Effect of Financial Incentives and Default Options on Food Choices of Adults With Low Income in Online Retail Settings

Abstract

ImportanceDespite recent growth in online redemption of Supplemental Nutrition Assistance Program (SNAP) benefits, no previous work has tested the impact of economic and behavioral economic strategies on food purchasing behaviors in an online grocery retail setting among adults with low income.ObjectiveTo examine the extent to which financial incentives and default shopping cart options influence fruit and vegetable purchases.Design, Setting, and ParticipantsThis randomized clinical trial used an experimental online grocery store for adults who currently or have ever received SNAP benefits. From October 7 to December 2, 2021, participants were instructed to shop for a week’s worth of groceries for their household, with a budget tailored to household size; no payment was taken.InterventionsRandom assignment to 1 of 4 conditions: no intervention, 50% discount on eligible fruits and vegetables, prefilled shopping carts with tailored fruit and vegetable items (ie, default options), or a combination of the discount and default options.Main Outcomes and MeasuresThe primary outcome was the percentage of nondiscounted dollars spent on eligible fruit and vegetables per basket.ResultsOf 2744 participants, mean (SD) age was 46.7 (16.0) years, and 1447 (52.7%) identified as women. A total of 1842 participants (67.1%) reported currently receiving SNAP benefits and 1492 (54.4%) reported shopping online for groceries in the previous 12 months. Participants spent a mean (SD) 20.5% (23.5%) of total dollars on eligible fruits and vegetables. Compared with no intervention, those in the discount condition spent 4.7% (98.3% CI, 1.7%-7.7%) of more total dollars on eligible fruits and vegetables; those in the default condition, 7.8% (98.3% CI, 4.8%-10.7%) more; and those in the combination condition, 13.0% (98.3% CI, 10.0%-16.0%) more (P < .001 for all). There was no difference between the discount and the default conditions (P = .06), but the effect in the combination condition was significantly larger than both discount and default conditions (P < .001). Default shopping cart items were purchased by 679 participants (93.4%) in the default condition and 655 (95.5%) in the combination condition, whereas 297 (45.8%) in the control and 361 (52.9%) in the discount conditions purchased those items (P < .001). No variation was observed by age, sex, or race and ethnicity, and results were similar when those who reported never shopping online for groceries were excluded.Conclusions and RelevanceIn this randomized clinical trial, financial incentives for fruits and vegetables and default options, especially in combination, led to meaningful increases in online fruit and vegetable purchases among adults with low income.Trial RegistrationClinicalTrials.gov Identifier: NCT04766034

Food Is Medicine: A Presidential Advisory From the American Heart Association

“…16,124 Previous FIM interventions have at times had limited success in improving diet quality, despite generous incentives, and making those incentives more effective dollar for dollar, combining them with other behavioral strategies, will be an important priority. 71,55,125,127 We will systematically test various behavior change strategies that recognize the inherent difficulties those with food or nutrition insecurity face and that incorporate humancentered design to create programs that have a better chance of meeting people where they are and achieving successful engagement. [128][129][130][131][132][133] An important contribution of the initiative be developing common data platforms that facilitate FIM research.…”

“…62,69 Although some modeling studies have suggested potentially large benefits from produce prescription programs, 70 these estimates come with substantial uncertainty given that their underlying assumptions about the degree to which reductions in healthy food prices translate into increased consumption have not been borne out in recent trials. 71 A substantial limitation of the produce prescription approach is the exclusive focus on the consumption of fruits and vegetables. Cashlike FIM interventions may be more impactful if they incentivize not only fruit and vegetable purchasing but also other important components of healthy diets such as whole grains, legumes, and lean proteins.…”

A scoping review of online food retail: Who’s using it, what they are buying, and what tactics are used to promote healthy or unhealthy purchases

“…Existing reviews of marketing practices in online grocers suggests that nudging interventions related to marketing and promotion, such as suggested food swaps for products with healthier characteristics than the ones selected by the shopper, food labeling, and default options, may improve the healthfulness of online food purchases [12,17]. In a recent randomized trial, the default option of a prefilled shopping cart with fruit and vegetable items led to a significant increase in fruit and vegetable purchases made online [164]. However, further research is needed to test various nudging interventions in realistic online settings.…”

U.S. food policy to address diet-related chronic disease

“…Pomeranz et al examined the feasibility of various national F/V subsidies in existing local programs and their population health outcome impacts and concluded a nationally mandated subsidy can help reduce diet-related chronic disease and U.S. health economic burdens (62). These programs should be broadly expanded in the 2023-24 Farm Bill and integrated into Electronic Benefits Transfer (EBT) modalities while broadly upscaling other innovative digital program administration and online grocery purchase options that work well for consumer preferences, such as the popular F/V 'double-bucks' formats (63)(64)(65). Ensuring a greater variety of access, ordering and delivery approaches with online modalities, sufficient Broadband infrastructure and retail hub access will be key to advancing innovative SNAP benefit participation and utilization, especially in rural areas featuring complex interactions between individual state, multi-state, federal and commerce networks (62).…”