A new study that models the combined effects of a sugar-based tax on beverages and targeted subsidies for minimally processed foods and drinks found that under these policies, low-income consumers would purchase less sugar-sweetened beverages and more fruits, vegetables, and healthier drinks, particularly in households without children.  

Researchers from the Global Food Research Program at UNC-Chapel Hill developed a model to simulate what would happen if national-level taxes on less-healthy, ultra-processed foods and beverages were used to fund subsidies for low-income households participating in food assistance programs to spend on minimally processed fruits, vegetables, healthy proteins, and unsweetened drinks. They found that this combined policy scenario would likely lead low-income households to improve the nutritional quality of their grocery purchases without increasing their overall costs or negatively impacting consumer satisfaction.

Targeted taxes are a proven, cost-effective means to reduce purchase and intake of sugary drinks, which could potentially save millions of years of life globally by reducing chronic diseases caused by excess sugar and calories. While over 60 countries and smaller jurisdictions worldwide have implemented health-focused sugary drink taxes, relatively few have earmarked the revenue raised to subsidize healthy food purchases.

In the United States, studies evaluating programs that provide additional cash benefits for food assistance participants to spend on fruits and vegetables consistently find that they increase consumers’ purchase and intake of targeted products. This new study’s findings support a novel policy approach, combining both policy types to expand low-income households’ access to additional healthier alternatives like minimally processed proteins such as beans, legumes, or unprocessed meats, and no- or low-sugar beverages.

“Our findings show that we can support healthier dietary patterns in the US by directing revenues from national taxes on ultra-processed products high in sugar, sodium and/or saturated fats towards additional benefits to help low-income households purchase more fruits, vegetables and other healthier alternatives,” said senior author Shu Wen Ng, PhD, Distinguished Scholar in Public Health Nutrition at the UNC-Chapel Hill.

“This is an equity-enhancing approach that sends a clear and consistent message to the public and the food industry on the overarching goal of improving dietary patterns and nutritional security,” added first author Pourya Valizadeh, PhD, who completed this research during a post-doctoral fellowship at UNC-Chapel Hill. “The taxes should not be primarily about generating revenue, but rather shifting the relative prices of unhealthy vs healthy foods so that lower-income families in the US can more reliably attain foods and beverages that support health.” This study’s findings could inform recent congressional bills including the “GusNIP Expansion Act” and the “Opt for Health with SNAP (OH SNAP) Close the Fruit and Vegetable Fap Act” that would levy taxes on unhealthy beverages and expand targeted subsidies beyond existing SNAP benefits for minimally processed foods and beverages to low-income households.

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This study was funded by Robert Wood Johnson Foundation Healthy Eating Research and Arnold Ventures.

AUTHORS

Shu Wen Ng
Pourya Valizadeh

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Read the full study in the American Journal of Preventive Medicine

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Learn more about
sugary drink taxes.

A new study published today in the November issue of Health Affairs underscores the positive impact of the Healthy Helping produce prescription program that provided North Carolinians facing food insecurity with $40 a month to spend on fruits and vegetables during the COVID-19 pandemic.

Researchers from the University of North Carolina at Chapel Hill and nonprofit Reinvestment Partners found that Healthy Helping participants doubled their purchases of fruits, vegetables, nuts, and legumes while enrolled in the program, spending $27 more every month on these healthy foods. What’s more, their spending at the participating supermarket chain increased by $57 per month—more than the $40 incentive amount—suggesting that they may have prioritized this retailer for their grocery shopping during the intervention.

Together, these findings indicate that healthy incentive programs like Healthy Helping can achieve double-duty action, addressing health concerns by improving the nutritional profile of grocery purchases among a high-need population while also supporting local economic development during a time of great economic uncertainty.

The study builds on findings from previous research on the Healthy Helping program finding that prevalence of food insecurity among participants fell by 11 percentage points and that participants were thankful for the benefit and appreciated the flexibility to choose more and a greater variety of nutritious foods that would normally be outside their budget. This research is timely given the announcement in September of the White House’s new National Strategy on Hunger, Nutrition, and Health and the upcoming Farm Bill renewal process in 2023.

“As discussions around the upcoming Farm Bill begin, policymakers should consider the growing evidence around these innovative COVID-relief efforts,” said senior author Shu Wen Ng, Distinguished Scholar in Public Health Nutrition and Associate Professor of Nutrition at the Gillings School of Global Public Health and co-director of the Global Food Research Program.

“Programs like Healthy Helping tackled both food and nutritional insecurity by improving access to healthier items. Going forward, we need to more adequate and permanent support for regulatory changes that build resiliency in non-emergency times.”

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This research was supported by the North Carolina Department of Health and Human Services from their Coronavirus Aid, Relief, and Economic Security (CARES) Act allocation via a grant to Reinvestment Partners.

AUTHORS

Caitlin Lowery
Richard Henderson
Neal Curran
Sam Hoeffler
Molly De Marco
Shu Wen Ng

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Read the study in Health Affairs

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READ MORE ABOUT FOOD ASSISTANCE DURING THE COVID-19 PANDEMIC:

Participant experiences in the Healthy Helping program

Changes to nutrition assistance programs during COVID-19

Increased WIC cash vouchers for fruits & vegetables

A new study from South Africa comparing three different front-of-package (FOP) labeling schemes found that a nutrient warning label helped more participants correctly identify unhealthy products and more strongly reduced their intention to purchase those products, compared to a “multiple traffic light” label and a Guideline Daily Amounts label.

These findings, published in Appetite, come at an important time as South African policymakers consider draft regulation for the country’s first mandatory front-of-package label. While research from other countries has found that nutrient warning labels are the stronger FOP label option for identifying and discouraging consumption of unhealthy foods, some studies find that other labels, such as the traffic light, can also be effective. This suggests that context plays an important role and underscores the importance of testing a label designed specifically for South Africa.

“It was important to create a warning label for South Africa that can help people from different language backgrounds and literacy levels make informed decisions on what to buy and eat,” said Makoma Bopape (left), first author and Senior Lecturer in Human Nutrition and Dietetics at the University of Limpopo. “We achieved this using a triangle shape and exclamation mark that are associated with ‘warning’ in South Africa and by including icons for each nutrient, for example a saltshaker for sodium.”

In a randomized controlled trial, researchers from the University Limpopo, the University of the Western Cape, the University of Antwerp, and the University of North Carolina at Chapel Hill compared how well the different label types helped South African consumers:

• Identify products high in sugar, salt, or saturated fat;
• Identify unhealthy products; and
• Reduce intention to purchase unhealthy products.

Participants were randomly selected from the general South African population, which resulted in a representative sample of nearly 2,000 households. They first answered questions about a set of fictional products with no FOP labels, as a control condition. Next, they were randomly assigned to one of the three FOP label conditions and shown another set of products featuring that label. They then answered the same questions about the labeled products.

Researchers measured how many participants in each group correctly identified products high in nutrients of concern (sugar, salt, and saturated fat), how many correctly identified products as unhealthy, and whether participants’ intention to purchase the unhealthy products changed after seeing them with a specific FOP label.

“These findings are consistent with a rapidly growing body of evidence from around the world showing that warning labels are the most effective label type for helping consumers rapidly identify unhealthy foods — and perhaps more importantly, discouraging consumers from buying them,” said Lindsey Smith Taillie (right), co-author and Associate Professor of Nutrition at the University of North Carolina at Chapel Hill.

This research comes on the heels of another study by Bopape, Taillie, and Rina Swart, senior author and professor in Dietetics and Nutrition at the University of the Western Cape, in which they examined how the same warning labels impacted parents’ food purchasing decisions and perceptions of unhealthy foods. When shown images of products with warning labels, parents said they would buy less of the foods with warning labels and switch to non-labeled, healthier options. Parents in the study also expressed that their children’s health was their top priority. Warning labels made them think about future health impacts if their children continued eating ultra-processed foods high in sodium, sugar, and saturated fat.

Like many countries worldwide, South Africa faces high rates of obesity and other diet-related diseases including type 2 diabetes, hypertension, and heart disease — all exacerbated by consuming a diet high in sugar, sodium, or saturated fat. In addition to helping consumers easily and more accurately identify foods high in nutrients of concern and discourage purchases of those products, requiring FOP warning labels on the least-healthy foods and drinks could incentivize industry to offer healthier product choices.

Policies using similar FOP nutrient warning labels have already been implemented or passed in ten other countries — most in the last three years. Evidence of their impact in Chile, where FOP warning labels have been required on unhealthy packaged foods and drinks since 2016, suggests that findings from experiments like this one in South Africa can translate into real, population-level changes in shopping behavior once a policy is implemented. In its first year, Chile’s FOP warning label policy was associated with a 24% drop in sugary drink purchases and declines in sodium (–37%), total calories (–24%), calories from sugar (–27%), and calories from saturated fat (–16%) purchased from all foods and beverages.

“If South Africa adopts the labels used in this study into the current draft regulations, ours will be the first African country and second country in the world after Israel to use a mandatory warning label with icons for different nutrients,” said Swart (left). “In addition to helping guide South African consumers toward healthier choices on what to buy, eat, and feed their families, this could provide important evidence for other countries that have diverse languages and literacy levels.”

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This research was funded by Bloomberg Philanthropies.

For inquiries, contact Emily Busey.

Read the full paper in Appetite:

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AUTHORS

Makoma Bopape
University of Limpopo,
University of the Wester Cape

Jeroen De Man
University of Antwerp

Lindsey Smith Taillie
UNC-Chapel Hill

Shu Wen Ng
UNC-Chapel Hill

Nandita Murukutla
Vital Strategies, New York

Rina Swart
University of the Western Cape

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RESOURCES

Read more about the evidence for front-of-package labels.

View different front-of-package labeling policies around the world.

Low-income North Carolinians who received a monthly fruit and vegetable benefit during the COVID-19 pandemic enjoyed the flexibility to choose more and a greater variety of nutritious foods during a time of profound food insecurity, according to a new study in the Journal of Hunger & Environmental Nutrition.

Researchers from UNC-Chapel Hill interviewed participants in the Healthy Helping Fruit and Vegetable Program, which provided beneficiaries $40 per month to purchase fresh, frozen, or canned fruits and vegetables at a chain supermarket retailer. Funded by state allocations from the federal CARES Act and operated by Durham-based nonprofit Reinvestment Partners, the Healthy Helping program ran from June–December 2020 and was offered to adults enrolled in the Supplemental Nutrition Assistance Program (SNAP) who were experiencing additional food insecurity during COVID-19 pandemic.

“We know that targeted fruit and vegetable benefit programs work to increase access and improve dietary quality, but we wanted to learn more about the program experience from participants’ points of view,” said Molly De Marco, leader of the Food, Fitness + Opportunity Research Collaborative at the UNC Center for Health Promotion and Disease Prevention and the study’s lead author.

De Marco and colleagues conducted phone interviews with 10 participants from rural and urban locations and ranging in age from 34 to 72 years. Key themes that emerged included:

• Participants were thankful for the benefit. They purchased more and a greater variety of fruits and vegetables that would normally be outside their budget.
• Using Healthy Helping benefits freed up money to use on other expenses.
• Participants enjoyed being able to choose what foods to buy with the benefit. Several interviewees who were also enrolled in other food assistance programs (e.g., School Meals, USDA’s Farmers to Families Food Boxes, or Meals on Wheels) noted that a lack of choice in how, when, and what foods they received deterred them from continuing to use other programs.

The research team also surveyed a larger group of 200 participants to examine overall dietary quality and found that despite high levels of food insecurity, the foods and drinks consumed in Healthy Helping households were similar to those in the typical American diet.

“Based on previous research, we might expect these lower-income households with food insecurity to be eating fewer fruits, vegetables, and whole grains than higher-income households. Our finding that their diet quality was similar suggests some improvement among Healthy Helping households after enrolling in the program,” said Shu Wen Ng, co-author and Associate Professor of Nutrition and Co-Director of the Global Food Research Program. “We can’t be sure, though, since we had no dietary measures from before respondents enrolled in the program.”

This study supports previous research showing that targeted fruit and vegetable benefit programs are effective and well-liked. “Healthy Helping is a model that offers flexibility for families to make their own decisions about what and how much healthy food to purchase,” said first author Isabel Lu, Healthy Helping project coordinator. “With rising food costs due to inflation and ongoing supply-chain issues, low-income households continue to need greater financial access to healthier diets. Incentive programs like Healthy Helping can help fill this gap.”

Options for expanding programs like Healthy Helping could occur through SNAP, as an additional benefit, or through healthcare settings. Healthcare payers who share an interest in improving patients’ dietary intake and overall health are pilot testing such benefits as a reimbursable, “produce prescriptions.”

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This research was supported by the North Carolina Department of Health and Human Services from their Coronavirus Aid, Relief, and Economic Security (CARES) Act allocation via a grant to Reinvestment Partners.

AUTHORS

Isabel Lu
Brett Sheppard
Shu Wen Ng
Sarah Burstein
Emile Charles
Taylor Williams
Molly De Marco

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READ MORE ABOUT FOOD ASSISTANCE DURING THE COVID-19 PANDEMIC:

Changes to nutrition assistance programs during COVID-19

Increased WIC cash vouchers for fruits & vegetables

A new health policy brief from Health Affairs, titled “COVID-19 Pandemic-Era Nutrition Assistance: Impact And Sustainability,” joins Health Affairs’ ongoing series of policy briefs on the social determinants of health.

Its authors, including Global Food Research Program faculty Shu Wen Ng write that COVID-19 became “a stress test” for the ability of the United States to feed those in need.

Early in the pandemic, a record number of households, including nearly fourteen million children, reported not having enough to eat, with Black and Latinx households being more severely affected than their White and Asian counterparts. The existing federal nutrition programs, detailed in the brief, primarily flow through the Department of Agriculture (USDA). For programs such as the USDA’s National School Lunch and School Breakfast Programs, the COVID-19 school closures made the normal distribution channels unavailable to recipients and their families.

The brief describes efforts undertaken by the federal government in the beginning of the pandemic, such as the Families First Coronavirus Response Act of 2020 and other legislation, which allowed the USDA to expand program eligibility, change how programs were accessed, and develop new programs offering novel experiments in nutritional assistance without compromising safe social distancing.

For example, a normal requirement of the USDA’s Supplemental Nutrition Assistance Program is an in-person enrollment interview. By replacing that requirement and allowing telephonic signatures for recertification, researchers estimate that some six million participants were able to be enrolled in the first few months of the pandemic.

The brief also describes some of the innovative temporary federal programs, such as the Farmers to Families Food Box Program, that were made possible with discretionary USDA funding, as well as complementary efforts by states, localities, tribes, and the private sector.

As Congress and the Biden administration prepare for the reauthorization of the Farm Bill in 2023, the authors recommend that many of the expansions, flexibilities, and new programming developed in response to the pandemic be allowed to continue. They note that these changes could help address the structural forces that create food insecurity. In addition, as policy makers also consider the next Child Nutrition Reauthorization, the authors suggest restoring and building on the 2010 federal nutrition standards and working to explore schools’ expanded role in providing high-quality food year-round to students and families.

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Funding support for this Health Policy Brief was provided by the Robert Wood Johnson Foundation.

AUTHORS

Caitlin Caspi
Rudd Center for Food Policy and Health, University of Connecticut

Hilary Seligman
Departments of Medicine and of Epidemiology and Biostatistics, University of California, San Francisco

Jerica Berge
Department of Family Medicine and Community Health, University of Minnesota

Shu Wen Ng
University of North Carolina at Chapel Hill

James Krieger
School of Public Health and School of Medicine, University of Washington

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Read the full policy brief in Health Affairs