Assessing and Monitoring Nutrition Security to Promote Healthy Dietary Intake and Outcomes in the United States.

The US Department of Agriculture's Economic Research Service leads the federal government in data development and research on food security in US households. Nutrition security is an emerging concept that, although closely related, is distinct from food security. No standard conceptualization or measure of nutrition security currently exists. We review the existing research on nutrition security and how it is informed by the more robust literature on food security and diet quality. Based on this review, we propose a conceptual framework for understanding nutrition security and its relationship to food security. We identify two constructs (healthy diets and nutritional status) and multiple subconstructs that form the basis of nutrition security. The proposed framework and corresponding constructs are intended to provide (a) understanding of how nutrition security arises and how it differs from food security, (b) background on why assessment and monitoring of nutrition security is important, and (c) guidance for a research agenda that will further clarify the meaning of nutrition security and its measurement.

The Special Supplemental Nutrition Program for Women, Infants, and Children is Associated with Several Changes in Nutrient Intakes and Food Consumption Patterns of Participating Infants and Young Children, 2008 Compared with 2016.

BACKGROUND: In 2009 the USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) updated the food packages provided to participants. OBJECTIVES: This study investigates associations between WIC participation and nutrients and food groups consumed using data from the Feeding Infants and Toddlers Study's 2008 and 2016 nationwide, cross-sectional surveys of children <4 y, weighted to be representative of the US population. METHODS: The study data included 2892 children aged 6-47.9 mo in 2008 and 2635 in 2016. Differences were analyzed by WIC participation, survey year, and child age (infants 6-11.9 mo old, toddlers 12-23.9 mo old, preschoolers 24-47.9 mo old). Usual nutrient intake distributions were estimated using National Cancer Institute methodology. Daily food group consumption differences were tested via multivariate regression. All analyses controlled for income. RESULTS: In 2016 18.6% of infants had iron intakes below the estimated average requirement (EAR), compared to 7.6% in 2008; 87% of WIC infants met the EAR, compared with 69% of non-WIC infants. In 2016 37% of WIC preschoolers met saturated fat guidelines, compared with 25% in 2008; in both years, fewer than one-third of non-WIC preschoolers met the guidelines. More WIC infants than non-WIC infants consumed infant cereals in 2016 (58% compared with 45%, respectively). More WIC infants ate vegetables daily in 2016 than in 2008 (74% compared with 59%, respectively).  In 2016, as compared with 2008, more WIC infants consumed baby-food vegetables (55% compared with 29%, respectively) and fruits (56% compared with 41%, respectively). In 2016 47% of WIC preschoolers drank low-fat milk, compared with 19% of non-WIC preschoolers. CONCLUSIONS: Infant iron intakes are concerning, although more WIC infants meet the EAR. WIC infants' vegetable intakes have improved; baby-food vegetables have become important contributors to their intakes. In 2016 WIC children were more likely than non-WIC children to shift to lower-fat milks at 2 y of age, likely contributing to lower saturated fat intakes.

Low-Income Parents' Use of Front-of-Package Nutrition Labels in a Virtual Supermarket.

OBJECTIVE: To examine the impact front-of-package nutrition labels (FOPLs) have on decision-making abilities among low-income parents in a virtual supermarket. DESIGN: A 4-by-2 experimental design with 3 FOPLs (summary, nutrient-specific, hybrid) and a no-FOPL comparison. Within the FOPL condition, participants either shopped with a time limit (10 minutes) or with no time limit. SETTING: A web-based, 3-dimensional virtual supermarket. PARTICIPANTS: Parents (n = 1,452) from low-income households with at least 1 child aged 4-12 years. MAIN OUTCOMES MEASURED: Index derived from the United Kingdom's Nutrient Profiling Model that summarized the overall nutrient profile of the participant's shopping basket. ANALYSIS: Analysis of covariance with post hoc estimations (pairwise) of condition means adjusted for multiple comparisons. RESULTS: All FOPLs led to healthier nutrient profiles than the no-FOPL condition (P < .001). Simple FOPLs (ie, summary, hybrid) led to healthier nutrient profiles than nutrient-specific FOPLs (P = .02 and P < .001, respectively). Among parents exposed to simple FOPLs, those under time pressure made less healthy choices than those who were not under time pressure (P = .05 and P = .03, respectively). Time pressure did not affect parents exposed to nutrient-specific FOPLs (P = .69). CONCLUSIONS AND IMPLICATIONS: Front-of-package nutrition labels can aid parents in selecting healthier products. Simple FOPLs provide greater utility for selecting healthier products than FOPLs that present an array of nutrient information. Time pressure can influence how parents interact with different types of label information.

Online Grocery Shopping Knowledge, Attitudes, and Behaviors Among SNAP Participants.

OBJECTIVE: To inform policy proposals to allow online grocery shopping with Supplemental Nutrition Assistance Program (SNAP) benefits by examining relevant behaviors, knowledge, and attitudes of SNAP recipients. METHODS: This qualitative study used a purposive recruitment strategy to conduct 4 1-hour focus groups in Las Cruces, NM. Participants were SNAP recipients who do the grocery shopping for their families. Focus groups were video and audio recorded, transcribed, and coded. RESULTS: Few participants had shopped for groceries online, and participants were generally uninterested in grocery shopping online. Identified barriers were cost, quality control for perishable foods in particular, and distrust of the overall process. Participants expressed interest in suggested services aimed at increasing the benefits of shopping online. CONCLUSIONS AND IMPLICATIONS: SNAP recipients in this study have not adopted online grocery shopping for various reasons. Additional research could inform policy by investigating which participants would benefit from using SNAP benefits online and strategies for facilitating use.

Community eligibility and other provisions for universal free meals at school: impact on student breakfast and lunch participation in California public schools.

United States Department of Agriculture (USDA) school meal programs are an important part of the safety net for reducing food insecurity, yet not all students who qualify for free or reduced-price meals participate. In 2014-2015, the Community Eligibility Provision became available nationwide. This provision, along with Provisions 1, 2, and 3 of the USDA school meals programs, allows local school food authorities to offer universal free meals at schools with high student poverty. It is expected that adoption of a provision allowing universal free meals will increase rates of student participation in meal programs at schools where many students are at risk for food insecurity. This study examines school-level adoption of any provision for universal free meals and subsequent changes in student participation rates for the School Breakfast Program and National School Lunch Program in California from 2013-2014 to 2016-2017. A database was assembled for 10,343 public schools, including meals served, demographics, eligibility for provisions, and use of provisions in each year. Multilevel regression models were used to examine school adoption and student participation rates over time. Difference-in-difference calculations from lagged longitudinal models adjusting for school demographics showed that when eligible schools adopted provisions, participation rates increased an average of 3.48 percentage points for breakfast and 5.79 points for lunch the following year. By 2016-2017, over half of all eligible schools were using a provision for universal free meals. Among eligible schools, provision adoption was more common at schools that were larger, had predominantly Latino students, and were in rural areas. When eligible schools adopt provisions for universal free meals, student participation rates significantly increase, improving program reach among children most at risk for food insecurity. However, not all eligible schools adopt a provision for universal free meals and some adopters drop out in subsequent years. Research to better understand factors influencing the decision whether to adopt a provision or to continue it could inform policy and program leaders. Increases in breakfast participation are smaller than those for lunch, suggesting that other barriers to breakfast participation warrant further investigation.

Dietary Guidance and New School Meal Standards: Schoolchildren's Whole Grain Consumption Over 1994-2014.

INTRODUCTION: Since 2005, the federal government's Dietary Guidelines for Americans have recommended at least half of total grain intake be whole grains. Beginning with the 2012-2013 school year, the U.S. Department of Agriculture updated school meal regulations to align with this recommendation. METHODS: Nationally representative food consumption survey data spanning 1994-2014 were analyzed in 2018 to construct a sample of 17,016 schoolchildren aged 5-19 years. Regression models were used to examine changes in whole grain/total grain intake by food source. For school-obtained foods, changes in whole grain intake are decomposed into changes in propensity (proportion of students consuming whole grains) and intensity (amount consumed by whole grain consumers). RESULTS: The whole grain/total grain ratio from all sources fell from 9.67% (1994-1998) to 7.6% (2005-2006) before climbing to 13.48% (2013-2014). Home-prepared foods topped the whole grain/total grain ratio among all sources until surpassed by school foods in 2013-2014 (17.16% vs 21.48%). The whole grain/total grain ratio from school rose from 4.02% to 21.48% during 1994-2014. Among those consuming school foods, increased intensity contributed more than propensity to increases in whole grain intake from school between 2005-2010 and 2011-2012; the opposite occurred between 2011-2012 and 2013-2014 because of increasing propensity, from one in four to one in two students consuming whole grains. CONCLUSIONS: During 1994-2006, the whole grain/total grain ratio of schoolchildren's diets declined, contrary to expert advice. Following the 2012 U.S. Department of Agriculture school meal regulations, both the propensity and the intensity of whole grain consumption from school rose considerably, demonstrating the important role school meals may play in improving children's diets.

Identifying gaps in the food security safety net: the characteristics and availability of summer nutrition programmes in California, USA.

OBJECTIVE: The US Department of Agriculture's Summer Food Service Program and Seamless Summer Option (summer nutrition programmes (SNP)) aim to relieve food insecurity for children and teens during summer months. More needs to be known about when and where SNP are available, and how availability varies by community characteristics, particularly in rural areas where food insecurity and reduced food access are more prevalent. DESIGN: The present study examined the geographic availability of SNP and summer meal uptake rates in 2016, using state-wide administrative claims data. SETTING: Public schools and SNP in California, USA.ParticipantsSchools (n 8842) and SNP (n 4685). RESULTS: Urban counties were more likely than rural counties to have higher summer uptake rates, calculated as the percentage of summer meals served relative to eligible students utilizing school meal programmes during the academic school year, but uptake overall was low at 18·2 % of target populations. Geographic availability analyses showed that 63·9 % of public urban schools had an SNP available within 1·6 km (1 mile), but availability was significantly higher within the proximity of larger, higher-poverty high schools with diverse or majority non-White students, and those with higher school-year breakfast participation rates. Availability of an SNP within 16 km (10 miles) of rural schools averaged 68·1 % but was significantly higher around larger schools, higher-poverty schools and those with diverse or majority non-White students. CONCLUSIONS: While many communities have SNP available, much more work is needed to increase the availability of these programmes to reduce summer food insecurity for children, particularly in rural communities.

WIC and non-WIC Infants and Children Differ in Usage of Some WIC-Provided Foods.

Background: USDA's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides expert-chosen supplemental foods to improve the diets and health of low-income infants and children <5 y of age, but dietary behaviors of WIC participants are not well characterized. Objective: The purpose of this analysis was to examine differences in food consumption patterns between WIC participants and nonparticipants. Methods: FITS 2016 is a nationwide cross-sectional study of children <4 y (n = 3235). Data were weighted to provide US population-representative results. Children were categorized as WIC participants or nonparticipants, with the latter divided into lower- and higher-income nonparticipants. Group differences were assessed via the Wald test (demographics) and Rao-Scott modified chi-square test (breastfeeding prevalence). Differences in percentage consuming WIC-provided and selected other foods between WIC participants and nonparticipants were evaluated with the use of ORs and 95% CIs. Results: WIC infants were less likely to breastfeed than were higher-income nonparticipants at 0-5.9 mo (45% compared with 74%) and less likely than both nonparticipant groups at 6-11.9 mo (30% compared with 49-60%). WIC 6- to 11.9-mo-olds were more likely to consume infant cereals and vegetables than were lower-income nonparticipants. WIC 12 to 23.9-mo-olds were more likely to drink whole milk (which WIC provides at this age) than were nonparticipants (72% compared with 59-64%), whereas WIC participants 24-47.9 mo were more likely to drink low- and nonfat milks (which WIC provides at this age) than were nonparticipants (45% compared with 13-22%). WIC participants 6-47.9 mo were more likely to drink juice than were nonparticipants. Conclusions: Continued improvements in early dietary patterns are warranted for WIC and non-WIC children. Breastfeeding among WIC participants is a continuing challenge. Findings suggest that baby-food cereals, vegetables, and fruits (all provided by WIC) contribute importantly to WIC infants' diets, whereas WIC children are more likely to use lower-fat milks after 2 y of age than are non-WIC participants.

Integrating Behavioral Economics into Nutrition Education Research and Practice.

Nutrition education has a long history of being informed by economic thinking, with the earliest nutrition education guides incorporating household food budgeting into nutrition advice. Behavioral economics research goes beyond that traditional role to provide new insights into how consumers make choices. These insights have numerous potential applications for nutrition interventions to promote healthy food choices consistent with the US Dietary Guidelines for Americans. Research to test the value of such applications can contribute to the development of evidence-based nutrition education practice called for in federal nutrition education programs.

Nutrition Assistance Programs: Cause or Solution to Obesity.

Three nutrition assistance programs-Supplemental Nutrition Assistance Program (SNAP), Special Nutrition Program for Women, Infants and Children (WIC), and National School Lunch Program (NSLP)-serve as the backbone of the nutrition safety net in the USA. These programs have been successful in achieving many of their initial goals of improving food purchases, food intake, and/or nutritional status of low-income, vulnerable Americans. The emphasis in these programs has now broadened to also include an obesity prevention focus. Recent changes in program components demonstrate the revised objectives of the program. SNAP, WIC, and NSLP increase economic access to an adequate diet but access alone is unlikely to be the total solution to obesity prevention. An ecological approach, incorporating the nutrition programs, appears to be a more promising strategy to leverage the impact of SNAP, WIC, and NSLP.

Impact on energy, sodium and dietary fibre intakes of vegetables prepared at home and away from home in the U.S.A.

OBJECTIVE: To examine how increasing vegetable consumption from foods prepared at home (FAH) and foods prepared away from home (FAFH) would impact energy, dietary fibre and Na (sodium) intakes in the U.S.A. DESIGN: Using data from the 2003­2004 U.S. National Health and Nutrition Examination Survey, dietary intake data from two separate days were fitted with a first-difference (fixed-effects) model. Vegetables consumed from all sources, including mixed foods and juices, were disaggregated and expressed as amounts equivalent to one cup of whole vegetables. SETTING: Nationally representative sample of the U.S. population. SUBJECTS: Individuals aged 2 years and above reporting 2 d of dietary intake data in 2003­2004 (n 7647). RESULTS: Holding constant the total amount of food consumed, consuming an additional cup of tomatoes and potatoes from FAFH increases energy intake by respectively 1522 and 665 kJ, as compared with 246 and 367 kJ for FAH. Each additional cup of tomatoes from FAH is associated with an additional 179 mg of Na, compared with 113 mg for FAFH. All vegetable consumption increases fibre intake, except for potatoes and tomatoes from FAFH. Dark green and orange vegetables from FAH add the largest amount of fibre (1.38 g/cup). CONCLUSIONS: Because U.S. consumers frequently consume vegetables as part of mixed foods that add energy and Na, heavier consumption of vegetables as currently prepared raises the energy content and Na density of the overall diet. This is particularly true for vegetables prepared away from home.

Understanding school food service characteristics associated with higher competitive food revenues can help focus efforts to improve school food environments.

Many school food services sell extra foods and beverages, popularly referred to as "competitive foods," in addition to USDA school meals. On the basis of national survey data, most competitive foods and beverages selected by students are of low nutritional value. Recent federal legislation will allow schools that participate in USDA school meal programs to sell competitive foods only if the food items they sell meet nutrition standards based on the Dietary Guidelines for Americans. Concerns have been raised about the potential effects of limiting competitive foods on local school food service finances. However, national data indicate that only in a subset of schools do food services receive large amounts of revenues from competitive foods. These food services are typically located in secondary schools in more affluent districts, serving higher proportions of students who do not receive free or reduced price meals. Compared to other food services, these food services couple higher competitive food revenues with lower school meal participation. Increasing school meal participation could increase meal revenues to offset any loss of competitive food revenues. Replacing less-healthful competitive items with healthier options could also help maintain school food service revenues while improving the school food environment. Nationally consistent nutrition standards for competitive foods may encourage development and marketing of healthful products.

Individual net-benefit maximization: a model for understanding breastfeeding cessation among low-income women.

OBJECTIVES: We use economic theory of individual net benefit maximization to motivate a comprehensive look at 32 social, economic, and psychological disincentives that potentially influence breastfeeding cessation. METHODS: The sample consists of 1,595 low-income families participating in the Healthy Steps for Young Children National Evaluation. Participants were recruited from 24 pediatric sites across the United States. Infants were enrolled at birth and followed through age 30-33 months. Survival analysis was used to assess the relation of social, economic and psychosocial factors with duration of breastfeeding. RESULTS: Disincentives significantly associated with cessation in multivariate hazard analysis were: WIC participation at 2-4 months (HR = 1.50; 95% CI: 1.29, 1.74), mother's returning to work for 20-40 h per week (HR = 1.47; 95% CI: 1.26, 1.71), mother's not attending a postpartum doctor's visit (HR = 1.39; 95% CI: 1.18, 1.63), father's not being in the home (HR = 1.38; 95% CI: 1.21, 1.57), a smoker in the household (HR = 1.34; 95% CI: 1.17, 1.52), no receipt of breastfeeding instruction at the pediatric office (HR = 1.20; 95% CI:1.06, 1.37), the doctor's not encouraging breastfeeding (HR = 1.19; 95% CI: 1.01, 1.39) and the mother experiencing depressive symptoms (HR = 1.16; 95% CI: 1.02, 1.33). CONCLUSIONS: The decision to stop breastfeeding is often complex. Research on breastfeeding cessation has been limited with regard to the social and economic issues that may influence the behavior of low-income women. The results support the need to develop interventions and policies to minimize disincentives associated with breastfeeding cessation.

Evaluating food stamp nutrition education: issues and opportunities.

Food Stamp Nutrition Education (FSNE) is an optional component of the Food Stamp Program aimed at improving food choices of program participants. The last decade has seen a dramatic expansion in FSNE, accompanied by increased interest in FSNE evaluation. The Society for Nutrition Education, as a leader in nutrition education research, has worked collaboratively with federal partners to improve FSNE evaluation. This is the first in a 3-part series of papers presented in this issue of the Journal of Nutrition Education and Behavior. The series reviews the issues, priority needs, and opportunities identified through this process; explains our current focus on the development of a brief measure assessing FSNE-relevant dietary behaviors; and describes plans for measurement development.

Evaluating the effects of the Dietary Guidelines for Americans on consumer behavior and health: methodological challenges.

The Dietary Guidelines for Americans is the official nutrition policy statement for the United States. Government involvement in providing information on private behavior, such as food choice, is justified by the high cost of poor diets, as measured in medical expenses and lost productivity. The Guidelines are intended to provide an up-to-date, consistent information base for federal nutrition education and information efforts and food assistance program regulations. Through these policy mechanisms, the Guidelines are assumed to improve dietary behavior, and, ultimately, health. By law, the Dietary Guidelines for Americans must be updated every five years; however, there is no mandate for evaluation. Evaluation could provide useful information to assess the extent to which the Guidelines positively influence health and provide insights into reasons for their successes and limitations. However, evaluation would also present considerable challenges. This paper discusses the critical data and methodological needs for improving evaluation of the Dietary Guidelines for Americans.

National trends in soft drink consumption among children and adolescents age 6 to 17 years: prevalence, amounts, and sources, 1977/1978 to 1994/1998.

OBJECTIVES: Trends between 1977/1978 and 1994/1998 in the prevalence, amounts, and sources of soft drink consumption were examined among youth age 6 to 17 years. DESIGN: Dietary intake data were examined from three national surveys: the Nationwide Food Consumption Survey 1977/1978 (n=8,908), and the combined Continuing Survey of Food Intakes by Individuals 1994/1996, and the Supplemental Children's Survey 1998 (n=3,177). Soft drinks were defined as carbonated beverages (all United States Department of Agriculture database codes starting with 924) and included flavored waters and juice drinks. Subjects/Setting A national sample of youth ages 6 to 17 years were interviewed for each of the 3 surveys. STATISTICAL ANALYSIS: t tests were conducted to examine between-survey changes in soft drink consumption and sources of soft drinks. RESULTS: The prevalence of soft drink consumption among youth ages 6 to 17 years increased 48%, from a prevalence of 37% in 1977/1978 to 56% in 1994/1998. Mean intake of soft drinks more than doubled, from 5 fl oz to 12 fl oz per day. Although the home environment remained the largest source of children's soft drink access, an increasing share was obtained from restaurants and fast-food establishments (+53%), vending machines (+48%), and other sources (+37%). CONCLUSIONS: Away-from-home sources of soft drink are an important factor for dietitians to consider when evaluating the dietary intake and nutritional status of youths.

Did fat intake in the United States really decline between 1989-1991 and 1994-1996?

The objectives of this study were to determine changes in fat and energy intakes in the United States between 1989-1991 and 1994-1996, and to examine the implications of expressing fat intake in grams vs as a percent of total energy intake. The source of data was the Continuing Survey of Food Intake by Individuals. The results suggest that intake of energy rose between the 2 time periods, primarily due to higher carbohydrate intake. There was also a modest increase in fat intake. However fat intake, as a percent of total energy, declined. The higher energy intakes were primarily from beverages, especially soft drinks, food mixtures, grain snacks, and pastries. The primary sources of higher fat intakes were meat mixtures, vegetables, and some categories of the grain group. Similar trends in the Food Supply Series suggested that the changes observed were not entirely due to changes in survey methodology. Because the increase in fat intake was masked by the increase in energy intake, we conclude that assessing trends in fat intake as a percent of energy consumption can be misleading, unless information on total energy and fat intake, in grams, is also provided. These preliminary findings should be interpreted cautiously until they are confirmed by formal secular trend analyses.

Unhealthy eating habits, physical exercise and macronutrient intakes are predictors of anthropometric indicators in the Women's Health Trial: Feasibility Study in Minority Populations.

The increasing prevalence of obesity in the USA, especially among minority populations, is a serious public health concern. This present study analysed repeated measurements at baseline and at 6 and 12 months on 351 women in the control group and 575 women in the intervention group of the Women's Health Trial: Feasibility Study in Minority Populations. Dynamic random effects models were estimated using the three repeated observations to explain the effects of energy and macronutrient intakes, physical exercise, unhealthy eating habits and socio-economic characteristics on the subjects' body weights and waist and hip circumferences. In both the control and intervention groups, physical exercise was negatively associated with body weight and with waist and hip circumferences, while an index of unhealthy eating habits was positively associated (P<0.05). The proportion of energy derived from carbohydrate and from saturated and monounsaturated fat were often significant predictors of body weight and of waist and hip circumferences in the two groups. The results indicated that nutrition education programmes for improving eating habits and increasing physical exercise can reduce obesity prevalence in the USA.