Background The North Carolina (NC) Healthy Food Small Retailer Program (HFSRP) was passed into law with a $250,000 appropriation (2016–2018) providing up to $25,000 in funding to small food stores for equipment to stock healthier foods and beverages. This paper describes an observational natural experiment documenting the impact of the HFSRP on store food environments, customers’ purchases and diets. Methods Using store observations and intercept surveys from cross-sectional, convenience customer samples (1261 customers in 22 stores, 2017–2020; 499 customers in 7 HFSRP stores, and 762 customers in 15 Comparison stores), we examined differences between HFSRP and comparison stores regarding: (1) change in store-level availability, quality, and price of healthy foods/beverages; (2) change in healthfulness of observed food and beverage purchases (“bag checks”); and, (3) change in self-reported and objectively-measured (Veggie Meter®-assessed skin carotenoids) customer dietary behaviors. Differences (HFSRP vs. comparison stores) in store-level Healthy Food Supply (HFS) and Healthy Eating Index-2010 scores were assessed using repeated measure ANOVA. Intervention effects on diet were assessed using difference-in-difference models including propensity scores. Results There were improvements in store-level supply of healthier foods/beverages within 1 year of program implementation (0 vs. 1–12 month HFS scores; p = 0.055) among HFSRP stores only. Comparing 2019 to 2017 (baseline), HFSRP stores’ HFS increased, but decreased in comparison stores (p = 0.031). Findings indicated a borderline significant effect of the intervention on self-reported fruit and vegetable intake (servings/day), though in the opposite direction expected, such that fruit and vegetable intake increased more among comparison store than HFSRP store customers (p = 0.05). There was no significant change in Veggie Meter®-assessed fruit and vegetable intake by customers shopping at the intervention versus comparison stores. Conclusions Despite improvement in healthy food availability, there was a lack of apparent impact on dietary behaviors related to the HFSRP, which could be due to intervention dose or inadequate statistical power due to the serial cross-sectional study design. It may also be that individuals buy most of their food at larger stores; thus, small store interventions may have limited impact on overall eating patterns. Future healthy retail policies should consider how to increase intervention dose to include more product marketing, consumer messaging, and technical assistance for store owners.

Objective: The North Carolina (NC) Legislature appropriated funds in 2016-2019 for the Healthy Food Small Retailer Program (HFSRP), providing small retailers located in food deserts with equipment to stock nutrient-dense foods and beverages. The study aimed to: (1) examine factors facilitating and constraining implementation of, and participation in, the HFSRP from the perspective of storeowners; and (2) measure and evaluate the impact and effectiveness of investment in the HFSRP. Design: This analysis uses both qualitative and quantitative assessments of storeowner perceptions and store outcomes, as well as two innovative measures of policy investment effectiveness. Qualitative semi-structured interviews and descriptive quantitative approaches including monthly financial reports and activity forms, and end-of-program evaluations were collected from participating HFSRP storeowners. Setting: Eight corner stores in North Carolina that participated in the two cohorts (2016-2018; 2017-2019) of the HFSRP. Participants: Owners of corner stores participating in the HFSRP. Results: All storeowners reported that the HFSRP benefitted their stores. In addition, the HFSRP had a positive impact on sales across each category of healthy food products. Storeowners reported that benefits would be enhanced with adjustments to program administration and support. Specific suggestions included: additional information regarding which healthy foods and beverages to stock; inventory management; handling of perishable produce; product display; modified reporting requirements; and a more efficient process of delivering and maintaining equipment. Conclusions: All storeowners reported several benefits of the HFSRP and would recommend that other storeowners participate. The barriers and challenges they reported inform potential approaches to ensuring success and sustainability of the HFSRP and similar initiatives underway in other jurisdictions.

Background Valid biomarkers of fruit and vegetable (FV) intake are needed for field-based nutrition research. Objective To examine criterion-related validity of pressure-mediated reflection spectroscopy as a proxy measure of FV intake, using plasma carotenoids and self-reported FV and carotenoid intake as primary and secondary criterion measures, respectively. Methods Healthy adults 18-65 years of age, self-identifying as African American/ black (n = 61), Asian (n = 53), white (n = 70), or Hispanic (n = 29) in North Carolina and Minnesota were recruited. Skin carotenoids were assessed via pressure-mediated reflection spectroscopy (Veggie Meter ®), skin melanin via spectrophotometer, and total plasma carotenoid concentration by HPLC-PDA. Self-reported carotenoid and FV intake was assessed using a semi-quantitative food frequency questionnaire. Relationships between skin carotenoids, plasma carotenoids, FV and carotenoid intake, with differences by race or ethnicity, age, sex, weight status, cholesterol, and melanin index, were examined by bivariate correlations and adjusted multivariate linear regressions. Results The overall unadjusted correlation between skin and total plasma carotenoids was r = 0.71 and ranged from 0.64 (non-Hispanic black) to 0.80 (Hispanic). Correlations between skin carotenoids and self-reported FV intake ranged from 0.24 (non-Hispanic black) to 0.53 (non-Hispanic white), with an overall correlation of r = 0.35. In models adjusted for age, sex, racial or ethnic group, and body mass index, skin carotenoids were associated with plasma carotenoids (R2 = 0.55), FV (R2 = 0.17), and carotenoid intake (R2 = 0.20). For both plasma carotenoid and FV measures, associations with skin carotenoids did not vary by race; but these relationships did differ by skin melanin – those with lower melanin had a lower correlation between skin and plasma carotenoids. Conclusions Reflection spectroscopy-assessed skin carotenoids may be a reasonable alternative to measurement of plasma carotenoids, a biomarker used to approximate FV intake.

Objective: To conduct a mixed-methods examination of the impact of the Partnerships to Improve Community Health produce prescription initiative in northeastern North Carolina. Design: Quantitative surveys were conducted among participants before and after the distribution of produce prescription vouchers. Univariate statistics were used to describe the participant population, and paired t tests were used to examine change in fruit and vegetable intake. Qualitative, in-depth telephone interviews were conducted among participants, health educators, and food retailers and coded for themes. Setting: Eight health promotion programs, 2 food pantries, and 11 food retailers. Participants: In each health promotion program or food pantry, between 6 and 97 participants were enrolled. Intervention: Produce prescription vouchers were distributed to participants and redeemed at local food retailers. Main Outcome Measure (s): An increase in local fruit and vegetable purchasing and consumption. Results: Of the produce prescription participants who completed the baseline survey (n = 93), 86% were female, 64% were African American, and 68% were food insecure. The voucher redemption rate was 18%. The majority of participants indicated that they visit farmers' markets more now than before the produce prescription initiative, that shopping at the farmers' market made it easy to include more fresh produce in their family's diet, and that they tried a new farmers' market because of the produce prescription initiative. All health educators and food retailers who participated felt that the initiative benefited their program or operation and were willing to partner with the program again. Conclusions: While redemption rates were lower than anticipated, the produce prescription initiative had positive impacts on participants' local fruit and vegetable purchasing and consumption. Because of COVID-19, the initiative was not implemented until late in the North Carolina produce season. Moving forward, the program will start earlier and work with local food retailers to connect with their communities to increase redemption rates.