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

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

Many U.S. families faced new or additional challenges to finding and paying for food during the COVID-19 pandemic. Among these are over 6 million women and young children who participate in the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides nutrition education, supplemental foods, breastfeeding promotion and support, and referrals for health care.

Beginning in June 2021, the American Rescue Plan Act provided a temporary increase in the cash value benefit (CVB) or voucher for WIC participants to buy fruits and vegetables. This increased the monthly CVB voucher amount from $9–11 per person to $35 per person. In September 2021, this temporary increase was extended, and the monthly benefit amounts were changed to $24 per child and $43–$47 for women (depending on whether they are pregnant, postpartum, or breastfeeding).

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To explore WIC participants’ experiences with the CVB changes, researchers at UNC-Chapel Hill held 10 online focus groups with WIC participants in North Carolina in March 2022. Each group had 4–8 participants from similar racial/ethnic backgrounds. Half of the participants lived in rural counties and half lived in urban or suburban counties. Participants were asked about their experiences shopping with WIC during the pandemic, their awareness of CVB changes, and their experiences using the higher CVB amount. The information collected in this study has the potential to inform changes to the WIC program and provide evidence for future emergency response policies. Key findings include:

Higher CVB met participants’ needs

• Participants welcomed the CVB increase: Responses to the higher CVB amount were overwhelmingly positive.

“But when they increased the [CVB] amount we loved it, we enjoyed every bit of it.”

“…that’s one of my kid’s main things. He loves fruits and vegetables…So we were very grateful for it.”

• The increase met household needs: Participants viewed the CVB increase as a beneficial change that helped meet their needs during the pandemic.

“I can’t stress this enough the amount that they gave us in fruits and vegetables during the pandemic…was an extreme help.”

• The pre-pandemic amount was not enough: Participants were dissatisfied with the $9-11/person amount and felt the amount only lasted one shopping trip.

“…But you know, anybody that shops for themselves knows that $9 in the produce department is going to last you maybe two days with children.”

“It’s just not really enough money to buy much, you know, it’s almost like an insult.”

• The CVB is one of the most valued parts of the WIC food package: Participants felt the CVB increase was one of the best changes to the food package because they use fruits and vegetables most.

“I think that’s the most beneficial change that, that WIC has made in a really long time…”

“So I would say like, it’s definitely giving me a reason to stay enrolled [in WIC] and everything.”

Increased CVB = healthier WIC families

• Higher CVB facilitates healthier eating habits: Participants stated their family ate healthier with more money for fruits and vegetables.

“I mean I liked it because it definitely changed the way like we were eating as a household… it became more convenient to grab an apple instead of a bag of chips you know.”

“Yes, it was the healthiest that we were able to eat in a very long time.”

• Introducing new fruits and vegetables to young children: Participants reported their children were able to try new types of fruit and vegetables, a critical part of forming healthy eating habits in childhood.

“With that increase in fruits and vegetables for my kids, I got to introduce them to vegetables that they would probably never eat at a young age.”

“But with the increase, I’ve been able to do other foods like cantaloupes, honeydew, other things that she would not have wanted to try…”

• Eating a more culturally appropriate diet: Some mentioned that the increase allowed them to eat a diet in line with their dietary/cultural preferences, especially participants with plant-based diets.

“I live in, like what they call a Latino household. So almost every meal that we have is based of fruits and vegetables…So it [the CVB increase] was very helpful for us.”

Challenges with implementation

• Uncertainty: The many changes in the CVB amounts in 2021 left participants confused about how much they were getting.

“…if it was something that we could rely on and was consistent, that would be better. But I mean, right now, it’s kind of you just got to play it by ear, because you don’t know what the changes are going to be.”

• Lack of awareness of changes: Many participants were not told about the CVB changes and found out while shopping or when checking their benefits in the WIC app.

“I wish I would’ve got a text or a call from one of the representatives…Instead of me going to store and me looking crazy ‘cause I’m finna buy all this fruit and I can’t ‘cause I ain’t got enough money.”

Recommendations

Based on these findings, researchers recommend the following for improving the CVB and promoting nutrition security among WIC participants:

• Make the CVB increase permanent to promote long-term healthy eating habits and reduce disparities

• Consider a new, higher CVB amount to account for inflation and meet participants’ needs

• Allow substitution of CVB for baby food for children ages 6-12 months to introduce fresh fruits and vegetables to their diet at an early age

• Increase efforts to inform participants of changes to the WIC program, including changes to CVB

Read the full research study in the International Journal of Environmental Research and Public Health.

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This research was funded in part by Healthy Eating Research, a national program of the Robert Wood Johnson Foundation.

AUTHORS:

Emily Duffy
Daniele Vest
Cassandra Davis
Marissa Hall
Molly De Marco
Shu Wen Ng
Lindsey Smith Taillie

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Read the full research brief:

The Duke Endowment has awarded a $765,000 grant to Dr. Shu Wen Ng and colleagues Dr. Thomas Keyserling (UNC School of Medicine), Dr. Ashley Price (Duke University Department of Family Medicine and Community Health), and Neal Curran and Sam Hoeffler (Reinvestment Partners) to expand their research on the benefits of the food prescription programs.

Administered by the Durham-based nonprofit Reinvestment Partners in communities across North Carolina, the RPRx food prescription program provides $40 per month — distributed electronically through Food Lion’s customer loyalty program — for participants to buy fruits and vegetables.

Previous research has already found that this model is effective at increasing fruit and vegetable purchases, and higher use of the program is associated with fewer hospitalizations. With the new grant, Ng and colleagues will further investigate whether the RPRx program is associated with improved health outcomes and lower health care costs for communities. Their findings will provide valuable information about the program’s cost effectiveness and contribute to the evidence base for efforts to incorporate the food prescription program model into standard health care practice.

Read more about this grant and the researchers’ aims in Gillings School of Global Public Health’s school news.

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Based in Charlotte and established in 1924 by industrialist and philanthropist James B. Duke, The Duke Endowment is a private foundation that strengthens communities in North Carolina and South Carolina by nurturing children, promoting health, educating minds and enriching spirits. Since its founding, it has distributed more than $4 billion in grants. The Endowment shares a name with Duke University and Duke Energy, but all are separate organizations.

See also:
SuperSNAP helps food-insecure households afford healthy foods