Supplemental Nutrition Assistance Program (SNAP)-authorized retailers received a low score using the Business Impact Assessment for Obesity and population-level nutrition (BIA-Obesity) tool.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) supports Americans with lower income to purchase dietary products at authorized retailers. This research aimed to evaluate SNAP-authorized retailers' public commitments in support of nutrition security and to examine differences between traditional grocers and nontraditional (e.g., convenience, drug, dollar) SNAP-authorized retailers' public commitments. METHODS: Prominent United States (U.S.) SNAP-authorized retailers nationally and in two U.S. states (California and Virginia) were identified based on number of store locations (n = 61). Public information available in grey literature were reviewed and scored using the Business Impact Assessment for Obesity and population-level nutrition (BIA-Obesity) tool. SNAP-authorized retailers were classified as traditional (e.g., grocery) or nontraditional (e.g., non-grocery) retailers. Total BIA-Obesity from 0 to 615, representing low to optimal support) and category scores were calculated for corporate strategy, relationships with external organizations, product formulation, nutrition labeling, product and brand promotion, and product accessibility. Descriptive statistics were used to describe BIA-Obesity scores overall and by category. Mann-Whitney U was used to test for potential differences in median BIA-Obesity total scores between traditional and nontraditional SNAP-authorized retailers (a priori, p < 0.05). RESULTS: Average total BIA-Obesity scores for SNAP-authorized retailers ranged from 0 to 112 (16.5 ± 23.3). Total BIA-Obesity scores for traditional SNAP-authorized retailers (32.7 ± 33.6; median 25) were higher than nontraditional SNAP-authorized retailer scores (11.2 ± 16; median 5) (p = 0.008). For BIA-Obesity categories, average scores were highest for the category relationships with external organizations (8.3 ± 10.3) and lowest for promotion practices (0.6 ± 2.1). CONCLUSIONS: Results of this research underscore a dearth of available evidence and substantial opportunity for improvement regarding SNAP-authorized retailer strategies to support nutrition security among Americans with lower income.

The American Rescue Plan Act Is a Great Start but More Increases in Supplemental Nutrition Assistance Program (SNAP) Benefits Are Likely Needed Due to Implicit Hidden Reductions.

The Supplemental Nutrition Assistance Program (SNAP) is intended to help low-income individuals reach the cost of a nutritious diet. In response to the Coronavirus disease 2019 (COVID-19) pandemic, SNAP benefits have been increased by 20.3% since October 2020. Given the intended goal of the program, is the 20.3% increase enough? Even prior to COVID-19, the literature had identified 3 separate shortcomings in the current formula that had not been addressed. Here, these shortcomings are integrated into a unifying framework that allows for a comparison between an adjusted formula, that accounts for all these shortcomings, and the current unadjusted formula, that does not account for these shortcomings. Using some average data from the literature, the current unadjusted formula gives the misleading impression that the government will provide 71% of the cost of a nutritious diet with households responsible for 29%. However, working with the adjusted formula, that takes into account the shortcomings, reveals the government actually only provides 41% of the adjusted cost of a nutritious diet and households are responsible for 59%. Some actual and recommended adjustments are shown to fall far short of the full adjustment required to reach a nutritious diet, on average. In particular, the 20.3% increase is less than half of the amount needed to fully correct for these omissions.

Supplemental Nutrition Assistance Program (SNAP)-Authorized Retailers' Perceived Costs to Use Behavioral Economic Strategies to Encourage Healthy Product Sales.

SNAP-authorized retailers could use marketing-mix and choice-architecture (MMCA) strategies to improve SNAP purchases, but associated costs are unknown. Perceived cost and inconvenience to implement eight MMCA strategies were assessed among 29 U.S. retailers. Differences in perspective were explored (owners vs. managers, corporate vs. independent retailers, and by format). Place changes (e.g., added refrigeration) were perceived more costly and prompting (e.g., shelf labeling) less costly. Managers rated the perceived inconvenience to make proximity changes higher than owners (3.78 ± 1.4 and 2.33 ± 1.2, respectively) (p < .05). Results can inform strategies to improve the adoption and implementation of healthy food retail programs.

Availability of Supplemental Nutrition Assistance Program-authorised retailers' voluntary commitments to encourage healthy dietary purchases using marketing-mix and choice-architecture strategies.

OBJECTIVE: To examine public commitments for encouraging United States consumers to make healthy dietary purchases with their Supplemental Nutrition Assistance Program (SNAP) benefits among of prevalent SNAP-authorised retailers. SETTING: National SNAP-authorised retail landscape in addition to stores located in California and Virginia, two states targetted for a Partnership for a Healthier America pilot social marketing campaign. PARTICIPANTS: SNAP-authorised retailers with the most store locations in selected settings. DESIGN: A review of retailers' publicly available business information was conducted (November 2016-February 2017). Webpages and grey literature sources were accessed to identify corporate social responsibility (CSR) reports and commitments describing strategies to encourage healthy consumer purchases aligned with the 2015-2020 Dietary Guidelines for Americans. Evidence was organised using a marketing-mix and choice-architecture (MMCA) framework to characterise strategies used among eight possible types (i.e. place, profile, portion, pricing, promotion, priming, prompting and proximity). RESULTS: Of the SNAP-authorised retailers (n 38) reviewed, more than half (n 20; 52·6 %) provided no information in the public domain relevant to the research objective. Few retailers (n 8; 21·1 %) had relevant CSR information; grey literature sources (n 52 articles across seventeen retailers) were more commonly identified. SNAP-authorised retailers in majority committed to increasing the number of healthy products available for purchase (profile). CONCLUSIONS: Substantial improvements are needed to enhance the capacity and commitments of SNAP-authorised retailers to use diverse strategies to promote healthy purchases among SNAP recipients. Future research could explore feasible approaches to improve dietary behaviours through sector changes via public-private partnerships, policy changes, or a combination of government regulatory and voluntary business actions.

A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005-2017.

BACKGROUND: Altering food store environments is a promising approach to encourage healthy product purchases by consumers to improve their diet quality and health. Food store owners and managers are intermediaries to ensure that environmental changes are enacted. Despite their role as gatekeepers to implement and sustain healthy food environment changes, no systematic review has been published that examines food store owner and manager (retailer) data. Thus a review of retailer information available within the expansive United States (US) food environment literature was the purpose of this research. METHODS: The PRISMA protocol was used. A search strategy, including published articles from years 1980-2017, was applied to six databases to locate relevant articles that addressed the perspective of food store retailers in the US. Data were extracted, organized, and agreed upon between two authors based on pre-designed constructs: (1) a social-ecological model to capture factors that influence retailer decision making; and (2) a marketing-mix and choice-architecture framework to examine perspectives of applied (or the prospective application of) strategies at the store-level. Study quality was assessed using quality criteria checklists for qualitative and quantitative research. RESULTS: Thirty-one articles met inclusion criteria and most studies (n = 22) were qualitative and conducted in urban food stores (n = 23). Multiple social-ecological factors influenced retailer decision making and ability or willingness to use marketing-mix and choice-architecture strategies to improve consumers' healthy choices to support dietary quality. These factors included: conflicting training outcomes to enhance retailers' knowledge and skills (individual, n = 9); the importance of trust (interpersonal, n = 8); views about marketing-mix and choice-architecture strategies in the food environment (n = 25); consumer demand or demographics (community, n = 19); supplier and food store management variables (systems or sectors, n = 18); local and federal policy (n = 8); and support for community health (norms/values, n = 8). CONCLUSIONS: Research partnerships can support favorable business and public health outcomes to align with retailers' business models and available resources. A participatory and translational approach to food environment research will likely maximize public health impact. Urban and rural food store retailers are important actors for future research to inform the feasibility of store retailers to apply MMCA strategies that are profitable and promote health.

Factors influencing high respiratory mortality in coal-mining counties: a repeated cross-sectional study.

BACKGROUND: Previous studies have associated elevated mortality risk in central Appalachia with coal-mining activities, but few have explored how different non-coal factors influence the association within each county. Consequently, there is a knowledge gap in identifying effective ways to address health disparities in coal-mining counties. To specifically address this knowledge gap, this study estimated the effect of living in a coal-mining county on non-malignant respiratory diseases (NMRD) mortality, and defined this as "coal-county effect." We also investigated what factors may accentuate or attenuate the coal-county effect. METHODS: An ecological epidemiology protocol was designed to observe the characteristics of three populations and to identify the effects of coal-mining on community health. Records for seven coal-mining counties (n = 19,692) were obtained with approvals from the Virginia Department of Health Office of Vital Statistics for the years 2005 to 2012. Also requested were records from three adjacent coal counties (n = 10,425) to provide a geographic comparison. For a baseline comparison, records were requested for eleven tobacco-producing counties (n = 27,800). We analyzed the association of 57,917 individual mortality records in Virginia with coal-mining county residency, county-level socioeconomic status, health access, behavioral risk factors, and coal production. The development of a two-level hierarchical model allowed the coal-county effect to vary by county-level characteristics. Wald tests detected sets of significant factors explaining the variation of impacts across counties. Furthermore, to illustrate how the model estimations help explain health disparities, two coal-mining county case studies were presented. RESULTS: The main result revealed that coal-mining county residency increased the probability of dying from NMRD. The coal-county effect was accentuated by surface coal mining, high smoking rates, decreasing health insurance coverage, and a shortage of doctors. In Virginia coal-mining regions, the average coal-county effect increased by 147% (p-value< 0.01) when one doctor per 1000 left, and the effect increased by 68% (p-value< 0.01) with a 1% reduction of health insurance rates, holding other factors fixed. CONCLUSIONS: This study showed a high mortality risk of NMRD associated with residents living in Virginia coal-mining counties. Our results also revealed the critical role of health access in reducing health disparities related to coal exposure.

Using pre- and post-survey instruments in interventions: determining the random response benchmark and its implications for measuring effectiveness.

OBJECTIVE: The present communication demonstrates that even if individuals are answering a pre/post survey at random, the percentage of individuals showing improvement from the pre- to the post-survey can be surprisingly high. Some simple formulas and tables are presented that will allow analysts to quickly determine the expected percentage of individuals showing improvement if participants just answered the survey at random. This benchmark percentage, in turn, defines the appropriate null hypothesis for testing if the actual percentage observed is greater than the expected random answering percentage. DESIGN: The analysis is demonstrated by testing if actual improvement in a component of the US Department of Agriculture's (USDA) Expanded Food and Nutrition Education Program is significantly different from random answering improvement. SETTING: USA. SUBJECTS: From 2011 to 2014, 364320 adults completed a standardized pre- and post-survey administered by the USDA. RESULTS: For each year, the statement that the actual number of improvements is less than the expected number if the questions were just answered at random cannot be rejected. This does not mean that the pre-/post-test survey instrument is flawed, only that the data are being inappropriately evaluated. CONCLUSIONS: Knowing the percentage of individuals showing improvement on a pre/post survey instrument when questions are randomly answered is an important benchmark number to determine in order to draw valid inferences about nutrition interventions. The results presented here should help analysts in determining this benchmark number for some common survey structures and avoid drawing faulty inferences about the effectiveness of an intervention.

The inverse relationship between food price and energy density: is it spurious?

OBJECTIVE: An important debate in the literature is whether or not higher energy-dense foods are cheaper than less energy-dense foods. The present communication develops and applies an easy statistical test to determine if the relationship between food price and energy density is an artifact of how the data units are constructed (i.e. is it 'spurious' or 'real'?). DESIGN: After matching data on 4430 different foods from the National Health and Nutrition Examination Survey with corresponding prices from the Center for Nutrition Policy and Promotion's Food Prices Database, we use a simple regression model to test if the relationship between food price and energy density is 'real' or 'spurious'. SETTING: USA. SUBJECTS: Total sample size is 4430 observations of consumed foods from 4578 participants from the non-institutionalized US adult population (aged 19 years and over). RESULTS: Over all 4430 foods, the null hypothesis of a spurious inverse relationship between food price per energy density and energy density is not rejected. When the analysis is broken down by twenty-five food groups, there are only two cases where the inverse relationship is not spurious. In fact, the majority of non-spurious relationships between food price and energy density are positive, not negative. CONCLUSIONS: One of the main arguments put forth regarding the poor diet quality of low-income households is that high energy-dense food is cheaper than lower energy-dense food. We find almost no statistical support for higher energy-dense food being cheaper than low energy-dense food. While economics certainly plays a role in explaining low nutritional quality, more sophisticated economic arguments are required and discussed.

Effect of different children's menu labeling designs on family purchases.

The majority of labeling studies at restaurants have focused on adults, not children, and utilized cross-sectional data with one menu labeling design, typically calorie information. The aim of this longitudinal study was to examine the effect of three different menu labeling designs for children's meals on total calories and fat selected by families. Each menu was implemented for 2months. Patrons' purchases were tracked from a control menu (with no nutrition information) through all three theoretically-based designs: calorie and fat information; followed by symbols denoting healthier choices; then nutrition bargain price. All menus were created specifically for the study. They featured six combination meals (pre-determined entrees and side items) and a la carte items (entrees and side items that could be ordered separately). Only combination meals contained labeling. Fixed effects models were estimated to detect changes in sales for each menu labeling design compared to the control. Overall, menu labeling did not result in a positive net effect on total calories or fat purchased by families, but resulted in significant shifts in purchases of combination and a la carte meals and healthy and unhealthy options. The most significant impact was seen for nutrition bargain price labeling, the last design.

COVID-19-related financial scarcity is associated with greater delay discounting but not probability discounting.

Prior studies suggest that scarcity increases delay discounting (devaluation of delayed outcomes) and disturbs other decision-making processes. Evidence on the effect of COVID-19 on delay discounting is mixed. Also, no study has examined the effect of COVID-19-related scarcity on probability discounting (devaluation of probabilistic outcomes). The goal of the study was to examine cross-sectional associations between financial impact during the COVID-19 pandemic, delay discounting, and probability discounting. During April 2020, 1012 participants with low income were recruited on Amazon Mechanical Turk and completed measures of delay and probability discounting, perceived COVID-19-related financial impacts, and food security. Regression analyses indicate that compared to those with no COVID-19-related financial impacts, those with severe COVID-19-related financial impacts had greater delay discounting of money and greater delay discounting of a grocery gift card. Also, greater food insecurity in the past month was associated with greater delay discounting of a grocery gift card but not delay discounting of money. Perceived COVID-19 related financial impact was not associated with probability discounting. Combined with laboratory experiments, this study provides additional support for the idea that feelings of scarcity may increase delay discounting. However, as this study was observational, no assumptions of causality should be made about the specific effect of COVID-19 on delay discounting.

A "sludge audit" for health system colorectal cancer screening services.

OBJECTIVES: "Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. STUDY DESIGN: Mixed methods sludge audit. METHODS: We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. RESULTS: Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. CONCLUSIONS: Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

The Thrifty Food Plan is not thrifty when labor cost is considered.

Recent research has shown that the typical Supplemental Food Assistance Program (SNAP) family falls short in meeting the Thrifty Food Plan (TFP) nutritional guidelines that underlie the SNAP even when they typically have sufficient monetary resources to eat a healthful diet (i.e. to follow the TFP recommendations). However, the TFP does not consider labor cost. This study uses a basic labor economics technique to value labor in a home food production scenario that is required to reach the TFP nutrition and budget targets and calculates the total cost (inclusive of labor) associated with the TFP. This TFP consistent total cost is then compared, using several metrics, with the total cost associated with actual choices made by those families sharing the same profiles as current SNAP participants. Once labor is included, we find the TFP is not very thrifty and the mean household falls short of the TFP guidelines even with adequate monetary resources.

Perceptions of Rural SNAP-Authorized Food Store Owners and Managers About Healthy Product Availability.

OBJECTIVE: Supplemental Nutrition Assistance Program (SNAP)-authorized retailers' healthy perceptions and store availability of healthy products were explored to plan a healthy food retail program. METHODS: Cognitive anthropology (free list) and quantitative (food environment measure) methods were used to assess retailers' healthy product perceptions and the availability of store products aligned with dietary guidance. Cultural domain analysis techniques and descriptive and inferential statistics were used to interpret data. RESULTS: SNAP-authorized retailers (n = 29) of rural grocery (17%), dollar (14%), convenience (66%), and specialty (3%) stores participated. There was low salience for what constituted healthy and misalignments with dietary guidance and inventory. Dried beans, nuts, and seeds were widely available products across all stores and were listed less frequently by retailers. CONCLUSIONS AND IMPLICATIONS: Engagement with SNAP-authorized retailers to develop retailer-focused nutrition education and/or training protocols is warranted to improve the capacity for retailers to market store products aligned with dietary guidance.

Rural independent and corporate Supplemental Nutrition Assistance Program (SNAP)-authorized store owners' and managers' perceived feasibility to implement marketing-mix and choice-architecture strategies to encourage healthy consumer purchases.

Supplemental Nutrition Assistance Program (SNAP) participants could benefit from exposure to marketing-mix and choice-architecture (MMCA) strategies that encourage healthy consumer purchases. However, the perceived feasibility of independent and corporate SNAP-authorized store owners and managers (e.g., retailers) to implement healthy MMCA strategies is understudied. The purpose of this study was to inform a healthy food retail program that meets both public health and business expectations by prioritizing retailer perspectives. A mixed methods approach was used. Retailers completed a card sorting exercise to determine perceived feasibility to implement MMCA strategies place, profile, portion, pricing, promotion, priming, prompting, and proximity. This process was audio-recorded. Chi-square was used to identify potential differences in perceived feasibility to implement healthy MMCA strategies between independent and corporate SNAP-authorized retailers. Qualitative data were coded among a panel to construct themes. Themes were organized by barriers and facilitators and coded for strategy acceptability, appropriateness, and feasibility. SNAP-authorized retailers' (n = 29) considered prompting (e.g., labeling; 83%) and proximity (e.g., location; 90%) strategies to encourage healthy consumer purchases highly feasible. Few differences were detected between independent and corporate retailers' perceived feasibility to implement healthy MMCA strategies. The largest barriers to implementing healthy MMCA strategies were related to strategy appropriateness. Priorities for healthy food retail initiatives included prompting and proximity changes that highlight products aligned with the DGA, without altering products available to consumers that are misaligned with the DGA. Future work is required to understand how other healthy MMCA strategies may be adapted to enhance their appropriateness for these settings.

Beyond the sticker price: including and excluding time in comparing food prices.

BACKGROUND: An ongoing debate in the literature is how to measure the price of food. Most analyses have not considered the value of time in measuring the price of food. Whether or not the value of time is included in measuring the price of a food may have important implications for classifying foods based on their relative cost. OBJECTIVE: The purpose of this article is to compare prices that exclude time (time-exclusive price) with prices that include time (time-inclusive price) for 2 types of home foods: home foods using basic ingredients (home recipes) vs. home foods using more processed ingredients (processed recipes). The time-inclusive and time-exclusive prices are compared to determine whether the time-exclusive prices in isolation may mislead in drawing inferences regarding the relative prices of foods. DESIGN: We calculated the time-exclusive price and time-inclusive price of 100 home recipes and 143 processed recipes and then categorized them into 5 standard food groups: grains, proteins, vegetables, fruit, and dairy. We then examined the relation between the time-exclusive prices and the time-inclusive prices and dietary recommendations. RESULTS: For any food group, the processed food time-inclusive price was always less than the home recipe time-inclusive price, even if the processed food's time-exclusive price was more expensive. Time-inclusive prices for home recipes were especially higher for the more time-intensive food groups, such as grains, vegetables, and fruit, which are generally underconsumed relative to the guidelines. CONCLUSION: Focusing only on the sticker price of a food and ignoring the time cost may lead to different conclusions about relative prices and policy recommendations than when the time cost is included.

Mitigating or exacerbating effects of maternal-fetal programming of female mice through the food choice environment.

Humans live, eat, and become overweight/obese in complex surroundings where there are many available food choices. Prenatal exposure to poor food choices predisposes offspring to increased negative health risks, including obesity. Many animal experiments have analyzed intergenerational body weight parameters in an environment without food choices, which may not be directly translatable to the human food environment. In this study, offspring from mothers with a defined high-fat diet (HFD) or low-fat diet (LFD) were arbitrarily assigned to either an exclusively LFD or HFD or to a diet where they have a choice between LFD and HFD (choice diet). Offspring displayed negative outcomes of increased body weight, body fat, serum leptin, and blood glucose levels when given the choice diet compared with offspring on the LFD. Conversely, improved energy expenditure was found for offspring given the choice diet compared with offspring from HFD dams given LFD. In addition, maternal diet-specific influences on offspring metabolic parameters were identified, especially in offspring from HFD dams, including positive outcomes of reduced leptin in LFD offspring, reduced corticosterone and cholesterol levels in HFD offspring, and increased exercise levels in choice offspring, as well as the negative outcome of increased calorie intake in LFD offspring from HFD dams. This defined model can now be used as the basis for future studies to characterize the cycle of inter- and intragenerational obesity and whether more realistic diet environments, especially those including choice, can mitigate phenotype.

A comparison of fruits, vegetables, sugar-sweetened beverages, and desserts in the packed lunches of elementary school children.

BACKGROUND: An estimated 40% of children bring a packed lunch to school. These lunches are not required to meet nutrition standards. The aim of this study was to compare differences in the nutritional quality of elementary packed lunches by the presence or absence of sugar-sweetened beverages (SSB), desserts, and fruits and vegetables (FVs). METHODS: Observational data for prekindergarten and kindergarten packed lunches were collected from three schools in rural Virginia for 5 consecutive school days and analyzed for macro- and micronutrients and by the presence or absence of food and beverage items. RESULTS: Of the 561 packed lunch observations collected, 41.7% contained no FV, 41.2% contained an SSB, and 61.1% contained a dessert. The nutrient profile of packed lunches with at least one fruit or vegetable had significantly higher levels of carbohydrate, fiber, sugar, vitamin A, and vitamin C. Packed lunches containing an SSB had significantly higher levels of sugar and vitamin C and significantly lower levels of protein, fiber, vitamin A, calcium, and iron. Packed lunches containing a dessert had significantly higher levels of energy, carbohydrate, fat, saturated fat, sodium, sugar, vitamin C, and iron and significantly lower levels of vitamin A. CONCLUSIONS: Additional research is needed to fully understand parent and child motivations for packing lunches and the decision processes that influence the inclusion of food items. The development of packed lunch interventions, encouragement of National School Lunch Program participation, or enactment of school policies to increase the nutritional value of packed lunches is warranted.

Food waste in a school nutrition program after implementation of new lunch program guidelines.

OBJECTIVE: To assess the amount of food waste by meal components according to the new National School Lunch Program guidelines among pre-kindergarten and kindergarten students. METHODS: For 5 consecutive school days in 1 elementary school, the research team collected school lunch trays and separated meal components into bins relative to each food or beverage appearing on the school's daily menu. Bins were weighed in grams and converted to ounces and cups at the end of each lunch period. RESULTS: The researchers examined 304 meals from 1 pre-kindergarten class and 5 kindergarten classes. Of 4,988 oz of food and beverages served, 2,261 oz (45.3%) were wasted during 1 full school week, totaling 141 lb. The greatest amount of food waste was generated from vegetables, the main entree, and milk, respectively. CONCLUSIONS AND IMPLICATIONS: Strategies to reduce food waste in school lunch should be researched and implemented.

Nutritional comparison of packed and school lunches in pre-kindergarten and kindergarten children following the implementation of the 2012-2013 National School Lunch Program standards.

OBJECTIVE: Approximately 40% of children bring a packed lunch to school. Little is known about the quality of these lunches. This study examined the nutritional quality of packed lunches compared with school lunches for pre-kindergarten and kindergarten children after the implementation of 2012-2013 National School Lunch Program standards. METHODS: The researchers collected observational data for packed and school lunches from 3 schools in rural Virginia for 5 consecutive school days and analyzed them for macro and micro nutrients. RESULTS: Of the 1,314 observations collected; 42.8% were packed lunches (n = 562) and 57.2% were school lunches (n = 752). Energy, fat, saturated fat, sugar, vitamin C, and iron were significantly higher whereas protein, sodium, fiber, vitamin A, and calcium were significantly lower for packed lunches than school lunches. CONCLUSIONS AND IMPLICATIONS: Packed lunches were of less nutritional quality than school lunches. Additional research is needed to explore factors related to choosing packed over school lunches.

Using national data to estimate average cost effectiveness of EFNEP outcomes by state/territory.

This report demonstrates how existing national data can be used to first calculate upper limits on the average cost per participant and per outcome per state/territory for the Expanded Food and Nutrition Education Program (EFNEP). These upper limits can then be used by state EFNEP administrators to obtain more precise estimates for their states, based on their state-specific knowledge. Across all states, EFNEP appears most cost effective in nutrition practices, followed by food resource management practices, and then food safety practices. All but 3 states have cost per quality adjusted life years that are considered cost effective.