Supplemental Nutrition Assistance Program (SNAP) Participation and Health Care Expenditures Among Low-Income Adults

Implications of Recent Federal Actions on Food Assistance Programs

This JAMA Forum discusses proposed budget cuts to the Supplemental Nutrition Assistance Program and their likely negative outcomes on public health.

Access to SNAP-Authorized Retailers and Diet Quality Among SNAP Recipients

Importance

Poor food environments are known to affect diet quality and health outcomes. In the US, the Supplemental Nutrition Assistance Program (SNAP) serves as a critical nutrition safety-net for millions of low-income residents; however, whether there is an association between access to SNAP-authorized retailers and diet quality among SNAP recipients remains unclear.

Objective

To evaluate the association of SNAP-authorized retailer access with diet quality among SNAP recipients.

Design, Setting, and Participants

This was a serial cross-sectional study using 24-hour dietary recall data from a nationally representative sample of SNAP-participating adults from 6 cycles of the restricted-use and public-access National Health and Nutrition Examination Survey from 2007 through 2008 to 2017 through 2018. Participants' residential locations were linked to SNAP-authorized retailers at the coordinate-date level using the Historical SNAP Retailer Locator dataset. Generalized linear models were used that accounted for the complex survey design and adjusted for age, sex, race and ethnicity, education, and family poverty income ratio. Data analyses were performed from February to October 2024.

Exposures

Availability of SNAP-authorized retailers within 1 mile (5 increments: ≤0.10, >0.10-0.25, >0.25-0.50, >0.50-1.00, and >1.00 mile) from the SNAP recipient's residence, and the distance to the nearest SNAP-authorized retailer.

Main Outcomes and Measures

Daily dietary quality assessed using the Healthy Eating Index-2015 (HEI-2015), a validated measure of adherence to the 2015-2020 Dietary Guidelines for Americans. HEI-2015 scores range from 0 (no adherence) to 100 (full adherence) to the guidelines.

Results

The study analysis included 5041 participants (mean age, 43.0 years; [weighted] 58% female and 42% male), with a mean (SD) HEI-2015 score of 46.88 (25.46). Residing closer to any SNAP-authorized retailer was associated with a 3.50 higher HEI-2015 (95% CI, 1.56-5.44) for those living within 0.10 miles, and 3.50 higher (95% CI, 1.46-5.55) for those living more than 0.10 to 0.25 miles compared to those living more than 1.00 miles away. Availability of superstores and grocery stores showed a positive association, with HEI-2015 scores of 7.09 (95% CI, 3.51-11.11) and 5.21 (95% CI, 3.12-7.29) higher for those within 0.10 miles, respectively. Each additional mile from any SNAP-authorized store was associated with a HEI-2015 score decrease of 0.99 (95% CI, 0.42-1.57). Subgroup analyses showed significant associations between store access and diet quality among participants with normal weight and prediabetes, whereas associations were not statistically significant for those with diabetes.

Conclusions and Relevance

This cross-sectional study found that access to SNAP-authorized retailers was associated with better diet quality among SNAP recipients, with the most substantial differences observed for proximity to superstores and grocery stores. These findings highlight the potential impact of food access on diet quality, and suggest that improving the availability of SNAP-authorized retailers in low-access areas may be an important strategy for enhancing public health and reducing diet-related conditions.

A New Approach To Guide Research And Policy At The Intersection Of Income, Food, Nutrition, And Health

Income distribution, food and nutrition insecurity, and poor diet quality contribute to diet-related disease, which is a major threat to population health and health equity. Based on our review and synthesis of the empirical evidence, we provide a new conceptual model for understanding the interrelationships among income, food security, nutrition security, diet quality, and health. We identify directions for future research and discuss the policy and program implications of the model. Overall, interventions that address income and food security can facilitate, but do not ensure, nutrition security and better diet quality, although they can improve health in other ways. Importantly, even people who are food and nutrition secure and have adequate income frequently have unhealthy diets. Addressing these challenges will require innovative policies to improve nutrition security, diet quality, and health. Such policies should include efforts to increase the availability and accessibility of Food Is Medicine interventions in health care. Health insurance coverage for evidence-based, clinically indicated Food Is Medicine programs is critical to the success of these efforts.

Incident Food Insecurity and Associated Risk Factors After Surgical Trauma

INTRODUCTION

Food insecurity, defined as a lack of access to adequate nutrition, impacts approximately 30% of the global population. Despite clear evidence regarding the benefit of proper nutrition on clinical outcomes, the burden of incident food insecurity after surgical intervention in previously food secure patients is unknown. The goal of the study was to quantify incident food insecurity post operatively and to identify associated risk factors.

METHODS

A multicenter, prospective, longitudinal study was conducted among adult surgical trauma patients at tertiary care public and private hospitals in India. The primary outcome was new food insecurity from initial admission for traumatic injury to 6 mo post operatively. Cox proportional hazards models were used to evaluate associations between clinical and sociodemographic variables and incident food insecurity.

RESULTS

Of 774 patients enrolled, 20% were food insecure at baseline. During the follow-up period, 21% of patients who were food secure at baseline experienced new food insecurity. Incident food insecurity was associated with longer length of stay (hazard ratio (HR): 3.76, 95% confidence interval (CI): 1.62-8.74; P = 0.002), intensive care unit admission (HR: 1.87, 95% CI: 1.05-3.31; P = 0.032), receiving welfare support (HR: 2.00, 95% CI: 1.00-3.98; P = 0.049) and daily wage, rather than salaried, employment (HR: 2.95, 95% CI: 1.24-7.06; P = 0.015). Higher total household income was associated with maintaining food security (HR: 0.24, 95% CI: 0.13-0.44; P < 0.001). Hospitalization-related financial toxicity was significantly associated with incident food insecurity (HR: 3.07, 95% CI: 2.09-4.50; P < 0.001).

CONCLUSIONS

High levels of incident food insecurity were observed among surgical trauma patients. This highlights the need for serial food insecurity assessment post discharge. In lieu of serial follow-up, risk factors associated with incident food insecurity can be used to identify high-risk patients prior to discharge to facilitate connection to food insecurity interventions such as food prescription programs, monetary support, and nutritional welfare policies.

A Multi-Level Approach to Childhood Obesity Prevention and Management: Lessons from Japan and the United States

BACKGROUND

Childhood obesity is a pressing global public health challenge, marked by significant disparities in prevalence and management across countries. Japan and the United States offer contrasting approaches to addressing this issue, presenting a valuable opportunity for comparative analysis.

OBJECTIVE

This review examines the effectiveness of public health policies, cultural dietary habits, and lifestyle factors in combating childhood obesity in Japan and the United States. It aims to identify actionable insights to inform global strategies for obesity prevention.

RESULTS

Japan exhibits one of the lowest childhood obesity rates globally, attributed to prevention-focused policies such as the food education program, stringent school lunch standards, and culturally ingrained healthy eating practices. These efforts are complemented by active lifestyle promotion through urban planning and school-based physical education programs. In contrast, the United States faces higher obesity rates due to systemic challenges, including socioeconomic disparities, reliance on processed foods, sedentary lifestyles, and inconsistent implementation of federal programs like the National School Lunch Program (NSLP) and Supplemental Nutrition Assistance Program Education (SNAP-Ed).

CONCLUSIONS

This review highlights Japan's success in aligning public health initiatives with cultural norms to achieve sustainable outcomes. In the United States, systemic barriers and cultural disconnects hinder obesity prevention efforts. Recommendations include adopting integrated, prevention-focused policies, addressing socioeconomic inequities, redesigning urban environments to promote active living, and fostering global collaboration. This comparative analysis underscores the importance of culturally tailored, multidimensional strategies for addressing childhood obesity and improving public health outcomes worldwide.

Missed Opportunities to Address SNAP for Nonenrolled Children

BACKGROUND

Primary care is an important setting to identify and support children who are eligible but not enrolled in the Supplemental Nutrition Assistance Program (SNAP) (the SNAP Gap), although there is concern that these programs may be limited in reach. We sought to identify patterns of health care use among eligible but unenrolled children.

METHODS

We conducted a cross-sectional analysis of the 2021 Medical Expenditure Panel Survey. We identified 975 SNAP eligible/nonenrolled children with household incomes less than 200% of federal poverty level. SNAP eligibility was modeled using income, employment, and household composition and SNAP enrollment was self-reported. We categorized health care encounters across 9 visit types and calculated annual primary care attendance rates. Multivariable logistic regression was used to measure associations with race, language, and chronic conditions.

RESULTS

SNAP eligible/nonenrolled children received an average of 6.04 health care encounters in 2021. Only half (52.9%) received a primary care visit. Primary care attendance was lowest for Black children (odds ratio [OR] = 0.40 [95% CI 0.20-0.81], P = .01), children speaking languages other than English (OR = 0.53 [95% CI 0.32-0.89], P = .02) and children without a chronic condition (OR = 0.08 [95% CI 0.04-0.15], P < .001). Visits to medical specialists (20.4% of all visits), behavioral health clinicians (10.9%), and dentists (10.0%) were the most common nonprimary care services received by SNAP eligible/nonenrolled children.

CONCLUSION

In a nationally representative sample of children who were potentially eligible but nonenrolled in SNAP, we found low primary care attendance in 2021 with evidence of racial and linguistic disparities. Clinicians beyond the primary care system are well-positioned to support children who jointly underuse government nutrition programs and primary care services.

SNAP Participation as a Moderator of Food and Nutrition Security and Combined Cardiometabolic Conditions: A Mixed Regression Approach

Objectives: To examine the relationships between food security, nutrition security, Supplemental Nutrition Assistance Program (SNAP) participation, and cardiometabolic outcomes, including hypertension, hyperlipidemia, or diabetes, among low-income U.S. individuals. Methods: A cross-sectional survey of 486 participants (April-June 2021) assessed food and nutrition security and cardiometabolic outcomes. Mixed-effects logistic regression models adjusted for covariates and included a random effect for state of residence. Moderation analyses evaluated SNAP participation's impact. Results: Very low food security was associated with higher odds of having at least one cardiometabolic condition, such as hypertension, hyperlipidemia, or diabetes (AOR = 1.96; 95% CI: 1.04-3.69; p = 0.04). SNAP moderated this relationship (p-interaction = 0.007), with non-participants experiencing significantly higher risk. Non-SNAP participants with very low food security had 3.17 (95% CI = 1.17-8.61) times higher odds of having a cardiometabolic condition. Among SNAP participants, very low food security was not significantly associated with having a cardiometabolic condition (OR = 1.62; 95% CI = 0.64-4.13). Higher nutrition security was associated with lower odds of having at least one cardiometabolic condition (AOR = 0.59; 95% CI: 0.41-0.83; p = 0.002). Conclusions: Nutrition security and SNAP participation mitigate cardiometabolic risks, underscoring their importance in public health interventions.

Food Insecurity Is Common in Patients with Inflammatory Bowel Disease and Is Associated with Increased Ultra-Processed Food Intake

BACKGROUND/OBJECTIVES

Food insecurity (FI) is defined as the lack of consistent access to enough food for an active and healthy life. FI affects over 30 million Americans and is associated with poor clinical outcomes and impaired quality of life and drives significant health inequities. Despite the rising prevalence of FI and the federal focus on improving access to healthy food, there is a paucity of research on FI in patients with inflammatory bowel disease (IBD). Therefore, the goal of this study was to define FI in a cohort of IBD patients and determine whether FI was associated with changes in dietary patterns, including specifically an increase in ultra-processed food (UPF) consumption in this high-risk patient population.

METHODS

This was a single-center, retrospective cohort study of patients with a diagnosis of IBD who were 18 years of age or older and who were seen in a nutrition focused clinic. Patients were screened for FI using the Hunger Vital Sign™, a 2-question validated FI screening tool and underwent a 24-h dietary recall. The degree of food processing was assessed using the NOVA Food Classification System.

RESULTS

Among 128 patients with IBD, we observed that FI is increasingly prevalent, with 45% of patients reporting difficulty with sufficient grocery access at least "sometimes" in the last 12 months and 10% reporting decreased food access "often" in the prior year. In addition, the patients at high-risk for FI were significantly more likely to eat NOVA 4 UPFs (54% vs. 27%, p = 0.001) and were significantly less likely to eat NOVA 1 unprocessed foods (32% vs. 61%, p = 0.001) as compared to those not at risk for FI. Finally, only a small percentage of those at highest risk for FI were enrolled in a federal food assistance program for grocery support.

CONCLUSIONS

The prevalence of FI is increasing in patients with IBD and is associated with reduced dietary quality.

Food Insufficiency Increased After The Expiration Of COVID-19 Emergency Allotments For SNAP Benefits In 2023

In response to economic distress and food insecurity during the COVID-19 pandemic, Congress expanded the Supplemental Nutrition Assistance Program (SNAP) by introducing emergency allotments to increase monthly benefits, starting in March 2020. In March 2023, emergency allotments expired in the thirty-five states and territories still offering them. We provide some of the first evidence of the impacts of this loss of nutrition support-in some cases, more than $250 a month-for economically disadvantaged households. Our quasi-experimental study examined the effects of the program's expiration on food insufficiency, mental health, and financial well-being, using data from the Census Bureau's Household Pulse Survey. In difference-in-differences analyses, we compared pre-post differences among SNAP participants with pre-post differences among income-eligible nonparticipants. The emergency allotment expiration led to a substantial increase in food insufficiency (8.4 percentage points) and greater food pantry use (2.1 percentage points) and difficulty paying expenses (2.0 percentage points). Non-Hispanic Black SNAP participants experienced a greater increase in anxiety symptoms compared with non-Hispanic White SNAP participants. This study has implications for ongoing policy making with respect to nutrition and safety-net programs to support vulnerable families, especially amid inflated food prices.

Barriers and Opportunities to Improve Healthcare Access for Uninsured Patients at a Student-Run Free Clinic in New Haven, Connecticut

INTRODUCTION

Uninsured patients have limited options to pay for necessary medical services. Most United States hospitals offer financial assistance programs (FAPs) to help patients pay for care, but the challenges of accessing these programs demonstrate a need for more solutions.

METHODS

This study was a retrospective review of 200 randomly sampled HAVEN Free Clinic patients from September 2022 to September 2023. Patients were eligible to be seen at HAVEN if 18-65 years old, without health insurance, and living in New Haven County, Connecticut. Application histories to Medicaid and hospital FAP at a non-profit tertiary care center in Connecticut were assessed.

RESULTS

In the 200-patient sample, average age was 43.4 ± 11.2 years old, 61.0% were female, and 86.5% were Hispanic or Latino. 68% were employed with a median household yearly income of $18,200 [$7,293-$26,741]. 80% had applied for a hospital FAP-71.1% were currently approved for Free Care or Discounted Care. 6% were approved for Medicaid; 2.5% were approved for Emergency Medicaid. Of those who applied for a hospital FAP, 28.3% received ≥ 1 application denial. Most common hospital FAP denial reasons were missing, wrong, or outdated proof of income (93.9%), and incomplete application (6.1%).

CONCLUSION

Hospital FAPs and Medicaid provide important access to care for uninsured patients, but are not without barriers and should not be viewed as the only solution. Improving hospital FAP access involves assessing eligibility at presentation, extending approval duration, and advocating for more funding. Addressing these barriers can advance equitable care for all.

Predicting Self-Reported Social Risk in Medically Complex Adults Using Electronic Health Data

BACKGROUND

Social barriers to health care, such as food insecurity, financial distress, and housing instability, may impede effective clinical management for individuals with chronic illness. Systematic strategies are needed to more efficiently identify at-risk individuals who may benefit from proactive outreach by health care systems for screening and referral to available social resources.

OBJECTIVE

To create a predictive model to identify a higher likelihood of food insecurity, financial distress, and/or housing instability among adults with multiple chronic medical conditions.

RESEARCH DESIGN AND SUBJECTS

We developed and validated a predictive model in adults with 2 or more chronic conditions who were receiving care within Kaiser Permanente Northern California (KPNC) between January 2017 and February 2020. The model was developed to predict the likelihood of a "yes" response to any of 3 validated self-reported survey questions related to current concerns about food insecurity, financial distress, and/or housing instability. External model validation was conducted in a separate cohort of adult non-Medicaid KPNC members aged 35-85 who completed a survey administered to a random sample of health plan members between April and June 2021 (n = 2820).

MEASURES

We examined the performance of multiple model iterations by comparing areas under the receiver operating characteristic curves (AUCs). We also assessed algorithmic bias related to race/ethnicity and calculated model performance at defined risk thresholds for screening implementation.

RESULTS

Patients in the primary modeling cohort (n = 11,999) had a mean age of 53.8 (±19.3) years, 64.7% were women, and 63.9% were of non-White race/ethnicity. The final, simplified model with 30 predictors (including utilization, diagnosis, behavior, insurance, neighborhood, and pharmacy-based variables) had an AUC of 0.68. The model remained robust within different race/ethnic strata.

CONCLUSIONS

Our results demonstrated that a predictive model developed using information gleaned from the medical record and from public census tract data can be used to identify patients who may benefit from proactive social needs assessment. Depending on the prevalence of social needs in the target population, different risk output thresholds could be set to optimize positive predictive value for successful outreach. This predictive model-based strategy provides a pathway for prioritizing more intensive social risk outreach and screening efforts to the patients who may be in greatest need.

Estimating the impact of addressing food needs on diabetes outcomes

Objective

To estimate the association between food needs and diabetes outcomes.

Research design and methods

Longitudinal cohort study, using a target trial emulation approach. 96,792 adults with type 2 diabetes mellitus who underwent food need assessment in a network of community-based health centers were followed up to 36 months after initial assessment. We used targeted minimum loss estimation to estimate the association between not experiencing food needs, compared with experiencing food needs, and hemoglobin a1c (HbA1c), systolic and diastolic blood pressure (SBP and DBP), and LDL cholesterol. The study period was June 24th, 2016 to April 30th, 2023.

Results

We estimated that not experiencing food needs, compared with experiencing food needs, would be associated with 0.12 percentage points lower (95% Confidence Interval [CI] -0.16% to -0.09%, p = < 0.0001) mean HbA1c at 12 months. We further estimated that not experiencing food needs would be associated with a 12-month SBP that was 0.67 mm Hg lower (95%CI -0.97 to -0.38 mm Hg, p < .0001), DBP 0.21 mm Hg lower (95%CI -0.38 to -0.04 mm Hg, p = .01). There was no association with lower LDL cholesterol. Results were similar at other timepoints, with associations for HbA1c, SBP, and DBP of similar magnitude, and no difference in LDL cholesterol.

Conclusions

We estimated that not experiencing food needs may be associated with modestly better diabetes outcomes. These findings support testing interventions that address food needs as part of their mechanism of action.

Association of Patient-Reported Social Needs with Emergency Department Visits and Hospitalizations Among Federally Qualified Health Center Patients

BACKGROUND

Health care systems are increasingly screening for unmet social needs. The association between patient-reported social needs and health care utilization is not well understood.

OBJECTIVE

To investigate the association between patient-reported social needs, measured by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), and inpatient and emergency department (ED) utilization.

DESIGN

This cohort study analyzed merged 2017-2019 electronic health record (EHR) data across multiple health systems.

PARTICIPANTS

Adult patients from a federally qualified health center (FQHC) in central North Carolina who completed PRAPARE as part of a primary care visit with behavioral health services.

MAIN MEASURES

The count of up to 12 unmet social needs, aggregated as 0, 1, 2, or 3 + . Outcomes include the probability of an ED visit and hospitalization 12 months after PRAPARE assessment, modeled by logistic regressions controlling for age, sex, race, ethnicity, comorbidity burden, being uninsured, and prior utilization in the past 12 months.

KEY RESULTS

The study population consisted of 1924 adults (38.7% male, 50.1% Black, 36.3% Hispanic, 55.9% unemployed, 68.2% of patients reported 1 + needs). Those with more needs were younger, more likely to be unemployed, and experienced greater comorbidity burden. 35.3% of patients had ED visit(s) and 36.3% had hospitalization(s) 1 year after PRAPARE assessment. In adjusted analysis, having 3 + needs was associated with a percentage point increase in the predicted probability of hospitalization (average marginal effect 0.06, SE 0.03, p < 0.05) compared with having 0 needs. Similarly, having 2 needs (0.07, SE 0.03, p < 0.05) or 3 + needs (0.06, SE 0.03, p < 0.05) was associated with increased probability of ED visits compared to 0 needs.

CONCLUSIONS

Patient-reported social needs were common and associated with health care utilization patterns. Future research should identify interventions to address unmet social needs to improve health and avoid potentially preventable escalating medical intervention.

Vision impairment and food insecurity in the national health and aging trends study

Introduction

Vision impairment (VI) may further exacerbate older adults' vulnerability to experiencing food insecurity and may be a unique and important target for policies addressing access to nutritional food. The purpose of this study is to determine the association of VI in older adults with food insecurity.

Methods

This is a cross-sectional analysis of round 11 (2021) of the National Health and Aging Trends Study (NHATS), a nationally representative survey of U.S. Medicare beneficiaries ages 65 and older. Participants include 2,815 older adults with complete data on at least one objective measure of vision (distance, near or contrast sensitivity) and food insecurity. Food insecurity was assessed using a previously developed indicator of food insecurity in NHATS. VI was defined as binocular visual acuity (VA) worse than 0.3 logMAR (Snellen equivalent 20/40) at distance or its near equivalent, or contrast sensitivity (CS) worse than 1.55 logUnits. Continuous VI measures included distance and near VA (per 0.1 logMAR), and CS (per 0.1 logCS).

Results

Participants were majority White (82%) and female (55%), and 3% had food insecurity. Older adults with any VI had a greater prevalence of food insecurity than adults without VI (5.0% vs. 2.0%, p < 0.05). In fully adjusted regression analyses, individuals with any VI experienced double the odds of food insecurity than individuals without VI (OR: 2.1, 95% CI: 1.2-3.6). Distance VI (measured continuously) was associated with 1.2 times the odds of food insecurity (OR = 1.2; 95% CI: 1.0-1.3, per 0.1 logMAR). All other vision measures trended towards higher odds of food insecurity, though not statistically significant.

Discussion

Older adults with VI experience higher rates of food insecurity than their peers. Interventions to improve food security should be targeted towards addressing the specific barriers faced by visually impaired older adults.

Healthcare costs attributable to abnormal weight in China: evidence based on a longitudinal study

BACKGROUND

The prevalence of abnormal weight is on the rise, presenting serious health risks and socioeconomic problems. Nonetheless, there is a lack of studies on the medical cost savings that can be attained through the mitigation of abnormal weight. The aim of this study was to estimate the impact of abnormal weight on healthcare costs in China.

METHODS

The study employed a 4-wave panel data from China Family Panel Studies (CFPS) between 2012 and 2018 (11,209 participants in each wave). Inpatient, non-inpatient and total healthcare costs were outcome variables. Abnormal weight is categorized based on body mass index (BMI). Initially, the two-part model was employed to investigate the impact of overweight/obesity and underweight on healthcare utilisation and costs, respectively. Subsequently, the estimated results were utilised to calculate the overweight/obesity attributable fraction (OAF) and the underweight attributable fraction (UAF).

RESULTS

In 2018, healthcare costs per person for overweight and obese population were estimated to be $607.51 and $639.28, respectively, and the underweight population was $755.55. In comparison to people of normal weight, individuals who were overweight/obese (OR = 1.067, p < 0.05) was more likely to utilise healthcare services. Overweight/obesity attributable fraction (OAF) was 3.90% of total healthcare costs and 4.31% of non-inpatient costs. Overweight/obesity does not result in additional healthcare expenditures for young people but increases healthcare costs for middle-aged adults (OAF = 7.28%) and older adults (OAF = 6.48%). The non-inpatient cost of underweight population was significantly higher than that of normal weight population (β = 0.060,p < 0.1), but the non-inpatient health service utilisation was not significantly affected.

CONCLUSIONS

Abnormal weight imposes a huge economic burden on individuals, households and the society. Abnormal weight in Chinese adults significantly increased healthcare utilisation and costs, particular in non-inpatient care. It is recommended that government and relevant social agencies provide a better social environment to enhance individual self-perception and promote healthy weight.

Low-Income Asian Americans: High Levels Of Food Insecurity And Low Participation In The CalFresh Nutrition Program

Little is known about food insecurity and the extent of Supplemental Nutrition Assistance Program (SNAP) participation in the heterogeneous Asian American population. Using California Health Interview Survey data from the period 2011-20, we examined both issues among low-income Asian American adults from six origin groups: Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese. We found high and varied levels of overall food insecurity, with the highest burden among Filipino adults (40 percent). Food insecurity by severity was also heterogenous; very low food security affected 2 percent of Chinese adults but 9 percent and 10 percent of Filipino and Japanese adults, respectively. Participation in CalFresh (California-implemented SNAP) ranged from 11 percent and 12 percent among Korean and Chinese adults, respectively, to 20 percent among Vietnamese adults. Compared with English-proficient low-income Asian American adults, those with limited English proficiency were no less likely to participate in CalFresh, possibly reflecting language assistance required by California law and provided by community-based organizations. These results underscore the importance of collecting and reporting disaggregated data by Asian origin group that could inform targeted outreach and interventions.

Food prescription pilots: feasibility, acceptability and affordability of improving diet through menu planning and grocery delivery

BACKGROUND

Lack of adherence is a primary reason people fail to maintain a healthy diet or lose weight. Multiple environmental factors, including aggressive marketing and convenience of nutrient-poor food, undermine people's best intentions. The aim was to assess the feasibility, acceptability and impact of food prescriptions in which participants' exposure to commercial food outlets is reduced, because the groceries are delivered with weekly menu plans and recipes.

METHODS

This is a series of pre-post pilot proof-of-concept studies. We recruited 37 members of Kaiser Permanente interested in improving their diet or losing weight. Weekly meal plans meeting more than 90% of recommended dietary allowances were designed to be low cost, in line with Supplemental Nutrition Assistance Program (SNAP) allowances. Five separate pilots targeted different populations. Participants were required to provide 24-h dietary recalls (ASA24) before and during the interventions. Weight management pilot participants had height, weight and blood pressure measured before and after 4-week pilots and followed sustainability guidelines, limiting meat and dairy.

RESULTS

Across pilots, the healthy eating index improved (+21.1 points; 95% CI [confidence interval] 15.9, 26.3). For the weight management pilots, most participants lost weight (average 10.3 lbs for men, 5.7 lbs for women; 95% CI -10.2, -5.4). The majority of participants liked the programme and considered it the easiest weight loss programme they ever tried.

CONCLUSIONS

These pilots suggest that meal planning and grocery delivery can be affordable and acceptable and could ultimately have a major impact on diet-related chronic diseases. Longer-term studies are needed to confirm how long compliance will endure.

Adoption Of Standard Medical Deduction Increased SNAP Enrollment And Benefits In 21 Participating States

The Supplemental Nutrition Assistance Program (SNAP) reduces food insecurity but is underused among many households. To increase SNAP participation, twenty-one states have adopted the standard medical deduction (SMD), which simplifies administrative requirements for eligible households (those with older adults or people with disabilities). However, to offset the costs of the SMD, states have reduced SNAP benefits elsewhere, raising concerns of negative spillover effects. Using national data from the period 2004-19 and a fixed-effects estimator, we found that the SMD was associated with increased SNAP participation among SMD-eligible households, in terms of aggregate household counts (20 percent) and as a share of households receiving SNAP (5 percentage points). Moreover, estimated annual SNAP benefits per state increased for SMD-eligible households but decreased (although not statistically significantly) for ineligible households. Offsetting SNAP costs may have benefited households with older adults and households with people with disabilities at the expense of others.

Diet and Food and Nutrition Insecurity and Cardiometabolic Disease

Poor nutrition is the leading cause of poor health, health care spending, and lost productivity in the United States and globally, which acts through cardiometabolic diseases as precursors to cardiovascular disease, cancer, and other conditions. There is great interest in how the social determinants of health (the conditions in which people are born, live, work, develop, and age) impact cardiometabolic disease. Food insecurity is an example of a powerful social determinant of health that impacts health outcomes. Nutrition insecurity, a distinct but related concept to food insecurity, is a direct determinant of health. In this article, we provide an overview of how diet in early life relates to cardiometabolic disease and then continue to focus on the concepts of food insecurity and nutrition insecurity. In the discussions herein we make important distinctions between the concepts of food insecurity and nutrition insecurity and provide a review of their concepts, histories, measurement and assessment devices, trends and prevalence, and links to health and health disparities. The discussions here set the stage for future research and practice to directly address the negative consequences of food and nutrition insecurity.

Supplemental Nutrition Assistance Program Access and Racial Disparities in Food Insecurity

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

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

INTRODUCTION

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Health disparities in chronic liver disease

The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.

Dose response relationship between food insecurity and quality of life in United States adults: 2016-2017

BACKGROUND

Food insecurity is associated with worse general health rating, but little research exists investigating whether there is a dose response relationship across levels of food security and mental and physical health domains at the population level.

METHODS

Data from the Medical Expenditure Panel Survey (2016-2017) with US adults aged 18 years and older was used. The physical component score (PCS) and mental component score (MCS) of Quality of Life, served as the outcome measures. Four categories of food insecurity (high, marginal, low, very low food security) served as the primary independent variable. Linear regression was used to run unadjusted followed by adjusted models. Separate models were run for PCS and MCS.

RESULTS

In a sample of US adults, 16.1% reported some degree of food insecurity. For PCS, marginal (β = - 2.54 (p < 0.001), low (β = - 3.41, (p < 0.001), and very low (β = - 5.62, (p < 0.001) food security was associated with worse PCS scores, compared to adults with high food security. For MCS, marginal (β = - 3.90 (p < 0.001), low (β = - 4.79, (p < 0.001), and very low (β = - 9.72, (p < 0.001) food security was associated with worse MCS scores, compared to adults with high food security.

CONCLUSION

Increasing levels of food insecurity were associated with decreased physical and mental health quality of life scores. This relationship was not explained by demographic factors, socioeconomic factors, insurance, or comorbidity burden. This study suggests work is needed to mitigate the impact of social risk, such as food insecurity, on quality of life in adults, and understand pathways and mechanisms for this relationship.

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 Participation and Emergency Department Use

OBJECTIVES

To examine whether Supplemental Nutrition Assistance Program (SNAP) participation is associated with emergency department use among low-income children and whether any such association is mediated by household food hardship and child health status and/or moderated by special health care needs (SHCN) status. We hypothesized SNAP to be associated with reduced likelihoods of emergency department use, with greater effect sizes for children with SHCN and mediation by food hardship and health status.

METHODS

In this secondary analysis, we estimated a bivariate probit model (with state-level SNAP administrative policies as instruments) within a structural equation modeling framework using pooled cross-sectional samples of children in low-income households from the 2016 to 2019 iterations of the National Survey of Children's Health (n = 24 990).

RESULTS

Among children with and without SHCN, respectively, SNAP was associated with: 22.0 percentage points (pp) (95% confidence interval [CI] 12.2-31.8pp) and 17.1pp (95% CI 7.2-27.0pp) reductions in the likelihood of household food hardship exposure (4.8pp difference-in-differences, 95% CI 2.3-7.4pp), 9.7pp (95% CI 3.9-15.5pp) and 7.9pp (95% CI 2.2-13.6) increases in the likelihood of excellent health status (1.9pp difference-in-differences, 95% CI 0.7-3.0pp), and 7.7pp (95% CI 2.9-12.5pp) and 4.3pp (95% CI 1.0-7.6pp) reductions in the likelihood of emergency department use (3.4pp difference-in-differences, 95% CI 1.8-5.1pp).

CONCLUSIONS

We found SNAP participation was associated with lower likelihoods of emergency department use, that better food hardship and health statuses mediated this association, and that effect sizes were larger among children with SHCN. Food hardship relief may improve outcomes for vulnerable children and the health systems serving them.

Consensus from an expert panel on how to identify and support food insecurity during pregnancy: A modified Delphi study

BACKGROUND

Food insecurity and hunger during pregnancy have significant implications for the health of the mother and baby. Assisting clinicians when they encounter women who are experiencing hunger or food insecurity during their pregnancy will increase the opportunity for better birth and pregnancy outcomes. At present there are no guidelines for Australian clinicians on how to do this.

METHODS

This study uses a modified Delphi technique, allowing diverse participation in the process, to create consensus on the ways to address and respond to food insecurity during pregnancy. This modified Delphi collected data via two rounds of consensus. The opinions collected from the first round were thematically categorised and grouped. The topics were integrated into the survey for the second round and circulated to participants. During the second round, priorities were scored by giving five points to the topic considered most important, and one point to the least important.

RESULTS

Through two rounds of consultation, the panel achieved consensus on how to identify food insecurity during pregnancy, with some clear items of consensus related to interventions that could be implemented to address food insecurity during pregnancy. Experts achieved consensus on items that have importance at the institution and policy level, as well as services that exist in the community. The consensus across the spectrum of opportunities for assistance, from the clinical, to community-provided assistance, and on to government policy and practice demonstrate the complexity of this issue, and the multipronged approach that will be required to address it.

CONCLUSION

This is the first time such a consultation with experts on hunger and food insecurity during pregnancy has been conducted in Australia. Items that achieved consensus and the importance of the issue suggest several ways forward when working with pregnant women who are hungry and/or food insecure.

The development of the Supplemental Nutrition Assistance Program enrollment accessibility (SNAP-access) score

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) is a federal public benefit providing food assistance to millions of Americans. However, it is typically administered by states, creating potential variation in accessibility and transparency of information about enrollment for people with disabilities.

OBJECTIVE

To develop and demonstrate the use of a method to assess the accessibility and transparency of information about the disability-inclusive process and practices of SNAP enrollment.

METHODS

Cross-sectional data was collected from SNAP landing and enrollment webpages from all 50 U.S. states, the District of Columbia, and New York City from June-August 2021. Based on principles of universal design and accessibility, scores were determined for each SNAP program across three areas: flexibility in the enrollment process (6 points), efficiency of finding information about enrollment on SNAP websites (6 points), and the accessibility of SNAP webpages (6 points). Total scores were the sum of these sub-categories (18 points maximum).

RESULTS

Of the 52 SNAP programs assessed, mean scores were 10.66 (SD = 2.51) for the total score, 2.67 (SD = 0.91) for flexibility in the enrollment process, 3.32 (SD = 1.19) for efficiency of finding information about enrollment on SNAP websites, and 4.67 (SD = 1.72) for the accessibility of SNAP webpages. No programs received the maximum flexibility score (6 points) on flexibility, 2 programs received the maximum on efficiency, and 31 programs the maximum on accessibility.

CONCLUSIONS

We found differences in the accessibility, flexibility, and efficiency of SNAP program enrollment information available on SNAP websites and outline room for improvement across all three of these areas.

Social determinants of health in pediatric scald burns: Is food access an issue?

BACKGROUND

Burn injury risk, severity, and outcomes have been associated with socioeconomic status. Limited data exist to evaluate health access-related influences at a structural population level. This study evaluated factors at the Census-tract level, specifically evaluating food access and social vulnerability in pediatric scald burns.

METHODS

A single-institution retrospective review using the trauma registry and electronic medical record was conducted of pediatric burns between 2016 and 2020. Home address was coded to the Census-tract level and bulk analyzed. Socioeconomic metrics of the home environment were evaluated from publicly available databases, the United States Food and Drug Administration Food Access Research Atlas, and the Centers for Disease Control's Social Vulnerability Index.

RESULTS

There were 840 patients that met inclusion criteria (49.8% scald, N = 418). The mean total body surface area for scalds was 6.6% with an age of 10.2 years; 76% (n = 317) of scalds had Medicaid, and 15% (n = 63) were due to hot noodles. Scalds occurred more in females (45.7%, N = 191 vs 28.0%, N = 118; P < .0001), non-White race (62.7%, N = 262 vs 29.1%, N = 123; P < .0001), and low-income and low-food access populations (39.8%, N = 147 vs 30.4%, N = 116; P = .007). Low-food access Black populations showed increased scald injury (18% [interquartile range 6-35] vs 10% [interquartile range 4-25]), whereas all other populations showed no association. The patients with scalds had a higher overall social vulnerability index (0.67 vs 0.62, P = .008).

CONCLUSION

Often related to poverty, health access, and health equity, population-level social determinants of health like social vulnerability and food access have significant impact on health care and should influence health outreach and systems improvement.

U.S. Nutrition Assistance Program Participation and Childhood Obesity: The Early Childhood Longitudinal Study 2011

INTRODUCTION

The Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch Program; and Special Supplemental Nutrition Program for Women, Infants, and Children reduce food insecurity for millions of Americans with lower incomes. However, critics have questioned whether they increase obesity. This study examined whether program participation was associated with BMI z-score from kindergarten to fifth grade.

METHODS

Data from 4,457 primary-grade students whose household incomes were equal to or below 200% of the federal poverty level from kindergarten to fifth grade as part of the Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 were analyzed. Marginal structural models with inverse probability of treatment/censoring weights were used to estimate associations between Supplemental Nutrition Assistance Program/Free and Reduced Priced Lunch participation over time and fifth-grade BMI z-score, accounting for lost-to-follow-up and time-varying confounders. Weighted generalized estimating equations were used to examine associations between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trends. All analyses incorporated sampling weights. The Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 data were collected from 2010-2016; analyses were conducted in 2021 and 2022.

RESULTS

At baseline, 2,419 (54.3%) respondents participated in the Supplemental Nutrition Assistance Program, 3,993 (89.6%) participated in Free/Reduced Priced Lunch, and 3,755 (84.2%) reported past participation in the Special Supplemental Nutrition Program for Women, Infants, and Children. No associations were found between any program and fifth-grade BMI z-score or between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trend.

CONCLUSIONS

Previous findings of relationships between program participation and BMI may have been because of weaker study designs and uncontrolled confounding. Participation in the Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch; and Special Supplemental Nutrition Program for Women, Infants, and Children was not associated with increased risk of childhood obesity in this recently conducted longitudinal study.

Strengthening Food and Nutrition Security to Promote Public Health in the United States: A Position Paper From the American College of Physicians

Food insecurity functions as a social driver of health, directly negatively impacting health status and outcomes, which can further negatively impact employment and income and increase medical expenditures-all of which exacerbates food insecurity. Progress in meaningfully reducing the food-insecurity rate has stalled in recent years. Although rates have decreased since their peak during the Great Recession, these gains have been reversed by the economic implications of the COVID-19 pandemic. As the federal government is the largest provider of food assistance, there is much potential in better leveraging nutrition assistance programs like the Supplemental Nutrition Assistance Program (SNAP) and the Child Nutrition Programs to increase access to healthful foods and improve public health. However, these programs face many funding challenges and internal shortcomings that create uncertainties and prevent maximal effect. Physicians and other medical professionals also have a role in improving nutritional health by screening for food insecurity and serving as connectors between patients, community organizations, and government services. Governments and payers must support these efforts by providing sufficient resources to practices to fulfill this role. In this position paper, the American College of Physicians (ACP) offers several policy recommendations to strengthen the federal food-insecurity response and empower physicians and other medical professionals to better address those social drivers of health occurring beyond the office doors.

The Logic of Policies to Address Income-Related Health Inequity: A Problem-Oriented Approach

Policy Points  Income is a fundamental cause of health across the life course. To address income-related health inequities, we need a set of overlapping and complementary policy approaches rather than focusing on a single policy.  During their lives, individuals inhabit different roles with regard to their ability to earn wages, and at any given time, only about 50% of the US population are expected to earn wages, while the rest (e.g., children, older adults, those who are disabled, unemployed, students, and/or caregivers) are not.  Three key "branch points" for designing policy approaches to address income-related health inequity are (1) should the needed good or service be obtained on the market? (2) do policy beneficiaries currently earn income? and (3) have policy beneficiaries earned income previously? The responses to these questions suggest one of four policy approaches: social services, social enfranchisement, social insurance, or social assistance.

Healthcare coverage and service access for low-income adults with substance use disorders

INTRODUCTION

Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders.

METHODS

The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population.

RESULTS

In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%).

CONCLUSIONS

Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders.

Women's health: optimal nutrition throughout the lifecycle

Sex differences are an important consideration when researching and establishing policies for nutrition and optimal health. For women's health, there are important physiologic, neurologic, and hormonal distinctions throughout the lifecycle that impact nutritional needs. Distinct from those for men, these nutritional needs must be translated into appropriate nutrition policy that aims to not only avoid overt nutritional deficiency, but also to promote health and minimize risk for chronic disease. Through a series of webinars, scientific experts discussed the advances in the understanding of the unique nutritional needs, challenges and opportunities of the various life stages for women across the life course and identified emerging nutritional interventions that may be beneficial for women. Nevertheless, there is concern that existing nutrition policy intended for women's health is falling short with examples of programs that are focused more on delivering calories than achieving optimal nutrition. To be locally effective, targeted nutrition needs to offer different proposals for different cultural, socio-economic, and geographic communities, and needs to be applicable at all stages of growth and development. There must be adequate access to nutritious foods, and the information to understand and implement proven nutritional opportunities. Experts provided recommendations for improvement of current entitlement programs that will address accessibility and other social and environmental issues to support women properly throughout the lifecycle.

Propensity score weighted associations between financial strain and subsequent inflammatory biomarkers of aging among a representative sample of U.S. older adults

BACKGROUND

Despite known socioeconomic disparities in aging-related outcomes, the underlying physiologic mechanisms are understudied. This study applied propensity score weighting to estimate the effect of financial strain on inflammation-related aging biomarkers among a national sample of older adults.

METHODS

Financial strain severe enough to lack money for housing, utilities, medical/prescription bills or food was measured among 4,593 community-dwelling National Health and Aging Trends Study participants aged ≥ 65 years in 2016. Inverse probability propensity score weights were generated based on 2015 background characteristics, including age, gender, race/ethnicity, income to poverty ratio, education, occupation, home ownership, retirement, Sect. 8 housing, Medicaid, food/energy assistance, childhood health, marital status, and U.S. region. Sampling weights additionally accounted for study design and non-response.

RESULTS

In propensity score-weighted analyses adjusting for age, gender, race/ethnicity, 2017 income to poverty ratio and education, those with 2016 financial strain had 15% higher IL-6 (p = 0.026) and 20% higher CRP levels (p = 0.002) in 2017 than those who were not strained, but did not differ with regard to hemoglobin A1c or CMV. In weighted comparisons, those with financial strain did not differ from those without with regard any 2015 background characteristics.

CONCLUSIONS

These results strengthen the etiologic evidence suggesting that financial strain increases inflammatory biomarkers among older adults. Importantly, inflammation is likely a key physiologic pathway contributing to socioeconomic disparities. Therefore, research is needed to address financial strain.

Supplemental Nutrition Assistance Program participation and health care expenditures in children

BACKGROUND

The Supplemental Nutrition Assistance Program (SNAP) has well-established positive impacts on child health outcomes, including increased birth weight and decreased likelihood of underweight status. Studies in adult populations suggest that SNAP is associated with lower health care costs, although less is known in children.

METHODS

Retrospective analysis of U.S. children (age <18 years) living in low-income households (< 200% of the federal poverty level) in the 2013-2017 Medical Expenditure Panel Survey. We used multivariable regression, adjusting for sociodemographic and clinical covariates, to model the effect of continuous SNAP enrollment on health expenditures as compared to non-enrollees at 12 and 24 months.

RESULTS

The sample included 5,626 children, of whom 49.2% consistently received SNAP for the entire two-year survey period. Compared with SNAP non-recipients, SNAP-recipient households more often had incomes below 100% FPL (78.3% vs 37.9%), and children in SNAP-recipient households were more often publicly insured (94.9% vs 64.5%). Unadjusted expenditures were lower for children in SNAP-recipient households at 12 ($1222 vs $1603) and 24 months ($2447 vs $3009). However, when adjusting for sociodemographic and clinical differences, no statistically significant differences in health care expenditures, including emergency department, inpatient, outpatient, and prescription costs, were identified.

CONCLUSION

SNAP participant children experience heightened social hardships across multiple domains. There were no differences in short term health care costs based on SNAP enrollment when accounting for differences in sociodemographic and clinical factors. Despite demonstrated child health benefits, we found that sustained enrollment in SNAP over a two-year period did not generate significant short- term health care cost reductions. Our findings suggest that although SNAP is intended to act as a benefit towards the health and well-being of its recipients, unlike among adults, it may not reduce health care costs among children.

An Assessment of the Relationship of SNAP and Anemia Among School-Aged Children and Adolescents Living in Households With Food Insecurity

Children in food-insecure households have an increased risk of anemia. Participation in Supplemental Nutrition Assistance Programs (SNAP) has several benefits. However, it is unknown if it ameliorates anemia among school-aged children and adolescents living in food-insecure households. This study aims to assess the association of SNAP participation and anemia among children and adolescents living in households experiencing food insecurity. The sample population (n = 1635), aged 6 to 18 years, were pooled from the 2003–2014 National Health and Nutrition Examination Survey (NHANES). The exposure of interest was self-reported household SNAP participation. The outcome variable was the presence or absence of anemia, classified using the blood hematocrit concentration values. Survey weighted logistic regression was performed to calculate the odds ratio (OR) and 95% Confidence Interval (CI) of the association between participation in SNAP and anemia in food-insecure children. We found that over 80% of anemic children and adolescents, living in food-insecure households, participated in SNAP, while 63% of non-anemic children and adolescents, living in food-insecure households participated in SNAP (p = .007). Among children living in food-insecure households, SNAP participants had 3-fold increased odds of anemia compared to those who do not participate in SNAP, after adjusting for confounders (OR = 3.33, 95% CI: 1.25–8.88). In this study, SNAP participation was associated with increased odds of anemia in children and adolescents living in food-insecure households. Additional research is needed to assess if these unexpected findings are related to the adequacy of SNAP, affordability, and accessibility to healthy foods, or the household and individual food preferences in food-insecure households.

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.

"Now I Feel a Little Bit More Secure": The Impact of SNAP Enrollment on Older Adult SSI Recipients

In June 2019, California expanded Supplemental Nutrition Assistance Program (SNAP) eligibility to Supplemental Security Income (SSI) beneficiaries for the first time. This research assesses the experience and impact of new SNAP enrollment among older adult SSI recipients, a population characterized by social and economic precarity. We conducted semi-structured, in-depth interviews with 20 SNAP participants to explore their experiences with new SNAP benefits. Following initial coding, member-check groups allowed for participants to provide feedback on preliminary data analysis. Findings demonstrate that SNAP enrollment improved participants' access to nutritious foods of their choice, contributed to overall budgets, eased mental distress resulting from poverty, and reduced labor spent accessing food. For some participants, SNAP benefit amounts were too low to make any noticeable impact. For many participants, SNAP receipt was associated with stigma, which some considered to be a social "cost" of poverty. Increased benefit may be derived from pairing SNAP with other public benefits. Together, the impacts of and barriers to effective use of SNAP benefits gleaned from this study deepen our understanding of individual- and neighborhood-level factors driving health inequities among low-income, disabled people experiencing food insecurity and SNAP recipients.

SNAP participation and the health and health care utilisation of low-income adults and children

OBJECTIVE

This article examined whether participation in the Supplemental Nutrition Assistance Program (SNAP) produced changes to adult and child health and health care utilisation during a period of economic recession.

DESIGN

Instrumental variables analysis relying on variation in state SNAP policies to isolate exogenous variation in household SNAP participation.

SETTING

Nationally representative data on child and adult health from the 2008 to 2013 National Health Interview Survey.

PARTICIPANTS

Participants were 92 237 adults and 45 469 children who were either eligible for SNAP based on household income and state eligibility rules or were low income but not eligible for SNAP benefits.

RESULTS

For adults, SNAP participation increased the probability of reporting very good or excellent health, and for both adults and children, reduced needing but having to go without dental care or eyeglasses. The size of these benefits was especially pronounced for children. However, SNAP participation increased the probability of needing but not being able to afford prescription medicine, and increased psychological distress for adults and behavioural problems for children under age 10.

CONCLUSIONS

SNAP's benefits for adult health and improved access to dental and vision care for adults and children suggest benefits from the program's expansions during the current COVID-induced crisis. Predicted negative effects of SNAP participation suggest the need for attention to program and benefit structure to avoid harm and the need for continued research to explore the causal effects of program participation.

Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults : A Cohort Study

BACKGROUND

Older adults dually eligible for Medicare and Medicaid have particularly high food insecurity prevalence and health care use.

OBJECTIVE

To determine whether participation in the Supplemental Nutrition Assistance Program (SNAP), which reduces food insecurity, is associated with lower health care use and cost for older adults dually eligible for Medicare and Medicaid.

DESIGN

An incident user retrospective cohort study design was used. The association between participation in SNAP and health care use and cost using outcome regression was assessed and supplemented by entropy balancing, matching, and instrumental variable analyses.

SETTING

North Carolina, September 2016 through July 2020.

PARTICIPANTS

Older adults (aged ≥65 years) dually enrolled in Medicare and Medicaid but not initially enrolled in SNAP.

MEASUREMENTS

Inpatient admissions (primary outcome), emergency department visits, long-term care admissions, and Medicaid expenditures.

RESULTS

Of 115 868 persons included, 5093 (4.4%) enrolled in SNAP. Mean follow-up was approximately 22 months. In outcome regression analyses, SNAP enrollment was associated with fewer inpatient hospitalizations (-24.6 [95% CI, -40.6 to -8.7]), emergency department visits (-192.7 [CI, -231.1 to -154.4]), and long-term care admissions (-65.2 [CI, -77.5 to -52.9]) per 1000 person-years as well as fewer dollars in Medicaid payments per person per year (-$2360 [CI, -$2649 to -$2071]). Results were similar in entropy balancing, matching, and instrumental variable analyses.

LIMITATION

Single state, no Medicare claims data available, and possible residual confounding.

CONCLUSION

Participation in SNAP was associated with fewer inpatient admissions and lower health care costs for older adults dually eligible for Medicare and Medicaid.

PRIMARY FUNDING SOURCE

National Institutes of Health.