The association between unhealthy dietary behaviors and participation in the Supplemental Nutrition Assistance Program (SNAP): No evidence in support of the self-selection hypothesis

Supplemental Nutrition Assistance Program (SNAP) participants tend to have unhealthier dietary consumption compared to eligible non-participants. It has been suggested, though never empirically tested, that individuals who enroll in SNAP may have unhealthy diets prior to program participation. Using a longitudinal cohort study design, we examined the association between low-income adults' SNAP participation status and prior dietary behaviors to test the argument that individuals with unhealthier dietary consumption self-select into SNAP. A sample of households from predominantly lower-income cities were surveyed at baseline (T1) and 2-4 years later (T2). The main analyses were restricted to adults who did not participate in SNAP at T1 and with household income <200% of the federal poverty line (n = 170) at both T1 and T2. Participants were grouped into two categories, based on their SNAP participation at T2; (a) Non-participants (n = 132): no SNAP participation at T1 or T2, and (b) T2 SNAP participants (n = 38): SNAP participation at T2 but not T1. Daily consumption frequency of whole fruits, fruit juice, vegetables, sugar-sweetened beverages (SSBs), and energy dense snacks were measured through self-reports. To observe dietary differences between the two groups prior to SNAP participation, T1 behaviors were compared. There were no significant differences in dietary behaviors at T1 (prior to SNAP participation) between non-participants and T2 participants, providing no evidence of self-selection of individuals with unhealthier dietary consumption into SNAP among our study sample. Improvements in SNAP participants' diets may benefit from focusing on policy changes that encourage healthy dietary habits during participation in the program.

Healthy diets positively associated with health-related quality of life in children and adolescents from low socioeconomic areas: Findings from the Greek Food Aid Program, DIATROFI

OBJECTIVES

To assess the relationship of diet with health-related quality of life (HRQoL) in vulnerable children and adolescents.

METHODS

Data included 6583 children and adolescents (aged 3-18 years old) from the Greek Food-Aid DIATROFI Program in the 2015 to 2016 and 2017 to 2018 school years. HRQoL was measured with the Pediatric Quality of Life Inventory questionnaire and diet with food frequency questionnaires. The healthy plant-based diet index (hPDI), animal score, and dietary patterns were investigated.

RESULTS

The hPDI and animal score were associated with good HRQoL (odds ratio [OR] [95% confidence interval], 10-unit increase: ORhPDI = 1.28 [1.05, 1.57], ORanimal = 1.51 [1.14, 2.00]) and physical (ORanimal = 1.62 [1.23, 2.13]), emotional (ORhPDI = 1.30 [1.07, 1.58], ORanimal = 1.41 [1.08, 1.85]) and school function (ORhPDI = 1.32 [1.09, 1.59], ORanimal = 1.46 [1.12, 1.89]). Dietary patterns of fruits, raw vegetables, and cheese were associated with good HRQoL (OR of 1-unit increase: 1.22 [1.13, 1.32]), and physical OR = 1.18 [1.09, 1.27]) and emotional function (OR = 1.09 [1.02, 1.18]). Starchy foods and sweetened beverages were associated with poor HRQoL (OR = 0.75 [0.63, 0.90]), and emotional (OR = 0.80 [0.68, 0.95]) and school function (OR = 0.72 [0.61, 0.85]).

CONCLUSION

Healthy diets and dietary patterns were positively associated with the HRQoL of vulnerable children and adolescents, which may offer opportunities for prevention.

Sleep Duration Is Associated with Household Food Insecurity and Sugar-Sweetened Beverage Intake Among Women, Infants and Children Participating Children Ages 0-5

PURPOSE

To determine associations between child and household characteristics and sleep duration among low-income children in Los Angeles County.

DESIGN

Cross-sectional study.

SETTING

Survey data collected in 2017 and 2020 in Los Angeles County, California.

SAMPLE

Special Supplemental Nutrition Program for Women, Infants and Children (WIC) households with children ages 4-60 months.

MEASURES

Sleep duration for children 4-60 months old (less than recommended (LTR), recommended range, more than recommended (MTR)), household food insecurity (HFI), sociodemographics, and daily servings of sugar-sweetened beverages (SSB).

ANALYSIS

Multinomial logistic regression, stratified by child age, was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for associations between household/child characteristics and LTR or MTR sleep compared to recommended duration among WIC participating children 4-60 months old.

RESULTS

The final sample included 3512 children ages 4-23 months and 6035 children ages 24-60 months. In the study population, 32% (3-5 years old) to 44% (4-11months) of children under 5 did not meet the recommended hours of sleep per night. HFI was associated with higher odds of LTR (OR 1.27, CI 1.12-1.45) and MTR (OR 1.46, CI 1.15-1.87) sleep among 24-60 month-old children. Each additional daily SSB serving was associated with higher odds of LTR sleep (4-23 months: OR 1.10, CI 1.02-1.19; 24-59 months: OR 1.12, CI 1.08-1.17).

CONCLUSIONS

HFI and SSB intake are associated with not getting the recommended amount of sleep among low-income WIC participating children. Nutrition assistance program participants may benefit from receiving information about recommended sleep duration for young children and how to establish sleep routines to optimize sleep duration.

Association of food insecurity with health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic

OBJECTIVES

To examine the associations between food insecurity and health, access to care, affordability of care, financial burden of care, and financial hardships among US adults during the COVID-19 pandemic and examine whether the associations were less pronounced among adults with safety nets.

STUDY DESIGN

We conducted a retrospective longitudinal cohort study using the 2020-2021 Medical Expenditure Panel Survey.

METHODS

Linear probability models were used to assess the associations between food insecurity in one year and the outcomes of interest in the following year while adjusting for baseline characteristics. We performed the analyses for the entire population and then conducted stratified analyses for adults with and without Supplemental Nutrition Assistance Program (SNAP) benefits or Medicaid coverage.

RESULTS

Compared with food-secure adults, food-insecure adults were 9.1 percentage points less likely to report life satisfaction and 9.9, 10.2, and 13.2 percentage points more likely to experience delays in getting medical care, postpone or forgo medical care because of cost, and struggle with paying medical bills. Food-insecure adults were 30.4, 27.2, and 23.5 percentage points more likely to face challenges in affording necessities, paying utility bills, and meeting rent or mortgage payments on time than food-secure adults. Notably, the strengths of these associations were attenuated among adults with SNAP benefits or Medicaid coverage.

CONCLUSIONS

Food insecurity was associated with poor health, limited access to and affordability of care, and a greater financial burden of care among US adults during the pandemic. Nevertheless, safety net programs can play a critical role in alleviating adverse consequences.

SNAP-Ed Programming for College Students Experiencing Food Insecurity: A Qualitative Process-Focused Evaluation

BACKGROUND

Growing recognition of food insecurity experienced by college students has led to efforts on college campuses to provide students with food assistance benefits and related nutrition education. A Supplemental Nutrition Assistance Program-Education (SNAP-Ed) program was developed for college students as one of these efforts.

OBJECTIVE

To explore program content, recruitment, and implementation through experiences of program implementers in a novel SNAP-Ed intervention among college students.

DESIGN

This qualitative study used focus groups and a case study approach to elicit program implementers' experiences delivering SNAP-Ed to college students.

PARTICIPANTS/SETTING

Students, staff, and faculty (n = 26) implementing SNAP-Ed with college students experiencing food insecurity across eight campuses in the California State University system participated in 8 focus groups in 2021-2022.

MAIN OUTCOME MEASURES

A process evaluation framework was used to evaluate content fit and orientation; recruitment, retention, and reach; and structure and capacity for implementation.

ANALYSES PERFORMED

Focus groups were recorded, transcribed, and coded via thematic analysis using NVivo (QSR International, Burlington, MA).

RESULTS

Five themes were identified: (1) need for this work to extend college-based basic needs services; (2) importance of aligning programming with college student context/needs; (3) common factors important for attracting/engaging the audience; (4) program barriers; and (5) training/team sharing for extending ideas.

CONCLUSIONS

Study findings suggest tailoring SNAP-Ed programming to the needs of college students experiencing food insecurity, such as integrating student-relevant cooking skills, recipes, and topics of interest. Additional intervention and research efforts may lead to a new model for serving college students with SNAP-Ed.

Caregiver Preferences for Primary Care Clinic-Based Food Assistance: A Discrete Choice Experiment

OBJECTIVE

The American Academy of Pediatrics recommends that pediatric providers screen families for food insecurity and connect them to appropriate resources. However, it is unclear how clinics can best provide families with resources consistent with their needs and preferences. In this study, we elicited caregiver preferences for clinic-based food assistance.

METHODS

We conducted a cross-sectional discrete choice experiment in which caregivers at 2 pediatric primary care clinics were asked to choose between hypothetical food programs. Programs varied across 4 categories: 1) resources provided (eg, food delivery, food in clinic, assistance enrolling in benefits); 2) support staff providing resources (eg, social worker, community health worker, physician, or nurse); 3) outreach modality (eg, phone, email, text); and 4) outreach frequency. Multinomial logistic regression was used to assess caregiver preferences within each category and the relative importance of each category to caregiver decisions.

RESULTS

We surveyed 142 caregivers who were predominantly Black (87%) and Medicaid-insured (90%). Caregiver preferences for food programs were most strongly influenced by the food resources provided. Caregivers preferred food delivery over other forms of food supports, such as food provided in clinic. They preferred assistance from a benefits enrollment specialist, community health worker, or social worker to assistance from a physician or nurse.

CONCLUSIONS

Pediatric clinics serving families at risk of food insecurity should use caregiver preferences to inform the design of family-centered interventions. Clinics should consider connecting caregivers with food delivery programs, and pediatric payors should adopt reimbursement models that support multidisciplinary team-based care to address food insecurity.

"What Matters to You?": A Participant-Centered Approach to Needs Identification and Referral to Community Resources

OBJECTIVE

Referral to social and health services is a core process of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). We evaluate the feasibility and acceptability of a referral innovation implemented at two New York City WIC sites. This program aimed to improve retention by increasing WIC's perceived value by addressing unmet needs of WIC families. The two main components were needs assessment via conversation and a closed-loop referral process for WIC families with children aged 6-9 months and 18-21 months.

DESIGN

Referral outcomes from Unite Us and program data were tracked and assessed using descriptive univariate analyses. We conducted 29 in-depth interviews with caregivers and six focus groups with WIC and CBO staff. Qualitative data were analyzed using thematic framework analysis.

RESULTS

From February 2020 through January 2021, 1,675 WIC caregivers participated in a conversation about their family's needs. Four hundred sixty-one caregivers were referred to at least one service. 95 received services or benefits. In interviews, caregivers viewed referrals to other services positively but were not aware WIC could address needs holistically. In focus groups, WIC staff liked the conversation script but highlighted barriers to making referrals. CBO partners valued network participation as it increased their reach to new families.

CONCLUSIONS AND IMPLICATIONS

Our approach facilitated targeted referrals for WIC participants. It is an acceptable enhancement of the WIC referral process with potential to strengthen WIC as a community provider.

Effects of Inclusion of Food Purchase Restrictions and Incentives in a Food Benefit Program on Diet Quality and Food Purchasing: Results From a Randomized Trial

BACKGROUND

There is interest in reshaping the Supplemental Nutrition Assistance Program (SNAP) to better support family nutrition.

OBJECTIVE

The Grocery Assistance Program Study (GAPS) for Families evaluated the effects of prohibiting using program funds for the purchase of certain sugary foods on the nutritional quality of foods purchased and consumed by program participants.

DESIGN

A randomized experimental trial was carried out with participants randomized to one of three food benefit conditions. Baseline and follow-up measures collected included interviewer-administered 24-hour dietary recalls, food purchase receipts, food security, height, and weight.

PARTICIPANT/SETTING

Adult-child dyads in households eligible for SNAP but currently not enrolled were recruited from the Minneapolis/St Paul MN metropolitan area from May of 2018 through May of 2019. A total of 293 adult-child dyads received the intervention as allocated. Of these dyads, 233 adults completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 20.5%. A total of 224 children completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 23.5%.

INTERVENTION

Participants were randomized to 1 of 3 conditions: restriction (not allowed to buy sugar-sweetened beverages [SSB], sweet baked goods, or candy with program funds); restriction paired with incentive (30% incentive for fruits and vegetables [FV] purchased with funds); and control (funds provided with no restrictions or incentives). Funds were provided on a 4-week cycle for 20 weeks via a study-provided debit card.

MAIN OUTCOME MEASURES

The primary outcome was the Healthy Eating Index (HEI)-2015 total score. Additional outcomes included selected HEI-2015 component scores; energy intake; food security; body weight; and purchasing of SSB, sweet baked goods, candies, fruits, and vegetables.

STATISTICAL ANALYSIS

Linear regression analyses were conducted with change in the outcome regressed on treatment condition for the primary outcome analyses.

RESULTS

No differences were observed between conditions in change in the nutrition and food security measures examined. Purchases of SSB and sweet baked goods and candies significantly differed by experimental condition. Purchase of restricted foods was lower at follow-up in the restriction and restriction paired with incentive conditions compared with the control condition. For example, spending on SSB at follow-up was significantly lower in the restriction ($2.66/week) and restriction paired with incentive ($2.06/week) conditions in comparison with control condition ($4.44/week) (P < 0.0003 and P < 0.0001, respectively).

CONCLUSIONS

This study failed to find evidence in support of prohibiting the purchase of sugary foods with food program funds as a strategy to improve program participant nutrition, even when paired with an FV incentive. Research carried out in the context of the SNAP program is needed for a more robust evidence base.

Reasons for Nonparticipation in the Special Supplemental Nutrition Program for Women, Infants, and Children

This cross-sectional study evaluates reasons reported for not participating in or withdrawing participation from the Special Supplemental Nutrition Program for Women, Infants, and Children from 2019 to March 2020.

An Affordable and Sustainable Thrifty-Like Meal Plan, FoodRx, That Meets the Recommended Dietary Allowances

There is considerable controversy as to whether a healthy diet is affordable given recent inflation. In order to determine whether a healthy, climate-friendly sustainable diet can be obtained within the allotments of the Supplemental Nutrition Assistance Program (SNAP), we created and purchased 26 weeks of meal plans designed to meet the EAT-Lancet sustainability guidelines and > 90% of the RDAs for 23 macro/micronutrients for households with at least 2 adults and 1-3 children. We compared the food quantities and cost of a healthy sustainable diet purchased in Los Angeles, 2023, to the Thrifty Food Plan, 2021. We compared the volume of food and cost of basic groceries to those recommended in the Thrifty Food Plan, 2021. The costs of the sustainable diet fell within the 2023 SNAP allotments as long as the average calories required per person did not exceed 2000. The volume of fruits, vegetables, legumes, nuts, and seeds were considerably higher for the sustainable diet compared to the Thrifty Food Plan. Given that calorie needs are the determinants of food quantity and costs, the USDA may consider offering supplemental coverage for individuals with higher calorie needs to make healthy eating affordable.

Integration of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Primary Care Settings

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to improve food and economic security, advance health and educational outcomes, and reduce health costs. Despite proven benefits, 54% of those eligible for WIC in Denver County are not enrolled, likely due to documented barriers including stigma, psychological costs, administrative resources, and physical access. In partnership with Denver County WIC, Denver Health's Federally Qualified Health Centers collaborated to create a Specialized WIC Co-Enrollment program to integrate WIC services into pediatric well-child and obstetric visits. WIC Co-Enrollment programmatic data were collected using a REDCap database. Program participant feedback and experiences were gathered through a bilingual survey after visits were completed. Program staff feedback and experiences were collected through third-party interviews and anonymous surveys. Data were analyzed using descriptive statistics and inductive thematic analysis. Between March 2021 and December 2022, 1,870 families were served in Specialized WIC Co-Enrollment appointments, serving a total of 3,347 individuals. Participants noted positive experiences and that receiving WIC services during healthcare visits saved them time, money, childcare, and transportation. Staff and providers noted the program was convenient for families and offered system-level benefits such as improved interprofessional collaboration and clinic efficiency. Specialized WIC Co-Enrollment has been popular among participants, providers, and staff. Integrating WIC services in a health system leverages existing touchpoints with Medicaid beneficiaries and eliminates barriers to accessing the WIC program, which could be beneficial in other communities where assistance program enrollment gaps exist.

Reducing WIC Administrative Burdens to Promote Health Equity

This Viewpoint discusses barriers to Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation for low-income and racial and ethnic minoritized families and outlines strategies that health care professionals and health systems can use to help families overcome these barriers.

Associations of Increased WIC Benefits for Fruits and Vegetables With Food Security and Satisfaction by Race and Ethnicity

Introduction

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition support for racially and ethnically diverse populations. In 2021, the monthly cash value benefit (CVB) for the purchase of fruits and vegetables increased from $9 to $35 and was later adjusted to $24. This study investigated, by racial and ethnic groups, whether CVB increases were associated with increases in CVB redemption, household food security, child fruit and vegetable intake, satisfaction with CVB amount, and likelihood of continued participation in WIC if the CVB returned to $9 per month.

Methods

We conducted a longitudinal study of WIC participants (N = 1,770) in southern California at 3 time points, from April 2021 through May 2022; the CVB amount was $9 at baseline, $35 at Survey 2, and $24 at Survey 3. Racial and ethnic groups were Hispanic English-speakers, Hispanic Spanish-speakers, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other, and non-Hispanic White. We used mixed-effect and modified Poisson regressions to evaluate outcomes by group.

Results

At baseline, groups differed significantly in dollars of CVB redeemed, percentage of CVB redeemed, household food security, and satisfaction with CVB amount. After the increase in CVB, we found increases in all groups in CVB redemption, household food security, and satisfaction. Non-Hispanic Black and Hispanic English-speaking groups, who had low levels of satisfaction at baseline, had larger increases in satisfaction than other groups. Reported likelihood of continued WIC participation if the monthly CVB returned to $9 also differed significantly by group, ranging from 62.5% to 90.0%.

Conclusion

The increase in CVB for children receiving WIC benefited all racial and ethnic groups. Continued investment in an augmented CVB could improve health outcomes for a racially and ethnically diverse WIC population.

Is that Hospital Food Pantry an Illegal Patient Inducement? Analysis of Health Care Fraud Laws as Barriers to Food and Nutrition Security Interventions

The complex regulatory framework governing the U.S. health care system can be an obstacle to programming that address health-related social needs. In particular, health care fraud and abuse law is a pernicious barrier as health care organizations may minimize or forego programming altogether out of real and perceived concern for compliance. And because health care organizations have varying resources to navigate and resolve compliance concerns, as well as different levels of risk tolerance, fears related to the legal landscape may further entrench inequities in access to meaningful programs that improve health outcomes. This article uses food and nutrition programming as a case study to explore the complexities presented by this area of law and to highlight pathways forward.

Effect of a Multicomponent Food Pantry Intervention in Client Subgroups

Nutrition promotion programs may have varying effects and influence health disparities. SuperShelf promotes healthy choices in food pantries through inventory changes and nudge implementation (e.g., choice architecture). This secondary analysis of the SuperShelf cluster-randomized trial assessed whether the effect of SuperShelf on client diet quality differed by equity characteristics. English-, Spanish-, or Somali-speaking adult clients from 11 food pantries in Minnesota were included (N = 193). We measured change in diet quality by the Healthy Eating Index 2015 (HEI-2015; maximum score 100) using up to two 24 h dietary recalls from pre-intervention and post-intervention periods. We used linear mixed-effects models to determine whether the effect of SuperShelf on diet quality varied by self-reported gender, race/ethnicity, education, and employment status. In separate adjusted models, the interactions of SuperShelf and gender, education, or employment status were not significant. The interaction of SuperShelf and race/ethnicity was significant (p-interaction = 0.008), but pairwise comparisons in diet quality were non-significant in all racial/ethnic subgroups. SuperShelf did not have differential effects on diet quality by gender, race/ethnicity, education, or employment status, suggesting it does not worsen dietary disparities among food pantry clients, though more subgroup analyses are needed to explore potential racial/ethnic disparities in this context.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic

INTRODUCTION

This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care.

METHODS

This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit.

RESULTS

Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96).

CONCLUSIONS

There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

State Supplemental Nutrition Assistance Program Policies and Substance Use Rates

INTRODUCTION

Food insecurity is associated with the development of substance misuse and use disorders (SUD). This study sought to estimate associations between state Supplemental Nutrition Assistance Program (SNAP) eligibility policies and substance-related outcomes.

METHODS

2014-2017 SNAP Policy Database and 2015-2019 National Survey on Drug Use and Health state-level estimates were used to estimate associations between state SNAP eligibility policies and alcohol use disorder (AUD), opioid misuse, illicit drug use disorder (IDUD), SUD, and needing but not receiving SUD treatment. State SNAP policies included those that (1) do not disqualify individuals with a felony drug conviction from SNAP and/or (2) expand SNAP eligibility by increasing the income limit or removing the asset test. Analyses were conducted January-May 2023.

RESULTS

States that adopted both SNAP eligibility policies had reduced rates of AUD (adjusted rate ratio (aRR): 0.92; 95% CI 0.86, 0.99), opioid misuse (aRR: 0.94; 95% CI 0.89, 0.98), IDUD (aRR: 0.91; 95% CI 0.85, 0.98), SUD (aRR: 0.91; 95% CI 0.85, 0.97), and needing but not receiving SUD treatment (aRR: 0.92; 95% CI 0.87, 0.98) compared to states with neither policy. Among states that did not adopt increases to the income limit or removal of the asset test, those that removed the felony drug disqualification had lower rates of IDUD, SUD, and needing but not receiving SUD treatment, compared to those that maintained a disqualification.

CONCLUSIONS

Expanded SNAP eligibility could help reduce rates of substance misuse and SUD. Opting out of the federal disqualification on SNAP participation for those with felony drug convictions may be particularly beneficial.

Food recovery and produce distribution as a system strategy for increasing access to healthy food among populations experiencing food insecurity: lessons for post-pandemic planning

Using data from an intercept survey of 428 adults who received free surplus produce at five distribution sites and qualitative data from 15 interviews with site personnel, we examined facilitators (e.g. community partnerships, coalition support) and challenges (e.g. limited refrigerated storage, lack of transportation infrastructure) to operating a food recovery and distribution program in Los Angeles County. Overall, this food system intervention appeared to fill an unmet need for recipients, nearly 80% of whom were food insecure and 60% visited a site several months/year or monthly. For many living in this county's underserved communities, this effort was instrumental in increasing access to healthy food before and during the COVID-19 pandemic. To sustain/expand this program's reach, local governments and food assistance programs should provide greater coordination and oversight, and invest more resources into this food recovery and distribution infrastructure.

SNAP Student Rules Are Not So Snappy: Lessons Learned From a Qualitative Study of California County Agency Workers

OBJECTIVE

To examine the college student Supplemental Nutrition Assistance Program (SNAP) application process from the perspective of county agency workers.

DESIGN

A qualitative study that included semistructured individual and group interviews (n = 14) between February and December, 2021.

SETTING

Nine California counties with a University of California campus.

PARTICIPANTS

A total of 24 county agency workers who regularly process or advise on college student SNAP applications.

PHENOMENON OF INTEREST

Facilitators and barriers to processing student SNAP applications.

ANALYSIS

Interviews were recorded, transcribed, and coded using thematic analysis.

RESULTS

Five themes were identified regarding student applications: (1) a need for more consistency in policy dissemination and program administration, (2) student exemptions and the application process are perceived as challenging for students, (3) facilitators of successfully processing student applications, (4) tracking policy changes is burdensome, and (5) eliminate the student rules.

CONCLUSION AND IMPLICATIONS

County agency workers perceived that students experience unnecessary barriers to accessing SNAP benefits and that implementing the student rules was taxing. Expanding SNAP access to low-income college students could be an equitable solution to mitigate the risk of student hunger while they pursue their degrees.

Do Household Headship and Gender Affect Diet Quality under the Supplemental Nutrition Assistance Program (SNAP)?

PURPOSE

Examine whether the association between Supplemental Nutrition Assistance Program (SNAP) participation and diet quality is different by gender and household headship.

DESIGN

Quantitative, cross-sectional.

SETTING

The 2007-2018 waves of the National Health and Nutrition Examination Survey (NHANES).

SUBJECTS

6180 individuals aged 20 to 65 with household annual income below 130% of the poverty level.

MEASURES

The outcome of diet quality was measured using the 2015 Healthy Eating Index (HEI) based on dietary intake from 24-hour diet recall. The exposures were self-reported participation in SNAP and socio-demographic variables.

ANALYSIS

Ordinary Least Square (OLS) regression models.

RESULTS

The study found that female household heads had higher average total HEI scores relative to their male and non-head counterparts (β = 1.81, 95% CI: -.27, 3.88). However, for SNAP participants, female household heads had lower average total HEI scores (β = -3.67, 95% CI: -7.36, .11).

CONCLUSION

Female household heads are more likely to experience difficulty in maintaining diet quality relative to their counterparts. The study suggests that intra-household effort allocation may play an important role in differentiating and maintaining diet quality.

Investigating the Poverty-Reducing Effects of SNAP on Non-nutritional Family Outcomes: A Scoping Review

INTRODUCTION/PURPOSE

Poverty-reduction efforts that seek to support households with children and enable healthy family functioning are vital to produce positive economic, health, developmental, and upward mobility outcomes. The Supplemental Nutrition Assistance Program (SNAP) is an effective poverty-reduction policy for individuals and families. This study investigated the non-nutritional effects that families experience when receiving SNAP benefits.

METHODS

We conducted a scoping review using the PRISMA Guidelines and strategic search terms across seven databases from 01 January 2008 to 01 February 2023 (n=2456). Data extraction involved two researchers performing title-abstract reviews. Full-text articles were assessed for eligibility (n=103). Forty articles were included for data retrieval.

RESULTS

SNAP positively impacts family health across the five categories of the Family Stress Model (Healthcare utilization for children and parents, Familial allocation of resources, Impact on child development and behavior, Mental health, and Abuse or neglect).

DISCUSSION/CONCLUSION

SNAP is a highly effective program with growing evidence that it positively impacts family health and alleviates poverty. Four priority policy actions are discussed to overcome the unintentional barriers for SNAP: distributing benefits more than once a month; increasing SNAP benefits for recipients; softening the abrupt end of benefits when wages increase; and coordinating SNAP eligibility and enrollment with other programs.

WIC Participation and Coping Strategies Adopted by Families During the Infant Formula Shortage Crisis

BACKGROUND

Availability of benefits and expanded flexibilities to obtain formula, granted by the US Department of Agriculture shortly after the onset of infant formula shortage in February 2022, could have mitigated adverse experiences related to the shortage in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) families.

OBJECTIVE

To examine association of household WIC participation with formula shortage experiences and coping strategies adopted by families using Household Pulse Survey data.

DESIGN

Cross-sectional.

PARTICIPANTS

The current study utilized Phase 3.7 of the Household Pulse Survey with the following data collection periods: December 9 through 19, 2022, January 4 through 16, 2023, and February 1 through 13, 2023. The primary analytic sample (N = 1,542) consisted of households with income ≤185% of the federal poverty level and children younger than age 18 months.

MAIN OUTCOME MEASURES

Experiences and coping strategies during the formula shortage.

STATISTICAL ANALYSES

Logistic regression examined associations of WIC participation with odds of being affected by formula shortage and difficulty in obtaining formula during the past week. Among those affected by the shortage, association of WIC participation with odds of utilizing coping strategies was examined.

RESULTS

No statistically significant differences were observed in the rates of being affected by formula shortage and having difficulty in obtaining formula during the past week between WIC participants and income-eligible nonparticipants. However, among those affected by the shortage, WIC participation was related to significantly lower odds of using suboptimal practices as a coping strategy (odds ratio 0.38, 95% CI 0.20 to 0.71; P = 0.003). WIC participants also had significantly higher odds of solely changing formula type, brand, or method of receipt (odds ratio 2.63, 95% CI 1.20 to 5.73; P = 0.02).

CONCLUSIONS

Findings from this study suggest that WIC participants may have utilized more optimal coping strategies during the infant formula shortage compared with income-eligible nonparticipants. Additional research is needed to determine whether or not these findings could be attributed to expanded flexibilities to maximize formula access among WIC participants during the shortage.

Association of Supplemental Nutrition Assistance Program participation duration with cost-related medication non-adherence and emergency department visits

OBJECTIVE

Administrative requirements could disrupt sustained Supplemental Nutrition Assistance Program (SNAP) participation among income-eligible individuals. To meet their food needs, low-income individuals without consistent SNAP benefits may compromise on medication use, posing a risk to their health. The objective of this study is to examine the association of SNAP participation duration in a given year with cost-related medication nonadherence (CRN) and emergency department (ED) use in income-eligible individuals.

DESIGN

Cross-sectional.

SAMPLE

Non-elderly and elderly adults who used prescription medications and participated in SNAP the previous year in 2016-2018 National Health Interview Survey. Subsamples included individuals with specific chronic conditions.

MEASUREMENTS

CRN and ED usage.

RESULTS

SNAP participation for <12 months in the previous year was related to increased CRN and ED use in nonelderly adults taking prescription medication, as well as in those with hypertension, cardiovascular disease and asthma. Further, <12-month SNAP participation was associated with greater odds of having at least one ED visit in nonelderly and elderly adults.

CONCLUSIONS

Sustained SNAP participation could help income-eligible individuals better adhere to their prescribed medications and reduce health complications requiring ED visits. Findings suggest the importance of addressing SNAP participation gaps among income-eligible individuals in health care settings.

Food is Medicine Initiative for Mitigating Food Insecurity in the United States

OBJECTIVES

While several food assistance programs in the United States tackle food insecurity, a relatively new program, "Food is Medicine," (FIM) initiated in some cities not only addresses food insecurity but also targets chronic diseases by customizing the food delivered to its recipients. This review describes federal programs providing food assistance and evaluates the various sub-programs categorized under the FIM initiative.

METHODS

A literature search was conducted from July 7, 2023 to November 9, 2023 using the search term, "Food is Medicine", to identify articles indexed within three major electronic databases, PubMed, Medline, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Eligibility criteria for inclusion were: focus on any aspect of the FIM initiative within the United States, and publication as a peer-reviewed journal article in the English language. A total of 180 articles were retrieved; publications outside the eligibility criteria and duplicates were excluded for a final list of 72 publications. Supporting publications related to food insecurity, governmental and organizational websites related to FIM and other programs discussed in this review were also included.

RESULTS

The FIM program includes medically tailored meals, medically tailored groceries, and produce prescriptions. Data suggest that it has lowered food insecurity, promoted better management of health, improved health outcomes, and has, therefore, lowered healthcare costs.

CONCLUSIONS

Overall, this umbrella program is having a positive impact on communities that have been offered and participate in this program. Limitations and challenges that need to be overcome to ensure its success are discussed.

POSITION STATEMENT: Pass the RESTORE (Re-entry Support Through Opportunities for Resources and Essentials) Act

Under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), current federal policy mandates a lifetime ban for individuals with a past felony drug conviction from receiving Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) benefits. Denying nutritional and financial assistance to individuals with a past felony conviction will widen existing structural health inequities, set back individuals' successful re-entry into society, and contribute to recidivism and poorer health outcomes. Therefore, the Society of Behavioral Medicine supports the RESTORE ACT (Re-Entry Support Through Opportunities for Resources and Essentials Act), which would repeal the lifetime ban on receiving SNAP and TANF benefits for individuals convicted of a drug felony.

Characterizing Trends in the Use of Food Donations and Other Food-Related Community-Based Social Assistance Programs in a Cohort of New Food Bank Users in Quebec, Canada

Objective: To characterize 12-month trends in the use of food donations and other food-related community-based social assistance programs (CB-SAPs) during the first year following the enrollment of new food bank (FB) users in Quebec, Canada. Methods: A cohort of 1,001 newly registered FB-users in Quebec from the Pathways Study were followed-up during 12-month following baseline assessment. Outcomes were monthly use of food donations and other food-related CB-SAPs. Main predictors were alternative food source utilization (AFSU) profiles: 1) exclusive-FB-users; 2) FB+fruit/vegetable-market-users; and 3) Multiple/diverse-AFS-users. Covariates included sociodemographic characteristics, health status, and major life events. We fit Bayesian hierarchical mixed-effect models, accounting for spatial clustering, temporal correlation, and censoring. Results: We observed an overall downward trend of food donation use among study completers (n = 745). Each AFSU profile had a distinctive monthly trend of food donation use, but probabilities of use across the three profiles overlapped, between 44% and 55%. The use of other food-related CB-SAPs was low and not correlated with AFSU profiles. Conclusion: De novo FB-users use food donations in different ways over time according to specific contextual AFSU profiles.

Food insecurity, fruit and vegetable consumption, and use of the Supplemental Nutrition Assistance Program (SNAP) in Appalachian Ohio

Food insecurity and inadequate nutrition are two major challenges that contribute to poor health conditions among U.S. households. Ohioans continue to face food insecurity, and rates of food insecurity in rural Southeast Ohio are higher than the state average. The main purpose of this project is to evaluate the associations between Supplemental Nutrition Assistance Program (SNAP) participation and food security in rural Ohio, and to explore the association between SNAP participation and fruit/vegetable consumption. We control for food shopping patterns, such as shopping frequency, because previous research reports a significant relationship between shopping patterns and food security. To achieve our purpose, we use novel household-level data on food insecurity and SNAP participation in rural Southeast Ohio, collected during the COVID-19 pandemic. We find that people who experience higher levels of food insecurity than others are more likely to participate in SNAP, though this is likely a function of selection bias. To correct for the bias, we employ the nearest neighbor matching method to match treated (SNAP participant) and untreated (similar SNAP nonparticipant) groups. We find that participating in SNAP increases the probability of being food secure by around 26 percentage points after controlling for primary food shopping patterns. We do not find any significant association between SNAP participation and estimated intake of fruits and vegetables. This study provides policymakers with suggestive evidence that SNAP is associated with food security in rural Southeast Ohio during the pandemic, and what additional factors may mediate these relationships.

Supplemental Nutrition Assistance Program and Adherence to Antihypertensive Medications

Importance

Nonadherence to antihypertensive medications is associated with uncontrolled blood pressure, higher mortality rates, and increased health care costs, and food insecurity is one of the modifiable medication nonadherence risk factors. The Supplemental Nutrition Assistance Program (SNAP), a social intervention program for addressing food insecurity, may help improve adherence to antihypertensive medications.

Objective

To evaluate whether receipt of SNAP benefits can modify the consequences of food insecurity on nonadherence to antihypertensive medications.

Design, Setting, and Participants

A retrospective cohort study design was used to assemble a cohort of antihypertensive medication users from the linked Medical Expenditure Panel Survey (MEPS)-National Health Interview Survey (NHIS) dataset for 2016 to 2017. The MEPS is a national longitudinal survey on verified self-reported prescribed medication use and health care access measures, and the NHIS is an annual cross-sectional survey of US households that collects comprehensive health information, health behavior, and sociodemographic data, including receipt of SNAP benefits. Receipt of SNAP benefits in the past 12 months and food insecurity status in the past 30 days were assessed through standard questionnaires during the study period. Data analysis was performed from March to December 2021.

Exposure

Status of SNAP benefit receipt.

Main Outcomes and Measures

The main outcome, nonadherence to antihypertensive medication refill adherence (MRA), was defined using the MEPS data as the total days' supply divided by 365 days for each antihypertensive medication class. Patients were considered nonadherent if their overall MRA was less than 80%. Food insecurity status in the 30 days prior to the survey was modeled as the effect modifier. Inverse probability of treatment (IPT) weighting was used to control for measured confounding effects of baseline covariates. A probit model was used, weighted by the product of the computed IPT weights and MEPS weights, to estimate the population average treatment effects (PATEs) of SNAP benefit receipt on nonadherence. A stratified analysis approach was used to assess for potential effect modification by food insecurity status.

Results

This analysis involved 6692 antihypertensive medication users, of whom 1203 (12.8%) reported receiving SNAP benefits and 1338 (14.8%) were considered as food insecure. The mean (SD) age was 63.0 (13.3) years; 3632 (51.3%) of the participants were women and 3060 (45.7%) were men. Although SNAP was not associated with nonadherence to antihypertensive medications in the overall population, it was associated with a 13.6-percentage point reduction in nonadherence (PATE, -13.6 [95% CI, -25.0 to -2.3]) among the food-insecure subgroup but not among their food-secure counterparts.

Conclusions and Relevance

This analysis of a national observational dataset suggests that patients with hypertension who receive SNAP benefits may be less likely to become nonadherent to antihypertensive medication, especially if they are experiencing food insecurity. Further examination of the role of SNAP as a potential intervention for preventing nonadherence to antihypertensive medications through prospectively designed interventional studies or natural experiment study designs is needed.

Increases in New but Not Returning Families to a Midwestern Food Pantry Network During the COVID-19 Pandemic

BACKGROUND

Food pantries are a resource for those experiencing food insecurity.

OBJECTIVE

The purpose of this study was to evaluate changes in food pantry utilization and volunteerism for a food pantry network during the COVID-19 pandemic.

DESIGN

This 36-month longitudinal, observational study is a secondary analysis of data collected from an Ohio food pantry network.

PARTICIPANTS/SETTING

Participants were clients of a food pantry network. The data represent visits from 12 months prepandemic (March 2019 through February 2020), during the pandemic (March 2020 through February 2021), and after vaccines were readily available (March 2021 through February 2022).

MAIN OUTCOME MEASURES

Each data point represents a visit to the pantry network. The main outcome measures were total, returning, and new visits (ie, households that had not previously used this pantry network). The secondary outcome was volunteer hours by month.

STATISTICAL ANALYSIS

In order to account for month-to-month variability in pantry utilization, the data were analyzed using a time-series linear regression analysis with the month as the unit of analysis.

RESULTS

A total of 174,397 visits were recorded during the course of 36 months. Sixty-nine percent of reporting household members were female, 48% reported at least 1 senior in the home, and 41% reported at least 1 child at home. There was no significant change in total or returning visits during the pandemic or after vaccines were available compared with prepandemic levels. However, there was a significant increase in new households to the food pantry network during the pandemic compared with prepandemic (P = .05). Volunteer hours decreased significantly during the pandemic compared with prepandemic months and remained low even after vaccines were available (P = .004 and P = .003, respectively).

CONCLUSIONS

Although there was an increase in households new to the food pantry, overall utilization did not increase.

Repeated Cross-Sectional Surveys of Registered Dietitian Nutritionists Demonstrate Rapid Practice Changes to Address Food Insecurity During the Coronavirus Disease 2019 Pandemic

BACKGROUND

The coronavirus disease 2019 pandemic had worldwide economic impact, exacerbating food insecurity risk for vulnerable populations.

OBJECTIVE

To describe changes in practice and challenges and areas of need related to addressing food insecurity during the coronavirus disease 2019 pandemic for registered dietitian nutritionist survey respondents.

DESIGN

A cross-sectional, anonymous, online survey distributed via the Academy of Nutrition and Dietetics e-mail communication platform and social media accounts from April through May 2020 (Wave 1 [W1]) and December 2020-February 2021 (Wave 2 [W2]).

PARTICIPANTS AND SETTING

Participants were US-based registered dietitian nutritionists practicing in community-based settings to address food insecurity (W1: n = 454; W2: n = 331).

STATISTICAL ANALYSES

Responses were descriptively summarized using means ± SD, medians and interquartile ranges, or number of observations and percentages. Open-ended responses were manually reviewed and organized into major themes.

RESULTS

Respondents had about 10 years of experience in addressing food insecurity and were most commonly involved with the Special Supplemental Nutrition Program for Women, Infants and Children, federal school nutrition programs, or food banks. Participants described increased demand for food security assistance (W1: 68%; W2: 60%). Among respondents involved in food preparation and handling (W1: n = 183; W2: n = 110), supply chain (W1: 61%; W2: 56%) and staffing (W1: 37%; W2: 50%) challenges were commonly reported. Child nutrition program professionals (W1: n = 143; W2: n = 84) reported widespread implementation of optional program waivers, with the most commonly implemented waivers allowing noncongregate meal service (W1: 83%; W2: 81%), caregivers to pick up meals (W1: 69%; W2: 85%), and flexibility in mealservice times (W1: 75%; W2: 87%).

CONCLUSIONS

Respondents quickly adapted programs to ensure staff and client safety while continuing to provide essential food security services. They identified the need for ongoing nutrition program policy advocacy and timely access to best practice resources during public health emergencies.

Longitudinal Associations of Diet, Food Insecurity, and Supplemental Nutrition Assistance Program Use with Global Cognitive Performance in Middle-Aged and Older Adults

BACKGROUND

Diet quality, food access, and food assistance policies may be key modifiable factors related to cognitive decline.

OBJECTIVE

We aimed to evaluate whether diet quality, food insecurity, and Supplemental Nutrition Assistance Program (SNAP) use are associated with longitudinal changes in cognition among older adults in the United States.

METHODS

Food intake data from the Health Care and Nutrition Study were linked with longitudinal health information from 5 waves of the Health and Retirement Study (2012-2020). The analytic sample (n = 6968) included community-dwelling United States adults aged ≥51 y without cognitive impairment. Global cognition was measured using a telephone-based cognitive status interview (range: 0-27). Diet quality was measured with the Healthy Eating Index, using participants' average intake of 13 dietary components. Questions regarding food access and affordability were used to determine food insecurity and use of SNAP benefits. Linear mixed-effects regression models were used to estimate longitudinal associations between diet-related factors and cognitive score changes.

RESULTS

Poorer diets [β: -0.24; 95% confidence interval (CI): -0.33, -0.15], food insecurity (β: -1.08; 95% CI: -1.31, -0.85), and SNAP use (β: -0.57; 95% CI: -0.82, -0.32) were associated with lower baseline cognitive scores. Poorer diets (β: -0.17; 95% CI: -0.29, -0.05) and food insecurity (β: -0.23; 95% CI: -0.47, -0.01) were associated with significantly steeper declines in cognitive scores over time, after 8 and 2 y of follow-up, respectively; however, SNAP use was not significantly associated with the rate of cognitive decline over time. Estimates were qualitatively similar when restricting the sample to participants aged ≥65 y.

CONCLUSIONS

Results suggest that food access and adherence to healthy diet recommendations may be important elements to maintain cognitive health in aging. SNAP benefits may be insufficient to prevent negative cognitive effects of poor diet and limited access to nutritious foods.

Trends in Food Insecurity Among Households with Children Participating in WIC and SNAP in California, 2005-2017

OBJECTIVES

To assess trends in food insecurity between 2005 and 2017-a period including the Great Recession-by participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

METHODS

Data from the California Health Interview Survey (CHIS), 2005-2017, were used, including 7421 households: WIC participants (n = 4184)-those participating in WIC only (n = 2315) and in the Supplemental Nutrition Assistance Program (SNAP) in addition to WIC (n = 1869)-and WIC-eligible non-participants (n = 3237). Multivariable logistic regression models were run with food insecurity as the outcome, WIC participation and survey year as predictors, and adjusted by children's and family's demographic and socioeconomic variables. Interactions between WIC participation and survey year were tested.

RESULTS

WIC + SNAP participating households had higher crude food insecurity prevalence across time compared to WIC only and WIC-eligible non-participant households. In fully adjusted models: (1) food insecurity was higher between 2009 and 2017, compared to 2005, for all groups; (2) WIC participating households had higher odds of food insecurity than WIC-eligible non-participants (OR = 1.23, 95%CI = 1.10-1.38); (3) when WIC participants were split into WIC only and WIC + SNAP, WIC + SNAP households had higher odds of food insecurity than WIC-eligible non-participants (OR = 1.45, 95%CI = 1.27-1.66); and (4) the association between food insecurity and WIC participation did not change across time (interaction p-value > 0.10).

CONCLUSIONS

Food insecurity increased post-Great Recession among low-income households with children in California, with those participating in WIC, particularly in WIC + SNAP, at higher risk. WIC should consider additional referrals for households who participate in WIC + SNAP.

Capacity, Communication, and Coordination Are Key to Successful Implementation of Policy, Systems, and Environmental Strategies at SNAP-Ed Partner Sites in One Southeastern US State: A Qualitative Approach

BACKGROUND

The United States Department of Agriculture expanded the Supplemental Nutrition Assistance Program (SNAP)-Ed program to all 50 states in 2004. In 2010, the Healthy, Hunger-Free Kids Act required that agencies implementing SNAP-Ed support policy, systems, and environmental (PSE) strategies, in addition to providing direct education (DE). Research has evaluated the impact of PSEs on health, but few studies have investigated the process of PSE implementation.

OBJECTIVE

The objective of this study was to identify facilitators and barriers to PSE implementation at SNAP-Ed partner sites from the perspectives of site contacts and SNAP-Ed implementers.

DESIGN

This study employed a qualitative longitudinal design. The PSE planning and implementation process was observed over 1 year at SNAP-Ed partner sites. Semistructured interviews were conducted with site contacts and SNAP-Ed implementers throughout the year.

PARTICIPANTS/SETTING

Participants were SNAP-Ed implementers (n = 8) and site contacts (n = 18) from 18 partner sites where both PSE and direct education were occurring. SNAP-Ed implementers were debriefed once, and site contacts were interviewed three times over the course of the study. This study was conducted in a Southern US state with SNAP-Ed partner sites that intended to implement PSEs. The duration of data collection was October 2017 through September 2018.

ANALYSIS

A thematic analysis of barriers and facilitators to PSE implementation across sites was conducted.

RESULTS

The PSE implementation barriers were lack of site or implementer readiness or capacity; breakdowns in communication; and DE prioritized over PSE. Facilitators were effective communication; site capacity or readiness; and alignment between site and SNAP-Ed goals.

CONCLUSIONS

Communication, capacity, and coordination between SNAP-Ed and partner sites were key components over the timeline of PSE planning and potential implementation.

Longitudinal Associations of Food Security with Health and Dietary Factors among Food FARMacy Participants during COVID-19 in New York City

In cross-sectional studies, food insecurity is associated with adverse health and dietary outcomes. Whether self-reported health and dietary outcomes change in response to improvements in food security has not been examined. We sought to examine how increases in food security are related to changes in health and dietary factors. In this longitudinal, observational study, we included adult participants in a clinical-community emergency food assistance program in New York City from July 2020 to November 2021. Program staff measured food security with a validated six-item measure at program enrollment and six-month re-enrollment. Participants self-reported health and dietary factors (vegetable, fruit, juice, and sugar-sweetened beverage (SSB) consumption frequency). We used multivariable regression to examine associations between change in food security with change in health and dietary factors over six months. Among 310 participants, the mean food security score improved by 1.7 ± 2.3 points over six months. In unadjusted models, each point improvement in food security was associated with increased vegetable (β = 0.10 times; 95% CI: 0.05-0.15); fruit (β = 0.08 times; 95% CI: 0.03-0.14); and juice (β = 0.10 times; 95% CI: 0.05-0.15) consumption. In adjusted models, results remained significant for vegetable and fruit consumption, but not juice. Change in food security was not associated with change in health or SSB outcomes. In this cohort during COVID-19, improved food security was associated with improved vegetable and fruit consumption. Randomized trials that examine the effectiveness of clinical-community partnerships focused on improving food security and nutrition are warranted.

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.

The association between the supplemental nutrition assistance programme participation and dental caries among U.S. adults

INTRODUCTION

The Supplemental Nutrition Assistance Programme (SNAP) is a federal programme aimed to alleviate hunger and improve food insecurity. The impact of SNAP participation on overall health has been studied. However, little is known about the effects of SNAP participation on oral health. We aimed to investigate the association between participating in SNAP and dental caries and to explore the role of food insecurity as a moderator in this relationship.

METHODS

We obtained data from the National Health and Nutrition Examination Survey (NHANES) cycles 2011-2012 and 2013-2014.The primary outcome was untreated dental caries (none vs. one or more). Self-reported SNAP participation status in the past 12 months was the predictor, and food security was the moderator. Food security was measured as overall food security status (full food secure/ food insecure) and household-level food security (full, marginal, low and very low). Bivariate and multiple logistic regression analyses were conducted to evaluate the relationship between SNAP and dental caries, and whether food insecurity moderates this relationship. Statistical analysis was carried out in September 2020.

RESULTS

Our results suggested that after adjusting for potential confounders, SNAP participants were more likely to have untreated dental caries than non-SNAP participants (odds ratio: 1.6; 95% CI: 1.2-2.0). Food security status did not alter the relationship between SNAP participation and untreated dental caries.

CONCLUSIONS

Food security status did not alter the relationship between SNAP participation and untreated dental caries. SNAP participation was associated with untreated dental caries among U.S. adults, and this was not affected by their food security status.

A Cluster-Randomized Evaluation of the SuperShelf Intervention in Choice-Based Food Pantries

BACKGROUND

Interventions in food pantry settings have the potential to improve health among clients at risk of diet-related disease.

PURPOSE

This study evaluates whether a cluster-randomized, behavioral intervention in food pantries resulted in improved client outcomes.

METHODS

Sixteen Minnesota food pantries were randomized to an intervention (n = 8) or control condition (n = 8). The intervention offered pantries technical assistance to improve healthy food supply and implement behavioral economics strategies to promote healthy food selection. A convenience sample of adult clients were enrolled (paired sample, 158 intervention, 159 control) and followed for 1 year. Additional clients were enrolled at follow-up to assess food selection (follow-up sample, 85 intervention, 102 control). Analysis was limited to data from 11 pantries (5 intervention, 6 control) due to COVID-19. Outcome measures included Healthy Eating Index-2015 (HEI-2015) total and subcomponent scores for 24-hr dietary recalls and client cart selections, and Life's Simple 7 (LS7) total and subcomponent scores. Multilevel mixed-effects models tested whether client outcomes differed by intervention condition.

RESULTS

In adjusted models, there were no statistically significant differences by intervention condition in HEI-2015 or LS7 scores. Clients in intervention food pantries had improved Refined Grain subcomponent scores (p = .004); clients in control pantries had worsened Saturated Fat subcomponents scores (p = .019) and improved physical activity scores (p = .007).

CONCLUSIONS

The intervention did not result in improved diet quality or cardiovascular health as measured by HEI-2015 or LS7. Coordinated efforts across settings are needed to address health risks facing this population.

A systematic review of factors associated with student use of campus food pantries: implications for addressing barriers and facilitating use

BACKGROUND

While campus food pantries have been important safety net programs for alleviating food insecurity among college students, factors related to accessing these vital resources have not been fully researched and summarized. This study systematically synthesized peer-reviewed literature on the predictors, barriers to, and facilitators of using campus food pantries among college students.

METHODS

A search was conducted on PubMed, CINAHL Complete, PsychInfo, PsycARTICLES, and ScienceDirect in April 2023. Included studies needed to be peer-reviewed, written in English, and focused on college or university students. Three authors independently screened all articles retrieved from the five databases based on titles, titles and abstracts, and a full article review. The Study Quality Assessment Tool from the National Heart, Lung, and Blood Institute was used to assess the risk of bias in the included cross-sectional studies. The risk of bias and quality of mixed methods or qualitative studies were assessed as well.

RESULTS

Eight studies were included in the systematic review. Students likely to use a college food pantry were food-insecure, who most often identified as Asian, Hispanic/Latino, Filipino or Pacific Islander; were first-generation to college; international students; sophomores and juniors; had student loans; were living off-campus; and were without stable housing. Stigma was the most frequently mentioned barrier to using a food pantry. Participants mentioned facilitators such as convenient location and hours of operation, access to fresh produce and nutritious and safe foods, availability of a variety of foods, friendly and helpful service, social support, and awareness of a pantry through fellow students and other members of the university such as staff and faculty.

CONCLUSIONS

Continued research must address students' systemic barriers to accessing food pantries. Campus food pantry leaders, university administrators, and policymakers need to work together to create cost-effective and sustainable solutions that will alleviate the stigma and burden of food-insecure students and provide them with safe, nutritious, and culturally acceptable foods.

Food Insecurity and Mental Distress Among WIC-Eligible Women in the United States: A Cross-Sectional Study

BACKGROUND

Women living in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible households may be pregnant or breastfeeding. Stress during pregnancy and breastfeeding may influence women's mental health making them more vulnerable to higher rates of food insecurity (FI).

OBJECTIVE

Determine whether or not FI is associated with moderate-to-severe mental distress among women living in WIC-eligible households, and whether or not the strength of the association differs among WIC participants compared with eligible nonparticipants with low income.

DESIGN

Cross-sectional data from the 2011-2018 National Health Interview Survey were utilized.

PARTICIPANTS/SETTING

A total of 7,700 women living in WIC-eligible households with at least one child were analyzed.

MAIN OUTCOME MEASURES

Moderate-to-severe mental distress was measured using the validated K6 nonspecific psychological distress scale. FI was measured using the 10-item, US Adult Food Security Survey Module.

STATISTICAL ANALYSES PERFORMED

Multivariate logistic regression was used to examine the association between FI and mental distress. The conditional effects of WIC participation were examined by including interaction terms for FI and WIC participation as well as by stratifying the sample by WIC participation.

RESULTS

Among women in WIC-eligible households, FI was associated with moderate-to-severe mental distress in a dose-response fashion: compared with those who were food secure, the adjusted odds of moderate-to-severe mental distress were 1.8 times higher among those with marginal food security (adjusted odds ratio [AOR] 1.83, 95% CI 1.50 to 2.23), 2.1 times higher among those with low food security (AOR 2.14, 95% CI 1.76 to 2.60), and 3.7 times higher among those with very low food security (AOR 3.73, 95% CI 2.95 to 4.71). The interaction between FI and WIC participation was not significant, with similar associations between FI and mental distress among WIC participants and nonparticipants.

CONCLUSIONS

Among this nationally representative sample of women in WIC-eligible households, increasing severity of food insecurity was associated with poor mental health among WIC participants and nonparticipants. WIC participation was not observed to moderate the association between FI and mental distress. More research should consider including mental health screening at WIC clinic visits to enable early identification and referral for care.

Surveillance of Infant Formula Shortages Using Special Supplemental Nutrition Program for Women, Infants, and Children Administrative Data

OBJECTIVE

To quantify self-reported difficulty accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-issued infant formula among participants early in the coronavirus disease 2019 (COVID-19) pandemic, to determine if infant formula redemption was associated with self-reported difficulty accessing infant formula, and to quantify changes in formula redemption during the 2022-2023 US infant formula shortages.

DESIGN

A cross-sectional study and time series data.

SETTING

Families participating in the WIC program in the Los Angeles metropolitan area from November 2019 to June 2023.

PARTICIPANTS

Families with infants (aged 0-12 months) issued infant formula by WIC with a completed 2020 Los Angeles County WIC Survey (n = 1,897) or issued infant formula by a large WIC program in Southern California between November 2019 and June 2023 (n = 109,135).

MAIN OUTCOME MEASURES

Incidence of ≥ 30% reduction in infant formula redemption and interval-scaled infant formula redemption.

ANALYSIS

Special Supplemental Nutrition Program for Women, Infants, and Children formula redemption data were matched to 2020 Los Angeles County WIC Survey data to determine if self-reported difficulty accessing infant formula was associated with administrative infant formula redemption data using negative binomial regression and were used to quantify the prevalence and severity of incomplete formula redemption during 2020-2023 formula shortages using ordinal logistic regression (outcome: interval-scaled formula redemption).

RESULTS

Few (13.0%) caregivers reported difficulty accessing the WIC-issued formula early in the COVID-19 pandemic. The 2.8% who reported an unresolved shortage early in the COVID-19 pandemic had 201% higher rates of ≥ 30% declines in formula redemption (incidence rate ratio [IRR], 3.01; 95% confidence interval, 1.57-5.79, P < 0.001) than those with no difficulties. Incomplete formula redemption odds were significantly elevated throughout the COVID-19 pandemic from March 2020 to January 2022 and increased further during the 2022-2023 infant formula shortages from February 2022 to June 2023, reaching 342% higher in October 2022 than February 2020 (odds ratio, 4.42; 95% confidence interval, 4.14-4.72; P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Special Supplemental Nutrition Program for Women, Infants, and Children redemption data are an adequate proxy for population-level infant formula access issues among households with low income but are insufficiently sensitive for screening at a household level. US formula shortages (2020-2023) demonstrate the need for improved coordination between nutrition assistance programs, regulatory bodies, and commercial food systems, particularly during acute supply crises.

Federal Nutrition Assistance for Young Children: Underutilized and Unequally Accessed

INTRODUCTION

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity among young children by helping cover the food costs for child care providers and families. This nationwide study evaluated the extent and predictors of the CACFP's utilization among licensed child care centers to identify opportunities for expanding CACFP nutrition support.

METHODS

Administrative data from the CACFP and child care licensing agencies in 47 states and District of Columbia were compiled and geocoded for 93,227 licensed child care centers. CACFP participation was predicted using a multivariable Bayesian spatial logistic regression model in the sample of low-income areas to target CACFP eligible child care centers. Data were collected in 2020-2021 and analyzed in 2022.

RESULTS

Of all licensed child care centers, 36.5% participated in the CACFP, ranging from 15.2% to 65.3% across states; when restricted to low-income areas, 57.5% participated (range, 15.7%-85.7%). Income differences did not explain the large variation in CACFP participation rates across states. Having at least three CACFP sponsoring agencies per state predicted a 38% higher probability of CACFP participation (OR=1.38; 95% Credible Interval=1.08-1.78).

CONCLUSIONS

Currently CACFP participation rates among licensed child care centers point to program underutilization and unequal access, particularly in some states and regions. Work at the federal and state levels is warranted to expand participation in the program, above all in low-income areas, so that more young children could eat healthfully with the CACFP.

Race, Ethnicity, and Cultural Identity Modify Postpartum Participation in the Minnesota WIC Program

OBJECTIVE

To examine the racial, ethnic and cultural differences in postpartum participation of women who participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) during pregnancy by completing a retrospective analysis of observational data on 35,903 women who enrolled in Minnesota WIC during pregnancy, from April 2018 to March 2020.

METHODS

Descriptive analyses were completed using chi-square tests of association to show differences in postpartum WIC participation by maternal demographics and health risk codes of the WIC participants. Binary logistic regression and multivariate logistic regression were used to obtain odds ratios to compare the likelihood of postpartum WIC participation across different races, ethnicities and cultural groups.

RESULTS

Asian/Pacific Islander, East African, Hispanic, Hmong, Multigenerational Black, and Other Black pregnant participants were more likely than White participants to return to WIC postpartum (adjusted odds ratio (AOR) 2.54, 95% confidence interval (CI) 1.87-3.46; AOR 3.35, 95% CI 2.40-4.66; 1.30, 95% CI 1.10-1.54; AOR 6.76, 95% CI 4.39-10.42; AOR 1.40, 95% CI 1.11-1.77, AOR 1.52, 95% CI 1.26-1.83, respectively). American Indian pregnant participants were less likely than White participants to return to WIC postpartum (AOR 0.70, 95% CI 0.54-0.92).

CONCLUSIONS FOR PRACTICE

These findings can help the Minnesota WIC program, as well as other WIC programs, better understand which cultural groups may need more specific outreach strategies to keep women participating in the program after giving birth. Further research is needed to understand why postpartum women choose to participate, or choose not to participate, in WIC.

A Formative Evaluation of an Online Meal Kit and Grocery Platform for Supplemental Nutrition Assistance Program Recipients

OBJECTIVE

To assess the barriers and facilitators to online food purchasing through a meal kit and grocery shopping website titled NY SNAP Express among Supplemental Nutrition Assistance Program (SNAP) beneficiaries.

METHODS

A purposive sample of SNAP-eligible adults residing in New York State participated in interviews guided by the Capabilities, Opportunities, Motivations, and Behaviors Model.

RESULTS

Barriers to online food purchasing among participants (n = 32) include physiological and health conditions, the weight of food, technology, language, the price of foods, transportation challenges, the stigma associated with SNAP, and concerns regarding the quantity and quality of meal kits. Facilitators include health and nutrition improvements, knowledge and skills, saving money, culturally relevant meals, increased efficiency in food purchases and preparation, and customization.

CONCLUSIONS AND IMPLICATIONS

Online platforms such as NY SNAP Express have the potential to increase nutritious food access and resources among SNAP recipients; however, improvements are necessary to meet the needs of its audience.

Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity

BACKGROUND AND OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities.

METHODS

We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained.

RESULTS

An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented.

CONCLUSIONS

Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.

Contextual Factors Influencing the Adoption of Physical Activity Direct Education and Policy, Systems, and Environmental Change Initiatives by Virginia EFNEP and SNAP-Ed Staff

OBJECTIVE

To explore factors influencing the adoption of direct education programs and policy, systems, and environmental (PSE) change initiatives focused on physical activity for Supplemental Nutrition Assistance Program-eligible audiences by Virginia Expanded Food and Nutrition Education Program and Supplemental Nutrition Assistance Program-Education (SNAP-Ed) staff.

METHODS

Online survey with Expanded Food and Nutrition Education Program and SNAP-Ed peer (paraprofessional) educators (n = 28) and SNAP-Ed agents (master of science level) (n = 9) in Virginia. Descriptive statistics were computed for sociodemographic characteristics and responses to questions on the basis of Likert-type scales. Exploratory factor analyses were run to identify the underlying structures of the different variables.

RESULTS

The main factors for peer educators were related to substituting nutrition programs or content for physical activity programs. Other factors included staff qualifications and expectations about leading vs teaching physical activities. For PSEs, the top factors were the capacity to reach many community members, attract new partners and stakeholders, and personal interest in the PSE.

CONCLUSIONS AND IMPLICATIONS

The results provide insight into potential barriers and motivators for adopting physical activity education and PSEs within community-based initiatives and can be used to inform program planning and staff training. Additional research is warranted to examine other factors influencing the adoption and implementation of physical activity programs and PSEs.

Healthcare-based food assistance programmes in the United States: a scoping review and typology

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

Perspectives on healthy eating practices and acceptance of WIC-approved foods among parents of young children enrolled in WIC

INTRODUCTION

The prevalence of childhood obesity remains high in the United States, particularly among children living in low-income households. Diet quality plays an important role in obesity prevention, particularly among mothers as they serve as role models. Those served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receive nutrient-rich foods aimed at increasing diet quality, yet redemption is low. Digital interventions targeting WIC parents show potential for behavior change and could be used for childhood obesity prevention.

METHODS

This study describes the formative research conducted to understand perspectives on healthy eating practices, acceptance of WIC-approved foods, and preferences for the use of digital tools to improve the purchasing and consumption of WIC-approved foods to improve diet quality. In-depth interviews were conducted with 13 WIC parents and caregivers.

RESULTS

A variety of definitions for and misconceptions about healthy eating exist among WIC caregivers. Most purchased foods were fruits, vegetables, milk, cheese, and eggs and the least purchased foods were yogurt and peanut butter. The biggest facilitator for purchasing WIC-approved foods was the preference of children and caregivers, whereas the biggest barrier was children's picky eating behaviors. Most caregivers reported using their phone to get nutrition information. Most caregivers reported their interest in receiving weekly text messages and indicated preferences about receiving recipes.

CONCLUSION

A text messaging program that includes sending weekly messages, recipes, and nutrition tips is hypothesized to improve diet quality and increase redemption of WIC-approved foods.

A "Food Is Medicine" Approach to Disease Prevention: Limitations and Alternatives

This Viewpoint argues that although “food is medicine” programs may help some patients prevent diet-related diseases, changing food industry behavior and ensuring that existing nutrition assistance programs are accessible and health-promoting are better strategies to make a difference.