Lilly Nhan MPH Capstone Spring 2018 Participation in WIC, NSLP, and SBP among Children in SNAP and Dietary Quality Introduce myself & topic Lilly Nhan MPH Capstone Spring 2018

SNAP WIC NSLP/SBP Provides food packages, nutrition education, referrals to other health services Available to pregnant/post-partum women, infants, and children up to age 5 at nutritional risk Provides monthly benefits for households to purchase food Available to people of all ages Provides nutritionally balanced meals each school day Available to school age children (grades PreK – 12) Supplemental Nutrition Assistance Program (SNAP) Special Supplemental Nutrition Program for Women, Infants and Children (WIC) National School Lunch Program (NSLP) School Breakfast Program (SBP) SNAP participants automatically meet income requirements for WIC and NSLP/SBP WIC Package Revisions, 2009: Increase in the benefit allotment for fruits and vegetable Expand whole grain and low-fat dairy options. HHFKA passed in 2010 Major changes to meal nutrition standards: Increase fruit, vegetable, low-fat dairy and whole grain offerings Students must take a fruit or vegetable Calorie ranges, saturated fat limits, trans fat limits

Research Question Primary: Is participation in multiple federal nutrition assistance programs (i.e., WIC, NSLP, SBP) among children in SNAP associated with differences in diet quality? Secondary: For school age-children, does dietary quality differ by years pre- and post-HHFKA? I hypothesize that participating in multiple federal nutrition assistance programs will be associated with higher dietary quality. Additionally, I predict that dietary quality in children who consume NSLP and/or SBP will be higher after implementation of HHFKA.

Methods Data: National Health and Nutrition Examination Survey (NHANES) Time Period: 2009-2014 Inclusion Criteria: Children who are currently participating in SNAP ≤ 200% Federal Poverty Limit (FPL) Participation Categories: Children Aged 2-5: SNAP only, SNAP + WIC Children Aged 6-18: SNAP only, SNAP + NSLP only, SNAP + NSLP + SBP Diet Quality: Healthy Eating Index (HEI) Measures adherence to Dietary Guidelines of Americans Ranges from 0-100 NHANES -- Cross-sectional, nationally representative Total score is the sum of 13 components: Total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, added sugars, and saturated fats Higher scores reflect greater adherence to Dietary Guidelines and a more nutritious diet

Adjusted Mean Overall HEI-2015 Total Score by Program Participation in Children (aged 2-5) 55.1 52.9

Implementation of HHFKA begins SY 12-13 Adjusted Mean Weekday HEI-2015 Total Score by Program Participation and NHANES cycle in Children (aged 6-18) Implementation of HHFKA begins SY 12-13

Conclusions Children aged 2-5: No statistically significant differences in HEI-2015 total score between SNAP only participants compared to SNAP + WIC. Children aged 6-18: Those participating in SNAP+NSLP+SBP had 4.7 points higher weekday HEI-2015 total score compared to SNAP only participants after implementation of HHFKA (2013-2014). Further program policy changes are needed to increase the availability and desirability of nutritious foods to improve dietary quality of low-income children. Overall, the low dietary quality among all children in federal nutrition programs highlight the need for policy changes to increase the availability and desirability of nutritious foods to improve dietary patterns in low-income children.

Strengths Limitations Nationally representative Accounts for breakfast and lunch participation Cross-sectional, observational study Cannot assess temporality or individual changes in dietary quality Diet recall data prone to error Misreporting, social desirability Self-selection into the programs

Thank you! Barbara Laraia Kris Madsen Maureen Lahiff Ryan Smith PHN Cohort Nutrition Policy Institute