Supplemental Nutrition Assistance Program Participation Research Articles

Sexual Orientation and Food Hardship: National Survey of Family Growth, 2011-2019.

Given the high rates of poverty observed among sexual minority groups and their social vulnerability, we examined the prevalence and correlation of food hardship, measured as food insecurity, receipt of free or reduced-cost food, and Supplemental Nutrition Assistance Program (SNAP) participation among low-income sexual minority and heterosexual adults using population-level health surveillance data. We used 4 waves of pooled data (2011-2019) from the National Survey of Family Growth for adults aged 18-44 years. We compared the sexual orientation subgroups and used logistic regression to predict the likelihood of food hardship. Among men, gay and bisexual men had higher odds of experiencing food insecurity than their heterosexual counterparts (adjusted odds ratio [aOR] = 1.97 and 1.83, respectively). Compared with heterosexual men, bisexual men had significantly higher odds of receiving free or reduced-cost food, but gay men did not. The odds of participating in SNAP did not differ significantly among gay, bisexual, and heterosexual men. Among women, only bisexual women were more prone to experiencing food insecurity than their heterosexual counterparts (aOR = 1.81). The odds of receiving free or reduced-cost food did not differ significantly among heterosexual, bisexual, and lesbian women. However, compared with heterosexual women, lesbian women had significantly lower odds (aOR = 0.62) and bisexual women had significantly higher odds (aOR = 1.24) of participating in SNAP. Our findings contribute to the limited literature examining trends in food hardship among sexual minority groups and suggest potentially different patterns of food insecurity, food assistance, and SNAP participation among sexual orientation subgroups, which may call for group-specific, nuanced approaches for lessening food hardship.

Healthfulness of Online Grocery Shopping Behaviors: Analyzing Receipt Data From Low-Income Households With Children

ObjectivesOnline grocery services hold potential to reduce physical barriers to equitable healthy food procurement, particularly among low-income families who often live far from groceries stores. During COVID-19, the USDA authorized the use of the Supplemental Nutrition Assistance Program (SNAP) benefits online in some retailers across the US. We aimed to evaluate the nutritional quality of online grocery purchases among SNAP-eligible families. MethodsItemized receipt data was analyzed from a larger mixed methods study of online grocery shopping behaviors of SNAP-eligible families in Maryland. Of the 310 participants who completed the survey, 39 submitted grocery receipts. Of those, 19 participants submitted receipts with complete data for nutritional analysis on total amount spent, number of items purchased and units, weight (oz), and % of expenditure on fruits, vegetables, and sugar sweetened beverages (SSB). Nutritional analysis compared purchases of propensity score matched samples of SNAP (n = 14) versus SNAP-eligible non-participant families (n = 5) using a zero-inflated Poisson regression, controlling for sociodemographic factors. Results43% of SNAP participants used SNAP benefits to purchase groceries online. Families spent, on average, 7.8% of their expenditure on SSBs, 5.3% on fruits and 4.5% on vegetables. SNAP participants purchased 61% less fruit by unit (p = 0.043) and 77% less fruit by weight (p = 0.004) compared to non-SNAP. Additionally, SNAP participants purchased 52% less vegetables by unit (p = 0.009), 65% less by weight (p = 0.006) and spent 69% less (p < 0.001) than non-SNAP. Lastly, SNAP participants purchased 247% more SSB by weight (p = 0.002) and spent 434% more on SSB (p = 0.001) than non-SNAP. ConclusionsSNAP participants may be purchasing more SSB and less fruits and vegetables online than SNAP-eligible non-participant. Findings call for future research using more rigorous receipt data sourced from larger, representative samples of SNAP-eligible families to evaluate the health behavior implications of equitable nutrition policies in the digital environment and direct future policy creation to promote equitable healthy food access. Funding SourcesHealthy Eating Research (Robert Wood Johnson Foundation).

Decisions that matter: State Supplemental Nutrition Assistance Program policy restrictiveness limits SNAP participation rate

AbstractObjectiveThe Supplemental Nutrition Assistance Program (SNAP) offers free benefits to qualifying individuals, but participation varies greatly from state to state. We explore the impact of SNAP administration policies, political factors, and socio‐demographic characteristics to explain this variation.MethodWe utilize a policy index that aggregates the effect of 10 SNAP administrative policies to evaluate the effects of policies over time on state SNAP participation rates.ResultsLess restrictive administrative policies are associated with increases in SNAP participation. Additionally, the unified Democratic control of state government, poverty, and unemployment all increase SNAP participation.ConclusionDifferences in SNAP state participation rates are not spurious. More restrictive administrative policies lower participation. Thus, SNAP policies are not purely “administrative” decisions; they can either work to encourage or discourage participation in the program.

Churn in the older adult SNAP population.

Using administrative records from Missouri, we investigate the characteristics of Supplemental Nutrition Assistance Program (SNAP) participants aged 60 and older who experience administrative churn. Among these adults, 1 in 4 experienced administrative churn, and 1 in 5 experienced more than one spell of churn. Risk of churn, frequency, duration of churn spells, and the value of foregone SNAP benefits varied with individual, household, and geographic characteristics, and was more common among non-whites, members of larger households, and those living in urban areas. Our findings suggest that a significant portion of older adults experience gaps in SNAP benefit receipt.

Trends in 10-Year Predicted Risk of Cardiovascular Disease Associated With Food Insecurity, 2007-2016.

IntroductionConsumption of a healthy diet improves cardiovascular (CV) risk factors and reduces the development of cardiovascular disease (CVD). Food insecure (FIS) adults often consume an unhealthy diet, which can promote obesity, type 2 diabetes mellitus (T2DM), hypertension (HTN), and hyperlipidemia (HLD). The Supplemental Nutrition Assistance Program (SNAP) is designed to combat food insecurity by increasing access to healthy foods. However, there is a paucity of data on the association of SNAP participation among FIS adults and these CVD risk factors.MethodsThe National Health and Nutrition Examination Survey (NHANES) is a publicly available, ongoing survey administered by the Centers for Disease Control and Prevention and the National Center for Health Statistics. We analyzed five survey cycles (2007–2016) of adult participants who responded to the CVD risk profile questionnaire data. We estimated the burden of select CVD risk factors among the FIS population and the association with participation in SNAP.ResultsAmong 10,449 adult participants of the survey, 3,485 (33.3%) identified themselves as FIS. Food insecurity was more common among those who were younger, female, Hispanic, and Black. Among the FIS, SNAP recipients, when compared to non-SNAP recipients, had a lower prevalence of HLD (36.3 vs. 40.1% p = 0.02), whereas rates of T2DM, HTN, and obesity were similar. Over the 10-year survey period, FIS SNAP recipients demonstrated a reduction in the prevalence of HTN (p < 0.001) and HLD (p < 0.001) which was not evident among those not receiving SNAP. However, obesity decreased only among those not receiving SNAP. The prevalence of T2DM did not change over the study period in either group.ConclusionOver a 10-year period, FIS adults who received SNAP demonstrated a reduction in the prevalence of HTN and HLD, which was not seen among those not receiving SNAP. However, the prevalence of obesity and T2DM did not decline among SNAP recipients, suggesting that additional approaches are required to impact these important CVD risk factors.

Changing patterns of SNAP take‐up and participation and the role of out‐of‐pocket medical expenses among older adults

AbstractWe use longitudinal data from the nationally representative Health and Retirement Study from 2002 to 2016 to document how Supplemental Nutrition Assistance Program (SNAP) participation and estimated take‐up changed over time for older adults and the role that out‐of‐pocket medical expenses has played in these changing patterns. We rely upon the state adoption of Medicaid expansion of the Affordable Care Act as a source of identifying variation and do not find evidence that Medicaid expansion changed estimated SNAP take‐up or participation. These findings suggest that out‐of‐pocket medical expenses are unlikely to be a major driver of SNAP take‐up decisions for the nondisabled population under age 65.

Differences in Supplemental Nutrition Assistance (SNAP) Program participation among Oklahoma counties

The Supplemental Nutrition Assistance Program (SNAP) is a federally funded and state adminis­tered program to combat food insecurity. Analyz­ing factors in SNAP participation is important to understanding consumption in food systems and supporting community development. As of 2019, 565,900 Oklahomans participate in the SNAP pro­gram, approximately 84% of those eligible for the program. This leads to two questions: why do those who are eligible participate, and how can we better reach those who do not? We analyzed county-level SNAP participation among the income-eligible to identify explanatory characteris­tics of SNAP usage. Data from sources such as the U.S. Department of Agriculture Economic Research Service (USDA ERS) and the U.S. Census Bureau were used to perform a regression analysis on 12 variables, such as store access and number of dependents. The percentage of house­holds with children under 18 and the unemploy­ment rate are associated with increases in SNAP participation among those eligible. Store access and rurality are associated with a decline in SNAP usage. These findings will aid policymakers, SNAP administrators, and outreach education groups in improving program participation by targeting groups susceptible to food insecurity and with low SNAP usage who could benefit from participation.

Supplemental Nutrition Assistance Program Participation is Associated with Lower Health Care Spending among Working Age Adults without Dependents.

Prior evidence suggests an association among food insecurity, poor health, and increased health care spending. In this study, we are using a natural experiment to confirm if longer participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with reduced Medicaid spending among a highly impoverished group of adults. In 2013, the mandatory work requirements associated with SNAP benefits were lifted for able-bodied adults without dependents (ABAWDs). Using 2013 to 2015 Medicaid and SNAP data of 24,181 Minnesotans aged 18-49, we examined if changes in SNAP enrollment duration affect health care expenditures. In fully adjusted within-participant regression models, for each additional month of SNAP, average annual health care spending was $98.8 lower (95% CI: -131.7, -66.0; p&lt;.001) per person. Our data suggests that allowing ABAWDs to receive SNAP even in months they are not working may be critical to their health as well as cost-effective.

Comparison of Fruit and Vegetable Prices between Farmers' Markets and Supermarkets: Implications for Fruit and Vegetable Incentive Programs for Food Assistance Program Participants.

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers’ markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers’ markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers’ market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers’ markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Food Retailers’ Perspectives on Pilot Program Strategies to Promote Healthy Eating in SNAP Participants

Food retailers are key stakeholders in the development, implementation, and effectiveness of Supplemental Nutrition Assistance Program (SNAP) nutrition pilot programs. Qualitative interviews were conducted to gather insight from food retailers regarding the feasibility of proposed strategies to improve food choices among SNAP participants. Two corporate and six local-level food retailer managers were identified for interviews based on SNAP participation, rural- urban code, and type of food retail settings in the selected counties. Qualitative thematic analysis was performed by four research team members, and themes were identified via consensus. Marketing, incentive, and disincentive program models were well-received, while restriction and stocking standards models were less well-received. Food retailers viewed simple programs with easy implementation and educational components positively. Driving sales and programs that align with corporate and social responsibility goals were important factors related to willingness to participate in pilot programs. Insights from this present study can inform future pilot programs and promote food retailer buy-in.

Change in Employment Status Due to the COVID-19 Pandemic, SNAP Participation, and Household Food Insecurity among Black and Latino Adults in Illinois.

The onset of the COVID-19 pandemic resulted in record-high unemployment rates. Black and Latino adults experienced disproportionately higher rates of unemployment. We aimed to examine associations between pandemic-related employment status change and household food insecurity among an economically diverse sample of Black and Latino adults in Illinois during the early months of the COVID-19 pandemic. Furthermore, we evaluated the significance of Supplemental Nutrition Assistance Program (SNAP) participation to determine if it modified associations. We analyzed cross-sectional data collected from 1,809 Black and Latino adults in two waves: May 2020 and June/July 2020. Participants listed their change in employment status as “lost job entirely”, “employed, but paid hours reduced”, “employed, but anticipate job lost”, or “no change”. Participants self-reported their SNAP status and completed the USDA’s six item U.S. Food Security Module to report household food security status. We used logistic regression to assess the significance of associations after controlling for socio-demographics. Approximately 15.5% of participants lost their job entirely, 25.2% were SNAP participants, and 51.8% reported low food security (LFS). All changes in employment were significantly associated with increased odds of LFS after adjusting for socio-demographics. SNAP participants who lost their job had higher odds of LFS (OR: 4.69; 95% CI: 2.69–8.17) compared to non-participants who lost their job (OR: 2.97; 95%: 1.95–4.52). In summary, we observed strong associations between changes in employment and household food insecurity, particularly among SNAP participants, which underscores the pandemic’s impact on low-income and minority populations.

Factors associated with COVID-19 vaccine intent among Latino SNAP participants in Southern California

BackgroundCOVID-19 is significantly impacting the health and well-being of the country, particularly for ethnic minority populations and low-income groups. Our goal was to determine COVID-19 vaccination intent in a low-income, Latino population receiving aid from the Supplemental Nutrition Assistance Program (SNAP) in Southern California, and identify contributing factors and concerns.MethodsA cross-sectional, mixed-methods survey was conducted among participants in the Southern California Nutrition Incentives Program (¡Más Fresco! More Fresh). Only Latino respondents were included in this analysis. Primary outcome was vaccine intent trichotomized into: “definitely/likely yes”, “not sure/don’t know”, and “definitely/likely not.”ResultsThe majority of participants (n = 486) were female (93%), Spanish speaking (74%), with a median age of 40 years (IQR = 13). Approximately half (48%) reported they would get a COVID-19 vaccine, 39% were unsure, and 13% reported “definitely/likely not”. In the multivariable multinomial logistic regression model, participants with a household member with a COVID-19 health risk factor were more likely to be unsure about getting the vaccine. Participants who were primarily English speaking, did not receive the influenza vaccine last season, and reported not reading or talking about COVID-19 were more likely to report not intending to receive the vaccine. Many respondents were concerned about “side effects and ingredients”, and did not trust the vaccine development process, particularly with how fast it happened.ConclusionLow-income Latinos in Southern California were generally hesitant to get a COVID-19 vaccine. Culturally sensitive vaccine promotion campaigns need to address the concerns of minority populations who experience increased morbidity and mortality from COVID-19.

Supplemental Nutrition Assistance Program participation and health care expenditures in children

BackgroundThe Supplemental Nutrition Assistance Program (SNAP) has well-established positive impacts on child health outcomes, including increased birth weight and decreased likelihood of underweight status. Studies in adult populations suggest that SNAP is associated with lower health care costs, although less is known in children.MethodsRetrospective analysis of U.S. children (age <18 years) living in low-income households (< 200% of the federal poverty level) in the 2013-2017 Medical Expenditure Panel Survey. We used multivariable regression, adjusting for sociodemographic and clinical covariates, to model the effect of continuous SNAP enrollment on health expenditures as compared to non-enrollees at 12 and 24 months.ResultsThe sample included 5,626 children, of whom 49.2% consistently received SNAP for the entire two-year survey period. Compared with SNAP non-recipients, SNAP-recipient households more often had incomes below 100% FPL (78.3% vs 37.9%), and children in SNAP-recipient households were more often publicly insured (94.9% vs 64.5%). Unadjusted expenditures were lower for children in SNAP-recipient households at 12 ($1222 vs $1603) and 24 months ($2447 vs $3009). However, when adjusting for sociodemographic and clinical differences, no statistically significant differences in health care expenditures, including emergency department, inpatient, outpatient, and prescription costs, were identified.ConclusionSNAP participant children experience heightened social hardships across multiple domains. There were no differences in short term health care costs based on SNAP enrollment when accounting for differences in sociodemographic and clinical factors. Despite demonstrated child health benefits, we found that sustained enrollment in SNAP over a two-year period did not generate significant short- term health care cost reductions. Our findings suggest that although SNAP is intended to act as a benefit towards the health and well-being of its recipients, unlike among adults, it may not reduce health care costs among children.

Successful Community Nutrition Incentive Program Data Collection during the COVID-19 Pandemic: A Case Study

BackgroundThe coronavirus 2019 (COVID-19) pandemic has complicated rigorous evaluation of public health nutrition programs. The USDA Gus Schumacher Nutrition Incentive Program (USDA GusNIP) funds nutrition incentive programs to improve fruit and vegetable purchasing and intake by incentivizing Supplemental Nutrition Assistance Program (SNAP) participants at the point of sale. GusNIP grantees are required to collect survey data (e.g., fruit and vegetable intake and food insecurity status) on a subset of participants. However, due to COVID-19, most GusNIP grantees faced formidable barriers to data collection. The Hunger Task Force Mobile Market (HTFMM), a Wisconsin-based 2019 GusNIP grantee, used particularly innovative methods to successfully collect these data (n > 500 surveys). ObjectivesThe aim was to explore HTFMM’s successful participant-level data-collection evaluation during COVID-19. MethodsA single case study methodological approach framed this study. The case is the HTFMM in Milwaukee, WI, USA. Participants included HTFMM leadership (n = 3), evaluators (n = 2), staff (n = 3), volunteers (n = 3), and customers (n = 10). These teleconference interviews were recorded and transcribed verbatim. Transcripts were coded using thematic qualitative analysis methods with 2 independent coders. ResultsFour salient themes emerged: 1) there were multiple key players with unique roles and responsibilities who contributed to personalized, proactive, and time-intensive, telephone-based proctored survey collection methods; 2) the importance of resources dedicated to comprehensive evaluation; 3) longstanding relationships rooted in trust and community-based service are key to successful program delivery, engagement, and evaluation; and 4) the COVID-19 data-collection protocol also serves to mitigate nonpandemic challenges to in-person survey collection. ConclusionsThese findings provide guidance on how alternative methods for data collection during COVID-19 can be used and applied to other situations that may affect the ability to collect participant-level data. These findings contribute to a growing body of literature as to best practices and approaches to collecting participant-level data to evaluate public health nutrition programs.

Patterns of Food Assistance Program Participation, Food Insecurity, and Pantry Use among U.S. Households with Children during the COVID-19 Pandemic.

This study aims to describe differences in participation in the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women and Children (WIC), and school meal programs by household characteristics prior to and during the pandemic, and to examine the association of program participation with food security status and food pantry use. We analyze secondary data (n = 470) from an online survey collected in July/August 2020 using weighted multiple logistic regression models. Participation in SNAP declined among households with children in the first four months of the pandemic, while participation in WIC increased slightly, and participation in school meals remained unchanged. There were significant differences in SNAP, WIC, and school meal programs use by race/ethnicity, income, and urbanicity before and during the pandemic. Food insecurity prevalence was higher among SNAP participants at both periods but the gap between participants and non-participants was smaller during the pandemic. Pantry use and food insecurity rates were consistently higher among federal nutrition assistance program participants, possibly suggesting unmet food needs. These results highlight the need for increased program benefits and improved access to food, particularly during periods of hardship.

Understanding SNAP use patterns among older adults

AbstractParticipation rates by older adults in the Supplemental Nutrition Assistance Program (SNAP) have increased since 2010 but remain lower than other groups despite high food insecurity. This study examines patterns of SNAP participation among older adults aged 51–69 years. Using longitudinal SNAP administrative data from Oregon (2014–2018), we find that older adults with long‐term SNAP receipt (&gt;55 months) represent the majority of this group at any given time, suggesting that lower participation rates likely reflect challenges of take‐up, rather than persistence. But younger cohorts (ages 51–59) experience lower persistence than older cohorts (ages 60–69), suggesting that approaching retirement presents a distinct set of challenges.

Using Formative Research to Develop a Social Marketing Campaign to Understand Food Shopping Behaviors in Young Mothers

Background The Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, serves as the primary method of governmental-funded defense against food insecurity in the USA through the provision of food-purchasing assistance to eligible low-income people and families. However, participation in SNAP has been associated with dietary disparities and increased risk of chronic disease associated with overweight and obesity. Low-income individuals are more vulnerable to diet-related chronic disease, as they often have limited resources, are unable to afford healthier foods, such as fruits and vegetables, experience a lack of geographic access to healthy foods, and find themselves without time to prepare healthy meals. As a result, financially marginalized populations are less likely to adhere to Federal Dietary Guidelines for Americans. Objective The purpose of this study was twofold: first, to gain insight into factors influencing food choices and grocery shopping behaviors of women with children, on a limited budget, who utilize or are eligible for SNAP; second, to develop and implement interventions based on these insights to enable participants to better adhere to the Federal Dietary Guidelines for Americans. Methods We conducted independent formative interviews with 19 women in Spring 2018 to develop a social marketing campaign to promote a behavior change associated with healthy grocery shopping practices. These participants were interviewed using a loosely guided interview that gauged barriers, benefits, motivators, competition, and influencers of using a food budget. Of these participants, we identified those who were actively practicing the selected behavior of budgeting for and purchasing healthy foods, like fruits and vegetables. To empower women within this community by drawing from the experiences and knowledge of other women from this same community, participants were selected to participate in a more thorough interview process, followed by a journey mapping exercise. Data collected from the interviews and journey mapping exercise were analyzed for barriers and facilitators to developing and maintaining the adoption and use of a healthy food budget. In response, the research team conducted a search for interventions that aligned with the outlined barriers noted from the interviews and developed a social marketing campaign. This social marketing campaign was then delivered in a series of sessions where pre- and post-surveys were administered to assess grocery shopping behaviors and budgeting practices. Results Specific topics yielded from the journey mapping exercise included tips and tricks mothers used to successfully budget for and purchase healthy foods. Additionally, mothers who participated in the social marketing intervention reported grocery shopping at least one to two times a week. When asked about their habits related to purchasing fruits and vegetables through pre- and post-surveys, 60% of the participants reported intentionally purchasing fruits and vegetables every time they went grocery shopping. Seventy nine percent (79%) of women reported creating a budget allocated for groceries before shopping, while 42% reported sticking to this budget. Implications The study identified three domains of determinants that influence budgeting and shopping for healthy groceries that can inform future formative research and development of interventions among women with children who utilize or are eligible for SNAP.

Associations between Household- and Child-Referenced Food Security Status and Dietary Intake among Low-Income Urban Black Children

ABSTRACT We examined whether dietary intake differs across household and child food security (FS) status, and Supplemental Nutrition Assistance Program (SNAP) participation among Black children (ages 9–15) in a low-income urban setting. This cross-sectional survey used the USDA 18-item Household Food Security Survey, which includes the 8-item Child Module, and a validated FFQ to assess children’s diet (n = 451). Nutrient intake differed across child FS status, but not household FS. SNAP participation was associated with better micronutrient intake (vitamin D and calcium) among food secure children. Assessing child-specific FS and nutrient adequacy clarifies children’s actual experience and informs child-targeted policies.

SNAP participation and food-at-home expenditures through the Great Recession: United States and the New York Area

As a result of economic stressors experienced by vulnerable populations during the Great Recession of 2007–09, participation in the Supplemental Nutrition Assistance Program (SNAP)—the nation’s largest food assistance program—nearly doubled from 2006 to a postrecession peak in 2013. Drawing on data from the 2006 to 2015 U.S. Bureau of Labor Statistics Consumer Expenditure Diary Survey, this article compares SNAP-recipient households to non-SNAP recipient households in the New York area and the United States as a whole for the period before, during, and after the recession. Among the major findings, this study shows substantial differences in characteristics between SNAP and non-SNAP households, including rates of renting, percentage of bachelor’s degree holders, and levels of weekly food-at-home expenditures. The regression analysis shows that food-at-home expenditures remain stable over the business cycle. SNAP participation is positively associated with the probability of making weekly food shopping trips and with an increase in the amount spent per trip nationwide, whereas in the local area, the differences are not significant. Further analysis shows that an income increase from SNAP benefits or other sources results in relatively small increases in food-at-home expenditures.

The Need to Incorporate Diversity, Equity, and Inclusion: Reflections from a National Initiative Measuring Fruit and Vegetable Intake

The Need to Incorporate Diversity, Equity, and Inclusion: Reflections from a National Initiative Measuring Fruit and Vegetable Intake