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Lobitz CA, Yamaguchi I. Lifestyle Interventions for Elevated Blood Pressure in Childhood-Approaches and Outcomes. Curr Hypertens Rep 2022; 24:589-598. [PMID: 35972678 DOI: 10.1007/s11906-022-01217-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of existing and emerging lifestyle treatments in the clinical management of primary elevated blood pressure and hypertension in pediatric patients. The authors hope to expand the knowledge base surrounding pediatric hypertension and update clinicians on best practices to improve outcomes. RECENT FINDINGS Elevated blood pressure is traditionally addressed with broad lifestyle recommendations such as limiting salt consumption and losing weight. This approach is not well adapted for pediatric patients. Novel and often underutilized approaches to the treatment of hypertension in pediatrics include psychological counseling for behavior modification, circadian nutrition, consistent use of interdisciplinary teams, manipulation of macronutrients, stress management, technology-infused interventions, and systemic changes to the food environment. Elevated blood pressure is a pervasive condition affecting cardiovascular disease and mortality risk. Increasingly, pediatric patients are presenting with elevated blood pressure with etiologies known to be affected by lifestyle behaviors. Weight management, dietary modifications, and daily physical activity are well-researched methods for improving individual blood pressure measurements. These strategies can sometimes be as effective as pharmacological interventions at lowering blood pressure. However, compliance with these individual recommendations is not consistent and has led to unsatisfactory results. There are emerging treatment trends that may provide non-traditional and more effective non-pharmacologic routes to blood pressure management in pediatric patients.
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Affiliation(s)
- C Austin Lobitz
- Pediatric Nephrology, University Health System, San Antonio, TX, USA.
| | - Ikuyo Yamaguchi
- Pediatric Nephrology, University of Oklahoma Health Science Center and Oklahoma Children's Hospital, OU Health, Oklahoma City, OK, USA
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Jackson A, Weaver RH, Weybright E, Lanigan J, Parker L, Iniguez A, Decker A. Changes in Social, Economic, and Health Risk Factors Across the Lifespan during the COVID-19 Pandemic: A Latent Transition Analysis. JOURNAL OF PREVENTION AND HEALTH PROMOTION 2022; 3:539-562. [PMID: 38603389 PMCID: PMC9510955 DOI: 10.1177/26320770221096839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The COVID-19 pandemic led to unique, pervasive, and changing global impacts. It is imperative to characterize groups of individuals based on modifiable factors, and to describe how groups have been impacted by the continuing pandemic in the United States to promote health and well-being and to inform preventive interventions. We used latent transition analysis to identify subgroups of modifiable psychosocial, economic, and health risk factors; to explore subgroup shifts across time; and to assess the prevalence of non-modifiable factors associated with subgroup membership. We recruited 450 participants 18 years and older living in the United States to complete a longitudinal survey exploring health during the pandemic. Participants completed three waves of data collection from April to November 2020. We used latent transition analysis to identify statuses, shifts in prevalence over three waves, and the relationships of non-modifiable covariates with each status. Five statuses were identified: high risk together, low risk together, high risk alone, low risk alone, and financial risk together. Statuses were relatively stable over time; the majority (60%-66%) of participants were in statuses categorized by multiple indicators of high modifiable risk, and the largest transitions were to lower risk subgroups. Increasing age, being male, and living in an urban area were the only non-modifiable covariates associated with status membership. It is imperative to continue to scale up targeted interventions aimed at promoting resilience, well-being, financial well-being, delays in healthcare use, food insecurity, and depression among individuals in higher-risk subgroups to promote health and well-being.
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Affiliation(s)
| | | | | | | | - Louise Parker
- Extension Youth and Families Unit,
Human Development, Washington State
University, Seattle, WA, USA
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DePuccio MJ, Garner JA, Hefner JL, Coovert N, Clark A, Walker DM. Multi-stakeholder perspectives on the implementation of a clinic-based food referral program for patients with chronic conditions: a qualitative examination. Transl Behav Med 2022; 12:927-934. [PMID: 36205467 PMCID: PMC9540973 DOI: 10.1093/tbm/ibac027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Clinic-based food referral programs (FRPs) may help alleviate food insecurity and improve access to nutritious foods by systematically identifying and referring food-insecure primary care patients to community-based food resources. The purpose of this study was to examine the barriers to and facilitators of implementation of an FRP offered to primary care patients who screen positive for food insecurity and have a qualifying chronic condition. we used a multi-stakeholder approach to conduct semi-structured interviews with healthcare providers and administrators from an academic medical center (AMC) (n = 20), representatives of a regional foodbank and its affiliated pantries (n = 11), and patients referred to the FRP (n = 20), during the initial phase of FRP implementation from April to September 2020. Interviews were audio-recorded, transcribed verbatim, and coded using a deductive dominant approach that allowed for the identification of emergent themes. Seven major themes emerged across the two domains of analysis: barriers to and facilitators of FRP implementation. Key barriers were (a) provider time constraints and competing demands; (b) inadequate physician feedback regarding patient use of the program; (c) patient transportation barriers; and (d) stigma associated with food pantry use. Key facilitators of implementation included (a) program champions; (b) screening and referral coordination; and (c) addressing food pantry-related stigma. This study identifies factors that deter and facilitate the implementation of an AMC-based FRP. Our findings highlight opportunities for healthcare and community-based organizations to refine and optimize FRP models toward the ultimate aim of advancing health equity for food-insecure patients.
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Affiliation(s)
| | - Jennifer A Garner
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH 43210, USA,The John Glenn College of Public Affairs, The Ohio State University, Columbus, OH 43210, USA
| | - Jennifer L Hefner
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH 43210, USA,Department of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| | - Nicolette Coovert
- The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Aaron Clark
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Daniel M Walker
- Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, OH 43210, USA,The Center for the Advancement of Team Science, Analytics, and Systems Thinking (CATALYST), College of Medicine, The Ohio State University, Columbus, OH 43210, USA
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Tester JM, Xiao L, Tinajero-Deck L, Juarez L, Rosas LG. Food Insecurity Influences Weight Trajectory in Children with Obesity. Child Obes 2022; 18:437-444. [PMID: 35171045 PMCID: PMC9634962 DOI: 10.1089/chi.2021.0311] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Social disadvantage is associated with children's risk of being overweight or obese, but little is known about how it impacts weight trajectory. This longitudinal analysis examines food insecurity and weight change over time among low-income children in a multidisciplinary weight management clinic. Methods: Food insecurity was assessed between 2008 and 2016 among 794 low-income patients (household income <$60k/year) who attended 3234 visits. Mixed-effects growth curve modeling was used to examine the association between baseline food security status and weight trajectory, using percentage of the 95th percentile for BMI (%BMIp95). Random effects (each child's growth curve) and fixed effects (food insecurity, starting age and %BMIp95, demographics, and months since the initial visit) were modeled, and interactions between food insecurity and elapsed time estimated the influence of food insecurity on weight trajectory. Results: Mean %BMIp95 was 129% (SD 24%), corresponding to severe obesity. Thirty percent of patients were food-insecure at baseline. After adjusting for other factors, monthly change in %BMIp95 was significantly smaller for food-insecure children compared to food-secure peers (difference in the coefficients for slope: 0.13, SE 0.05, p = 0.009). The modeled 12-month change in %BMIp95 was significant for food-secure children (-2.28, SE 0.76, p = 0.0026), but not for food-insecure children (-1.54, SE 1.22, p = 0.21). Conclusion: Household food insecurity was associated with a less optimal weight trajectory among children with obesity.
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Affiliation(s)
- June M. Tester
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
- Department of Pediatrics, University of California San Francisco (UCSF) School of Medicine, San Francisco, CA, USA
| | - Lan Xiao
- Department of Epidemiology and Population Health, Stanford School of Medicine, Palo Alto, CA, USA
| | - Lydia Tinajero-Deck
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
- Department of Pediatrics, University of California San Francisco (UCSF) School of Medicine, San Francisco, CA, USA
| | - Lourdes Juarez
- UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Lisa G Rosas
- Department of Epidemiology and Population Health, Stanford School of Medicine, Palo Alto, CA, USA
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Gold R, Kaufmann J, Gottlieb LM, Weiner SJ, Hoopes M, Gemelas JC, Torres CH, Cottrell EK, Hessler D, Marino M, Sheppler CR, Berkowitz SA. Cross-Sectional Associations: Social Risks and Diabetes Care Quality, Outcomes. Am J Prev Med 2022; 63:392-402. [PMID: 35523696 DOI: 10.1016/j.amepre.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/25/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Social risks (e.g., food/transportation insecurity) can hamper type 2 diabetes mellitus (T2DM) self-management, leading to poor outcomes. To determine the extent to which high-quality care can overcome social risks' health impacts, this study assessed the associations between reported social risks, receipt of guideline-based T2DM care, and T2DM outcomes when care is up to date among community health center patients. METHODS A cross-sectional study of adults aged ≥18 years (N=73,484) seen at 186 community health centers, with T2DM and ≥1 year of observation between July 2016 and February 2020. Measures of T2DM care included up-to-date HbA1c, microalbuminuria, low-density lipoprotein screening, and foot examination, and active statin prescription when indicated. Measures of T2DM outcomes among patients with up-to-date care included blood pressure, HbA1c, and low-density lipoprotein control on or within 6‒12 months of an index encounter. Analyses were conducted in 2021. RESULTS Individuals reporting transportation or housing insecurity were less likely to have up-to-date low-density lipoprotein screening; no other associations were seen between social risks and clinical care quality. Among individuals with up-to-date care, food insecurity was associated with lower adjusted rates of controlled HbA1c (79% vs 75%, p<0.001), and transportation insecurity was associated with lower rates of controlled HbA1c (79% vs 74%, p=0.005), blood pressure (74% vs 72%, p=0.025), and low-density lipoprotein (61% vs 57%, p=0.009) than among those with no reported need. CONCLUSIONS Community health center patients received similar care regardless of the presence of social risks. However, even among those up to date on care, social risks were associated with worse T2DM control. Future research should identify strategies for improving HbA1c control for individuals with social risks. TRIAL REGISTRATION This study is registered at www. CLINICALTRIALS gov NCT03607617.
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Affiliation(s)
- Rachel Gold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; OCHIN Inc., Portland, Oregon.
| | - Jorge Kaufmann
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Laura M Gottlieb
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Saul J Weiner
- Department of Medicine, College of Medicine, The University of Illinois at Chicago, Chicago, Illinois
| | | | - Jordan C Gemelas
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Erika K Cottrell
- OCHIN Inc., Portland, Oregon; Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Miguel Marino
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Leiman DA, Madigan K, Carlin M, Cantrell S, Palakshappa D. Food Insecurity in Digestive Diseases. Gastroenterology 2022; 163:547-551.e13. [PMID: 35661723 PMCID: PMC9627473 DOI: 10.1053/j.gastro.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 12/02/2022]
Affiliation(s)
- David A Leiman
- Division of Gastroenterology, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Katelyn Madigan
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Megan Carlin
- Duke University Hospital, Durham, North Carolina
| | - Sarah Cantrell
- Medical Center Library and Archives, Duke University School of Medicine, Durham, North Carolina
| | - Deepak Palakshappa
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina; Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Zack RM, Rodríguez Bronico JV, Babbin M, Nguyen T, Weil R, Granick J, Fiechtner L, Mulugeta W, Odayar V, Cortés DE. Facilitators and Barriers to Patient Attendance at a Free Health Center Produce Market. Am J Prev Med 2022; 63:S131-S143. [PMID: 35987525 PMCID: PMC10680439 DOI: 10.1016/j.amepre.2022.03.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/24/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Patient participation in healthcare system‒sponsored efforts to address food insecurity varies widely. This mixed-methods study sought to understand the patient sociodemographic factors associated with and barriers and facilitators to the use of a monthly produce market held at Cambridge Health Alliance in partnership with The Greater Boston Food Bank. METHODS Baseline surveys (N=715) were conducted from February 2019 to March 2020 before market attendance, followed by 1-year follow-up surveys (n=514) and qualitative interviews (n=45). Robust Poisson regression estimated associations between sociodemographic characteristics and market attendance. Analyses were conducted from 2021 to 2022. RESULTS A total of 37.1% attended the market ≥1 time. Market attendance was associated with being aged 30-49 years (Risk Ratio (RR)=1.36, 95% CI=1.00, 1.86), having a monthly household income <$1,000 (RR=1.73, 95% CI=1.29, 2.32), identifying as Asian (RR=2.48, 95% CI=1.58, 3.89), having a preferred language for medical care other than English (RR=1.35, 95% CI=1.03, 1.76), being retired (RR=1.90, 95% CI=1.17, 3.08), and living in the city of the market's location (RR=1.36, 95% CI=1.12, 1.63). Barriers included limited time (28%), work conflict (23%), forgetfulness (23%), and not knowing market location/date (22%). Interviews revealed that accessibility barriers (e.g., limited market hours, transportation issues, competing demands, medical conditions, long lines) were obstacles to attendance, whereas access to novel, healthy foods motivated attendance. CONCLUSIONS Healthcare-based food distributions have the potential to reach patients with unmet food needs who cannot or would not access other forms of food assistance. Time constraints, physical limitations, and transportation challenges impact attendance; program modifications are necessary to improve accessibility.
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Affiliation(s)
- Rachel M Zack
- The Greater Boston Food Bank, Boston, Massachusetts.
| | | | - Molly Babbin
- Community Health Improvement Department, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Tra Nguyen
- The Greater Boston Food Bank, Boston, Massachusetts
| | - Rachel Weil
- The Greater Boston Food Bank, Boston, Massachusetts
| | - Jean Granick
- Community Health Improvement Department, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Lauren Fiechtner
- The Greater Boston Food Bank, Boston, Massachusetts; Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts; Division of Gastroenterology and Nutrition, Mass General Hospital for children, Boston, Massachusetts
| | | | - Varshini Odayar
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Dharma E Cortés
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Massachusetts
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Zimmer R, Strahley A, Weiss J, McNeill S, McBride AS, Best S, Harrison D, Montez K. Exploring Perceptions of a Fresh Food Prescription Program during COVID-19. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10725. [PMID: 36078442 PMCID: PMC9518155 DOI: 10.3390/ijerph191710725] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/12/2022] [Accepted: 08/26/2022] [Indexed: 06/15/2023]
Abstract
This qualitative study aimed to elicit the perspectives of individuals with food insecurity (FI) who were enrolled in a Fresh Food Prescription (FFRx) delivery program through a collaboration between an academic medical center and multiple community partners in the southeastern United States. Semi-structured interviews and open-ended survey responses explored the experiences of participants enrolled in a FFRx delivery program during the COVID-19 pandemic. The interviews probed the shopping habits, food security, experience, and impact of the program on nutrition, health, and well-being; the surveys explored the perceptions of and satisfaction with the program. A coding scheme was developed inductively, and a thematic analysis was conducted on raw narrative data using Atlas.ti 8.4 to sort and manage the data. The themes included that the program promoted healthy dietary habits, improved access to high-quality foods, improved well-being, enhanced financial well-being, and alleviated logistical barriers to accessing food and cooking. Participants provided suggestions for FFRx improvement. Future studies may facilitate improved clinical-community partnerships to address FI.
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Affiliation(s)
- Rachel Zimmer
- Department of Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
| | - Ashley Strahley
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
| | - Jane Weiss
- BestHealth, Atrium Health Wake Forest Baptist, Winston Salem, NC 27157, USA
| | - Sheena McNeill
- Department of Public Health Sciences, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
| | - Allison S. McBride
- Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
| | - Scott Best
- H.O.P.E. of Winston Salem, Winston Salem, NC 27106, USA
| | | | - Kimberly Montez
- Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA
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Yang P, Hernandez BS, Plastino KA. Social determinants of mental health and adolescent anxiety and depression: Findings from the 2018 to 2019 National Survey of Children's Health. Int J Soc Psychiatry 2022; 69:795-798. [PMID: 35978559 DOI: 10.1177/00207640221119035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a current crisis in children's mental health. Defining social determinants of mental health (SDMH) facilitates investigations of social impact on mental health. AIMS To examine associations between nine SDMH and adolescent depression and anxiety in a U.S. nationally representative sample. METHODS Poor access to health care, caregiver underemployment, food insecurity, poorly built environment, housing insecurity, household dysfunction adverse childhood experiences (ACEs), racism, caregiver poor education, and poverty/income inequality were assessed from the 2018 to 2019 National Survey of Children's Health (NSCH) (N = 24,817). RESULTS The likelihood of reporting adolescent depression and/or anxiety was assessed for each SDMH using multinomial logistic regressions. All SDMH, besides caregiver underemployment, were associated with increased odds of reporting adolescent anxiety, depression, or anxiety and depression. Only household dysfunction ACEs and racism had statistically significant associations for all three mental health outcomes. CONCLUSIONS Interventions targeting ACEs and racism may be more impactful in mitigating mental health challenges associated with SDMH during adolescence. The NSCH may provide an important public health tool to investigate SDMH in children.
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Affiliation(s)
- Phillip Yang
- Joe R. & Teresa Lozano Long School of Medicine, UT Health San Antonio, TX, USA
| | - Brian S Hernandez
- Department of Population Health Sciences, UT Health San Antonio, TX, USA
| | - Kristen A Plastino
- Department of Obstetrics and Gynecology, UT Teen Health, Joe R. & Teresa Lozano Long School of Medicine, UT Health San Antonio, TX, USA
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Nikolaus CJ, Hebert LE, Zamora-Kapoor A, Sinclair K. Risk of Food Insecurity in Young Adulthood and Longitudinal Changes in Cardiometabolic Health: Evidence from the National Longitudinal Study of Adolescent to Adult Health. J Nutr 2022; 152:1944-1952. [PMID: 35285891 PMCID: PMC9361738 DOI: 10.1093/jn/nxac055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have demonstrated relations between food insecurity, the lack of access to enough nutritious food, and greater risk of diet-sensitive chronic diseases. However, most prior evidence relies on cross-sectional studies and self-reported disease. OBJECTIVES The objective was to assess the longitudinal relation between risk of food insecurity in young adulthood and changes in diet-sensitive cardiometabolic health outcomes across 10 y among non-Hispanic white, non-Hispanic black, American Indian or Alaska Native, and Hispanic adults. METHODS Data from the fourth and fifth waves (n = 3992) of the National Longitudinal Study of Adolescent to Adult Health were used. Measures included risk of food insecurity, body weight, diabetes, and sociodemographic characteristics. Body weight and diabetes were assessed with direct measures. Mixed-effects models assessed the association of risk of food insecurity with BMI, obesity, and diabetes while accounting for sociodemographic characteristics and the complex survey design. RESULTS Risk of food insecurity was associated with increases in BMI as well as incidence of obesity and diabetes from young to middle adulthood in unadjusted and adjusted models (all P < 0.01). In models stratified by race and ethnicity, the relations of risk of food insecurity with body weight outcomes and diabetes varied. CONCLUSIONS Risk of food insecurity in young adulthood was related to BMI and obesity during young and middle adulthood but not in changes over time. Risk of food insecurity in young adulthood related to an increased incidence of diabetes in middle adulthood. However, the relations among specific racial and ethnic groups were unclear. Estimates of the relation between food insecurity and cardiometabolic health outcomes within racial and ethnic groups experiencing the highest prevalence of these conditions should be refined.
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Affiliation(s)
- Cassandra J Nikolaus
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Luciana E Hebert
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Anna Zamora-Kapoor
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
- Department of Sociology, Washington State University, Pullman, WA, USA
| | - Ka`imi Sinclair
- Institute for Research and Education to Advance Community Health, Washington State University, Seattle, WA, USA
- College of Nursing, Washington State University, Spokane, WA, USA
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Association of family characteristics with health status and needs among children with congenital heart disease. Cardiol Young 2022; 32:1276-1284. [PMID: 34602116 DOI: 10.1017/s1047951121004042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Low socio-economic status is associated with poorer quality of life among children with congenital heart disease (CHD), but this finding is based on disparities among children remaining under cardiology follow-up. We used a population-based health survey data set to analyse the impact of socio-economic status on health and functional status among children with CHD. MATERIALS AND METHODS We used 2007-2018 National Health Interview Survey data, selecting children 2-17 years of age who had been diagnosed with CHD. Outcomes included caregiver-rated general health, presence of functional limitations, number of missed school days, need for special education, and need for special equipment related to the child's health conditions. Socio-economic status measures included maternal educational attainment, food stamp programme participation, poverty status, and insurance coverage. RESULTS Based on a sample of 233 children with CHD, 10% had fair or poor health, 38% reported having any health-related limitation on their usual activities, 11% needed special equipment, and 27% received special education services. On multivariable analysis, lower maternal educational attainment was correlated with worse caregiver-rated health, and children without insurance were especially likely to experience functional limitations. Black children with CHD had significantly worse caregiver-rated health compared to White children (ordered logit odds ratio: 0.19; 95% confidence interval: 0.08, 0.45; p < 0.001). CONCLUSIONS In a population-based survey of children with CHD, race and several measures of socio-economic status disadvantage were associated with worse health outcomes. Further evaluation of social determinants of health during cardiology follow-up may help improve outcomes for children with CHD in socio-economically disadvantaged families.
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Perspectives of Caregivers Experiencing Persistent Food Insecurity at an Academic Primary Care Clinic. Acad Pediatr 2022; 22:892-899. [PMID: 34365031 PMCID: PMC8818048 DOI: 10.1016/j.acap.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Food insecurity (FI) is often transitory and instigated by changes in family circumstances or environmental events. Clinics have developed interventions to address FI, yet families may face persistent FI. Little is known about persistently food insecure families' experiences with clinic-based interventions. The objective of this study was to evaluate the perspectives of caregivers experiencing persistent FI in a clinical setting. METHODS We conducted 40 semistructured interviews at one academic primary care clinic between July 2019 and December 2019. The clinic routinely screened families for FI at every visit; families screening positive could meet with a care navigator and receive bags of nonperishable foods. Caregivers who received food bags at ≥3 visits, spoke English or Spanish, and were ≥18 years old were eligible to participate. Interviews were recorded, de-identified, transcribed, and systematically coded using inductive content analysis. A modified constant comparative method was used to iteratively review codes, identify emerging themes, and resolve differences through consensus. RESULTS Forty caregivers were interviewed; all were women; 45% were Hispanic/Latinx and 37.5% African American/Black. Three major themes emerged: 1) unmet social and medical needs and the challenges of caregiving complicate FI; 2) social supports help address FI and other social challenges that present barriers to accessing resources; and 3) caregivers provide practical recommendations for addressing persistent FI. CONCLUSION Families experiencing persistent FI described important social supports that help address FI and other social challenges that present barriers to accessing resources. Clinic-based resources were welcomed interventions, but their impact may be limited; practical recommendations were made.
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Serchen J, Atiq O, Hilden D. Strengthening Food and Nutrition Security to Promote Public Health in the United States: A Position Paper From the American College of Physicians. Ann Intern Med 2022; 175:1170-1171. [PMID: 35759767 DOI: 10.7326/m22-0390] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.
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Affiliation(s)
- Josh Serchen
- American College of Physicians, Washington, DC (J.S.)
| | - Omar Atiq
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (O.A.)
| | - David Hilden
- Hennepin Healthcare, Minneapolis, Minnesota (D.H.)
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Bakre S, Shea B, Ortega K, Scharen J, Langheier J, Hu EA. Changes in food insecurity among individuals using a telehealth and nutrition platform: a longitudinal study (Preprint). JMIR Form Res 2022; 6:e41418. [DOI: 10.2196/41418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
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Toma KG, Masini I, Johnson G, Birring P, Alkafaji R, Do C, Cui CL, Malinak D, Beck E. Implementation of an On-Site Food Prescription Project to Address Food Insecurity in Multiple Free Clinic Sites Serving an Adult Latinx Population. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2022. [DOI: 10.1080/19320248.2022.2097037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Kalodiah G. Toma
- Department of Medicine, University of California, San Diego, California, USA
| | - Irene Masini
- Department of Medicine, University of California, Irvine, California, USA
| | - Garrick Johnson
- Department of Medicine, University of California, Riverside, California, USA
| | - Paramveer Birring
- Department of Medicine, University of California, Irvine, California, USA
| | - Rhaya Alkafaji
- Department of Medicine, University of California, San Diego, California, USA
| | - Carter Do
- Department of Medicine, Rush University Medical College, Chicago, Illinois, USA
| | - Christina L. Cui
- Department of Vascular and Endovascular Surgery, Duke University, Durham, North Carolina, USA
| | - David Malinak
- Department of Medicine, University of California, San Diego, California, USA
- Department of Internal Medicine, VA San Diego Healthcare System, San Diego, California, USA
| | - Ellen Beck
- Department of Medicine, University of California, San Diego, California, USA
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Canterberry M, Figueroa JF, Long CL, Hagan AS, Gondi S, Bowe A, Franklin SM, Renda A, Shrank WH, Powers BW. Association Between Self-reported Health-Related Social Needs and Acute Care Utilization Among Older Adults Enrolled in Medicare Advantage. JAMA HEALTH FORUM 2022; 3:e221874. [PMID: 35977222 PMCID: PMC9270697 DOI: 10.1001/jamahealthforum.2022.1874] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/08/2022] [Indexed: 12/31/2022] Open
Abstract
Importance There is increased focus on identifying and addressing health-related social needs (HRSNs). Understanding how different HRSNs relate to different health outcomes can inform targeted, evidence-based policies, investments, and innovations to address HRSNs. Objective To examine the association between self-reported HRSNs and acute care utilization among older adults enrolled in Medicare Advantage. Design Setting and Participants This cross-sectional study used data from a large, national survey of Medicare Advantage beneficiaries to identify the presence of HRSNs. Survey data were linked to medical claims, and regression models were used to estimate the association between HRSNs and rates of acute care utilization from January 1, 2019, through December 31, 2019. Exposures Self-reported HRSNs, including food insecurity, financial strain, loneliness, unreliable transportation, utility insecurity, housing insecurity, and poor housing quality. Main Outcomes and Measures All-cause hospital stays (inpatient admissions and observation stays), avoidable hospital stays, all-cause emergency department (ED) visits, avoidable ED visits, and 30-day readmissions. Results Among a final study population of 56 155 Medicare Advantage beneficiaries (mean [SD] age, 74.0 [5.8] years; 32 779 [58.4%] women; 44 278 [78.8%] White; and 7634 [13.6%] dual eligible for Medicaid), 27 676 (49.3%) reported 1 or more HRSNs. Health-related social needs were associated with statistically significantly higher rates of all utilization measures, with the largest association observed for avoidable hospital stays (incident rate ratio for any HRSN, 1.53; 95% CI, 1.35-1.74; P < .001). Compared with beneficiaries without HRSNs, beneficiaries with an HRSN had a 53.3% higher rate of avoidable hospitalization (incident rate ratio, 1.53; 95% CI, 1.35-1.74; P < .001). Financial strain and unreliable transportation were each independently associated with increased rates of hospital stays (marginal effects of 26.5 [95% CI, 14.2-38.9] and 51.2 [95% CI, 30.7-71.8] hospital stays per 1000 beneficiaries, respectively). All HRSNs, except for utility insecurity, were independently associated with increased rates of ED visits. Unreliable transportation had the largest association with increased hospital stays and ED visits, with marginal effects of 51.2 (95% CI, 30.7-71.8) and 95.5 (95% CI, 65.3-125.8) ED visits per 1000 beneficiaries, respectively. Only unreliable transportation and financial strain were associated with increased rates of 30-day readmissions, with marginal effects of 3.3% (95% CI, 2.0%-4.0%) and 0.4% (95% CI, 0.2%-0.6%), respectively. Conclusions and Relevance In this cross-sectional study of older adults enrolled in Medicare Advantage, self-reported HRSNs were common and associated with statistically significantly increased rates of acute care utilization, with variation in which HRSNs were associated with different utilization measures. These findings provide evidence of the unique association between certain HRSNs and different types of acute care utilization, which could help refine the development and targeting of efforts to address HRSNs.
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Affiliation(s)
| | - Jose F. Figueroa
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | - Suhas Gondi
- Harvard Medical School, Boston, Massachusetts
| | - Andy Bowe
- Humana Healthcare Research, Louisville, Kentucky
| | | | | | | | - Brian W. Powers
- Humana Inc, Louisville, Kentucky
- Tufts University School of Medicine, Boston, Massachusetts
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Janssen JMM, van der Velde LA, Kiefte-de Jong JC. Food insecurity in Dutch disadvantaged neighbourhoods: a socio-ecological approach. J Nutr Sci 2022; 11:e52. [PMID: 35836698 PMCID: PMC9257769 DOI: 10.1017/jns.2022.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022] Open
Abstract
Food insecurity is an important public health concern; however, research into this phenomenon within the Netherlands is limited. Food insecurity is not solely related to individual factors, but can also be influenced by various factors in the social and physical environment. Therefore, this study aimed to identify determinants of food insecurity within the personal, social and physical environment, based on the social ecological model (SEM), and to identify their relative importance for experiencing food insecurity. The study population consisted of 307 participants living in disadvantaged neighbourhoods of the Dutch city The Hague, of which approximately one-quarter were food insecure. Participant characteristics showing bivariate associations P < 0⋅20 were placed in a predetermined level of the SEM, after which a multivariate logistic regression was performed for each level and the Nagelkerke pseudo R 2 was presented. Determinants of food insecurity were BMI, gross monthly income, highest educational attainment, smoking status, diet quality, employment status, marital status and religion (P < 0⋅05). The results showed that 29⋅7 % of the total variance in food insecurity status was explained by all included determinants together. The personal, social and physical environment explained 20⋅6, 14⋅0 and 2⋅4 % of the total variance, respectively. Our findings suggest that determinants within the personal environment are most important for explaining differences in experienced food insecurity. The present study contributes to furthering the knowledge about the relative importance of the personal, social and physical environment, indicating that determinants within the personal environment may be most promising for developing targeted interventions to reduce food insecurity.
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Key Words
- BMI, body mass index
- DHC, Dutch Health Council
- Determinants
- Explained variance
- FFQ, food frequency questionnaire
- FI, food insecure
- FS, food secure
- Food insecurity
- Food security
- IQR, interquartile range
- ISCED, International Standard Classification of Education
- LUMC, Leiden University Medical Center
- MAR, missing at random
- MCS, mental component summary
- MI, multiple imputation
- NNC, Netherlands Nutrition Center
- PCS, physical component summary
- SEM, social ecological model
- SEP, socio-economic position
- SF-12, 12-Item Short Form Health Survey
- SNAP, Supplement Nutrition and Assistance Program
- Social ecological model
- USDA, United States Department of Agriculture
- WMO, ‘Wet medisch-wetenschappelijk onderzoek’, in English: Medical Research Involving Human Subjects Act
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Affiliation(s)
- Jolien M. M. Janssen
- Department of Public Health and Primary Care/Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
| | - Laura A. van der Velde
- Department of Public Health and Primary Care/Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
| | - Jessica C. Kiefte-de Jong
- Department of Public Health and Primary Care/Health Campus The Hague, Leiden University Medical Centre, The Hague, The Netherlands
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Kelly A, Fazio D, Padgett D, Ran Z, Castelblanco DG, Kumar D, Doran KM. Patient views on emergency department screening and interventions related to housing. Acad Emerg Med 2022; 29:589-597. [PMID: 35064727 DOI: 10.1111/acem.14442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/15/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022]
Abstract
Objectives Emergency departments (EDs) serve as a health care "safety net" and may be uniquely suited to screening for and addressing patients' unmet social needs. We aimed to better understand patient perspectives on ED-based screening and interventions related to housing instability, as a step toward improving future efforts. Methods We present findings from a qualitative study using in-depth, one-on-one interviews with ED patients who had become homeless in the past 6 months. Qualitative interviewees were asked their thoughts on ED staff asking about and helping to address homelessness and housing issues. Interviews were professionally transcribed verbatim. Multiple coders identified interview text segments focused on ED-based housing screening and intervention, which were then independently analyzed thematically and discussed to reach consensus. Researchers also categorized each participant's overall opinion on ED housing screening and interventions as positive, neutral, or negative. Results Qualitative interviews were conducted with 31 patients. Four themes related to ED-based housing screening and interventions emerged: (1) patients generally welcome ED staff/providers asking about and assisting with their housing situation, with caveats around privacy and respect; (2) ED conversations about housing have potential benefits beyond addressing unmet housing needs; (3) patients may not consider the ED as a site to obtain help with housing; (4) patients' experiences navigating existing housing services can inform best approaches for the ED. Most participants expressed overall positive views of ED staff/providers asking patients about their housing situation. Conclusions Study participants generally felt positively about screening and interventions for housing in the ED. Insights from this study can inform future ED-based housing instability screening and interventions.
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Affiliation(s)
- Audrey Kelly
- Department of Emergency Medicine NYU School of Medicine New York New York USA
| | - Daniela Fazio
- Department of Emergency Medicine NYU School of Medicine New York New York USA
| | | | - Ziwei Ran
- NYU Silver School of Social Work New York New York USA
| | | | - Diana Kumar
- Department of Emergency Medicine NYU School of Medicine New York New York USA
| | - Kelly M. Doran
- Department of Emergency Medicine NYU School of Medicine New York New York USA
- Department of Population Health NYU School of Medicine New York New York USA
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Steeves-Reece AL, Totten AM, Broadwell KD, Richardson DM, Nicolaidis C, Davis MM. Social Needs Resource Connections: A Systematic Review of Barriers, Facilitators, and Evaluation. Am J Prev Med 2022; 62:e303-e315. [PMID: 35078672 PMCID: PMC9850790 DOI: 10.1016/j.amepre.2021.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/20/2021] [Accepted: 12/01/2021] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Healthcare organizations increasingly are screening patients for social needs (e.g., food, housing) and referring them to community resources. This systematic mixed studies review assesses how studies evaluate social needs resource connections and identifies patient- and caregiver-reported factors that may inhibit or facilitate resource connections. METHODS Investigators searched PubMed and CINAHL for articles published from October 2015 to December 2020 and used dual review to determine inclusion based on a priori selection criteria. Data related to study design, setting, population of interest, intervention, and outcomes were abstracted. Articles' quality was assessed using the Mixed Methods Appraisal Tool. Data analysis was conducted in 2021. RESULTS The search identified 34 articles from 32 studies. The authors created a taxonomy of quantitative resource connection measures with 4 categories: whether participants made contact with resources, received resources, had their social needs addressed, or rated some aspect of their experience with resources. Barriers to resource connections were inadequacy, irrelevancy, or restrictiveness; inaccessibility; fears surrounding stigma or discrimination; and factors related to staff training and resource information sharing. Facilitators were referrals' relevancy, the degree of support and simplicity embedded within the interventions, and interventions being comprehensive and inclusive. DISCUSSION This synthesis of barriers and facilitators indicates areas where healthcare organizations may have agency to improve the efficacy of social needs screening and referral interventions. The authors also recommend that resource connection measures be explicitly defined and focus on whether participants received new resources and whether their social needs were addressed.
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Affiliation(s)
- Anna Louise Steeves-Reece
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon; Oregon Rural Practice-based Research Network, School of Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Annette Marie Totten
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon; Oregon Rural Practice-based Research Network, School of Medicine, Oregon Health & Science University, Portland, Oregon; Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon; Department of Medical Informatics & Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Katherine DuBose Broadwell
- Oregon Rural Practice-based Research Network, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Dawn Michele Richardson
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - Christina Nicolaidis
- School of Social Work, Portland State University, Portland, Oregon; Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Melinda Marie Davis
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon; Oregon Rural Practice-based Research Network, School of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
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Ruder E, Demment M, Graham M. Supplemental Nutrition Assistance Program (SNAP) Shoppers Experience in A Grocery Store Fruit and Vegetable Incentive Program: A Qualitative Study. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2022. [DOI: 10.1080/19320248.2022.2067511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Elizabeth Ruder
- Wegmans School of Health and Nutrition, Rochester Institute of Technology, Rochester, NY USA
| | - Meg Demment
- Collaborative Health Research, LLC, Rochester, NY, USA
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Zimmer RP, Moore JB, Yang M, Evans J, Best S, McNeill S, Harrison D, Martin H, Montez K. Strategies and Lessons Learned from a Home Delivery Food Prescription Program for Older Adults. J Nutr Gerontol Geriatr 2022; 41:217-234. [PMID: 35694773 PMCID: PMC11289850 DOI: 10.1080/21551197.2022.2084204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Food insecurity (FI) is a growing health problem, worsening during the COVID-19 pandemic. Fresh food prescription programs (FFRx) have been shown to increase healthy eating and decrease FI, but few FFRx are community-informed, or theory based. Our FFRx was a delivery program developed to alleviate FI for older adults. It was implemented in an academic medical center and guided by the Capabilities, Opportunities, Motivations, and Behaviors and Theoretical Domains Framework. We tested impacts of the program on FI, Fruit and Vegetable (FV) intake, depression, and loneliness at six-month intervals. During the FFRx, 31 people completed surveys every six months. FI decreased by an average of 2.03 points (p = <.001) while FV intake increased from a mean of 2.8 servings per day to 2.9 servings per day (p = .53). Depression and loneliness scores stayed stable. Preliminary data from this FFRx program, a partnership between an academic medical center and community partners, had positive impacts on FI.
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Affiliation(s)
- Rachel P Zimmer
- Atrium Health Wake Forest Baptist, Winston Salem, North Carolina, USA
- Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Justin B Moore
- Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Mia Yang
- Atrium Health Wake Forest Baptist, Winston Salem, North Carolina, USA
- Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Joni Evans
- Atrium Health Wake Forest Baptist, Winston Salem, North Carolina, USA
| | - Scott Best
- HOPE of Winston Salem, Winston Salem, North Carolina, USA
| | - Sheena McNeill
- HOPE of Winston Salem, Winston Salem, North Carolina, USA
| | | | - Heather Martin
- Second Harvest Food Bank, Winston Salem, North Carolina, USA
| | - Kimberly Montez
- Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
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Woo Baidal JA, Meyer D, Partida I, Duong N, Rosenthal A, Hulse E, Nieto A. Feasibility of Food FARMacia: Mobile Food Pantry to Reduce Household Food Insecurity in Pediatric Primary Care. Nutrients 2022; 14:1059. [PMID: 35268034 PMCID: PMC8912842 DOI: 10.3390/nu14051059] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/29/2022] Open
Abstract
Despite recommendations for systematic food insecurity screening in pediatric primary care, feasible interventions in clinical settings are lacking. The goal of this study was to examine reach, feasibility, and retention in Food FARMacia, a pilot clinically based food insecurity intervention among children aged <6 years. We examined electronic health record data to assess reach and performed a prospective, longitudinal study of families in Food FARMacia (May 2019 to January 2020) to examine attendance and retention. We used descriptive statistics and bivariate analyses to assess outcomes. Among 650 pediatric patients, 172 reported household food insecurity and 50 registered for Food FARMacia (child mean age 22 ± 18 months; 88% Hispanic/Latino). Demographic characteristics of Food FARMacia participants were similar to those of the target group. Median attendance rate was 75% (10 sessions) and retention in both the study and program was 68%. Older child age (retention: age 26.7 ± 18.7 months vs. attrition: age 12.1 ± 13.8 months, p = 0.01), Hispanic/Latino ethnicity (retention: 97% vs. attrition: 69%, p < 0.01), and larger household size (retention: 4.5 ± 1.1 vs. attrition: 3.7 ± 1.4, p = 0.04) correlated with retention. A clinically based mobile food pantry pilot program and study reached the target population and were feasible.
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Affiliation(s)
- Jennifer A. Woo Baidal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (I.P.); (N.D.)
- NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY 10032, USA;
| | - Dodi Meyer
- NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY 10032, USA;
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA
| | - Ivette Partida
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (I.P.); (N.D.)
| | - Ngoc Duong
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032, USA; (I.P.); (N.D.)
| | | | - Emma Hulse
- Division of Community and Population Health, NewYork-Presbyterian, New York, NY 10032, USA; (E.H.); (A.N.)
| | - Andres Nieto
- Division of Community and Population Health, NewYork-Presbyterian, New York, NY 10032, USA; (E.H.); (A.N.)
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Canavan CR, D'cruze T, Kennedy MA, Hatchell KE, Boardman M, Suresh A, Goodman D, Dev A. Missed opportunities to improve food security for pregnant people: a qualitative study of prenatal care settings in Northern New England during the COVID-19 pandemic. BMC Nutr 2022; 8:8. [PMID: 35067225 PMCID: PMC8784232 DOI: 10.1186/s40795-022-00499-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/29/2021] [Indexed: 01/20/2023] Open
Abstract
Background Food insecurity during pregnancy has important implications for maternal and newborn health. There is increasing commitment to screening for social needs within health care settings. However, little is known about current screening processes or the capacity for prenatal care clinics to address food insecurity among their patients. We aimed to assess barriers and facilitators prenatal care clinics face in addressing food insecurity among pregnant people and to identify opportunities to improve food security among this population. Methods We conducted a qualitative study among prenatal care clinics in New Hampshire and Vermont. Staff and clinicians engaged in food security screening and intervention processes at clinics affiliated with the Northern New England Perinatal Quality Improvement Network (NNEPQIN) were recruited to participate in key informant interviews. Thematic analysis was used to identify prominent themes in the interview data. Results Nine staff members or clinicians were enrolled and participated in key informant interviews. Key barriers to food security screening and interventions included lack of protocols and dedicated staff at the clinic as well as community factors such as availability of food distribution services and transportation. Facilitators of screening and intervention included a supportive culture at the clinic, trusting relationships between patients and clinicians, and availability of clinic-based and community resources. Conclusion Prenatal care settings present an important opportunity to identify and address food insecurity among pregnant people, yet most practices lack specific protocols for screening. Our findings indicate that more systematic processes for screening and referrals, dedicated staff, and onsite food programs that address transportation and other access barriers could improve the capacity of prenatal care clinics to improve food security during pregnancy. Supplementary Information The online version contains supplementary material available at 10.1186/s40795-022-00499-7.
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Affiliation(s)
- Chelsey R Canavan
- Department of Population Health, Dartmouth-Hitchcock Medical Center, Medical Center Drive, Lebanon, NH, 03766, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Tiffany D'cruze
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Meaghan A Kennedy
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Kayla E Hatchell
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Maureen Boardman
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Arvind Suresh
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Daisy Goodman
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Alka Dev
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Taher S, Muramatsu N, Odoms-Young A, Peacock N, Michael CF, Courtney KS. An embedded multiple case study: using CFIR to map clinical food security screening constructs for the development of primary care practice guidelines. BMC Public Health 2022; 22:97. [PMID: 35030999 PMCID: PMC8758892 DOI: 10.1186/s12889-021-12407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/10/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Food insecurity (FI), the limited access to healthy food to live an active and healthy life, is a social determinant of health linked to poor dietary health and difficulty with disease management in the United States (U.S.). Healthcare experts support the adoption of validated screening tools within primary care practice to identify and connect FI patients to healthy and affordable food resources. Yet, a lack of standard practices limits uptake. The purpose of this study was to understand program processes and outcomes of primary care focused FI screening initiatives that may guide wide-scale program implementation. METHODS This was an embedded multiple case study of two primary care-focused initiatives implemented in two diverse health systems in Chicago and Suburban Cook County that routinely screened patients for FI and referred them to onsite food assistance programs. The Consolidated Framework for Implementation Research and an iterative process were used to collect/analyze qualitative data through semi-structured interviews with N = 19 healthcare staff. Intended program activities, outcomes, actors, implementation barriers/facilitators and overarching implementation themes were identified as a part of a cross-case analysis. RESULTS Programs outcomes included: the number of patients screened, identified as FI and that participated in the onsite food assistance program. Study participants reported limited internal resources as implementation barriers for program activities. The implementation climate that leveraged the strength of community collaborations and aligned internal, implementation climate were critical facilitators that contributed to the flexibility of program activities that were tailored to fill gaps in resources and meet patient and clinician needs. CONCLUSION Highly adaptable programs and the healthcare context enhanced implementation feasibility across settings. These characteristics can support program uptake in other settings, but should be used with caution to preserve program fidelity. A foundational model for the development and testing of standard clinical practice was the product of this study.
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Affiliation(s)
- Sabira Taher
- Department of Preventive Medicine, Northwestern Feinberg School of Medicine, 680 N Lake Shore Drive Suite 1400, Chicago, IL, 60611, USA.
| | - Naoko Muramatsu
- Department of Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Chicago, IL, 60612, USA
| | - Angela Odoms-Young
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA
| | - Nadine Peacock
- Department of Community Health Sciences, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Chicago, IL, 60612, USA
| | - C Fagen Michael
- Department of Preventive Medicine, Northwestern Feinberg School of Medicine, 680 N Lake Shore Drive Suite 1400, Chicago, IL, 60611, USA
| | - K Suh Courtney
- Department of Family Medicine, Loyola Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL, 60153, USA
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South E, Rodgers M, Wright K, Whitehead M, Sowden A. Reducing lifestyle risk behaviours in disadvantaged groups in high-income countries: A scoping review of systematic reviews. Prev Med 2022; 154:106916. [PMID: 34922995 PMCID: PMC8803546 DOI: 10.1016/j.ypmed.2021.106916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/06/2021] [Accepted: 12/12/2021] [Indexed: 11/20/2022]
Abstract
High prevalence of risk behaviours may exacerbate existing poor health in disadvantaged groups. We aimed to identify and bring together systematic reviews with a focus on reducing risk behaviours in disadvantaged groups and highlight where evidence is lacking. We searched MEDLINE and Embase up to October 2020, with supplementary searching in Epistemonikos and Health Systems Evidence. We included systematic reviews that reported behavioural outcomes and targeted smoking, excessive alcohol use, unhealthy diet, or physical inactivity in groups with the following characteristics: low income or low socio-economic status (SES), unemployed people, homeless people, care leavers, prisoners, refugees or asylum seeker, Gypsies, Travellers, or Roma, people with learning disabilities and people living in disadvantaged areas. Reviews that included primary studies from any high-income country were eligible. Reviews were mapped based on the disadvantaged group(s) and behaviour(s) targeted. Ninety-two reviews were included, with the majority (n = 63) focusing on people with low income or low SES. We identified gaps in the evidence for care leavers; Gypsies, Travellers, and Roma and limited evidence for refugees and unemployed people. Few reviews targeted alcohol use. There was limited evidence on barriers and facilitators to behaviour change. This suggests there is insufficient evidence to inform policy and practice and new reviews or primary studies may be required.
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Affiliation(s)
- Emily South
- Centre for Reviews and Dissemination, University of York, York, United Kingdom.
| | - Mark Rodgers
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Margaret Whitehead
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, United Kingdom
| | - Amanda Sowden
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
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76
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Hatchell KE, Canavan CR, D’cruze T, Suresh A, Dev A, Boardman M, Kennedy MA. The Impact of the COVID-19 Pandemic on Food Insecurity in Northern New England Primary and Prenatal Care Settings. J Prim Care Community Health 2022; 13:21501319221106626. [PMID: 35712859 PMCID: PMC9210087 DOI: 10.1177/21501319221106626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE Food insecurity (FI) is associated with adverse health outcomes across the lifespan. Primary care and prenatal practices can identify and address FI among patients through screening and interventions. It is unclear how practices and communities responded to FI during the COVID-19 pandemic, and how the pandemic may have impacted practices' FI strategies. We aimed to understand how practices providing primary care or prenatal care in northern New England experienced changes in FI during the COVID-19 pandemic. METHODS We conducted a web-based survey of clinicians and staff from 43 unique practices providing primary care or prenatal care in northern New England. RESULTS Most practices (59.5%) reported at least 1 new food program in the practice or community since the pandemic began. Practices reporting new practice- or community-based food programs were more likely to be rural, federally qualified health centers, and have greater confidence in practice and community capacity to address FI (chi-square tests, P < .05). CONCLUSION Results suggest that practices and surrounding communities in northern New England responded to FI during the pandemic by increasing food support programs. Future work is needed to examine the impact of food programs initiated during the pandemic and determine optimal strategies for practices to address FI among patients.
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Affiliation(s)
| | - Chelsey R. Canavan
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | | | - Arvind Suresh
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Alka Dev
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
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McDougall JA, Jaffe SA, Guest DD, Sussman AL. The Balance Between Food and Medical Care: Experiences of Food Insecurity Among Cancer Survivors and Informal Caregivers. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2022; 17:380-396. [PMID: 35757157 PMCID: PMC9216194 DOI: 10.1080/19320248.2021.1892295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Defined as an inability to acquire enough food because of insufficient money or other resources, the prevalence of food insecurity is markedly higher among cancer survivors than the general population. The objective of this qualitative study was to understand and characterize the experience of food insecurity from the perspective of cancer survivors' and their informal caregivers using qualitative interviews. Barriers to healthy eating, behaviors and strategies in times of food shortage, and unmet educational needs shaped the experience of food insecurity. These experiences and insights for addressing food insecurity in oncology practice have broad implications for future interventions.
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Affiliation(s)
- Jean A. McDougall
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM,Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | | | - Dolores D. Guest
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM,Department of Internal Medicine, University of New Mexico, Albuquerque, NM
| | - Andrew L. Sussman
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM,Department of Community and Family Medicine, University of New Mexico, Albuquerque, NM
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78
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Fraze TK, Beidler LB, Savitz LA. "It's Not Just the Right Thing . . . It's a Survival Tactic": Disentangling Leaders' Motivations and Worries on Social Care. Med Care Res Rev 2021; 79:701-716. [PMID: 34906013 PMCID: PMC9397397 DOI: 10.1177/10775587211057673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Health care organizations face growing pressure to improve their patients’ social conditions, such as housing, food, and economic insecurity. Little is known about the motivations and concerns of health care organizations when implementing activities aimed at improving patients’ social conditions. We used semi-structured interviews with 29 health care organizations to explore their motivations and tensions around social care. Administrators described an interwoven set of motivations for delivering social care: (a) doing the right thing for their patients, (b) improving health outcomes, and (c) making the business case. Administrators expressed tensions around the optimal role for health care in social care including uncertainty around (a) who should be responsible, (b) whether health care has the needed capacity/skills, and (c) sustainability of social care activities. Health care administrators could use guidance and support from policy makers on how to effectively prioritize social care activities, partner with other sectors, and build the needed workforce.
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Affiliation(s)
| | | | - Lucy A Savitz
- Kaiser Permanente Center for Health Research, Portland, OR, USA
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79
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Budd Nugent N, Byker Shanks C, Seligman HK, Fricke H, Parks CA, Stotz S, Yaroch AL. Accelerating Evaluation of Financial Incentives for Fruits and Vegetables: A Case for Shared Measures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212140. [PMID: 34831902 PMCID: PMC8621044 DOI: 10.3390/ijerph182212140] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022]
Abstract
Food insecurity, or lack of consistent access to enough food, is associated with low intakes of fruits and vegetables (FVs) and higher risk of chronic diseases and disproportionately affects populations with low income. Financial incentives for FVs are supported by the 2018 Farm Bill and United States (U.S.) Department of Agriculture’s Gus Schumacher Nutrition Incentive Program (GusNIP) and aim to increase dietary quality and food security among households participating in the Supplemental Nutrition Assistance Program (SNAP) and with low income. Currently, there is no shared evaluation model for the hundreds of financial incentive projects across the U.S. Despite the fact that a majority of these projects are federally funded and united as a cohort of grantees through GusNIP, it is unclear which models and attributes have the greatest public health impact. We explore the evaluation of financial incentives in the U.S. to demonstrate the need for shared measurement in the future. We describe the process of the GusNIP NTAE, a federally supported initiative, to identify and develop shared measurement to be able to determine the potential impact of financial incentives in the U.S. This commentary discusses the rationale, considerations, and next steps for establishing shared evaluation measures for financial incentives for FVs, to accelerate our understanding of impact, and support evidence-based policymaking.
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Affiliation(s)
- Nadine Budd Nugent
- Gretchen Swanson Center for Nutrition, Omaha, NE 68114, USA; (C.B.S.); (H.F.); (C.A.P.); (A.L.Y.)
- Correspondence: ; Tel.: +1-410-991-0767
| | - Carmen Byker Shanks
- Gretchen Swanson Center for Nutrition, Omaha, NE 68114, USA; (C.B.S.); (H.F.); (C.A.P.); (A.L.Y.)
| | - Hilary K. Seligman
- Division of General Internal Medicine, University of California, San Francisco, CA 94143, USA;
| | - Hollyanne Fricke
- Gretchen Swanson Center for Nutrition, Omaha, NE 68114, USA; (C.B.S.); (H.F.); (C.A.P.); (A.L.Y.)
| | - Courtney A. Parks
- Gretchen Swanson Center for Nutrition, Omaha, NE 68114, USA; (C.B.S.); (H.F.); (C.A.P.); (A.L.Y.)
| | - Sarah Stotz
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Colorado School of Public Health, Aurora, CO 80045, USA;
| | - Amy L. Yaroch
- Gretchen Swanson Center for Nutrition, Omaha, NE 68114, USA; (C.B.S.); (H.F.); (C.A.P.); (A.L.Y.)
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80
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Palakshappa D, Ip EH, Berkowitz SA, Bertoni AG, Foley KL, Miller DP, Vitolins MZ, Rosenthal GE. Pathways by Which Food Insecurity Is Associated With Atherosclerotic Cardiovascular Disease Risk. J Am Heart Assoc 2021; 10:e021901. [PMID: 34743567 PMCID: PMC8751929 DOI: 10.1161/jaha.121.021901] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022]
Abstract
Background Food insecurity (FI) has been associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk; however, the pathways by which FI leads to worse cardiovascular health are unknown. We tested the hypothesis that FI is associated with ASCVD risk through nutritional/anthropometric (eg, worse diet quality and increased weight), psychological/mental health (eg, increased depressive symptoms and risk of substance abuse), and access to care pathways. Methods and Results We conducted a cross-sectional study of adults (aged 40-79 years) using the 2007 to 2016 National Health and Nutrition Examination Survey. Our primary exposure was household FI, and our outcome was 10-year ASCVD risk categorized as low (<5%), borderline (≥5% -<7.5%), intermediate (≥7.5%-<20%), and high risk (≥20%). We used structural equation modeling to evaluate the pathways and multiple mediation analysis to determine direct and indirect effects. Of the 12 429 participants, 2231 (18.0%) reported living in a food-insecure household; 5326 (42.9%) had a low ASCVD risk score, 1402 (11.3%) borderline, 3606 (29.0%) intermediate, and 2095 (16.9%) had a high-risk score. In structural models, we found significant path coefficients between FI and the nutrition/anthropometric (β, 0.130; SE, 0.027; P<0.001), psychological/mental health (β, 0.612; SE, 0.043; P<0.001), and access to care (β, 0.110; SE, 0.036; P=0.002) pathways. We did not find a significant direct effect of FI on ASCVD risk, and the nutrition, psychological, and access to care pathways accounted for 31.6%, 43.9%, and 15.8% of the association, respectively. Conclusions We found that the association between FI and ASCVD risk category was mediated through the nutrition/anthropometric, psychological/mental health, and access to care pathways. Interventions that address all 3 pathways may be needed to mitigate the negative impact of FI on cardiovascular disease.
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Affiliation(s)
- Deepak Palakshappa
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
- Department of PediatricsWake Forest School of MedicineWinston‐SalemNC
| | - Edward H. Ip
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Seth A. Berkowitz
- Division of General Medicine and Clinical EpidemiologyDepartment of MedicineUniversity of North Carolina at Chapel Hill School of MedicineChapel HillNC
- Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillNC
| | - Alain G. Bertoni
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Kristie L. Foley
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - David P. Miller
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Mara Z. Vitolins
- Division of Public Health SciencesWake Forest School of MedicineWinston‐SalemNC
| | - Gary E. Rosenthal
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNC
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81
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Affiliation(s)
- Gary Bloch
- Department of Family and Community Medicine (Bloch), University of Toronto; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Inner City Health Associates (Bloch); Independent qualitative health research consultant (Rozmovits), Toronto, Ont.
| | - Linda Rozmovits
- Department of Family and Community Medicine (Bloch), University of Toronto; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Inner City Health Associates (Bloch); Independent qualitative health research consultant (Rozmovits), Toronto, Ont
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82
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Poulos NS, Nehme EK, O'Neil MM, Mandell DJ. Implementing food bank and healthcare partnerships: a pilot study of perspectives from charitable food systems in Texas. BMC Public Health 2021; 21:2025. [PMID: 34742273 PMCID: PMC8572069 DOI: 10.1186/s12889-021-12031-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/15/2021] [Indexed: 12/05/2022] Open
Abstract
Background Partnerships between charitable food systems and healthcare systems have been forming across the country to support individuals and families experiencing food insecurity, yet little research has focused on these partnerships, particularly from a food bank perspective. The objective of this exploratory pilot study was to identify implementation challenges and facilitators of charitable food system and healthcare partnerships from the food bank perspective. Method Texas food banks with existing food bank/healthcare partnerships were identify through website review and support from Feeding Texas. Interview questions were tailored to each interview, but all focused on identify program components of the food bank/healthcare partnership and implementation barriers/facilitators of the partnership. In total, six interviews were conducted with food bank/healthcare partnership leaders (n = 4) and charitable food system experts (n = 2) about their experiences of working with food bank/healthcare partnerships. All interviews were completed via Zoom and took between 30 and 60 min to completed. Detailed notes were taking during each interview, and immediately discussed with the complete research time to formulate broad implementation themes. Results Interviews suggest unique implementation challenges exist at all levels of food bank/healthcare partnerships including the partnership, program, and system levels. Partnership-level implementation challenges focused on issues of partnership scale and data collection, sharing, and analysis. Program-level implementation challenges focused on food and produce expectations. Structural-level implementation challenges included issues of food safety, subsidized food regulations, and patient privacy. Implementation facilitators included leadership support, mission compatibility/organizational readiness, food insecurity training, and identify of partnership champions. Conclusions This study adds to the growing interest in food bank/healthcare partnership as it highlights unique implementation challenges and facilitators for cross-sector partnerships between healthcare systems and community-based charitable food systems. Ultimately, we believe that collaborative discussion among leaders of charitable food systems and healthcare systems is needed to overcome outlined implementation challenges to better facilitate sustainable, equitable implementation of food bank/healthcare partnerships.
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Affiliation(s)
- Natalie S Poulos
- Department of Community Health, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, Tyler, TX, United States, 75708.
| | - Eileen K Nehme
- Department of Community Health, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, Tyler, TX, United States, 75708
| | - Molly M O'Neil
- Department of Community Health, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, Tyler, TX, United States, 75708
| | - Dorothy J Mandell
- Department of Community Health, University of Texas Health Science Center at Tyler, 11937 US Hwy 271, Tyler, TX, United States, 75708
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83
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Parry J, Vanstone M, Grignon M, Dunn JR. Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature. Int J Equity Health 2021; 20:219. [PMID: 34620188 PMCID: PMC8496150 DOI: 10.1186/s12939-021-01546-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is broadly accepted that poverty is associated with poor health, and the health impact of poverty has been explored in numerous high-income country settings. There is a large and growing body of evidence of the role that primary care practitioners can play in identifying poverty as a health determinant, and in interventions to address it. PURPOSE OF STUDY This study maps the published peer-reviewed and grey literature on primary care setting interventions to address poverty in high-income countries in order to identify key concepts and gaps in the research. This scoping review seeks to map the tools in use to identify and address patients' economic needs; describe the key types of primary care-based interventions; and examine barriers and facilitators to successful implementation. METHODS Using a scoping review methodology, we searched five databases, the grey literature and the reference lists of relevant studies to identify studies on interventions to address the economic needs-related social determinants of health that occur in primary health care delivery settings, in high-income countries. Findings were synthesized narratively, and examined using thematic analysis, according to iteratively identified themes. RESULTS Two hundred and fourteen papers were included in the review and fell into two broad categories of description and evaluation: screening tools, and economic needs-specific interventions. Primary care-based interventions that aim to address patients' financial needs operate at all levels, from passive sociodemographic data collection upon patient registration, through referral to external services, to direct intervention in addressing patients' income needs. CONCLUSION Tools and processes to identify and address patients' economic social needs range from those tailored to individual health practices, or addressing one specific dimension of need, to wide-ranging protocols. Primary care-based interventions to address income needs operate at all levels, from passive sociodemographic data collection, through referral to external services, to direct intervention. Measuring success has proven challenging. The decision to undertake this work requires courage on the part of health care providers because it can be difficult, time-consuming and complex. However, it is often appreciated by patients, even when the scope of action available to health care providers is quite narrow.
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Affiliation(s)
- Jane Parry
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - Michel Grignon
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
| | - James R. Dunn
- Department of Health, Aging and Society, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8 Canada
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84
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Magnan S. Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act. NAM Perspect 2021; 2021:202106c. [PMID: 34532697 DOI: 10.31478/202106c] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Sanne Magnan
- Health Partners Institute and the University of Minnesota
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85
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Srinivasan M, Cen X, Farrar B, Pooler JA, Fish T. Food Insecurity Among Health Care Workers In The US. Health Aff (Millwood) 2021; 40:1449-1456. [PMID: 34495718 DOI: 10.1377/hlthaff.2021.00450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Food insecurity, or the lack of access to an adequate supply of nutritious food, is associated with poor health outcomes including diabetes, heart disease, and depression. Food insecurity research has grown in the past two decades and has spurred efforts in the US health care system to "screen and intervene" for patient food insecurity. Using nationally representative data from the period 2013-18, this study is the first to our knowledge to investigate the prevalence of food insecurity for the health care workforce, an industry that ranges from low-skill, low-wage hourly jobs to highly specialized salaried positions. We found that relative to health diagnosing and treating practitioners, the odds of being food insecure were 5.1 times higher for health care support workers and 2.5 times higher for health technologists and technicians. The health care industry is the largest and fastest-growing US employer, and it is vital that leaders and policy makers address food insecurity among the health care workforce.
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Affiliation(s)
- Mithuna Srinivasan
- Mithuna Srinivasan is a principal research scientist, Health Care Department, NORC at the University of Chicago, in Bethesda, Maryland
| | - Xi Cen
- Xi Cen is a research associate, Health Division, IMPAQ International, in Oakland, California
| | - Brandy Farrar
- Brandy Farrar is a principal research associate, Health Division, IMPAQ International, in Washington, D.C
| | - Jennifer A Pooler
- Jennifer A. Pooler is a senior study director, Food and Nutrition Practice Area, Insight Policy Research, in Arlington, Virginia
| | - Talia Fish
- Talia Fish is a research associate, Health Division, IMPAQ International, in Brooklyn, New York
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Cook M, Ward R, Newman T, Berney S, Slagel N, Bussey-Jones J, Schmidt S, Sun Lee J, Webb-Girard A. Food Security and Clinical Outcomes of the 2017 Georgia Fruit and Vegetable Prescription Program. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2021; 53:770-778. [PMID: 34509277 DOI: 10.1016/j.jneb.2021.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Evaluate improvements in food security and health outcomes associated with participation in a produce prescription program. DESIGN Program evaluation with repeated measures over 6 months. SETTING Six sites across Georgia. PARTICIPANTS Of the 159 enrolled through primary care sites, 122 participants were considered graduates (attended at least 3 of the 6 monthly visits). The majority of program graduates were Black (78.7%), earned <$25,000 annually (76.6%), and were food insecure (74.2%). INTERVENTION Six-month program offering group-based nutrition and cooking education along with subsidies for fresh produce worth $1 per family member per day, redeemable weekly. MAIN OUTCOME MEASURES Food security, blood pressure, body mass index, waist circumference, and glycated hemoglobin. ANALYSIS Linear mixed models estimating association of change in outcomes with program visits 1-6. Fixed effects included participant sex and age, whereas random effects included random intercepts and slopes for the site of program participation and participants. RESULTS Participation in a produce prescription program combining subsidies for produce and nutrition education decreased food insecurity (P < 0.001) and diastolic blood pressure significantly (P = 0.019). CONCLUSIONS AND IMPLICATIONS These findings highlight the promise of this program and similar programs for improving patient food security and health outcomes among the most vulnerable, underserved communities while aiding in setting realistic expectations and suggestions for program implementation.
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Affiliation(s)
- Miranda Cook
- Laney Graduate School, Emory University, Atlanta, GA.
| | | | - Taylor Newman
- College of Family and Consumer Sciences, University of Georgia, Athens, GA
| | | | - Nicholas Slagel
- College of Family and Consumer Sciences, University of Georgia, Athens, GA
| | | | | | - Jung Sun Lee
- College of Family and Consumer Sciences, University of Georgia, Athens, GA
| | - Amy Webb-Girard
- Hubert Department of Global Health, Emory University, Atlanta, GA
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Oronce CIA, Miake-Lye IM, Begashaw MM, Booth M, Shrank WH, Shekelle PG. Interventions to Address Food Insecurity Among Adults in Canada and the US: A Systematic Review and Meta-analysis. JAMA HEALTH FORUM 2021; 2:e212001. [PMID: 35977189 PMCID: PMC8796981 DOI: 10.1001/jamahealthforum.2021.2001] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022] Open
Abstract
Importance Inadequate access to food is a risk factor for poor health and the effectiveness of federal programs targeting food insecurity, such as the Supplemental Nutrition Assistance Program (SNAP), are well-documented. The associations between other types of interventions to provide adequate food access and food insecurity status, health outcomes, and health care utilization, however, are unclear. Objective To review evidence on the association between food insecurity interventions and food insecurity status, clinically-relevant health outcomes, and health care utilization among adults, excluding SNAP. Data Sources A systematic search for English-language literature was performed in PubMed Central and Cochrane Trials databases (inception to January 23, 2020), the Social Interventions Research and Evaluation Network database (December 10, 2019); and the gray literature using Google (February 1, 2021). Study Selection Studies of any design that assessed the association between food insecurity interventions for adult participants and food insecurity status, health outcomes, and health care utilization were screened for inclusion. Studies of interventions that described addressing participants' food needs or reporting food insecurity as an outcome were included. Interventions were categorized as home-delivered food, food offered at a secondary site, monetary assistance in the form of subsidies or income supplements, food desert interventions, and miscellaneous. Data Extraction and Synthesis Data extraction was performed independently by 3 reviewers. Study quality was assessed using the Cochrane Risk of Bias Tool, the ROBINS-I (Risk of Bias in Non-Randomized Studies of Interventions) tool, and a modified version of the National Institutes of Health's Quality Assessment Tool for Before-After Studies With No Control. The certainty of evidence was based on GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and supplemented with mechanistic and parallel evidence. For outcomes within intervention categories with at least 3 studies, random effects meta-analysis was performed. Main Outcomes and Measures Food insecurity (measured through surveys; eg, the 2-item Hunger Vital Sign), health outcomes (eg, hemoglobin A1c), and health care utilization (eg, hospitalizations, costs). Results A total of 39 studies comprising 170 605 participants were included (8 randomized clinical trials and 31 observational studies). Of these, 14 studies provided high-certainty evidence of an association between offering food and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.53; 95% CI, 0.33-0.67). Ten studies provided moderate-certainty evidence of an association between offering monetary assistance and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.64; 95% CI, 0.49-0.84). There were fewer studies of the associations between interventions and health outcomes or health care utilization, and the evidence in these areas was of low or very low certainty that any food insecurity interventions were associated with changes in either. Conclusions and Relevance This systematic review with meta-analysis found that providing food and monetary assistance was associated with improved food insecurity measures; however, whether it translated to better health outcomes or reduced health care utilization was unclear.
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Affiliation(s)
- Carlos Irwin A. Oronce
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- David Geffen School of Medicine, University of California, Los Angeles
- National Clinician Scholars Program, University of California, Los Angeles
| | - Isomi M. Miake-Lye
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Meron M. Begashaw
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
| | - Marika Booth
- RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | | | - Paul G. Shekelle
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
- David Geffen School of Medicine, University of California, Los Angeles
- RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
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Venkatesh A, Chang A, Green EA, Randall T, Gallagher R, Wildes JE, Graham AK. Perceived Facilitators and Barriers to Engaging with a Digital Intervention among Those with Food Insecurity, Binge Eating, and Obesity. Nutrients 2021; 13:2458. [PMID: 34371967 PMCID: PMC8308534 DOI: 10.3390/nu13072458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022] Open
Abstract
Interventions that address binge eating and food insecurity are needed. Engaging people with lived experience to understand their needs and preferences could yield important design considerations for such interventions. In this study, people with food insecurity, recurrent binge eating, and obesity completed an interview-based needs assessment to learn facilitators and barriers that they perceive would impact their engagement with a digital intervention for managing binge eating and weight. Twenty adults completed semi-structured interviews. Responses were analyzed using thematic analysis. Three themes emerged. Participants shared considerations that impact their ability to access the intervention (e.g., cost of intervention, cost of technology, accessibility across devices), ability to complete intervention recommendations (e.g., affordable healthy meals, education to help stretch groceries, food vouchers, rides to grocery stores, personalized to budget), and preferred intervention features for education, self-monitoring, personalization, support, and motivation/rewards. Engaging people with lived experiences via user-centered design methods revealed important design considerations for a digital intervention to meet this population's needs. Future research is needed to test whether a digital intervention that incorporates these recommendations is engaging and effective for people with binge eating and food insecurity. Findings may have relevance to designing digital interventions for other health problems as well.
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Affiliation(s)
- Anu Venkatesh
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (A.V.); (A.C.)
| | - Angela Chang
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (A.V.); (A.C.)
| | - Emilie A. Green
- Department of Psychology, Rosalind Franklin University for Medical Sciences, Chicago, IL 60064, USA;
| | - Tianna Randall
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL 60208, USA; (T.R.); (R.G.)
| | - Raquel Gallagher
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL 60208, USA; (T.R.); (R.G.)
| | - Jennifer E. Wildes
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Chicago, IL 60611, USA;
| | - Andrea K. Graham
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; (A.V.); (A.C.)
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89
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Knight JK, Fritz Z. Doctors have an ethical obligation to ask patients about food insecurity: what is stopping us? JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107409. [PMID: 34261802 PMCID: PMC9554025 DOI: 10.1136/medethics-2021-107409] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/28/2021] [Indexed: 05/03/2023]
Abstract
Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions (on both individual and public health policy levels) frequently focus on facilitating 'healthy choices', with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours (eg, smoking and alcohol use), as well as with doctors' frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians' ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities.
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Affiliation(s)
- Jessica Kate Knight
- Department of Acute Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Zoe Fritz
- Department of Acute Medicine, The Healthcare Improvement Studies Institute, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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90
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Estrella A, Scheidell J, Khan M, Castelblanco D, Mijanovich T, Lee DC, Gelberg L, Doran KM. Cross-sectional Analysis of Food Insecurity and Frequent Emergency Department Use. West J Emerg Med 2021; 22:911-918. [PMID: 35354018 PMCID: PMC8328160 DOI: 10.5811/westjem.2021.3.50981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/08/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients have higher than average levels of food insecurity. We examined the association between multiple measures of food insecurity and frequent ED use in a random sample of ED patients. METHODS We completed survey questionnaires with randomly sampled adult patients from an urban public hospital ED (n = 2,312). We assessed food insecurity using four questions from the United States Department of Agriculture Household Food Security Survey. The primary independent variable was any food insecurity, defined as an affirmative response to any of the four items. Frequent ED use was defined as self-report of ≥4 ED visits in the past year. We examined the relationship between patient food insecurity and frequent ED use using bivariate and multivariable analyses and examined possible mediation by anxiety/depression and overall health status. RESULTS One-third (30.9%) of study participants reported frequent ED use, and half (50.8%) reported any food insecurity. Prevalence of food insecurity was higher among frequent vs. non-frequent ED users, 62.8% vs 45.4% (P <0.001). After controlling for potential confounders, food insecurity remained significantly associated with frequent ED use (adjusted odds ratio 1.48, 95% confidence interval, 1.20-1.83). This observed association was partially attenuated when anxiety/depression and overall health status were added to models. CONCLUSION The high observed prevalence of food insecurity suggests that efforts to improve care of ED patients should assess and address this need. Further research is needed to assess whether addressing food insecurity may play an important role in efforts to reduce frequent ED use for some patients.
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Affiliation(s)
- Alex Estrella
- UMMS-Baystate, Department of Emergency Medicine, Springfield, Massachusetts
| | - Joy Scheidell
- New York University School of Medicine, NYU Langone Health, Department of Population Health, New York, New York
| | - Maria Khan
- New York University School of Medicine, NYU Langone Health, Department of Population Health, New York, New York
| | - Donna Castelblanco
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Tod Mijanovich
- New York University Steinhardt School of Culture, Education, and Human Development, Department of Applied Statistics, Social Science, and Humanities, New York, New York
| | - David C Lee
- New York University School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, Department of Family Medicine, Los Angeles, California.,UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Office of Healthcare Transformation and Innovation, Los Angeles, California
| | - Kelly M Doran
- New York University School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
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91
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Eldred D, Kameg BN. Addressing Food Insecurity in Primary Care. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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92
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Madigan KE, Leiman DA, Palakshappa D. Food Insecurity Is an Independent Risk Factor for Depressive Symptoms in Survivors of Digestive Cancers. Cancer Epidemiol Biomarkers Prev 2021; 30:1122-1128. [PMID: 33849966 PMCID: PMC8172480 DOI: 10.1158/1055-9965.epi-20-1683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/26/2021] [Accepted: 03/31/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Colorectal and other digestive cancer survivors are at increased risk of depression, which can negatively affect health outcomes. Food insecurity (FI), the lack of consistent access to enough food, can also contribute to these health complications. The objective of this study was to determine the relationship between FI and depressive symptoms within this population. METHODS We conducted a cross-sectional analysis of data from the 2007-2016 National Health and Nutrition Examination Survey. We included all adults (≥20 years) with a self-reported history of a digestive cancer (including colorectal, esophageal, stomach, liver, and pancreas cancer). Our primary exposure was household FI, and our outcome of interest was depressive symptoms, as measured by the validated 9-item Patient Health Questionnaire. We used multivariable ordinal logistic regression to test the association between FI and depressive symptoms, controlling for demographic and clinical covariates. RESULTS We included 229 adult digestive cancer survivors (weighted N = 1,510,579). The majority of the study sample was female and non-Hispanic White with mean of 11.0 years since cancer diagnosis; 14.3% reported FI. In multivariable models controlling for demographic and clinical covariates, we found that food insecure digestive cancer survivors had significantly higher odds of depressive symptoms than food secure digestive cancer survivors (OR: 3.25; 95% confidence interval: 1.24-8.55; P = 0.02). CONCLUSIONS Among a nationally representative sample of colorectal cancer and other digestive cancer survivors, FI was associated with increased odds of depressive symptoms. IMPACT This study adds further evidence to the negative impact FI may have on survivors' physical and mental health.
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Affiliation(s)
- Katelyn E Madigan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Deepak Palakshappa
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Tamargo JA, Hernandez-Boyer J, Teeman C, Martin HR, Huang Y, Johnson A, Campa A, Martinez SS, Li T, Rouster SD, Meeds HL, Sherman KE, Baum MK. Immune activation: A link between food insecurity and chronic disease in people living with HIV. J Infect Dis 2021; 224:2043-2052. [PMID: 33993311 DOI: 10.1093/infdis/jiab257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/11/2021] [Indexed: 11/14/2022] Open
Abstract
Persistent immune activation is a hallmark of HIV infection and thought to play a role on chronic diseases in people with HIV (PWH). Food insecurity is disproportionately prevalent in PWH and is associated with adverse health outcomes. We determined whether food insecurity was associated with increased plasma levels of sCD14, sCD27, and sCD163 in 323 antiretroviral -treated PWH from the Miami Adult Studies on HIV (MASH) Cohort. Nearly half (42.7%) of participants were food insecure and 85.5% were virally suppressed (<200 copies/mL). Food insecurity was independently associated with higher levels of sCD14 and sCD27. Very low food security was associated with increased sCD163 levels among those with lower CD4+ cell counts. Food insecurity may promote immune activation in PWH, suggesting a biological link between food insecurity and chronic disease among PWH. Improving financial security and access to high-quality diets could reduce the burden of disease in this highly vulnerable population.
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Affiliation(s)
- Javier A Tamargo
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | | | - Colby Teeman
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Haley R Martin
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Yongjun Huang
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Angelique Johnson
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Adriana Campa
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Sabrina S Martinez
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
| | - Tan Li
- Department of Biostatistics, Florida International University, Miami, FL, USA
| | - Susan D Rouster
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Heidi L Meeds
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Marianna K Baum
- Department of Dietetics and Nutrition, Florida International University, Miami, FL, USA
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Burruss NC, Girgis M, Green KE, Lu L, Palakshappa D. Association between food insecurity and access to a mental health professional: cross-sectional analysis of NHANES 2007-2014. BMC Public Health 2021; 21:754. [PMID: 33874932 PMCID: PMC8054684 DOI: 10.1186/s12889-021-10818-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background To determine if individuals with food insecurity (FI) were less likely to have seen a mental health professional (MHP) within the past year than individuals without FI. Methods This is a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) conducted in the United States between 2007 and 2014. All participants 20 years of age or older were eligible for this study. We excluded participants who were pregnant, missing FI data, or missing data from the Patient Health Questionnaire (PHQ-9). The primary outcome was self-reported contact with a MHP in the past 12 months. We used multivariable logistic regression models to test the association between FI and contact with a MHP, controlling for all demographic and clinical covariates. Results Of the 19,789 participants, 13.9% were food insecure and 8.1% had major depressive disorder (MDD). In bivariate analysis, participants with FI were significantly more likely to have MDD (5.3% vs 2.8%, p < 0.0001) and to have been seen by a MHP in the preceding 12 months (14.0% vs 6.9%, p < 0.0001). In multivariable models, adults with FI had higher odds of having seen a MHP (OR = 1.32, CI: 1.07, 1.64). Conclusions This study demonstrates that individuals with FI were significantly more likely to have seen a MHP in the preceding 12 months compared to individuals without FI. Given the growing interest in addressing unmet social needs in healthcare settings, this data suggests that visits with MHPs may be a valuable opportunity to screen for and intervene on FI.
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Affiliation(s)
- Nina Camille Burruss
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Present address: Department of Psychiatry, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Marina Girgis
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Departments of Internal Medicine and Pediatrics, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Karen Elizabeth Green
- Department of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lingyi Lu
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Deepak Palakshappa
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Departments of Internal Medicine and Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
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95
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Chen M, Tan X, Padman R. Social determinants of health in electronic health records and their impact on analysis and risk prediction: A systematic review. J Am Med Inform Assoc 2021; 27:1764-1773. [PMID: 33202021 DOI: 10.1093/jamia/ocaa143] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/10/2020] [Accepted: 06/20/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This integrative review identifies and analyzes the extant literature to examine the integration of social determinants of health (SDoH) domains into electronic health records (EHRs), their impact on risk prediction, and the specific outcomes and SDoH domains that have been tracked. MATERIALS AND METHODS In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a literature search in the PubMed, CINAHL, Cochrane, EMBASE, and PsycINFO databases for English language studies published until March 2020 that examined SDoH domains in the context of EHRs. RESULTS Our search strategy identified 71 unique studies that are directly related to the research questions. 75% of the included studies were published since 2017, and 68% were U.S.-based. 79% of the reviewed articles integrated SDoH information from external data sources into EHRs, and the rest of them extracted SDoH information from unstructured clinical notes in the EHRs. We found that all but 1 study using external area-level SDoH data reported minimum contribution to performance improvement in the predictive models. In contrast, studies that incorporated individual-level SDoH data reported improved predictive performance of various outcomes such as service referrals, medication adherence, and risk of 30-day readmission. We also found little consensus on the SDoH measures used in the literature and current screening tools. CONCLUSIONS The literature provides early and rapidly growing evidence that integrating individual-level SDoH into EHRs can assist in risk assessment and predicting healthcare utilization and health outcomes, which further motivates efforts to collect and standardize patient-level SDoH information.
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Affiliation(s)
- Min Chen
- Department of Information Systems and Business Analytics, College of Business, Florida International University, Miami, Florida, USA
| | - Xuan Tan
- Department of Information Systems and Business Analytics, College of Business, Florida International University, Miami, Florida, USA
| | - Rema Padman
- The H. John Heinz III College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
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96
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Cullen D, Abel D, Attridge M, Fein JA. Exploring the Gap: Food Insecurity and Resource Engagement. Acad Pediatr 2021; 21:440-445. [PMID: 32795688 PMCID: PMC7878565 DOI: 10.1016/j.acap.2020.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/06/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pediatric health care institutions are increasingly implementing food insecurity (FI) screens, but there is limited information about participant interest in referral and engagement with resources provided. METHODS In this descriptive cross-sectional study, we recruited participants from a consecutive sample of adult caregivers arriving with pediatric patients in the emergency department at an urban, freestanding children's hospital. Caregivers completed a validated, 2-question screen for FI. All participants received a list of food access resources. Direct referral to a partnered community food resource agency was offered to those who screened positive for FI; that agency completed a phone call to the participant for resource provision within 2 weeks. RESULTS Among the 1818 participants recruited, 20.6% (375) screened positive for FI, consistent with the area's reported child FI rate. Of those who screened positive, 54.9% (206) opted to receive a direct-referral via phone call to a food resource agency, and 35.9% (74) of these were reached by phone. About 31.1% (23) of those contacted were no longer interested in food resource referrals, 10.8% (8) were signed up for the Supplemental Nutrition Assistance Program, and 59.5% (44) were referred to local food pantries. CONCLUSIONS Through hospital-community partnership in an initial attempt to screen and offer direct-referral for FI, we elicited considerable interest among families for connection to resource agencies. However, there was a substantial gap between referral acceptance and ultimate connection with the resource agency stemming from 2 major sources: inability to re-contact and loss of interest after contact.
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Affiliation(s)
- Danielle Cullen
- Pediatric Emergency Medicine, The Children's Hospital of Philadelphia (D Cullen and JA Fein), Philadelphia, Pa.
| | - Dori Abel
- New York-Presbyterian Morgan Stanley Children's Hospital (D Abel), New York, NY
| | - Megan Attridge
- Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago (M Attridge), Chicago, Ill
| | - Joel A Fein
- Pediatric Emergency Medicine, The Children's Hospital of Philadelphia (D Cullen and JA Fein), Philadelphia, Pa
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97
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TAYLOR LAURENA, BYHOFF ELENA. Money Moves the Mare: The Response of Community-Based Organizations to Health Care's Embrace of Social Determinants. Milbank Q 2021; 99:171-208. [PMID: 33420728 PMCID: PMC7984660 DOI: 10.1111/1468-0009.12491] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points Health policies that encourage health and social integration can induce community-based organizations (CBOs) to adopt new ways of working from health care organizations, including their language, staffing patterns, and metrics. These changes can be explained by CBOs' perceptions that health care organizations may provide new sources of revenue. While the welfare implications of these changes are not yet known, policymakers should consider balancing the benefits of professionalizing CBOs against the risks of medicalizing them. CONTEXT Recent health policies incentivize health care providers to collaborate with community-based organizations (CBOs), such as food pantries and homeless shelters, to address patients' social determinants of health (SDOH). The perspectives of health care leaders on these policy changes have been studied, but the perspectives of CBO managers have not. METHODS Our research question was: How are CBOs in Massachusetts perceiving and responding to new Medicaid policies that encourage collaboration between health care organizations and CBOs? We interviewed 46 people in leadership positions at CBOs in Massachusetts for approximately an hour each. We analyzed these data abductively, meaning that we iterated between inductively coding transcripts and consulting existing theories and frameworks. FINDINGS We found evidence of a knowing-doing gap among CBOs. Even though CBOs value their distinctiveness and autonomy from health care, they have undertaken a series of organizational changes in response to the new Medicaid policy that make their organizations appear more like health care organizations. These changes include adopting new performance metrics, hiring clinical staff to the board and senior management positions, and using medical language to describe nonmedical work. Drawing on institutional theory, we suggest that the nonprofits undertake such changes in an effort to demonstrate legitimacy to health care organizations, who may be able to provide new sources of critically needed revenue. CONCLUSIONS Massachusetts CBOs perceive health systems as potential sources of revenue, due in part to an ongoing Medicaid redesign that encourages the integration of health and social services. This perception is driving CBOs to appear more like health care organizations, but the impacts of these changes on welfare remain unknown.
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Affiliation(s)
| | - ELENA BYHOFF
- Department of MedicineTufts University School of Medicine and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center
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98
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Abstract
PURPOSE OF REVIEW This review examines the current evidence about the ways in which food insecurity relates to obesity in children and adolescents, examining diet and diet-related behaviors, and taking into consideration the role of stress. RECENT FINDINGS While living with food insecurity impacts stress and diet-related behaviors in children and adolescents, it is not clear whether food insecurity is associated with obesity above and beyond the influence of poverty. However, strategies to mitigate food insecurity and obesity are inherently connected, and recent examples from clinical practice (e.g., screening for food insecurity among patients) and advocacy (e.g., policy considerations regarding federal food programs such as the Supplemental Nutrition Assistance Program, or SNAP) are discussed. Food insecurity and obesity coexist in low-income children and adolescents in the USA. The COVID-19 pandemic exerts disproportionate burden on low-income children and families, magnifying their vulnerability to both food insecurity and pediatric obesity.
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Affiliation(s)
- June M Tester
- Division of Pediatric Endocrinology, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, Oakland, 94609, CA, USA.
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, 550 16th Street, 4th Floor Box 0110, San Francisco, CA, USA.
| | - Lisa G Rosas
- Epidemiology and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Cindy W Leung
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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99
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Cooksey Stowers K, Marfo NYA, Gurganus EA, Gans KM, Kumanyika SK, Schwartz MB. The hunger-obesity paradox: Exploring food banking system characteristics and obesity inequities among food-insecure pantry clients. PLoS One 2020; 15:e0239778. [PMID: 33085685 PMCID: PMC7577435 DOI: 10.1371/journal.pone.0239778] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/11/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose Heightened obesity risk among food-insecure food pantry clients is a health equity issue because the co-occurrence of obesity and hunger is deeply-rooted in systematic social disadvantage and historical oppression. This qualitative study examined key stakeholders’ perspectives of the relationship between the U.S. food banking system and obesity disparities among food insecure clients. Methods We conducted in-depth, semi-structured interviews with 10 key stakeholders (e.g., food bank director, food bank board member, advocate) who are familiar with food bank operations. Data were transcribed verbatim, coded in NVivo [v11], and analyzed using thematic analysis. Results Multiple themes emerged drawing linkages between structural characteristics of the food banking system and disparities in the dual burden of food insecurity and obesity: [a] access to unhealthy food from donors; [b] federal emergency food policy and programming; [c] state-level emergency food policy and programming; [d] geography-based risk profiles; and [e] inadequate food supply versus client need. Interviewees also identified social challenges between system leaders and clients that maintain disparities in obesity risk among individuals with very low food security including: [a] media representation and stereotypes about food pantry clients; [b] mistrust in communities of color; [c] lack of inclusion/representation among food bank system leaders; and [d] access to information. Conclusion Future efforts to alleviate obesity inequities among clients chronically burdened by food insecurity, especially among certain subpopulations of clients, should prioritize policy, systems, and environmental strategies to overcome these structural and social challenges within the food banking system.
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Affiliation(s)
- Kristen Cooksey Stowers
- Department of Allied Health Sciences, Storrs, Connecticut, United States of America
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut, United States of America
- * E-mail:
| | - Nana Yaa A. Marfo
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, United States of America
| | - Eminet Abebe Gurganus
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, Connecticut, United States of America
| | - Kim M. Gans
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut, United States of America
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, Connecticut, United States of America
| | - Shiriki K. Kumanyika
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, United States of America
| | - Marlene B. Schwartz
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut, United States of America
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, Connecticut, United States of America
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100
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Berkowitz SA, Chang Y, Porneala B, Cromer SJ, Wexler DJ, Delahanty LM. Does the effect of lifestyle intervention for individuals with diabetes vary by food insecurity status? A preplanned subgroup analysis of the REAL HEALTH randomized clinical trial. BMJ Open Diabetes Res Care 2020; 8:e001514. [PMID: 32978121 PMCID: PMC7520816 DOI: 10.1136/bmjdrc-2020-001514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/21/2020] [Accepted: 08/13/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We aimed to test the effectiveness of a lifestyle intervention (LI) for individuals with food insecurity and type 2 diabetes. RESEARCH DESIGN AND METHODS Adults with type 2 diabetes, body mass index ≥25 kg/m2 (or ≥23 kg/m2 if Asian), hemoglobin A1c of 6.5%-11.5% (48-97 mmol/mol) and who were willing to lose 5%-7% bodyweight were enrolled in REAL HEALTH-Diabetes. This practice-based randomized clinical trial compared LI (delivered inperson or by telephone) with medical nutrition therapy (MNT) on weight loss at 6 and 12 months. Two or more affirmative responses on the six-item US Department of Agriculture Food Security Survey Module indicated food insecurity. In this prespecified subgroup analysis, we tested using linear mixed effects models whether the intervention effect varied by food security status. RESULTS Of 208 participants, 13% were food insecure. Those with food insecurity were more likely to be racial/ethnic minorities (p<0.001) and have lower education (p<0.001). LI, versus MNT, led to greater weight loss at 6 months (5.1% lost vs 1.1% lost; p<0.0001) and 12 months (4.7% lost vs 2.0% lost; p=0.0005). The intervention effect was similar regardless of food security status (5.1% bodyweight lost vs 1.1% in food secure participants and 5.1% bodyweight lost vs 1.3% in food insecure participants at 6 months; 4.7% bodyweight lost vs 2.1% in food secure participants and 4.5% bodyweight lost vs 0.9% in food insecure participants at 12 months; p for interaction=0.99). CONCLUSIONS The REAL HEALTH-Diabetes lifestyle intervention led to meaningful weight loss for individuals with food insecurity and type 2 diabetes. TRIAL REGISTRATION NUMBER NCT02320253.
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Affiliation(s)
- Seth A Berkowitz
- Division of General Medicine & Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Yuchiao Chang
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bianca Porneala
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sara J Cromer
- Diabetes Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Deborah J Wexler
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Diabetes Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Linda M Delahanty
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Diabetes Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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