Mixed methods evaluation of the COVID-19 changes to the WIC cash-value benefit for fruits and vegetables.

Introduction: Recent cash-value benefit (CVB) increases are a positive development to help increase WIC participant fruits and vegetables (FV) access. Little is known about the impacts of the CVB changes on FV redemptions or about implementation successes and challenges among WIC State and local agencies. This mixed method study aimed to evaluate (a) the CVB changes' impact on FV access among WIC child participants measured by CVB redemption rates, (b) facilitators and barriers to CVB changes' implementation, and (c) differences in FV redemption and facilitators and barriers by race/ethnicity. Methods: We requested redemption data from all 89 State agencies for April 2020 to September 2022 and utilized descriptive statistics, interrupted time series analysis (ITS), and generalized linear regression analysis. Additionally, we recruited State agencies, local agencies, and caregivers across the U.S. for interviews and used rapid qualitative analysis to find emerging themes anchored in policy evaluation and implementation science frameworks. Results: We received redemption data from 27 State agencies and interviewed 23 State agencies, 61 local agencies, and 76 caregivers of child WIC participants. CVB monthly redemptions increased at $35/child/month compared to $9/child/month; however, adjusted ITS analyses found a decrease in redemption rates at $35/child/month. The decrease was not significant when the transition/first implementation month was excluded with rates progressively increasing over time. Differences were found among racial/ethnic groups, with lower redemption rates observed for non-Hispanic Black caregivers. Overall, WIC caregivers reported high satisfaction and utilization at the $35/child/month. The frequent and quick turnaround CVB changes strained WIC agency resources with agencies serving higher caseloads of diverse racial and ethnic populations experiencing greater issues with implementing the CVB changes. Conclusion: Despite implementation challenges, the increased CVB shows promise to improve WIC participant FV access and satisfaction with WIC. WIC agencies need adequate lead time to update the CVB amounts, and resources and support to help ensure equitable distribution and utilization of the FV benefits.

Using the Australian Dietary Guidelines 2&5 education message in supermarket shopping trolleys to nudge shoppers to purchase more fruit and vegetables: A feasibility study using an intervention design.

Fruit and vegetable (F&V) consumption is associated with a reduced risk of developing chronic diseases; however, only one in 16 Australian adults consume F&Vs at the recommended two servings of fruit and five servings of vegetables per day. What and how much people eat is influenced by their social and physical environments. Supermarkets are a key setting influencing food purchases, and as such, they can shape consumption patterns of F&Vs. Implementing effective strategies to increase F&V intake is crucial. The objective of this research was to test the feasibility of modifying shopper purchasing behaviour to purchase more F&Vs using the Australian Dietary Guidelines 2&5 education message covering one-half of the base of shopping trolleys. Placards giving the message that eating 2 fruits and 5 vegetables every day for good health were placed at the base of shopping trolleys as an educational nudge. Applying an intervention research design, 30 out of ~100 trolleys were fitted with the placards and shopper purchases were measured by collecting paper sales receipts to measure the weight (kg), total spending and F&V-specific spending (Australian dollars) for intervention versus control trolleys for one Saturday. We also conducted a short intercept survey that was administered independently from the research study day on non-trial shoppers. Shoppers who selected trolleys with the 2&5 education nudge placards (n = 101) purchased 1.66 kg less weight of F&Vs (Intervention: mean = 3.89 kg, SD = 3.40 kg, 95% CI = 3.21 kg, 4.56 kg, vs. Control: mean 5.55 kg, SD = 4.16 kg, 95% CI = 4.73 kg, 6.37 kg, p = 0.002) and spent less on F&Vs compared to shoppers in the control group (n = 102; Intervention: mean = $26.00, SD = $21.60, 95% CI = $21.78, $30.32 vs. Control: mean $36.00, SD = $27.00, 95% CI = $30.72, $42.36, p = 0.004). Intervention group shoppers also spent less in total spending between groups (Intervention: mean = $115.40, SD = $68.30, 95% CI = $101.95, $128.95 vs. Control: mean $151.30, SD = $79.40, 95% CI = $135.73, $166.93, p = 0.001). The 2&5 education nudge placard had the opposite effect as intended on shoppers' purchases to buy more F&Vs, although there may have been other differences between the intervention and the control groups since they were not randomised. Larger studies are required to elucidate and confirm these findings over the longer term.

Impact of price reductions, subsidies, or financial incentives on healthy food purchases and consumption: a systematic review and meta-analysis.

Poor diets are a global concern and are linked with various adverse health outcomes. Healthier foods such as fruit and vegetables are often more expensive than unhealthy options. This study aimed to assess the effect of price reductions for healthy food (including fruit and vegetables) on diet. We performed a systematic review and meta-analysis on studies that looked at the effects of financial incentives on healthy food. Main outcomes were change in purchase and consumption of foods following a targeted price reduction. We searched electronic databases (MEDLINE, EconLit, Embase, Cinahl, Cochrane Library, and Web of Science), citations, and used reference screening to identify relevant studies from Jan 1, 2013, to Dec 20, 2021, without language restrictions. We stratified results by population targeted (low-income populations vs general population), the food group that the reduction was applied to (fruit and vegetables, or other healthier foods), and study design. Percentage price reduction was standardised to assess the effect in meta-analyses. Study quality was assessed using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. 34 studies were eligible; 15 took place in supermarkets and eight took place in workplace canteens in high-income countries, and 21 were targeted at socioeconomically disadvantaged communities. Pooled analyses of 14 studies showed a price reduction of 20% resulted in increases in fruit and vegetable purchases by 16·62% (95% CI 12·32 to 20·91). Few studies had maintained the price reduction for over 6 months. In conclusion, price reductions can lead to increases in purchases of fruit and vegetables, potentially sufficient to generate health benefits, if sustained.

Linking a sugar-sweetened beverage tax with fruit and vegetable subsidies: A simulation analysis of the impact on the poor.

BACKGROUND: US individuals, particularly from low-income subpopulations, have very poor diet quality. Policies encouraging shifts from consuming unhealthy food towards healthy food consumption are needed. OBJECTIVES: We simulate the differential impacts of a national sugar-sweetened beverage (SSB) tax and combinations of SSB taxes with fruit and vegetable (FV) subsidies targeted to low-income households on SSB and FV purchases of lower and higher SSB purchasers. METHODS: We considered a 1-cent-per-ounce SSB tax and 2 FV subsidy rates of 30% and 50% and used longitudinal grocery purchase data for 79,044 urban/semiurban US households from 2010-2014 Nielsen Homescan data. We used demand elasticities for lower and higher SSB purchasers, estimated via longitudinal quantile regression, to simulate policies' differential effects. RESULTS: Higher-SSB-purchasing households made larger reductions (per adult equivalent) in SSB purchases than lower SSB purchasers due to the tax (e.g., 4.4 oz/day at SSB purchase percentile 90 compared with 0.5 oz/day at percentile 25; P < 0.05). Our analyses by household income indicated low-income households would make larger reductions than higher-income households at all SSB purchase levels. Targeted FV subsidies induced similar, but nutritionally insignificant, increases in FV purchases of low-income households, regardless of their SSB purchase levels. Subsidies, however, were effective in mitigating the tax burdens. All low-income households experienced a net financial gain when the tax was combined with a 50% FV subsidy, but net gains were smaller among higher SSB purchasers. Further, low-income households with children gained smaller net financial benefits than households without children and incurred net financial losses under a 30% subsidy rate. CONCLUSIONS: SSB taxes can effectively reduce SSB consumption. FV subsidies would increase FV purchases, but nutritionally meaningful increases are limited due to low purchase levels before policy implementation. Expanding taxes beyond SSBs, providing larger FV subsidies, or offering subsidies beyond FVs, particularly for low-income households with children, may be more effective.

Changes in food pricing and availability on the Navajo Nation following a 2% tax on unhealthy foods: The Healthy Diné Nation Act of 2014.

INTRODUCTION: In 2014, the Navajo Nation Healthy Diné Nation Act (HDNA) was passed, combining a 2% tax on foods of 'minimal-to-no-nutritional value' and waiver of 5% sales tax on healthy foods, the first-ever such tax in the U.S. and globally among a sovereign tribal nation. The aim of this study was to measure changes in pricing and food availability in stores on the Navajo Nation following the implementation of the HDNA. METHODS: Store observations were conducted in 2013 and 2019 using the Nutrition Environment Measurement Survey-Stores (NEMS-S) adapted for the Navajo Nation. Observations included store location, type, whether healthy foods or HDNA were promoted, and availability and pricing of fresh fruits and vegetables, canned items, beverages, water, snacks and traditional foods. Differences between 2013 and 2019 and by store type and location were tested. RESULTS: The matched sample included 71 stores (51 in the Navajo Nation and 20 in border towns). In 2019, fresh produce was available in the majority of Navajo stores, with 71% selling at least 3 types of fruit and 65% selling at least 3 types of vegetables. Compared with border town convenience stores, Navajo convenience stores had greater availability of fresh vegetables and comparable availability of fresh fruit in 2019. The average cost per item of fresh fruit decreased by 13% in Navajo stores (from $0.88 to $0.76) and increased in border stores (from $0.63 to $0.73), resulting in comparable prices in Navajo and border stores in 2019. While more Navajo stores offered mutton, blue corn and wild plants in 2019 compared to 2013, these changes were not statistically significant. DISCUSSION: The findings suggest modest improvements in the Navajo store environment and high availability of fruits and vegetables. Navajo stores play an important role in the local food system and provide access to local, healthy foods for individuals living in this rural, tribal community.

Affordability of Different Isocaloric Healthy Diets in Germany-An Assessment of Food Prices for Seven Distinct Food Patterns.

Affordability of different isocaloric healthy diets in Germany-an assessment of food prices for seven distinct food patterns Background: For decades, low-fat diets were recommended as the ideal food pattern to prevent obesity, type 2 diabetes and their long-term complications. Nowadays, several alternatives considering sources and quantity of protein, fat and carbohydrates have arisen and clinical evidence supports all of them for at least some metabolic outcomes. Given this variety in diets and the lack of a single ideal diet, one must evaluate if patients at risk, many of which having a lower income, can actually afford these diets. AIM: We modelled four-week food plans for a typical family of two adults and two school children based on seven different dietary patterns: highly processed standard omnivore diet (HPSD), freshly cooked standard omnivore diet (FCSD), both with German average dietary composition, low-protein vegan diet (VeganD), low-fat vegetarian diet (VegetD), low-fat omnivore diet (LFD), Mediterranean diet (MedD) and high-fat moderate-carb diet (MCD). The isocaloric diets were designed with typical menu variation for all meal times. We then assessed the lowest possible prices for all necessary grocery items in 12 different supermarket chains, avoiding organic foods, special offers, advertised exotic super foods and luxury articles. Prices for dietary patterns were compared in total, stratified by meal time and by food groups. RESULTS: Among all seven dietary patterns, price dispersion by supermarket chains was 12-16%. Lowest average costs were calculated for the VegetD and the FCSD, followed by HPSD, LFD, VeganD, MedD and-on top-MCD. VeganD, MedD and MCD were about 16%, 23% and 67% more expensive compared to the FCSD. Major food groups determining prices for all diets are vegetables, salads and animal-derived products. Calculations for social welfare severely underestimate expenses for any kind of diet. CONCLUSIONS: Food prices are a relevant factor for healthy food choices. Food purchasing is financially challenging for persons with very low income in Germany. Fresh-cooked plant-based diets are less pricy than the unhealthy HPSD. Diets with reduced carbohydrate content are considerably more expensive, limiting their use for people with low income. Minimum wage and financial support for long-term unemployed people in Germany are insufficient to assure a healthy lifestyle.

Association of a Fruit and Vegetable Subsidy Program With Food Purchases by Individuals With Low Income in the US.

Importance: Food insecurity is associated with a less healthy diet. The Supplemental Nutrition Assistance Program (SNAP) is associated with reduced food insecurity, but benefit levels may be insufficient for beneficiaries to afford healthy foods. Objective: To evaluate whether participation in SuperSNAP, a program that provides an additional $40 per month for the purchase of fruits and vegetables with no added sugar, sodium, or fat to SNAP beneficiaries, is associated with changes in food purchasing. Design, Setting, and Participants: This longitudinal cohort study used data from transaction records of a large supermarket chain with approximately 500 stores located across North Carolina from October 2019 to April 2020. Participants were SNAP beneficiaries. Exposure: SuperSNAP participation. Main Outcomes and Measures: Monthly spending on all fruits, vegetables, legumes, and nuts (primary outcome); spending on less healthy food categories; and spending on sugar-sweetened beverages as 1 category of less healthy foods. Monthly data on purchases by SNAP beneficiaries before and during SuperSNAP participation were compared with data from SNAP beneficiaries not enrolled in the program who shopped at the same stores. Overlap weighting (a propensity score-based method) was used to account for confounding, and linear mixed-effects models were fitted with random effects to account for repeated measures and clustering by store. Results: The study included 667 SuperSNAP participants and 33 246 SNAP beneficiaries who did not use SuperSNAP but shopped in the same stores; 436 SuperSNAP participants had preintervention data and were included in the main analysis. SuperSNAP participation was associated with increased monthly purchases of fruits, vegetables, nuts, and legumes ($31.84; 95% CI, $31.27-$32.42; P < .001; 294.52 oz; 95% CI, 288.84-300.20 oz; P < .001). Only a small increase in spending on less healthy food categories compared with the SNAP beneficiaries who did not use SuperSNAP ($1.60; 95% CI, $0.67-$2.53; P < .001) was observed. As total spending increased, the proportion of total food and beverage spending on less healthy foods significantly decreased (difference, 4.51%; 95% CI, 4.27%-4.74%; P < .001). Monthly spending on sugar-sweetened beverages decreased (difference, $1.83; 95% CI, $1.30-$2.36; P < .001). Conclusions and Relevance: In this cohort study, participation in SuperSNAP was associated with meaningful increases in healthy food purchasing. Subsequent studies should investigate whether healthy food incentive programs improve health outcomes.

Agricultural cooperatives participating in vegetable supply chain integration: A case study of a trinity cooperative in China.

Supply chain integration plays an important role in the development of the vegetable industry in terms of vegetable quality, vegetable safety, and vegetable security in rural China. This paper explores how agricultural cooperatives integrate the vegetable supply chain by taking a trinity cooperative as an example in China. It explains the translation concatenation of supply chain integration for this cooperative by constructing actor networks in four development stages, including the seed stage, start-up stage, development stage, and mature stage. The findings show that supply chain integration in production cooperation, supply & sales cooperation, and credit cooperation is a useful trinity cooperative model of supply chain integration for investigating vegetable supply chain integration through internal integration and external integration. This paper suggests that cooperatives in the vegetable supply chain should facilitate close coordination among different shareholders and further improve the efficiency of supply chain integration. The government should provide training opportunities and funding to encourage cooperatives to participate in supply chain integration within the vegetable industry.

Detection of Cyclospora cayetanensis on bagged pre-cut salad mixes within their shelf-life and after sell by date by the U.S. food and drug administration validated method.

Recently, outbreaks of Cyclospora cayetanensis in the U.S. were linked to the consumption of a variety of salads containing romaine and/or iceberg lettuce, carrots and/or red cabbage. The Bacteriological Analytical Manual (BAM) Chapter 19b method was validated for the detection of C. cayetanensis in carrots, cabbage and romaine lettuce, but has not been previously evaluated in ready-to-eat (RTE) salad mixes. In addition, the only samples available for traceback investigations are sometimes leftovers in bad conditions. This study evaluated the validated BAM method for detection of C. cayetanensis in two different RTE mixed salads (mix 1: romaine and iceberg lettuces, carrots, and red cabbage and mix 2: romaine and iceberg lettuces, carrots, red cabbage, radish, and pea pods) in good condition and after their sell by date. Individual samples (25 g) were seeded with five and 200 C. cayetanensis oocysts. Unseeded produce was used as negative control. The method included washing of the produce, concentration and extraction of C. cayetanensis DNA and molecular detection of C. cayetanensis 18 S rRNA gene. As few as five oocysts were detected in both fresh and after sell by date mix salads. All unseeded samples were negative, and all samples of both salad types seeded with 200 oocysts were positive. In samples seeded with 200 oocysts, average 18 S rRNA C. cayetanensis CT values were significantly higher in fresh salad mix 1 compared to fresh salad mix 2; CT values were significantly higher in the after sell by date salads compared to their respective fresh mixes (p < 0.05). In conclusion, the BAM method was able to detect as few as five oocysts even in after sell by date RTE mix salads. However, the differences in detection observed, highlight the importance of evaluating the performance of the validated C. cayetanensis detection method in different food matrices and conditions, in advance for future outbreak investigations.

The prevalence of Clostridioides difficile on farms, in abattoirs and in retail foods in Ireland.

An increasing proportion of Clostridioides difficile infections (CDI) are community acquired. This study tested farm, abattoir and retail food samples for C. difficile, using peer reviewed culture and molecular methods. The contamination rate on beef, sheep and broiler farms ranged from 2/30 (7%) to 25/30 (83%) in faeces, soil and water samples, while concentrations ranged from 2.9 log10 cfu/ml to 8.4 log10 cfu/g. The prevalence and associated counts were much lower in abattoir samples. Although 26/60 were C. difficile positive by enrichment and PCR, only 6 samples yielded counts by direct plating (1.1 log10 cfu/cm2 to 5.1 log10 cfu/g). At retail, 9/240 samples were C. difficile positive, including corned beef (1), spinach leaves (2), iceberg lettuce, little gem lettuce, wild rocket, coleslaw, whole milk yogurt and cottage cheese (1 sample each), with counts of up to 6.8 log10 cfu/g. The tcdA, tcdB, cdtA, cdtB, tcdC and tcdR genes were detected in 41%, 99.2%, 33.6%, 32%, 46.7% and 31.1%, respectively, of the 122 C. difficile isolates obtained. It was concluded that although the prevalence of C. difficile decreased along the food chain, retail foods were still heavily contaminated. This pathogen may therefore be foodborne, perhaps necessitating dietary advice for potentially vulnerable patients.

Impact of COVID-19 on vegetable supply chain and food security: Empirical evidence from Bangladesh.

In Bangladesh, the COVID-19 pandemic is likely to have substantial effects on the livelihood of people, but smallholder vegetables growers will be even more affected because of the perishability nature of the product. The first case of COVID-19 was confirmed in Bangladesh on 8th March, 2020 and consequently the country went into lockdown on 26 March, 2020. This study has made a survey of vegetables farmers through a mobile phone to understand the impact of COVID-19 on vegetables supply chain, gross margin and the future production plan of the growers. In Bangladesh, the lockdown has disrupted the food supply chain and increases the likelihood of food insecurity. Lockdown has impeded vegetable farmers' access to markets, thus limiting their productive and sales capacities. The price of yield has dropped by more than half resulting in huge loss for vegetable growers. The loss incurred by the farmers for producing Brinjal, Cucumber, Pointed gourd, Yardlong beans and Bottle gourd are BDT 4900, BDT 10900, BDT 57400, BDT 52500 and BDT 18500 per acre respectively as a result of COVID-19. The decreased income increases farmers' likelihood of vulnerability and food insecurity and poses a challenge to continued produce. 'Cash support' is more important than 'food support' in order to keep vegetable farmers in farming, to ensure a ready supply of necessary low-cost resources, and to help fight against the upcoming food shortage.

The Food Environments of Fruit and Vegetable Consumption in East and Southeast Asia: A Systematic Review.

Fruit and vegetable (FV) consumption benefits the health of populations. This can be especially the case in locations which have undergone significant changes in their food environments, such as East and Southeast Asian countries. This current systematic review is the first to study the food environments-facilitators, barriers, and moderators-associated with FV consumption in East and Southeast Asia. We consulted five electronic academic databases of English peer-reviewed papers published between 2010 and 2020 and found 31 studies. Results of these studies show that individuals strongly perceive FVs as being high-quality and safe, and having trust in their benefits. Food businesses with modernized systems have significantly fostered the consumption of FVs. A main barrier to FV consumption, however, is financial concerns, exacerbated by food businesses with FV unavailability and urbanization-induced FV price inflation and dietary patterns. Demographics and shopping patterns further hinder FV consumption. The fragmented and conditionalized findings of the 31 studies require standardized FV consumption measurements. Unlike the impact of FV consumption determinants and their interactions in Western countries, those in Asia, particularly countries other than China, have been substantially understudied. Therefore, as the research gaps in studies of food environments and FV consumption in East and Southeast Asia urgently demand scholarly attention, this paper proposes recommendations that favour the consumption of FVs.

Qualitative Study on Participant Perceptions of a Supermarket Fruit and Vegetable Incentive Program.

BACKGROUND: Complete Eats Rx is a fruit and vegetable prescription program designed to incentivize fruit and vegetable consumption among Supplemental Nutrition Assistance Program (SNAP) participants via $10 incentives distributed either weekly or per encounter to purchase fruits and vegetables at a mid-price supermarket chain in Washington State. OBJECTIVE: To better understand SNAP participants' experience, and to determine perceived impacts and consequences of the program. DESIGN: Qualitative analysis of nine photovoice sessions. Participants chose the topics for discussion. Sessions were audiorecorded and transcribed. Thematic content analysis was performed to identify key emergent themes using Atlas.ti. SETTING: Spokane, Seattle, and Yakima, Washington. PARTICIPANTS: Twenty-six individuals who received a fruit and vegetable prescription within the past 6 months, 23 of whom attended all three photovoice sessions offered at their site. Participants were recruited from three participating health care or public health organizations in Spokane, Seattle, and Yakima, Washington. ANALYSIS: Transcriptions were coded using inductive methods. Coded statements were organized into major themes. Coding structures and analysis were strengthened by iterative interactions between researchers. RESULTS: Participants reported Complete Eats Rx was an important resource for families and improved food security, diet quality, and the ability to purchase healthy foods, including a greater variety of fruits and vegetables. Primary barriers to food security and fruit and vegetable consumption included limited geographic accessibility and the high cost of fruits and vegetables, exacerbated by other financial constraints such as rising housing costs. Participants reported supermarket checkout difficulty because of embarrassment, stigmatization, and inability to redeem incentives. The most frequently mentioned barrier to perceived program acceptability was having only one supermarket chain as the acceptor of the incentive. CONCLUSION: Partnering with supermarkets to accept fruit and vegetable incentives is a unique strategy to increase produce purchasing that can be adopted by other localities. Focus on geographic accessibility, appropriate price points, and positive shopping experiences via expansion to local grocers, improvements in staff interactions, and a transition to an electronic system may improve incentive redemption and usability.

Exploring Influential Factors Including COVID-19 on Green Food Purchase Intentions and the Intention-Behaviour Gap: A Qualitative Study among Consumers in a Chinese Context.

This study applied a qualitative approach to investigate the underlying influences on consumers' green food consumption from the intention generation phase to intention execution phase in the perspectives of purchase intention and the intention-behaviour gap (IBG). Additionally, the impact of the "Coronavirus Disease 2019" (COVID-19) pandemic on consumers' green food purchases was explored. Research data were derived from semi-structured in-depth interviews with 28 consumers and analyzed using grounded theory. The findings identified factors that influenced intentions and the IBG in the process of consumers' green food purchases. Specifically, these findings reported that health consciousness, perceived attributes, environmental consciousness, social influence, family structure, and enjoyable shopping experiences were identified as major drivers for generating consumers' green food purchase intentions. High prices of green food, unavailability issues, mistrust issues, and limited knowledge were factors triggering the gap between green food purchase intentions and behaviours. In addition, the results revealed that the COVID-19 crisis increased consumers' green food purchase intentions, whereas the IBG widens as a result of issues of unavailability, price, and panic. These findings will help stakeholders build future policy and suitable strategies to better promote green food consumption in the Chinese context.

Quantifying risk factors associated with light-induced potato tuber greening in retail stores.

Light conditions in retail stores may contribute to potato greening. In this study, we aimed to develop a potato tuber greening risk rating model for retail stores based on light quality and intensity parameters. This was achieved by firstly exposing three potato varieties (Nicola, Maranca and Kennebec) to seven specific light wavelengths (370, 420, 450, 530, 630, 660 and 735 nm) to determine the tuber greening propensity. Detailed light quality and intensity measurements from 25 retail stores were then combined with the greening propensity data to develop a tuber greening risk rating model. Our study showed that maximum greening occurred under blue light (450 nm), while 53%, 65% and 75% less occurred under green (530 nm), red (660 nm) and orange (630 nm) light, respectively. Greening risk, which varied between stores, was found to be related to light intensity level, and partially explained potato stock loss in stores. Our results from this study suggested that other in-store management practices, including lighting duration, average potato turnover, and light protection during non-retail periods, likely influence tuber greening risk.

State-level income inequality and the odds for meeting fruit and vegetable recommendations among US adults.

BACKGROUND: Previous research indicates that income inequality is associated with risk for mortality, self-rated health status, chronic conditions, and health behavior, such as physical activity. However, little is known about the relationship between income inequality and dietary intake, which is a major risk factor for common chronic diseases including heart disease, stroke, diabetes, and certain types of cancers. The objective of this study is to determine the association between US state income inequality and fruit and vegetable consumption among adults. METHODS: Cross-sectional data on 270,612 U.S. adults from the U.S. 2013 Behavioral Risk Factor Surveillance System was used. Fruit and vegetable consumption was assessed from the six-item fruit and vegetable frequency questionnaire, which is part of the Behavioral Risk Factor Surveillance System. Multilevel modeling was used to determine whether US state-level income inequality (measured by the z-transformation of the Gini coefficient) was associated with fruit and vegetable consumption adjusting for individual-level and state-level covariates. RESULTS: In comparison to men, women were more likely to consume fruits and vegetables ≥5 times daily, fruits ≥2 times daily, vegetables ≥3 times of daily, and less likely to consume fruit juice daily. Among both men and women, a standard deviation increase in Gini coefficient was associated with an increase in consuming fruit juice daily (OR = 1.07, 95% CI = 1.03, 1.11). However, among women, a standard deviation increase in Gini coefficient was associated with a decreased likelihood in meeting daily recommended levels of both fruits and vegetables (OR = 0.93; 0.87-0.99), fruits only (OR = 0.95; 95% CI, 0.92-0.99) and vegetables only (OR = 0.92; 95% CI, 0.89-0.96). CONCLUSIONS: This study is one of the first to show the relationship between income inequality and fruit and vegetable consumption among U.S. adults empirically. Women's health is more likely to be detrimentally affected when living in a state with higher income inequality.

Legal Feasibility and Implementation of Federal Strategies for a National Retail-Based Fruit and Vegetable Subsidy Program in the United States.

Policy Points Suboptimal intake of fruit and vegetables is associated with increased risk of diet-related diseases. A national retail-based fruit and vegetable subsidy program could broadly benefit the health of the entire population. Existing fruit and vegetable subsidy programs can inform potential implementation mechanisms; Congress's powers to tax, spend, and regulate interstate commerce can be leveraged to create a federal program. Legal and administrative feasibility considerations support a conditional funding program or a federal-state cooperative program combining regulation, licensing, and state or local options for flexible implementation strategies. Strategies to engage key stakeholders would enable the program to utilize lessons learned from existing programs. CONTEXT: Suboptimal intake of fruit and vegetables (F&Vs) is associated with increased risk of diet-related diseases. Yet, there are no US government programs to support increased F&V consumption nationally for the whole population, most of whom purchase food at retail establishments. To inform policy discussion and implementation, we identified mechanisms to effectuate a national retail-based F&V subsidy program. METHODS: We conducted legal and policy research using LexisNexis, the UConn Rudd Center Legislation Database, the Centers for Disease Control and Prevention Chronic Disease State Policy Tracking System, the US Department of Agriculture's website, Congress.gov, gray literature, and government reports. First, we identified existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize F&Vs. Second, we evaluated Congress's power to implement a national retail-based F&V subsidy program. FINDINGS: We found five federal programs, three federal bills, four state laws, and 17 state (including the District of Columbia [DC]) bills to appropriate money to supplement federal food assistance programs with F&Vs; 74 programs (six multistate, 22 state [including DC], and 46 local) administered by state and local governments and NGOs that incentivize the purchase of F&Vs for various subpopulations; and two state laws and 11 state bills to provide tax exemptions for F&Vs. To create a national F&V subsidy program, Congress could use its Commerce Clause powers or its powers to tax or spend, through direct regulation, licensing, taxation, tax incentives, and conditional funding. Legal and administrative feasibility considerations support a voluntary conditional funding program or, as a second option, a mandatory federal-state cooperative program combining regulation and licensing. CONCLUSIONS: Multiple existing programs provide an important foundation to inform potential implementation mechanisms for a national F&V subsidy program. Results also highlight the value of state and local participation to leverage existing networks and stakeholder knowledge.

The effect of food taxes and subsidies on population health and health costs: a modelling study.

BACKGROUND: One possible policy response to the burden of diet-related disease is food taxes and subsidies, but the net health gains of these approaches are uncertain because of substitution effects between foods. We estimated the health and cost impacts of various food taxes and subsidies in one high-income country, New Zealand. METHODS: In this modelling study, we compared the effects in New Zealand of a 20% fruit and vegetable subsidy, of saturated fat, sugar and salt taxes (each set at a level that increased the total food price by the same magnitude of decrease from the fruit and vegetable subsidy), and of an 8% so-called junk food tax (on non-essential, energy-dense food). We modelled the effect of price changes on food purchases, the consequent changes in fruit and vegetable and sugar-sweetened beverage purchasing, nutrient risk factors, and body-mass index, and how these changes affect health status and health expenditure. The pre-intervention intake for 340 food groups was taken from the New Zealand National Nutrition Survey and the post-intervention intake was estimated using price and expenditure elasticities. The resultant changes in dietary risk factors were then propagated through a proportional multistate lifetable (with 17 diet-related diseases) to estimate the changes in health-adjusted life years (HALYs) and health system expenditure over the 2011 New Zealand population's remaining lifespan. FINDINGS: Health gains (expressed in HALYs per 1000 people) ranged from 127 (95% uncertainty interval 96-167; undiscounted) for the 8% junk food tax and 212 (102-297) for the fruit and vegetable subsidy, up to 361 (275-474) for the saturated fat tax, 375 (272-508) for the salt tax, and 581 (429-792) for the sugar tax. Health expenditure savings across the remaining lifespan per capita (at a 3% discount rate) ranged from US$492 (334-694) for the junk food tax to $2164 (1472-3122) for the sugar tax. INTERPRETATION: The large magnitude of the health gains and cost savings of these modelled taxes and subsidies suggests that their use warrants serious policy consideration. FUNDING: Health Research Council of New Zealand.

Are Housing Prices Associated with Food Consumption?

OBJECTIVE: Since January 2010, the U.S. has experienced economic recovery, including a 39% increase in home prices nationally. While higher home prices represent a wealth increase for some homeowners, it may decrease real purchasing power for others. The objective of this study is to examine the relationship between local area housing values and consumption of four food categories. DESIGN: Observational study using data from the Behavioral Risk Factor Surveillance System between 2011 and 2015. Outcomes included number of times per week food was consumed and binary measures denoting consumption ≥2 times per day for four categories: vegetables, fruit, legumes and fruit juice. The primary explanatory variables were metropolitan/micropolitan statistical area home and rental price indices from Zillow. Differential associations by home ownership, age, race/ethnicity and education were examined. RESULTS: Overall, housing values were not associated with intake of vegetables or fruit juice. Among homeowners, a $10,000 increase in home price was associated with small, but statistically significant reductions in fruit and legume consumption. These inverse associations were pronounced among Hispanic and non-Hispanic Black adults. CONCLUSIONS: Lower fruit and legume consumption associated with greater housing values may represent one of several explanations including a decrease in purchasing power, given increases in home prices and limited wage growth since 2010.

A social cost-benefit analysis of meat taxation and a fruit and vegetables subsidy for a healthy and sustainable food consumption in the Netherlands.

BACKGROUND: Implementation of food taxes or subsidies may promote healthier and a more sustainable diet in a society. This study estimates the effects of a tax (15% or 30%) on meat and a subsidy (10%) on fruit and vegetables (F&V) consumption in the Netherlands using a social cost-benefit analysis with a 30-year time horizon. METHODS: Calculations with the representative Dutch National Food Consumption Survey (2012-2014) served as the reference. Price elasticities were applied to calculate changes in consumption and consumer surplus. Future food consumption and health effects were estimated using the DYNAMO-HIA model and environmental impacts were estimated using Life Cycle Analysis. The time horizon of all calculations is 30 year. All effects were monetarized and discounted to 2018 euros. RESULTS: Over 30-years, a 15% or 30% meat tax or 10% F&V subsidy could result in reduced healthcare costs, increased quality of life, and higher productivity levels. Benefits to the environment of a meat tax are an estimated €3400 million or €6300 million in the 15% or 30% scenario respectively, whereas the increased F&V consumption could result in €100 million costs for the environment. While consumers benefit from a subsidy, a consumer surplus of €10,000 million, the tax scenarios demonstrate large experienced costs of respectively €21,000 and €41,000 million. Overall, a 15% or 30% price increase in meat could lead to a net benefit for society between €3100-7400 million or €4100-12,300 million over 30 years respectively. A 10% F&V subsidy could lead to a net benefit to society of €1800-3300 million. Sensitivity analyses did not change the main findings. CONCLUSIONS: The studied meat taxes and F&V subsidy showed net total welfare benefits for the Dutch society over a 30-year time horizon.