SNAP-Ed Policy,Systems, and Environmental Interventions and Caregivers’ Dietary Behaviors

ObjectiveTo examine dietary behaviors and diet quality among caregivers of children regarding the number of policy, systems, and environmental (PSE) change interventions implemented in their neighborhoods.MethodsHouseholds with incomes ≤185% of the federal poverty level were randomly sampled throughout California. A validated 24-h dietary recall assessment tool was administered by telephone. The independent variable was the number of Supplemental Nutrition Assistance Program Education PSE change interventions per census tract where the caregivers lived.ResultsMost (69.1%) of the 2,222 caregivers were Latino. Policy, systems, and environmental reach predicted decreased intake of sugar-sweetened beverages (P = 0.022, Cohen d = −0.12) and added sugar (P = 0.014, Cohen d = −0.18), and increased Healthy Eating Index–2015 scores (P = 0.046, Cohen d = 0.18), regardless of race and/or ethnicity, age, or reach of Supplemental Nutrition Assistance Program Education direct education.Conclusions and ImplicationsReplication of these methods and findings, and comparisons of dietary outcomes in association with PSE change interventions with and without direct education activities aimed at the same population under study, are encouraged.     

Food Insecurity Nutrition Incentive Grant Program: Implications for the 2018 Farm Bill and Future Directions

The 2018 Farm Bill was finalized in mid-December of 2018 after months of discussion and debate between policymakers. The Farm Bill has many implications for low-income and food-insecure populations in the United States. One program within the Farm Bill that helps bridge the nutrition gap for low-income Supplemental Nutrition Assistance Program participants is the Food Insecurity Nutrition Incentive Grant Program (FINI). This commentary explores the best practices and promising findings of FINI projects to inform future policy discussions and implementation of FINI. In addition, we discuss knowledge gaps and opportunities within the context of the extant literature. Stakeholders and FINI grantees reported positive impacts of FINI grants, describing outcomes across farmers, grocery store owners, local economies, and Supplemental Nutrition Assistance Program participants (eg, increased fruit and vegetable consumption). The 2018 Farm Bill was largely in alignment with the Academy's recommendations, and preserved the integrity of the Supplemental Nutrition Assistance Program as well as increased funding for FINI.     

Use of Survival Analysis to Predict Attrition Among Women Participating in Longitudinal Community-Based Nutrition Research

ObjectiveTo identify participant characteristics and study methodology that influenced the completion of a 15-month community-based longitudinal study evaluating the impact of the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program.DesignObservational longitudinal 15-month study across 12 data collection timepoints. Sociodemographic characteristics were collected with a paper-based survey at baseline.SettingFive counties across central and southern Illinois.ParticipantsWomen, aged 18 to 65 years (n = 297), recruited at sites likely to serve families eligible for the Supplemental Nutrition Assistance Program Education and Expanded Food and Nutrition Education Program (housing departments, child care centers, etc).Main Outcome MeasuresPredictors of participant attrition during the study duration.AnalysisCox proportional hazard models.ResultsNinety-seven participants were retained across the full study. In unadjusted models, greater income and education levels were significantly related to lower attrition; however, this relationship did not persist in a multivariate model. When adjusted for other characteristics, larger household size was the only measured variable significantly related to greater odds of attrition (odds ratio = 1.09; 95% confidence interval = 1.02, 1.17).Conclusions and ImplicationsSeveral characteristics predicting attrition in other settings were not significant in this study. Future attrition analyses that evaluate social support, transportation capacity, and type of phone in longitudinal nutrition education studies are warranted.     

Participation in the Supplemental Nutrition Assistance Program and Dietary Behaviors: Role of Community Food Environment

BackgroundThe United States Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) is the country’s largest nutrition assistance program for low-income populations. Although SNAP has been shown to reduce food insecurity, research findings on the diet quality of program participants are inconsistent.ObjectiveThis study evaluated whether the community food environment is a potential moderator of the association between SNAP participation and eating behaviors.DesignThis cross-sectional study used participant data from a telephone survey of 2,211 households in four cities in New Jersey. Data were collected from two cross-sectional panels from 2009 to 2010 and 2014. Food outlet data were purchased from commercial sources and classified as supermarkets, small grocery stores, convenience stores, or limited service restaurants.Participants/settingAnalysis is limited to 983 respondents (588 SNAP participants) with household incomes below 130% of the federal poverty level.Main outcome measuresEating behaviors were assessed as frequency of consumption of fruit, vegetables, salad, and sugar-sweetened beverages.Statistical analyses performedInteraction and stratified analyses using gamma regression determined the differences in the association between SNAP participation and eating behaviors by the presence or absence of food outlets adjusted for covariates.ResultsSNAP participation was associated with a higher frequency of consuming sugar-sweetened beverages (P<0.05) when respondents lived within ¼ to ½ mile of a small grocery store, supermarket, and limited service restaurant. SNAP participants who did not live close to a convenience store reported a lower frequency of sugar-sweetened beverage consumption (P=0.01), and those living more than ½ mile away from a supermarket reported a lower frequency of fruit consumption (P=0.03).ConclusionsThe findings from this study suggest that the community food environment may play a role in moderating the association between SNAP participation and eating behaviors. Although SNAP participation is associated with some unhealthy behaviors, this association may only hold true when respondents live in certain food environments.     

Few Changes in Food Security and Dietary Intake From Short-term Participation in the Supplemental Nutrition Assistance Program Among Low-income Massachusetts Adults

ObjectiveTo examine whether short-term participation in the Supplemental Nutrition Assistance Program (SNAP) affects food security and dietary quality among low-income adults recruited from a Massachusetts-wide emergency food hotline.MethodsA 3-month, longitudinal study was conducted among 107 adults recruited at the time of SNAP application assistance. Outcomes included household food security (10-item US Department of Agriculture Food Security Survey Module), dietary intake (eg, grains, fruit) and diet quality (modified Alternate Healthy Eating Index). Data were analyzed using paired t tests and multivariable linear regression.ResultsSupplemental Nutrition Assistance Program participation was not associated with improved household food security over 3 months (P = .25). Compared with non-participants, SNAP participants increased refined grain intake by 1.1 serving/d (P = .02), from baseline to follow-up. No associations were observed with other foods, nutrients, or dietary quality.Conclusion and ImplicationsPolicies that simultaneously improve household food security and dietary quality should be implemented to support the health of low-income Americans participating in this crucial program.     

Impact of Food Insecurity Nutrition Incentives on Household Fruit and Vegetable Expenditures

ObjectiveEvaluate the impact of the Food Insecurity Nutrition Incentive (FINI) grant program on self-reported fruit and vegetable (FV) expenditures.DesignPre-post quasi-experimental study design.SettingFarmers markets and grocery stores in states with FINI projects.ParticipantsA total of 2,471 Supplemental Nutrition Assistance Program (SNAP) households in 4 intervention groups who lived near a FINI retailer (farmers market or grocery store) and 4 matched comparison groups who did not live near a FINI retailer.Main Outcome MeasuresAwareness and use of point-of-sale incentives and changes in self-reported monthly household FV expenditures.AnalysisOrdinary least squares intent-to-treat regression model using lagged dependent variable model framework.ResultsAwareness of FINI was higher among households who were near a FINI retailer and had shopped there before FINI than those who lived near a FINI retailer but had not shopped there before FINI; the number of information sources from which SNAP participants heard about FINI was positively associated with incentive receipt (P < 0.05). Among those who received incentives, the average amount of incentives received at the last shopping trip ranged from $15 to $23. The FINI program had a positive impact on the average monthly FV expenditures for those in the farmers market shopper, grocery store shopper, and grocery store general intervention groups—increases ranged from $9 to $15 (P < 0.05).Conclusions and ImplicationsPoint-of-sale incentives were associated with an increase in FV expenditures among SNAP households. Further research is needed to examine (1) effective messaging strategies to increase incentive awareness and (2) the long-term impact of incentives on FV expenditures.     

Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic

ObjectiveThis study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic.DesignWeekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes.SettingNorth Carolina large chain grocery stores.ParticipantsLarge chain grocery store/SNAP shoppers.InterventionRural/urban status of the stores and COVID-19 pandemic onset.Main Outcome MeasuresShare of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM).AnalysisMultivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors.ResultsWe did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (−0.43%) and less healthful food (−1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05).Conclusions and ImplicationsUrban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.     

State Implementation of SNAP Waivers and Flexibilities During the COVID-19 Pandemic: Perspectives From State Agency Leaders

ObjectiveTo describe state agencies’ implementation of the Supplemental Nutrition Assistance Program (SNAP) during the first year of the coronavirus disease of 2019 (COVID-19) pandemic, barriers and facilitators to SNAP implementation, and recommendations to improve SNAP implementation.DesignQualitative methodology guided by Bullock's determinants of policy implementation framework using 7 semistructured, virtual focus groups in April 2021.SettingTwenty-six states representing all 7 US Department of Agriculture Food and Nutrition Service regions.ParticipantsFour focus groups with state-level SNAP administrators and 3 focus groups with state-level SNAP supportive services (Supplemental Nutrition Assistance Program-Education, Employment & Training, and Outreach) supervisors (n = 62).Phenomenon of InterestSupplemental Nutrition Assistance Program implementation during the COVID-19 pandemic.AnalysisThematic analysis using a phronetic iterative approach.ResultsSix primary themes emerged: the policy response, technology needs, collaboration, participant communication, funding realities, and equity. Implementation challenges included the design of waivers in the early pandemic response, inadequate federal guidance and funding, outdated technology, and prepandemic regulations limiting state authority. Modernized technology systems, availability of virtual programming, partnerships, and enhanced benefits facilitated SNAP implementation.Conclusions and ImplicationsSupplemental Nutrition Assistance Program administrators adapted their programs to deliver services virtually during the COVID-19 pandemic. These experiences highlighted the importance of certain policy determinants, such as modernized technology and streamlined application processes, to improve outcomes for SNAP participants and staff.     

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption

ObjectiveExamine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7–18 years) receiving free/reduced-price school meals.MethodsCross-sectional study. Caregiver–child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants.ResultsAmong 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44).Conclusions and ImplicationsIn this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.     

Identification of a Framework for Best Practices in Nutrition Education for Low-Income Audiences

To promote effective low-income nutrition education programs, an expert panel of nutrition education and public health researchers built consensus around 28 best practices grouped into 5 domains (Program Design, Program Delivery, Educator Characteristics, Educator Training, and Evaluation) targeting direct delivery of nutrition education. These best practices can be used to assess program strengths, promote fidelity in delivery and evaluation, and design research to strengthen programs’ evidence base. A survey of Supplemental Nutrition Assistance Program–Education nutrition education leaders helped identify staff development needs and interest relative to specific best practices. Best practices can be used to identify staff development needs among frontline educators, supervisors, and program leaders in Supplemental Nutrition Assistance Program–Education, Expanded Food and Nutrition Education Program, and other programs targeting low-income audiences.     

Training Needs of Nutrition Educators Engaged in Policy,Systems, and Environmental Approaches

ObjectiveAssess training needs of nutrition educators incorporating policy, systems, and environmental (PSE) approaches into their obesity prevention efforts, to identify content for online training.MethodsConducted a national, online survey of state and local Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program Education professionals engaged in PSE efforts.ResultsRespondents (n = 601) rated the importance of 24 training topics related to planning, implementing, and evaluating PSE approaches. Most (21) topics were rated very important or essential, confirming the need for a comprehensive approach. Paired-sample t tests found significant differences (P <0.001) in some training needs between local and state staff (eg, training in evaluation rated higher for state staff). Training needs did not differ by program, region, or length of employment. The top 5 settings for PSE efforts were schools, farmers’ markets, food banks/pantries, community gardens, and after-school programs.Conclusions and ImplicationsResults informed the development of an online training for program implementers. Future research will be needed to assess and refine training needs further, which will evolve as nutrition educators gain more experience in PSE approaches.     

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

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

Food Resource Management Mediates the Relationship Between Participation in a SNAP-Ed Nutrition Education Program and Diet Quality

ObjectiveTo examine the mediating effects of food resource management skills (FRM) on the relationship between participation in a Supplemental Nutrition Assistance Program Education (SNAP-Ed) nutrition education program and diet quality.DesignSecondary analysis of data from a propensity score-matched sample of participants (n = 396) and nonparticipants (n = 111) in a SNAP-Ed nutrition education program.AnalysisIndependent-samples t tests were used to compare entry, exit, and gain scores in FRM and diet quality between participants and nonparticipants. Structural equation modeling was used to examine direct and mediated relationships among participation, FRM, and diet quality.Main Outcome MeasuresFood resource management was measured as a summated rating scale, and diet quality measured as Healthy Eating Index and program participation.ResultsMediated effect of FRM on the relationship between participation in a SNAP-Ed program and diet quality was statistically significant (P < 0.01). The effect size for the mediation effect indicated that about 70% of program participation on diet quality was transferred by FRM skills. The hypothesized model had acceptable fit indices as model χ² was nonsignificant (P = 0.31), all fit indices were above 0.9, and the root mean square of error approximation was low at 0.02.Conclusions and ImplicationsParticipation in a SNAP-Ed program enhanced participants’ FRM, which in turn enhanced their diet quality.     

Can the introduction of a full-service supermarket in a food desert improve residents' economic status and health?

PurposeTo estimate the impacts of a new supermarket in a low-income desert, on residents' economic status and health.MethodsWe surveyed a randomly selected cohort in two low-income Pittsburgh neighborhoods before and about 1 year following the opening of a supermarket. We used difference-in-difference approach to test changes across the two neighborhoods in residents' food security, United States Department of Agriculture Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women Infant and Children participation, employment, income, and self-reported health/chronic disease diagnoses.ResultsWe observed declines in food insecurity (−11.8%, P < .01), Supplemental Nutrition Assistance Program participation (−12.2%, P < .01), and fewer new diagnoses of high cholesterol (−9.6%, P = .01) and arthritis (−7.4%, P = .02) in the neighborhood with the new supermarket relative to residents of the comparison neighborhood. We also found suggestive evidence that residents' incomes increased more ($1550, P = .09) and prevalence of diabetes increased less in the neighborhood with the supermarket than in the comparison neighborhood (−3.6%, P = .10).ConclusionsLocating a new supermarket in a low-income neighborhood may improve residents' economic well-being and health. Policymakers should consider broad impacts of neighborhood investment that could translate into improved health for residents of underserved neighborhoods.     

Family Nutrition Program Assistants' Perception of Farmers' Markets,Alternative Agricultural Practices,and Diet Quality

ObjectiveTo explore Family Nutrition Program assistants' perception of farmers' markets and alternative agricultural practices for themselves and their clients.MethodsCross-section design, survey of Virginia Expanded Food and Nutrition Education Program (NEP) and Supplemental Nutrition Assistance Program–Education Family Nutrition Program assistants (n = 52) working with limited-resource populations.ResultsTwenty-one percent to 55% of FNP assistants valued alternative agricultural practices, and only 5% to 8% of FNP assistants perceived that their clients did so. Benefits to shopping at farmers' markets included supporting local economies, and food price, quality, and safety. Barriers included lack of transportation, location/convenience, hours, and food prices. Assistants rated the benefits to shopping at farmers' markets similarly for themselves and their clients, but rated many of the barriers to shopping at farmers' markets as significantly lower (P < .05) for themselves than for their clients.Conclusions and ImplicationsFuture assistant trainings should address the connection between agriculture and health, and how to overcome barriers to shopping at farmers' markets for their clients.     

The Impact of ABAWD Time Limit Reinstatement on SNAP Participation and Employment

ObjectiveEstimate the impact of the Supplemental Nutrition Assistance Program (SNAP) time limit for able-bodied adults without dependents (ABAWD) on SNAP participation, employment, and earnings.DesignA quasi-experimental study using state administrative SNAP and earnings data to compare outcomes for SNAP participants before and after the time limit went into effect.ParticipantsSupplemental Nutrition Assistance Program participants in the study cohorts in Colorado, Missouri, and Pennsylvania (N = 153,599).Main Outcome MeasuresMonthly SNAP participation, quarterly employment, annual earnings.AnalysisLogistic and ordinary least squares multivariate regression models.ResultsTime limit reinstatement reduced SNAP participation by 7 to 32 percentage points in the 12th month of time limit reinstatement but did not generate evidence of improved employment or annual earnings (1 year after time limit reinstatement, employment decreased by 2 to 7 percentage points and annual earnings decreased by $247 to $1,230).Conclusions and ImplicationsThe ABAWD time limit reduced SNAP participation but did not improve employment and earnings. SNAP may provide helpful support to participants as they seek to enter or re-enter employment, and removing this support may be detrimental to their employment prospects. These findings can inform decisions about requesting waivers or pursuing changes to ABAWD legislation or regulations.     

Assessment of low-income adults' access to technology: implications for nutrition education

ObjectiveThe main objective of this study was to investigate access and use of technologies such as the Internet among Indiana's low-income population. The secondary objective was to determine whether access and use of computers significantly differed by age, race, and/or education level.MethodsData were collected from low-income adult Supplemental Nutrition Assistance Program Education participants for a 2-year period using a cross-sectional questionnaire about access and use of technology.ResultsApproximately 50% of the total respondents (n = 1,620) indicated that they had a working computer in their home, and of those, the majority (78%) had a high-speed Internet connection. Chi-square analysis revealed that younger adults who were white and had more education were more likely to have a computer (P < .001) and Internet.Conclusions and ImplicationsThe results of this study provide evidence that using Internet-based nutrition education in a low-income population is a viable and possibly cost-effective option.     

Evaluation of supplemental nutrition assistance program education: application of behavioral theory and survey validation

ObjectiveApplication of the Transtheoretical Model (TTM) to Supplemental Nutrition Assistance Program Education (SNAP-Ed) evaluation and development and validation of an evaluation tool used to measure TTM constructs is described.MethodsSurveys were collected from parents of children receiving food at Summer Food Service Program sites prior to SNAP-Ed participation.ResultsItem analysis of survey data (n = 149) suggests the survey is valid and reliable. Structural Equation Modeling confirmed the use of the TTM constructs in predicting SNAP-Ed participants' fruit and vegetable consumption. Perceived barriers (P = .04) and self-efficacy (P = .006) were associated with fruit and vegetable consumption, whereas perceived benefits were not.Conclusions and ImplicationsApplication of theory and survey validation can enhance SNAP-Ed evaluation.     

Validity and Reliability of the Healthy Families Survey: A Key Component of the Maryland Supplemental Nutrition Assistance Program–Education (SNAP-Ed) Evaluation

Objective

This study established the validity and reliability of the Healthy Families Survey, a 45-item survey measuring nutrition and physical activity behaviors among children and parents enrolled in the Maryland Supplemental Nutrition Assistance Program–Education.