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:

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