PBH 695 SNAP-Ed Thesis

RUNNING HEAD: Impact of SNAP-Ed Program on Eating Habits

A Public Health Capstone Project presented to the faculty of the Community & Global Public Health Programs, College of Health Sciences, Arcadia University in partial fulfillment of the requirements for the Master of Public Health Degree.

An Assessment of the Impact of SNAP-Ed Programs on Eating Habits in Household Food Shoppers

Erin C. McDermott

Master of Public Health Degree Candidate

Arcadia University

Faculty Advisor: Dr. Katherine Isslemann DiSantis PhD, MPH

May, 2015

Impact of SNAP-Ed Program on Eating Habits ii

Table of ContentsAbstract ………………………………………………………………………………………......iv

List of Tables and Figures………………………………………………………………………..vi

Introduction…………………………………………………………………………………..…...1

Theoretical Foundation…………………………………………………………………………...7

Theory of Planned Behavior……………………………………………………………...7

Transtheoretical Model…………………………………………………………………...9

Literature Review………………………………………………………………………………...14

SNAP-Ed History………………………………………………………………………..14

Food Insecurity…………………………………………………………………………..16

Expanded Food and Nutrition Behavior Education……………………………………...17

Process of dietary-related behavior change……………………………………...17

Effectiveness of EFNEP…………………………………………………………20

Food Labeling……………………………………………………………………………26

Food Safety………………………………………………………………………………27

Food Budgeting…………………………………………………………………………..29

Methods…………………………………………………………………………………………..31

Research Questions………………………………………………………………………31

Retrieval of Current SNAP-Ed Programs………………………………………………..31

Data Collection…………………………………………………………………………..33

Analysis…………………………………………………………………………………..34

Results………………………………………………………………………………………...….36

Color Me Healthy………………………………………………………………………..36

Nutrition and Physical Activity Self-Assessment and Child-Care………………………38

Impact of SNAP-Ed Program on Eating Habits iii

Healthy Food Environments Pricing Inventive………………………………………….39

Faithful Families Eat Smart and Moving More………………………………………….41

Baltimore Healthy Stores………………………………………………………………...42

We Can! Ways to Enhance Children’s Activity and Nutrition…………………………..44

Out of School Nutrition and Physical Activity………………………………………......47

The Kindergarten Initiative………………………………………………………………49

Riverside United School Districts Farmers Market Salad Bar Program…………………51

Farm to Work…………………………………………………………………………….52

Discussion………………………………………………………………………………………..60

Changes in Dietary Behavior……………………………………………………….……60

Food Budgeting, Food Labeling, Food Safety…………………………………………...62

Theory Based Practices…………………………………………………………………..64

Strengths and Limitations………………………………………………………………..66

Conclusion……………………………………………………………………………………….67

References………………………………………………………………………………………..68

Appendix…………………………………………………………………………………………77

Impact of SNAP-Ed Program on Eating Habits iv

AbstractBackground: During each year, about 15% of US Households experience food insecurity, which

puts them at risk for poor dietary intake, both in terms of quality and quantity of food.

Supplemental Nutrition Assistance Program [SNAP] is by far the largest federal program to help

low-income families, and serves more than 39 million participants nationwide, with the aim of

alleviating food insecurity and improving the nutritional status of its participants. SNAP-Ed is a

portion of SNAP that is a combination of educational strategies, accompanied by environmental

supports, designed to facilitate voluntary adoption of food and physical activity choices.

Evaluations of SNAP-Ed programs offered across the country have not been performed in a

comprehensive manner.

Purpose: To assess the benefits the SNAP-Ed program has on increasing fruit and vegetable

consumption and lowering sugar intake with its participants.

Methods: A policy review was conducted searching the following database: United States

Department of Agriculture [USDA] - The SNAP-Ed Strategies & Interventions: An Obesity

Prevention Toolkit for States. Existing programs were randomly selected and were assessed.

Food budgeting, food labeling and food safety were three topic areas that were examined during

program assessment. Finally increase in fruit and vegetable consumption, and decreasing sugar

intake were specific behavior changes that were assessed.

Results: A total of 10 out of 60 programs were selected to be analyzed, with the shortest

program being 12 weeks and the longest being one year. North Carolina, Texas, California,

Kentucky, Massachusetts, Pennsylvania and Maryland were States where the programs are being

implemented. SNAP-Ed programs that taught or discussed at least one topic on food budgeting,

food safety or food labeling, had a high rate of effectiveness on its participants. With continuous

Impact of SNAP-Ed Program on Eating Habits v

implementation of SNAP-Ed programs, SNAP-Ed will help participant’s make healthy dietary

behavior changes for them and their families.

Conclusion: Through SNAP-Ed programs, participants were taught about food labeling, food

budgeting and food safety among other skills to help increase consumption of fruits and

vegetables, lower sugar intake and decrease weight. Future research can benefit from creating a

standardized form for SNAP-Ed programs to fill out to register their programs, share methods

and results in order to provide data on their program.

Impact of SNAP-Ed Program on Eating Habits vi

List of Tables and Figures

Figure 1 Transtheoretical Model: Stages of Change & Associated Barriers…………………….13

Figure 2 Food Budgeting, Food Labeling, Food Safety Addressed in Programs………………..59

Figure 3 Frequency of Topics Addressed………………………………………………………..59

Table 1 Summary of Topics Covered in SNAP-Ed Courses………………………………….....25

Table 2 Methodology of SNAP-Ed Interventions……………………………………………55-56

Table 3 Food budgeting, Food Labeling, Food Safety topics addressed………………………..57

Table 4 Effectiveness of Programs on Dietary Behavior Change……………………………….58

Impact of SNAP-Ed Program on Eating Habits 1

Introduction

Food insecurity is often focused on for its effect on the nutrition of individuals and is a

daily reality for hundreds of millions of people around the world (Ivers & Cullen, 2011; Webb et

al., 2006). It is defined as “limited or uncertain ability to secure acceptable foods in socially

acceptable ways” (Jilcott, Wall-Bassett, Burke & Moore, 2011). Food insecurity has important

implications for the health and nutrition of individuals who are food insecure (Ivers & Cullen,

2011). The most severe form of food insecurity is defined as households where children are

experiencing reduced food intake and hunger (Dinour, Bergen, & Yeh, 2007). Food insecurity

with hunger is defined as “the uneasy or painful sensation caused by a lack of food,”(Anderson,

1990, p 1560) and households are characterized in which one or more people experienced hunger

at times during the year, e.g. skipping meals (Coleman-Jensen & Gregory, 2014). Contrary to

that, food insecurity without hunger is those individuals who report reduced quality, variety or

desirability of diet with little or no indication of reduced food intake (Coleman-Jensen &

Gregory, 2014). Most often, people fall prey to food deprivation not so much because food is

unavailable to them but rather their accessibility to purchase food is limited (Webb et al., 2006).

A report developed by the USDA showed that in 2009, 14.7% of all US households were

food insecure some time during the year (Ivers & Cullen, 2011). Food-insecure households are

further classified as having low food security or very low food security; with very low food

security being a severe range of food insecurity by reduced food intake and disrupted eating

patterns of one or more household member, where low food security is reports of reduced

quality, variety, or desirability of diet with little or no indication of reduced food intake, with

5.7% of individuals experiencing “very low” food security in 2009 (Nord & Prell, 2011; Ivers &

Cullen, 2011). Food insecure households are, at times, unable to acquire adequate food for an


active, healthy life for all of their household members because they may have insufficient funds

and other resources for food (Nord & Prell, 2011). A household becomes food insecure when

they are unable to alleviate the negative struggles associated to, or loss of, food availability,

access and/or utilization (Webb et al., 2006).

Food insecurity increases the risk of individuals becoming malnourished, which can lead

to weaker immune systems, delayed maturation and decreased energy levels (Food Insecurity,

2014). Food insecurity and obesity can co-exist in the same individual; family or community

(Food Research and Action Center, 2011). It is no secret that the United States has an obesity

problem where, two-thirds of adults and one-third of children are obese or overweight

(Blumenthal et al., 2012). With the rise in obesity, it threatens the next generation’s life, leading

to a lifetime of weight related diseases like diabetes, high blood pressure, and cardiovascular

disease (SNAP-Ed, 2014). Children that grow up malnourished are more likely to have lower

academic achievement, live in poverty as adults, dental problems and mental illness (Blumenthal

et al., 2012). Unhealthful eating habits and obesity are serious problems that affect Americans at

all income levels. Tackling these problems demands a thoughtful and comprehensive approach,

based in an understanding the data. Therefore strategies need to focus on Americans from all

income levels, and on communities and neighborhoods (FRAC, 2013).

The prevalence of food insecurity with hunger is about twice as high among

Supplemental Nutrition Assistance Program [SNAP] participants as among nonparticipant

households (Wilde, 2007). Some households with limited resources participate in one or more of

the Federal food and nutrition assistance programs and/or obtain food from emergency food

providers in their communities (Colman-Jensen, Nord & Singh 2013). Policymakers and

advocates have long hypothesized that the SNAP participation reduces food insecurity (Malbi et


al, 2013). The Census Bureau indicates that the value of SNAP benefits, when added to cash

income, moved 13 percent of participating households above the federal poverty line in 2010

(Blumenthal et al., 2012). SNAP is also widely regarded as one of the most important stimulus

programs in place for mitigating the impact of economic recessions in America (Blumenthal et

al., 2012). For these reason, it is important to raise participation in federal food programs (White

House Task Force on Childhood Obesity, 2010). There have been several federal programs over

the past decades that have been created to help low-income families improve their diet quality by

providing access to food, a healthful diet, and nutrition education (You, Mitchell & Nayga, 2011;

Coleman-Jenson, Nord & Singh, 2013). SNAP is by far the largest federal program, which serves

more than 39 million participants nationwide, with the aim of alleviating food insecurity and

improving the nutritional status of its participants (You et al., 2011; Leung et al., 2013). To be

eligible for SNAP, a household without an elderly or disable member must have a monthly gross

income at or below 130% of the federal poverty guidelines (Dinour et al., 2007).

Prior to 2008 SNAP was referred to the Food Stamps Program. The new name reflects

the changes that were made to meet the needs of the clients, including a focus on nutrition and an

increase in benefit amounts (SNAP Research, 2013). In 2005, SNAP spent $31 billion and

served a monthly average of 25.7 million low-income Americans (Wilde, 2007). In December of

2009, 12.9% of Americans received SNAP benefits, which were up from 10.6 percent a year

earlier (Nord & Prell, 2011). Previous research on SNAP has found that participation in SNAP

has been effective at increasing food expenditures, nutrient availability, and decreasing food

insecurity (You et al., 2011).

Participants in SNAP receive an average monthly benefit of $227 per household or $101

per person (You et al., 2011). States issue SNAP benefits through local State or county offices to


households that are eligible to receive them. Those clients, who are eligible to receive SNAP

benefits (SNAP, 2014). The local county office provides eligible households the SNAP EBT

card so they can buy groceries from authorized food stores (SNAP, 2014). Benefits are

automatically loaded into the household’s account each month on a designated date.

SNAP-Ed is a portion of SNAP that is a combination of educational strategies,

accompanied by environmental supports, designed to facilitate voluntary adoption of food and

physical activity choices. Nutrition education and obesity prevention services are delivered

through multiple venues and involve activities at the individual, community and appropriate

policy levels (USDA, 2014). State participation in SNAP-Ed is voluntary and requires a State

resource match as well as an approved budget and implementation plan. State agency

commitment to nutrition education has grown in recent years. In 1992, the first year of the Food

and Nutrition Services (FNS) funding, seven States had nutrition education plans approved, with

total Federal funding of $661,076. In 2007, all States have approved FNS budget. The approved

Federal dollars totaled over $341 million in 2009, which covered half of the total amount the

States spend on SNAP-Ed that year (USDA Economic Research Service, 2015).

The FNS expects States to incorporate at least two approaches in their SNAP-Ed Plans

which are: individual or group based nutrition education, health promotion and intervention

strategies; comprehensive, multi-level interventions at multiple complementary organizational

and institutional levels; and community and public health approaches to improve nutrition.

Evaluations of SNAP-Ed outcomes are limited and evaluations need improvement, researchers

and local implementers report positive behavior changes and gains in food security as a result of

SNAP-Ed (Food Research and Action Center, 2013). With the recent SNAP-Ed enhancements,


more SNAP participants can benefit from nutrition education efforts that promote healthy diets

and reduce obesity (FRAC, 2013).

There are many reasons why SNAP-Ed is important to offer to SNAP participants. It can

help increase an individual’s knowledge on nutrition and improve on their ability to feed their

families healthier. This was found to be true in one study conducted by Wiig, Dammann and

Smith (2009). Results found that women relied on their limited knowledge of nutrition health,

and cooking when providing food for their families, which leads to irregular and often

unhealthful food-related behaviors. They also found from their focus groups that education and

peer support may be useful in passing on educational materials and building skill sets for

practicing healthful behaviors. Finally, Wiig et al. (2009) suggest that low income families must

be educated on prevention of obesity and treatment strategies to improve poor diet in a cultural

context.

SNAP-Ed is important to those who participant and should continue to be implemented in

every State but can benefit to making improvements to help increase outcomes. Enhancing

SNAP-Ed and its goal to improve community health through education, marketing,

environmental change, and policy can enhance the impact of SNAP (Blumenthal et al., 2012). In

order for SNAP-Ed interventions to be effective, it must be diverse for the audience and

communities and must be carefully targeted, surround consumers with cues to action, use

multiple community channels where food and physical activity decisions are made, and be of

sufficient duration and intensity (Blumenthal et al., 2012).

Food labeling, food safety and food budgeting are three topics that are an important part

of the SNAP-Ed. With these three topics intermixed in SNAP-Ed programs, they benefit the

participants once they complete the program. With food labeling, it teaches individuals how to


read labels correctly and what healthy nutrients to look for. It also allows an individual to

compare products side-by-side and determine which food is healthier. Food safety, gives proper

instructions on how to cook and store food properly which avoids contracting food borne

illnesses. Finally with food budgeting, it allows SNAP-Ed participants to learn how to make their

money last longer, how to create a shopping list and how to clip coupons. Thus, the purpose of

this study is to assess the benefits the SNAP-Ed program has on healthy behavior changes with

its participants.


Theoretical Foundation

The use of a theoretical model has been suggested as a strategy to evaluate behavior

change as a strategy to make improvements to the evaluation process of SNAP-Ed program

(Savoie et al., 2014). The two theories that will be applied to this systematic review will be: The

Theory of Planned Behavior and the Transtheoretical Model.

Theory of Planned Behavior

The Theory of Planned Behavior (TPB) was created from the Theory of Reasoned

Action, when they added construct perceived behavioral control, based on the ideas that

behavioral performance is determined jointly by intention and behavioral control. Perceived

control is determined by control beliefs concerning the presence or nonexistence of facilitators

and barriers to behavioral performance, which is weighted down by their perceived power or the

impact of each control factor to facilitate or inhibit the specific behavior (Glanz, Rimer &

Viswanath, 2008). Since important beliefs and attitudes are changeable, TPB provides a

systematic method to identify those issues that are most important to a person’s decision about

performing a specific behavior (Glanz, Rimer & Viswanath, 2008).

In the TPB, there are three constructs that explain the process of behavior change:

perceived behavioral control, attitude toward behavior and subjective norm (Savoie et al, 2014).

TPB focuses on theoretical constructs concerned with individual motivational factors as

determinants of the likelihood of performing a specific behavior. The addition of perceived

behavioral control, concerned with facilitating or constraining conditions that affect behavior and

intention (Glanz, Rimer & Viswanath, 2008). TPB assumes the best predictor of a behavior is

behavioral intention, which is determined by attitude toward the behavior, social normative

perceptions regarding it and perceived behavioral control (Glanz, Rimer & Viswanath, 2008).

Behavioral intentions measures can assess planning, desire and expectation.


Finally, TPB emphasizes that attitude can affect behavior only through intention.

Attitudes are often directly predicted behavior not mediated by intentions. Intentions and

attitudes can change over time, making their relationship with behavior change a moving target.

The TPB offers a systematic way of identifying those issues that are most important to a person’s

decision about performing a specific behavior change. Since most attitudes and intentions are

changed easily, they are the best targets for education interventions (Glanz, Rimer & Viswanath,

2008). If attitude and subjective norm are used in an intervention, a person’s perception of the

behavioral performance will affect his/her behavioral intention.

The participant’s attitude will be the most vital piece to measure during a study

specifically with experiential attitude (affect), instrumental attitude and indirect measure. For

direct measure in regards to experiential attitude, it is important to see the overall affective

evaluation of the behavior. For experiential attitude and indirect measure it is key to understand

the belief that behavioral performance is associated with certain positive or negative feelings

(Glanz, Rimer & Viswanath, 2008). It is important to assess how the individual feels about the

idea of the behavior. For example, how does the individual feel about increasing fruit and

vegetable intake on a daily basis?

A study conducted by Savoie et al.,(2014) used TBP to assess SNAP-Ed. During their

study they used perceived behavioral control and intention to change constructs, which are

considered to be the most proximal determinants of behavior change. The study used the intent to

change contrast as the foundation for the evaluation process. Since intentions can be expected to

produce behaviors only if an individual has control over their behavior, a wide variety of

optional classes, menu planning or shopping lessons, were made available to the SNAP

participants by using a flexible schedule. The intent to improve nutrition-related behaviors of the


individual questions from pretest to posttest increased significantly. Savoie et al., (2014) results

demonstrated that participants in either the menu planning or shopping lessons had a positive

impact on the intent of participants to improve nutrition-related behaviors, food labeling and

food budgeting.

Transtheoretical Model

The Transtheoretical Model (TTM) uses stages of change to integrate processes and

principles of change across major theories of intervention. This model was first used for a

conductive analysis that compared smokers who quit on their own compared to smokers who

were in a professional facility treatment (Glanz, Rimer & Viswanath, 2008). Over the course of

the study, the emergence of behavior change occurred in stages. They became known as the 6

stages of change that unfold over time which are: progress, pre-contemplation, contemplation,

preparation, action, maintenance and termination (Glanz, Rimer & Viswanath, 2008). Although

each stage of change has a certain time frame that each person may spend in each stage, it will

vary from person to person on how they advance through the model.

The first stage of change, pre-contemplation is where a person does not intend on making

any behavior changes for at least six months. People may be in this stage due to lack of

appropriate knowledge of their health behavior. In contemplation people have developed some

knowledge of their health behavior and intend on making changes within the next 6 months. For

preparation, the participant has taken some behavioral steps in making positive lifestyle change,

and intend on taking action within the next 30 days. For example, they may have created a plan

of action such as attending a health education class or consulting with their doctor. Next with the

action stage, people have made changes to their overt behavior within the past 6 months. Since

action is observable, behavior change is often equated with the action stage. Maintenance is the


stage in which someone has been practicing their behavior change for more than 6 months and is

continuously practicing their behavior change to avoid relapse. Those people who are in

maintenance are also less tempted to relapse and are extremely more confident that they can

continue with their behavior change. Final in termination have zero temptation to relapse and

100 percent self-efficacy. They are positive that they will not return to their original unhealthy

behavior (Glanz, Rimer & Viswanath, 2008). It is important to note that individuals might enter

and exit relapse at any stage of their behavior change.

Along with the stages of change, this model contains ten processes of change that serve

as guidelines for intervention programs to provide activities for participants through the process

of behavior change. The ten processes of change are: conscious raising, dramatic relief, self-

reevaluation, environmental reevaluation, self-liberation, social liberation, counterconditioning,

stimulus control, contingency management and helping relationships. These processes have been

used in studies that are designed to help participants change health behaviors such as: weight

loss, dietary changes, substance use, and dental hygiene (Glanz, Rimer & Viswanath, 2008). The

constructs of this model are a tool to be used because it can measure decisional balance, an

individual’s relative weighing of behavior change by using the pro and con method, temptation

and self-efficacy (Glanz, Rimer & Viswanath, 2008).

Self-efficacy is the situation specific confidence that people can cope with high-risk

situations without relapsing to their former behaviors (Glanz, Rimer & Viswanath, 2008). This is

a key factor when educating participants in SNAP. By increasing participant’s self-efficacy, in

regards to proper food storage, and creating a shopping list, it will provide them with confidence

to maintain healthy behaviors changes that they learned while attending education sessions. Once

they have increased and maintain their self-efficacy, it will help individuals make and maintain


better healthy choices for them and their family because they have the confidence and education

to make these changes.

The transtheoretical model has been used in previous studies that were identifying the

relationship between SNAP-Ed and positive behavior change in food skills. One study conducted

by Wyker et al. (2012) used TTM to test the linkage between the TTM mediators and dietary

behavior specifically, perceived barriers and benefits of eating fruits and vegetables and self-

efficacy regarding eating more fruits and vegetables were issues identified as facilitators or

inhibitors. The Food Stamp Program Fruit and Vegetable checklist (FVC) was used to measure

behaviors related to fruit and vegetable consumption. The scales for perceived benefits, self-

efficacy, and the FVC each satisfied the recommended significance level of .70, whereas the

perceived barriers scale met the minimally acceptable significance level of .60. Perceived

benefits, perceived barriers and self-efficacy were each placed in the structural model as external

variables. This pattern emphasizes the importance of recognizing appropriate determinants to

target SNAP-Ed.

The model provided information on how well the constructs of interest from the TTM

predict fruit and vegetable consumption behavior. Results showed that an association was not

found between perceived benefits of eating fruits and vegetables and consumption behaviors,

whereas there is a significant association between perceived barriers and self-efficacy and

consumption behaviors. This study demonstrates how the application of theory and survey

validation can enhance the evaluation of SNAP-Ed projects. Moreover, theoretical framework

applied is appropriate and the domains in the model explained a fair amount of the variance in

fruit and vegetable consumption. The constructs could be used to determine if existing SNAP-Ed


State Programs are addressing these barriers/constructs such as improving self-efficacy,

throughout the course of their lessons.

Application of Theory to Current Study

The Theory of Planned Behavior and Transtheoretical Model were applied in this policy

review to assess behavior change and how they are being applied in the SNAP-Ed toolkit. Figure

1, provides a visual understanding of the behavior changes individuals would experience by

stage while participating in SNAP-Ed. It addresses the participants unaware of their unhealthy

eating habits, through maintenance phase of practicing healthy behavior skills at home. The

figure is an overview of the barriers SNAP-Ed participants face before, during and after they

attend nutrition education classes. The barriers presented in the figure are based off of the TTM.


Figure 1. Individual behavior changes through the constructs of TTM

Transtheoretical model

Pre-contemplation

Unaware of unhealthy eat

habits

Contemplation

Gather information on

education classes

Review personal eating and

shopping habits

Preparation

Create schedule for SNAP-Ed

classes

Action

Attend classes

Make behavior changes

Maintenance

Read food labels Practice food safety skills

Budget food stamps by creating

shopping list


Literature Review

SNAP-Ed History

The SNAP-Ed program is a voluntary participation component of SNAP, in which

educational messages on dietary quality, food safety, and food resource management are

delivered to low-income individuals (Wyker et al., 2012). SNAP-Ed is a widely endorsed

pathway to promote healthy eating habits among participants (You et al., 2011). There are two

key federal partners with SNAP-Ed: NIFA and the USDA Food and Nutrition Service (FNS)

(USDA, 2014). NIFA- facilitates communication among federal, state and local partners, and

provides programmatic leadership to university contractors for effective nutrition education

through land-grant system (USDA, 2014). The FNS determines national policies and procedures,

monitors state programs, and reimburses states for up to half of program costs. Lessons for

SNAP-Ed are developed by each individual State with registered dietitians and delivered by

certified paraprofessional nutrition education assistants (Savoie et al., 2014).

The mission of SNAP-Ed is to reduce hunger and food insecurity in partnership with

cooperating organizations by providing children and needy people access to food, a healthful

diet, and nutrition education in a manner that supports American agriculture and inspires public

confidence (USDA, 2014). The goal of SNAP-Ed is to improve the likelihood that persons

eligible for SNAP will make healthy food choices within a limited budget and choose physically

active lifestyles consistent with the current Dietary Guidelines for Americans and the USDA

food guidance (USDA, 2014). SNAP-Ed continues to move forward implementing the re-

structuring of the Program based on the changes to the Food and Nutrition Act (FNA). The FNA

is an act to strengthen the agricultural economy, to provide for improved levels of nutrition

among low-income households through a cooperative Federal-State program of food assistance


to be operated through normal channels of trade (FNA, 2014). Keeping that in mind, the Food

and Nutrition Service emphasizes to States that all projects and interventions included in State

SNAP-ED Plans must be evidence based as required by the FNA (USDA, 2014).

The primary focus of SNAP-Ed programs is:

Health promotion to help the SNAP-Ed target audience establish healthy eating

habits and a physically active lifestyle; and,

Primary prevention of diseases to help the SNAP target audience who have risk

factors for nutrition-related chronic disease or postpone the onset of disease by

establishing healthier eating habits and being more physically active.

The Dietary Guidelines for Americans [DGA] are the foundation of nutrition education in

all FNS nutrition assistance program. Messages that are delivered through SNAP-Ed should be

consistent with the Dietary Guidelines for Americans and all activities must promote healthy

food choices based on the recent DGA (USDA, 2014). The DGA have been in use since the US

Department of Agriculture and the Department of Health and Human Services jointly published

them in 1980, and have been updated every 5 years since (Harnack, Nicodemus, Jacobs, &

Folsom, 2002). The DGA provide advice for healthy Americans aged 2 years and over, about

food choices that promote health and prevent disease, serve as the basis for federal nutrition

policy and nutrition education activities (Harnack et al., 2002). Through this advice it is

important to increase fruit and vegetable consumption, lower sugar intake and decrease overall

weight.

SNAP-Ed is delivered directly through group and individual interactive learning

opportunities as well as indirectly through the distribution of print and video materials.

Regardless of how education is delivered to the participant, SNAP-Ed is a learner-centered and


behavioral-focused (USDA, 2014). The federal SNAP-Ed program determined key behavioral

objectives for their state partners to emphasize in their teaching of SNAP clients, which include:

eating fruits and vegetables every day; eating whole grains and low-fat or fat-free dairy products

every day; being physically active every day; and balancing caloric intake from food and

beverages (Koszewski, Sehi, Behrends, & Tuttle, 2011). States must integrate multiple

approaches (as mentioned in the introduction) in implementing evidence based SNAP-Ed

nutrition education and obesity prevention activities. Some examples of implementing activities

from all three approaches are: holding cooking, teaching children about nutrition education, and

creating social marketing program to change norms around the food environment and healthy

eating (USDA, 2014).

Food Insecurity

The term “food insecurity” is used to characterize households that have “limited or

uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to

acquire acceptable food in socially acceptable ways” (Eicher-Miller et al. pg 161, 2009). A

recent report found that participation in SNAP was associated with less food insecurity, about 12

percent of participants, when taking into account self-selection of participants into the program

(Jilcott, Wall-Bassett, Burke, & Moore, 2011). Numerous studies have found from their research

that SNAP participants that receive education courses have a decreased rate of food insecurity.

Ivers and Cullen (2011) presented that 219 female heads of households receiving food stamps

who were randomly assigned to either receive or not receive education regarding food insecurity

and nutrition showed a significant improvement in food security in the intervention group.

Along with the previous studies discussed, Dollahite, Olson and Scott-Pierce (2008)

developed a similar study and found that the number of lessons completed by graduates was


directly and significantly associated with a greater decrease in food insecurity, reinforcing the

importance that nutrition education is accounting for the change. Similarly Eicher-Miller et al.,

(2009) examined the effects of Food Stamp Nutrition Education (FSNE) lessons on the food

security of its participants. They hypothesized that the series of 5 tailored education lessons

provided through FSNE, interactive presentation of preparing meals, learning how to read food

labels, and practical tips on budgeting and thrifty shopping, would improve participants self-

reported food security level and food sufficiency compared to those not receiving the lessons.

Food insufficiency is defined as “an inadequate amount of food intake due to a lack of money or

resources.” After completion of the five FSNE lessons there was also significant improvement in

food insecurity in FSNE participants who received 5 lessons compared to those who received 1

lesson and 4 delayed educational lessons.

The results of these studies support the importance of education in decreasing food

insecurity in families because it provides families with the knowledge to confidently purchase

healthy food items for their meals. It also suggests that there is a relationship between the

number of education lessons received and a decrease in food insecurity. This emphasizes the

importance role that nutrition education plays in diminishing food insecurity to its participants

and will continue to help families improve their lifestyle.

Expanded Food and Nutrition Behavior Education

Process of dietary-related behavior change. Changing an individual’s dietary-related

behavior is just one part in helping them improve their health. In the Savoie et al., (2014) study

they wanted to assess whether participation in selected SNAP-Ed lessons had an impact on the

intent of participants to improve nutrition-related behaviors. The lessons were delivered to the

participants in a variety of styles, a lecture component, a cooking demonstration, and a sample


tasting of the food prepared in class, which were based off of the Theory of Planned Behavior.

The researchers used a retrospective post-then-pre design, which runs the preprogram assessment

alongside the posttest by asking individuals to recall their knowledge and behavior prior to the

program, to assess whether participation in SNAP-Ed was having an impact on nutrition-related

behavior change. Koszewski et al. (2011) also used a post-then-pre survey design research to

determine if adult graduates from SNAP and Expanded Food and Nutrition Education Program

(EFNEP) maintained their behavior changes six months after completing a minimum of, six

nutrition and food budgeting classes. The participants completed a behavior checklist survey that

was identical to the pre and post survey they completed when they enrolled and graduated from

either the SNAP-Ed program or EFNEP. By using this design approach, it used the determination

of intention to change behaviors as a predictor of future behavior change. Koszewski et al.

(2011) participants receive additional information in six months after completing the EFNEP

courses. The educational packet they received contained information on basic nutrition, physical

activity, and food budgeting every other month for the next six months.

For Savoie et al., (2014) questions for the post then pretest were developed to measure

the intention to change nutrition-related behaviors; some question emphasized current nutrition

related behaviors and others focused on intent to change the same behaviors. The questions that

were developed for the pretest emphasized current nutrition related behavior, and posttest

focused on intent to change the same behavior based on what they learned in lessons. Compared

to the Koszewski et al., 2011) study where a total of 4,400 graduates with 1,100 participating in

the follow-up behavior checklist survey, with a response rate of 25 percent.

Similar results were found in both Savoie et al., (2014) and Koszewski et al., (2011)

studies in which participation in federally funded nutrition education programs can change the


intentions to improve or maintain their nutrition-related behaviors. Results also demonstrate that

participation in either of the 2 selected lessons had a positive impact on the reported intent of

participants to improve nutrition-related behaviors. This data helps support the motion that

EFNEP and SNAP are able to help limited resource clients change and maintain healthy

behaviors.

A study with a comparable design was conducted by Van Assema, Steenbakkers,

Rademaker and Brug (2005) and used a quasi-experimental control group design. The Regional

Public Health Institute designed two nutrition education sessions as part of the course of teaching

budget, to those struggling with their finances. The objective was to increase dietary variety,

decrease the intake of saturated fat, and increase the intake of vegetables. One month after the

nutrition education sessions, van Assema et al (2005) participants were phoned three times

randomly over a course of one month and were questioned about the main meal they had just

eaten, including yesterday’s main meal along with fruit and vegetable consumption. Sixteen

participants in the intervention group self-reported that they had made at least one dietary change

as a result of the intervention. Most participants found it very important to have received the

information in the first session and had heard a few new things in the first session and a lot of

new information in the second session.

Multiple levels of SNAP policies were targeted in Leung et al (2013); individual, retailer,

and government, all that might influence health. They performed a qualitative study of 27

nutrition experts to assess factors that influence the eating patterns and dietary behaviors of

SNAP recipients and strategies to improve nutrition in SNAP. There was a 10 question interview

guide that was developed to examine respondents’ perceptions of existing barriers as well as

innovative strategies to improve the nutritional status of SNAP beneficiaries. The experts


interviewed frequently mentioned nutrition education as a benefit from participants and it ranged

from allowing more flexible formats and topic coverage in SNAP-Ed programs, to increased

program evaluation to promote effective approaches. Focusing on innovate strategies that target

the individual, the retailer and state and federal policy will help to improve nutritional status of

SNAP recipients.

All studies highlighted provide evidence that nutrition education for federally funded

programs targeted to low-income individuals may be effective in improving reported intent

related to healthy nutrition-related behaviors and potentially changing behaviors in the future.

Through these studies, it shows that through nutrition education participants will change their

unhealthy behavior to one that is healthier for them and their families. With continued education

and practicing of the skills learned from the education classes, individuals will be able to

maintain their behavior change.

Effectiveness of EFNEP. The Expanded Food and Nutrition Education Program

(EFNEP), is a program through National Institute of Food and Agriculture, which helps

participants identify and develop strategies to manage their food budgets and related sources

such as food stamps (Dollahite et al., 2008). EFNEP provides nutrition education to families with

children at or below 185% of the federal poverty line. One of EFNEP’s primary objectives is to

promote food security by helping participants identify and develop strategies to manage their

food budgets (Dollahite et al., 2008). The focus of EFNEP’s lessons are budgeting, comparing

prices, using coupons, shopping with a grocery list and planning meals ahead of time, this helps

participants expand and develop skills.

Dollahite et al., (2008) study included 16,146 EFNEP participants which represented

ethnically and racially diverse population. At the beginning and end of the program the


participants complete a “Behavior Checklist,” which included questions such as: “How often do

you run out of food before the end of the month?” and answers ranged from do not do to almost

always. Data was collected prior to participants taking education, then around at six lessons, and

finally when education was completed and participants were ready to graduate.

Greenwell, Arnold and Sobal (2000) developed a study to investigate changes in nutrition

knowledge, food practices, and nutrition intakes in female participants in EFNEP during their

time in EFNEP and a year after they completed the program. They hypothesized that the least

healthy food and nutrition knowledge and practices would occur at baseline, increased

knowledge and healthier practices would be present at graduation and maintenance of graduation

level would appear at the follow-up assessment. Similarly, Dollahite et al., (2014) designed a

study to assess the effect of EFNEP education on reported nutrition behaviors and longitudinal

retention of reported behavior change. The hypothesis tested was that participants completing at

least 6 EFNEP sessions would report behaviors that significantly improve from pre- to post-

education as compared to those not enrolled in EFNEP; and 8 weeks after graduation,

participants would report behavior changes similar to those at post-education. During both these

studies, the number of EFNEP classes taken during entry and graduation, time between each

lesson, duration between entry and graduation was assessed.

Both programs focused on improving knowledge, (food) skills, budget and food choices

with hands-on, dialogue-based activities that included preparation of healthy recipes and food

tasting, which was found in both results. Finally, one of the greatest behavior change benefits of

EFNEP was learning how to balance a food budget, practices for food management, food safety

practices and nutrition. These results support the hypothesis that food practices would improve


during the program and be maintained after they graduated. Participants reported significant

behavior change, indicating that the education itself had the greatest influence.

Education can be an important tool to increase nutrition and healthy behaviors in low-

income populations; which is what Rustad and Smith (2013) observed in their study. The

purpose of their study was to test the efficacy of a short-term nutrition intervention, using

education about a broad range of nutrition and health topics through activities fostering hands-on

experience and skill building. Rustad and Smith (2013) found that nutrition knowledge can

impart favorable dietary and health behavioral changes in low-income populations through short-

term nutrition education on health benefits of all food groups; identification of healthful foods;

shopping, cooking; and energy balance.

Wall, Least, Gromis and Lohse (2012) similarly provided education to fourth grade

children, offering 4 lessons on vegetables. With both studies they consisted of pre- and post-

intervention surveys were given to the participants to test food preference, attitude, and self-

efficacy, from their surveys. Results of Wall et al. (2012) showed that a carefully designed and

implemented intervention that addresses mediators of behavior change using approaches that is

recommended by nutrition experts, can positively impact mediator of vegetable intake in fourth

graders. After reviewing these studies they support the notion that nutrition education is

beneficial in improving food knowledge, and skills to its participants. As well as increase self-

efficacy, proper food handling and storage as a result of taking part in education courses.

A study conducted by Wiig and Smith (2008) had focus group discussion with 92 females

who had at least one child aged 9 to 13 years old in their household. The questions from the

focus group discussed personal, behavioral and environmental influences on grocery shopping,

and food choice, questions were framed in the context of the Social Cognitive Theory. While this


study used focus groups as their data collection method, an online education curriculum design

was used for May, Brady, van Offelen and Johnson (2014) study that provided guidance and

structure of nutrition education through hands on cooking in Simply Good Cooking. The

curriculum used a hands-on cooking and interactive learning theory to help low-income

individuals and families improve cooking and shopping skills to increase self-efficacy in food

purchasing and meal preparation.

Those who participated in the focus group, for Wiig and Smith (2008) study also took

part in a grocery shopping activity, which was a way for the women to discuss how they

prioritize food purchases given a limited budget. For the activity, they received 177 food items

and their prices and were asked to write down what they would purchase on a budget of $50 US

for a one-week period. Participants said they made adequate food purchases based on a variety of

factors including what the household needed and what items could be obtained through other

food assistance programs. The online Simply Good Cooking curriculum was designed to

introduce a nutrient-rich food and its corresponding food group; they were grouped as grains,

vegetables, fruits, general, perfect poultry and dairy.

Similar results were found from both Mary et al., (2014) and Wiig and Smith (2008)

expressed that nutrition education that teaches food budgeting skills and meal preparation

strategies involving less fatty meat and more fruits and vegetables could be useful to those in

low-income families make the best of their food dollars. Having hands-on activities helped

participants learn how to shop and store the food, observed a cooking skills demonstration,

practiced preparing and cooking food and discussed nutrition related topics. Finally analysis of

pre and post test data from the May et al. (2104) study showed significant changes in self-

efficacy, general food related behaviors, and food-and-health related knowledge.


The review of these studies provided, highlights the important role nutrition education

plays in our society. Refer to Table 1 to see what three topics were covered during the studies

just discussed. Nutrition education has the ability to influence individuals to make better,

healthier choices with the food to improve their lifestyle. The next sections highlighted are food

labeling, food safety and food budgeting. These three topics were chosen to be discussed since

they are topics that are addressed and taught to SNAP-Ed participants during some of the

program participation.


Citation Number of Sessions Topics

Food Safety Food Labeling Budgeting

Wiig and Smith (2008) 1 X X

Dollahite et al, (2014) 6 X X X

Greenwall, Arnold and Sobal (2000)

6 X X X

May, Brady, van Offelen, and Johnson (2014)

6 X X

Table 1 Summary of Specific Topics Covered in SNAP-Ed courses


Food Labeling

The benefit of food labeling education has been assessed among SNAP participants for

its impact on eating behaviors. Bryd-Bredbenner, Alfieri, and Kiefer (2000) developed a study

with 453 women to focus on the importance of increased awareness on how to understand

nutrition facts labels. There were two parts of the study; part one focused on collecting data

about the participants self-rating of her diet quality, health status and the degree she was

informed about nutrition, and frequency of label use. Part two consisted of a three-label-reading

knowledge scale to measure the participant’s ability to use and interpret nutrition labels. Ahmadi,

Torkamani, Sohrabi and Ghahremani (2013) conducted a similar study which, aimed to assess

women’s nutritional knowledge and their food label perception and to identify their correlations

in order to improve their food choices. They conducted a cross-sectional study with 380

participants. They collected data through face-to-face interview with women referring to the

supermarkets for food purchasing. Questions consisted of nutritional knowledge of consumers

about specific food components such as fat, sugar, salt and some food group and knowledge on

labeling.

Results from Bryd-Bredbenner et al. (2000) and Ahmadi et al. (2013) showed that more

than half of the participants reported that they were ‘label readers,’ where only about one-quarter

indicated that they always read nutrition labels. Those who read nutrition labels in the studies

compared to those who did not have an effect on one’s ability to use labels to make dietary

planning decisions. In the Ahmadi et al., (2013) study the average knowledge about fat type and

amount, added sugar, saturated fat, calorie content was near 50% of knowledge. Whereas,

consumer information about food labels was less than 50% in regards to effect of labels on

purchase intention, specificity of labels, and the effect of nutrients on purchasing. The findings


from Bryd-Bredbenner et al., (2000) study indicates that nutrition labels appear to have an

important influence on women’s food purchasing decisions. It was also discovered that the

nutrient-content claims did affect participant’s perceptions of the food and that participants used

the Nutrition Label to discern the truthfulness of the claims. Both study results show that

nutrition labels are an important focus of nutrition education that has the potential to improve

nutrient intake.

Food Safety

Along with food labeling, food safety is an important skill that SNAP-Ed participants can

learn to preserve their food purchases. Trepka et al. looked at individual’s knowledge on food

safety and practices among WIC participants in 2006. Then in 2008 a randomized controlled trial

was conducted to determine if interactive multimedia is a more effective model than pamphlets

for delivering food safety education; with both studies using focus groups as their data collection

method. The Women, Infant and children (WIC) program, provides nutrition education and food

supplementation to women, infants and young children each month. Education within in the WIC

program is mandatory for its participants.

The 2006 focus group study discussed questions about beliefs and attitudes, specifically

those in regards to participants’ perceptions of their susceptibility to and the seriousness of

foodborne illnesses (Trepka et al., 2006). Each participant had to read the Partnership for Food

Safety Education’s Fight BAC pamphlet. After the focus groups, results showed that WIC

participants did not perceive foodborne illnesses as a major concern and were unaware of the

importance of proper food handling. In 2008, the focus groups with WIC clients and interviews

with clinic nutritionists were conducted to identify food-safety education delivery methods and

barriers to safe food handling. To assess baseline knowledge and knowledge gaps, a survey of


WIC clients was conducted. Those participants who were in the pamphlet group served as the

control group. A questionnaire was designed to capture five constructs of food-safety behavior,

including avoiding unsafe foods during pregnancy, and constructs of clean, separate, cook and

chill.

Results showed that lack of knowledge of cleaning, cooking, food handling practices, and

food, were common themes found as general barriers to improving food safety practices, from

the Trepka et al, (2006) study. There was a larger improvement in mean scores among

participants in the interactive multimedia group than among participants in the pamphlet group

(Trepka et al, 2008). Women in both conducted studies reported safer food-handling practices in

the overall scores and for all constructs. Both studies show that there remain several gaps in

knowledge with WIC participants, which stresses the importance of food safety education within

in WIC.

One other study was found that showed the benefits of food safety. Jayaratne, Harrison,

and Bales (2009), wanted to study the relationship between the changes in the knowledge and

behavior of childcare providers participating in a food safety self-study course. The concepts and

behaviors targeted in the study were developed based on current research in safe food practices.

The curriculum of the course consisted of 12 short video segments and the impact of the food

safety study was evaluated using a pre- and post-test design. The design of the study was to test

participant’s behavior change related to 19 food safety-related core practices. Some practices

looked at proper food handling and storage practices. The mean food safety knowledge pre-test

score was 70.5% and the mean post-test score was 88%. After completing the course,

participants’ food safety behavior increased from 67.7% to 93.8%. An increase in childcare

providers’ food safety knowledge is related to positive changes in their safe and proper food


handling practices. By improving participant’s food safety skills, it will help SNAP-Ed

participants keep their food fresher and longer for the month.

Food Budgeting

Cost is a major barrier to healthy eating for low-income individuals who may be trying to

balance a restricted income (Dobson, Beardsworth Keil, & Walker, 1994). A consequence of

low-budget, healthier food items may be overlooked in favor of less healthy, more energy-dense

items (Drewonski & Spector, 2004). Thus, this supports the idea of the importance of food

budgeting to SNAP-Ed participants. Inglis, Ball and Crawford (2009) wanted to conduct a quasi-

experimental design to examine the extent to which modifications (increase or decrease) to food

budgets impact on food purchasing decisions of low- and high-income women. The study

involved 74 women and it required the women to complete and itemized shopping list reflecting

their grocery purchases for their entire household for the week. Each woman was asked what ten

food items they would add if they were given an increase of 25% of their budget, and what ten

items they would take away if they had 25% less of their budget. They were given the chance to

expand on their responses in open-ended questions.

Total expenditure for the women’s original shopping list was conducted and found that

low-income households spent less on their original lists then high-income households. High-

income women chose 60% of their food choices from the healthy foods compared to low-income

women. When given more money to their budget, low-income women added a greater proportion

of healthy foods compared to those of high-income. Low-income women were more used to

budgeting their household food expenditure and were able to articulate the foods they would

remove. Conclusions from this study show that low-income women were more restricted with

their income in terms of their healthy food purchasing choices and strategies.


Each of the topics covered support the hypothesis that providing nutrition education to

SNAP-Ed participants will help improve their knowledge and skills to lead a healthier life.

Research has been highlighted that have shown that there are interventions that work in helping

SNAP-Ed participants change their behavior. The purpose of this policy review was to address

which SNAP-Ed programs are helping participants change and maintain their healthy behavior.

Analysis took place of interventions noting what the programs education aspect offered to those

who participated and how they were helping change their behaviors.


Methods

Research Questions:

The purpose of this study was to identify the benefits the SNAP-Ed program has on fruit

and vegetable consumption, low sugar, low fat intake, and decrease weight with its participants.

Based off of the research noted above, low sugar and low fat is also associated with food

budgeting, food labeling and food safety which are predictors or indicators. Thus the research

questions are:

1. Do existing SNAP-Ed programs address food budgeting, proper food safety skills, and

food labeling?

2. What is the level of effectiveness of existing SNAP-Ed programs related to decreasing

sugar consumption, and increasing the consumption of fruits and vegetables?

3. Does effectiveness of existing SNAP-Ed programs vary based on whether food

budgeting, food safety or food labeling was the focus?

These questions were addressed through a review of existing SNAP-Ed program documents.

Retrieval of Current SNAP-Ed Programs

This study searched the following database: United States Department of Agriculture

(USDA SNAP Connection Access). The SNAP-Ed Strategies & Interventions: An Obesity

Prevention Toolkit for States was used for this policy review. The toolkit is used as data source

to gather information on the names of programs that are being implemented for SNAP-Ed

participants. The SNAP-Ed Strategies & Interventions: An Obesity Prevention Toolkit for States

(USDA SNAP Connection Access) was assessed to see what programs are being offered to

participants to help change their behavior. For example, there may be programs offered that

focus on an individual’s intent to change eating behavior by assessing a person’s knowledge or


understanding pre and post intervention. A total of 10 programs described in the toolkit will be

analyzed for this policy review. These two sources were used to identify relevant programs to

include in the analysis and to locate necessary data for these programs.

The SNAP-Ed toolkit was designed to help State SNAP-Ed administrative and

implementing agencies identify evidence-based obesity prevention policy, systems, and

environmental changes (PSE) strategies and interventions to include in their SNAP-Ed plans to

comply with the SNAP-Ed Guidance requirements. The toolkit identifies evidence-based and

emerging PSE strategies to help reach low-income households that are most impacted by health

disparities. The interventions that have been added to the toolkit have been designated research-

tested, practice-tested, or emerging. PSE strategies intend to supplement individual, group, and

community-based education strategies used by nutrition and physical activity educators in a

multi-component program delivery model. In order to appropriately answer the research

questions related to individual level dietary changes, only programs targeting individual level

change will be included. The toolkit puts forth strategies and interventions along with additional

resources.

States may use the toolkit to identify interventions that will complement the healthy

eating recommendations of the Dietary Guidelines for Americans. To foster collaborative

relationships and to determine which interventions might best fit the needs of the State’s low-

income population; FNS suggests that State SNAP-Ed officials consult with other State nutrition

assistance program officials before choosing interventions to include in their SNAP-Ed plans.

This toolkit is offered as a starting point for ideas that States may use to further their obesity

prevention efforts through SNAP-Ed. This is the best approach for this policy review because it

provides interventions that are currently being used throughout the country that are helping


individuals change their behaviors. It is best to understand what programs are or are not working

with the SNAP-Ed program, to help States in the future.

Data Collection

In order to address the research questions, a total of 10 out of 60 programs from the

toolkit were described and analyzed. The 10 programs provided examples of SNAP-Ed programs

that are offered to its participants, they were assessed and how it is changing participant’s

behavior or how it intends to change participant’s behaviors during the lessons. The programs

selected for review, were balanced in terms of States where program are implemented, the

duration of the program, and what behavior changes are being promoted. Exclusion criteria were

any programs that aim to improve sugar or salt intake for its participants. In the end, a narrative

summary was created for each program and what topics are covered and what activities were

utilized.

A content analysis was performed on documents/websites describing each program,

including the toolkit and State-data. The toolkit that is provided for States to use provides

examples of interventions that are currently implemented or being research-tested. The programs

were reviewed based off of their website that is provided in the toolkit. The website was assessed

on what additional educational information and materials are provided to the participants. Such

as printable recipes, tips on buying healthy foods and proper portion sizes. The summary

documents and program materials provide a thorough overview of the program’s topics and their

effectiveness on the outcomes of sugar and fat intake. Thus a systematic assessment of the

content allows for an objective assessment of the frequency of the targeted three main topics and

of the effectiveness of the program.


Each program that is provided as an example, gives a brief description of the program

and a link to its website. The websites were used as reference points to look over the lesson that

is provided to the participants. It will be addressed to see if the programs cover the three main

topics that are taught through SNAP-Ed which are food labeling, food safety and food are

budgeting. The programs were looked at closely and the topics covered were described in a table

that will be created. An extraction survey was developed and was used to systematically assess

relevant characteristics of the program, Appendix. The survey allowed for the objective retrieval

of data needed for analysis.

Food budgeting was noted as a topic if the following words were described as a core

element and/or observed as a component in participant materials: “food budgeting,” “food cost,”

“cost of food,” “unit pricing,” “eats for less.” Food safety was noted as a topic if the following

words were described as a core element and/or observed as a component in participant materials:

“food safety,” “wash food,” “wash dishes,” “wash utensils,” “sanitize kitchen surfaces,”

“refrigerate food after cooked,” “do not leave food sitting out,” “cook foods thoroughly.” Finally

food labeling was noted as a topic if the following words were described as a core element

and/or observed as a component in participant materials: “food labeling,” “check calories,”

“check serving size,” “check the percent daily value,” “limit foods that are high gram content,”

“calorie recommendation.”

Analysis

The analysis first provided a narrative summary of each program’s origin, details on the

topics covered and resources provided. A brief description of information on the States that are

being represented was provided as an overview of their biggest health issues. Along with looking

at the topics covered, it was also discussed how the program came to be created and why it was


thought that the program will be beneficial to its community. This was a way to see what

programs were working in states, and if they were, how can they be duplicated to another state to

help its members. Each program was addressed on what level they intend to change individual’s

behavior and/or are there stages of change throughout the program.

A quantitative approach was used to answer the primary research questions on the three

main topics, food budgeting, food labeling and food safety were addressed. There were certain

questions that were used when analyzing each intervention. Once those questions were

addressed, it was important to discuss what changes should be made to the interventions to help

improve them for its participants. If the websites offer participants review of the program, it will

help this research understand how those who participated in the program, felt once they

completed the lessons.

The level of effectiveness was measured based on any changes in decrease in sugar, low

fat intake, and decrease in weight with participants made once they completed the program. For

the three main topics, it was assessed whether they were taught and/or mentioned in the program.

Based off of the description of the program and the information provided, it was determined if

any of the topics were relevant in the program. Tables were presented to illustrate the impact and

effectiveness of the programs specific to consumption of fruits and vegetables, and the frequency

of offering the three main topics. Finally a table was created to illustrate the relationship between

the effectiveness of the program and the three main topics.


Results

The interventions that were addressed in this policy review, aim to educate participants in

the SNAP-Ed program. Each program’s website was used as a resource to gather information

along with the Center for Training and Research Translation (Center TRT), at www.centertrt.org.

The Center TRT provides descriptive information on the intervention, providing similar

information for each intervention reviewed and offered links to the program sites where

information was extracted. A total of 10 out of 60 programs were selected to be analyzed, with

the shortest program being 12 weeks and the longest being a continuous program. North

Carolina, Texas, California, Alabama, Massachusetts, Pennsylvania and Maryland were States

where chosen programs are being implemented (see Table 2).

Color Me Healthy

North Carolina has the 14th highest adult obesity rate in the nation, where two-thirds of

adults are overweight or obese (Trust for America’s Health, 2011; Behavioral Risk Factor

Surveillance System, 2011). In comparison, nearly one out of three children ages 10-17 are

overweight or obese (North Carolina Child Health Assessment and Monitoring Program, 2011).

Color Me Healthy (CMH) is a developmentally appropriate curriculum, for children aged 4-5 in

child care or preschool, which is highly visual and interactive. CMH primarily addressed

individual and interpersonal behavior. It used color, music, dance and imaginary play to provide

opportunities for physical activity and to teach children about fruits and vegetables. CMH

provided a toolkit that contains 12 lesson plans for teachers, who were trained prior to

implementation. It also includes supporting instructional materials needed to implement the

curriculum: four sets of picture cards, three color classroom posters, a CD with seven original

songs, 14 parent newsletters and two color posters for parents. With its educational strategies and

materials that were incorporated into the curriculum, it is ideal for SNAP audiences.

http://www.centertrt.org/


Through social support of teachers and parents modeling healthy eating and physical

activity, it helped create a supportive environment for healthy choices. With the implementation

of CMH there were some barriers that they faced such as: lack of parent awareness, active

participation and support is necessary in order to impact children’s increase consumption of

fruits and vegetables, lack of administrator support and high staff turnover during training. Once

the program was completed an eight week follow-up survey was completed by the child care

providers on perceived impact. The effectiveness of Color Me Healthy showed that the

intervention group, compared to a control group, was more likely to increase consumption of

fruits and vegetables snacks when presented at 1 week and 3 months after the program was

completed.

When presented with a fruit or vegetable snack, children who participated in the CMH

program significantly increase fruit snack consumption by approximately 21% and vegetable

consumption by 33%, from baseline to 3-months after completion of the program. During the

teacher surveys, 90% thought the children were more willing to try new foods and were

consuming more fruits and vegetables, while all the teachers reported improved fruit and

vegetable recognition, since program initiation. In the childcare setting, the 93% of care givers

perceived that using the CMH program increased the children’s knowledge about healthy eating,

while 79% indicate that the children were more willing to try new foods and finally 82%

reported that the curriculum had improved fruit and vegetable recognition.

On the CMH website it provides additional information for parents to explore, including

newsletters, and information for families on healthy eating and physical activity. During the

intervention food budgeting, food labeling and food safety skills were not specifically addressed

but on the CMH website they provide additional information on the topics for parent access.


There are sections on fitness, recipes and newsletters, which allows the parents to seek more

information for their families. The Eat Smart section provides ways for families to prepare meals

at home with tips on food safety, how to read food labels, and buying healthy foods on a budget.

With additional information available, parents are able to print out educational information as a

reference.

Nutrition and Physical Activity Self-Assessment for Child-Care

The high rates of obesity on the State of North Carolina were mentioned previously. The

Nutrition and Physical Activity Self-Assessment for Child-Care (NAP SACC) was a 6 month

intervention, designed to enhance nutrition and physical activity practices for young children

aged 2-5 years old, by improving nutritional quality, amount and quality of physical activity, and

educational opportunities for children, parents and providers. NAP SACC targets early care and

education program practices and policy that can help set children on a lifelong path to healthy

eating and activity by focusing on inter-personal and organizational behavior. NAP SACC was

tested in childcare centers located in both rural and urban parts of North Carolina.

Five ready to use workshops on childhood obesity, nutrition for young children, physical

activity for young children, personal health and wellness for staff and working with families,

who were not all SNAP participates, to promote healthy weight behaviors, are delivered to the

childcare facility staff. NAP SACC relies on trained consultants, familiar with child care

facilities to implement the intervention. The NAP SACC intervention also used strategies for

both healthy eating and physical activity that include: social support for healthy eating and

physical activity, changing access and availability to favor healthy foods and beverages through

menu changes, school-based physical activity and physical education and increasing access to

and number of place for physical activity. The intervention imbedded skill-building activities in


each workshop to allow staff to increase their self-efficacy. Before the intervention occurred the

program overcame some barriers to implementation, which are scheduling, staff turnover, control

over food selection, and addressing physical activity areas.

The intervention served as a randomized control and collected data based on whether

centers were received the intervention or served as the control NAP SACC data showed that

compared to a control group, intervention centers are more likely to make significant changes in

nutrition policies, environments, and practices and finally some positive changes in physical

activity polices and environments. Child care centers completing most or all of the intervention

components improved their nutrition and physical activity policies and practices more than

control facilities. There was a 16% increase in changes in the total child care nutrition

environment scores. Nutrition effects were assessed with 51 items and physical activity with 24

items. The mean change in nutrition scores was 4.3 point improvement in the intervention

centers compared to -0.5 change in the controls. Physical activity scores increased by 3.6 in the

intervention centers compared to a -0.2 change in the controls. During the evaluation process,

they did not evaluate individual consumption changes. The NAP SACC website provides both

parents and childcare staff with information on nutrition and physical activity. It does not address

food budgeting, food labeling, and food safety specifically but does provide helpful tips on

portion sizes and ways to improve family eating time.

Healthy Food Environments Pricing Incentives

Healthy Food Environments Pricing Incentives is developed by the North Carolina

Prevention Partners to increase availability, visibility, and affordability of healthy foods and

beverages for employees, visitors, and volunteers on hospital campuses. This a grant funded

intervention for three years, with the goal of transforming hospitals, vending machines and food


offerings at all hospital related events such as providing access to healthy foods. The intended

population of the study was employees, visitors and volunteers at hospitals. The intervention

includes a pricing policy incentive to encourage purchase of healthier items (which is through a

price decrease) and discourage purchase of less healthier items (price increase). The five main

principles in the overall Healthy Food Environment initiative was: provide access to healthy

foods, use pricing to promote healthy foods, use marketing techniques to promote healthy foods,

use benefit design and incentives to encourage behavior change, and educate staff and visitors

about healthy foods.

Prior to implementation of the program, training was provided for food service personnel

on nutrition criteria, including food preparation methods and portion sizes. To improve keys to

success look to school wellness and vending initiatives as a model for change. Also with point of

purchase and point of decision labeling to favor foods and beverages by displaying nutrition

information will help increase participation. However lack of executive level support and

concerns about the financial impact may make it difficult to implement comprehensive policy

changes.

Sales data that was provided for the Healthy Food Environment indicated that the policy,

along with the supporting principles had been effective at increasing the sales of healthier foods

like fresh fruits and decreasing the sales of unhealthy items such as a fried chicken sandwich.

The website that was given was not a useful resource. Overall sales increased after nine months

of implementation of the pricing incentive. Based off a sales data excerpt there was a 698%

difference in the purchase of turkey burgers between the years 2006-2008, where the hamburger

had a -45% difference in purchase. These results highlight the significant importance of the

intervention.


There was no mention of Healthy Food Environments on the NC Prevention Partners

website and was difficult to navigate. By not having a website, it lacked support for individuals.

During the duration of the intervention, food budgeting was addressed, but not food labeling or

food safety. Finally, on the Center TRT website, they do provide information on nutrition criteria

which includes food item categories, and nutrition criteria in terms of calories, total fat, saturated

fat, trans fat, sodium etc.

Faithful Families Eating Smart and Moving More

Faithful Families Eating Smart and Moving More (FFESMM) was a yearlong program

that focuses on healthy environmental and policy changes within faith communities in North

Carolina. It also promoted healthy eating habits and increased physical activity through a series

of group nutrition/physical activity education sessions. Combining best practices that targets

individual behavior with environmental and policy changes, FFESMM was able to link

economically disadvantaged community members to education and resources, empowering them

to eat healthier, increase physical activity and become advocates for positive policy and

environmental changes within their communities. Nutrition/physical activity educators, co-

deliver with faith community lay leaders the series of nine nutrition, food safety, and food

resource management lessons. Through dialogue and goal setting, individuals and families were

encouraged to change their risk behaviors and set goals for healthy eating and daily physical

activity.

Faith communities were recruited and given preference if the majority of members were

eligible for Medicaid, eligible for free or reduced school lunches and/or at 200% of the federal

poverty level. The faith community lay leader were essential to connecting with program

participants. They use scriptures, reading and faith-based practices to connect health information


for their community. Recruiting faith communities is time consuming and relies on building local

relationships, which may be a barrier to overcome. Two surveys were administered at the

beginning and end of each program year to assess intervention effects on individuals,

environments and policies.

Findings suggest that the FFESMM nutrition classes may have an effect on individual

behavior change. The most involved faith communities made multiple positive changes to their

food and physical activity polices and environments. A pre- and post- intervention survey of

those who attended group sessions found improvements in dietary intake, dietary behaviors and

physical activity. Those 59 graduates from FFESMM, increased fruit consumption by 43%, and

increased vegetable consumption by 47% and 35% increased the amount of the physical activity.

FFESMM’s website was easily accessible. It provides many program’s and tools for easy access.

Individuals are able to choose the setting of their choice, and then receive information on healthy

eating and physical activity. It offers meal planning and activity logs, snack and drink guide,

eating smart and moving, and a guide to create outdoor activities. During the intervention and

using the curriculum, the nutrition/physical activity educators and lay leaders taught nine lessons

on nutrition, food safety, food budgeting and food resource management.

Baltimore Healthy Stores

According to data from the U.S. CDC in 2011, 28.3 percent of adults in Maryland were

obese and is the 26th most obese State. If this trend continues, by 2030, the obesity rate could

reach 58.8 percent (Trust in America’s Health, 2011). In Baltimore, 15.6 percent or adolescents

are overweight and 12.2 percent are obese (CDC, 2012). Baltimore Healthy Stores (BHS) was a

10 month program that focused on changing the local food environment by directly influencing

the availability of healthier food options in stores and increasing awareness and skills of patrons


to select and prepare healthier foods through point-of-purchase promotions. The intended

populations were residents and store owners in undeserved, low-income communities where

prepared food venues and corner stores are the primary food sources. BHS targeted individual

behavior by seeking to change consumer behaviors and organization behavior by seeking to

change corner store practices. With exposure to this type of intervention, it had the potential to

increase patrons’ knowledge and self-efficacy and improve behavioral intentions.

The majority of small store owners taking part of BHS were Korean Americans. Once

stores were selected for participation, they were provided nutrition education, and specific

guidelines for stocking and preparing healthier options. BHS had five phases, healthy breakfast,

cooking at home, healthy snacks, carry-out foods and healthy beverages, with each phase lasting

about two months. Each phase included theme-specific behavioral and environmental objectives,

promoted foods, and health communication strategies. During each phase certain foods were

promoted and minimum standards set for food and beverage stocking and for marketing

materials within stores. Store owners were requested to stock minimum quantities of healthy

food options, specific to each phase. Consumers were provided with informational posters, fliers,

nutrition education sessions, and cooking demonstrations. Corner store interventions can be labor

intensive, obtaining store owner support can be difficult and small store owners can be hesitant

to risk any decrease in sales are all barriers to implementation that were addressed.

The BHS intervention collected data on multiple levels: at the store level related to

environmental and practice changes (food stocking, placement), at the store owner level related

to psycho-social impact of the intervention (self-efficacy to change stocking and preparing food)

and at the consumer level related to behavior change (increased purchasing and consumption of

healthier foods) and psycho-social impact (knowledge of nutrition, self-efficacy to change diet).


For BHS there is evidence for small environmental and behavioral changes resulting from the

intervention. Overall there were no significant changes in overall outcome expectations self-

efficacy and knowledge scores were observed comparing the intervention and comparison, at the

store-owner level. Healthy food preparation behavior, measured by pre-and post-intervention

questionnaires, significantly improved in the intervention consumers as compared to comparison

group. While overall food purchasing behavior did not significantly change, an association

between exposure to shelf labels and increases in healthy food purchasing was found among

consumers in the intervention group. Finally positive changes were observed in most of the food

related psychosocial factors (knowledge, self-efficacy) from baseline to post intervention.

Data available at the time of review suggest that, compared to the comparison stores, the

intervention stores were more likely to stock healthier foods (low-sugar cereals, and low-salt

crackers) from baseline to immediately post intervention. Six months post intervention, the

stocking of baked/low-fat chips, was sustained in the intervention group. Participants based in

the intervention area of Baltimore also reported improved healthy food preparation such as

washing utensils and counters prior to cooking. Also there was an association found between

exposure to shelf labels and increase in healthy food purchases in the intervention group.

Through its intentions to increase patron knowledge and self-efficacy, it benefits those

individuals that participate. Based off of the program review, food budgeting, food labeling and

food safety were not addressed in their program.

We Can! Ways to Enhance Children Activities and Nutrition

Alabama now has the eight highest adult obesity rate in the nation at 32.4 percent (The

State of Obesity, 2014). The Alabama Department of Public Health’s Worksite Wellness

Division and the Nutrition and Physical Activity Division worked collaboratively on the We Can


project. We Can was a turn-key, science-based national education program developed by the

National Institutes of Health (NIH) to help organizations address the important issue of

childhood obesity. We Can focused on three important behaviors to help children aged 8-13

maintain a healthy weight: improved food choices, increased physical activity and reduced

screen time by providing parents and caregivers with tools, and fun activities. We Can also

offered organizations, community groups, and healthy professional a centralized resource to

promote a healthy weight in youth through community outreach, partnership development, and

media activities that can be adapted to meet the needs of diverse populations.

The Alabama Department of Public Health worked hard to disseminate We Can statewide

and participated in three community events that attracted over 700 community members. The

events provided materials on health and wellness, physical activity games to participate in, health

screenings and healthy food to munch on. A non-profit organization, Success by 6, provided staff

support, facilities and partnership for community events and programming. The Obesity Task

Force provided communication support by acting as liaison to various state and local agencies as

well as industry and non-profit organizations with interests in lowering obesity rates.

The parent six-lesson curriculum was developed specifically for parents and caregivers.

In a fun hands-on way, it teaches participants essential skills that help families make healthful

food choices and become more physically active. The parent curriculum was implemented to a

group of adults that met once a week. By offering the program in three sessions, meeting once

per week for three weeks, they were able to accommodate the parents’ schedules. The

participants especially loved the “portion-distortion” lesson and asked lots of questions about

their children’s nutrition habits.


By the end of the parent curriculum, parents reported more often reading nutrition fact

labels and ensuring that foods high in fat and sugar are not easily available at home. An analysis

of eight respondent surveys found significant increases in healthy food behaviors. The analysis

also suggested positive movement on nine measures (energy balance knowledge and attitudes,

healthy eating attitudes, portion size attitudes and behaviors, physical activity knowledge and

behaviors and screen time attitudes and behaviors) related to We Can objectives. The findings

were not significant.

The Alabama Department of Health worked with an elementary school to offer children

the CATCH Kids Club program during afterschool and summer sessions. CATCH is designed to

help children adopt healthier dietary and physical activity behaviors by positively influencing the

healthy environments of recreation programs. An analysis of 34 respondent surveys found

statistically significant increases in food attitudes: intentions to reduce fat and decreases in

screen time behaviors. At the completion of the CATCH curriculum, youths reported increased

intentions to reduce intake of higher-fat foods and reduced video game playing and Internet

surfing. The analysis also suggested positive movement toward We Can objectives related to

physical activity attitudes, screen time behaviors, food knowledge, food attitudes: self-efficacy

and intentions to drink skim milk, and healthy eating behaviors: eating fiber, and eating fruits

and vegetables.

We Can offered an interactive website for parents, caregivers and health professionals.

Under the tools and resources tab there are parent tips and handbooks on calories needed each

day, energy balance, eating healthy and moving more, healthy back to school habits and many

more. There are also subsections on weight management, nutrition, physical activity, reduced

screen time, curricula and toolkits, and parent tip sheets. The nutrition subsection provides tips


on healthy cooking and meal planning, which has weekly meal planner tool to help parents plan

healthier meals for their families and provides ideas and recipes for healthier breakfasts, lunches

and dinners. Finally there is a specific section for materials to share with teens and children. This

section has kid friendly charts/booklets for children to understand what foods are nutritious and

the importance of physical activity. A booklet for teens detailed information to help teens take

charge of their health to make simple steps to maintain a healthy weight. During the program or

in the additional materials food labeling and food budgeting were addressed in one way.

Out of School Nutrition and Physical Activity

Obesity in Massachusetts is a concern, with the overall adult obesity rate in the Boston

are at 22 percent. Among high school students, the obesity rate is 15 percent, which is

comparable to the national rate (Community Profile: Boston, Massachusetts, 2013). The Out of

School Nutrition and Physical Activity (OSNAP) Initiative was designed to increase healthy

nutrition for children, including frequency with which water is served during snack at afterschool

programs for elementary school children. By promoting water the OSNAP Initiative decreased

the caloric impact of beverages served in afterschool programs. Providing access to drinking

water is both a low-cost and relatively easy target for making healthy changes.

OSNAP strategies to increase drinking water access consisted of engaging stakeholders,

facilitating learning communities to change policies and practices, reviewing and changing snack

menus and serving water to children every day in after school programs. Learning communities

included training of after school program coordinators and writing afterschool policies, was a

core element of OSNAP. One component of the OSNAP initiative focused on providing access

to free drinking water at snack time. With the recent local and national policy requiring greater


access to water for school children, this intervention could be readily scaled up to meet the need

of potable drinking water in schools.

Strategies to increase drinking water targeted changing access and availability to favor

healthy foods and beverages, food and beverage marketing to favor healthy foods and beverages

and social support for healthy eating. During implementation there are some barriers to

overcome; identifying funds to support initial cost of staff time and compensation for afterschool

staff, and lack of buy-in from school administrators, afterschool program staff and food service

staff. On the OSNAP interactive website, they offered parents and guardians helpful tips on

cooking, how to increase physical activity, promote fruits and vegetables, sample snack items

and water. The website was effective for the afterschool program staff and organizational leaders

with resources to improve their program practices and polices related to healthy foods, drinks

and physical activity. The website discussed food budgeting and food safety for individuals.

The OSNAP initiative has the potential to reach a large number of children with one of

the key evidence-based interventions for obesity prevention, by replacing the consumption of

sugar sweetened beverages with water. Water provides a healthy, low-cost, zero-calorie beverage

option, and water consumption is associated with a number of health benefits including

preventing obesity, proper hydration and improving cognitive functions. OSNAP was able to

increase access fresh potable water and decreases access to sugar sweetened beverages. This is a

necessary first step in implementing recent new policies regarding beverages served in schools.

Primary and secondary outcomes related to drinking water access included average

changes in 1) ounces of water served during snack; 2) beverage calories served at snack 3)

ounces of juice and milk served and 4) number of times each beverage was served at snack. The

intervention level of effectiveness, resulted in an increase of 3.6 ounces of water served per day


and a decreased in beverage calories served by 60.9 kcals. Finally the frequency, in which water

was served, increased significantly by an additional 0.6 times per day, which is equivalent to

having served water 3 additional times over a 5-day school week. With these results found, it is

surprising to find that they did not evaluate intake of water of participants.

Overall the OSNAP is an obesity prevention intervention that replaces the consumption

of sugar sweetened beverages with water. With these findings it supports that consuming water is

associated with a number of health benefits including preventing obesity, reducing dental caries

and supporting proper hydration. Continuous implementation of the OSNAP program will help

communities provide their children with fresh drinking water, thereby improving their overall

health. Food budgeting and food safety were both addressed during various points of the

intervention.

The Kindergarten Initiative

Pennsylvania’s adult obesity rate is 29.1%, ranking 20th among all states in obesity

prevalence (Trust for America’s Health, 2011). Children have just as high of a percentage of

obesity with 29.7% being considered overweight or obese (NICH, 2007). Pennsylvania ranks

first in overweight/obese among children in poor families with a rate of 26.7% (NICH, 2007)

which is why The Kindergarten Initiative (KI) was created. The KI was created by The Food

Trust and was designed to help children make healthy food choices and helping to ensure that

their minds and bodies grow healthy and strong. The KI was a yearlong school-based program

that focused on the individual/interpersonal behavior change. This well evaluated program

brought the best practices and research in public health and nutrition education together to create

a program that children, teachers and parents can enjoy.


The KI was designed to promote healthy eating habits in kindergarten students and their

parents, through nutrition and agriculture education, school snacks from local farms, and parent

engagement activities. It was created with the goal of increasing consumption of fruits and

vegetables and providing a new market for farmers. KI takes a holistic approach to educating

children about food and how it grows. Learning how food grows and who grows it, combined

with frequent food tasting, may help increase fruit and vegetable consumption among young

children. To address these approaches children were taught nutritional and local farming

concepts in the classroom, and hosts farm field trips to connect children to growing and promotes

taste-testing of new fruits and vegetables. The KI had three components: serving locally grown,

healthy snacks to kindergarten students three times a week; integrating nutrition and local

food/agriculture education into the standard core curriculum, which includes identification of

fruits and vegetables; finally partnering with parents and caregivers by providing cooking

demonstrations, newsletters, supermarket tours and mini-farm stores. With these components

come barriers to success; attitudes and perceptions in the school community, parents not having

access to local healthy foods, and depending on existing local food infrastructure.

In selecting schools to participate, preference was given to schools located in areas where

a high percentage of children are eligible for free and reduced-price school meals. Farmers

markets were recruited if they were able to supply and deliver products to school, host field trips

and supply fruits and vegetables for the kindergarten farm store. Teachers were trained at pre-

program in-service, interactive trainings to generate excitement, explain the program and help

teachers integrate nutrition, agriculture and physical activity into curricula.

The 2005-2006 data showed improvement in a) children’s knowledge of a healthy diet

(recommended number of daily servings of fruits and vegetables, portion sizes of foods) b)


children’s awareness of where food is grown and c) the number of fruits consumed by children

per day. Children in both intervention and control schools also increased their ability to read food

labels. Data on the number of healthy snacks served per week also suggested that the

intervention had a positive impact on students’ access to healthy foods. KI had its own toolkit

that parents and guardians can access voluntarily on their website. The KI toolkit addressed

connecting children to growing, partnering with families to create changes and bringing the

community on board. During the intervention, only food labeling was addressed to its

participants.

Riverside Unified School District Farmers’ Markets Salad Bar Program

California falls between two states with 23.8% of adults being overweight or obese in

2011 (Trust for America’s Health, 2011). Based in California, Riverside United School District

(RUSD) Farmers’ Markets Salad Bar Program was intended for primary school children to

promote healthy eating by increasing the availability of fruits and vegetables in school lunches

and providing nutrition education to increase knowledge of and improve attitudes toward eating

a variety of locally grown produce. The primary component of RUSD Farm to School Program

was the Farmers’ Market Salad Bar, with a daily salad bar stocked with locally grown produce

and a secondary focus on individual behavior change. The salad bar program was offered year

round as an alternative to the hot lunches served.

Intended for primary school children, RUSD changed school food environment and

supported healthy eating with multiple hands-on educational opportunities. The program offered

cooking cards, chef and farm visits to the classroom, school gardens, and field trips to farms and

farmers markets. This program provided a unique opportunity to forge a partnership among the

school, the community and the farmers. Common barriers faced/reported included: some schools


may have trouble finding local farmers who are interested in selling to school, planning for the

delivery of produce to and acquiring start-up funds to purchase the salad bar equipment.

RUSD Farmers’ Market Program was effective at changing the food environment by

providing greater access to fresh fruits and vegetables. The Center for Food and Justice, in

collaboration with RUSD’s Nutrition Services, conducted an evaluation in 2005. During this

evaluation it was found that students eating at the salad bar ate an average of 2.36 servings of

fruits and vegetables for lunch compared to 1.49 servings from those students who ate from the

hot bar. They also found modest increases in student’s knowledge, awareness and preferences for

a variety of locally grown fruits and vegetables. By offering a salad bar at school as an

alternative or addition to school lunches, increased the access and availability to fresh fruits and

vegetables for everyone in the school, not just the students.

The RUSD website provided additional important information for parents on nutrition,

physical activity and education. This website was easily accessible and easy to navigate to gather

the necessary information. The website also had healthy recipes that parents can print out, a

video on understanding how to read food labels, smart shopping on a budget, a video library on

nutrition services and interactive games for children to play and how to cut and store food

properly. Based off information provided, on the website, food labeling, food safety and food

budgeting were mentioned during this intervention.

Farm to Work

An emerging program, Farm to Work, is an intervention based on its use of evidence-

based strategies. Texas ranks the 19th most obese among all states in 2011 in obesity prevalence,

with 29.2% of adults being obese or overweight (Trust for America’s Health, 2011), Farm to

Work was implemented to increase access to fresh fruits and vegetables in the work environment


by providing a weekly opportunity for purchase and delivery of fresh produce from local

farmers. The primary focus was to promote individual and group behavior change by modifying

the work environment to increase access, availability, purchases, and use of healthy fruits and

vegetables from local farms. Utilizing an online ordering system and delivering baskets of

produce on a regular basis, Farm to Work made it easier for employees to get a variety and

amount of produce that they might not otherwise have in their neighborhoods. From a larger

perspective, knowing that the produce was grown by local farmers and learning more about

individual farmers, creates larger community social support for healthy eating.

Identifying a staff member who has the time to be the internal coordinator can be a

challenge, because they must coordinate the start-up of the program, and depending on the size

of the worksite and demand for local produce are barriers that must be overcome for

achievement. At this time, there is not enough evidence to conclude that Farm to Work

succeeded in improving access to fresh produce. Farm to Work does provide a toolkit to

worksites that choose participate. The toolkit provides suggestions for posters, bags, T-shirts and

PowerPoint presentations to promote the program. Exposure to the images and messages from

the toolkit is likely to increase positive attitudes towards these products. Finally, including ways

to learn more about the farmers and learning recipes to use with the produce will serve as

positive marketing for fresh produce.

The Farm to Work program is able to provide social support for healthy eating. First, the

workplace is supporting healthy eating by offering the program. Second, when multiple people

from the same worksite purchase the baskets, they will see each other at pick up and be able to

discuss what they are getting and what they plan to do with it. Farm to Work does not discuss

food budgeting or food labeling with food safety being the only topic addressed during this


intervention. The website provides individuals with additional outside resources such as public

cooking classes and recipes on how to use your produce. There also is a link to the Food and

Drug Administration website for proper food handling. However, through several attempts the

toolkit could not be located. Reviews of the program show that with continued implementation, it

may have a high success rate with the participants.

The 10 SNAP-Ed programs that have been highlighted show how they are increasing

participant’s knowledge on fruit and vegetable consumption, consuming low sugar and fat and

decreasing their weight. These eating habits have a high rate of effectiveness on the participants

by helping improve their skills specifically with food budgeting, food labeling and food safety.

With continuous implementation of these programs, individuals will continue to adopt healthy

eating habits into their everyday lives.


Table 2 Methodology of SNAP-Ed Interventions on Effectiveness

Name of Intervention

Description of Intervention

InterventionDesign

LOS Intended Population Durationof Study

Activities Offered Topics Addressed

Level of Effectiveness

Color Me Healthy

Designed to improved f & v intake and increase physical activity

Randomized controlled trial, with random assignment

NC Children ages 4-5 12 weeks 7 songs, 6 imaginary trips, 4 sets of picture cards, 3 posters

Healthy eating and being active

Children in program more likely to increase consumption of f & v snacks

NAP SACC Enhance nutrition and physical activity practices

Randomized Control trial

NC Children aged 2-5 6 months Nutrition education and physical activity

Improve nutrition & physical activity

Changes in nutrition & physical activity policies


Increase availability, visibility, affordability of healthy foods & beverages

Organizational policy, environmental change

NC Employees, visitors of hospitals

6 months Menu redesign, marketing, develop action plan, determine pricing

Healthy foods

Increase sales of healthier items

FFESMM Healthy environ. and policy changes in faith comm. healthy eating, physical activity

Pre/post survey NC Faith comm. w/limited resources

1 year Safe food handling, shop for less, moving more, eat at home, plan what’s for dinner, shop for value

F & v, physical activity

Positive changes to f & v, physical activity

Baltimore Healthy Stores

Designed to increase the supply of healthy foods and promotion of their purchase

Quasi-experimental with a comparison group

MD Residents and store owners in low-income comm.

10 months Nutrition education, incentives, guidelines

Healthy breakfast, cooking at home, snacks, carry-out beverages

Small environment and behavioral changes. Stores were more likely to stock healthier food

Abbreviations: F & V = Fruit and Vegetables, N/A = not available, LOS= Location of Study


Table 2 (cont.) Methodology of SNAP-Ed Interventions on Effectiveness

Name of Intervention

Description of Intervention

Intervention Design

LOS Intended Population

Duration of Study

Activities Offered Topics Addressed

Level of Effectiveness

We Can! Ways to Enhance Children's Activity and Nutrition

Helping youth maintain a healthy weight

n/a AL Children 8-13 Continuous Nutrition education, keep track of daily physical activities, plan meals and activities ahead, take class to develop new skills, review dietary guidelines

Improved food choices, increased physical activity, reduced screen time

Children have increased intentions to reduce intake of higher-fat foods, parents increase reading food labels

OSNAP Increase consumption of drinking water

Randomized control

MA Children aged 6-11 9 months Review snack menus, provide 5 gallon water cooler

Physical activity, water consumption, f & v intake

Increase access to potable water, decrease access to sugary beverages

The Kindergarten Initiative

Designed to promote healthy eating habits

Randomized control

PA Kindergarten children

9 months Taste testing, cooking in the classroom, farm trips

Where food is grown, & farmers’ markets

Increase knowledge of healthy diet & where food is grown

RUSD Farmers’ Market Salad Bar Program

Promote healthy eating by increasing education & availability of healthy foods

Pre/post intervention

CA Kids grade K-6 9 months Taste testing, farm visits, food safety, school gardens, farm field trips, chef visit, planting lessons

Eating more f & v

Increase access to f & v knowledge

Farm to Work Increase access to f & v in the work environment

Experimental TX Employees of worksites

Continuous Online ordering system, market local produce, support local farms

Increase use of f & v from local farms

n/a

Abbreviations: F & V= fruit and vegetables, N/A= not available, LOS= Location of Study


Table 3 Food budgeting, food labeling and food safety addressed in programs

Program Was food labeling a noted topic in the program?

Was food budgeting a noted topic in the program?

Was food safety a noted topic in the program?

Color Me Healthy Yes Yes Yes

Nutrition and Physical Activity Self-Assessment for Child-Care

No No No


No Yes No

Faithful Families Eating Smart and Moving More

No Yes Yes

Baltimore Healthy Stores Yes No Yes

We Can! Ways to Enhance Children’s Activity and Nutrition

Yes Yes No

OSNAP No Yes Yes

The Kindergarten Initiative Yes No No

RUSD Farmers’ Market Salad Bar Program

Yes Yes Yes

Farm to Work No No Yes


Table 4 Effectiveness of ProgramsProgram Fruit and Vegetable

ConsumptionLow-Sugar Decrease Weight

Color Me Healthy Yes No YesNAP SACC Yes Yes NoHealthy Food Environments Yes No YesFFESMM Yes Yes NoBaltimore Healthy Stores Yes No YesWe Can! Ways to Enhance Children’s Activity & Nutrition

Yes Yes Yes

OSNAP No Yes YesKindergarten Initiative Yes No NoRUSD Farmer’s Market Salad Bar Yes Yes NoFarm to Work Yes No No


Figure 2

Figure 3

All topics addressed

20%

None of the topics addressed

10%

One topic addressed

30%

Two topics addressed

40%

Frequency of food budgeting, food labeling, and food safety addressed during SNAP-Ed programs.

Summary of the percentage of food budgeting, food labeling and food safety topics addressed during SNAP-Ed programs.


Discussion

This study aimed to assess the benefits the SNAP-Ed program has on low sugar,

consumption of fruits and vegetables, and decrease in weight for its participants. This assessment

reviewed current SNAP-Ed programs that are being implemented across the country. The intent

of each program was unique and some aimed to: increase fruit and vegetable consumption, lower

intake of sugar and fat, and increase access to healthy foods, which were specific outcomes.

Food budgeting, food labeling and food safety were key topics that were addressed in many

SNAP-Ed programs.

Changes in Dietary Behaviors

All SNAP-Ed programs reviewed aimed to increase either, participant’s fruit and

vegetable consumption, lower sugar or low fat intake and decrease weight. CMH, Healthy Food

Environments Pricing Incentive, FFESMM, KI, RUSD Farmer’s Market Salad Bar Program and

Farm to Work were programs that specifically targeted fruit and vegetable consumption. The

programs just listed were able to help participants increase their consumption of fruits and

vegetables during the program and once the program was completed. With this focus it is

beneficial to participants because, fruits and vegetables are generally low in energy density and

often good sources of fiber and potassium (Hornick & Weiss, 2011). Also, convincing evidence

suggests that consumption of fruits and vegetables is a useful strategy for significantly reducing

the incidence of chronic diseases (Liu, 2003).

The effectiveness of programs reviewed is linked to the topics that were addressed during

the program. Those programs, who discussed fruit and vegetable consumption, resulted in

participants having an increase in their consumption once they completed the program. Similarly

KI and RUSD Farmer’s Market Salad Bar Program addressed where fruit and vegetables are


grown, farms and knowledge on the importance of consuming these foods by having interactive

activities such as visiting farms and picking fruits and vegetables.

NAP SACC, FFESMM, We Can! Ways to Enhance Children’s Activity and Nutrition,

OSNAP and RUSD Farmer’s Market Salad Bar Program each had goal intentions specific to

lowering sugar intake with their participants. The Dietary Guidelines Advisory Committee, in

2000, recommended that people should ‘choose beverages and foods that moderate your intake

of sugars’ (US Department of Agriculture, 2000). These programs increased participant’s

knowledge on the benefits of decreasing sugar intake therefore, making improvements to the

amount of sugared beverages and foods they consume. These strategies resulted in a high

effectiveness rate with its participants.

Children and adolescents in the United States consume diets that are substantially higher

in dietary fat than the recommendation of <30% of energy from fat, with current estimates

ranging from 34% to 36% of energy from fat (US Department of Agriculture 1998). This was

taken into consideration for CMH, Healthy Food Environments Pricing Incentive, BHS, We

Can! Ways to Enhance Children’s Activity and Nutrition and OSNAP programs which aimed to

improve participant’s awareness of the benefits of decreasing their weight by lowering their fat

intake. Throughout the stages of the programs the topics of increasing physical activity and

eating more fresh foods, were addressed to help participants understand a healthier way of

decreasing their weight. These topic areas helped the programs have a high effectiveness rates

with its participants.

Finally the SNAP-Ed program helps improve diet quality of those who participate.

Hershey et al. (2014) conducted research, similar to this one on how SNAP-Ed can improve

nutrition for low-income participants. They selected projects that are possible models of SNAP-


Ed programs. The outcome measures were daily at-home consumption of fruit and vegetables.

These evaluations found significant effects in programs offered in a child care setting, and senior

center, suggesting that SNAP-Ed has the potential to be effective at improving nutrition

behaviors across all age groups. These programs systematically refined and improved their

efforts over prior years, suggesting that sustained efforts to refine and improve SNAP-Ed

programs can positively affect participants’ behavior. Finally their findings indicate that SNAP-

Ed has the potential to improve nutrition behaviors among low-income individuals. This research

supports the current research that was conducted. Based off of the results the SNAP-Ed programs

reviewed had a high effectiveness rate with its participants. Continuous implementation of

SNAP-Ed programs will help participants increase consumption of fruits and vegetables, lower

sugar in-take and decrease their weight.

Food Budgeting, Food Labeling & Food Safety

Throughout the literature and on the SNAP-Ed website, food budgeting, food labeling,

and food safety were mentioned as three topics taught to participants in certain programs. The

skills that were taught on these topics help participants stretch their money; keep food fresher for

longer and understanding how to read a food label. After researching programs that are currently

being implemented to SNAP-Ed participants, it was found that 80% of the programs reviewed

taught one or more of these topics and that those programs that offered this content had high

success rates from its participants.

In the literature that was reviewed, Greenwell, Arnold and Sobal (2000) and Dollhaite et

al. (2014) both addressed all three of these topics during their studies. Both studies focused their

efforts on improving knowledge, skills, budget and food choices with hands-on activities in

SNAP populations. Since their intended population was children and their parents, the activities


reflected the population appropriately and kept them engaged during implementation. They

provided participants the opportunity to have hands on experience such as visiting farms and

picking their own fruits and vegetables, creating their own menus, and proper food handling.

These hands on experiences gave participants the opportunity to practice how to use their skills

in a setting outside of the program. The literature and the current programs show that food

practices and nutrition knowledge can be improved significantly when participants are offered

activities that help them practice their skills.

One past study found that food safety was an explicit concern for low-income shoppers.

A study conducted by Webber, Sobal & Dollahite (2010) used a naturalistic, qualitative approach

to examine the experience of grocery shopping by low-income households through their first-

hand knowledge about living and shopping in underserved rural and inner city settings. They

found that shoppers were concerned about the freshness of fruits and vegetables, their safety and

healthfulness. Safety concerns spanned through the entire food system, from how and where the

food was grown, processed, packaged and transported, to sanitary practices of farm workers and

store employees. Participants also reported doing considerable inspecting of food themselves,

checking the date, looking for mildew, spoilage and suspicious odor. The influence of product

prices on the purchase of produce varied according to the importance attached to it by the

shopper. All households were on a limited budget and found it cost-effective to buy produce

from stores selling higher quality selection. This study cuts across two SNAP-Ed topics, food

safety and food budgeting. This study was able to highlight the importance of food shopping and

the influence many factors have on individual’s selection of groceries.

Along with addressing the three topics, these studies also addressed increasing

consumption of fruit and vegetables. The topics paired with the behavior changes, created a


unique opportunity to allow the educators to increase participant knowledge and skills in many

areas of healthy behavior. Additional information such as flyers, and sample recipes, were given

to participants to help them and their families remain on a healthy track once they have

completed the program. They also encouraged participants to seek information from their

website.

Overall the current and past studies on food budgeting, food labeling and food safety

highlight important skills SNAP-Ed is teaching their participants. The studies addressed, showed

that participants continued to use the skills they learned, once they completed the program.

Therefore showing that food budgeting, food labeling, and food safety are skills that are helping

participants make improvements with their shopping and cooking habits once they complete the

programs. With continuous implementation of these topics throughout SNAP-Ed programs, the

topics will continue to make strides to improving dietary habits of its participants.

Theory Based Practices

During the research of theories, The Theory of Planned Behavior (TPB) was seen as

having high potential related to this research. However, once the research was conducted it was

found that TPB was not used in any current interventions. It is surprising to note since TPB uses

intention and behavioral control, which are important constructs to the programs reviewed.

However, while reviewing the SNAP-Ed programs, it was discovered that the Social-Ecological

(SE) Model of Prevention was used as a foundation for many of the SNAP-Ed programs.

The core concepts of the SE Model is that behavior has multiple levels of influences,

often including intrapersonal, interpersonal, organizational, community, physical environment

and policy. Ecological models are believed to provide comprehensive frameworks for

understanding the multiple and interacting determinants of health behaviors (Glanz, Rimer &


Viswanath, 2008). Finally ecological models can be used to develop comprehensive intervention

approaches that systematically target mechanisms of change at each level of influence (Glanz,

Rimer & Viswanath, 2008). Behavior change is expected to be maximized when environments

and policies support healthful choices, when social norms and social support for healthful

choices are strong, and when individuals are motivated and educated to make those choices

(Glanz, Rimer &Viswanath, 2008). This was found in the ten SNAP-Ed programs reviewed in

this study. Many of the programs reviewed used the individual level and interpersonal levels of

the SE Model.

Food budgeting, food labeling and food safety cut across levels of interventions.

Specifically, food budgeting allows the individual to adapt to their individual level financial

situation and better interact with their food environment such as prices at supermarkets. In

regards to food labeling it allows participants to adapt to their physical environment by being

able to correctly read and identify healthy ingredients (low salt, sugar) in foods they are

purchasing at the grocery store. Finally with food safety, it provides the opportunity for

individuals to target change when preparing and storing food properly.

After reviewing both of these models, future research may benefit from using both of the

models together. They both focus on individual behavior change, which will create beneficial

constructs for future programs. Balancing both models within a program will be able to help

individuals make positive behavior changes throughout their time in the intervention. Briggs and

Briggs (2008) found that the growing recognition of diet and nutrition as a major cause of non-

communicable disease paralleled developments in the field of nutrition education as attempts to

change diet behaviors progressed from simply distributing scientific nutrition information to


exploring and addressing relationships among psychological, social, cultural, political and

economic influences on diet.

Strengths & Limitations

This study is strengthened by the detail of review for each program. Through the

extraction survey that was created, it provided the opportunity to systematically gather detailed

information for each program. Each program highlighted its core elements which is important for

those who are not familiar with SNAP-Ed and its programs. Another strength of the study is

using the SNAP-Ed Strategies and Interventions: An Obesity Prevention Toolkit for States. By

using the toolkit, it provided important introductory information about SNAP-Ed, which offered

a full understanding of the program. It also provided the list of SNAP-Ed programs currently

being implemented. The toolkit was easily accessible and helped to locate information on the

programs. However information on each program’s webpage was not standardized so it was

challenging to ensure all the needed information for each program was located.

One limitation within this study is that no primary data was collected from current

SNAP-Ed participants. A way to collect viable information on the benefits of SNAP-Ed

programs would be prospective data collection. This gathers information on whether their

behavior is changing as a result of participating in the SNAP-Ed program. Another limitation to

the study is that there were only certain programs listed in the SNAP-Ed toolkit for review. Only

about 17% of the programs available on the SNAP-Ed toolkit were assessed. With only a limited

amount of programs provided, it does not give a full scope of programs that are being

implemented. Also, the likely measured outcomes from each program were completed in

different ways by those assigned to review SNAP-Ed programs. Finally each program assessed

some outcomes that were not similar to what we were addressing.


Conclusion

After conducting this research, it would have been easier if information for each program

was provided similarly. Thus, improvements of the SNAP-Ed website and toolkit can be to

crease a database that has standardized forms for programs to fill out. The standardized forms

will give the programs the opportunity to register their programs, and share methods and results

in order to provide data on their program. If each program a part of SNAP-Ed completed the

standardized forms, it will be able to inform future development of other similar programs and

keep a record of all data that is being collected from the programs. The programs should also

have common outcome measures such as diet inventories and fruit and vegetable consumption.

This type of database would have been beneficial to this research in that it would have shortened

data collection time and it would have been easier to find the necessary information for each

program.

SNAP-Ed serves as a program to help educate participants to lead healthier lives.

Through the SNAP-Ed programs they taught and continue to teach participants about food

budgeting, food labeling, and food safety, among other skills. The skills participants acquire

during the studies will be able to stay with them once they have completed the program and help

make healthy dietary changes. With systematic evaluations, SNAP-Ed will be more effectively

implemented, which will impact the nutritional health of participants. Overall, SNAP-Ed is

providing beneficial nutrition information and skills to individuals that are part of the SNAP

program. It is important to continue the implementation of SNAP-Ed because it will help make

strides with individual’s dietary habits in increasing fruit and vegetable consumption, lowering

sugar intake and decreasing weight.


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Appendix

Extraction Survey

1. Does the program focus on individual behavior change?

2. Do the programs focus on intention to change individual’s behavior?

3. Are there stages of change throughout the program?

4. Does participation in the program help increase self-efficacy?

5. Is additional information available upon request?

6. If children are the target population, is information provided to the guardians to help makes

changes at home?

7. Is training offered to staff prior to implementation?

8. How are participants recruited for the program?

9. What is the length of the program?

10. What role does the program play in the community?

11. Has the program addressed barriers to implementation?

12. How was data being collected?

13. What setting was the program implemented?

Documents

PBH 695 SNAP-Ed Thesis