Identifying the Effects of SNAP (Food Stamps) on Child Health Outcomes When Participation Is Endogenous and Misreported

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.

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.

Causal effects of mental health on food security

Although mental health conditions are known to be associated with socioeconomic hardships, their causal effects remain largely unexplored. Using a sample of low-income families in the National Health Interview Survey (NHIS), we assess causal effects of serious mental illness (SMI) and related mental health conditions on family food security. We apply partial identification methods to account for fundamental endogeneity and measurement identification problems in a unified framework. To implement these methods, we combine a proxy measure of SMI in the NHIS with an estimate of the true rate of SMI from the Substance Abuse and Mental Health Services Administration. We also develop an innovative approach to approximate true prevalence rates when only self-reported prevalence rates are available. Applying relatively weak monotonicity assumptions on latent food security outcomes, we find that alleviating SMI would improve the food security rate by at least 9.5 percentage points, or 15 %. JEL codes: C21, I10, I38.

Food insecurity gaps in the Supplemental Nutrition Assistance Program based on disability status

BACKGROUND

Households including someone with disabilities experience disproportionately high food insecurity rates and likely face disproportionate barriers accessing Supplemental Nutrition Assistance Program (SNAP) benefits.

OBJECTIVE

This article aims to examine the role of SNAP with regard to food insecurity disparities based on disability status.

METHODS

Modified Poisson regression models examined food insecurity risk based on disability status (household includes no one with disabilities vs. those with work-limiting disabilities or non-work-limiting disabilities) among 2018 Survey of Income and Program Participation households eligible for SNAP (income ≤130% of the poverty threshold). Weighted estimates were used to account for the study design and non-response.

RESULTS

Households including someone with work-limiting disabilities were more than twice as likely to be food insecure than households including no one with disabilities (PR = 2.16, 95% CI: 1.90, 2.45); households including someone with non-work-limiting disabilities were 65% more likely (PR = 1.65, 95% CI: 1.39, 1.95). However, disparities were more pronounced among households not participating in SNAP (PR = 2.67, 95% CI: 2.22, 3.23 for work-limiting disabilities and PR = 1.86, 95% CI: 1.44, 2.40 for non-work-limiting disabilities) than SNAP-participating households (PR = 1.71, 95% CI: 1.45, 2.03 and PR = 1.46, 95% CI: 1.17, 1.82, respectively). Approximately 4.2 million low-income U.S. households including someone with disabilities are food insecure. Of these, 1.4 million were not participating in SNAP and another 2.8 million households were food insecure despite participating in SNAP.

CONCLUSIONS

Access to SNAP benefits is not proportionate to the scale of food insecurity among households that include people with disabilities. Action is needed to strengthen food assistance for those with disabilities.

County- and state-level immigration policies are associated with Supplemental Nutrition Assistance Program (SNAP) participation among Latino households

The purpose of this study was to investigate the association between county- and state-level immigrant criminalizing and integrating policies and Latino household participation in the largest safety net program against food insecurity in the U.S., the Supplemental Nutrition Assistance Program (SNAP). Our outcome, county-level proportion of SNAP-participating Latino households, and county-level covariates were obtained from the American Community Survey 1-year county files (N = 675 counties) for 13 years (2007-2019). Our exposures were county-level presence of sanctuary policies and a state-level immigrant friendliness score, created based on 19 immigrant criminalizing and integrating state-level policies obtained from the Urban Institute's State Immigration Policies Resource. We classified every county in the sample as 1) sanctuary policy + immigrant friendly state, 2) sanctuary policy + immigrant unfriendly state, 3) no sanctuary policy + immigrant friendly state, and 4) no sanctuary policy + immigrant unfriendly state. Using multivariable generalized linear models that adjusted for poverty levels and other social composition characteristics of counties, we found that county-level SNAP participation among Latino households was 1.1 percentage-point higher in counties with sanctuary policies (B = 1.12, 95%CI = 0.26-1.98), compared to counties with no sanctuary policies, and 1.6 percentage-point higher in counties with sanctuary policies in immigrant friendly states (B = 1.59, 95%CI = 0.33-2.84), compared to counties with no sanctuary policy in immigrant unfriendly states. Local and state immigration policy, even when unrelated to SNAP eligibility, may influence SNAP participation among Latino households. Jurisdictions which lack sanctuary policies or have more criminalizing and less integrating policies should consider adopting targeted outreach strategies to increase SNAP enrollment among Latino households.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Childhood food insecurity, mental distress in young adulthood and the supplemental nutrition assistance program

Food insecurity affects 14% of US homes with children and has been associated with increased mental health problems. Few studies have examined long-term consequences for mental health and the role of social policies. This study examined the association between childhood household food insecurity (HHFI) and young adult psychological distress, and the moderating role of caregiver psychological distress and the Supplemental Nutrition Assistance Program (SNAP) using data from the Panel Study of Income Dynamics (1995-2015). The sample comprised 2782 children ages 0-12 years in 1997. Past-year HHFI was measured using the USDA 18-item questionnaire in 1997, 1999, 2001 and 2003. Young adults' non-specific psychological distress was measured with the Kessler (K6) scale in 2005, 2007, 2009, 2011, 2013 and 2015. Three trajectories of food insecurity were identified: 1) Persistent food security (70.5%); 2) Intermediate/fluctuating food insecurity (24.6%), and; 3) Persistent food insecurity (4.9%). Compared to persistent food security, fluctuating and persistent food insecurity were associated with significantly higher levels of psychological distress. This association was robust to adjusting for socio-demographic factors, caregiver psychological distress, and family access to governmental supports: [Adj. ORs (95% CI's = 1.72 (1.59-1.85) and 2.06 (1.81-2.33)]. Having a caregiver who suffered from psychological distress (1997 and/or 2002) and growing up with persistent food insecurity placed children at greater risk for mental health problems. Access to SNAP attenuated this risk. Early HHFI is associated with psychological distress in young adulthood. Interventions to increase access to SNAP and address caregivers mental health may prevent mental health problems associated with childhood HHFI.

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.

Senior food insecurity in the USA: a systematic literature review

OBJECTIVE

Understanding the factors associated with senior food insecurity is key to understanding senior-specific needs to develop targeted interventions and ultimately lower the prevalence and the incidence of food insecurity. We aimed to systematically review published literature and summarise the associated factors of food insecurity in older adults in the USA.

DESIGN

We searched PubMed, Scopus, Web of science, EconLit and JSTOR databases for peer-reviewed articles published in English between January 2005 and September 2019 that assessed food security or its associated factors for US adults aged 60 years and older. After a two-step screening process, twenty articles were retained and included in the review.

SETTING

NA.

PARTICIPANTS

NA.

RESULTS

The majority of studies were cross-sectional (70 %), consisted of data from one state (60 %), and had large sample sizes. Food-insecure individuals were more likely to be younger, less educated, Black or African American, female, a current smoker, low income, and self-report fair/poor health, have chronic conditions, and utilise government assistance programmes. Food insecurity was associated with medication non-adherence, poor mental health outcomes and limitations in physical functioning. Results were mixed for overweight/obesity status. There was no discernable pattern related to the consistency of findings by the assessed quality of the included studies.

CONCLUSIONS

Food insecurity is a prevalent and pervasive issue for older adults. The numerous correlates identified suggest that interventions aimed at enhancing food and nutrition safety net and medication assistance programmes are warranted, and upstream, systemic-level interventions may be best suited to deal with the correlates of food insecurity.

Economic Impact Payments and Household Food Insufficiency during COVID-19: The Case of Late Recipients

During the COVID-19 pandemic, the U.S. government distributed Economic Impact Payments (EIPs) to ease the economic hardships of American households. Using the Household Pulse Survey, we study the association of first-round EIPs with household-level food insufficiency in a sample of late recipients of EIPs. Studying the late recipients is important for two reasons, first, about 12 million eligible individuals did not automatically receive EIPs, and second, the late receipt of EIPs and the low-income status of late recipients allow us to tease out the relationship between EIPs and food insufficiency. We find that EIPs were associated with a 9.2 percentage points decrease in the likelihood of food insufficiency. However, households kept relying on free food acquisition to fight food hardship. Our results suggest that government efforts to provide more timely stimulus payments could be very impactful and significantly impact household food insufficiency.

Changes in dietary practices of mother and child during the COVID-19 lockdown: Results from a household survey in Bihar, India

The outbreak of COVID-19, and the national-level lockdown to contain it, were expected to disrupt supply chains, lead to livelihood loss, and reduce household income. Studies anticipated a decline in food security in India, leading to a near famine-like situation. In this study, we examine the change in Dietary Score (number of food groups consumed out of a possible eight) and proportion of respondents complying with Minimum Dietary Diversity norms (consuming at least four food groups) among women aged 15-49 years and their youngest child (aged between 7 and 36 months) during the lockdown. The present study also analyses whether ownership of ration cards and contacts with the party in power locally helped the household to tide over the crisis. The data was collected through a two-phase primary survey undertaken in January-March 2020 (pre-lockdown period) and October-November 2020 (post-lockdown period). It was undertaken in six districts of Bihar, a state with a history of poor maternal and child health outcomes and dysfunctional delivery of health services. We find that dietary practices of women deteriorated, while that of children remained the same. The deterioration is less among households owning ration cards or having political contacts. The analysis suggests that, during pandemics or similar crisis periods, the need to supplement the supply of staple items through the Public Distribution System with a direct transfer of cash will allow households to maintain diversity in the consumption basket.

Job loss and psychological distress during the COVID-19 pandemic: Longitudinal Analysis from residents in nine predominantly African American low-income neighborhoods

While psychological distress is a common sequelae of job loss, how that relationship continued during the COVID-19 pandemic is unclear, for example, given higher health risk to working due to disease exposure. This paper examines changes in psychological distress depending on job loss among a cohort of randomly selected residents living in nine predominantly African American low-income neighborhoods in Pittsburgh PA across four waves between 2013 and 2020. Between 2013 and 2016, we found an increase in psychological distress after job loss in line with the literature. In contrast, between 2018 and 2020 we found change in psychological distress did not differ by employment loss. However, residents who had financial concerns and lost their jobs had the largest increases in psychological distress, while residents who did not have serious financial concerns-potentially due to public assistance-but experienced job loss had no increase in distress, a better outcome even than those that retained their jobs. Using partial identification, we find job loss during the pandemic decreased psychological distress for those without serious financial concerns. This has important policy implications for how high-risk persons within low-income communities are identified and supported, as well as what type of public assistance may help.

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.

The SNAP Cycle and Diabetes Management During a One-Time Change in Disbursement Schedule

OBJECTIVE

The 2018-2019 federal government partial shutdown resulted in a one-time disruption to the usual disbursement schedule of Supplemental Nutrition Assistance Program (SNAP) benefits nationwide. We assessed the relationship between this disruption and hyperglycemia and hypoglycemia medical encounters among beneficiaries with diabetes.

RESEARCH DESIGN AND METHODS

To estimate whether the one-time change in benefit disbursement affected the monthly cycle of hyperglycemia or hypoglycemia encounter rates, we used linked administrative Medicaid claims and SNAP disbursement data from West Virginia in a fixed-effects model with interactions between week of the month and the two months of interest-January and February 2019. We controlled for week, month, year, and county effects as well as individual characteristics, and we clustered SEs by individual.

RESULTS

We found that the early disbursement of SNAP benefits in January 2019 resulted in a spike in hyperglycemia four times the rate in a typical month. Further, we found a decrease in both hyperglycemia and hypoglycemia in late February.

CONCLUSIONS

Our findings suggest that the early distribution of benefits led to a temporary increase in food consumption among West Virginia Medicaid beneficiaries with diabetes. Findings from late February also imply that individuals may have a way to prepare for reduced food resources. These results shed new light on the effects of unexpected changes to the timing of safety net payments as well as an understanding of unintended consequences of government shutdowns.

The Affordable Care Act Medicaid expansion: A difference-in-differences study of spillover participation in SNAP

The Affordable Care Act’s Medicaid expansion to individuals with adults under 138 percent of the federal poverty level led to insurance coverage for millions of Americans in participating states. This study investigates Medicaid expansion’s potential spillover participation in the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program). In addition to providing public insurance, the policy connects individuals to SNAP, affecting social determinants of health such as hunger. We use difference-in-differences regression to estimate the effect of the Medicaid expansion on SNAP participation among approximately 414,000 individuals from across the United States. The Current Population Survey is used to answer the main research question, and the SNAP Quality Control Database allows for supplemental analyses. Medicaid expansion produces a 2.9 percentage point increase (p = 0.002) in SNAP participation among individuals under 138 percent of federal poverty. Subgroup analyses find a larger 5.0 percentage point increase (p = 0.002) in households under 75 percent of federal poverty without children. Able-Bodied Adults Without Dependents (ABAWDs) are a category of individuals with limited access to SNAP. Although they are a subset of adults without children, we found no spillover effect for ABAWDs. We find an increase in SNAP households with $0 income, supporting the finding that spillover was strongest for very-low-income individuals. Joint processing of Medicaid and SNAP applications helps facilitate the connection between Medicaid expansion and SNAP. Our findings contribute to a growing body of evidence that Medicaid expansion does more than improve access to health care by connecting eligible individuals to supports like SNAP. SNAP recipients have increased access to food, an important social determinant of health. Our study supports reducing administrative burdens to help connect individuals to safety net programs. Finally, we note that ABAWDs are a vulnerable group that need targeted program outreach.

Oncology registered dietitian nutritionists' knowledge, attitudes and practices related to food insecurity among cancer patients: a qualitative study

BACKGROUND

Understanding the knowledge, attitudes and practices pertaining to food insecurity among oncology Registered Dietitian Nutritionists (RDNs) is critical to ensuring that cancer survivors have adequate nutrition-a fundamental component of successful treatment and recovery.

OBJECTIVE

To qualitatively assess Oncology RDN's knowledge, attitudes and practices regarding the food access needs of their patients using a qualitative semantic approach to thematic analysis.

DESIGN

The qualitative cross-sectional study was conducted from September 2018 to January 2019.

PARTICIPANTS/SETTING

Forty-one oncology RDNs working with cancer survivors in various clinical settings across the U.S participated.

MAIN OUTCOME MEASURES

Participants completed a semi-structured, in-depth interview via telephone, lasting an average of 49 minutes.

STATISTICAL ANALYSES PERFORMED

Two coders (primary and secondary) trained in qualitative thematic data analysis methods used a semantic approach to thematic analysis to analyze transcripts. A qualitative and mixed methods online coding program, Dedoose, was used to organize and analyze the data.

RESULTS

Participants defined FI as a lack of access to nutritious foods and a lack of resources to purchase nutritious foods. RDNs stated they believe FI is a serious problem in the U.S., has a greater impact on cancer survivors than healthy individuals and they have specific concerns about FI among their own patients. Despite their concerns, most expressed that they do not use a validated tool to identify FI, nor were they aware that any exists. Only a small proportion of the RDNs stated that they regularly ask patients about their food access needs.

CONCLUSIONS

While Oncology RDNs have heard of FI, they do not routinely assess patients' food security status with a validated tool, nor do they consistently ask patients directly about their food access needs. These findings suggest there is a need for developing education and training opportunities for oncology RDNs in order to enhance their ability to screen for and address FI with their patients.

Giving kids a boost: The positive relationship between frequency of SNAP participation and Infant's preventative health care utilization

Well-child visits are protective for child health but underutilized in the United States. The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program in the United States, has been shown to reduce food insecurity and may also promote child health by supporting preventative health care utilization. We examined the relationship between SNAP participation and infant well-child visits using state administrative data from Missouri's Department of Social Services for the period January 2006 to July 2014 for more than 50,000 infant-mother dyads. We find that compared to always receiving SNAP, leaving SNAP or receiving SNAP unstably reduces the likelihood that an infant receives all recommended well-child visits in the first year. These patterns are more pronounced for infants living in urban areas, infants with Black or Hispanic mothers, and infants whose mothers are diagnosed with depression. We also find that stable SNAP participation primarily influences vaccination rates through well-child visits, which is when most infants receive their immunizations. Given the increased public health risk of foregone care, these results may inform policy makers as they consider making permanent policy waivers to reduce the administrative burden of the recertification process and increase the stability of SNAP participation.

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Leaving SNAP reduces the likelihood an infant receives all recommended well-visits.

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Receiving SNAP unstably reduces the likelihood of infants receiving five well-visits.

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These patterns are larger for Hispanics, Blacks, and infants living in urban areas.

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The “leaving SNAP” pattern is larger for infants with mothers with depression.

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Stable SNAP participation mainly influences vaccinations through well-child visits.

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.

Bounding the joint distribution of disability and employment with misclassification

Understanding the relationship between disability and employment is critical and has long been the subject of study. However, estimating this relationship is difficult, particularly with survey data, since both disability and employment status are known to be misreported. Here, we use a partial identification approach to bound the joint distribution of disability and employment status in the presence of misclassification. Allowing for a modest amount of misclassification leads to bounds on the labor market status of the disabled that are not overly informative given the relative size of the disabled population. Thus, absent further assumptions, even a modest amount of misclassification creates much uncertainty about the employment gap between the non-disabled and disabled. However, additional assumptions considered are shown to have some identifying power. For example, under our most stringent assumptions, we find that the employment gap is at least 15.2% before the Great Recession and 22.0% afterward.

Society of Behavioral Medicine (SBM) does not support "Public Charge Rule" changes affecting immigrants' food security

Federal nutrition assistance programs, especially the Supplemental Nutrition Assistance Program (SNAP), are an important safety net for households in the USA. Although few immigrant households are eligible for SNAP, those who need the program are less likely to participate than nonimmigrant households. Documented barriers to participation include language challenges and anti-immigrant rhetoric. However, previous research indicates that when immigrant households do participate in SNAP, their young children experience less food insecurity and the household as a whole makes fewer tradeoffs between food and other necessities. The Public Charge Rule limits ability to obtain a green card based on participation in public assistance programs. A recent change to this rule added programs to include some noncash programs, including SNAP. Although the vast majority of immigrants who are subject to the Public Charge Rule are not eligible for SNAP, misunderstanding of the rule and fear threaten to reduce SNAP enrollment and consequently increase food insecurity in immigrant families. Spillover effects may occur for families not targeted by changes in the Public Charge Rule as well as decreasing access to other safety net programs that are not impacted by the proposed changes, such as The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and school meals programs. In order to support the food security of immigrant families in the USA, we recommend that the Department of Homeland Security and the Department of State remove all non-cash safety net programs from the Public Charge Rule.

The Effect of the US Safety Net on Material Hardship over Two Decades

We address a question at the center of many policy debates: how effective is the US safety net? Many existing studies evaluate the effect of one program on economic hardship in isolation, though families typically participate in multiple programs. Using 1992-2011 data from the Survey of Income and Program Participation, our analyses examine the simultaneous effect of participation in three programs, TANF, SNAP, or Medicaid/SCHIP, on a set of outcomes of intrinsic importance-measures of material hardship. We find that a 10 percentage point increase in participation in any of these three safety net programs by low-to-moderate income families with children reduces their average number of hardships by 0.11 (-0.41 elasticity), and the incidence of food insufficiency by 1.7 percentage points (-1.27 elasticity). This analysis suggests that hardship would be even more prevalent in the United States without the existence of the current safety net programs.

Do additional SNAP benefits matter for child weight?: Evidence from the 2009 benefit increase

We know that youth who live in low-income households tend to have lower nutritional health outcomes-including higher rates of obesity-when compared to their higher-income counterparts. The Supplemental Nutrition Assistance Program (SNAP) is the largest U.S. federal nutrition program and has been found to improve food security and to serve as an income support. It is less clear how SNAP may affect obesity in low-income youth. From a policy perspective, it is essential to understand how the largest federal nutrition assistance program influences the health of children and adolescents. We use the exogenous increase in SNAP benefits that was a part of the American Recovery and Reinvestment Act (ARRA) to identify how a change in benefits is linked with obesity in youth. We find evidence that the ARRA increase in SNAP benefits is associated with healthier weight outcomes in three of the four age groups examined. SNAP-eligible toddlers are less likely to be overweight and adolescents are less likely to be obese. These findings can help policy makers understand how additional SNAP benefits from the Families First Coronavirus Response Act may influence weight outcomes in children and adolescents.

Misclassification of Medicaid Participation by Dual Eligibles: Evidence From the Medicare Current Beneficiary Survey

Previous studies show that survey-based reports of Medicaid participation are measured with error, but no prior study has examined measurement error in an important segment of the Medicaid population-low-income adults enrolled in Medicare. Using the Medicare Current Beneficiary Survey, we examine whether respondent self-reports of Medicaid enrollment match administrative records and present several key findings. First, among low-income Medicare beneficiaries, the false negative rate is 11.5% when the self-report is interpreted as full Medicaid and 3.7% when the self-report is interpreted as full or partial Medicaid. Second, the likelihood of a false negative report is systematically associated with respondent traits. Third, systematic measurement error results in biased coefficient estimates in models of Medicaid participation defined from self-reports, and the bias is more significant when the researcher interprets self-reports as full Medicaid coverage only. Researchers should use caution when interpreting survey reports as pertaining to full Medicaid coverage only.

SNAP timing and food insecurity

This paper makes several contributions to the literature regarding the measurement of food insecurity and implications for estimating factors that affect this outcome. First, we show that receipt of benefits from the Supplemental Nutrition Assistance Program (SNAP) has a systematic effect on responses to questions in the 12-month food security module (FSM). We find that the probability of affirming more severe food hardships items, and the probability of being classified as having very low food security (VLFS), is higher just before and just after households receive their benefits. This leads to an under-estimate of VLFS by 3.2 percentage points for the SNAP sample (about 17 percent of prevalence). We also provide informative bounds on the relationship between SNAP and VLFS and show that the treatment effect of SNAP on VLFS is also likely underestimated.

The Effects of Changing SNAP Work Requirement on the Health and Employment Outcomes of Able-Bodied Adults without Dependents

OBJECTIVE

The Supplemental Nutrition Assistance Program (SNAP) provides nutritional assistance for United States residents with low income. Current SNAP policy discussion focuses on its work requirement: the Able Bodied Adults without Dependents (ABAWDs) time limit. This study sets out to analyze the effects the work requirement has on ABAWDs' health and employment status.

METHODS

States can apply a waiver on the ABAWD work requirement if they can establish a labor surplus. Many states had this waiver expired due to economic recovery after the 2008 economic crisis. This study took advantage of a recent natural experiment created by states' differentiated timelines in phasing out the three-month waiver and applies a triple-differences approach to study the effects of the SNAP work requirement, using data from the Behavioral Risk Factor Surveillance System, 2015-2016.

RESULTS

SNAP-eligible individuals, including ABAWDS, had more serious physical and mental health conditions compared with higher income individuals. Losing SNAP eligibility increased the incidence of experiencing physically unhealthy days by 14% (p < 0.05) but caused no significant change in employment status.

CONCLUSIONS

The ABAWD time limit on SNAP may have negative consequences when there are insufficient opportunities for employment or positions in governmental Employ and Training programs. More studies are needed to better understand the reason for high SNAP participation even when the unemployment rate suggested a strong economy in 2015-2016. Decision-makers should be cautious in removing SNAP eligibility for ABAWDs or states' time-limit waivers.

Impact of Restricting Sugar-Sweetened Beverages From the Supplemental Nutrition Assistance Program on Children's Health

INTRODUCTION

Children enrolled in the Supplemental Nutrition Assistance Program are at higher risk of poor diet, including higher intake of sugar-sweetened beverages than non-Supplemental Nutrition Assistance Program participants. This study aims to identify the impact of restricting sugar-sweetened beverage purchases with Supplemental Nutrition Assistance Program benefits on children's consumption and health.

METHODS

Using Supplemental Nutrition Assistance Program participation and dietary data of children (aged 2-19 years) in the National Health and Nutrition Examination Survey (2009-2016), a microsimulation model was constructed to assess expected changes in daily sugar-sweetened beverage consumption, total calorie intake, BMI, incidence of dental caries, and obesity prevalence of 2019 U.S. children over a 10-year period, incorporating differences in food consumption and disease risks between the Supplemental Nutrition Assistance Program and the general U.S.

POPULATIONS

Sensitivity analyses were conducted with various food substitution patterns and Supplemental Nutrition Assistance Program participation characteristics. Analysis was performed in 2019.

RESULTS

Sugar-sweetened beverage restriction in the Supplemental Nutrition Assistance Program was estimated to reduce daily sugar-sweetened beverage intake by 112.5 g/person (95% CI= -115.9, -109.2), which was estimated to decrease the number of decayed teeth by 0.53/person (95% CI= -0.55, -0.51), an 8.0% decline from the baseline. If sugar-sweetened beverages were substituted with fruit juice and milk, the restriction would be expected to reduce daily total calorie intake by 39.2 kcal/person (95% CI= -39.8, -38.7), resulting 2.6 kg/m² (95% CI= -2.9, -2.4) decrease in BMI and a 6.2 percentage point (95% CI= -6.5, -5.8) decrease in obesity prevalence among Supplemental Nutrition Assistance Program participants. Estimated changes in total calorie intake and obesity were subject to food substitution patterns.

CONCLUSIONS

Restricting sugar-sweetened beverage purchases in Supplemental Nutrition Assistance Program could promote a healthier diet and significantly lower the incidence of dental caries and potentially obesity prevalence in children.

Measuring the Effects of a Demonstration to Reduce Childhood Food Insecurity: A Randomized Controlled Trial of the Nevada Healthy, Hunger Free Kids Project

BACKGROUND

To reduce childhood hunger, the US Department of Agriculture funded a set of demonstration projects, including the Nevada Healthy, Hunger-Free Kids (HHFK) project.

OBJECTIVE

The study objective was to test whether the Nevada HHFK project reduced child food insecurity (FI-C) among low-income households with young children.

DESIGN

Households were randomly assigned to treatment and control groups, with outcomes measured using household surveys and administrative data. Survey data were collected at baseline (n=3,088) and follow-up (n=2,074) 8 to 12 months into the project.

PARTICIPANTS/SETTING

Eligible households in Las Vegas, NV, had children under age 5 years, received Supplemental Nutrition Assistance Program (SNAP) benefits, and had incomes below 75% of the federal poverty level.

INTERVENTION

Between June 2016 and May 2017, treatment households on SNAP received an additional $40 in monthly SNAP benefits per child under age 5 years.

MAIN OUTCOME MEASURES

Key outcomes included FI-C (primary), food security among adults and households, and food expenditures (secondary).

STATISTICAL ANALYSES PERFORMED

Differences between the treatment and control groups were estimated by a logistic regression model and controlling for baseline characteristics. Analyses were also performed on socioeconomic subgroups.

RESULTS

The Nevada HHFK project did not reduce FI-C (treatment=31.2%, control=30.6%; P=0.620), very low food security among children (P=0.915), or food insecurity among adults (P=0.925). The project increased households' monthly food expenditures (including SNAP and out-of-pocket food purchases) by $23 (P<0.001).

CONCLUSIONS

A demonstration project to reduce FI-C by increasing SNAP benefits to Las Vegas households with young children and very low income did not reduce FI-C or other food-insecurity measures. This finding runs counter to prior research showing that SNAP and similar forms of food assistance have reduced food insecurity. This project was implemented during a period of substantial economic growth in Las Vegas. Future research should explore the role of the economic context, children's ages, and household income in determining how increases in SNAP benefits affect food insecurity. CLINICALTRIALS.

GOV IDENTIFIER

NCT04253743 (http://www.clinicaltrials.gov) FUNDING/SUPPORT: This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

An Increase in SNAP Benefits Did Not Impact Food Security or Diet Quality in Youth

BACKGROUND

Low diet quality during childhood and adolescence is associated with adverse health outcomes later in life. Diet quality is generally poor in American youth, particularly in youth of low socioeconomic status. The Supplemental Nutrition Assistance Program (SNAP) is the primary safety net to help low-income households afford a healthy diet. Yet self-selection into the program creates challenges in estimating the relationship between SNAP and diet outcomes.

OBJECTIVE

This study examined how the increase in SNAP benefits during the American Recovery and Reinvestment Act (ARRA) affected food security and diet quality in low-income youth.

DESIGN

This analysis used a difference-in-differences design and data from the National Health and Nutrition Examination Survey 2007-2008 to 2011-2012 waves.

PARTICIPANTS/SETTING

The sample included children and adolescents aged 2 to 18 years with household income ≤250% of the Federal Poverty Line. Food security and diet outcomes in SNAP-eligible youth (n = 2,797) were examined, with children in nearly SNAP-eligible households serving as a comparison group (n = 1,169). The diet quality analysis stratified the sample by age range.

MAIN OUTCOME MEASURES

The study assessed food security and 6 dietary outcomes: 2 nutrients (sodium and fiber), 3 food categories (fruit, vegetables, and sugar-sweetened beverages), and 1 measure of overall diet quality (Healthy Eating Index 2010).

STATISTICAL ANALYSIS PERFORMED

Logistic regression and linear regression were used to estimate the relationship between SNAP eligibility and child food security and diet.

RESULTS

In unadjusted analysis, approximately 64% of SNAP-eligible children were food secure before ARRA and 73% were food secure while ARRA was in effect. Using logistic regression in a difference-in-differences framework, the ARRA SNAP benefit increase was not significantly associated with food security (odds ratio 1.37, P = 0.43). Diet quality of SNAP-eligible children was low, scoring a 46 out of 100 on the Healthy Eating Index 2010. Measures of diet quality did not significantly change from the pre-ARRA period to the ARRA period; this did not differ by age range.

CONCLUSIONS

The increase in SNAP benefits during ARRA did not significantly impact food security or diet quality in low-income children and adolescents. Additional research to better understand how SNAP benefits impact dietary choice is warranted.

The Effect Of The Supplemental Nutrition Assistance Program On Mortality

The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States. Although participation in it has been shown to reduce food insecurity, there is comparatively less clear causal evidence of positive health effects of participation, particularly among adults. We examined the relationship between SNAP participation and premature mortality using data for 1997-2009 from the National Health Interview Survey, linked to data for 1999-2011 from the National Death Index. Results from bivariate probit models found that participation in SNAP led to a populationwide reduction of 1-2 percentage points in mortality from all causes and a reduction in specific causes of death among people ages 40-64.

The Use of Charitable Food Assistance Among Low-Income Households in the United States

BACKGROUND

About 11% of US households are food insecure, and many of those households seek charitable food assistance (CFA). However, little is understood about the nutritional composition of the diets of households receiving CFA, or the relationship between CFA and Supplemental Nutrition Assistance Program (SNAP) usage among low-income households.

OBJECTIVE

The aim of the study was to compare the nutritional quality of foods obtained by CFA clients to those of similar nonclients. Furthermore, the study examined the timing of CFA use relative to the timing of SNAP use among CFA clients during the week.

DESIGN/PARTICIPANTS

Analyses were conducted using 2012 US Department of Agriculture National Household Food Acquisition and Purchase Survey (FoodAPS), which collected data for 4826 households' food acquisitions during a 7-day survey week. Sixty-seven households reported using CFAs during the survey week.

MAIN OUTCOMES MEASURE

The nutritional quality of food was measured by the ratios between food acquisition quantities and the US Department of Agriculture Thrifty Food Plan consumption recommendations. The date of SNAP use was compared with that of CFA use for CFA clients who were also SNAP recipients.

STATISTICAL ANALYSES PERFORMED

Propensity score matching was utilized to construct a matching sample of CFA clients and nonclients. T tests were used to compare the means of variables.

RESULTS

CFA clients were more likely to be food insecure (48% vs 28%, P < .001) and less likely to have access to a car (61.2% vs 84.8%, P < .001) than CFA nonclients. CFAs represent an important source of foods for CFA clients, taking up 28% of their total food at home acquisitions. CFA clients obtained more nonstarchy vegetables than matched nonclients. Furthermore, among the 45% of CFA clients who also participated in SNAP, the majority (52.4%) of them used SNAP benefits within 10 days of SNAP benefits distribution while most (67.9%) of those households used CFAs starting on day 11 or later after SNAP benefits were allocated.

CONCLUSIONS

CFAs provide a substantial portion of the diets of their clients and, in particular, for foods that constitute components of healthy diets. For the proportion of CFA clients who received SNAP, this study finds evidence that CFA clients relied more on CFAs when their SNAP benefits were likely to run low.

Loss Of SNAP Is Associated With Food Insecurity And Poor Health In Working Families With Young Children

The Supplemental Nutrition Assistance Program (SNAP) helps working families meet their nutritional needs. Families whose earned income increases in a given month may have their SNAP benefits abruptly reduced or cut off in the following month. Using sentinel sample data from 2007-15 for families with children younger than age four, we investigated how SNAP benefit reductions or cutoffs resulting from increased income were related to economic hardships (food and energy insecurity, unstable housing, forgone health and/or dental care, and health cost sacrifices) and to caregiver and child health. After we controlled for covariates, we found that the groups whose SNAP benefits were reduced or cut off had significantly increased odds of household and child food insecurity, compared to a group with consistent participation in SNAP. Reduced benefits were associated with 1.43 and 1.22 times greater odds of fair or poor caregiver and child health, respectively. Policy modifications to smooth changes in benefit levels as work incomes improve may protect working families with young children from increased food insecurity, poor health, and forgone care.

Is less more? Examining the relationship between food assistance benefit levels and childhood weight

BACKGROUND

The Supplementary Nutrition Assistance Program (SNAP) is a critical lifeline for millions of low-income US families, but some studies suggests that it may inadvertently increase obesity risk. Building on research contesting the SNAP-obesity link, we examine the effect of SNAP participation on BMI among multiyear participants at varying levels of SNAP benefit levels to provide some of the first evidence on the relationship between SNAP participation, state-level SNAP resources, and body weight. We focus on children given the strong links between early-life obesity and later-life health.

METHODS

Linking state-level data on SNAP benefit levels with three waves of longitudinal individual-level data from the Child Development Supplement of the Panel Study of Income Dynamics, we use child- and state-level fixed effects to examine whether exogenous differences in SNAP benefit allotments influence the relationship between SNAP participation and weight gain.

RESULTS

Lower SNAP benefit levels were associated with only modest increases in BMI among children; higher benefit levels showed no association with BMI.

CONCLUSIONS

Although concerns that more food assistance promotes obesity have spurred calls for cuts in the SNAP program, we find the opposite - that SNAP participation is associated with an increase in childhood BMI only when benefit levels are low. This study adds to the mounting evidence suggesting that SNAP does not cause obesity. It also contributes to the literature on the political economy of health, especially that pertaining to social policy variation across US states.

Supplemental Nutrition Assistance Program participation and current restricted food expenditures: implications for policy

OBJECTIVE

National concerns over food insecurity and obesity have prompted legislation seeking to further restrict Supplemental Nutrition Assistance Program (SNAP) purchases. The objective of this study is to provide insight on the potential impact of proposed purchase restrictions by comparing SNAP participant and income-eligible non-participants' expenditures on current SNAP-restricted foods, that is, hot foods, prepared foods, alcohol, vitamins and meal supplements.

DESIGN

Cross-sectional study. Bivariate analysis and multivariable regression analysis with an instrumental variables approach were employed to compare the probability of purchasing and expenditures on current SNAP-restricted foods among SNAP participants and income-eligible non-participants.

SETTING

National Household Food Acquisition and Purchase Survey, 2012-2013.

PARTICIPANTS

2513 households, of which 1316 were SNAP participants and 1197 were income-eligible non-participants.

RESULTS

Both the share of households purchasing and household expenditures on current SNAP-restricted foods were similar among SNAP participants and income-eligible non-participants.

CONCLUSIONS

Results provide further empirical evidence that proposed SNAP purchase restrictions on sugar-sweetened beverages, snack foods and luxury foods are unlikely to have a meaningful effect on SNAP household food purchases.

Household food insufficiency, health status and emergency healthcare utilisation among children with and without special healthcare needs

OBJECTIVE

To compare exposure to household food insufficiency and the relationship between household food insufficiency and both health status and emergency healthcare utilisation among children with and without special healthcare needs (SHCN).

DESIGN

Analysing pooled data from the 2016-2017 iterations of the National Survey of Children's Health, we conducted multivariate logistic regressions on household food insufficiency, health status and emergency healthcare utilisation. We assessed interactions between household food insufficiency and children's SHCN status in our models of health status and utilisation.

SETTING

United States.

PARTICIPANTS

Parents of a nationally representative sample of non-institutionalised children (aged 0-17 years).

RESULTS

Children with SHCN were more likely to experience household food insufficiency (70 v. 56 %), non-excellent health status (67 v. 28 %) and emergency healthcare utilisation (32 v. 18 %) than other children. Household food insufficiency was associated with 37 % (children with SHCN) and 19 % (children without SHCN) reductions in the likelihood of having excellent health. Household food insufficiency was associated with a roughly equal (16-19 %) increase in the likelihood of emergency department utilisation across groups.

CONCLUSIONS

Compared with other children, children with SHCN have an elevated risk of exposure to household food insufficiency and experiencing greater reductions in health status when exposed.

Food security and health in transition to adulthood for individuals with disabilities

BACKGROUND

Due to a more stringent disability definition used for eligibility redetermination at age 18, individuals with disabilities may lose eligibility for the Supplement and Nutrition Assistance Program (SNAP).

OBJECTIVE

This study examines how the transition to adulthood may affect the association between food security and self-rated health and healthcare needs for individuals with disabilities.

METHODS

The study uses five years of data (2011-2015) from the National Health Interview Survey (NHIS). One health indicator, self-rated health status, and two indicators of unmet healthcare needs, delayed medical care and not receiving medical care due to cost, are analyzed as dependent variables. The effects of food security status on health and health-related outcomes are closely examined for the four groups: youth without disabilities, youth with disabilities, young adults without disabilities and young adults with disabilities.

RESULTS

Results indicate a statistically significant association between food security status and self-rated health and unmet healthcare needs in late childhood and young adulthood. Such association is stronger for young adults than for youth. The association between low food security and self-rated health and health-related outcomes does not significantly differ between the two youth groups or the two young adult groups by disability status.

CONCLUSIONS

Suggestions for improving accessibility of public food and nutrition programs are discussed. The study also suggests the importance of creating a healthcare system that benefits every member of the society.

Maternal Place of Birth, Socioeconomic Characteristics, and Child Health in US-Born Latinx Children in Boston

OBJECTIVE

Among US-born children of Latina US (USB) and Latina foreign-born mothers (FBM), to determine whether 1) household and child characteristics differ; 2) child health outcomes differ; 3) these differences diminish for children of FBM with longer duration of residence in the United States; and 4) these differences can be explained by food insecurity (FI) or by Supplemental Nutrition Assistance Program (SNAP) participation.

METHODS

Cross-sectional survey of 2145 Latina mothers of publicly insured US-born children 0 to 48 months old in a Boston emergency department (ED) 2004 to 2013. Predictors were FBM versus USBM and duration of residence in the United States. Outcomes were mothers' report of child health, history of hospitalization, developmental risk, and hospital admission on the day of ED visit. Multivariable logistic regression adjusted for potential confounders and effect modification.

RESULTS

FBM versus USBM households had more household (31% vs 26%) and child (19% vs 11%) FI and lower SNAP participation (44% vs 67%). Children of FBM versus USBM were more likely to be reported in fair/poor versus good/excellent health (adjusted odds ratios 1.9, 95% confidence interval [1.4, 2.6]), with highest odds for children of FBM with shortest duration of residence, and to be admitted to the hospital on the day of the ED visit (adjusted odds ratios 1.7, 95% confidence interval [1.3, 2.2]). SNAP and FI did not fully explain these outcomes.

CONCLUSION

When providing care and creating public policies, clinicians and policymakers should consider higher rates of food insecurity, lower SNAP participation, and risk for poor health outcomes in Latinx children of FBM.

Local food prices, SNAP purchasing power, and child health

The Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) is one of the most important elements of the social safety net. Unlike most other safety net programs, SNAP varies little across states and over time, which creates challenges for quasi-experimental evaluation. Notably, SNAP benefits are fixed across 48 states; but local food prices vary, leading to geographic variation in the real value - or purchasing power - of SNAP benefits. In this study, we provide the first estimates that leverage variation in SNAP purchasing power across markets to examine effects of SNAP on child health. We link panel data on regional food prices to National Health Interview Survey data and use a fixed effects framework to estimate the relationship between local purchasing power of SNAP and children's health and health care utilization. We find that lower SNAP purchasing power leads to lower utilization of preventive health care and more days of school missed due to illness. We estimate no effect on parent-reported health status.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

SNAP, Young Children's Health, and Family Food Security and Healthcare Access

INTRODUCTION

The Supplemental Nutrition Assistance Program (SNAP) is the largest nutrition assistance program in the U.S. This study's objective was to examine the associations between SNAP participation and young children's health and development, caregiver health, and family economic hardships.

METHODS

Cross-sectional data from 2006 to 2016 were analyzed in 2017 for families with children aged <3 years in 5 cities. Generalized estimating equations and logistic regression were used to evaluate the associations of SNAP participation with child and caregiver health outcomes and food insecurity, forgone health care, and health cost sacrifices. Nonparticipants that were likely to be eligible for SNAP were compared with SNAP participants and analyses adjusted for covariates including Consumer Price Index for food to control for site-specific food prices.

RESULTS

The adjusted odds of fair or poor child health status (AOR=0.92, 95% CI=0.86, 0.98), developmental risk (AOR=0.82, 95% CI=0.69, 0.96), underweight, and obesity in children were lower among SNAP participants than among nonparticipants. In addition, food insecurity in households and among children, and health cost sacrifices were lower among SNAP participants than among nonparticipants.

CONCLUSIONS

Participation in SNAP is associated with reduced household and child food insecurity, lower odds of poor health and growth and developmental risk among infants and toddlers, and reduced hardships because of healthcare costs for their families. Improved SNAP participation and increased SNAP benefits that match the regional cost of food may be effective preventive health strategies for promoting the well-being of families with young children.

A Systematic Review of the Evaluation of Interventions to Tackle Children's Food Insecurity

Purpose of Review

To synthesise the research which has sought to evaluate interventions aiming to tackle children’s food insecurity and the contribution of this research to evidencing the effectiveness of such interventions.

Recent Findings

The majority of studies in this review were quantitative, non-randomised studies, including cohort studies. Issues with non-complete outcome data, measurement of duration of participation in interventions, and accounting for confounds are common in these evaluation studies. Despite the limitations of the current evidence base, the papers that were reviewed provide evidence for multiple positive outcomes for children participating in attended and subsidy interventions, inter alia, reductions in food insecurity, poor health and obesity. However, current evaluations may overlook key areas of impact of these interventions on the lives and outcomes of participating children.

Summary

This review suggests that the current evidence base which evaluates food insecurity interventions for children is both mixed and limited in scope and quality. In particular, the outcomes measured are narrow, and many papers have methodological limitations. With this in mind, a systems-based approach to both implementation and evaluation of food poverty interventions is recommended.

The Supplemental Nutrition Assistance Program and Child Weight Status: A Review

CONTEXT

The Supplemental Nutrition Assistance Program (SNAP) is a food assistance program that helps Americans afford a healthy diet. However, its influence on children's weight status is unclear. This review examined the evidence of the relationship between SNAP participation and child weight.

EVIDENCE ACQUISITION

The following databases were searched: PubMed, EconLit, Web of Science, and the U.S. Department of Agriculture Economic Research Service. The last search was performed in October 2018. This systematic review gives a narrative synthesis of included studies.

EVIDENCE SYNTHESIS

Twenty-three studies that examined the weight outcomes of children aged 2-18 years and SNAP participation were included. Eleven studies found no significant relationship between SNAP and child weight outcomes. Nine found that SNAP participation was associated with increased weight outcomes in certain subpopulations, and four found that SNAP was linked to a predicted decrease in weight outcomes in some subpopulations. However, many of these studies did not address a key methodologic challenge: self-selection. Of those that did, five found that SNAP participation was associated with an increased risk of being overweight and elevated weight in certain subpopulations.

CONCLUSIONS

SNAP participation may help boys maintain a healthy body weight but can be a contributing factor in being overweight or obese in girls who are long-term participants, or who are already overweight. Food security and participation in multiple food assistance programs may be important modifiers. These findings are relevant to policymakers who are considering reducing SNAP funding or restructuring the program. Further research that utilizes strong designs is needed.

Restrictive state laws aimed at immigrants: Effects on enrollment in the food stamp program by U.S. citizen children in immigrant families

This paper examines whether a chilling effect of restrictive state laws aimed at immigrants creates a barrier to enrollment in the food stamp program (now called the Supplemental Nutrition Assistance Program or SNAP) for U.S. citizen children in low-income immigrant families. This analysis looks at 20 states in the continental United States from 2000 to 2008 that were either at or above the U.S. average for percentage of foreign-born population, or states that ranked in the top 10 percent in terms of change in foreign-born population for that time period. To examine this issue, a multivariate, regression-based difference-in-differences (DD) analysis was applied. The "treatment" group is immigrant families with a U.S. citizen child that is 130% of the federal poverty level or below in states with restrictive immigrant related legislation and the "control" group is native families meeting the same federal poverty level guidelines as well as low-income immigrant families in states without the restrictive legislation. The research findings show that there does not appear to be a chilling effect associated with restrictive state laws on participation in the food stamp program. Food insecurity is an immediate need that may override the impediments to enrollment due to immigration status, causing families to apply despite a negative climate toward immigrants. For policy makers and immigrant advocates it is important to know where chilling effects might not occur in order to work with politicians and federal agencies on crafting sound evidence-based policy. Independent of any chilling effect, the model shows that immigrant families are less likely to enroll in food stamp benefits, consistent with other literature. In addition, independent of the effects of restrictive immigration legislation, both non-citizen and naturalized mothers were less likely to be in a family with food stamp benefits compared to similar native-born mothers. This indicates that all states have a gap in food stamp program enrollment that merits further attention and research.

The Future of Observational Epidemiology: Improving Data and Design to Align With Population Health

Improvements in data resources and computational power provide important opportunities to ensure the continued relevance and growth of observational epidemiology. To achieve that promise, rigorous statistical analyses are important but not sufficient. We must prioritize articulating relevant research questions and developing strong study designs. Relevance depends on designing observational research so it delivers actionable clinical or population health evidence. Expanding data sources, including administrative records and data from emerging technologies such as sensors, can potentially be leveraged to improve study design, statistical power, measurement, and availability of evidence on diverse populations. With these advantages, particularly evidence on the heterogeneity of treatment effects, observational research can better guide design of randomized trials. Evidence on the heterogeneity of treatment effects is also essential to extend the evidence from randomized trials beyond the narrow range of settings and populations for which trials have been conducted. Machine learning tools will likely grow in importance in observational epidemiology in coming years, although we need careful attention to the appropriate uses of prediction models. Despite the potential of these innovations, they will only be useful if embedded in theoretical frameworks motivated by applied clinical and population health questions.

Trends in Food Insecurity and SNAP Participation among Immigrant Families U.S.-Born Young Children

Immigrant families are known to be at higher risk of food insecurity compared to non-immigrant families. Documented immigrants in the U.S. <5 years are ineligible for the Supplemental Nutrition Assistance Program (SNAP). Immigration enforcement, anti-immigrant rhetoric, and policies negatively targeting immigrants have increased in recent years. Anecdotal reports suggest immigrant families forgo assistance, even if eligible, related to fear of deportation or future ineligibility for citizenship. In the period of January 2007–June 2018, 37,570 caregivers of young children (ages 0–4) were interviewed in emergency rooms and primary care clinics in Boston, Baltimore, Philadelphia, Minneapolis, and Little Rock. Food insecurity was measured using the U.S. Department of Agriculture’s Food Security Survey Module. Overall, 21.4% of mothers were immigrants, including 3.8% in the U.S. <5 years (“<5 years”) and 17.64% ≥ 5 years (“5+ years”). SNAP participation among <5 years families increased in the period of 2007–2017 to 43% and declined in the first half of 2018 to 34.8%. For 5+ years families, SNAP participation increased to 44.7% in 2017 and decreased to 42.7% in 2018. SNAP decreases occurred concurrently with rising child food insecurity. Employment increased 2016–2018 among U.S.-born families and was stable among immigrant families. After steady increases in the prior 10 years, SNAP participation decreased in all immigrant families in 2018, but most markedly in more recent immigrants, while employment rates were unchanged.

Trends in Food Insecurity and SNAP Participation among Immigrant Families U.S.-Born Young Children

Immigrant families are known to be at higher risk of food insecurity compared to non-immigrant families. Documented immigrants in the U.S. <5 years are ineligible for the Supplemental Nutrition Assistance Program (SNAP). Immigration enforcement, anti-immigrant rhetoric, and policies negatively targeting immigrants have increased in recent years. Anecdotal reports suggest immigrant families forgo assistance, even if eligible, related to fear of deportation or future ineligibility for citizenship. In the period of January 2007-June 2018, 37,570 caregivers of young children (ages 0-4) were interviewed in emergency rooms and primary care clinics in Boston, Baltimore, Philadelphia, Minneapolis, and Little Rock. Food insecurity was measured using the U.S. Department of Agriculture's Food Security Survey Module. Overall, 21.4% of mothers were immigrants, including 3.8% in the U.S. <5 years ("<5 years") and 17.64% ≥ 5 years ("5+ years"). SNAP participation among <5 years families increased in the period of 2007-2017 to 43% and declined in the first half of 2018 to 34.8%. For 5+ years families, SNAP participation increased to 44.7% in 2017 and decreased to 42.7% in 2018. SNAP decreases occurred concurrently with rising child food insecurity. Employment increased 2016-2018 among U.S.-born families and was stable among immigrant families. After steady increases in the prior 10 years, SNAP participation decreased in all immigrant families in 2018, but most markedly in more recent immigrants, while employment rates were unchanged.

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

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