Healthy food benefit programs, fruit and vegetable consumption, and food security

Importance: Diet quality, including fruit and vegetable intake, is a determinant of health, yet fresh fruits and vegetables are inaccessible to many lower-income and marginalized households. Healthy food benefit programs may reduce health disparities by increasing fruit and vegetable consumption.

Objectives: To estimate the outcomes of a $40 per month healthy food benefit program on food security and diet.

Design, Setting, and Participants: Cohort study with randomly assigned treatment groups composed of participants seeking enrollment in Fresh Bucks, a healthy food benefit program for lower-income populations in Seattle, Washington. Participants were randomly assigned to enrollment in the program and to a waiting list. Outcomes were examined at baseline (October 2021) and follow-up (June 2022).

Exposure: Two exposure groups were examined. First, random assignment to newly receive program benefits for 6 months vs assignment to a waiting list. Second, random assignment to be disenrolled from program benefits vs continued enrollment for 6 months.

Main Outcomes and Measures: A modified version of the Behavioral Risk Factor Surveillance System Fruit and Vegetable Screening Questionnaire was used to calculate daily frequency of fruit and vegetable consumption as a continuous outcome and a binary indicator of consuming less than 3 vs 3 or more times per day. Food security was measured using the 2-item Hunger Vital Signs screener.

Results: A total of 1973 participants were included, with 757 who received the program and 1216 who were disenrolled (1339 [68%] aged ≥60 years; 1007 [51%] Asian; 209 [11%] Black; 523 [27%] White). The program was associated with a 5.5 percentage point (pp) (95% CI, 0.05-10.91 pp) increase in food security and a 7.5 pp (95% CI, 0.39-14.52 pp) increase in the proportion of participants consuming fruit and vegetables 3 or more times per day. Continuous fruit and vegetable consumption changes were null; however, differential outcomes by income, language, and race and ethnicity were found. Examining these same outcomes in a population assigned to disenrollment, lower fruit and vegetable intake and food security were found vs those who remained in the program.

Conclusions and Relevance: This cohort study of a healthy food benefit program found reduced food insecurity and improved fruit and vegetable consumption in a lower-income population randomly assigned to program enrollment.