title: Financial incentives increase fruit and vegetable intake among Supplemental Nutrition Assistance Program participants: a randomized controlled trial of the USDA Healthy Incentives Pilot.
abstract: BACKGROUND
  US fruit and vegetable (FV) intake remains below recommendations, particularly for low-income populations. Evidence on effectiveness of rebates in addressing this shortfall is limited.
  
  
  OBJECTIVE
  This study evaluated the USDA Healthy Incentives Pilot (HIP), which offered rebates to Supplemental Nutrition Assistance Program (SNAP) participants for purchasing targeted FVs (TFVs).
  
  
  METHODS
  As part of a randomized controlled trial in Hampden County, Massachusetts, 7500 randomly selected SNAP households received a 30% rebate on TFVs purchased with SNAP benefits. The remaining 47,595 SNAP households in the county received usual benefits. Adults in 5076 HIP and non-HIP households were randomly sampled for telephone surveys, including 24-h dietary recall interviews. Surveys were conducted at baseline (1-3 mo before implementation) and in 2 follow-up rounds (4-6 mo and 9-11 mo after implementation). 2784 adults (1388 HIP, 1396 non-HIP) completed baseline interviews; data were analyzed for 2009 adults (72%) who also completed ≥1 follow-up interview.
  
  
  RESULTS
  Regression-adjusted mean TFV intake at follow-up was 0.24 cup-equivalents/d (95% CI: 0.13, 0.34 cup-equivalents/d) higher among HIP participants. Across all fruit and vegetables (AFVs), regression-adjusted mean intake was 0.32 cup-equivalents/d (95% CI: 0.17, 0.48 cup-equivalents/d) higher among HIP participants. The AFV-TFV difference was explained by greater intake of 100% fruit juice (0.10 cup-equivalents/d; 95% CI: 0.02, 0.17 cup-equivalents/d); juice purchases did not earn the HIP rebate. Refined grain intake was 0.43 ounce-equivalents/d lower (95% CI: -0.69, -0.16 ounce-equivalents/d) among HIP participants, possibly indicating substitution effects. Increased AFV intake and decreased refined grain intake contributed to higher Healthy Eating Index-2010 scores among HIP participants (4.7 points; 95% CI: 2.4, 7.1 points).
  
  
  CONCLUSIONS
  The HIP significantly increased FV intake among SNAP participants, closing ∼20% of the gap relative to recommendations and increasing dietary quality. More research on mechanisms of action is warranted. The HIP trial was registered at clinicaltrials.gov as NCT02651064.
authors.affiliation: Abt Associates, Cambridge, MA; and lauren_olsho@abtassoc.com.
authors.forename: Lauren Ew
authors.identifier: http://orcid.org/0000-0003-4503-9745
authors.initials: LE
authors.lastname: Olsho
authors.affiliation: Abt Associates, Cambridge, MA; and.
authors.forename: Jacob A
authors.initials: JA
authors.lastname: Klerman
authors.affiliation: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA.
authors.forename: Parke E
authors.identifier: http://orcid.org/0000-0002-9596-9230
authors.initials: PE
authors.lastname: Wilde
authors.affiliation: Abt Associates, Cambridge, MA; and.
authors.forename: Susan
authors.initials: S
authors.lastname: Bartlett
mesh_terms: D000293:Adolescent; D000328:Adult; D003365:Costs and Cost Analysis; D004032:Diet / Q000191:economics* / Q000592:standards; D005191:Family Characteristics; D005247:Feeding Behavior; D005260:Female; D063105:Food Assistance; D005638:Fruit; D015438:Health Behavior; D006293:Health Promotion / Q000379:methods; D006801:Humans; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D009042:Motivation; D010865:Pilot Projects; D011203:Poverty; D015397:Program Evaluation; D014481:United States; D016885:United States Department of Agriculture; D014675:Vegetables; D055815:Young Adult
keywords: Healthy Incentives Pilot; Supplemental Nutrition Assistance Program; financial incentives; fruits and vegetables; randomized controlled trial