The SNAP-Ed Evaluation Framework: demonstrating the impact of a national framework for obesity prevention in low-income populations.

The United States Department of Agriculture's Supplemental Nutrition Assistance Program Education, known as SNAP-Ed, is the country's largest and most diverse community nutrition program. In 2017, nearly 140 SNAP-Ed implementing agencies (SIAs) and hundreds of contractors delivered nutrition education to almost 5 million people in nearly 60,000 low-resource sites. Millions more were impacted with social marketing campaigns and policy, systems, and environmental changes. This article introduces and describes the benefits of the newly developed SNAP-Ed Evaluation Framework (Framework) and companion Interpretive Guide to consistently measure SNAP-Ed outcomes across different settings. The Framework uses the social ecological model as its underlying theory and features 51 indicators across four levels: Individual, Environmental Supports, Sectors of Influence, and Population Results. Topline findings from the first-year Census to track Framework adoption found that most SIAs intended to impact indicators closer to the inner levels of influence: Individual (mean = 59% of SIAs; SD = 22%) and Environmental Settings (mean = 48%; SD = 23%). As yet, few SIAs targeted outcomes for long-term indicators (mean = 26%; SD = 15%), Sectors of Influence (mean = 20%; SD = 12%), or Population Results (mean = 30%; SD = 11%). An in-depth example of how one state is using the Framework is described. The SNAP-Ed Evaluation Framework offers a new suite of evaluation measures toward eliminating disparities that contribute to poor diet, physical inactivity, food insecurity and obesity. Practitioners will need technical assistance to implement the Framework, especially to measure longer-term, multi-sector and population results, and to maximize effectiveness in SNAP-Ed.

Strategies to improve the dietary quality of Supplemental Nutrition Assistance Program (SNAP) beneficiaries: an assessment of stakeholder opinions.

OBJECTIVE: To examine the opinions of stakeholders on strategies to improve dietary quality of Supplemental Nutrition Assistance Program (SNAP) participants. DESIGN: Participants answered a thirty-eight-item web-based survey assessing opinions and perceptions of SNAP and programme policy changes. SETTING USA SUBJECTS: Survey of 522 individuals with stakeholder interest in SNAP, conducted in October through December 2011. RESULTS: The top three barriers to improving dietary quality identified were: (i) unhealthy foods marketed in low-income communities; (ii) the high cost of healthy foods; and (iii) lifestyle challenges faced by low-income individuals. Many respondents (70 %) also disagreed that current SNAP benefit levels were adequate to maintain a healthy diet. Stakeholders believed that vouchers, coupons or monetary incentives for purchasing healthful foods might have the greatest potential for improving the diets of SNAP participants. Many respondents (78 %) agreed that sodas should not be eligible for purchases with SNAP benefits. More than half (55 %) believed retailers could easily implement such restrictions. A majority of respondents (58 %) agreed that stores should stock a minimum quantity of healthful foods in order to be certified as a SNAP retailer, and most respondents (83 %) believed that the US Department of Agriculture should collect data on the foods purchased with SNAP benefits. CONCLUSIONS: Results suggest that there is broad stakeholder support for policies that align SNAP purchase eligibility with national public health goals of reducing food insecurity, improving nutrition and preventing obesity.

Associations of food stamp participation with dietary quality and obesity in children.

OBJECTIVE: To determine if obesity and dietary quality in low-income children differed by participation in the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program. METHODS: The study population included 5193 children aged 4 to 19 with household incomes ≤130% of the federal poverty level from the 1999-2008 NHANES. Diet was measured by using 24-hour recalls. RESULTS: Among low-income US children, 28% resided in households currently receiving SNAP benefits. After adjusting for sociodemographic differences, SNAP participation was not associated with a higher rate of childhood obesity (odds ratio = 1.11, 95% confidence interval [CI]: 0.71-1.74). Both SNAP participants and low-income nonparticipants were below national recommendations for whole grains, fruits, vegetables, fish, and potassium, while exceeding recommended limits for processed meat, sugar-sweetened beverages, saturated fat, and sodium. Zero percent of low-income children met at least 7 of 10 dietary recommendations. After multivariate adjustment, compared with nonparticipants, SNAP participants consumed 43% more sugar-sweetened beverages (95% CI: 8%-89%), 47% more high-fat dairy (95% CI: 7%, 101%), and 44% more processed meats (95% CI: 9%-91%), but 19% fewer nuts, seeds, and legumes (95% CI: -35% to 0%). In part due to these differences, intakes of calcium, iron, and folate were significantly higher among SNAP participants. Significant differences by SNAP participation were not evident in total energy, macronutrients, Healthy Eating Index 2005 scores, or Alternate Healthy Eating Index scores. CONCLUSIONS: The diets of low-income children are far from meeting national dietary recommendations. Policy changes should be considered to restructure SNAP to improve children's health.

Using an opinion poll to build an obesity-prevention social marketing campaign for low-income Asian and Hispanic immigrants: report of findings.

OBJECTIVE: To gain opinions from low-income, limited-English-speaking Hispanic and Asian immigrants for formative research in a social marketing campaign. DESIGN: Nineteen questions on obesity prevention-related topics were embedded into a larger random digit-dial survey investigating the effects of language and cultural barriers on health care access. Participants were selected by ethnic encoding from consumer databases. SETTING: California's northern, southern, and Central Valley regions. PARTICIPANTS: Nine hundred and five adult Hispanic, Chinese, Vietnamese, Hmong, and Korean Californians from households < 130% of the Federal Poverty Level interviewed in 2005. VARIABLES MEASURED: Media usage, food stamp participation, health insurance, health problems, access and availability of fruits and vegetables (FVs) and physical activity, beliefs about overweight, and related regulation and policy change. ANALYSIS: Descriptive statistics and percentages for all questions. RESULTS: Latinos reported receiving most information from television; Hmong from radio. Hispanics, Koreans, and Vietnamese thought diabetes was the greatest health issue in California. Among Hmong, 83% thought FVs were too expensive, and 49% of Vietnamese thought good quality, affordable fresh FVs were too hard to find. CONCLUSIONS AND IMPLICATIONS: Identifying characteristics and opinions that distinguish these ethnic immigrant populations better enables the Network for a Healthy California to develop culturally relevant social marketing campaigns and materials.

Using a Toolbox of tailored educational lessons to improve fruit, vegetable, and physical activity behaviors among African American women in California.

OBJECTIVE: Evaluate the effectiveness of the Fruit, Vegetable, and Physical Activity Toolbox for Community Educators (Toolbox), an intervention originally designed for Spanish- and English-speaking audiences, in changing knowledge, attitudes, and behavior among low-income African American women. DESIGN: Quasi-experimental design with treatment and control groups. SETTING: Four community-based organizations and direct health service provider sites. PARTICIPANTS: African American women ages 18-54 (156 treatment, 171 control), 75% of whom were low income. INTERVENTION: Six 1-hour Toolbox classes. MAIN OUTCOME MEASURES: Knowledge, attitudes, self-efficacy, empowerment, and behavior change related to fruits and vegetables and physical activity. ANALYSIS: Dependent t tests pre- to posttest and chi-square test between control and treatment groups. RESULTS: Women in the treatment group reported significant changes in 9 measures of attitude, compared to 1 measure in the control group, as well as 12 measures of confidence and 5 measures of empowerment for which the control group showed no changes. Compared to those in the control group, women in the treatment group were also more likely to make behavioral changes to meet recommendations for fruit and vegetable consumption and physical activity. CONCLUSIONS AND IMPLICATIONS: Toolbox lessons were effective in increasing participants' knowledge, attitudes, self-efficacy, empowerment, and reported fruit and vegetable- and physical activity-related behaviors.

California adults increase fruit and vegetable consumption from 1997-2007.

OBJECTIVE: To determine whether fruit and vegetable consumption among California adults significantly increased from 1997-2007. DESIGN: Biennial telephone surveillance surveys of California adults' dietary practices. PARTICIPANTS: California adults (n = 9,105 total all 6 surveys). INTERVENTION: Surveillance data reporting. MAIN OUTCOME MEASURES: Changes in fruit and vegetable consumption over time between 1997-2007, measured by mean servings and percentage of adults eating ≥ 5 servings on any given day. ANALYSIS: Comparisons of subsets both within the same year and across years were made using t tests, chi-square, and Tukey Studentized Range tests at 5% procedure-wise error rate. RESULTS: California adults significantly increased mean daily servings of fruits and vegetables from 3.8 servings in 1997 to 5.2 servings in 2007. CONCLUSIONS AND IMPLICATIONS: Since 1998, notable improvements in fruit and vegetable consumption have occurred to California populations, including the target audience groups of the Network for a Healthy California.

Using geographic information systems and local food store data in California's low-income neighborhoods to inform community initiatives and resources.

OBJECTIVES: We examined conditions in California low-income neighborhoods that affect obesity to inform program planning, nutrition education, community participation, investment of resources, and involvement of stakeholders. METHODS: Staff members in 18 local health departments were trained to use an online geographic information system (GIS) and conduct field surveys. GIS data were aggregated from 68 low-income neighborhoods of 1 or more census tracts. Data were collected in 2007 to 2009 from 473 grocery stores in 62 neighborhoods. RESULTS: Thirty-one percent of neighborhoods mapped had no supermarket within any of their census tract boundaries, but health department staff members estimated that 74.2% of residents had access to a large grocery store within 1 mile. Eighty-one percent of small markets sold produce, and 67.6% offered 4 or more types of fresh vegetables. CONCLUSIONS: Small markets and corner stores in California's low-income neighborhoods often have fresh produce available for sale. Stores providing healthy options in typically underserved areas can be part of community efforts to promote healthy eating behaviors.

Seizing the moment: California's opportunity to prevent nutrition-related health disparities in low-income Asian American population.

Asian Americans and Pacific Islanders (AAPI) have the fastest growing rate of overweight and obese children. Aggressive programs are urgently needed to prevent unhealthy acculturation-related changes in diet and physical activity and to promote the healthier aspects of traditional lifestyle habits. We conducted focus groups and key informant interviews to explore knowledge, attitudes, dietary practices, and physical activity levels among three low-income Asian American ethnic groups, Chinese, Vietnamese, and Hmong, in California. Content analysis was used to identify similarities and differences among the groups. Several common health beliefs clearly emerged. Participants noted the importance of fresh (not frozen) fruit and vegetable consumption and physical activity for general health. The concept of good health included having a harmonious family, balance, and mental and emotional stability. All groups also expressed the general belief that specific foods have hot or cold properties and are part of the Yin/Yang belief system common to Asian cultures. The lure of fast food, children's adoption of American eating habits, and long work hours were identified as barriers to a healthy, more traditional lifestyle. A California campaign for Asian Americans using multilevel strategies is recommended to counter the alarming rise of obesity among AAPI youth. Strategies directed to individual, community, and policy levels should emphasize maintenance of healthy traditional diets, informed selection of mainstream U.S. foods, and promotion of active lifestyles to prevent an impending burden from cancer and nutrition-related chronic diseases in AAPI populations.