Positive influence of the revised Special Supplemental Nutrition Program for Women, Infants, and Children food packages on access to healthy foods

BackgroundThe Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has important potential for preventing diet-related disease in low-income children. WIC food packages were recently revised to offer foods that better reflect dietary recommendations for Americans.ObjectiveThis article reports on how implementation of the new healthier WIC food packages affected access of low-income populations to healthy foods (eg, whole grains, fruit and vegetables, and lower-fat milk).DesignA pre–post store inventory was completed using a standardized instrument to assess availability, variety, quality and prices of WIC-approved foods (65 food items). Stores were assessed before (spring 2009) and shortly after the new WIC package implementation (spring 2010).Participants/settingAll convenience stores and nonchain grocery stores located in five towns of Connecticut (N=252), including 33 WIC-authorized stores and 219 non-WIC stores.Statistical analyses performedThe healthy food supply score was constructed to summarize postrevision changes in availability, variety, prices of healthy foods, and produce quality. The effect of the WIC food package revisions was measured by differential changes in the scores for stores authorized to accept WIC benefits and stores not participating in WIC, including differences by neighborhood income. Multivariate multilevel regression models were estimated.ResultsThe 2009 introduction of the revised WIC food packages has significantly improved availability and variety of healthy foods in WIC-authorized and (to a smaller degree) non-WIC convenience and grocery stores. The increase in the composite score of healthy food supply varied from 16% in WIC convenience and grocery stores in higher-income neighborhoods to 39% in lower-income areas. Improved availability and variety of whole-grain products were responsible for most of the increase in the composite score of healthy food supply.ConclusionsDesigned as cost-neutral changes, the WIC food package revisions have improved access to healthy foods for WIC participants and society at large.     

The Contribution of Major Food Categories and Companies to Household Purchases of Added Sugar in Australia

BackgroundThe Australian Government will soon be releasing a series of sugar reformulation targets for packaged foods.ObjectiveTo estimate the amount of added sugar purchased from packaged food and beverages and the relative contribution that food categories and food companies made to these purchases in 2018. The secondary objective was to examine differences in purchases of added sugar across income levels.DesignCross-sectional study.Participants/settingWe used 1 year of grocery purchase data from a nationally representative panel of Australian households (the NielsenIQ Homescan panel), combined with a packaged food and beverage database (FoodSwitch).Main outcome measuresAdded sugar purchases (grams per day per capita), purchase-weighted added sugar content (grams per 100 g) and total weight of products (with added sugar) purchased (grams per day per capita).Statistical analyses performedFood categories and food companies were ranked according to their contribution to added sugar purchases. Differences in added sugar purchases by income levels were assessed by 1-factor analysis of variance.ResultsAdded sugar information was available from 7188 households and across 26,291 unique foods and beverages. On average, the amount of added sugar acquired from packaged foods and beverages was (mean ± SE) 35.9 ± 0.01 g/d per capita. Low-income households purchased 11.0 g/d (95% CI: 10.9-11.0 g/d, P < .001) more added sugar from packaged products than high-income households per capita. The top 10 food categories accounted for 82.2% of added sugar purchased, largely due to purchases of chocolate and sweets, soft drinks, and ice cream and edible ices. Out of 994 food companies, the top 10 companies contributed to 62.1% of added sugar purchases.ConclusionsThe Australian Government can strengthen their proposed sugar reduction program by adding further category-specific targets, prioritizing engagement with key food companies and considering a broader range of policies to reduce added sugar intakes across the Australian population.     

Main Retailers In Which Mexican Households Acquire Their Food Supply

ObjectiveTo describe the frequency of food and beverages purchased made by Mexican households at different types of grocery retailers.DesignA national cross-sectional survey.SettingMexico.ParticipantsA representative sample of Mexican households (n = 70,311).Main Outcome Measure(s)Household food and beverages purchases.AnalysisThe association between amounts of food and beverages supply bought in different food retailers (as outcome) and households’ sociodemographic characteristics (as covariates) was assessed using logistic and linear regression models.ResultsMexican households acquired their food and beverages primarily from abarrotes stores, followed by supermarkets and mercados and tianguis. Abarrotes stores and supermarkets were sources of unprocessed and processed foods. Specialized stores, mercados, and tianguis were primary sources of unprocessed foods. Households with low socioeconomic status and those in the central or southern regions acquired more foods from abarrotes stores, mercados and tianguis, and specialized stores. Households with high socioeconomic status and living in the northern region acquired more foods from supermarkets and convenience stores.Conclusions and ImplicationsAbarrotes stores are the primary source of food and beverages for Mexican households; however, some interventions are needed to increase their supply of unprocessed foods. Public health interventions aiming at increasing access to unprocessed foods could be done through traditional retailers.     

Purchases Made with a Fruit and Vegetable Voucher in a Rural Mexican-Heritage Community

Recent recommendations for US food assistance programs are intended to ensure foods provided through these programs help households consume a varied, healthful diet. From a policy viewpoint, it is important to examine the impact of economic incentives to purchase healthy foods across subpopulations, particularly low-income Latinos, who comprise 40% of the WIC program nationwide. Our aim was to determine how rural, Mexican-heritage households (N?=?227) residing in California’s Central Valley distributed fruit and vegetable (F/V) voucher spending among F/V subgroups and specific items over a 1-year period. Households contained at least one child who was between 3 and 8 years old at baseline and had a parent of Mexican-heritage. F/V voucher purchase data were collected via grocery store scanners. Expenditure and frequency shares of subgroups and individual items were analyzed to determine purchasing habits. Fruits were the most commonly purchased subgroup, representing 55% of spending and 45% of frequency. Households allocated low percentages of their voucher to dark green and red/orange vegetables—7 and 9% respectively. Approximately 20% of purchases were good potassium sources and 30% of purchases were good fiber sources. Many of the most frequently purchased items were of cultural significance (tomatillo, chayote, chili/jalapeño pepper, and Mexican squash). This study suggests that economic incentives can contribute important nutrients to participants’ diets and targeted vouchers provided by food assistance programs should continue to include culturally important foods and be aware of the cultural values of their participants.     

Customer Characteristics and Shopping Patterns Associated with Healthy and Unhealthy Purchases at Small and Non-traditional Food Stores

Small and non-traditional food stores (e.g., corner stores) are often the most accessible source of food for residents of lower income urban neighborhoods in the U.S. Although healthy options are often limited at these stores, little is known about customers who purchase healthy, versus less healthy, foods/beverages in these venues. We conducted 661 customer intercept interviews at 105 stores (corner stores, gas marts, pharmacies, dollar stores) in Minneapolis/St. Paul, Minnesota, assessing all food and beverage items purchased. We defined three categories of “healthy” and four categories of “unhealthy” purchases. Interviews assessed customer characteristics [e.g., demographics, body-mass index (BMI)]. We examined associations between healthy versus unhealthy purchases categories and customer characteristics. Overall, 11% of customers purchased ≥1 serving of healthy foods/beverages in one or more of the three categories: 8% purchased fruits/vegetables, 2% whole grains, and 1% non-/low-fat dairy. Seventy-one percent of customers purchased ≥1 serving of unhealthy foods/beverages in one or more of four categories: 46% purchased sugar-sweetened beverages, 17% savory snacks, 15% candy, and 13% sweet baked goods. Male (vs. female) customers, those with a lower education levels, and those who reported shopping at the store for convenience (vs. other reasons) were less likely to purchase fruits/vegetables. Unhealthy purchases were more common among customers with a BMI ≥30 kg/m² (vs. lower BMI). Results suggest intervention opportunities to increase healthy purchases at small and non-traditional food stores, particularly interventions aimed at male residents, those with lower education levels and residents living close to the store.     

Types and Amounts of Nonnutritive Sweeteners Purchased by US Households: A Comparison of 2002 and 2018 Nielsen Homescan Purchases

BackgroundPurchases of foods containing nonnutritive sweetener (NNS) alone or in combination with caloric sweeteners (CS) has increased in recent years in the United States. At the same time clinical evidence is emerging of different cardiometabolic effects of each NNS type.ObjectiveTo examine the prevalence and volume purchased of commonly consumed types of NNS in packaged food and beverage products comparing 2002 and 2018 using data from nationally representative samples of US households.Participants/settingNielsen Homescan Consumer Panels (The Nielsen Company); 2002 and 2018.Main outcome measuresPrevalence and volume of foods and beverages purchased containing CS, NNS, both CS and NNS, or neither CS nor NNS, as well as prevalence and volume of products containing specific NNS types.Statistical analyses performedDifferences examined using Student t test, P value of <.05 considered significant.ResultsVolume of products purchased containing CS decreased comparing 2002 and 2018 (436.6 ± 1.6 to 362.4 ± 1.3 g/d; P < .05), yet increased for products containing both CS and NNS (10.8-36.2 g/d; P < .05). Regarding specific types of NNS, changes were noted in the prevalence of households purchasing products containing saccharin (1.3%-1.1%; P < .05), aspartame (60.0%-49.4%; P < .05), rebaudioside A (0.1%-25.9%) and sucralose (38.7%-71.0%). Non-Hispanic whites purchased twice the volume of products containing NNS compared to Hispanics and non-Hispanic blacks in both years. Beverages were predominantly responsible for larger volume per capita purchases of products containing only NNS as well as both CS and NNS.ConclusionsA decline in purchases of products containing CS occurred in tandem with an increase in purchases of products containing both CS and NNS, along with a large shift in the specific types of NNS being purchased by US households. New NNS types enter the market regularly, and it is important to monitor changes in the amount of NNS and products containing NNS that consumers purchase.     

Socioeconomic differences in purchases of more vs. less healthy foods and beverages: Analysis of over 25,000 British households in 2010

Socioeconomic inequalities in diet-related health outcomes are well-recognised, but are not fully explained by observational studies of consumption. We provide a novel analysis to identify purchasing patterns more precisely, based on data for take-home food and beverage purchases from 25,674 British households in 2010. To examine socioeconomic differences (measured by occupation), we conducted regression analyses on the proportion of energy purchased from (a) each of 43 food or beverage categories and (b) major nutrients. Results showed numerous small category-level socioeconomic differences. Aggregation of the categories showed lower SES groups generally purchased a greater proportion of energy from less healthy foods and beverages than those in higher SES groups (65% and 60%, respectively), while higher SES groups purchased a greater proportion of energy from healthier food and beverages (28% vs. 24%). At the nutrient-level, socioeconomic differences were less marked, although higher SES was associated with purchasing greater proportions of fibre, protein and total sugars, and smaller proportions of sodium. The observed pattern of purchasing across SES groups contributes to the explanation of observed health differences between groups and highlights targets for interventions to reduce health inequalities.     

The Special Supplemental Nutrition Program for Women,Infants, and Children Spillover Effect: Do Siblings Reap the Benefits?

BackgroundParticipation in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) among 0- to 5-year-old children is associated with healthier diets. Extension of dietary benefits to older, age-ineligible children (5-18 years old) residing in WIC households has not been fully investigated.ObjectiveExamine the association between household WIC participation and dietary behaviors of age-ineligible children.DesignCross-sectional secondary analysis of data collected from 2 independent panels (2009-2010 and 2014) of the New Jersey Child Health Study, using household surveys. Questions derived from national surveys assessed consumption frequency of specific foods among 5- to 18-year-old children.Participants/settingThe analytic sample included 616 age-ineligible children from households with incomes below 200% of the federal poverty level, 398 of whom were from WIC-participating households.Main outcome measuresEating behaviors were measured as frequency of daily consumption of fruit, vegetables, 100% juice, sugar-sweetened beverages, and sweet and salty snacks.Statistical analysisMultivariable negative binomial models examined the association between eating behaviors and household WIC participation status adjusting for child’s age, sex, and race; mother’s education; city of residence; household size; and panel. Results are expressed as incidence rate ratios (IRRs).ResultsHousehold WIC participation was not associated with dietary behaviors among age-ineligible children (5-18 years old) in the overall sample. However, healthier dietary patterns were observed for specific demographic groups. Compared with age-ineligible children in non-WIC households, age-ineligible children in WIC households had (1) a higher frequency of vegetable consumption among 12- to 18-year-old children (IRR = 1.29; 95% confidence interval [CI] 1.05-1.58; P = .015); (2) a marginally significant higher frequency of 100% juice consumption among females (IRR = 1.27; 95% CI 1.00-1.62; P = .053); and (3) a lower frequency of sugar-sweetened beverages consumption among Hispanic children (IRR = 0.61; 95% CI 0.43-0.86; P = .004).ConclusionsHousehold WIC participation may positively influence dietary behaviors of age-ineligible children, suggesting a possible WIC spillover effect. Revisions to WIC package composition should consider the possible dietary implications for all children in the household.     

The availability and cost of healthier food alternatives

BACKGROUND: Many people, especially low-income consumers, do not successfully follow dietary recommendations to eat more whole grains and less fat and added sugar. The food environment may have a significant impact on the choice by low-income consumers to eat healthier foods, as both the availability and price of healthier food items may limit their ability to eat a healthier diet. We investigated the cost and availability of a standard market basket of foods, and a healthier basket that included low-fat meat and dairy and whole grain products. METHODS: Market-basket surveys were conducted in 25 stores in Los Angeles and Sacramento. Stores were selected from neighborhoods that were varied by income and surveyed three times from September 2003 to June 2004. The average cost of a standard market basket (based on the U.S. Department of Agriculture's Thrifty Food Plan [TFP]) and a healthier market basket was calculated from these prices and compared using a standard t-test to determine if they were significantly different from each other. The analysis was conducted in 2005. RESULTS: In neighborhoods served by smaller grocery stores, access to whole-grain products, low-fat cheeses, and ground meat with <10% fat is limited. Among all items that were unavailable, 64% were in small grocery stores. For the 2-week shopping list, the average TFP market-basket cost was $194, and the healthier market-basket cost was $230. The average cost of the healthier market basket was more expensive by $36 due to higher costs of whole grains, lean ground beef, and skinless poultry. The higher cost of the healthier basket is equal to about 35% to 40% of low-income consumers' food budgets of $2410 a year. CONCLUSIONS: The lack of availability in small grocery stores located in low-income neighborhoods, and the higher cost of the healthier market basket may be a deterrent to eating healthier among very low-income consumers. Public policies should take the food environment into account in order to develop successful strategies to encourage the consumption of healthier foods.     

Caloric Beverage Intake Among Adult Supplemental Nutrition Assistance Program Participants

Objectives. We compared sugar-sweetened beverage (SSB), alcohol, and other caloric beverage (juice and milk) consumption of Supplemental Nutrition Assistance Program (SNAP) participants with that of low-income nonparticipants.Methods. We used 1 day of dietary intake data from the 2005–2008 National Health and Nutrition Examination Survey for 4594 adults aged 20 years and older with household income at or below 250% of the federal poverty line. We used bivariate and multivariate methods to compare the probability of consuming and the amount of calories consumed for each beverage type across 3 groups: current SNAP participants, former participants, and nonparticipants. We used instrumental variable methods to control for unobservable differences in participant groups.Results. After controlling for observable characteristics, SNAP participants were no more likely to consume SSBs than were nonparticipants. Instrumental variable estimates showed that current participants consumed fewer calories from SSBs than did similar nonparticipants. We found no differences in alcoholic beverage consumption, which cannot be purchased with SNAP benefits.Conclusions. SNAP participants are not unique in their consumption of SSBs or alcoholic beverages. Purchase restrictions may have little effect on SSB consumption.People in the Unites States consume about 20% of their calories from beverages, a share that has increased greatly over recent decades.1 Calories from beverages may be less satiating than calories from food and may therefore contribute to weight gain.2–5 Calories from sugar-sweetened beverages (SSBs) may be particularly problematic because they provide little if any essential nutrients. Policies suggested or enacted to reduce SSB consumption include taxing SSB purchases6–9 and restricting the size of SSBs sold by food service establishments. Most recently, the discussion has moved to whether participants in the Supplemental Nutrition Assistance Program (SNAP) should be prohibited from using benefits to purchase SSBs. SNAP provides nutrition assistance to low-income individuals and families through electronic benefit transfer cards that can be used to purchase food at authorized food retailers. SNAP benefits can be used to purchase almost all foods, with the exceptions of hot foods or food that will be eaten in the stores, alcoholic beverages and tobacco products.New York City requested a waiver from the Food and Nutrition Service of the US Department of Agriculture to restrict the use of SNAP benefits for purchases of some SSBs10 but was denied. Several high-profile commentators argued that the SNAP program may be subsidizing obesity and should be modified to encourage greater consumption of healthy foods and reduced consumption of empty calories such as SSBs.11,12 Others have argued that such restrictions could increase administrative costs but would have little impact on consumption patterns because most participants’ SNAP benefit only covers a portion of the household’s total food spending, and they could just use their cash food budgets to purchase SSBs.13 It has also been argued14 that imposing restrictions on only 1 part of the population is unfair when consumption of SSBs and obesity are fairly widespread among all Americans. Restrictions on SNAP purchases could have unintended consequences, such as reducing participation or substitution with other energy-dense foods.Despite the prominent appeals to restrict SNAP participants’ purchases, little evidence has shown that SNAP participants’ SSB consumption is different from that of the average consumer or other low-income consumers. Using longitudinal data for a cohort of US youths, no differences were found between SNAP participants and otherwise similar nonparticipants in the frequency of consumption (not total calories) of soft drinks, 100% fruit juice, and milk.15 Purchases of different beverages at 1 chain grocery store in New England for a sample of families that participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program over a 2-year period showed that among the participants, those who also received SNAP benefits purchased a higher percentage of SSBs than did non-SNAP participants.16 This study did not consider all SNAP households (or any other low-income households that did not participate in either SNAP or the Special Supplemental Nutrition Program for Women, Infants, and Children); examined beverage purchases at only 1 grocery store chain in New England; did not consider beverage purchases at bars, restaurants, or other food retailers; and did not consider beverage intake among household members. Both of these studies examined only a segment of all SNAP participants.Alcoholic beverages contribute a sizable share of total beverage calories for those who consume them. Alcoholic beverages cannot be purchased with SNAP benefits. If SSB purchases are restricted in SNAP, participants could use other resources to purchase SSBs, just as they may to purchase alcoholic beverages. Although there are important distinctions between SSBs and alcohol (e.g., tax rates, controlled points of purchase, limits on who can purchase, and some health benefits of moderate consumption), examining how alcohol consumption differs between participants and nonparticipants may provide insight into how a restriction on SSBs could affect purchases among SNAP participants.We used national-level data on individual beverage intake to investigate intake of SSBs, alcohol, and other caloric beverages (milk and juice) for SNAP participants and otherwise similar nonparticipants. After comparing average intake of these beverage types, we used regression to explore whether differences across participant groups are explained by differences in observable characteristics. We separately estimated the probability of consuming each beverage type and the total number of calories consumed among consumers of each beverage. We augmented our main estimates with instrumental variable estimates that account for self-selection of SNAP participants.     

Select Food Group Intake of US Children Aged 2 to 4 Years by WIC Participation Status and Income

BackgroundFood group and nutrient priorities for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Package IV for children aged 2 to 4 years were described in the 2017 review of the WIC Food Package. Research has evaluated priority nutrient intake, but priority food group intake remains unknown.ObjectivesTo compare mean intake of priority food groups/subgroups of WIC children to WIC-eligible nonparticipants and higher income children. Further, we hoped to assess differences in percent contribution of food subgroups to total food group intake by WIC participation status and income.DesignCross-sectional study conducted using data from the 2011-14 National Health and Nutrition Examination Survey.Participants/settingOne thousand forty-seven children aged 2 to 4 years.Main outcome measuresMean intake reported in cup equivalents and ounce equivalents. We also looked at mean percent that food subgroups contributed to total intake within a food group. Analyses were performed for high and low priority food groups/subgroups: high = seafood, total vegetables, dark green vegetables, red/orange vegetables, whole grains, and nuts/seeds/soy; low = total starchy vegetables, other vegetables, legumes computed as vegetables, total dairy, and total protein foods.Statistical analyses performedMultivariable linear regression analysis was used evaluate the relationship between income/WIC participation and mean intake/percent food subgroups contributed to total food group intake.ResultsAmong low-income WIC-eligible children, participation in WIC was associated with greater mean intake of red/orange vegetables (0.18 ± 0.03 vs 0.01 ± 0.06 c equivalents; P < 0.05) and legumes (0.07 ± 0.01 vs 0.01 ± 0.02 c equivalents; P < 0.01). No differences in mean intake were observed between WIC children and higher income children. Grain intake of WIC children was composed of a higher percentage of whole grains (19.1% ± 1.6% vs 13.2% ± 1.5%; P < 0.01) compared with higher income children. The percent vegetable subgroups contributed to total vegetable intake varied by income; no differences were observed for dairy or protein subgroups.ConclusionsAmong low-income children, participation in WIC was associated with greater intake of certain vegetables. Participation in WIC may also help close the diet quality gap between low-income and higher income children for priority foods targeted by the WIC food package. Future research should explore socioeconomic disparities in intake of nutrient-poor foods.     

Accessibility of Nutritious African Foods for an Adequate Diet in Bulawayo,Zimbabwe

Despite being an agriculturally productive country, Zimbabwe has a high prevalence of undernutrition. Our purpose was to study the implications of food pricing policies on the accessibility of nutritious foods purchased through the formal market economy to the urban black (indigenous) population of Bulawayo, Zimbabwe. A validated food basket was created to calculate the cost of meeting the nutritional needs of a typical low-income urban family. Food prices were surveyed during July (winter) 1995 in three regions of Bulawayo. The mean monthly cost of the food basket in the high-density suburbs (low-income region) was Z$l,181.12 (± 74.60).This is 7% higher than in the city center (predominantly nonresidential; mean basket cost = $1,101.65 ± 52.83) and 10% higher than in the low-density suburbs (higher income region; mean basket cost = $1,069.46 ± 44.37). Comparison of monthly food basket costs in the high-density suburbs to government-stipulated minimum wages typical of employed low-income families revealed food costs 2.3 to 4.88 times the total monthly salary for one worker.The household food insecurity experienced by the low-income urban black population is discussed in relation to government policies adopted in response to structural adjustment programs.     

Socio-demographic influences on food purchasing among Canadian households

OBJECTIVE: To characterize the relationships between selected socio-demographic factors and food selection among Canadian households. DESIGN: A secondary analysis of data from the 1996 Family Food Expenditure survey was conducted (n=10,924). Household food purchases were classified into one of the five food groups from Canada's Food Guide to Healthy Eating. Parametric and non-parametric modelling techniques were employed to analyse the effects of household size, composition, income and education on the proportion of income spent on each food group and the quantity purchased from each food group. RESULTS: Household size, composition, income and education together explained 21-29% of the variation in food purchasing. Households with older adults spent a greater share of their income on vegetables and fruit (P<0.0001), whereas households with children purchased greater quantities of milk products (P<0.0001). Higher income was associated with purchasing more of all food groups (P<0.0001), but the associations were nonlinear, with the strongest effects at lower income levels. Households where the reference person had a university degree purchased significantly more vegetables and fruit, and less meat and alternatives and 'other' foods (P<0.0001), relative to households with the lowest education level. CONCLUSIONS: Household socio-demographic characteristics have a strong influence on food purchasing, with the purchase of vegetables and fruit being particularly sensitive. Results reinforce concerns about constraints on food purchasing among lower income households. Furthermore, the differential effects of income and education on food choice need to be considered in the design of public health interventions aimed at altering dietary behaviour.     

Food items consumed by students attending schools in different socioeconomic areas in Cape Town, South Africa

OBJECTIVE: We investigated the food consumption patterns of adolescent students at schools. Our findings are intended to reveal the overall nutritional quality of foods eaten by students at school, including foods brought to school and foods purchased at school. METHODS: A questionnaire was completed by 476 students, mostly from grades 7 and 10, from 14 schools in Cape Town, South Africa. The schools were representative of the various ethnic groups and socioeconomic strata of the population. The questionnaire requested information on eating habits at school, foods brought to school and food purchases, and breakfast consumption before school. We also tested whether students knew which foods are healthy and which are less healthy choices. RESULTS: The students were mostly 12 to 16 y of age (mean age 14.5 y). The large majority had breakfast before school (77.8%) and ate at school (79.7%). Food was brought to school by 41% to 56%, whereas 69.3% purchased food at school, mainly at the school store (tuck shop). Predefined "unhealthy" foods brought to school outnumbered "healthy" ones by 2 to 1. Among students who purchased food at school, 70.0% purchased no healthy items, whereas 73.2% purchased two or more unhealthy items. With six foods 84% of students correctly stated whether they were healthy or unhealthy; however, with cola drinks, samoosas (deep-fried pastry with spicy filling), and pies, only 47% to 61% knew that these were less healthy choices. Students' scores on this question were unrelated to whether they purchased healthy or unhealthy foods. Students who attended schools of high socioeconomic status were twice as likely to bring food to school (64.7% versus 31.0%, P<0.001), scored higher marks on the quiz of healthy versus unhealthy foods (P<0.01), but were no more likely to purchase healthy food. CONCLUSIONS: The large majority of food eaten by adolescent students in Cape Town is classified as being unhealthy choices. This applies to foods brought to school and food purchases. Consideration needs to be given to policy measures to improve this situation and to improve education of students and their parents.     

A Cross-Sectional Study of the Street Foods Purchased by Customers in Urban Areas of Central Asia

This study aimed to describe street food purchases in cities from Central Asia, considering customers’ characteristics and the nutritional composition of the foods and beverages. Cross-sectional studies were conducted in 2016/2017 in Dushanbe (Tajikistan), Bishkek (Kyrgyzstan), Ashgabat (Turkmenistan) and Almaty (Kazakhstan). Direct observation was used to collect data on the purchases made by street food customers, selected by random and systematic sampling. Nutritional composition was estimated using data from chemical analyses, food composition tables or food labels. A total of 714 customers (56.6% females, 55.5% aged ≥35 years, 23.3% overweight/obese) were observed, who bought 852 foods and beverages, the most frequent being savoury pastries/snacks (23.2%), main dishes (19.0%), sweet pastries/confectionery (17.9%), tea/coffee (11.3%) and soft drinks/juices (9.8%). Fruit was the least purchased food (1.1%). Nearly one-third of customers purchased industrial food items (31.9%). The median energy content of a street food purchase was 529 kcal/serving. Saturated and trans-fat median contents were 4.7 g/serving and 0.36 g/serving (21.4% and 16.5% of maximum daily intake recommendations, respectively). Median sodium and potassium contents were 745 mg/serving (37.3% of maximum recommendation) and 304 mg/serving (8.7% of minimum recommendation), respectively. In general, the purchases observed presented high contents of energy, saturated-fat, trans-fat and sodium, and low levels of potassium. Policies towards the improvement of these urban food environments should be encouraged.     

The Food Environment of Primary School Learners in a Low-to-Middle-Income Area in Cape Town,South Africa

Rapid changes in food environments, where less nutritious foods have become cheaper and more accessible, have led to the double burden of malnutrition (DBM). The role food environments have played in shaping the DBM has attained global interest. There is a paucity of food environment research in low-to-middle-income countries. We conducted a case study of the food environments of school aged learners. A primary school in Cape Town was recruited. A multi-method design was used: a home food and eating behaviours questionnaire completed by 102 household respondents and four questions completed by 152 learners; learner participatory photography; a semi-structured school principal interview; a tuckshop inventory; observation of three-day tuckshop purchases. Foods that were commonly present in households: refined carbohydrates, fats/oils, chicken, processed meats, vegetables, fruit, legumes, snacks/drinks. Two thirds of households had rules about unhealthy drinks/snacks, ate supper together and in front of the TV, ate a home cooked meal five–seven times/week and ate breakfast together under two times/week. Vegetables were eaten under two times/week in 45% of households. A majority of learners (84%) took a lunchbox to school. Twenty-five learners photographed their food environment and 15 participated in semi-structured interviews. Six themes emerged: where to buy; what is available in the home; meal composition; family dynamics; peer engagement; food preparation. Items bought at informal food outlets included snacks, drinks and grocery staples. The principal interview revealed the establishment of a healthy school food environment, including a vegetable garden, although unhealthy snacks were sold at the tuckshop. Key dimensions of the food environment that require further investigation in disadvantaged urban and informal settlement areas include the home availability of unhealthy foods, eating behaviours in households and healthfulness of foods sold by informal food outlets.