Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care

Importance

Health-related social needs are increasingly being screened for in primary care practices, but it remains unclear how much additional financing is required to address those needs to improve health outcomes.

Objective

To estimate the cost of implementing evidence-based interventions to address social needs identified in primary care practices.

Design, Setting, and Participants

A decision analytical microsimulation of patients seen in primary care practices, using data on social needs from the National Center for Health Statistics from 2015 through 2018 (N = 19 225) was conducted. Primary care practices were categorized as federally qualified health centers (FQHCs), non-FQHC urban practices in high-poverty areas, non-FQHC rural practices in high-poverty areas, and practices in lower-poverty areas. Data analysis was performed from March 3 to December 16, 2022.

Intervention

Simulated evidence-based interventions of primary care-based screening and referral protocols, food assistance, housing programs, nonemergency medical transportation, and community-based care coordination.

Main Outcomes and Measures

The primary outcome was per-person per-month cost of interventions. Intervention costs that have existing federally funded financing mechanisms (eg, the Supplemental Nutrition Assistance Program) and costs without such an existing mechanism were tabulated.

Results

Of the population included in the analysis, the mean (SD) age was 34.4 (25.9) years, and 54.3% were female. Among people with food and housing needs, most were program eligible for federally funded programs, but had low enrollment (eg, due to inadequate program capacity), with 78.0% of people with housing needs being program eligible vs 24.0% enrolled, and 95.6% of people with food needs being program eligible vs 70.2% enrolled. Among those with transportation insecurity and care coordination needs, eligibility criteria limited enrollment (26.3% of those in need being program eligible for transportation programs, and 5.7% of those in need being program eligible for care coordination programs). The cost of providing evidence-based interventions for these 4 domains averaged $60 (95% CI, $55-$65) per member per month (including approximately $5 for screening and referral management in clinics), of which $27 (95% CI, $24-$31) (45.8%) was federally funded. While disproportionate funding was available to populations seen at FQHCs, populations seen at non-FQHC practices in high-poverty areas had larger funding gaps (intervention costs not borne by existing federal funding mechanisms).

Conclusions and Relevance

In this decision analytical microsimulation study, food and housing interventions were limited by low enrollment among eligible people, whereas transportation and care coordination interventions were more limited by narrow eligibility criteria. Screening and referral management in primary care was a small expenditure relative to the cost of interventions to address social needs, and just under half of the costs of interventions were covered by existing federal funding mechanisms. These findings suggest that many resources are necessary to address social needs that fall largely outside of existing federal financing mechanisms.

Healthy home food environments of pregnant Black women are shaped by food outlet access and participation in nutrition assistance programs

OBJECTIVES

Improving access to healthy food in Black communities is imperative to combat intergenerational health disparities. Pregnant Black women represent an especially vulnerable population to multiple (and overlapping) sources of socioeconomic and political disenfranchisement and thus for whom maternal nutrition is crucial. This study aimed to (1) define household food environment types, (2) determine whether the distribution of community food outlets is associated with these household food environment types, and (3) determine whether the community-household food environment relationship differs by maternal education or participation in nutrition assistance programs.

METHODS

Cross-sectional data for pregnant Black women in North Carolina (n = 429) come from the Mothers & Others study, an obesity-prevention randomized control trial, with linked spatial data on all community food outlets (n = 6312) in the study area in 2015. Factor analysis was used to define household food environment types. These factor scores were regressed on access metrics to community food outlets. Adjusted linear regressions tested interaction by maternal education and nutrition assistance programs.

RESULTS

Four household food environment types were defined: Factor 1 (fresh fruits and vegetables (F/V), low snack), Factor 2 (canned F/V, sweet drinks), Factor 3 (dried/frozen F/V, candy), and Factor 4 (low F/V, soda). Having more convenience stores within 0.25 miles was associated with higher Factor 4 scores. No food outlets were associated with higher Factor 1 scores overall. However, SNAP or WIC participating households saw higher Factor 1 scores with increased access to supermarkets, convenience stores, and dollar stores.

CONCLUSIONS

Nutrition assistance programs play an important role as buffers against unhealthy community food environments which influence household food environments and maternal nutrition.

Pantry clients and Supplemental Nutrition Assistance Program-Education practitioners' perspectives on factors influencing healthy eating policy, system and environmental interventions in food pantries

The Supplemental Nutrition Assistance Program-Education identified food pantries as a targeted setting for policy, system, and environmental (PSE) interventions to promote healthy eating among households who rely on pantries to supplement their food needs. The present study sought to identify factors influencing capacity and readiness to implement healthy eating PSE interventions in food pantries. Qualitative interviews were conducted via zoom with twenty-six community residents with experience receiving SNAP benefits and twelve SNAP-Ed staff in rural and urban counties in Ohio to identify themes and indicators related to community/organisational capacity and readiness to implement healthy eating PSE interventions in food pantries. Themes and related indicators generated based on inductive and deductive coding of interview transcripts were prioritised and weighted by eleven community nutrition experts during a virtual consensus conference. Five themes emerged; expert-derived weights (scaled low, 0 to high, 1) reflect the perceived importance of each to implementation of healthy eating PSE interventions in food pantries: food pantry capacity and logistics [0⋅252], networks and relationships [0⋅228], community nutrition practitioner capacity [0⋅212], food pantry user characteristics [0⋅156], and stigma and stereotypes [0⋅1⋅52]. Overall, seventeen indicators were identified reflecting these themes. Successful and sustained PSE interventions at food pantries will require a tailored approach that considers food pantries' capacity, needs and opportunities within the community, and capacity of community nutrition practitioners. The themes and indicators identified provide guidance for responsive PSE approaches in food pantries that meet communities where they are.

Distribution of fresh foods in food pantries: challenges and opportunities in Illinois during the COVID-19 pandemic

BACKGROUND

The charitable food system distributes free food to clients across the U.S., but many nutrition and health-focused efforts encounter barriers to success, which were exacerbated during the COVID-19 pandemic. The objective of the current study was to understand barriers and facilitators to distributing nutritious, fresh foods in food pantries across Illinois during the COVID-19 pandemic.

METHODS

Forty-nine pantry representatives participated in focus groups in October 2021. A codebook was created based on relevant literature, stakeholder interests, and an initial review of the recordings. Transcripts of each group were coded and analyzed using a basic interpretive approach.

RESULTS

Pantries distribution of fresh foods was impacted by community partners, food bank policies and practices, and the quality of the donated fresh foods. Physical constraints of pantries limit fresh food storage capacity. The COVID-19 pandemic magnified stressors in the charitable food system which highlighted how community partners might improve fresh food distribution.

CONCLUSION

Focus groups with food pantry representatives across Illinois provided key insights that can inform future efforts to facilitate fresh food distribution in the charitable food system. Future studies should evaluate the effects of the suggested initiatives and changes at the food pantry, food bank, and policy levels.

Perceptions of the Right to Food Among Adults Aged 60 Years and Older

This study explores perceptions of the right to food and issues around food assistance and access among older adults. We conducted 20 semi-structured interviews with adults aged 60+ in Iowa, half of whom were food insecure. Most respondents expressed the right to food concerns freedom of choice rather than physical and financial access. The respondents said poor food access was due to improper choices or not accessing food assistance. While respondents believed food insecurity was morally wrong, they also believed current food assistance services are sufficient. These results have important implications for understanding how older adults think about food access.

Assessment of an Online Nutrition Education Program to Improve Mealtime Practices Among Families Receiving SNAP and WIC

PURPOSE

This study examines if participation in an online nutrition education program holds promise for improving mealtime practices in families using SNAP and WIC.

DESIGN

Pre-post self-report surveys.

SETTING

Digital program delivered online, nationally in the United States.

SAMPLE

Two hundred fifty-seven parents receiving SNAP and/or WIC.

INTERVENTION

Parents signed up to participate in Affordable Flavors, an online self-guided 30-day meal plan, developed by culturally diverse dietitians, aligned with the Dietary Guidelines, and linked with social media support.

MEASURES

Overall program utilization and acceptability were assessed along with parent meal preparation practices, diet quality of meals served to children, self-efficacy, mealtime stress, grocery spending, and food insecurity.

ANALYSIS

Paired t-tests (continuous variables) and McNemar's tests (categorical variables).

RESULTS

Overall program utilization and acceptability were high. Participants reported improvements in meal preparation practices (t(255) = 6.6, P < .001), diet quality of meals served to children (t(245) = 4.0, P < .001), and self-efficacy (t(251) = 10.0, P < .001), and decreases in grocery spending (t(175) = -4.3, P < .001), mealtime stress (t(256) = -8.8, P < .001) and food insecurity (26.8% vs 10.9%, P < .001).

CONCLUSION

Affordable Flavors is an acceptable, cost-effective, and easily disseminatable program that holds promise for improving parent self-efficacy to prepare and serve healthy meals to children and increase diet quality in families receiving SNAP and WIC. Engaging online nutrition education programs that can be used by a variety of health professionals, especially in settings where direct nutrition education services are not feasible or cost prohibitive, are needed.

Prevalence and associations between food insecurity and overweight/obesity among native Hawaiian and Pacific Islander adolescents

OBJECTIVE

This study estimates the prevalence of, and associations between, family food insecurity and overweight/obesity among Native Hawaiian and Pacific Islander (NHPI) adolescents and explores socio-demographic factors which might have a moderation effect on the association.

DESIGN

Cross-sectional study using 2014 NHPI-National Health Interview Survey data reported by a parent or guardian. Family-level food security was assessed by the US Department of Agriculture 10-item questionnaire. BMI for age and sex ≥ 85th and 95th percentiles defined overweight and obesity, respectively, according to US Centers for Disease Control and Prevention criteria.

SETTING

The USA, including all 50 states and the District of Columbia.

PARTICIPANTS

383 NHPI adolescents aged 12-17 in the USA.

RESULTS

A third (33·5 %) of NHPI adolescents aged 12-17 were overweight (19·1 %) or obese (14·4 %); 8·1 % had low food security; and 8·5 % had very low food security. Mean family food security score was 1·06, which corresponds to marginal food security. We found no association between family food insecurity and adolescent overweight/obesity or between any other covariates and overweight/obesity, except for family Supplemental Nutrition Assistance Program (SNAP) participation. Odds of being overweight/obese were 77 % lower for adolescents in families participating in SNAP (OR: 0·23, 95 % CI: 0·08, 0·64, P = 0·007). The association between SNAP participation and lower odds of overweight/obesity was particularly pronounced for adolescent girls in food-insecure families.

CONCLUSIONS

The association between SNAP participation and lower odds of overweight/obesity suggests potential benefit of research to determine whether interventions to increase SNAP enrollment would improve NHPI adolescents' health outcomes.

Federal Food Program Participation and Beverage Intake Among Families With Low Household Income

OBJECTIVE

Examine beverage intake among families with low income by household participation in federal food assistance programs.

DESIGN

Cross-sectional study conducted in fall/winter 2020 via an online survey.

PARTICIPANTS

Mothers of young children insured by Medicaid at the time of the child's birth (N = 493).

VARIABLES MEASURED

Mothers reported household federal food assistance program participation, later categorized as Supplementation Nutrition Program for Women, Infants, and Children (WIC) only, Supplemental Nutrition Assistance Program-Education (SNAP) only, both WIC and SNAP, and neither. Mothers reported beverage intake for themselves and their children aged 1-4 years.

ANALYSIS

Negative binomial and ordinal logistic regression.

RESULTS

After accounting for sociodemographic differences between groups, mothers from households participating in WIC and SNAP consumed sugar-sweetened beverages (incidence rate ratio, 1.63; 95% confidence interval [CI], 1.14-2.30; P = 0.007) and bottled water (odds ratio, 1.76; 95% CI, 1.05-2.96; P = 0.03) more frequently than mothers from households in neither program. Children from households participating in WIC and SNAP also consumed soda (incidence rate ratio, 6.07; 95% CI, 1.80-20.45; P = 0.004) more frequently than children in either program. Few differences in intake were observed for mothers or children participating in only WIC or SNAP vs both programs or neither program.

CONCLUSION AND IMPLICATIONS

Households participating in both WIC and SNAP may benefit from additional policy and programmatic interventions to limit sugar-sweetened beverage intake and reduce spending on bottled water.

Usual nutrient intakes and diet quality among United States older adults participating in the Supplemental Nutrition Assistance Program compared with income-eligible nonparticipants

BACKGROUND

The proportion of older adults with food insecurity at 8% has increased faster than that of the general United States population from 2001 to 2017. Many low-income food-insecure older adults rely on food-assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), for meeting energy and nutrient needs, whereas others are eligible but do not participate. Neither updated nutrient intake estimates nor potential differences in meeting the Dietary Reference Intakes from foods alone and with dietary supplements (DS) among low-income older adults using or eligible for SNAP are known.

OBJECTIVES

This study assessed and compared national estimates of usual nutrient adequacy and dietary quality of United States older adults using SNAP and income-eligible nonparticipants.

METHODS

Usual dietary intake was estimated among older adults (≥60 y; n = 2582) in the 2007-2016 NHANES cross-sectional national survey. Data on food-assistance participation and eligibility (poverty-income-ratio ≤130%), DS use, and ≥24-h dietary recalls were used. The NCI method (Markov Chain Monte Carlo approach) was applied to estimate mean usual nutrient intakes, proportion of inadequate nutrient intake, and dietary quality using the 2015 Healthy Eating Index.

RESULTS

Neither usual nutrient intake from dietary and total sources nor dietary quality differed between older adult SNAP participants and eligible nonparticipants. Low dietary quality and high percentage of inadequate intake for several nutrients were apparent among both groups, especially from food sources alone, including vitamins A (56%), C (55%), D (97%), E (99%), calcium (73%), and magnesium (74%), but rates were attenuated when DS were also considered (i.e., 36% reduced risk for vitamin D inadequacy).

CONCLUSIONS

Diet quality and usual nutrient intake among older adult SNAP participants and eligible nonparticipants were poor, but DS lowered the risk of nutrient inadequacy. Future policies and programs should focus on improving the intake of vitamins A, C, D, E, calcium, and magnesium and dietary quality for all older adults.

The impact of the 2021 Thrifty Food Plan benefit re-evaluation on SNAP participants' short-term food security and health outcomes

Introduction

The Supplemental Nutrition Assistance Program (SNAP) is the largest federal nutrition assistance program in the United States, and played a critical role in mitigating food insecurity during the COVID-19 pandemic. In 2021, the updated Thrifty Food Plan (TFP), which provides the basis of SNAP benefit allotments, led to a 21% monthly benefit increase for SNAP participants. The objective of this study was to examine the effects of the TFP re-evaluation on food insecurity, diet quality, and mental health using a natural experiment design.

Methods

A longitudinal, web-based study was conducted among 1,004 United States adults with incomes at or below $65,000 in September 2021 (prior to the policy change) and February 2022 (after the policy change). Outcomes of interest included household food security, diet quality, perceived stress, and anxiety/depression, assessed using validated instruments. We used difference-in-differences regression modeling to assess the effects of the policy change on participants' outcomes, adjusting for sociodemographic covariates. Qualitative responses to open-ended questions about the policy change were analyzed using thematic analysis.

Results

Prior to the policy change, SNAP participants had significantly worse food insecurity, lower diet quality scores, and higher perceived stress and anxiety/depression when compared to non-participants (all Ps < 0.05). After adjustment for differences in sociodemographic characteristics, there were no significant effects of the TFP re-evaluation on food insecurity, diet quality, and mental health outcomes among SNAP participants relative to non-participants (all Ps > 0.05). Qualitative responses suggested that rising food prices and growing inflation potentially negated the benefits of the policy change; however, most SNAP participants described the added benefits as helpful in purchasing additional food supplies and offsetting other household costs during this period.

Discussion

The TFP benefit increase may have helped to prevent inflation-related disparities in food insecurity and health outcomes from widening among SNAP participants and non-participants. Further research is needed to determine the long-term impacts of this policy change.

Plant-Based Family Food Packages and Weight Change in Children During the COVID-19 Pandemic

Food insecurity and obesity coexist among children and families. We examined the association between receipt of plant-based family food packages from the Massachusetts General Hospital Revere Food Pantry and change in body mass index (BMI), adjusted for age and sex, among children during the COVID-19 pandemic. Among 35 children aged 2 to 18 years who received the packages between January 2021 and February 2022, we observed a change in BMI of -0.04 kg/m2 (95% CI, -0.08 kg/m2 to -0.01 kg/m2) for each package received. Our results suggest plant-based food packages might mitigate, and potentially reverse, BMI increase in children in households seeking food assistance.

"A Growing Relationship": Cultivating Organizational Readiness to Influence Implementation of Policy, Systems, and Environmental (PSE) Change Programming in SNAP-Ed Funded School-Community Partnerships

OBJECTIVE

Provide a nuanced understanding of how Supplemental Nutrition Assistance Program-Education (SNAP-Ed) implementers decide what programming a school is ready to implement and the organizational factors that facilitate the initial implementation of programming in schools.

DESIGN

Case studies conducted at schools during 2018-19.

SETTING

Nineteen School District of Philadelphia schools receiving nutrition programming funded by SNAP-Ed.

PARTICIPANTS

Interviews were conducted with 119 school staff and SNAP-Ed implementers. A total of 138 hours of observations of SNAP-Ed programming were completed.

PHENOMENON OF INTEREST

How do SNAP-Ed implementers decide what PSE programming a school is ready to implement? What organizational factors can be developed to facilitate the initial implementation of PSE programming in schools?

ANALYSIS

Interview transcripts and observation notes were coded deductively and inductively on the basis of theories of organizational readiness for programming implementation.

RESULTS

Supplemental Nutrition Assistance Program-Education implementers focused on schools' existing capacity when determining readiness for programming.

CONCLUSIONS AND IMPLICATIONS

Findings suggest that if SNAP-Ed implementers only focus on a school's existing capacity when assessing its readiness for programming, the school might not receive the programming it needs. Findings suggest SNAP-Ed implementers could develop a school's readiness for programming by concentrating efforts on cultivating relationships, program-specific capacity, and motivation at schools. Findings have equity implications for partnerships in underresourced schools that may have limited existing capacity and consequentially could be denied vital programming.

Supplemental Nutrition Assistance Program Access and Racial Disparities in Food Insecurity

Importance

Racially minoritized people experience disproportionately high rates of food insecurity. The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity.

Objective

To evaluate SNAP access with regard to racial disparities in food insecurity.

Design, Setting, and Participants

This cross-sectional study used data from the 2018 Survey of Income and Program Participation (SIPP). On the basis of random sampling strategies, 44 870 households were eligible for the SIPP, and 26 215 (58.4%) participated. Sampling weights accounted for survey design and nonresponse. Data were analyzed from February 25 to December 12, 2022.

Exposures

This study examined disparities based on household racial composition (entirely Asian, entirely Black, entirely White, and multiple races or multirace based on SIPP categories).

Main Outcomes and Measures

Food insecurity during the prior year was measured using the validated 6-item US Department of Agriculture Food Security Survey Module. SNAP participation during the prior year was classified based on whether anyone in the household received SNAP benefits. Modified Poisson regression tested hypothesized disparities in food insecurity.

Results

A total of 4974 households that were eligible for SNAP (income ≤130% of the poverty threshold) were included in this study. A total of 218 households (5%) were entirely Asian, 1014 (22%) were entirely Black, 3313 (65%) were entirely White, and 429 (8%) were multiracial or of other racial groups. Adjusting for household characteristics, households that were entirely Black (prevalence rate [PR], 1.18; 95% CI, 1.04-1.33) or multiracial (PR, 1.25; 95% CI, 1.06-1.46) were more likely to be food insecure than entirely White households, but associations differed depending on SNAP participation. Among households that did not participate in SNAP, those that were entirely Black (PR, 1.52; 97.5% CI, 1.20-1.93) or multiracial (PR, 1.42; 97.5% CI, 1.04-1.94) were more likely to be food insecure than White households; however, among SNAP participants, Black households were less likely than White households to be food insecure (PR, 0.84; 97.5% CI, 0.71-0.99).

Conclusions and Relevance

In this cross-sectional study, racial disparities in food insecurity were found among low-income households that do not participate in SNAP but not among those that do, suggesting that access to SNAP should be improved. These results also highlight the need to examine the structural and systemic racism in food systems and in access to food assistance that may contribute to disparities.

Disparities in Cardiovascular Health by Food Security Status and Supplemental Nutrition Assistance Program Participation Using Life's Essential 8 Metrics

This cross-sectional study examines the associations among household food security, Supplemental Nutrition Assistance Program participation, and cardiovascular health among 2013-2018 National Health and Nutrition Examination Survey participants.

Predictors of WIC uptake among low-income pregnant individuals: a longitudinal nationwide analysis

BACKGROUND

Nutrition during pregnancy is important for maternal and infant health. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional support for low-income pregnant and postpartum individuals and children under the age of 5 y. However, WIC participation was in decline in the decade leading up to 2019.

OBJECTIVES

This study examined individual and state predictors associated with WIC uptake among eligible individuals so as to identify subgroups for targeted intervention to improve participation.

METHODS

Data came from the 2004-2019 waves of the Pregnancy Risk Assessment Monitoring System (PRAMS), a national survey of individuals who recently gave birth (N = 288,531). Multivariable logistic regressions were used to examine individual- and state-level and temporal predictors of WIC uptake among WIC-eligible respondents.

RESULTS

Among WIC-eligible respondents, ages of >35 (OR: 0.68; 95% CI: 0.66, 0.70), more than high school education (OR: 0.63; 95% CI: 062, 0.65), English language proficiency (OR: 0.71; 95% CI: 0.68, 0.74), being married (OR: 0.70; 95% CI: 0.69, 0.72), White race, smaller family size, not having prepregnancy diabetes, and higher income were associated with lower odds of WIC uptake. Respondents in states with higher earned income tax credit rates and in the Northeast, Midwest, and West (compared with the South) had lower WIC uptake. Respondents in states with higher gross domestic product, higher unemployment rates, higher Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, and Medicaid caseloads, and Democrat governors had higher uptake; however, effect estimates were small and may not represent a meaningful change. Associations were the strongest during 2009-2015 than during other years, particularly for race/Hispanic origin, language, marital status, prepregnancy diabetes, family size, and prepregnancy.

CONCLUSIONS

This study identified several individual- and state-level characteristics associated with WIC uptake among low-income eligible respondents, paving the way for future interventions to target key subgroups to improve program participation.

Disparities in Infant Nutrition: WIC Participation and Rates of Breastfeeding in Florida

Being cognizant of the pronounced health advantages of breastfeeding for both the nursing mother and her infant, the breastfeeding dyad, we examined breastfeeding rates among Floridian women who gave birth from 2012 to 2014 (N = 639,052). We investigated the associations between breastfeeding initiation and WIC-based breastfeeding support (the Special Supplemental Nutrition Program for Women, Infants, and Children), education level, and race and ethnicity. We compared the percentage of breastfeeding mothers between those in the WIC program and those who were not, and we compared breastfeeding rates across racial and ethnic groups. Consistent with previous reports, black newborns in this study were breastfed at lower rates than other racial groups, and WIC program participants were less likely to breastfeed than non-WIC program participants. However, by breaking down the data by education level and race, and ethnicity, we see a significantly increased rate of breastfeeding due to WIC participation for both Hispanic and black women with less than a high school education. Further, we assessed differences by insurance type, race, and WIC participation. In multivariable logistic regression, we showed that the WIC program has a significant positive impact on breastfeeding rates for all but white non-Hispanic mothers, independent of sociodemographic and geographic variables. We also note a trend of increasing breastfeeding rates over the study period (p-value < 0.0001), which has positive public health implications.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Differences in a Chain Supermarket's Sales to SNAP Shoppers Before and Since the COVID-19 Pandemic

OBJECTIVE

This study 1) compares grocery sales to Supplemental Nutrition Assistance Program (SNAP) shoppers in rural and urban grocery stores and 2) estimates changes in sales to SNAP shoppers in North Carolina (NC) since the pandemic.

DESIGN

Weekly transaction data among loyalty shoppers at a large grocery chain across NC from October 2019 to December 2020 (n = 32; 182 store weeks) to assess nutritional outcomes.

SETTING

North Carolina large chain grocery stores.

PARTICIPANTS

Large chain grocery store/SNAP shoppers.

INTERVENTION

Rural/urban status of the stores and COVID-19 pandemic onset.

MAIN OUTCOME MEASURES

Share of total calories sold from fruits, vegetables, nuts, and legumes (FVNL) with and without additives, sugar-sweetened beverages (SSB), less healthful foods (LHF), and processed meats (PM).

ANALYSIS

Multivariate random effects models with robust standard errors to examine the association of rural/urban status before and since coronavirus disease 2019 with the share of calories sold to SNAP shoppers from each food category. We controlled for county-level factors (eg, sociodemographic composition, food environment) and store-level factors.

RESULTS

We did not find significant rural-urban differences in the composition of sales to SNAP shoppers in adjusted models. There was a significant decrease in the mean share of total calories from sugar-sweetened beverages (-0.43%) and less healthful food (-1.32%) and an increase in the share from processed meats (0.09%) compared with before the pandemic (P < 0.05).

CONCLUSIONS AND IMPLICATIONS

Urban-rural definitions are insufficient to understand nuances in food environments, and more support is needed to ensure healthy food access.

Food insecurity, SNAP participation and glycemic control in low-income adults with predominantly type 2 diabetes: a cross-sectional analysis using NHANES 2007-2018 data

INTRODUCTION

Diabetes, characterized by elevated blood glucose levels, affects 13% of US adults, 95% of whom have type 2 diabetes (T2D). Social determinants of health (SDoH), such as food insecurity, are integral to glycemic control. The Supplemental Nutrition Assistance Program (SNAP) aims to reduce food insecurity, but it is not clear how this affects glycemic control in T2D. This study investigated the associations between food insecurity and other SDoH and glycemic control and the role of SNAP participation in a national socioeconomically disadvantaged sample.

RESEARCH DESIGN AND METHODS

Adults with likely T2D and income <185% of the federal poverty level (FPL) were identified using cross-sectional National Health and Nutrition Examination Survey (NHANES) data (2007-2018). Multivariable logistic regression assessed the association between food insecurity, SNAP participation and glycemic control (defined by HbA1c 7.0%-8.5% depending on age and comorbidities). Covariates included demographic factors, clinical comorbidities, diabetes management strategies, and healthcare access and utilization.

RESULTS

The study population included 2084 individuals (90% >40 years of age, 55% female, 18% non-Hispanic black, 25% Hispanic, 41% SNAP participants, 36% low or very low food security). Food insecurity was not associated with glycemic control in the adjusted model (adjusted OR (aOR) 1.181 (0.877-1.589)), and SNAP participation did not modify the effect of food insecurity on glycemic control. Insulin use, lack of health insurance, and Hispanic or another race and ethnicity were among the strongest associations with poor glycemic control in the adjusted model.

CONCLUSIONS

For low-income individuals with T2D in the USA, health insurance may be among the most critical predictors of glycemic control. Additionally, SDoH associated with race and ethnicity plays an important role. SNAP participation may not affect glycemic control because of inadequate benefit amounts or lack of incentives for healthy purchases. These findings have implications for community engaged interventions and healthcare and food policy.

Dietary intake of individuals receiving Supplemental Nutrition Assistance Program and food pantry assistance in North Texas

OBJECTIVE

Food pantries and the Supplemental Nutrition Assistance Program (SNAP) are widely available resources for individuals facing food insecurity, yet the dietary quality of individuals using both programmes is not well characterised. We describe the dietary intake of individuals in North Texas who use both food pantries and SNAP to identify nutritional gaps and opportunities to improve food assistance programmes.

DESIGN

We analysed baseline data from a randomised controlled trial examining food security and dietary intake. At baseline, we administered the validated, 26-item Dietary Screener Questionnaire (DSQ). We calculated descriptive statistics for dietary intake variables and compared with the 2020-2025 Dietary Guidelines for Americans recommended intake values.

SETTING

Two large food pantries in Dallas County, TX.

PARTICIPANTS

Eligible participants were English or Spanish speaking adults receiving SNAP benefits who had used the food pantry within the last 4 months.

RESULTS

We analysed baseline DSQ data from 320 participants (mean age 47 years; 90% female; 45% Black or African American; 37% Hispanic or Latino). Despite receiving SNAP benefits and food pantry assistance, most participants did not meet the minimum recommended intake values for fruits (88.4%), vegetables (97.4%), fibre (90·7%), whole grains (99·7%), dairy products (98·4%) and Ca (83·4%). Furthermore, 73·2% of participants exceeded the maximum recommended intake for added sugar. Still, the gap between median daily intake and recommended daily intake could be partially bridged with food obtained through current food assistance programmes.

CONCLUSIONS

Multilevel, coordinated approaches within both SNAP and food pantry networks are needed to improve diet quality in individuals receiving food assistance.

Food security among SNAP participants 2019 to 2021: a cross-sectional analysis of current population survey food security supplement data

Surveillance data indicate that food security rates increased among Supplemental Nutrition Assistance Program (SNAP) participants during the COVID-19 pandemic (2020 and 2021) compared with pre-pandemic (2019), but this could have been due to increased participation from better resourced households. Our objective was to examine if demographic differences between SNAP-participating households in each year were responsible for the increased prevalence of food secure households. We calculated the observed 30-d food security prevalence among SNAP-participating households for each year. We used indirect standardisation to produce expected 2020 and 2021 prevalences with 2019 as the standard population using household size, income, age, sex, race, Hispanic ethnicity, presence of children, single parent household, metropolitan status and census region. We calculated standardised prevalence ratios (SPRs) to understand if the observed prevalence was higher than expected given any changes in the demographic profile compared to 2019. The Current Population Survey data were collected by the United States Census Bureau and Department of Agriculture. Our sample included 5,245 SNAP-participating households. The observed prevalence of food secure households increased by 3⋅6 percentage points comparing 2019 to 2020 (SPR = 1⋅06, 95 % confidence interval = 1⋅00, 1⋅11) and by 8⋅6 percentage comparing 2019 to 2021 (SPR = 1⋅13, 95 % confidence interval = 1⋅07, 1⋅18). The greater prevalence of food secure SNAP households during the pandemic did not appear to be attributable to socio-demographic differences compared to pre-pandemic. Despite hesitance among policymakers to expand or enhance social safety net programmes, permanently incorporating COVID-19-related policy interventions could lessen food insecurity in years to come.

COVID-19 Benefits and Dietary Behaviors Among Mothers From Low-Income, Food-Insecure Households

OBJECTIVE

To examine the dietary behaviors of mothers from very low food security (VLFS) households following the availability of coronavirus disease 2019 (COVID-19) unemployment and Supplemental Nutrition Assistance Program benefits.

METHODS

Diet and food security status were obtained from 2,584 California mothers during Federal Fiscal Year 2020. Fruits, vegetables, and 100% fruit juice (FV100%FJ), sugar-sweetened beverages, and water intake, and Healthy Eating Index-2015 scores, were compared across 4 groups (before vs after COVID-19 benefits by VLFS vs non-VLFS households) with race/ethnicity and age as covariates.

RESULTS

Before COVID-19 benefits, VLFS was associated with fewer cups of FV100%FJ (P = 0.010), more fluid ounces of sugar-sweetened beverages (P = 0.004), and poorer diet quality (P = 0.003). After COVID-19 benefits, mothers from VLFS vs non-VLFS households reported similar dietary outcomes. VLFS mothers reported 0.96 (95% confidence interval, 0.53-1.38) more cups of FV100%FJ after COVID-19 benefits.

CONCLUSIONS AND IMPLICATIONS

Coronavirus disease 2019 benefits may have reduced dietary inequities among low-income families. Associations between increased Supplemental Nutrition Assistance Program and unemployment benefits and decreased costs associated with the negative health outcomes linked to food insecurity and poor diets would be of value.

A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts

BACKGROUND

The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVE

The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month.

DESIGN

These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC.

PARTICIPANTS/SETTING

Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed.

MAIN OUTCOME MEASURES

Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category.

STATISTICAL ANALYSES PERFORMED

For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month.

RESULTS

On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only.

CONCLUSIONS

Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

The Impact of ABAWD Time Limit Reinstatement on SNAP Participation and Employment

OBJECTIVE

Estimate the impact of the Supplemental Nutrition Assistance Program (SNAP) time limit for able-bodied adults without dependents (ABAWD) on SNAP participation, employment, and earnings.

DESIGN

A quasi-experimental study using state administrative SNAP and earnings data to compare outcomes for SNAP participants before and after the time limit went into effect.

PARTICIPANTS

Supplemental Nutrition Assistance Program participants in the study cohorts in Colorado, Missouri, and Pennsylvania (N = 153,599).

MAIN OUTCOME MEASURES

Monthly SNAP participation, quarterly employment, annual earnings.

ANALYSIS

Logistic and ordinary least squares multivariate regression models.

RESULTS

Time limit reinstatement reduced SNAP participation by 7 to 32 percentage points in the 12th month of time limit reinstatement but did not generate evidence of improved employment or annual earnings (1 year after time limit reinstatement, employment decreased by 2 to 7 percentage points and annual earnings decreased by $247 to $1,230).

CONCLUSIONS AND IMPLICATIONS

The ABAWD time limit reduced SNAP participation but did not improve employment and earnings. SNAP may provide helpful support to participants as they seek to enter or re-enter employment, and removing this support may be detrimental to their employment prospects. These findings can inform decisions about requesting waivers or pursuing changes to ABAWD legislation or regulations.