Comparison of Fruit and Vegetable Intake Among Urban Low-Income US Adults Receiving a Produce Voucher in 2 Cities

Abstract

Fruit and vegetable vouchers have been implemented by cities and counties across the US to increase fruit and vegetable intake and thereby improve overall nutritional quality. To determine whether and why use of fruit and vegetable vouchers are associated with varied nutritional intake across different populations and environments. In a population-based pre-post cohort study of 671 adult participants with low income before and during (6 months after initiation) participation in a 6-month program, fruit and vegetable vouchers were distributed for redemption at local San Francisco and Los Angeles neighborhood grocery and corner stores between 2017 and 2019. A transportability analysis was performed to identify factors that may explain variation in voucher use between cities. Receipt of $20 per month in produce vouchers for 6 months from 2017 to 2019. Change in total fruits and vegetables (as defined by the US Department of Agriculture) consumed per person per day (change in cup-equivalents between month 6 and month 0). A total of 671 adults (median age, 54.9 years [interquartile range, 45.0-65.0 years]; 61.7% female; 30.9% Black; 19.7% Hispanic) were enrolled. An increase in fruit and vegetable intake of 0.22 cup-equivalents per day overall (95% CI, 0.14-0.31 cup-equivalents; P < .001) was observed. However, the observed increase was larger in Los Angeles compared with San Francisco (0.64 cup-equivalents per day; 95% CI, 0.41-0.88 cup-equivalents vs 0.10 cup-equivalents per day; 95% CI, 0.01-0.19 cup-equivalents). When the concurrently sampled San Francisco group (n = 157) was weighted in transportability analysis to demographically match the Los Angeles group (n = 155) in observed covariates, the weighted San Francisco group had an estimated increase of 0.53 fruit and vegetable cup-equivalents per day (95% CI, 0.27- 0.79 cup-equivalents, P = .03), with income being the variable needed to allow the 95% confidence intervals to overlap between the weighted San Francisco and unweighted Los Angeles populations. In this study, the use of fruit and vegetable vouchers appeared to be associated with greater benefit among those with lower incomes, suggesting that further investigation of flat-rate rather than income-scaled benefits is warranted.