy checkout policies. To understand the extent to which such policies could improve nutrition equity, we assessed the prevalence and sociodemographic correlates of purchasing items found at (i.e., from) checkout. METHODS: We assessed self-reported checkout purchasing and sociodemographic characteristics in a national convenience sample of adults (n = 10,348) completing an online survey in 2021. RESULTS: Over one third (36%) of participants reported purchasing foods or drinks from checkout during their last grocery shopping trip. Purchasing items from checkout was more common among men; adults < 55 years of age; low-income consumers; Hispanic, non-Hispanic American Indian or Alaska Native, and non-Hispanic Black consumers; those with a graduate or professional degree; parents; and consumers diagnosed with type 2 diabetes or pre-diabetes (p-values < 0.05). CONCLUSIONS: Purchasing foods or beverages from store checkouts is common and more prevalent among low-income and Hispanic, American Indian or Alaska Native, and Black consumers. These results suggest that healthy checkout policies have the potential to improve nutrition equity.

The Impact of the National Nutrition Program 2017-2030 on People's Food Purchases: A Revenue-Based Perspective.

The General Office of the State Council of China promulgated the National Nutrition Program 2017-2030 in 2017 to guide the people to improve their food supply and nutritional intake. This study uses qualitative and quantitative information which are analyzed to estimate the change in people's food purchases following the implementation of the National Nutrition Program 2017-2030, and puts forward measures that should be taken by the competent authorities and stakeholders. We use the translog revenue function of the food industry, and based on the data of listed companies of Chinese food enterprises from 2015 to 2020, and this study find that the National Nutrition Program 2017-2030 has had a positive impact on people's food purchases, and the impact is more obvious in people's food purchases from large food manufacturers. Finally, we also provide regulators with public policy implications, and provide food manufacturers with development suggestions.

Development of a System Dynamics Model to Guide Retail Food Store Policies in Baltimore City.

Policy interventions to improve food access and address the obesity epidemic among disadvantaged populations are becoming more common throughout the United States. In Baltimore MD, corner stores are a frequently used source of food for low-income populations, but these stores often do not provide a range of affordable healthy foods. This research study aimed to assist city policy makers as they considered implementing a Staple Food Ordinance (SFO) that would require small stores to provide a range and depth of stock of healthy foods. A System Dynamics (SD) model was built to simulate the complex Baltimore food environment and produce optimal values for key decision variables in SFO planning. A web-based application was created for users to access this model to optimize future SFOs, and to test out different options. Four versions of potential SFOs were simulated using this application and the advantages and drawbacks of each SFO are discussed based on the simulation results. These simulations show that a well-designed SFO has the potential to reduce staple food costs, increase corner store profits, reduce food waste, and expand the market for heathy staple foods.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University.

BACKGROUND: The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience. OBJECTIVE: Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue. DESIGN: A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019). PARTICIPANTS/SETTING: Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia. INTERVENTION: A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging. MAIN OUTCOME MEASURES: Changes in red, amber, and green volume sales, and revenue compared with predicated sales. STATISTICAL ANALYSES PERFORMED: Interrupted time series analysis of sales data compared post-policy sales with predicted sales. RESULTS: In the 13th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold. CONCLUSIONS: Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

The Revised WIC Food Package and Child Development: A Quasi-Experimental Study.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one of the largest US safety net programs, was revised in 2009 to be more congruent with dietary guidelines. We hypothesize that this revision led to improvements in child development. METHODS: Data were drawn from a cohort of women and children enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study from 2006 to 2011 (Shelby County, TN; N = 1222). Using quasi-experimental difference-in-differences analysis, we compared measures of growth, cognitive, and socioemotional development between WIC recipients and nonrecipients before and after the policy revision. RESULTS: The revised WIC food package led to increased length-for-age z scores at 12 months among infants whose mothers received the revised food package during pregnancy (ß = .33, 95% confidence interval: 0.05 to 0.61) and improved Bayley Scales of Infant Development cognitive composite scores at 24 months (ß = 4.34, 95% confidence interval: 1.11 to 7.57). We observed no effects on growth at age 24 months or age 4 to 6 years or cognitive development at age 4 to 6 years. CONCLUSIONS: This study provides some of the first evidence that children of mothers who received the revised WIC food package during pregnancy had improved developmental outcomes in the first 2 years of life. These findings highlight the value of WIC in improving early developmental outcomes among vulnerable children. The need to implement and expand policies supporting the health of marginalized groups has never been more salient, particularly given the nation's rising economic and social disparities.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE: Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined. DATA SOURCES: We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations. DATA SYNTHESIS: Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition. CONCLUSION: To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.

Australian Consumers Are Willing to Pay for the Health Star Rating Front-of-Pack Nutrition Label.

The Australia and New Zealand Ministerial Forum on Food Regulation has supported the recommendations set out in the 2019 Health Star Rating System Five Year Review Report. Specifically, the forum supported, in principle, Recommendation 9, to mandate the Health Star Rating if clear uptake targets were not achieved while the system is voluntary. Given that mandatory labelling is being considered, it is important to investigate how much consumers value the Health Star Rating in order to understand potential consumer uptake and inform industry. The aim of this study was to assess consumers' valuation of the Health Star Rating system by analysing their willingness to pay for a packaged food product with the Health Star Rating label, utilising a double-bounded dichotomous choice contingent valuation approach. The results indicate that almost two-thirds of Australian household grocery shoppers were willing to pay more for a product with the Health Star Rating, on average up to an additional 3.7% of the price of the product. However, public health nutrition benefits associated with consumers' willingness to pay more for products with the Health Star Rating is currently limited by the lack of guarantee of the systems' accuracy. Given consumer support, a well validated and comprehensive Health Star Rating labelling system can potentially improve health outcomes, cost effectiveness and reduce environmental impacts.

Shaping Physical, Economic, and Policy Components of the Food Environment to Create Sustainable Healthy Diets.

BACKGROUND: Sustainable healthy diets are those dietary patterns that promote all dimensions of individuals' health and well-being; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. The food environment, defined as the interface between the wider food system and consumer's food acquisition and consumption, is critical for ensuring equitable access to foods that are healthy, safe, affordable, and appealing. DISCUSSION: Current food environments are creating inequities, and sustainable healthy foods are generally more accessible for those of higher socioeconomic status. The physical, economic, and policy components of the food environment can all be acted on to promote sustainable healthy diets. Physical spaces can be modified to improve relative availability (ie, proximity) of food outlets that carry nutritious foods in low-income communities; to address economic access certain actions may improve affordability, such as fortification, preventing food loss through supply chain improvements; and commodity specific vouchers for fruits, vegetables, and legumes. Other policy actions that address accessibility to sustainable healthy foods are comprehensive marketing restrictions and easy-to-understand front-of-pack nutrition labels. While shaping food environments will require concerted action from all stakeholders, governments and private sector bear significant responsibility for ensuring equitable access to sustainable healthy diets.

Updating the Mediterranean Diet Pyramid towards Sustainability: Focus on Environmental Concerns.

BACKGROUND: Nowadays the food production, supply and consumption chain represent a major cause of ecological pressure on the natural environment, and diet links worldwide human health with environmental sustainability. Food policy, dietary guidelines and food security strategies need to evolve from the limited historical approach, mainly focused on nutrients and health, to a new one considering the environmental, socio-economic and cultural impact-and thus the sustainability-of diets. OBJECTIVE: To present an updated version of the Mediterranean Diet Pyramid (MDP) to reflect multiple environmental concerns. METHODS: We performed a revision and restructuring of the MDP to incorporate more recent findings on the sustainability and environmental impact of the Mediterranean Diet pattern, as well as its associations with nutrition and health. For each level of the MDP we provided a third dimension featuring the corresponding environmental aspects related to it. CONCLUSIONS: The new environmental dimension of the MDP enhances food intake recommendations addressing both health and environmental issues. Compared to the previous 2011 version, it emphasizes more strongly a lower consumption of red meat and bovine dairy products, and a higher consumption of legumes and locally grown eco-friendly plant foods as much as possible.

Results from an Epidemiological Follow-Up Survey on Home Artificial Nutrition in Switzerland from 2010 to 2015.

BACKGROUND: Home artificial nutrition (HAN) is an established treatment for malnourished patients. Since July 2012, the costs for oral nutrition supplements (ONS) are covered by the compulsory health insurance providers in Switzerland if the patient has a medical indication based on the Swiss Society for Clinical Nutrition guidelines. Therefore, the purpose of our study was to analyse the development of HAN, including ONS, before and after July 2012. METHODS: We obtained the retrospective and anonymized data from the Swiss association for joint tasks of health insurers (SVK), who registered patients on HAN. Since not all health insurers are working with SVK, this retrospective study recorded nearly 65% of all new patients on HAN in Switzerland from January 1, 2010, to December 31, 2015. RESULTS: A total of 33,410 patients (49.1% men and 50.9% women) with a mean BMI of 21.3 ± 4.5 kg/m2 and mean age of 68.9 ± 17.8 years were recorded. The number of patient cases on ONS increased from 808 cases in 2010 to 18,538 cases in 2015, while patient cases on home enteral nutrition (HEN) and home parenteral nutrition (HPN) remained approximately the same. The relative distribution of type of HAN changed from 26.2% cases on ONS, 68.7% cases on HEN and 5.1% cases on HPN in 2010 to 86.1% cases on ONS, 12.8% cases on HEN, and 1.1% cases on HPN in 2015. Treatment duration decreased for ONS from 698 ± 637 days to 171 ± 274 days, for HEN from 416 ± 553 days to 262 ± 459 days, and for HPN from 96 ± 206 days to 72 ± 123 days. Mean costs per patient decreased for ONS from 1,330 CHF in 2010 to 606 CHF in 2015. Total costs for HAN increased from 16,895,373 CHF in 2010 to 32,868,361 CHF in 2015. CONCLUSION: Our epidemiological follow-up study showed an immense increase in number of patients on HAN in Switzerland after July 2012. Due to shorter therapy duration and reduced mean costs per patient, total costs were only doubled while the number of patients increased 7-fold.

The effects of taxing sugar-sweetened beverages in Ecuador: An analysis across different income and consumption groups.

To analyze the effects of taxing sugar-sweetened beverages (SSBs) in Ecuador, this study estimates a Quadratic Almost Ideal Demand System model using data from the 2011-2012 National Survey of Income and Expenditure for Urban and Rural Households. We derive own- and cross-price elasticities by income quintiles and consumption deciles for five beverages, including two types of sugary drink: (i) milk, (ii) soft drinks, (iii) water, (iv) other sugary drinks, and (v) coffee and tea. Overall, results show that a 20% increase in the price of SSBs will decrease the consumption of soft drinks and other sugary drinks by 27% and 22%, respectively. Heterogeneous consumer behavior is revealed across income and consumption groups, as well as policy-relevant complementarity and substitution patterns. Policy impacts are simulated by considering an 18 cents per liter tax, implemented in Ecuador, and an ad-valorem 20% tax on the price. Estimated tax revenues and weight loss are larger for the latter. From a health perspective, high-income and heavy consumer households would benefit the most from this policy. Our study supports an evidence-based debate on how to correctly design and monitor food policy.

Culturally Optimised Nutritionally Adequate Food Baskets for Dietary Guidelines for Minimum Wage Estonian Families.

Although low socioeconomic groups have the highest risk of noncommunicable diseases in Estonia, national dietary guidelines and nutrition recommendations do not consider affordability. This study aims to help develop nutritionally adequate, health-promoting, and culturally acceptable dietary guidelines at an affordable price. Three food baskets (FBs) were optimised using linear programming to meet recommended nutrient intakes (RNIs), or Estonian dietary guidelines, or both. In total, 6255 prices of 422 foods were collected. The Estonian National Dietary Survey (ENDS) provided a proxy for cultural acceptability. Food baskets for a family of four, earning minimum wage, contain between 73 and 96 foods and cost between 10.66 and 10.92 EUR per day. The nutritionally adequate FB that does not follow Estonian dietary guidelines deviates the least (26% on average) from ENDS but contains twice the sugar, sweets, and savoury snacks recommended. The health-promoting FB (40% deviation) contains a limited amount of sugar, sweets, and savoury snacks. However, values for vitamin D, iodine, iron, and folate are low compared with RNIs, as is calcium for women of reproductive age. When both the RNIs and dietary guidelines are enforced, the average deviation (73%) and cost (10.92 EUR) are highest. The composition of these FBs can help guide the development of dietary guidelines for low income families in Estonia.

Cardiovascular Healthcare Cost Savings Associated with Increased Whole Grains Consumption among Adults in the United States.

Little is known about the potential health economic impact of increasing the proportion of total grains consumed as whole grains to align with Dietary Guidelines for Americans (DGA) recommendations. Health economic analysis estimating difference in costs developed using (1) relative risk (RR) estimates between whole grains consumption and outcomes of cardiovascular disease (CVD) and a selected component (coronary heart disease, CHD); (2) estimates of total and whole grains consumption among US adults; and (3) annual direct and indirect medical costs associated with CVD. Using reported RR estimates and assuming a linear relationship, risk reductions per serving of whole grains were calculated and cost savings were estimated from proportional reductions by health outcome. With a 4% reduction in CVD incidence per serving and a daily increase of 2.24 oz-eq of whole grains, one-year direct medical cost savings were estimated at US$21.9 billion (B) (range, US$5.5B to US$38.4B). With this same increase in whole grains and a 5% reduction in CHD incidence per serving, one-year direct medical cost savings were estimated at US$14.0B (US$8.4B to US$22.4B). A modest increase in whole grains of 0.25 oz-eq per day was associated with one-year CVD-related savings of $2.4B (US$0.6B to US$4.3B) and CHD-related savings of US$1.6B (US$0.9B to US$2.5B). Increasing whole grains consumption among US adults to align more closely with DGA recommendations has the potential for substantial healthcare cost savings.

Analysis of stakeholder networks for breastfeeding policies and programs in Ghana.

BACKGROUND: Suboptimal breastfeeding practices are driven by multiple factors. Thus, a multi-sectoral approach is necessary to design and implement appropriate policies and programs that protect, promote, and support breastfeeding. METHODS: This study used Net-Map, an interactive social network interviewing and mapping technique, to: a) identify key institutional actors involved in breastfeeding policy/programs in Ghana, b) identify and describe links between actors (i.e., command, dissemination, funding, and technical assistance (TA)), and c) document actors influence to initiate or modify breastfeeding policy/programs. Ten experts were purposively selected from relevant institutions and were individually interviewed. Interview data was analysed using social networking mapping software, Gephi (version 0.9.2). RESULTS: Forty-six unique actors were identified across six actor categories (government, United Nations agencies, civil society, academia, media, others), with one-third being from government agencies. Dissemination and TA links accounted for two-thirds of the identified links between actors (85/261 links for dissemination; 85/261 for TA). Command links were mainly limited to government agencies, while other link types were observed across all actor groups. Ghana Health Service (GHS) had the greatest in-degree centrality for TA and funding links, primarily from United Nations Children's Fund (UNICEF) and development partners. The World Health Organization, UNICEF, Ministry of Health, and GHS had the highest weighted average relative influence scores. CONCLUSIONS: Although diverse actors are involved in breastfeeding policy and programming in Ghana, GHS plays a central role. United Nations and donor agencies are crucial supporters of GHS providing breastfeeding technical and financial assistance in Ghana.

Legal Feasibility and Implementation of Federal Strategies for a National Retail-Based Fruit and Vegetable Subsidy Program in the United States.

Policy Points Suboptimal intake of fruit and vegetables is associated with increased risk of diet-related diseases. A national retail-based fruit and vegetable subsidy program could broadly benefit the health of the entire population. Existing fruit and vegetable subsidy programs can inform potential implementation mechanisms; Congress's powers to tax, spend, and regulate interstate commerce can be leveraged to create a federal program. Legal and administrative feasibility considerations support a conditional funding program or a federal-state cooperative program combining regulation, licensing, and state or local options for flexible implementation strategies. Strategies to engage key stakeholders would enable the program to utilize lessons learned from existing programs. CONTEXT: Suboptimal intake of fruit and vegetables (F&Vs) is associated with increased risk of diet-related diseases. Yet, there are no US government programs to support increased F&V consumption nationally for the whole population, most of whom purchase food at retail establishments. To inform policy discussion and implementation, we identified mechanisms to effectuate a national retail-based F&V subsidy program. METHODS: We conducted legal and policy research using LexisNexis, the UConn Rudd Center Legislation Database, the Centers for Disease Control and Prevention Chronic Disease State Policy Tracking System, the US Department of Agriculture's website, Congress.gov, gray literature, and government reports. First, we identified existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize F&Vs. Second, we evaluated Congress's power to implement a national retail-based F&V subsidy program. FINDINGS: We found five federal programs, three federal bills, four state laws, and 17 state (including the District of Columbia [DC]) bills to appropriate money to supplement federal food assistance programs with F&Vs; 74 programs (six multistate, 22 state [including DC], and 46 local) administered by state and local governments and NGOs that incentivize the purchase of F&Vs for various subpopulations; and two state laws and 11 state bills to provide tax exemptions for F&Vs. To create a national F&V subsidy program, Congress could use its Commerce Clause powers or its powers to tax or spend, through direct regulation, licensing, taxation, tax incentives, and conditional funding. Legal and administrative feasibility considerations support a voluntary conditional funding program or, as a second option, a mandatory federal-state cooperative program combining regulation and licensing. CONCLUSIONS: Multiple existing programs provide an important foundation to inform potential implementation mechanisms for a national F&V subsidy program. Results also highlight the value of state and local participation to leverage existing networks and stakeholder knowledge.