Association of participation in the supplemental nutrition assistance program and psychological distress

Intersection of adverse childhood experiences, suicide and overdose prevention

Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.

Experiences participating in federal nutrition assistance programs during the early months of the COVID-19 pandemic: an investigation in Vermont

BACKGROUND

Federal nutrition assistance programs serve as safety nets for many American households, and participation has been linked to increased food security and, in some instances, improved diet quality and mental health outcomes. The COVID-19 pandemic brought new and increased economic, social, and psychological challenges, necessitating inquiry into how nutrition assistance programs are functioning and associated with public health outcomes.

METHODS

Using data from a representative statewide survey administered in Vermont (n = 600) between July and September 2020, we examined participant experiences with major federal nutrition assistance programs: the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and school meal programs. We explored quantitative and qualitative responses regarding perceptions of program utility, and used nearest neighbors matching analyses in combination with bivariate statistical tests to assess associations between program participation and food insecurity, perceived stress, and fruit and vegetable intake as indicators of dietary quality.

RESULTS

One in four respondents (27.3%) used at least one federal nutrition assistance program. As compared to non-participants, we found higher rates of food insecurity among program participants (57.5% vs. 18.1%; p < 0.001), an association that persisted even when we compared similar households using matching techniques (p ≤ 0.001). From matched analyses, we found that, compared to low-income non-participants, low-income program participants were less likely to meet fruit intake recommendations (p = 0.048) and that low-income SNAP and WIC participants were less likely to meet vegetable intake recommendations (p = 0.035). We also found lower rates of perceived stress among low-income school meal participant households compared to low-income non-participants (p = 0.039). Despite these mixed outcomes, participants broadly valued federal nutrition assistance programs, characterizing them as helpful or easy to use.

CONCLUSIONS

We found that federal nutrition assistance programs as a group were not sufficient to address food insecurity and stress or increase fruit and vegetable intake in the state of Vermont during the early months of the COVID-19 pandemic. Nonetheless, participants perceived benefits from participation in these programs. Optimizing the utility of nutrition assistance programs depends on critical examination of their functioning under conditions of great stress.

Child meal support program, food and nutrition insecurity, and health among Korean children

BACKGROUND

Korea's child meal support program (CMSP) aims to reduce food and nutrition insecurity (FNI) and improve health among children from low-income households.

AIM

We examined the impact of different types of CMSP on children's FNI and health in Korea, analyzing meal frequency and healthful food consumption (FNI), and general health and depression (health) among child meal card (CMC) and facility meal service (FMS) participants compared with nonparticipants.

METHODS

The 2018 Comprehensive Survey on Korean Children data were analyzed. Precisely, 847 children from low-income households aged 9-17 were categorized into CMC (n = 331), FMS (n = 209), and income-eligible nonparticipants (n = 307). Propensity score-weighted generalized linear models assessed CMSP's impact on FNI and health. Stratified generalized linear models examined heterogeneity in FNI-health associations by CMSP status.

RESULTS

CMC participants reported more frequent breakfast consumption (odds ratio [OR] = 0.662, p < 0.05) but poorer self-rated general health (OR = 1.890, p < 0.05); FMS participants were less likely to have three meals (OR = 1.814, p < 0.05), fruits and vegetables (OR = 2.194, p < 0.001), and protein-rich foods daily (OR = 1.695, p < 0.05) than nonparticipants. Health risks associated with healthful food consumption and meal frequency were more pronounced among CMC and FMS/nonparticipants, respectively.

CONCLUSION

CMSP had a limited impact on reducing FNI and improving health among children from low-income households. CMC appeared more effective than FMS in alleviating FNI, notwithstanding potential health concerns. Food assistance programs should seek comprehensive enhancements in children's food and nutrition security and health.

Investigating psychological distress and peer influence in the longitudinal path linking food insecurity to adolescent substance use: a nationwide low-income cohort study

Food insecurity (FI), defined as the limited or uncertain availability of nutritionally adequate and safe foods, remains a major life concern among many poor subpopulations. Few investigations have been made into the mechanism underlying its impact on adolescent substance use. This study aimed to examine the longitudinal relationship between FI and cigarette and alcohol use among economically disadvantaged adolescents and then explore the role of psychological distress and peer substance use in the aforementioned association. Data of 1,243 adolescents (Mage = 13.3 years; 645 males) were obtained from a nationwide cohort study on Taiwanese adolescents from low-income families. Multiple hierarchical regression analyses based on generalized linear mixed-effects models with binomial distribution found that FI was consistently associated with cigarette smoking (β = 0.458, p < 0.001) but not alcohol drinking (β = 0.142, p = 0.143) when both psychological distress and peer substance use were adjusted. In the moderated mediation analysis based on bootstrap methods, we observed that psychological distress mediated the association between food insecurity and alcohol drinking (β = 0.036, 95% CI = 0.015-0.063) but not cigarette smoking (β = 0.018, 95% CI =-0.001-0.037). Furthermore, the indirect effects varied by peer drinking status (index of moderated mediation = 0.04, 95% CI 0.015-0.072). Clinical and public health attention should be given to evaluating food-insecure adolescents' psychological well-being and peer influence when counseling their substance use issues.

Household Food Security Status and Allostatic Load among United States Adults: National Health and Nutrition Examination Survey 2015-2020

BACKGROUND

Household food insecurity has been linked to adverse health outcomes, but the pathways driving these associations are not well understood. The stress experienced by those in food-insecure households and having to prioritize between food and other essential needs could lead to physiologic dysregulations [i.e., allostatic load (AL)] and, as a result, adversely impact their health.

OBJECTIVE

To assess the association between household food security status and AL and differences by gender, race and ethnicity, and Supplemental Nutrition Assistance Program (SNAP) participation.

METHODS

We used data from 7640 United States adults in the 2015-2016 and 2017-March 2020 National Health and Nutrition Examination Survey to estimate means and prevalence ratios (PR) for AL scores (based on cardiovascular, metabolic, and immune biomarkers) associated with self-reported household food security status from multivariable linear and logistic regression models.

RESULTS

Adults in marginally food-secure [mean = 3.09, standard error (SE) = 0.10] and food-insecure households (mean = 3.05; SE = 0.08) had higher mean AL than those in food-secure households (mean = 2.70; SE = 0.05). Compared with adults in food-secure households in the same category, those more likely to have an elevated AL included: SNAP participants [PR = 1.12; 95% confidence interval (CI):  1.03, 1.22] and Hispanic women (PR = 1.20; 95% CI: 1.05, 1.37) in marginally food-secure households; and non-Hispanic Black women (PR = 1.14; 95% CI: 1.03, 1.26), men (PR = 1.13; 95% CI: 1.02, 1.26), and non-SNAP non-Hispanic White adults (PR = 1.22; 95% CI: 1.08, 1.39) in food-insecure households.

CONCLUSIONS

AL may be one pathway by which household food insecurity affects health and may vary by gender, race and ethnicity, and SNAP participation.

Examining the Connection Between Health Outcomes, State Political Ideology, and Food Access in the United States

OBJECTIVES

To estimate the impact of county-level income, access to food, availability of health resources, socioeconomic factors, and state political ideology on population obesity and mental health in US counties.

DESIGN

We compiled a county-level data set from the US Census, County Health Rankings, USDA Food Environment Atlas, the American Community Survey, and the State Ideology Database. We specify 2 multivariable regression models for county-level obesity rate and per capita poor mental health days and control for rurality, food access, income, availability of health care resources, state political ideology, and socioeconomic characteristics.

RESULTS

We find that higher food access reduces obesity in counties; an increase in per capita full-service restaurants by 1 unit is associated with reduction in obesity rate by 1.24 points and an increase in per capita grocery stores reduces poor mental health days by 0.14. We also find that counties in liberal-leaning states tend to have lower obesity rates. Access to primary care providers (increase in primary care physicians by 1 is associated with decline in obesity rate by 1.18 points and poor mental health days by 0.11 days), and recreational facilities (increase in recreational facilities per 1000 by 1 is associated with reduction in obesity rate by 3.16 points and poor mental health days by 0.47 days) reduces obesity rates and poor mental health days. Median income is associated with decrease in obesity rate and poor mental health days. Increase in median household income by 1% is associated with reduction in obesity rate 4.75% and reduction in poor mental health days by 1.39 days.

CONCLUSIONS

We find that access to food and health care at county level and state ideology through policy making affects health outcomes. Our analysis indicates that counties can improve access to food and health care by investing in these services thereby improving county-level health outcomes and save dollars in the process.

State expansion of supplemental nutrition assistance program eligibility and rates of interpersonal violence

INTRODUCTION

Food insecurity is associated with an increased likelihood of interpersonal violence. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the U.S. States can eliminate the asset test and/or increase the income limit for SNAP eligibility, expanding the number of households receiving assistance. We examined the association of state elimination of the asset test and increases in the income limit with rates of interpersonal violence, including intimate partner violence (IPV), other relationship violence (violence by a parent, friend, etc.), and stranger violence.

METHODS

We used data from the SNAP Policy Database and state-level estimates of rates of interpersonal violence per 1000 population ages ≥12 years from the 2012-2014 to 2016-2018 National Crime Victimization Survey.

RESULTS

States that adopted both SNAP eligibility policies (eliminated the asset test and increased the income limit) had a lower rate of IPV (β = -0.4, 95% CI -0.9, 0.0) and other relationship violence (β = -2.4, 95% CI -3.8, -1.1) compared to states that did not adopt either policy. The rate of stranger violence (β = -0.5, 95% CI -2.3, 1.4) did not differ for states that adopted both policies compared to states that did not adopt either policy. Rates of IPV (β = -0.4, 95% CI -0.9, 0.2), other relationship violence (β = -1.2, 95% CI -3.2, 0.7), and stranger violence (β = -0.2, 95% CI -2.0, 1.6) did not differ for states that eliminated the asset test only compared to states that did not adopt either policy.

CONCLUSION

Expanding SNAP eligibility may help prevent interpersonal violence at the population-level.

The joint effect of female sex and food insecurity on self-reported mood disorder among Canadian adults: the Canadian community health survey

BACKGROUND

Food insecurity is prevalent in Canada and may influence mental health, particularly among females. The present study examined the joint effect of female sex and food insecurity on mood disorders.

METHODS

The study used data from 104,420 adults aged 18 years or older who participated in the 2017/2018 Canadian Community Health Survey (CCHS). Log-binomial models explored the independent and joint associations of female sex and food insecurity with the prevalence of self-reported mood disorder. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated. Relative excess risk due to interaction (RERI), attributable proportion (AP), and synergy index (S) were used to assess the additive interaction of female sex and food insecurity. The complex survey design was taken into consideration.

RESULTS

The prevalence of mood disorder was 6.7% for males and 11.4% for females, with an adjusted prevalence ratio being 1.59 (95% CI 1.51, 1.68) for females versus males. Mood disorder was associated with moderate food insecurity (PR 2.06, 95% CI 1.91, 2.23) and severe food insecurity (PR 3.29, 95% CI 3.06, 3.55). There was a significant additive interaction between female sex and food insecurity in association with the prevalence of mood disorders among females aged 18 to 39 years (RERI 1.19, 95% CI 0.27,2.08).

CONCLUSION

Food insecurity was associated with an increased prevalence of mood disorders, especially in younger females. Interventions that facilitate access to food while being cognizant of the socioeconomic vulnerabilities of females may have substantial benefits for the prevention and management of mood disorders.

Association of parent-child interactions with parental psychological distress and resilience during the COVID-19 pandemic

Introduction

The effects of psychological distress/resilience on parent-child engagement (e.g., family dinners, reading) during the COVID-19 pandemic have not been well studied. Among very young children from underrepresented backgrounds enrolled in the ongoing longitudinal Bronx Mother Baby Health Study of healthy term infants, we (1) examined associations between exposures to COVID-19-related events, demographic factors and parental psychological distress and resilience; and (2) correlated these factors with parent-child engagement activities.

Methods

Between June 2020-August 2021, parents of 105 Bronx Mother Baby Health Study participants aged birth-25 months completed questionnaires related to exposures to COVID-19-related events, frequency of positive parent-child engagement activities, food and housing insecurity, and parental psychological distress and resilience. Families were also asked open ended questions about the pandemic's impact.

Results

29.8% and 47.6% of parents reported food and housing insecurity, respectively. Greater exposures to COVID-19-related events were associated with increased parental psychological distress. Positive parent-child interactions were associated with demographic factors and higher levels of maternal education, but not with exposures to COVID-19-related events.

Discussion

This study adds to a growing body of literature on the negative impacts of COVID-19 exposures and psychosocial stressors on families during the pandemic, supporting the need for enhanced mental health resources and social supports for families.

Impact of the Affordable Care Act on participation in the Supplemental Nutrition Assistance Program among low-income older Medicare beneficiaries

BACKGROUND

The Affordable Care Act (ACA) provisions, especially Medicaid expansion, are believed to have "spillover effects," such as boosting participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible individuals in the United States (US). However, little empirical evidence exists about the impact of the ACA, with its focus on the dual eligible population, on SNAP participation. The current study investigates whether the ACA, under an explicit policy aim of enhancing the interface between Medicare and Medicaid, has improved participation in the SNAP among low-income older Medicare beneficiaries.

METHODS

We extracted 2009 through 2018 data from the US Medical Expenditure Panel Survey (MEPS) for low-income (≤ %138 Federal Poverty Level [FPL]) older Medicare beneficiaries (n = 50,466; aged ≥ 65), and low-income (≤ %138 FPL) younger adults (aged 20 to < 65 years, n = 190,443). MEPS respondents of > %138 FPL incomes, younger Medicare and Medicaid beneficiaries, and older adults without Medicare were excluded from this study. Using a quasi-experimental comparative interrupted time-series design, we examined (1) whether ACA's support for the Medicare-Medicaid dual-eligible program, through facilitating the online Medicaid application process, was associated with an increase in SNAP uptake among low-income older Medicare beneficiaries, and (2) in the instance of an association, to assess the magnitude of SNAP uptake that can be explicitly attributed to the policy's implementation. The outcome, SNAP participation, was measured annually from 2009 through 2018. The year 2014 was set as the intervention point when the Medicare-Medicaid Coordination Office started facilitating Medicaid applications online for eligible Medicare beneficiaries.

RESULTS

Overall, the change in the probability of SNAP enrollment from the pre- to post-intervention period was 17.4 percentage points higher among low-income older Medicare enrollees, compared to similarly low-income, SNAP-eligible, younger adults (β = 0.174, P < .001). This boost in SNAP uptake was significant and more apparent among older White (β = 0.137, P = .049), Asians (β = 0.408, P = .047), and all non-Hispanic adults (β = 0.030, P < .001).

CONCLUSIONS

The ACA had a positive, measurable effect on SNAP participation among older Medicare beneficiaries. Policymakers should consider additional approaches that link enrollment to multiple programs to increase SNAP participation. Further, there may be a need for additional, targeted efforts to address structural barriers to uptake among African Americans and Hispanics.

Association Between Supplemental Nutrition Assistance Program Use and Memory Decline: Findings From the Health and Retirement Study

BACKGROUND AND OBJECTIVES

Studies on the effect of the Supplemental Nutrition Assistance Program (SNAP) on the cognitive health of older adults are scarce. We sought to examine the associations between SNAP use and memory decline among SNAP-eligible US older adults.

METHODS

Participants aged 50+ years and SNAP-eligible in 1996 from the Health and Retirement Study were included. Participants' SNAP eligibility was constructed using federal criteria. Participants also self-reported whether they used SNAP. Memory function was assessed biennially from 1996 through 2016 using a composite score. To account for preexisting differences in characteristics between SNAP users and nonusers, we modeled the probability of SNAP use using demographic and health covariates. Using linear mixed-effects models, we then modeled trajectories of memory function for SNAP users and nonusers using inverse probability (IP) weighting and propensity score (PS) matching techniques. In all models, we accounted for study attrition.

RESULTS

Of the 3,555 SNAP-eligible participants, a total of 15.7% were SNAP users. At baseline, SNAP users had lower socioeconomic status and a greater number of chronic conditions than nonusers and were more likely to be lost to follow-up. Our multivariable IP-weighted models suggested that SNAP users had worse memory scores at baseline but slower rates of memory decline compared with nonusers (the annual decline rate is -0.038 standardized units [95% CI = -0.044 to -0.032] for users and -0.046 [95% CI = -0.049 to -0.043] for nonusers). Results were slightly stronger from the PS-matched sample (N = 1,014) (the annual decline rate was -0.046 units [95% CI = -0.050 to -0.042] for users and -0.060 units [95% CI = -0.064 to -0.056] for nonusers). Put in other words, our findings suggested that SNAP users had approximately 2 fewer years of cognitive aging over a 10-year period compared with nonusers.

DISCUSSION

After accounting for preexisting differences between eligible SNAP users and nonusers as well as differential attrition, we find SNAP use to be associated with slower memory function decline.

SNAP work requirements increase mental health care use

OBJECTIVE

We measured the impact of Supplemental Nutrition Assistance Program (SNAP) work requirements on mental health care use.

DATA SOURCES AND STUDY SETTING

We used 2015-2018 West Virginia Medicaid and SNAP data.

STUDY DESIGN

Nine counties were exposed to SNAP work requirements. Using an event study framework, we assessed how this changed the probability and number of visits for depression and anxiety in the treatment versus the control group.

DATA COLLECTION/EXTRACTION METHODS

The sample included individuals aged 18-49, enrolled in both SNAP and Medicaid at the start of the study. Dually eligible individuals were excluded.

PRINCIPAL FINDINGS

At baseline, the probability of having a mood disorder visit was 6.1% among women and 5.3% among men, rising by 0.9 percentage points (SE 0.4, relative change +14.1%) among women and 0.7 percentage points (SE 0.3, relative change +13.0%) among men after exposure to work requirements. The probability of having an anxiety visit rose by 1.0 (SE 0.4) percentage points among women, a 17.8% relative increase over the baseline of 5.8%. Among men, the likelihood of having an anxiety visit increased by 1.0 percentage points (SE 0.5), a relative change of 24.3% over a baseline probability of 5.0%, though this effect occurred much more gradually compared to women.

CONCLUSIONS

Exposure to SNAP work requirements was associated with increases in health care use for mood disorders and anxiety among enrollees. The policy's effect differed between men and women.

How food support improves mental health among people living with HIV: A qualitative study

BACKGROUND

Food insecurity is associated with poor mental health among people living with HIV (PLHIV). This qualitative study explored the mental health experiences of PLHIV participating in a medically appropriate food support program.

METHODS

Semi-structured interviews were conducted post-intervention (n = 34). Interview topics included changes, or lack thereof, in mental health and reasons for changes. Interviews were audio-recorded, transcribed, and double-coded. Salient themes were identified using an inductive-deductive method.

RESULTS

Positive changes in mental health self-reported by PLHIV included improved mood and reduced stress, worry, and anxiety. Participants attributed these changes to: 1) increased access to sufficient and nutritious foods, 2) increased social support, 3) reduced financial hardship, 4) increased sense of control and self-esteem, and 5) reduced functional barriers to eating.

CONCLUSIONS

Medically appropriate food support may improve mental health for some PLHIV. Further work is needed to understand and prevent possible adverse consequences on mental health after programs end.

How Does Consistency of Food and Nutrition Support Effect Daily Food Consumption among Children Living in Poverty? Recession-Era Implications

Underutilization of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the Supplemental Nutrition Assistance (SNAP) food safety net programs may compromise child nutritional benefits for families with limited incomes. Using a sample of children surveyed before (2003−2006) and after the Great Recession (2007−2009), we examine whether consistent access to WIC and SNAP during times of increased economic stress moderated the association between poverty level (i.e., income-needs ratio [INR]) and fruits and vegetables (FV) or foods high in saturated fats and added sugars (SFAS). Fragile Families and Child Wellbeing Study income-eligible mothers/children (≤185% of poverty) with available FV and SFAS data at the 5- (2003−2006) and 9-year (2007−2010) waves (n = 733) were included. Main effects of INR and interaction effects of consistency of WIC, SNAP, and dual WIC and SNAP support from birth through age 5 were examined. INR was associated with decreased FV consumption frequency from age 5 to 9, conditional upon consistency of dual WIC/SNAP enrollment. FV declined when there was low consistency (<1 year) of dual support. FV consumption was stable across INR when combined WIC/SNAP support lasted at least 2 years. Results can inform strategies for optimizing the nutritional impact of WIC and SNAP by focusing on those most at risk for underutilization of multiple benefits.

Food insecurity, diet quality, and suboptimal diabetes management among US adults with diabetes

INTRODUCTION

A healthy diet is recommended to support diabetes management, including HbA1c, blood pressure, and cholesterol (ABC) control, but food insecurity is a barrier to consuming a healthy diet. We determined the prevalence of food insecurity and diet quality among US adults with diabetes and the associations with ABC management.

RESEARCH DESIGN AND METHODS

Cross-sectional analyses were conducted among 2075 adults ≥20 years with diagnosed diabetes who participated in the 2013-2018 National Health and Nutrition Examination Surveys. Food insecurity was assessed using a standard questionnaire and diet quality was assessed using quartiles of the 2015 Healthy Eating Index. Adjusted ORs (aOR, 95% CI) were calculated from logistic regression models to determine the association between household food insecurity/diet quality and the ABCs while controlling for sociodemographic characteristics, healthcare utilization, smoking, medication for diabetes, blood pressure, or cholesterol, and body mass index.

RESULTS

Overall, 17.6% of adults had food insecurity/low diet quality; 14.2% had food insecurity/high diet quality; 33.1% had food security/low diet quality; and 35.2% had food security/high diet quality. Compared with adults with food security/high diet quality, those with food insecurity/low diet quality were significantly more likely to have HbA1c ≥7.0% (aOR=1.85, 95% CI 1.23 to 2.80) and HbA1c ≥8.0% (aOR=1.79, 95% CI 1.04 to 3.08); food insecurity/high diet quality was significantly associated with elevated HbA1c; and food security/low diet quality with elevated A1c.

CONCLUSIONS

Food insecurity, regardless of diet quality, was significantly associated with elevated A1c. For people with food insecurity, providing resources to reduce food insecurity could strengthen the overall approach to optimal diabetes management.

Social Spending and Educational Gaps in Infant Health in the United States, 1998-2017

Recent expansions of child tax, food assistance, and health insurance programs have made American families' need for a robust social safety net highly evident, while researchers and policymakers continue to debate the best way to support families via the welfare state. How much do children-and which children-benefit from social spending? Using the State-by-State Spending on Kids Dataset, linked to National Vital Statistics System birth data from 1998 to 2017, we examine how state-level child spending affects infant health across maternal education groups. We find that social spending has benefits for both low birth weight and preterm birth rates, especially among babies born to mothers with less than a high school education. The stronger benefits of social spending among lower educated families lead to meaningful declines in educational gaps in infant health as social spending increases. Our findings are consistent with the idea that a strong local welfare state benefits infant health and increases equality of opportunity, and that spending on nonhealth programs is equally beneficial for infant health as investments in health programs.

A qualitative analysis of SNAP and minimum wage policies as experienced by workers with lower incomes

Work-related policies, including minimum wage and food assistance work requirements, can affect food security for people with lower incomes. This study conducted 112 qualitative interviews to understand participant policy experiences in two contexts (Raleigh, North Carolina and Minneapolis, Minnesota). Participants experienced frequent, destabilizing changes to their United States Department of Agriculture Supplemental Nutrition Assistance Program benefits, which they identified as part of a broader safety net. Raleigh workers described an unsupportive policy environment; Minneapolis workers reaped few benefits from an ongoing wage increase. Many workers face complex financial tradeoffs; more sophisticated evaluations should consider broader policy contexts and long-range effects.

State Policy and Mental Health Outcomes under COVID-19

CONTEXT

The COVID-19 pandemic has caused enormous damage to physiological health and economic security, especially among racial and ethnic minorities. We examined downstream effects on mental health, how effects vary by race and ethnicity, and the role of existing state-level social policies in softening the pandemic's impact.

METHODS

We analyze an online, multi-wave Census Bureau survey fielded to nearly a million respondents between late April and July 2020. The survey includes questions measuring psychological distress as well as indirect measures of experience with the pandemic. We combined these data with state-level measures of COVID-19 cases, lockdown orders, unemployment filings, and safety net policy.

FINDINGS

We find significant mental stress among all respondents and a sizeable gap between nonwhite and white respondents. Adjusting for pandemic experiences eliminates this gap. The effect of losing work as a result of the pandemic is slightly offset by state policies such as unemployment benefit size and Medicaid expansion. The magnitude of these offsetting effects is similar across racial/ethnic groups.

CONCLUSIONS

The racialized impacts of the pandemic are exacerbated by inequalities in state policy exemplifying structural racism. If the least generous states matched the policies of the most generous, inequalities caused by the pandemic would be diminished.

Food Insecurity and Psychological Distress: a Review of the Recent Literature

PURPOSE OF REVIEW

Food insecurity is the lack of sufficient food in quantity and/or quality. Psychological distress includes mental health issues such as depression and anxiety. This review provides current information on research examining the association between food insecurity and psychological distress.

RECENT FINDINGS

Among studies published in the previous 5 years, food insecurity was significantly and positively associated with multiple indicators of psychological distress. This included cross-sectional and longitudinal studies, as well as primary data collection and secondary data analyses, from countries of varying income levels. Articles also provided evidence within various populations, such as adults of all ages, college students, those living with chronic disease, and parents. Food insecurity and psychological distress are interconnected health issues. Future research should consider a number of important gaps in the literature, with the most important being the development of interventions to improve food insecurity and psychological health concurrently.

Food Insecurity Is Associated with Depression among a Vulnerable Workforce: Early Care and Education Workers

Objective: We aimed to explore the association between food insecurity and depression among early care and education (ECE) workers, a vulnerable population often working in precarious conditions. Design: We utilized cross-sectional data from a study exploring the effects of wage on ECE centers. Participants were enrolled between August 2017 and December 2018. Food insecurity was measured using the validated six-item U.S. Household Food Security Survey Module and participants were categorized as food secure (score = 0–1), low food security (score = 2–4), and very low food security (score = 5–6). Depression (defined as a score ≥ 16) was measured using the 20-item Center for Epidemiologic Studies Depression Scale-Revised. We employed a logistic regression model to examine the relationship between food insecurity and depression. All models controlled for marital status, nativity, race/ethnicity, number of children in the household, job title, weekly hours of work, education, income, and study site. Setting: Participants were from Seattle (40%) and South King County (26%), Washington, and Austin, Texas (34%). Participants: Participants included 313 ECE workers from 49 ECE centers. Results: A majority of participants were female, non-Hispanic White, born in the U.S., and did not have children. Compared to being food secure, very low and low food insecurities were associated with a 4.95 (95% confidence interval (CI): 2.29, 10.67) and 2.69 (95% CI: 1.29, 5.63) higher odds of depression, respectively. Conclusions: Policies and center-level interventions that address both food insecurity and depression may be warranted, in order to protect and improve the health of this valuable, yet vulnerable, segment of the U.S. workforce.

The Intersection of Food Insecurity and Tobacco Use: A Scoping Review

Cigarette smoking is increasingly concentrated in socioeconomically disadvantaged groups, and food insecurity also disproportionately affects lower-income groups. Recent studies have suggested that smoking and food insecurity operate as risk factors for one another, but there is limited understanding of their intersection. This scoping review aimed to synthesize the published literature on the association between food insecurity and tobacco use across population groups in the United States and Canada. We searched PubMed, Web of Science, and PsycINFO using key words. Studies included were published in English between 2008 and 2018, reported empirical findings, measured both tobacco use and food insecurity, and considered either variable as a study outcome. Nineteen articles were identified; 6 examined tobacco use as an outcome variable and 13 examined food insecurity as an outcome variable. Most articles were of studies using cross-sectional designs. Study samples ranged from general populations, clinical samples, and underserved populations. For each article, we extracted information including specific findings related to the association between food insecurity and tobacco use. We synthesized the current research by formulating a model by which food insecurity and tobacco use are bidirectionally associated. This scoping review concludes that the co-occurrence of food insecurity and tobacco use exists across populations in the United States and Canada. As the evidence is largely from cross-sectional investigations, there is a need for longer term, comprehensive assessments of relationships between tobacco use and food insecurity. Such investigations can inform policies and interventions aimed toward addressing the inequitable burden of tobacco use and of food insecurity among disadvantaged populations.

The association of household food insecurity and HIV infection with common mental disorders among newly diagnosed tuberculosis patients in Botswana

OBJECTIVE

To determine the association between food insecurity and HIV infection with depression and anxiety among new tuberculosis (TB) patients.

DESIGN

Our cross-sectional study assessed depression, anxiety and food insecurity with Patient Health Questionnaire (PHQ-9), Zung Anxiety Self-Assessment Scale (ZUNG) and Household Food Insecurity Access Scale, respectively. Poisson regression models with robust variance were used to examine correlates of depression (PHQ-9 ≥ 10) and anxiety (ZUNG ≥ 36).

SETTING

Gaborone, Botswana.

PARTICIPANTS

Patients who were newly diagnosed with TB.

RESULTS

Between January and December 2019, we enrolled 180 TB patients from primary health clinics in Botswana. Overall, 99 (55·0 %) were HIV positive, 47 (26·1 %), 85 (47·2 %) and 69 (38·5 %) indicated depression, anxiety and moderate to severe food insecurity, respectively. After adjusting for potential confounders, food insecurity was associated with a higher prevalence of depression (adjusted prevalence ratio (aPR) = 2·30; 95 % CI 1·40, 3·78) and anxiety (aPR = 1·41; 95 % CI 1·05, 1·91). Prevalence of depression and anxiety was similar between HIV-infected and HIV-uninfected participants. Estimates remained comparable when restricted to HIV-infected participants.

CONCLUSIONS

Mental disorders may be affected by food insecurity among new TB patients, regardless of HIV status.

Examining associations of food insecurity with major depression among older adults in the wake of the Great Recession

As a psychosocial stressor, the degree to which food insecurity impacts major depression may be dependent on macro-level context, which can be examined in the wake of the Great Recession. The objective of this study was to determine (1) whether food insecurity transition status (i.e. initially food insecure, becoming food insecure, and remaining food insecure vs. not food insecure) was associated with major depression in older adults and; (2) whether this association was moderated by macro-level context. Data came from the United States Health and Retirement Study, 2008-2016. Multivariable logistic regression across all years revealed that major depression was associated with any exposure to food insecurity, however; this association was moderated by time period. Remaining food insecure was associated with major depression during all time periods. In contrast, becoming food insecure was associated with major depression in the years during and immediately following the Recession, but not in later time periods. Findings suggest that associations of food insecurity with major depression among older adults are moderated by macro-level context, consistent with theories of social comparison and relative disadvantage. Food insecurity may represent an important risk factor for major depression and mental health disparities across socioeconomic strata in old age. Thus, policies that increase access to food assistance programs or improve the quality of local food environments may buffer against the impact of food insecurity on depression and associated complications among older adults.

Impact of sex and marital status on the prevalence of perceived depression in association with food insecurity

Background

While both food insecurity and depression have been reported to be closely related to sex and marital status, the impact of sex and marital status on the prevalence of perceived depression in association with food security status has not been evaluated.

Materials & methods

We performed a nationwide population study using data for 19,866 adults obtained from the 2012–2015 Korean National Health and Nutrition Examination Surveys. Household food insecurity status was evaluated using the 18-item Food Security Survey Module. Perceived depression was measured using one item questionnaire or the 9-item Patient Health Questionnaire (PHQ-9). We cross-sectionally analyzed associations between perceived depression and variables, including socio-demographic factors and food security status. The prevalence of perceived depression was compared according to sex, marital status, and food security status. We applied survey sampling weights in all analyses.

Results

The overall prevalence of perceived depression was 10.5%. Prevalence rates of perceived depression in the high food security group, marginal food security group, low food security group, and very low food security group were 8.9%, 13.6%, 19.7%, and 35.0%, respectively (P < 0.001). Of total participants, 1.8% were categorized as having both perceived depression and food insecurity. After adjusting for confounding covariates, female sex (adjusted odds ratio [aOR]; 2.37), never married (aOR; 1.37), divorced/widowed/separated (aOR; 1.50), low food security (aOR; 1.72), and very low food security (aOR; 3.65) were associated with increased risk of perceived depression. Men with very low food security and divorced/widowed/separated status were most likely to have perceived depression (53.2%), followed by women with very low food security and divorced/widowed/separated status (48.7%), women with very low food security and married status (42.0%), and women with low food security and divorced/widowed/separated status (33.3%).

Conclusions

Female sex and marital status of divorced/widowed/separated were strongly associated with perceived depression. These two factors and food insecurity synergistically contributed to perceived depression.

Food Insecurity and Psychological Distress: a Review of the Recent Literature

PURPOSE OF REVIEW

Food insecurity is the lack of sufficient food in quantity and/or quality. Psychological distress includes mental health issues such as depression and anxiety. This review provides current information on research examining the association between food insecurity and psychological distress.

RECENT FINDINGS

Among studies published in the previous 5 years, food insecurity was significantly and positively associated with multiple indicators of psychological distress. This included cross-sectional and longitudinal studies, as well as primary data collection and secondary data analyses, from countries of varying income levels. Articles also provided evidence within various populations, such as adults of all ages, college students, those living with chronic disease, and parents. Food insecurity and psychological distress are interconnected health issues. Future research should consider a number of important gaps in the literature, with the most important being the development of interventions to improve food insecurity and psychological health concurrently.

Links of the Supplemental Nutrition Assistance Program With Food Insecurity, Poverty, and Health: Evidence and Potential

The Supplemental Nutrition Assistance Program (SNAP) is a highly effective program, vital to our nation's health and well-being. SNAP's entitlement funding structure allows it to provide benefits to anyone who meets the program's eligibility requirements, and this structure also enables SNAP to respond quickly when need increases. Research shows that SNAP reduces poverty for millions, improves food security, and is linked with improved health.Despite SNAP's successes, there is room to build on its considerable accomplishments. Evidence suggests that current benefit levels are not adequate for many households. Some vulnerable groups have limited SNAP eligibility, and some eligible individuals face barriers to SNAP participation.Policymakers should address these shortcomings by increasing SNAP benefits and expanding SNAP eligibility to underserved groups. The federal government and states should also continue improving policies and procedures to improve access for eligible individuals.

Welfare stigma as a risk factor for major depressive disorder: Evidence from the Supplemental Nutrition Assistance Program

BACKGROUND

Negative public attitude about welfare is known to impair feelings of self-worth and psychological well-being in welfare recipients. What is missing in the extant literature is whether the stress of being on welfare increases the risk for clinically severe depression. To fill this gap, the present study examines the association between participation in the food stamp program and major depressive disorder.

METHODS

Study data is drawn from the 2008-2014 waves of the Health and Retirement Study (N = 67076). Depressive symptom is assessed with the Composite International Diagnostic Interview - Short Form, and modeled by a continuous score of major depressive symptoms (0-7) and a binary indicator for three or more symptoms. A fixed effects regression is used to estimate changes in depressive symptoms explained by the food stamp participation, adjusted for confounding covariates.

RESULTS

Food stamp participation was associated with an average of 19% increases in depressive symptoms (p < 0.001) and 29% higher odds of having major depression (p < 0.01). The associations were statistically significant only for men, middle-aged adults, Whites, and those without disability - groups that are more likely to be stigmatized by the social norm for not being able to rise above poverty.

LIMITATIONS

Depression outcomes are self-reported. Causality remains not established. The recession during the study periods may have dampened the stigma effects.

CONCLUSIONS

Welfare participation is a risk factor for clinical depression in a low-income setting. Depressive symptoms induced by welfare stigma need to be clinically targeted through counseling and cognitive therapy programs.

Food stamps, food insecurity, and health outcomes among elderly Americans

This study examined associations between very low food security and health outcomes in older adults, and tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) mitigates adverse health consequences associated with very low food security. Data were drawn from the 1998-2014 waves of the Health and Retirement Study (N = 148,138 from 27,281 persons). A longitudinal analysis of the relationship between very low food security and health condition depending on SNAP participation was conducted using the individual fixed effects regression. Respondents' health status was assessed by self-rated health, grip strength, and depressive symptoms. The correlations between very low food security and physical health outcomes were negatively significant prior to SNAP enrollment (p < 0.05) but became insignificant upon participation, indicating that SNAP may have prevented poor physical health resulting from very low food security. However, results concerning mental health showed that SNAP enrollment does not modify the association between very low food security and depression; very low food security remained a significant risk factor of depressive symptoms conditional on SNAP enrollment (p < 0.001). Further analyses showed that SNAP participation is correlated with negative self-attitudes (p < 0.05), and that the correlation between SNAP and depression becomes insignificant after controlling for self-attitudes. These results suggest that a stigma effect arising from welfare use may have reduced self-esteem and resulted in depressive moods. Future research needs to delve into whether reforms to the food assistance program aimed at reducing stigma can help alleviate emotional distress among welfare recipients.

Aligning Programs and Policies to Support Food Security and Public Health Goals in the United States

Food insecurity affects 1 in 8 US households and has clear implications for population health disparities. We present a person-centered, multilevel framework for understanding how individuals living in food-insecure households cope with inadequate access to food themselves and within their households, communities, and broader food system. Many of these coping strategies can have an adverse impact on health, particularly when the coping strategies are sustained over time; others may be salutary for health. There exist multiple opportunities for aligning programs and policies so that they simultaneously support food security and improved diet quality in the interest of supporting improved health outcomes. Improved access to these programs and policies may reduce the need to rely on individual- and household-level strategies that may have negative implications for health across the life course.

Food Insecurity and Odds of High Allostatic Load in Puerto Rican Adults: The Role of Participation in the Supplemental Nutrition Assistance Program During 5 Years of Follow-Up

OBJECTIVE

Limited evidence demonstrates pathways linking food insecurity (FI) to chronic disease. Allostatic load (AL) may elucidate potential pathways, capturing both primary (neuroendocrine, inflammation) and secondary (metabolic, cardiovascular) physiological disturbances. We examined the longitudinal association of FI with 5-year AL and primary and secondary subsystem dysregulation and tested moderation by Supplemental Nutrition Assistance Program (SNAP) participation.

METHODS

We analyzed data from the longitudinal Boston Puerto Rican Health Study among 733 adults aged 45 to 75 years. Participants categorized as food insecure (assessed by US survey module) experienced FI at baseline and/or year 5. AL score comprised 11 biological components (5 primary, 6 secondary). We classified participants as having high scores for AL (≥6 dysregulated components), primary system (≥3), and secondary system (≥4). Multivariate models estimated odds ratios (OR), adjusting for baseline AL, sociodemographic, cultural, and behavioral characteristics.

RESULTS

By study end, 33.8% had experienced FI, 65.5% had participated in SNAP, and 37.5% had high AL. In adjusted models, FI was not associated with AL (OR [95% confidence intervals] = 1.07 [0.70-1.64]) or secondary system (0.82 [0.48-1.40]) scores, but was associated with high primary system scores (1.71 [1.25-2.36]). SNAP participation seemed to moderate the FI-primary system relationship (p = .06); food-insecure participants never receiving SNAP (mean (SE) = 2.06 (0.14)) had higher scores than food-secure participants receiving (1.72 (0.06], p = .02) or never receiving SNAP (1.64 (0.10), p = .01) and food-insecure participants receiving SNAP (1.80 (0.07), p = .08).

CONCLUSIONS

FI is associated with dysregulated components of the primary AL system, and this relationship may be stronger for those not receiving SNAP. Research is needed in additional populations to test AL as a plausible pathway connecting FI to chronic disease and SNAP as a moderator.

Associations between food insecurity and the severity of psychological distress among African-Americans

BACKGROUND

Little research exists on the association between food insecurity and mild to moderate psychological distress (MPD) among Black/African-Americans. In this study, we assess the relationship between food insecurity with and without hunger to that of both MPD and serious psychological distress (SPD) among this population.

METHODS

2009 and 2011/2012 adult public-use data from African-American respondents of the California Health Interview Survey were utilized for this study (n = 4003). Descriptive statistics were utilized to identify prevalence of psychological distress among sociodemographic and mental-health associated variables. Bivariate analyses were conducted between these variables and psychological distress using survey-weighted chi-square analyses. To evaluate the association between psychological distress, our primary exposure variable of food security, and other variables, we utilized survey-weighted multinomial logistic regression.

RESULTS

Prevalence of mild to MPD was higher among those reporting food insecurity while SPD was highest for those with food insecurity and hunger. Results of multinomial logistic regression analysis demonstrate that while MPD was significantly associated with food insecurity, Black/African-Americans with food insecurity and hunger displayed over sixfold odds of higher serious psychological distress, as compared to those living at or above 200% federal poverty level.

CONCLUSION

Our findings add to this growing segment of the literature on psychological distress and food insecurity. Further focus should be placed on improving the efficacy and reach of both formal and informal food support networks to improve the collective health and well-being of poor Black/African-American communities.

Food Insecurity and Psychological Distress Among Former and Current Smokers With Low Income

PURPOSE

To examine how food insecurity and psychological distress interact in its association with smoking and to explore how food insecurity and psychological distress are associated with quitting smoking using quit ratio estimates.

DESIGN

Cross-sectional study.

SETTING

Data from the 2015 California Health Interview Survey.

PARTICIPANTS

A total of 3007 lower income adults who have ever smoked.

MEASURES

Ever smoking was defined as smoking 100+ cigarettes in the entire lifetime, with current smoking defined as smoking "every day" or "some days" and former smoking defined as smoking "not at all." Psychological distress and food insecurity were measured by the 6-item K6 Psychological Distress Scale and the 6-item Food Security Survey Short Form, respectively.

ANALYSIS

Multiple logistic regression analysis was used to examine correlates of smoking status. Quit ratios (percentage of ever smokers who have quit) were calculated across study variables.

RESULTS

Reporting food insecurity with psychological distress was independently associated with lower odds of being a former smoker, compared to reporting food security without psychological distress. The quit ratio was lower among ever smokers reporting food insecurity with distress (41%) compared to ever smokers reporting food security without distress (63%).

CONCLUSIONS

Specific conditions of impoverishment, such as food insecurity, interact with psychological distress in its association with continued smoking. Interventions to reduce socioeconomic disparities in smoking should consider the interacting role of food insecurity and psychological distress.

Participation in the Supplemental Nutrition Assistance Program and maternal depressive symptoms: Moderation by program perception

RATIONALE

Previous studies have observed an association between participation in the Supplemental Nutrition Assistance Program (SNAP) and depression, which is contrary to SNAP's potential to alleviate food insecurity and financial strain.

OBJECTIVE

This study investigated the impact of change in SNAP participation status on maternal depression, and whether perceptions of government assistance moderate this association.

METHODS

Data were from the Fragile Families and Child Wellbeing Study (FFCWS). Logistic regression models with individual-specific fixed-effects, were fit to SNAP-eligible mothers who changed SNAP participation and depression status (N = 256) during waves 2 to 4. Perceptions of government assistance were defined as feelings of humiliation or loss of freedom and tested for interactions with SNAP participation.

RESULTS

Perceptions of government assistance moderated the association between SNAP participation and depression (p-interaction = 0.0208). Those with positive perceptions of welfare had 0.27 (95% CI = 0.08 to 0.89) times lower odds of depression when enrolled vs. not enrolled in SNAP. Among those with negative perceptions of welfare, SNAP enrollment was not associated with depression (OR = 1.13; 95% CI = 0.85 to 1.51).

CONCLUSION

Evidence suggests that SNAP mental health benefits may be context specific. SNAP's capacity to improve mental health may depend on individual perceptions of government assistance. More research is needed to determine whether interventions aimed at mitigating negative perceptions of programs like SNAP could ameliorate poor mental health among program participants.

Food insecurity, social networks and symptoms of depression among men and women in rural Uganda: a cross-sectional, population-based study

OBJECTIVE

To assess the association between food insecurity and depression symptom severity stratified by sex, and test for evidence of effect modification by social network characteristics.

DESIGN

A population-based cross-sectional study. The nine-item Household Food Insecurity Access Scale captured food insecurity. Five name generator questions elicited network ties. A sixteen-item version of the Hopkins Symptom Checklist for Depression captured depression symptom severity. Linear regression was used to estimate the association between food insecurity and depression symptom severity while adjusting for potential confounders and to test for potential network moderators.

SETTING

In-home survey interviews in south-western Uganda.

SUBJECTS

All adult residents across eight rural villages; 96 % response rate (n 1669).

RESULTS

Severe food insecurity was associated with greater depression symptom severity (b=0·4, 95 % CI 0·3, 0·5, P<0·001 for women; b=0·3, 95 % CI 0·2, 0·4, P<0·001 for men). There was no evidence of effect modification by social network factors for women. However, for men who are highly embedded within in their village social network, and (separately) for men who have few poor contacts in their personal network, the relationship between severe food insecurity and depression symptoms was stronger than for men on the periphery of their village social network, and for men with many poor personal network contacts, respectively.

CONCLUSIONS

In this population-based study from rural Uganda, food insecurity was associated with mental health for both men and women. Future research is needed on networks and food insecurity-related shame in relation to depression symptoms among food-insecure men.

Childhood Adversity and Adult Reports of Food Insecurity Among Households With Children

INTRODUCTION

Exposure to childhood adversity, including abuse, neglect, and household dysfunction, is associated with negative long-term health and economic outcomes. Little is known about how adversity exposure in parents' early lives may be related to later food insecurity for parents and their children. This study investigated the association between female caregivers' adverse childhood experiences (ACEs) and household and child food insecurity, taking into account depressive symptoms.

METHODS

This study used cross-sectional data from 1,255 female caregivers of children aged <4 years surveyed in an urban clinical setting from March 2012 through June 2014. Measures included sociodemographic characteristics; caregivers' ACEs, including abuse, neglect, and household dysfunction; depressive symptoms; and household and child food insecurity. Multinomial and logistic regression analyses assessed the relationship among ACEs, depressive symptoms, and household and child food security status.

RESULTS

Caregiver depressive symptoms modified associations between ACEs and food insecurity level. After adjusting for covariates, caregivers reporting both depressive symptoms and four or more ACEs were 12.3 times as likely to report low food security (95% CI=6.2, 24.7); 28.8 times as likely to report very low food security (95% CI=12.8, 64.8); and 17.6 times as likely to report child food insecurity (95% CI=7.3, 42.6) compared with those reporting no depressive symptoms and no ACEs.

CONCLUSIONS

Depressive symptoms and ACEs were independently associated with household and child food insecurity, and depressive symptoms modified the association between ACEs and household and child food insecurity. Comprehensive policy interventions incorporating nutrition assistance and behavioral health may address intergenerational transmission of disadvantage.