The healthfulness of food and beverage purchases after the federal food package revisions: The case of two New England states

ObjectiveIn 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented new food packages to improve dietary intake among WIC participants. This paper examines how the healthfulness of food purchases among low-income households changed following this reform.MethodsPoint-of-sale data for 2137 WIC-participating and 1303 comparison households were obtained from a regional supermarket chain. The healthfulness of purchased foods and beverages was determined per their saturated fat, sugar, and sodium content. A pre-post assessment (2009–2010) of the product basket healthfulness was completed using generalized estimating equation models. Data were analyzed in 2015.ResultsAt baseline, healthy products accounted for most of the food volume purchased by WIC participants, but beverages were dominated by moderation (less healthy) items. With new subsidies for fruit, vegetables and whole grains, the WIC revisions increased the volume of healthy food purchases of WIC-participating households by 3.9% and reduced moderation foods by 1.8%. The biggest improvements were reductions in moderation beverages (down by 24.7% in volume), driven by milk fat restrictions in the WIC food package revisions. The healthfulness of the product basket increased post-WIC revisions; mainly due to a reduction in the volume of moderation food and beverages purchased (down by 15.5%) rather than growth in healthy products (up by 1.9%). No similar improvements were seen in a comparison group of low-income nonparticipants.ConclusionsAfter the WIC revisions, the healthfulness of participant purchases improved, particularly for beverages. Efforts to encourage healthy eating by people receiving federal food assistance are paying off.     

Neighborhood food store availability in relation to food intake in young Japanese women

ObjectiveInformation on the association between the local food environment and the diet of individuals is limited, particularly in settings with high population density and, hence, high food-store density, such as Japan. This cross-sectional study examined the association between neighborhood food-store availability and individual food intake in a group of young Japanese women.MethodsParticipants were 990 female Japanese dietetic students 18–22 y of age. Neighborhood food-store availability was defined as the number of food stores within a 1-km mesh-block of residence, derived from the census of commerce. Dietary intake was estimated using a validated, comprehensive self-administered diet-history questionnaire.ResultsAfter adjustment for potential confounding factors, including household socioeconomic status, geographic variables, and the frequency of eating out, neighborhood store availability for confectioneries and bread (based on confectionery stores/bakeries, supermarkets, and grocery and convenience stores) was significantly positively associated with the intake of confectioneries and bread. No significant independent association was seen between neighborhood store availability for the other foods examined, including meat (meat stores, supermarkets, and grocery stores), fish (fish stores, supermarkets, and grocery stores), fruit and vegetables (fruit/vegetable stores, supermarkets, and grocery stores), and rice (rice stores, supermarkets, and grocery and convenience stores) with intake of each food.ConclusionIn a group of young Japanese women, increasing neighborhood store availability for confectioneries and bread was independently associated with higher intake of confectioneries and bread. In contrast, no association between availability and intake was seen for meat, fish, fruit and vegetables, or rice.     

Food Outlet Density,Distance, and Food Quality Offered to Preschool-Aged Children at Family Child Care Homes

ObjectiveTo examine how food environments around family child care homes (FCCHs) are associated with the healthfulness of foods served to children.DesignCross-sectional data from a mail survey of FCCH providers, InfoUSA.ParticipantsThe study included 132 Mississippi FCCHs (26% response).Main Outcome MeasuresDependent: compliance with nutrition best practices for 9 food categories; composite healthfulness score. Independent: counts of supermarkets, small-medium grocery stores, produce stores, convenience stores within 5 miles; distance to supermarket.AnalysisLogistic regression estimated associations between best-practice compliance and food environment. Linear regression estimated associations between composite food healthfulness and food environment. Models stratified by rural/urban location.ResultsRural FCCHs with higher counts of supermarkets, convenience stores, and produce stores had lower compliance with selected best practices (fried/prefried potatoes, high-sugar/high-fat foods). Urban FCCHs with more supermarkets had higher compliance with fruit not canned in syrup; those with more small-medium grocery stores and convenience stores had lower compliance with selected best practices (fried/prefried potatoes, vegetables, low-fat meats).Conclusions and ImplicationsFood environment measures were associated with some nutrition best practices, though not consistently in the expected direction. Future research could examine food quality at stores near rural FCCHs. Programs that improve local food environments may improve foods served at FCCHs.     

How Online Grocery Stores Support Consumer Nutrition Information Needs

ObjectiveTo evaluate the availability of nutrition-related information and features on leading online grocery store Web sites.MethodsTwelve US grocery Web sites were assessed to determine (1) if Nutrition Facts panel or ingredient statements were available for 26 food items; and (2) if options to filter or sort search results by nutrition-related food attributes were available.ResultsNutrition Facts panel and ingredient statement information were available for most foods for which this information is required on product packaging (85% of foods). Most stores offered the ability to filter food search results by a nutrition-related food attribute. The ability to sort search results by a nutrition attribute was not an option at any of the stores.Conclusions and ImplicationsOnline grocery stores include a variety of nutrition-related features. However, the Nutrition Facts panel and ingredient statement information are not universally available for foods for which this information is required on product packaging.     

Evidence That Changes in Community Food Environments Lead to Changes in Children’s Weight: Results from a Longitudinal Prospective Cohort Study

BackgroundStrategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited.ObjectiveOur aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children’s body mass index z scores (zBMIs).DesignWe conducted a longitudinal cohort study.Participants/settingTwo cohorts of 3- to 15-year-old children living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2.Main outcome measuresWe measured change in children’s zBMIs between T1 and T2.Statistical analysisChanges in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child’s home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment.ResultsIncreased zBMIs were observed in children with greater exposure to convenience stores over time, with a consistent pattern of significant associations across varying proximities and lengths of exposure. For example, exposure to an additional convenience store over 24 months within 1 mile of a child’s home resulted in 11.7% higher odds (P = 0.007) of a child being in a higher zBMI change category at T2. Lower zBMIs were observed in children with increased exposure to small grocery stores selling an array of healthy items, with exposure to an additional small grocery store within 1 mile over 24 months, resulting in 37.3% lower odds (P < 0.05) of being in a higher zBMI change category at T2. No consistent patterns were observed for changes in exposure to supermarkets, limited service restaurants, or pharmacies.ConclusionsIncreased availability of small grocery stores near children’s homes may improve children’s weight status, whereas increased availability of convenience stores is likely to be detrimental.     

Increasing Access to WIC through Discount Variety Stores: Findings from Qualitative Research

BackgroundMany low-income neighborhoods do not include a full-service grocery store. In these communities, discount variety stores (DVS) can be convenient points of food access. However, no identified DVS are authorized to accept Special Supplemental Nutrition Program for Women, Infants, and Children Program (WIC) benefits.ObjectiveOne national DVS retailer implemented WIC in 10 stores located in low-income communities in North Carolina over a 10-month pilot period to assess WIC feasibility.MethodsTo better understand the facilitators and barriers to WIC implementation from the perspective of DVS staff, we analyzed 36 in-depth interviews with employees of this DVS chain at corporate, manager, and store clerk levels.ResultsMost participants provided positive feedback about implementing and offering WIC. Many store employees had personal experience participating in WIC, which increased their understanding of the WIC shopping experience. Store staff’s prior WIC participation and customers’ proximity to DVS locations were facilitators to implementation. Primary barriers included limited choice of store products for customers, complicated or unclear labeling of WIC products, and difficulty training employees to process WIC vouchers.ConclusionsThese findings suggest that whereas most employees viewed WIC positively, barriers related to product selection and training must be addressed. Notably, North Carolina’s recent change to an electronic system to process WIC transactions requires minimal manual employee training and should address several barriers to implementation. However, the computer system upgrades necessary to accept electronic WIC transactions may be a barrier for DVS to continued WIC acceptance. Future research is needed to evaluate implementation of electronic WIC transactions in DVS.     

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.     

Impact of Policy Changes on Infant Feeding Decisions Among Low-Income Women Participating in the Special Supplemental Nutrition Program for Women,Infants, and Children

Objectives. We present infant feeding data before and after the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package change that supported and incentivized breastfeeding. We describe the key role of California WIC staff in supporting these policy changes.Methods. We analyzed WIC data on more than 180 000 infants in Southern California. We employed the analysis of variance and Tukey (honestly significant difference) tests to compare issuance rates of postpartum and infant food packages before and after the changes. We used analysis of covariance to adjust for poverty status changes as a potential confounder.Results. Issuance rates of the “fully breastfeeding” package at infant WIC enrollment increased by 86% with the package changes. Rates also increased significantly for 2- and 6-month-old infants. Issuance rates of packages that included formula decreased significantly. All outcomes remained highly significant in the adjusted model.Conclusions. Policy changes, training of front-line WIC staff, and participant education influenced issuance rates of WIC food packages. In California, the issuance rates of packages that include formula have significantly decreased and the rate for those that include no formula has significantly increased.The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), funded by the US Department of Agriculture (USDA), provides nutritious food and nutrition and breastfeeding education to low-income pregnant and postpartum women, and children up to age 5 years. It is considered one of the premier public health nutrition programs in the United States; more than 9 million women, infants, and children receive WIC benefits,1 with more than 1.4 million in California alone.2 Nationwide, about half of all infants receive services from the WIC program.1Breastfeeding support is a significant priority of the WIC program and, as outlined in the 2011 Surgeon General’s Call to Action to Support Breastfeeding,3 is a nationally recognized primary prevention strategy for early childhood obesity. Numerous studies have shown breastfeeding to be associated with a 20% to 50% lower risk of overweight and obesity in children, depending on duration of breastfeeding and degree of supplementation.4,5 At the same time, research has documented that WIC participation is associated with lower rates of breastfeeding when one compares WIC participants to nonparticipants.6–12 Obesity disproportionately affects low-income individuals, and implementation of policies that increase breastfeeding rates among low-income families served by WIC may be an important strategy for combatting the obesity epidemic. Motivated by these assumptions, the 2006 Institute of Medicine Committee to Review the WIC Food Packages recommended significant policy changes to the WIC Program to incentivize and support breastfeeding.The year 2009 marked a historic change to the WIC program by increasing support of breastfeeding and aligning the foods available through the WIC program, referred to as the WIC food package, with the 2005 Dietary Guidelines for Americans. On the basis of the Institute of Medicine recommendations, USDA made significant changes to the food packages for women and children to include fruits, vegetables, and whole grains, and to limit milk purchases to only lower-fat options for all women and all children older than 2 years.13 For postpartum women and infants, significant changes were made to the food packages to better incentivize and support breastfeeding: increasing the value of the WIC package for mothers who fully breastfeed, reducing the amount of formula for mothers who partially breastfeed, calibrating formula amounts for infants by age, and postponing complementary infant foods. In addition, California adopted the suggested federal policy of no routine issuance of infant formula to breastfeeding mothers in the first month postpartum.13 These breastfeeding-supportive changes were welcomed by the public health community, with hopes that the changes would increase breastfeeding rates among low-income mothers served by WIC. The objective of this study was to assess whether the key goals of the changes in the breastfeeding policies and food packages—to increase the issuance of the infant food package that does not include formula and decrease the issuance of the infant food packages that include formula—were achieved among a large population of WIC participants in California.     

Impact of the Revised Special Supplemental Nutrition Program for Women,Infants, and Children (WIC) Food Package Policy on Fruit and Vegetable Prices

Obesity is generally inversely related to income among women in the United States. Less access to healthy foods is one way lower income can influence dietary behaviors and body weight. Federal food assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are an important source of healthy food for low-income populations. In 2009, as part of a nationwide policy revision, WIC added a fruit and vegetable (F/V) voucher to WIC food packages. This quasi-experimental study determined whether F/V prices at stores authorized to accept WIC (ie, WIC vendors) decreased after the policy revision in seven Illinois counties. It also examined cross-sectional F/V price variations by store type and neighborhood characteristics. Two pre-policy observations were conducted in 2008 and 2009; one post-policy observation was conducted in 2010. Small pre- to post-policy reductions in some F/V prices were found, particularly for canned fruit and frozen vegetables at small stores. Compared with chain supermarkets, mass merchandise stores had lower prices for fresh F/V and frozen F/V and small stores and non-chain supermarkets had higher canned and frozen F/V prices, but lower fresh F/V prices. Limited price differences were found across neighborhoods, although canned vegetables were more expensive in neighborhoods with higher concentrations of either Hispanics or blacks and fresh F/V prices were lower in neighborhoods with more Hispanics. Results suggest the WIC policy revision contributed to modest reductions in F/V prices. WIC participants’ purchasing power can differ depending on the type and neighborhood of the WIC vendor used.     

Food store types, availability, and cost of foods in a rural environment

OBJECTIVE: To characterize the built nutritional environment in terms of types and number of food stores, availability, and cost of selected food items in a rural area. DESIGN: A cross-sectional survey of food stores conducted in 2004. SUBJECTS/SETTING: We selected a rural county (population 91,582; 1,106 square miles). Food stores identified from a database were mapped and presence, location, and store type verified by ground-truthing. Stores were surveyed for availability and cost of selected foods. MAIN OUTCOME MEASURES: Price and availability of a limited number of staple foods representing the main food groups. STATISTICAL ANALYSES PERFORMED: Availability comparisons used least square means models and price comparisons used t tests. RESULTS: Of 77 stores identified, 16% were supermarkets, 10% grocery stores, and 74% convenience stores. There were seven stores per 100 square miles and eight stores per 10,000 residents. Availability of more healthful foods was substantially higher at supermarkets and grocery stores. For instance, low-fat/nonfat milk, apples, high-fiber bread, eggs, and smoked turkey were available in 75% to 100% of supermarkets and groceries and at 4% to 29% of convenience stores. Foods that were available at both supermarkets and convenience stores tended to be substantially more expensive at convenience stores. The healthful version of a food was typically more expensive than the less healthful version. CONCLUSIONS: In this rural environment, stores offering more healthful and lower-cost food selections were outnumbered by convenience stores offering lower availability of more healthful foods. Our findings underscore the challenges of shopping for healthful and inexpensive foods in rural areas.     

A national study of the association between food environments and county-level health outcomes

Purpose: This national, county‐level study examines the relationship between food availability and access, and health outcomes (mortality, diabetes, and obesity rates) in both metro and non‐metro areas. Methods: This is a secondary, cross‐sectional analysis using Food Environment Atlas and CDC data. Linear regression models estimate relationships between food availability and access variables (direct‐to‐consumer farm sales, per capita grocery stores, full‐service restaurants, fast food restaurants, and convenience stores) with health outcomes. Controls include smoking, race/ethnicity, gender, age, education, poverty, primary care availability, recreational facility availability, and mobility/distance‐from‐grocery‐store. Findings: Non‐metro findings: Lower adjusted mortality rates were associated with more per capita full‐service restaurants and grocery stores, and greater per capita direct farm sales. Lower adjusted diabetes rates were associated with a lower per capita supply of fast food restaurants and convenience stores, and more per capita full‐service restaurants and grocery stores. Lower adjusted obesity rates were associated with more per capita full‐service restaurants and grocery stores. Unexpectedly, obesity rates were positively associated with per capita grocery stores and negatively associated with fast food restaurants. Metro findings: More per capita full‐service restaurants, grocery stores, and direct farm sales are associated with positive health outcomes; fast food restaurants and convenience stores are associated with negative health outcomes. Conclusions: The food access/availability environment is an important determinant of health outcomes in metro and non‐metro areas. Future research should focus on more refined specifications that capture variability across non‐metro settings.     

Relative and Absolute Availability of Healthier Food and Beverage Alternatives Across Communities in the United States

Objectives. We examined associations between the relative and absolute availability of healthier food and beverage alternatives at food stores and community racial/ethnic, socioeconomic, and urban–rural characteristics.Methods. We analyzed pooled, annual cross-sectional data collected in 2010 to 2012 from 8462 food stores in 468 communities spanning 46 US states. Relative availability was the ratio of 7 healthier products (e.g., whole-wheat bread) to less healthy counterparts (e.g., white bread); we based absolute availability on the 7 healthier products.Results. The mean healthier food and beverage ratio was 0.71, indicating that stores averaged 29% fewer healthier than less healthy products. Lower relative availability of healthier alternatives was associated with low-income, Black, and Hispanic communities. Small stores had the largest differences: relative availability of healthier alternatives was 0.61 and 0.60, respectively, for very low-income Black and very low-income Hispanic communities, and 0.74 for very high-income White communities. We found fewer associations between absolute availability of healthier products and community characteristics.Conclusions. Policies to improve the relative availability of healthier alternatives may be needed to improve population health and reduce disparities.Poor diet is common in the United States, particularly among disadvantaged groups, and is a risk factor for obesity and numerous chronic diseases.1,2 The retail food environment may present barriers to healthy eating in Black, low-income, rural, and central-city communities in the United States. Considerable research demonstrates that healthier foods and beverages, such as low-fat dairy and whole-grain products, are less available in Black, low-income, rural, and central-city communities than in White, higher-income, and urban and suburban communities.3–6 Other studies show no systematic differences in healthier food availability across communities.7,8 Some contend that it is not just absolute availability of foods and beverages but rather the relative availability of less healthy products compared with healthier alternatives that may influence food choices.9–12 Although studies generally have not compared relative availability across communities, relative availability of healthier to less healthy foods was related to lower risk of overweight and obesity in 1 study.9Differences in store composition across communities may partially explain observed community differences in absolute and relative availability of healthier food and beverage products. Inequities in the spatial accessibility of supermarkets and other retail food stores, such as convenience stores, are well documented, with low-income, Black, rural, and central-city communities having less access to supermarkets, for example.13–16 Supermarkets have greater availability of healthier products than do convenience stores and many small grocery stores.10,17,18 Yet research shows that differences in healthier food and beverage availability across communities persist among stores of the same type or after accounting for differences in the types of stores present.19In one of the first nationwide studies of directly observed food availability in the United States, we examined associations between the relative and absolute availability of healthier food and beverage alternatives and community characteristics (racial/ethnic composition, socioeconomic characteristics, and urbanicity). Our study was novel not only because of its focus on relative availability of healthier alternatives, but also because it examined communities nationwide, compared the food environment across a continuum of community characteristics (e.g., urban–rural, predominant race/ethnicity, high–low income), and had ample statistical power to detect differences because of the large number of stores.     

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.     

Variety and quality of healthy foods differ according to neighbourhood deprivation

This study addresses a gap in the food environment literature by investigating spatial differences in the inter relationship of price, variety and quality of food in southern England. We conducted a survey of all grocery stores (n=195) in the city of Southampton, UK, and ranked neighbourhoods according to national quintiles of deprivation. We found no difference in availability or cheapest price across neighbourhoods. However, the poorest neighbourhoods had less variety of healthy products and poorer quality fruit and vegetables than more affluent neighbourhoods. Dietary inequalities may be exacerbated by differences in the variety and quality of healthy foods sold locally; these factors may influence whether or not consumers purchase healthy foods.