Association between household food insecurity and annual health care costs

Medicaid Nutrition Supports Associated With Reductions In Hospitalizations And ED Visits In Massachusetts, 2020-23

The Massachusetts Medicaid and Children's Health Insurance Program launched the Flexible Services Program to address food insecurity through partnerships with social service organizations under its Section 1115 demonstration waiver. We evaluated the effects of Flexible Services Program nutritional services (or Food Is Medicine programs) on health care use and costs during the first three-year program cycle (January 2020-March 2023). Our analyses pooled data on 20,403 Flexible Services Program participants from seventeen accountable care organizations. In propensity score-weighted analyses, program participation was associated with a 23 percent reduction in hospitalizations and a 13 percent reduction in emergency department visits compared with the number of hospitalizations and visits for 2,108 eligible nonparticipants. Modestly lower health care costs for Flexible Services Program participants were not statistically significant. Health care costs were $1,721 lower among participants after the COVID-19 emergency (2022-23) and $2,502 lower among adults with more than ninety days of enrollment during all study years (2020-23). These findings are important for Medicaid policy nationwide as other state Medicaid programs pursue similar Section 1115 demonstrations.

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.

Food Insecurity in the Community: A Cross-Sectional Study in the Portuguese and Immigrant Population of Amadora

Introduction

Food insecurity, defined as limited or uncertain access to adequate food, is recognized as a public health problem linked to poor eating habits, chronic diseases, and social inequalities. This study aims to characterize and compare food insecurity status among immigrant and Portuguese populations receiving primary healthcare in Amadora.

Methods

A cross-sectional study was conducted based on interviews with individuals aged 18 and above, living in Amadora for at least 1 year. Sociodemographic and health status variables were collected, and food insecurity was assessed using a Portuguese-adapted version of the US Department of Agriculture Household Food Security Survey Module. Data analysis included binary logistic regression to explore the predictive capacity of variables, with food insecurity as the outcome.

Results

The estimated prevalence of household food insecurity was 29.7%, with 10.5% classified as severely food insecure. Single individuals (OR: 3.090; CI: 1.353-7.059), those with basic education (OR: 3.296; CI: 1.175-9.247); immigrants (OR: 4.358; CI: 2.206-8.611), households with three or more members (OR: 2.686; CI: 1.019-7.079), and incomes below EUR 1,100 (OR: 7.359; CI: 2.613-20.726) were more likely to belong to food insecure households. When Portuguese households were analyzed, low income (OR: 8.730; CI: 2.607-29.232) and smoking habits (OR: 3.375; CI: 1.345-8.469) were found to be potential determinants of food insecurity. As for immigrant households, being single (OR: 6.002; CI: 1.404-25.659), having a household with three or more members (OR: 13.953; CI: 2.119-91.887), and low income (OR: 7.110; CI: 1.257-40.226) increased the risk of food insecurity.

Conclusion

The results of this study show that food insecurity is significantly associated with sociodemographic and health factors, with differences between Portuguese and immigrant populations. Awareness of this problem and the need for monitoring should therefore be raised to prioritize community interventions.

Associations Between Food Security, Housing and Health in South Australia

ISSUE ADDRESSED

Food security is becoming increasingly difficult to achieve for many households. Research has shown that food insecurity is associated with socioeconomic disadvantage, including housing pressures, and may contribute to poor health outcomes. There is lack of data on these associations in the South Australian setting, where food security is not consistently monitored.

METHODS

A population health survey was administered to South Australian participants in April 2023. Descriptive analysis was conducted on data regarding food insecurity, housing circumstances, chronic and mental health conditions. Multivariate logistic regression analysis was performed to assess associations between food security and health outcomes.

RESULTS

From a sample of 3002 participants, 16.4% reported low and very low food security. These participants tended to be renting, facing housing cost pressures, and lacking infrastructure to store and prepare food. When controlling for confounders, food insecurity was found to be associated with increased likelihood of having at least one chronic condition, mental health condition, and decreased overall wellbeing.

CONCLUSION

Food security is itself a determinant of health. Regular monitoring of the prevalence of household food insecurity and addressing the structural factors influencing food affordability and availability are required. Further research on its links to health outcomes is warranted. SO WHAT?: Evidence-based action to address food insecurity will become more pressing as the crises of cost-of-living, housing, health system pressures and environmental disasters converge.

Can health financing programmes reduce food insecurity in a developing country?

Despite the devastating effects of out-of-pocket healthcare expenditures on households' financial outlays, which potentially stifle household resources needed for food consumption, the health financing program-food insecurity nexus is yet to receive much needed attention in the literature. This study makes a significant contribution by investigating the effect of health financing program, conceptualised as membership of a National Health Insurance Scheme, on household food insecurity using the food insecurity experience scale (FIES) and several quasi-experimental methods. Using data from the seventh round of the Ghana Living Standards Survey, our endogeneity-corrected results indicate that membership of a health financing program can contribute to reduction in household food insecurity. The results are robust to alternative conceptualisations of food insecurity and different quasi-experimental methods. The effect of health financing programme membership on food insecurity is more pronounced among urban and female-headed households. Our findings further point to household savings as an important channel through which membership of health financing program reduces food insecurity.

Does food insecurity compromise diet quality among Finnish private sector service workers?

OBJECTIVE

To investigate the association between food insecurity (FI) and diet quality in private sector service workers.

DESIGN

Data were collected via electronic questionnaires (2019) and the national register data (2018-2019). FI was measured using the Household Food Insecurity Access Scale (HFIAS) and diet quality using an FFQ and a modified Healthy Food Intake Index (mHFII). The associations between HFIAS and mHFII were studied using ANOVA and ordinal regression analysis.

SETTING

Cross-sectional survey and register data for all municipalities in Finland in 2018-2019.

PARTICIPANTS

Individuals (n 6435) belonging to the Finnish Service Union United. The members are predominantly women and work mainly in retail trade, tourism, restaurant and leisure services, property maintenance and security services.

RESULTS

Overall diet quality, measured by mHFII, was significantly lower in those experiencing severe FI than in those who were food secure (8·0 v. 9·1). Additionally, those with severe FI were less likely to have higher (more optimal) scores in sugar-sweetened beverages (OR: 0·67), fibre-rich grains (OR: 0·79), vegetables (OR: 0·54), fruits and berries (OR: 0·61), vegetable oil (OR: 0·80), fish (OR: 0·65), milk (OR: 0·89) and nuts and seeds (OR: 0·66) than food-secure participants. Severe FI was associated with higher odds for less frequent consumption of red and processed meat (OR: 1·15, a higher score represents less frequent consumption).

CONCLUSIONS

Severe FI was linked to both lower overall diet quality and suboptimal consumption of several food groups. Individuals experiencing severe FI may be predisposed to accumulating dietary risk factors for chronic diseases.

Food Insecurity Status and Health Care Utilization Among COPD Patients: A Retrospective Study

BACKGROUND

Government programs-targeting chronic disease patients with high health care costs-focus on clinical conditions, factors internal to the health care system, and individual patient education, not on addressing modifiable social determinants of health to reduce health care utilization.

OBJECTIVE

To evaluate differences in sociodemographic variables and health care utilization between patients with chronic obstructive pulmonary disease (COPD) who reported food insecurity and those who did not.

METHODS

This descriptive retrospective cross-sectional study used data from the electronic health records of a convenience sample of 854 participants with a discharge diagnosis of COPD or COPD with acute exacerbation, admitted via the emergency department of participating hospitals in Southern California. Chi-square (or Fisher's exact) tests and t tests were used to evaluate group differences, and multivariate (or Firth) logistic regression to identify factors that increased the odds of emergency department visits and hospitalizations.

RESULTS

Significant differences between groups were identified for food insecurity (sometimes or often vs never insecure) and age (P < .001), race (P = .022), medical insurance (P < .001), zip code (P = .022), homeless status (P < .001), smoking status (P < .001), and emergency department visits (P = .033). No significant differences were found for food insecurity and hospitalizations (P = .592).

CONCLUSION

This study contributes to the growing body of research supporting the association of upstream social factors (food insecurity, homelessness, zip code) and downstream health outcomes (repeated emergency room visits), and how existing programs can be effectively utilized to impact downstream health outcomes such as health care utilization.

What qualitative research can tell us about food and nutrition security in the UK and why we should pay attention to what it is telling us

Poor dietary patterns leading to poorer health and increased health care use have affected people living in disadvantaged economic circumstances in the UK for decades, which many fear will be exacerbated due to the UK's current so-called 'cost of living crisis'. The voices of experts by experience of those health and social inequalities are not routinely included in health improvement intervention development in relation to obesity prevention policy and programmes. Obesity is highly correlated with food insecurity experience in high-income country contexts (where food insecurity data are routinely collected) and is similarly socially patterned. Using a health equity lens, this review paper highlights qualitative research findings that have revealed the perspectives and direct experiences of people living with food insecurity, or those others supporting food-insecure households, that shed light on the role and influence of the socio-economic contextual factors food-insecure people live with day-to-day. Insights from qualitative research that have focused on the granular detail of day-to-day household resource management can help us understand not only how food insecurity differentially impacts individual household members, but also how behavioural responses/food coping strategies are playing into pathways that lead to avoidable ill health such as obesity, diabetes and other chronic health conditions, including mental health problems. This review paper concludes by discussing research and policy implications in relation to food-insecure households containing people with chronic health conditions, and for pregnant women and families with infants and very young children living in the UK today.

Prevalence of micronutrient inadequacy differs by severity of food insecurity among adults living in Canada in 2015

Household food insecurity is generally associated with poorer quality diets in Canada, but whether household food insecurity heightens the probability of inadequate micronutrient intakes is unknown. The objective of this research was to investigate how prevalence of micronutrient inadequacy differed by severity of household food insecurity among adults in Canada. Using the 2015 Canadian Community Health Survey Nutrition, this study included participants aged 19-64 years who completed up to two 24 h dietary recalls and provided details about household food insecurity (n = 9486). Children and older adults were not included due to sample size limitations. Usual micronutrient intake distributions were estimated by a four-level measure of food insecurity status using the National Cancer Institute method. Welch's t tests assessed differences in prevalence of inadequacy for selected micronutrients. Prevalence differed for some micronutrients among those living in marginally and moderately food insecure compared to food-secure households. The greatest differences in prevalence of inadequacy were observed between severely food-insecure and food-secure households: vitamin A (60.0%, SE = 11.9 vs. 40.6%, SE = 2.7, p < 0.0001), vitamin B6 (42.7%, SE = 9.1 vs. 12.8%, SE = 2.5, p < 0.0001), folate (39.4%, SE = 10.0 vs. 15.9%, SE = 2.2, p < 0.0001), vitamin C (63.3%, SE = 5.2 vs. 29.1%, SE = 2.8, p < 0.0001), calcium (78.6%, SE = 6.4 vs. 58.7%, SE = 1.3, p < 0.0001), magnesium (75.6%, SE = 9.5 vs. 48.7%, SE = 1.2, p < 0.0001), and zinc (34.9%, SE = 10.0 vs. 23.2%, SE = 2.4, p = 0.0009). Apparent underreporting also differed by severity of food insecurity, with increased underreporting observed with worsening food insecurity. The probability of inadequate micronutrient intakes among adults rises sharply with more severe household food insecurity in Canada.

Spatial variations and determinants of receiving cash and food from the productive safety net program among households in Ethiopia: spatial clustering and multilevel analyses

Background

There is a global struggle with food insecurity and undernutrition among women, and Ethiopia has been particularly impacted by these issues. To address this challenge, Ethiopia has implemented a cash and food safety net program over many years. However, there is limited information available regarding the program's factors and spatial distributions, with no recent national evidence from Ethiopia. Consequently, the objective of this study is to investigate the spatial clustering and determinants of the Productive Safety Net Program (PSNP) in Ethiopia.

Method

This study utilized data from the Ethiopian Demographic and Health Survey. The sample included 8,570 weighted households. Given the hierarchical nature of the data, a multilevel logistic regression model was employed to identify factors influencing the outcome variable. Geographical clusters of individuals receiving assistance from the PSNP were examined using SaTScan software and the Bernoulli model, along with the Kulldorff methods. The nationwide distribution of the program beneficiaries was visualized using ArcGIS version 10.8. Variables were considered statistically significant if their p-value was <0.05.

Results

The overall coverage of the PSNP was 13.54% [95% confidence interval (CI): 12.84-14.29] among households in Ethiopia. The study revealed that people from richer households adjusted odds ratio [AOR = 0.46 (95% CI: (0.33, 0.64))], those from the richest households [AOR = 0.26 (95% CI:(0.17,0.41))], and those with educated household heads [AOR = 0.45 (95% CI:(0.28, 0.71))] have a lower likelihood of utilizing the PSNP compared to their counterparts. Conversely, a unit increase in household heads' age [AOR = 1.02 (95% CI:(1.01, 1.02))] and family size [AOR = 1.05 (95% CI:1.021.10)] showed a higher likelihood of joining the PSNP, respectively. Household heads who have joined community health insurance [AOR = 3.21 (95% CI:(2.58, 4.01))] had significantly higher odds of being included in the PSNP than their counterparts. Heads who belong to a community with a high poverty level [AOR = 2.68 (95% CI:(1.51, 4.79))] and community health insurance [AOR = 2.49 (95% CI:(1.51, 4.11))] showed more inclination to utilize the PSNP compared to their counterparts.

Conclusion

PSNP was judged to have a low implementation status based on the findings gathered regarding it. We found factors such as age, sex, region, wealth, education, family size, regions, and health insurance to be statistically significant. Therefore, encouraging women empowerment, community-based awareness creation, and coordination with regional states is advisable.

Food prescribing in Canada: evidence, critiques and opportunities

INTRODUCTION

There is growing interest in food prescriptions, which leverage health care settings to provide patients access to healthy foods through vouchers or food boxes. In this commentary, we draw on our experiences and interest in food prescribing to provide a summary of the current evidence on this intervention model and critically assess its limitations and opportunities.

RATIONALE

Food insecurity is an important determinant of health and is associated with compromised dietary adequacy, higher rates of chronic diseases, and higher health service utilization and costs. Aligning with recent discourse on social prescribing and "food is medicine" approaches, food prescribing can empower health care providers to link patients with supports to improve food access and limit barriers to healthy diets. Food prescribing has been shown to improve fruit and vegetable intake and household food insecurity, although impacts on health outcomes are inconclusive. Research on food prescribing in the Canadian context is limited and there is a need to establish evidence of effectiveness and best practices.

CONCLUSION

As food prescribing continues to gain traction in Canada, there is a need to assess the effectiveness, cost-efficiency, limitations and potential paternalism of this intervention model. Further, it is necessary to assess how food prescribing fits into broader social welfare systems that aim to address the underlying determinants of food insecurity.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients.

METHODS

We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation.

RESULTS

The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults.

CONCLUSIONS

Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Food Insecurity and Social Policy: A Comparative Analysis of Welfare State Regimes in 19 Countries

We sought to determine whether a country's social policy configuration-its welfare state regime-is associated with food insecurity risk. We conducted a cross-sectional study of 2017 U.N. Food and Agriculture Organization individual-level food insecurity survey data from 19 countries (the most recent data available prior to COVID-19). Countries were categorized into three welfare state regimes: liberal (e.g., the United States), corporatist (e.g., Germany), or social democratic (e.g., Norway). Food insecurity probability, calibrated to an international reference standard, was calculated using a Rasch model. We used linear regression to compare food insecurity probability across regime types, adjusting for per-capita gross domestic product, age, gender, education, and household composition. There were 19,008 participants. The mean food insecurity probability was 0.067 (SD: 0.217). In adjusted analyses and compared with liberal regimes, food insecurity probability was lower in corporatist (risk difference: -0.039, 95% CI -0.066 to -0.011, p  =  .006) and social democratic regimes (risk difference: -0.037, 95% CI -0.062 to -0.012, p  =  .004). Social policy configuration is strongly associated with food insecurity risk. Social policy changes may help lower food insecurity risk in countries with high risk.

Association of food insecurity with successful aging among older Indians: study based on LASI

PURPOSE

Whether food insecurity (FI), a social determinant of health, is linked with successful aging (SA) in the older generation remains uncertain. This study explored the association of FI with SA among older Indians.

METHODS

Data were collected from the Longitudinal Ageing Study in India (LASI) wave 1 (2017-2018). Older adults (≥ 60 years) who completed both the FI and the SA surveys were selected. FI was indicated by the lack of access to enough food in the past year. SA was determined by five components: (1) low probability of diseases; (2) low probability of disability; (3) high cognitive functionality; (4) low probability of depression; and (5) active social engagement. The association of FI and SA was assessed using multivariable logistic regression adjusted for potential covariates. Subgroup analyses were performed to evaluate interactions with age, sex, alcohol use, smoking, and place of residence.

RESULTS

27,579 participants met the eligibility criteria. Overall prevalence was 7.13% for FI and 19.41% for SA. Following full adjustment, FI was inversely associated with SA (OR 0.56; 95% CI 0.49-0.65) and with each of SA's five components. No significant interactions of FI and SA were observed in subgroup analyses stratified by age, sex, alcohol use, smoking, or place of residence.

CONCLUSIONS

FI was inversely associated with SA among older Indians. These findings need to be validated by future studies which should also explore potential underlying mechanisms, and whether interventions decreasing FI might increase SA.

Health-related social needs information in the emergency department: clinician and patient perspectives on availability and use

BACKGROUND

Patient health-related social needs (HRSN) complicate care and drive poor outcomes in emergency department (ED) settings. This study sought to understand what HRSN information is available to ED physicians and staff, and how HRSN-related clinical actions may or may not align with patient expectations.

METHODS

We conducted a qualitative study using in-depth semi-structured interviews guided by HRSN literature, the 5 Rights of Clinical Decision Support (CDS) framework, and the Contextual Information Model. We asked ED providers, ED staff, and ED patients from one health system in the mid-Western United Stated about HRSN information availability during an ED encounter, HRSN data collection, and HRSN data use. Interviews were recorded, transcribed, and analyzed using modified thematic approach.

RESULTS

We conducted 24 interviews (8 per group: ED providers, ED staff, and ED patients) from December 2022 to May 2023. We identified three themes: (1) Availability: ED providers and staff reported that HRSNs information is inconsistently available. The availability of HRSN data is influenced by patient willingness to disclose it during an encounter. (2) Collection: ED providers and staff preferred and predominantly utilized direct conversation with patients to collect HRSNs, despite other methods being available to them (e.g., chart review, screening questionnaires). Patients' disclosure preferences were based on modality and team member. (3) Use: Patients wanted to be connected to relevant resources to address their HRSNs. Providers and staff altered clinical care to account for or accommodate HRSNs. System-level challenges (e.g., limited resources) limited provider and staff ability to address patients HRSNs.

CONCLUSIONS

In the ED, HRSNs information was inconsistently available, collected, or disclosed. Patients and ED providers and staff differed in their perspectives on how HSRNs should be collected and acted upon. Accounting for such difference in clinical and administrative decisions will be critical for patient acceptance and effective usage of HSRN information.

Identifying the top 10 research priorities for the school food system in the UK: a priority setting exercise

INTRODUCTION

The school food system varies widely between schools and across the UK. There is a need to understand evidence gaps in school food research to allow the development, implementation and evaluation of policies and interventions to support children's healthy eating at school. This study aimed to conduct a priority setting exercise to co-produce research priorities in relation to the UK school food system.

METHODS

The James Lind Alliance process informed this priority setting exercise; all key steps engaged a wide range of UK school food stakeholders (including teachers, parents, principals, school governors, policymakers, caterers). An initial online stakeholder survey identified perceived research priorities. In a second survey, stakeholders were asked to rank these priorities. Lastly, an online priority setting workshop with stakeholders elicited the most important research priorities.

RESULTS

In 2021, school food stakeholders (n=1280) completed the first survey, from which 136 research priorities were identified. In the second survey, participants (n=107) ranked these research priorities regarding their importance. Lastly, 30 workshop participants discussed and reached consensus on the research priorities. After final refinement by the research team, 18 priorities resulted, with the top 10 being related to the provision of free school meals (effectiveness of cost-effectiveness of different levels of eligibility, including universal provision), implementation of policy (including improving uptake) and food standards, issues around procurement, leadership, inequalities, social norms, the eating environment, food culture throughout the school setting and healthy eating.

CONCLUSION

The top 10 research priorities were elicited through a rigorous approach, including a wide range of stakeholders across the UK. These should be considered by policymakers, researchers and others to inform research, evidence-based policy development and, ultimately, improve the UK school food system.

The association between household food insecurity and healthcare costs among Canadian children

OBJECTIVE

To examine the relationship between household food insecurity and healthcare costs in children living in Ontario, Canada.

METHODS

We conducted a cross-sectional, population-based study using four cycles of the Canadian Community Health Survey (2007-2008, 2009-2010, 2011-2012, 2013-2014) linked with administrative health databases (ICES). We included Ontario children aged 1-17 years with a measure of household food insecurity (Household Food Security Survey Module) over the previous 12 months. Our primary outcome was the direct public-payer healthcare costs per child over the same time period (in Canadian dollars, standardized to year 2020). We used gamma-log-transformed generalized estimating equations accounting for the clustering of children to examine this relationship, and adjusted models for important sociodemographic covariates. As a secondary outcome, we examined healthcare usage of specific services and associated costs (e.g. visits to hospitals, surgeries).

RESULTS

We found that adjusted healthcare costs were higher in children from food-insecure than from food-secure households ($676.79 [95% CI: $535.26, $855.74] vs. $563.98 [$457.00, $695.99], p = 0.047). Compared with children living in food-secure households, those in insecure households more often accessed hospitals, emergency departments, day surgeries, and home care, and used prescription medications. Children from food-secure households had higher usage of non-physician healthcare (e.g. optometry) and family physician rostering services.

CONCLUSION

Even after adjusting for measurable social determinants of health, household food insecurity was associated with higher public-payer health services costs and utilization among children and youth. Efforts to mitigate food insecurity could lessen child healthcare needs, as well as associated costs to our healthcare systems.

Exploring the Implications of COVID-19 on Food Security and Coping Strategies among Urban Indigenous Peoples in Saskatchewan, Canada

The COVID-19 pandemic has notably impacted food security, especially among urban Indigenous communities. This study aimed to examine the impact of the pandemic and related lockdown measures on the food security of urban Indigenous peoples in Saskatchewan, Canada. In partnership with Indigenous co-researchers, we designed an online survey disseminated via SurveyMonkey® (San Mateo, CA, USA) from August 2021 to August 2022. This survey detailed background information, the Household Food Security Survey Module (HFSSM), state of food access, and traditional food consumption habits. Of the 130 Indigenous respondents, 75.8% were female, 21.9% male, and 2.3% non-binary, with an average age of 36.2 years. A significant 68.4% experienced food insecurity during the pandemic's first four months. Increased food prices (47.1%) and reduced market availability (41.4%) were the dominant causes. Additionally, 41.8% highlighted challenges in accessing traditional foods. Relying on community resources and government food distribution programs (40.7%) was the most reported coping strategy for those experiencing food insecurity. Notably, 43.6% reported receiving no government financial support during the crisis. This study emphasizes the severe food insecurity among urban Indigenous communities in Saskatchewan during the pandemic. The findings highlight the immediate need for interventions and policies that ensure access to culturally relevant food, especially for future crises.

Food Insecurity and Health: Marital Status and Gender Variations

Existing research has established the detrimental effects of food insecurity on health. However, understanding of the social conditions that may moderate this relationship remains limited. To address this gap, the study investigates two questions: First, does marital status moderate the association between food insecurity and self-rated health? Second, if such moderation exists, does its impact vary based on gender? Data from the 2017-2018 Canadian Community Health Survey, a nationally representative survey conducted by Statistics Canada (n =101 647), were utilized for this investigation. The findings demonstrated that individuals living in food-insecure households reported poorer self-rated mental and general health. However, the negative impact of food insecurity on both health outcomes was less pronounced among married individuals than among their unmarried counterparts. Furthermore, the stress-buffering role of marriage was found to be more substantial among men than among women. In light of the significant stress-buffering role of marriage revealed in this study, it is crucial for policies to aim at providing comparable coping resources to unmarried individuals, particularly women.

Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States

BACKGROUND

Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations.

METHODS

This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2-17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4-10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI z-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program.

RESULTS

After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68-1.02) and 0.26 (95% CI, 0.06-0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52-0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30-2.02]) and children (odds ratio, 2.37 [1.70-3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by -0.29% age points (-0.42 to -0.16); among adults with hypertension, systolic and diastolic blood pressures declined by -8.38 mm Hg (-10.13 to -6.62) and -4.94 mm Hg (-5.96 to -3.92); and among adults with overweight or obesity, BMI decreased by -0.36 kg/m2 (-0.64 to -0.09). Child BMI z-score did not change -0.01 (-0.06 to 0.04).

CONCLUSIONS

In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health.

Examining attitudes toward a proposed sugar-sweetened beverage tax among urban Indigenous adults: a qualitative study using a decolonizing lens

BACKGROUND

Sugar-sweetened beverage taxation has been proposed as a public health policy to reduce consumption, and compared with other ethnic or racialized groups in Canada, off-reserve Indigenous populations consume sugar-sweetened beverages at higher frequencies and quantities. We sought to explore the acceptability and anticipated outcomes of a tax on sugar-sweetened beverages among Indigenous adults residing in an inner-city Canadian neighbourhood.

METHODS

Using a community-based participatory research approach, we conducted semistructured interviews (November 2019-August 2020) with urban Indigenous adults using purposive sampling. Interviews were audio-recorded, transcribed verbatim and analyzed using theoretical thematic analysis.

RESULTS

All 20 participants (10 female, 8 male and 2 two-spirit) consumed sugar-sweetened beverages on a regular, daily basis at the time of the interview or at some point in their lives. Most participants were opposed to and concerned about the prospect of sugar-sweetened beverage taxation owing to 3 interconnected themes: government is not trustworthy, taxes are ineffective and lead to inequitable outcomes, and Indigenous self-determination is critical. Participants discussed government's mismanagement of previous taxes and lack of prioritization of their community's specific needs. Most participants anticipated that Indigenous people in their community would continue to consume sugar-sweetened beverages, but that a tax would result in fewer resources for other necessities, including foods deemed healthy.

INTERPRETATION

Low support for the tax among urban Indigenous people is characterized by distrust regarding the tax, policy-makers and its perceived effectiveness. Findings underscore the importance of self-determination in informing health policies that are equitable and nonstigmatizing.

Perspective: Food and Nutrition Insecurity in Europe: Challenges and Opportunities for Dietitians

In recent years, the interest in food and nutrition insecurity in high-income countries has skyrocketed. However, its recognition in Europe is still developing. This perspective summarizes the evidence on food and nutrition insecurity across Europe in terms of prevalence, consequences, and current mitigation strategies, with the aim of outlining the challenges and opportunities for dietitians. Prevalence in the general population ranges between 5% and 20%, with higher rates identified in women, children, older adults, single-parent households, those with low educational attainment, and on low or unstable income and/or employment. In users of food aid, the prevalence of food insecurity is above 70%. Responses to food and nutrition insecurity include welfare policies and food assistance programs at regional and national levels. However, most current strategies are not successful in tackling the structural drivers of food and nutrition insecurity, nor do they guarantee diet quality. Despite limited involvement to-date, dietitians can play an important role in addressing food and nutrition insecurity across Europe. This narrative identifies 4 areas: 1) create awareness of the existence and severity of food and nutrition insecurity, 2) advocate for comprehensive, robust data on the determinants and prevalence, 3) partner with diverse stakeholders, social assistance providers, local authorities, and nongovernmental organizations in a comprehensive, intersectoral, and integrated manner, 4) participate in the development of political instruments and interventions that ensure equitable access to high-quality safe food.

A Tale of Two Cities During the COVID-19 Pandemic: Evaluating Food Insecurity in Chicago and New York City

BACKGROUND

COVID-19 revealed and broadened existing disparities in large cities. This article interprets the early impacts of COVID-19 on food insecurity (FI) in the Chicago and New York City (NYC) metropolitan areas for Black, Indigenous, and People of Color (BIPOC) and provides a study using a Social Determinants of Health (SDOH) framework.

METHODS

A cross-sectional survey adapted from the National Food Access and COVID Research Team (NFACT) was deployed in Chicago (N = 680) and in NYC (N = 525) during summer 2020 and oversampled for race, ethnicity, and socioeconomic status. Multivariate binary logistic regression generated adjusted odds ratios (aOR) and 95% CIs for FI and select SDOH variables, which was conducted on each dataset.

RESULTS

The prevalence of FI in NYC increased to 66.8% (from 57.8%) and in Chicago to 44.8% (from 41.0%). While higher income protected against FI before, protection was diminished or eliminated since COVID-19. FI declined for households with children in NYC while odds increased and became significant in Chicago. Respondents with chronic health conditions experienced increased odds of FI since COVID. In Chicago, this variable had the highest odds of FI. Respondents with depression or anxiety had increased odds of FI. In NYC, depression had the highest odds of FI. Females in NYC were protected against FI. Hispanics in NYC lost protection against FI from before to since COVID-19.

CONCLUSIONS

Results support the observed rise of FI for BIPOC and its association with health status. The analysis has multifaceted, structural policy implications for reducing FI in urban centers.

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.

Food Insecurity, Healthcare Utilization, and Healthcare Expenditures: A Longitudinal Cohort Study

Objective: This study examines the longitudinal association between household food insecurity and healthcare utilization and expenditure. Methods: A multi-wave longitudinal cohort study was conducted using the 2008-2019 and 2021 waves of the Korean Welfare Panel Study. The baseline data included participants aged ≥19 years with valid responses to the food insecurity and healthcare questionnaires in the 2008 wave (n = 12,166). Healthcare outcomes encompassed outpatient visits, inpatient admissions, days hospitalized, and personal healthcare expenditure. Random effects Poisson and linear regressions were estimated. Results: Severe food insecurity was associated with a higher incidence rate of outpatient visits (IRR, 1.14; 95% CI, 1.12-1.17), days of hospitalization (IRR, 1.18; 95% CI, 1.13-1.22), and inpatient admissions (IRR, 1.40; 95% CI, 1.18-1.65). Moderate food insecurity was associated with 10.4% (β = -0.11; 95% CI, -0.14 to -0.07) or 238,276 KRW reductions in personal healthcare expenditures in the subsequent year. Conclusion: Household food insecurity was linked to increased healthcare utilization and reduced personal healthcare expenditure among Korean adults. Our findings present opportunities to identify target populations for healthcare policies and interventions.

Household food insecurity and health service use for mental and substance use disorders among children and adolescents in Ontario, Canada

BACKGROUND

Food insecurity is a serious public health problem and is linked to the mental health of children and adolescents; however, its relationship with mental health service use is unknown. We sought to estimate the association between household food insecurity and contact with health services for mental or substance use disorders among children and adolescents in Ontario, Canada.

METHODS

We used health administrative data, linked to 5 waves of the Canadian Community Health Survey, to identify children and adolescents (aged 1-17 yr) who had a household response to the Household Food Security Survey Module. We identified contacts with outpatient and acute care services for mental or substance use disorders in the year before survey completion using administrative data. We estimated prevalence ratios for the association between household food insecurity and use of mental health services, adjusting for several confounding factors.

RESULTS

The sample included 32 321 children and adolescents, of whom 5216 (16.1%) were living in food-insecure households. Of the total sample, 9.0% had an outpatient contact and 0.6% had an acute care contact for a mental or substance use disorder. Children and adolescents in food-insecure households had a 55% higher prevalence of outpatient contacts (95% confidence interval [CI] 41%-70%), and a 74% higher prevalence of acute care contacts (95% CI 24%-145%) for a mental or substance use disorder, although contacts for substance use disorders were uncommon.

INTERPRETATION

Children and adolescents living in a food-insecure household have greater use of health services for mental or substance use disorders than those living in households without food insecurity. Focused efforts to support food-insecure families could improve child and adolescent mental health and reduce strain on the mental health system.

Cost analysis and cost effectiveness of a subsidized community supported agriculture intervention for low-income families

BACKGROUND

The food system has a dynamic influence on disparities in food security and diet-related chronic disease. Community supported agriculture (CSA) programs, in which households receive weekly shares of produce from a local farmer during the growing season, have been examined as a possible food systems-based approach for improving diet and health outcomes. The purpose of this study was to estimate the cost of implementing and participating in a multi-component subsidized community supported agriculture intervention and calculate cost-effectiveness based on diet and food security impacts.

METHODS

Using data from the Farm Fresh Foods for Healthy Kids (F3HK) randomized controlled trial in New York, North Carolina, Vermont, and Washington (n = 305; 2016-2018), we estimated programmatic and participant costs and calculated incremental cost-effectiveness ratios (ICERs) for caregivers' daily fruit and vegetable (FV) intake, skin carotenoids, and household food security from program and societal perspectives.

RESULTS

F3HK cost $2,439 per household annually ($1,884 in implementation-related expenses and $555 in participant-incurred costs). ICERs ranged from $1,507 to $2,439 per cup increase in caregiver's FV intake (depending on perspective, setting, and inclusion of juice); from $502 to $739 per one thousand unit increase in skin carotenoid score; and from $2,271 to $3,137 per household shifted out of food insecurity.

CONCLUSIONS

Given the known public health, healthcare, and economic consequences of insufficient FV intake and living in a food insecure household, the costs incurred to support these positive shifts in individual- and household-level outcomes via a F3HK-like intervention may be deemed by stakeholders as a reasonable investment. This work helps to advance a critical body of literature on the cost-effectiveness of subsidized CSAs and other economic and food system interventions for the sake of evidence-based allocation of public health resources.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT02770196. Registered 5 April 2016. Retrospectively registered. https://www.

CLINICALTRIALS

gov/ct2/show/NCT02770196 .

Patterns and predictors of material hardship among poor families with children

Experiences of material hardship vary across poor families, but little is understood about this variability. The present study aimed to distinguish subtypes of material hardship as well as which characteristics predict subtypes. Latent class analysis with data from a large, longitudinal study of families with youth children investigated subtypes of material hardship as well as predictors of subtypes. Multinomial logistic regression then predicted class membership used on known housing risk factors maternal IPV victimization, depression, and substance use. Analyses identified three distinct subtypes of material hardship: "Housing Insecure," "Food Insecure," and "Cost-Burdened but Managing." Maternal IPV victimization and depression reduced likelihood of membership in the "Managing" class, but no predictors distinguished families who become food versus housing insecure. Findings suggest widespread financial stress and complex tradeoffs for low-income families, who struggle to afford basic needs. Maternal safety and mental health prove crucial to families' coping abilities. Increased systemic supports targeting specific circumstances may promote stability and prevent more severe hardship.

Evaluation of a Produce Prescription Program for Patients With Diabetes: A Longitudinal Analysis of Glycemic Control

OBJECTIVE

Produce prescriptions have shown promise in improving diabetes care, although most studies have used small samples or lacked controls. Our objective was to evaluate the impacts of a produce prescription program on glycemic control for patients with diabetes.

RESEARCH DESIGN AND METHODS

Participants included a nonrandom enrollment of 252 patients with diabetes who received a produce prescription and 534 similar control participants from two clinics in Hartford, Connecticut. The start of the COVID-19 pandemic in March 2020 coincided with program implementation. Produce prescription enrollees received vouchers ($60 per month) for 6 months to purchase produce at grocery retail. Controls received usual care. The primary outcome was change in glycated hemoglobin (HbA1c) between treatment and control at 6 months. Secondary outcomes included 6-month changes in systolic (SBP) and diastolic blood pressure (DBP), BMI, hospitalizations, and emergency department admissions. Longitudinal generalized estimating equation models, weighted with propensity score overlap weights, assessed changes in outcomes over time.

RESULTS

At 6 months, there was no significant difference in change in HbA1c between treatment and control groups, with a difference of 0.13 percentage points (95% CI -0.05, 0.32). No significant difference was observed for change in SBP (3.85 mmHg; -0.12, 7.82), DBP (-0.82 mmHg; -2.42, 0.79), or BMI (-0.22 kg/m2; -1.83, 1.38). Incidence rate ratios for hospitalizations and emergency department visits were 0.54 (0.14, 1.95) and 0.53 (0.06, 4.72), respectively.

CONCLUSIONS

A 6-month produce prescription program for patients with diabetes, implemented during the onset of the COVID-19 pandemic, was not associated with improved glycemic control.

Predictors of food variety and food consumption scores of adolescents living in a rural district in Ghana

INTRODUCTION

There is a dearth of information about the food variety and consumption scores of adolescents in Ghana. This study assessed predictors of food variety and consumption scores of adolescents living in a rural district in Ghana.

METHOD

In this cross-sectional study, a multi-stage sampling method was used to select one hundred and thirty-seven (137) adolescents from the Asante-Akim South Municipality of Ghana. A structured questionnaire was used to collect data on sociodemographic, food practices and dietary intakes of study participants. Descriptive, chi-square, T-test, partial correlation and binary logistic regression were used for the data analysis.

RESULTS

The mean food variety score was 25.8±6.4 (range 7-42) and food consumption score was 35±5.1 (range 18.6-49.9). Food variety score was significantly (p<0.05) associated with guardian income status. A significant and positive partial correlation existed between food variety score and calcium intake (r = 0.236, p<0.05). About 49% and 51% of adolescents were food insecure and food secure, respectively. Food consumption score had significant association (p<0.05) with gender (X2 = 6.1), residence (X2 = 7.0), frequency of meal (X2 = 6.8) and food variety score (X2 = 5.4). Adolescent male (AOR = 2.3, 95% CI (1.2-4.6), p = 0.017), peri-urban residency (AOR = 2.1, 95%CI (1.0-4.4), p = 0.036), having three or more meals per day (AOR = 4.2, 95% CI (1.3-13.6), p = 0.018), and a high food variety score (AOR = 2.1, 95%CI (1.0-4.2), p = 0.041) significantly predicted food consumption scores.

CONCLUSION

Moderate income status was associated with food variety score in our study participants. Linear relationship existed between food variety and calcium intake. Adolescent males, peri-urban residency, frequency of meals and high food variety score were the predictors of food consumption score. Nutrition-specific and nutrition sensitive programmes aimed at promoting adolescent health should involve guardians.

Patients' experiences with a community fruit and vegetable box program prescribed by their health provider

BACKGROUND

Food insecurity is "the state of being without reliable access to a sufficient quantity of affordable, nutritious food". Observational studies have associated food insecurity with many negative health effects including the development and exacerbations of chronic diseases, higher health care use and increased mortality. Health care providers prescribing food is a growing area of interest and research, however it is not known how patients feel about receiving fruit and vegetable prescriptions (FVRx) from their health provider versus other means of food provision. This pilot study was conducted to explore the experiences and opinions of Canadian adults with food insecurity who were recipients of a FVRx box program prescribed by their health provider.

METHODS

Potential participants were recruited to 3 focus groups using flyers included in their monthly food box. Questions were kept open to encourage participation of all group members. The focus groups were audiotaped, transcribed verbatim, and analyzed by the research team using descriptive qualitative research methodology.

RESULTS

Participants described shame and frustration trying to obtain enough food through local food banks. In comparison, they perceived their team dietitian, family physician or addictions physician as directly helping them with their health by prescribing food. The boxed fruit and vegetables were prepared in many ways and often shared to reduce waste and to reduce the food insecurity of extended family members. Positive effects of the FVRx on physical and mental health were reported. Participants believed that follow up with their health provider helped support them and their behavioural changes towards better nutrition. Limitations of the program included lack of choice, non-flexible pick-up times and the program being limited to 6 months. Being able to choose their own fruit and vegetables, instead of receiving a set box, was suggested by most to help meal planning and to increase autonomy.

CONCLUSIONS

Health providers prescribing FVRx boxes to adult patients with food insecurity was positively received in this study. Evaluation of similar programs in other regions in Canada and internationally, and comparison of food prescriptions to basic income guarantee programs is recommended.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Food Insecurity and COVID-19 Vaccination Status and Vaccination Hesitancy in the United States

During the COVID-19 pandemic, vaccination hesitancy emerged as a factor that impacted vaccine uptake. In addition, during this period, there was a substantial increase in food insecurity in the United States (US). However, there is a lack of research on the potential connection between food insecurity and COVID-19 vaccine intentions. This study assesses whether experiencing food insecurity during the COVID-19 pandemic is associated with COVID-19 vaccination uptake and vaccination hesitancy. Data were from the 2021 Crime, Health, and Politics Survey, a national probability sample of community-dwelling adults 18 years and older living in the US (N = 1741) conducted from May 10, 2021, to June 1, 2021. Results from multinomial logistic regression analyses found that mild food insecurity and moderate-to-severe food insecurity were associated with an increased relative risk of not planning to get the COVID-19 vaccination compared with having been vaccinated or planning to get vaccinated. Moderate-to-severe food insecurity was associated with an increased risk of being unsure about getting the COVID-19 vaccine. The results suggest that efforts to expand vaccination and health literacy outreach to food-insecure populations are essential steps to promote greater health equity.

Observational study of population level disparities in food costs in 2021 in Canada: A digital national nutritious food basket (dNNFB)

The aim of this work was to assess the feasibility and effect of applying a nationally representative and highly disaggregated food costing measure across Canada, through the novel application of web-scraping technology to the methods of the National Nutritious Food Basket (NNFB). Further, this study tested the hypothesis that a product-matched digital NNFB (dNNFB) correlates with existing market basket measures and quantified any differences in costs. This was an observational cross-sectional study using web scraped food price data collected in November 2021. Food price data was collected from the majority of Loblaw's banners across Canada, resulting in a final store sample of 751 stores sourced from 11 retail banners. Stores were located across all five Statistics Canada regions, including all provinces and territories with the exception of Nunavut. Store-level dNNFB costs were computed, adjusted by age-sex group, and summarized by geographic region and banner. dNNFB costs were then compared with existing national statistics office estimates (Market Basket Measure thresholds for reference families). dNNFB costs varied widely across the country, with notable differences by regional, store-level, and age-sex group characteristics. When compared to reported national statistics, our estimates exceeded the national market basket measure in every comparison in corresponding sub-national geography across the country, with correlation varying from 0.49 to 0.78 dependent on summary comparator. Digital collection of food price data was a feasible strategy for market basket costing. Our findings suggest we may be routinely underestimating the impact of food inflation for consumers, particularly those restricted to certain food environments.

Prevalence of household food insecurity in the marginal area of Birjand, Iran

Introduction

The right to food is a human right. Food insecurity refers to the inability to prepare proper and healthy food. Food insecurity is associated with adverse outcomes among households. To determine the prevalence of food insecurity, its level, and the factors affecting it among households covered by health centers in marginalized areas of Birjand city.

Methods

This descriptive-analytical cross-sectional study was performed on 396 households aged 20-60 years covered by health centers in the marginal areas of Birjand in 2019. We used a 9-item Household Food Insecurity Access Scale (HFIAS) questionnaire. Chi-square, Fisher, and logistic regression analyses were performed using SPSS 22 software at a significance level of less than 0.05.

Results

The mean age of the subjects was 34.04 ± 9.41 years. In total, 48% of the subjects had a level of food insecurity, of which 7.6% had severe, 12.6% moderate, and 27.5% mild insecurity. The prevalence of food insecurity in families with low members and higher levels of education is significantly lower (p &lt; 001). Backward Logistic regression showed that illiteracy (OR: 8.26) and primary education (OR: 2.65), rental housing status (OR: 1.69), lower-income levels being covered by support organizations (OR: 3.13), employed members between 3-4 and more than five (OR: 2.73 and 2.93, respectively), and low weight (OR: 2.55) were associated with food insecurity. The prevalence of food insecurity in this study was high.

Conclusion

The high prevalence of insecurity in studied households is an alarm for the authorities, which can be due to poverty and the low level of nutritional literacy of households' heads and mothers. Helping to improve the quality of life of families and food insecurity of households by improving physical and economic access, increasing literacy and nutritional culture, and reducing the burden of non-communicable diseases related to nutrition is a suggested solution.

The Effect of Food is Medicine Interventions on Diabetes-related Health Outcomes Among Low-income and Food-insecure Individuals: A Systematic Review and Meta-analysis

OBJECTIVE

In this study, we aim to review the current evidence of Food is Medicine interventions on diabetes outcomes among low-income or food-insecure individuals.

METHODS

Seven databases were searched from January 1, 2000 to October 26, 2021 for full-text articles written in English. The studies included experimental studies of any duration and design which addressed the effect of Food is Medicine interventions on fruit and vegetable (F&V) intake and glycated hemoglobin (A1C) levels among low-income or food-insecure populations with prediabetes or diabetes of any age group. Only direction of effect of interventions on F&V intake were ascertained due to high variability in outcome measurement. A1C results were pooled using generic inverse variance with a fixed-effects model. Heterogeneity was assessed using Cochran's Q and quantified by I².

RESULTS

Sixteen studies were included. Five of the 8 studies reported a significant increase in F&V intake. Seven of the 14 studies reported a significant decrease in A1C levels. A meta-analysis of 5 randomized controlled trials (n=843) resulted in clinically meaningful reductions in A1C compared with control (mean difference, -0.47%; 95% confidence interval, -0.66 to -0.29, I²=88%, p<0.0001). Half (n=8) of the studies have a high risk of bias due to missing data, detection bias, and confounding.

CONCLUSIONS

Food is Medicine interventions are effective in increasing F&V intake and reducing A1C levels of the target population. More randomized controlled studies are needed to validate the results.

Impact of COVID-19 Pandemic on Food Insecurity in an Urban Emergency Department Patient Population

INTRODUCTION

Food insecurity (FI) has been associated with adverse health outcomes and increased healthcare expenditures. Many families experienced reduced access to food during the coronavirus disease 2019 (COVID-19) pandemic. A 2019 study revealed that the pre-pandemic prevalence of FI at an urban, tertiary care hospital's emergency department (ED) was 35.3%. We sought to evaluate whether the prevalence of FI in the same ED patient population increased during the COVID-19 pandemic.

METHODS

We performed a single-center, observational, survey-based study. Surveys assessing for FI were administered to clinically stable patients presenting to the ED over 25 consecutive weekdays from November-December 2020.

RESULTS

Of 777 eligible patients, 379 (48.8%) were enrolled; 158 (41.7%) screened positive for FI. During the pandemic, there was a 18.1% relative increase (or 6.4% absolute increase) in the prevalence of FI in this population (P=0.040; OR=1.309, 95% CI 1.012-1.693). The majority (52.9%) of food-insecure subjects reported reduced access to food due to the pandemic. The most common perceived barriers to access to food were reduced food availability at grocery stores (31%), social distancing guidelines (26.5%), and reduced income (19.6%).

CONCLUSION

Our findings suggest that nearly half of the clinically stable patients who presented to our urban ED during the pandemic experienced food insecurity. The prevalence of FI in our hospital's ED patient population increased by 6.4% during the pandemic. Emergency physicians should be aware of rising FI in their patient population so that they may better support patients who must choose between purchasing food and purchasing prescribed medications.

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.

Reprint of: Position of the Academy of Nutrition and Dietetics: Food Insecurity in the United States

It is the position of the Academy of Nutrition and Dietetics that systematic and sustained action is needed to achieve food and nutrition security in the United States. To achieve food security, effective interventions are needed, along with adequate funding for, and increased utilization of, food and nutrition assistance programs; inclusion of nutrition education in such programs; strategies to support individual and household economic stability; and research to measure impact on food insecurity- and health-related outcomes. Millions of individuals living in the United States experience food insecurity. Negative nutritional and non-nutritional outcomes are associated with food insecurity across the lifespan, including substandard academic achievement, inadequate intake of key nutrients, increased risk for chronic disease, and poor psychological and cognitive functioning. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, play key roles in addressing food insecurity and are uniquely positioned to make valuable contributions through competent and collaborative practice, provision of comprehensive food and nutrition education and training, innovative research related to all aspects of food insecurity, and advocacy efforts at the local, state, regional, and national levels.

The association of food insecurity and cardiometabolic risk factors was independent of body mass index in Iranian women

Background

Investigations on food insecurity have shown that food insecurity is inversely associated with health. We examined the association of food insecurity and cardiometabolic risk factors in women living in Shiraz, Iran.

Methods

The cross-sectional study was performed on 190 females. Food insecurity was assessed by Household Food Insecurity Access Scale. Cardiometabolic risk factors including anthropometric characteristics, blood pressure, and serum glucose and lipids were measured. Metabolic syndrome score was calculated according to the criteria described for Iranian adults. The association of food insecurity and cardiometabolic risk factors was assessed by linear regression.

Results

The prevalence of food security, and mild, moderate, and severe food insecurity was 42.6%, 40.5%, 15.8%, and 1.1%, respectively. Cardiometabolic risk factors worsened with increasing severity of food insecurity. Among the risk factors, body mass index (BMI) had the strongest association with food insecurity. After controlling demographic factors and BMI, fasting blood glucose, triglycerides, total, LDL, and HDL cholesterols, and metabolic syndrome score still showed significant associations with food insecurity (P < 0.01) but systolic and diastolic blood pressure were no longer associated with food insecurity after adjustment for BMI.

Conclusion

Overall, although BMI was strongly associated with food insecurity, cardiometabolic risk factors including blood glucose, triglycerides, total, HDL, and LDL cholesterols, and metabolic syndrome score were associated with food insecurity independent of BMI, suggesting that other factors such as lifestyle and diet may have contributed to the exacerbated cardiometabolic risk in food insecure participants of this study. Future studies need to clarify underlying factors in the association of food insecurity and cardiometabolic risk factors.

Social Determinants of Health Influence Future Health Care Costs in the Medicaid Cohort of the District of Columbia Study

Policy Points Social determinants of health are an important predictor of future health care costs. Medicaid must partner with other sectors to address the underlying causes of its beneficiaries' poor health and high health care spending.

CONTEXT

Social determinants of health are an important predictor of future health care costs but little is known about their impact on Medicaid spending. This study analyzes the role of social determinants of health (SDH) in predicting future health care costs for adult Medicaid beneficiaries with similar past morbidity burdens and past costs.

METHODS

We enrolled into a prospective cohort study 8,892 adult Medicaid beneficiaries who presented for treatment at an emergency department or clinic affiliated with two hospitals in Washington, DC, between September 2017 and December 31, 2018. We used SDH information measured at enrollment to categorize our participants into four social risk classes of increasing severity. We used Medicaid claims for a 2-year period; 12 months pre- and post-study enrollment to measure past and future morbidity burden according to the Adjusted Clinical Groups system. We also used the Medicaid claims data to characterize total annual Medicaid costs one year prior to and one year after study enrollment.

RESULTS

The 8,892 participants were primarily female (66%) and Black (91%). For persons with similar past morbidity burdens and past costs (p < 0.01), the future morbidity burden was significantly higher in the upper two social risk classes (1.15 and 2.04, respectively) compared with the lowest one. Mean future health care spending was significantly higher in the upper social risk classes compared with the lowest one ($2,713, $11,010, and $17,710, respectively) and remained significantly higher for the two highest social risk classes ($1,426 and $3,581, respectively), given past morbidity burden and past costs (p < 0.01). When we controlled for future morbidity burden (measured concurrently with future costs), social risk class was no longer a significant predictor of future health care costs.

CONCLUSIONS

SDH are statistically significant predictors of future morbidity burden and future costs controlling for past morbidity burden and past costs. Further research is needed to determine whether current payment systems adequately account for differences in the care needs of highly medically and socially complex patients.

Food insecurity in children and adults with food allergies

Food allergy is a substantial public health concern associated with risk of severe or potentially life-threatening reactions and requiring life-altering changes in dietary habits. This increasingly prevalent health concern is associated with adverse medical, nutritional, psychosocial, and economic effects on the estimated 32 million affected individuals in the United States. Management of food allergy requires life-altering dietary modifications and constant vigilance to avoid implicated allergens to minimize the risk of anaphylaxis, which can lead to considerable anxiety and reduced quality of life. Specialized diets are expensive and often difficult to access, particularly for low-income and minority individuals with food allergy. The overlap of food insecurity with diet-treated illnesses further increases the burden on patients with food allergies and their families, with overall rates of food insecurity increasing substantially during the coronavirus disease 2019 pandemic. Universal screening to identify food insecure households and connect them with appropriate resources is a critical step in addressing unmet needs at the individual and family level. At the systems level, integrated advocacy approaches addressing the complex interplay between multiple societal issues such as poverty, systemic racism, wage inequality, housing insecurity, lack of transportation, and other social determinants of health are vital to ensure access to safe, healthy, nutritionally complete options for patients with food allergies and their families.

The spatial distribution of urban community gardens and their associated socio-economic status in Tehran, Iran

Urban community gardens are a type of green space presenting a diverse role in urban systems. They can also be beneficial for solving the matter of food insecurity by providing self-sufficiency and resilience in low-income communities and increasing the continuity of agricultural activities. Even though plenty of research has been conducted around community gardens, there is a noticeable research gap concerning case studies in different geographic contexts, especially in the Middle East. This paper in response to the said gap aims at mapping the spatial distribution of community gardens and their socio-economic attributes in Tehran, Iran. A methodology consisting of semi-structured interviews, qualitative and descriptive analysis along with tools such as ArcGIS was employed and secondary data were obtained from various sources such as the Tehran statistical yearbook of the year 2020. The results demonstrate that currently there are a total of 26 community gardens in Tehran and they run based on governmental funds and support with a strong educational motive backing them up. There is also an evident geographical distribution imbalance in terms of gardens placement with them mostly being present in the southern part of the city, while in the northern districts the idea of community gardens has almost been nonexistent. Only districts 22, 8, and 7 among northern districts in Tehran have community gardens. In the southern part, district 19 includes the majority of gardens having seven in total. In short, gardens are mainly placed in areas with lower average land prices, median household income, and higher education graduates.

Hunger and its associated factors in the western Brazilian Amazon: a population-based study

BACKGROUND

Hunger affects millions of people worldwide. In the current pandemic scenario of coronavirus Brazil has experienced an epidemic peak of hunger, amplifying existing prepandemic vulnerabilities, mainly in the North Region of the country. The aim of the present study was to investigate the prevalence of food insecurity and its associated factors in homes with children under 5 years of age in an urban area of a municipality of the western Brazilian Amazon.

METHODS

A household survey was conducted with a probabilistic sample of 557 children and their families. Food insecurity (FI) was determined using the Brazilian Food Insecurity Scale. Associations between variables were analyzed based on the prevalence ratio (PR) and respective 95% confidence intervals (CI) calculated through multiple Poisson regression analysis. Variables with a P value < 0.05 after adjustments were considered significantly associated with the outcome.

RESULTS

A prevalence of 76.5% (CI 1.36-2.67) food insecurity was found among the families in the study; 42.9% had moderate (CI 1.31-2.83) and severe (CI 1.10-1.83) food insecurity. Moderate and severe FI was associated with low family income (P = 0.00), participation in governmental income transfer programs (P = 0.01), and heads of household with less than 7 years of schooling (P = 0.02). Moreover, substantial frequencies of height deficit and being overweight were found among the children.

CONCLUSIONS

The high prevalence of hunger and food insecurity and its associated factors reflects the context of geographic isolation and social exclusion in which these families live, suggesting that a substantial portion of the population under 5 years of age had experienced episodes of hunger in the 90 days prior to the survey. The prevalence of height deficit and being overweight among the children reveals a scenario of epidemiological/nutritional polarization, requiring the formulation of specific public policies for this population.

Dietary Intake Patterns and Lifestyle Behaviors of Pregnant Women Living in a Manitoba First Nations Community: Implications for Fetal Alcohol Spectrum Disorder

The information on the nutrition status of women at-risk of carrying a child with fetal alcohol spectrum disorder (FASD) is scarce, particularly in the First Nations population living on reserve. This study examined and compared nutrition status, dietary intake, and lifestyle patterns of pregnant at-risk, defined as those who consume alcoholic drink during the current pregnancy, and non-at-risk women living in northern Manitoban community. Thirty-seven pregnant, First Nations women (at-risk n = 15; non-at-risk, n = 22) were recruited to participate in the study. A questionnaire, presented in paper and iPad formats, collected information on participants’ demographics, dietary intake, lifestyle, pregnancy outcomes, and maternal health. A food frequency questionnaire and 24-h recall were used to determine nutrient intake. Nutrient values were assessed using Dietary Reference Intakes (DRI). At-risk and non-at-risk women were below the Canada Food Guide serving size recommended for Vegetable and Fruit, Grain, and Milk Products with 93%, 92%, and 93% of participants not meeting the recommendations, respectively. Women met the recommendations for vitamins A, B1, B12, C, niacin, choline, as well as calcium, and zinc. Sixty eight percentage (%) of participants did not meet the recommendations for folate and iron, and 97% for docosahexaenoic acid (DHA). Significant differences were observed between non-at-risk and at-risk women for mean % DRI intakes of vitamin C (313 ± 224 vs. 172 ± 81 mg/day), niacin (281 ± 123 vs. 198 ± 80 mg/day), folate (70 ± 38 vs. 10 ± 22 mcg/day), and iron (101 ± 74 vs. 74 ± 30 mg/day). The findings of this study lay a fundamental premise for the development of community nutrition programs, nutrition education, and nutrition intervention, such as community specific prenatal supplementation. These will assist in ensuring adequate maternal nutrient intake and benefit families and communities in Northern Manitoba with and without alcohol insult.

Influence of Social Adversity on Perceived Health Status and Depressive Symptoms among Portuguese Older People

This study aims to investigate how exposure to poverty, food insecurity, and abuse at older ages relates to health outcomes. A questionnaire collecting data on sociodemographic and economic characteristics, health status, depressive symptoms, food insecurity, and abuse was administered to a sample of 677 older adults. Logistic regression was used to quantify the association of poverty, food insecurity, and abuse with perceived health status and depressive symptoms. If the older person only reported experiences of abuse, it was more likely to report the presence of depressive symptoms, even after adjustment for covariates. If it was only reported the experience of food insecurity, it was more likely to report a worse health status. Older people exposed to at least two factors of vulnerability were significantly more likely to report (very) poor perceived health status (OR: 7.11, 95% CI: 2.77–18.25) and the presence of relevant depressive symptoms (OR: 4.34; 95% CI: 2.04–9.22). Thus, the combined effect of vulnerabilities was significantly associated with worse health among older people. Public health policies to mitigate these adverse exposures should be developed to promote health and well-being in this population.

What is known about the prevalence of household food insecurity in Canada during the COVID-19 pandemic: a systematic review

INTRODUCTION

Household food insecurity (HFI) is a persistent public health issue in Canada that may have disproportionately affected certain subgroups of the population during the COVID-19 pandemic. The purpose of this systematic review is to report on the prevalence of HFI in the Canadian general population and in subpopulations after the declaration of the COVID-19 pandemic in March 2020.

METHODS

Sixteen databases were searched from 1 March 2020 to 5 May 2021. Abstract and full-text screening was conducted by one reviewer and the inclusions verified by a second reviewer. Only studies that reported on the prevalence of HFI in Canadian households were included. Data extraction, risk of bias and certainty of the evidence assessments were conducted by two reviewers.

RESULTS

Of 8986 studies identified in the search, four studies, three of which collected data in April and May 2020, were included. The evidence concerning the prevalence of HFI during the COVID-19 pandemic is very uncertain. The prevalence of HFI (marginal to severe) ranged from 14% to 17% in the general population. Working-age populations aged 18 to 44 years had higher HFI (range: 18%-23%) than adults aged 60+ years (5%-11%). Some of the highest HFI prevalence was observed among households with children (range: 19%-22%), those who had lost their jobs or stopped working due to COVID-19 (24%-39%) and those with job insecurity (26%).

CONCLUSION

The evidence suggests that the COVID-19 pandemic may have slightly increased total household food insecurity in Canada during the COVID-19 pandemic, especially in populations that were already vulnerable to HFI. There is a need to continue to monitor HFI in Canada.