Understanding food insecurity risk in the United States: A longitudinal analysis.

Background: Food insecurity, lack of consistent access to the food needed for an active, healthy life, harms population health. Although substantial biomedical evidence examines the connections between food insecurity and health, fewer studies examine why food insecurity occurs. Methods: We propose a conceptual understanding of food insecurity risk based on institutions that distribute income-the factor payment system (income distribution stemming from paid labor and asset ownership), transfers within households, and the government tax-and-transfer system. A key feature of our understanding is 'roles' individuals inhabit in relation to the factor payment system: child, older adult, disabled working-age adult, student, unemployed individual, caregiver, or paid laborer. A second feature is that the roles of others in an individual's household also affect an individual's food insecurity risk. We tested hypotheses implied by this understanding, particularly hypotheses relating to role, household composition, and income support programs, using nationally-representative, longitudinal U.S. Current Population Survey data (2016-2019). Results: There were 16,884 participants (year 1 food insecurity prevalence: 10.0%). Inhabiting roles of child (Relative Risk [RR] 1.79, 95% Confidence Interval [95%CI] 1.67 to 1.93), disabled working age-adult (RR 3.74, 95%CI 3.25 to 4.31), or unemployed individual (RR 3.29, 95%CI 2.51 to 4.33) were associated with a greater risk of food insecurity than being a paid laborer. Most food insecure households, 74.8%, had members inhabiting roles of child or disabled working age-adult, and/or contained individuals who experienced job loss. Similar associations held when examining those transitioning from food insecurity to food security in year 2. Conclusions: The proposed understanding accords with the pattern of food insecurity risk observed in the U.S. An implication is that transfer income programs for individuals inhabiting roles, such as childhood and disability, that limit factor payment system participation may reduce food insecurity risk for both those individuals and those in their household.

Food Insecurity Disparities Among Immigrants in the U.S.

Introduction: Food insecurity negatively impacts public health and costs the U.S. healthcare system $53 billion annually. Immigrants are at higher risk of food insecurity. We sought to (1) characterize the prevalence of food insecurity among immigrants (i.e., noncitizens and naturalized citizens) and U.S.-born citizens and (2) determine whether Supplemental Nutrition Assistance Program utilization and income-poverty ratio levels impact the relationship between immigration status and food insecurity. Methods: Multivariable logistic regression models were used to determine the odds of food insecurity (dependent variables) using nationally representative data from the 2019-2020 National Health Interview Survey. Independent variables included immigration status, Supplemental Nutrition Assistance Program utilization, income-poverty ratio, and other important demographics. AORs with their 95% CIs are reported. Analysis was conducted in 2022. Results: After controlling for independent variables, noncitizens had 1.28 (95% CI=1.02, 1.61) times higher odds of food insecurity than U.S.-born citizens. There was no food insecurity disparity between naturalized citizens and U.S.-born citizens. However, the association between immigration status and food insecurity varied significantly at different levels of Supplemental Nutrition Assistance Program utilization and income-poverty ratio. There were no food insecurity disparities between immigrants and U.S.-born citizens when they utilized the Supplemental Nutrition Assistance Program and when they had an income below 200% federal poverty level. Noncitizens who did not utilize the Supplemental Nutrition Assistance Program or those with an income above 200% federal poverty level were more likely to report food insecurity than their U.S.-born counterparts (AOR=1.32, 95% CI=1.01, 1.73 and AOR=1.88, 95% CI=1.24, 2.86, respectively). Moreover, naturalized citizens with an income above 200% federal poverty level were also more likely to report food insecurity than their U.S.-born counterparts (AOR=1.61, 95% CI=1.21, 2.14). Conclusions: Supplemental Nutrition Assistance Program utilization may likely eliminate food insecurity disparities among immigrants and U.S.-born citizens. However, among non-Supplemental Nutrition Assistance Program utilizers, significant food insecurity disparities remained between noncitizens and U.S.-born citizens after adjusting for independent variables. In addition, among individuals with incomes above 200% federal poverty level, significant food insecurity disparities were observed between immigrants and U.S.-born citizens. More research is needed to further understand the role that fear of deportation, ineligibility or lack of awareness about eligibility for the Supplemental Nutrition Assistance Program, and other factors such as structural racism play in food insecurity disparities between immigrants and U.S.-born citizens.

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

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

Additional Fruit and Vegetable Vouchers for Pregnant WIC Clients: An Equity-Focused Strategy to Improve Food Security and Diet Quality.

Women with low household income and from racial/ethnic minority groups are at elevated risk of food insecurity. Food insecurity during pregnancy is associated with overall less healthy diets, lower intake of the pregnancy-supportive nutrients iron and folate, and significant variations in diet across the course of a month. The goal of this study was to explore the impact of an ongoing $40/month supplement for fruits and vegetables (F&Vs) provided to pregnant people enrolled in the Special Supplemental Nutrition Program for Women and Children (WIC). Our primary outcome was food insecurity using the USDA 6-item survey, and our secondary outcome was dietary intake of F&Vs based on the 10-item Dietary Screener Questionnaire. Participants in intervention and comparison counties completed surveys at enrollment and approximately three months later (n = 609). Mean ± SD food insecurity at baseline was 3.67 ± 2.79 and 3.47 ± 2.73 in the intervention and comparison groups, respectively, and the adjusted between-group change from baseline to follow-up in food insecurity was 0.05 [95% CI: −0.35, 0.44] (p > 0.05). F&V intake (in cup equivalents) was 2.56 ± 0.95 and 2.51 ± 0.89 at baseline in the two groups, and the adjusted mean between-group difference in changes from baseline was −0.06 [−0.23, 0.11] (p > 0.05). Recruitment and data collection for this study coincided with the most intensive of America's COVID relief efforts. Our results may indicate that small increases in highly targeted food resources make less of a difference in the context of larger, more general resources being provided to individuals and households in need.

Strengthening US Food Policies and Programs to Promote Equity in Nutrition Security: A Policy Statement From the American Heart Association.

Nutritionally inadequate dietary intake is a leading contributor to chronic cardiometabolic diseases. Differences in dietary quality contribute to socioeconomic and racial and ethnic health disparities. Food insecurity, a household-level social or economic condition of limited access to sufficient food, is a common cause of inadequate dietary intake. Although US food assistance policies and programs are designed to improve food security, there is growing consensus that they should have a broader focus on nutrition security. In this policy statement, we define nutrition security as an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease. Despite existing policies and programs, significant gaps remain for achieving equity in nutrition security across the life span. We provide recommendations for expanding and improving current food assistance policies and programs to achieve nutrition security. These recommendations are guided by several overarching principles: emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across programs, ensuring stability of access to programs across the life course, and ensuring equity and dignity for access and utilization. We suggest a critical next step will be to develop and implement national measures of nutrition security that can be added to the current US food security measures. Achieving equity in nutrition security will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand existing food assistance policies and programs and to develop and implement new policies and programs that will improve cardiovascular health and reduce disparities in chronic disease.

Anti-obesity medication prescriptions by race/ethnicity and use of an interpreter in a pediatric weight management clinic.

Background: Race/ethnicity and low English proficiency healthcare disparities are well established in the United States. We sought to determine if there are race/ethnicity differences in anti-obesity medication (AOM) prescription rates among youth with severe obesity treated in a pediatric weight management clinic and if, among youth from non-primary English speaking families, there are differences in prescriptions between those using interpreters during visits versus not. Methods: We reviewed electronic health records of 2- to 18-year-olds with severe obesity seen from 2012 to 2021. Race/ethnicity was self-report, and AOMs included topiramate, stimulants (e.g. phentermine, lisdexamfetamine), naltrexone (±bupropion), glucagon-like peptide-1 agonists, and orlistat. We used general linear regression models with log-link to compare incidence rate ratios (IRRs) within the first 1 and 3 years of being followed, controlling for age, percent of the 95th BMI percentile (%BMIp95), number of obesity-related comorbidities (e.g. insulin resistance, hypertension), median household income, and interpreter use. We repeated similar analyses among youth from non-primary English speaking families, comparing those using interpreters versus not. Results: 1,725 youth (mean age 11.5 years; %BMIp95 142%; 53% non-Hispanic White, 20% Hispanic/Latino, 16% non-Hispanic black; 6% used interpreters) were seen, of which 15% were prescribed AOMs within 1 year. The IRR for prescriptions was lower among Hispanic/Latino compared to non-Hispanic White youth at one (IRR 0.70; CI: 0.49-1.00; p = 0.047) but not 3 years. No other statistically significant differences by race/ethnicity were found. Among non-primary English speaking families, the IRR for prescriptions was higher at 1 year (IRR 2.49; CI: 1.32-4.70; p = 0.005) in those using interpreters versus not. Conclusions: Among youth seen in a pediatric weight management clinic, AOM prescription incidence rates were lower in Hispanics/Latinos compared to non-Hispanic Whites. Interpreter use was associated with higher prescription incidence rates among non-primary English speakers. Interventions to achieve equity in AOM prescriptions may help mitigate disparities in pediatric obesity.

Changes in Food Insecurity and Changes in Patient-Reported Outcomes: a Nationally Representative Cohort Study.

BACKGROUND: Cross-sectional studies have found that health-related quality of life and mental health are worse among food-insecure compared with food-secure individuals. However, how these outcomes change as food insecurity changes is unclear. OBJECTIVE: To evaluate how common patient-reported health-related quality of life and mental health scales change in response to changes in food security. DESIGN: Retrospective cohort study using data representative of the civilian, adult, non-institutionalized population of the USA. PARTICIPANTS: Food insecure adults who completed the 2016-2017 Medical Expenditure Panel Survey. MAIN MEASURES: Mental health, as measured by the mental component score of the Veterans Rand 12-Item Health Survey (VR-12) (primary outcome), along physical health (physical component score of the VR-12), self-rated health status, psychological distress (Kessler 6), depressive symptoms (PHQ2), and the SF-6D measure of health utility. We fit linear regression models adjusted for baseline outcome level, age, gender, race/ethnicity, education, health insurance, and family size followed by predictive margins to estimate the change in outcome associated with a 1-point improvement in food security. KEY RESULTS: A total of 1,390 food-insecure adults were included. A 1-point improvement in food security was associated with a 0.38 (95%CI 0.62 to 0.14)-point improvement in mental health, a 0.15 (95%CI 0.02 to 0.27)-point improvement in psychological distress, a 0.05 (95%CI 0.01 to 0.09)-point improvement in depressive symptoms, and a 0.003 (95%CI 0.000 to 0.007)-point improvement in health utility. Point estimates for physical health and self-rated health were in the direction of improvement, but were not statistically significant. CONCLUSIONS: Improvement in food insecurity was associated with improvement in several patient-reported outcomes. Further work should investigate whether similar changes are seen in food insecurity interventions, and the most useful scales for assessing changes in health-related quality of life and mental health in food insecurity interventions.

Accelerating Evaluation of Financial Incentives for Fruits and Vegetables: A Case for Shared Measures.

Food insecurity, or lack of consistent access to enough food, is associated with low intakes of fruits and vegetables (FVs) and higher risk of chronic diseases and disproportionately affects populations with low income. Financial incentives for FVs are supported by the 2018 Farm Bill and United States (U.S.) Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) and aim to increase dietary quality and food security among households participating in the Supplemental Nutrition Assistance Program (SNAP) and with low income. Currently, there is no shared evaluation model for the hundreds of financial incentive projects across the U.S. Despite the fact that a majority of these projects are federally funded and united as a cohort of grantees through GusNIP, it is unclear which models and attributes have the greatest public health impact. We explore the evaluation of financial incentives in the U.S. to demonstrate the need for shared measurement in the future. We describe the process of the GusNIP NTAE, a federally supported initiative, to identify and develop shared measurement to be able to determine the potential impact of financial incentives in the U.S. This commentary discusses the rationale, considerations, and next steps for establishing shared evaluation measures for financial incentives for FVs, to accelerate our understanding of impact, and support evidence-based policymaking.

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

BACKGROUND: Older adults dually eligible for Medicare and Medicaid have particularly high food insecurity prevalence and health care use. OBJECTIVE: To determine whether participation in the Supplemental Nutrition Assistance Program (SNAP), which reduces food insecurity, is associated with lower health care use and cost for older adults dually eligible for Medicare and Medicaid. DESIGN: An incident user retrospective cohort study design was used. The association between participation in SNAP and health care use and cost using outcome regression was assessed and supplemented by entropy balancing, matching, and instrumental variable analyses. SETTING: North Carolina, September 2016 through July 2020. PARTICIPANTS: Older adults (aged ≥65 years) dually enrolled in Medicare and Medicaid but not initially enrolled in SNAP. MEASUREMENTS: Inpatient admissions (primary outcome), emergency department visits, long-term care admissions, and Medicaid expenditures. RESULTS: Of 115 868 persons included, 5093 (4.4%) enrolled in SNAP. Mean follow-up was approximately 22 months. In outcome regression analyses, SNAP enrollment was associated with fewer inpatient hospitalizations (-24.6 [95% CI, -40.6 to -8.7]), emergency department visits (-192.7 [CI, -231.1 to -154.4]), and long-term care admissions (-65.2 [CI, -77.5 to -52.9]) per 1000 person-years as well as fewer dollars in Medicaid payments per person per year (-$2360 [CI, -$2649 to -$2071]). Results were similar in entropy balancing, matching, and instrumental variable analyses. LIMITATION: Single state, no Medicare claims data available, and possible residual confounding. CONCLUSION: Participation in SNAP was associated with fewer inpatient admissions and lower health care costs for older adults dually eligible for Medicare and Medicaid. PRIMARY FUNDING SOURCE: National Institutes of Health.

Federal Nutrition Programs after the Pandemic: Learning from P-EBT and SNAP to Create the Next Generation of Food Safety Net Programs.

It is thought that childhood food insecurity rates increased to 18 million impacted children in 2020. In response, innovative policy solutions from the Supplemental Nutrition Assistance Program (SNAP) and the Pandemic Electronic Benefit Transfer (P-EBT) were swiftly implemented. These innovations must serve as catalysts to create the next generation of food safety net programs. These include the removal of administrative barriers to enrollment, the use of streamlined procedures to access food, the expansion of P-EBT to daycare and childcare centers, and the uncoupling of receipt of benefits from physical presence in schools. Critical gaps also remain. SNAP benefit amounts are often too low, leaving many families ineligible. More realistic benefit amounts are needed, such as those used in the USDA's Moderate Cost Food Plan. Eligibility cut-offs exclude many food insecure families. Better alignment of SNAP eligibility with income levels that substantially increase food insecurity risk are critical. Lastly, creating slower phase-out periods for benefits as incomes rise is essential. Additionally, food insecurity continues to disproportionately impact racial and ethnic minority populations and low-income households. These deeply rooted inequalities in access to nutrition play an important role in driving health disparities, including obesity, hypertension, diabetes, and other chronic comorbidities and must be further examined. Changes to SNAP and the P-EBT program illustrate how innovative, broad-scale policy solutions can expeditiously support the nutritional needs of families with children. While pandemic-inspired innovation offers critical lessons for designing the next generation of nutrition assistance, there remain gaps that can perpetuate disparities in access to food and health. As a community of medical providers, we must advocate for broader, more inclusive policies to support those facing food insecurity. The future depends on it.

Perspective: The Convergence of Coronavirus Disease 2019 (COVID-19) and Food Insecurity in the United States.

During the coronavirus disease 2019 (COVID-19) pandemic, food insecurity has doubled overall and tripled among households with children in the United States. Food insecurity and COVID-19 may exacerbate one another through bidirectional links, leading to a syndemic, or sequential disease clusters, which exacerbate one another. Experiencing food insecurity may be associated with macronutrient and micronutrient deficiencies, which can weaken host defenses, thus increasing susceptibility to COVID-19. Food insecurity is associated with chronic medical conditions, which may afford a higher risk of severe COVID-19 illness. People experiencing food insecurity may have increased exposure to COVID-19 while procuring food. People with COVID-19 may be unable to work, generate income, and procure food while quarantined, which may exacerbate food insecurity. Clinicians should screen for food insecurity during the COVID-19 pandemic and provide referrals to food-assistance programs when appropriate. Policymakers should expand benefits for the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to address increases in the depth and breadth of food insecurity during the COVID-19 pandemic.

School Closures During COVID-19: Opportunities for Innovation in Meal Service.

In 2019, the National School Lunch Program and School Breakfast Program served approximately 15 million breakfasts and 30 million lunches daily at low or no cost to students.Access to these meals has been disrupted as a result of long-term school closures related to the COVID-19 pandemic, potentially decreasing both student nutrient intake and household food security. By the week of March 23, 2020, all states had mandated statewide school closures as a result of the pandemic, and the number of weekly missed breakfasts and lunches served at school reached a peak of approximately 169.6 million; this weekly estimate remained steady through the final week of April.We highlight strategies that states and school districts are using to replace these missed meals, including a case study from Maryland and the US Department of Agriculture waivers that, in many cases, have introduced flexibility to allow for innovation. Also, we explore lessons learned from the pandemic with the goal of informing and strengthening future school nutrition policies for out-of-school time, such as over the summer.

Point-of-Care Hemoglobin A1C Testing System in Community Settings: Challenges, Opportunities, and Measurement Characteristics.

BACKGROUND: Point-of-care (POC) hemoglobin A1c (A1C) testing provides clinicians and diabetic patients real-time information on glycemic control. POC testing in community settings may expand reach, but feasibility is underexplored. We sought to describe challenges, opportunities, and quality control results of POC testing conducted in community food pantries. METHODS: Food bank staff who were directly involved in POC testing provided feedback in telephone interviews, weekly team calls, and quarterly open-ended surveys. We evaluated device performance using test-retest comparisons (n = 58) and comparisons between POC results and laboratory results from medical records (n = 72). LESSONS LEARNED: Study staff performed 1,771 POC A1c tests. Barriers were administrative, regulatory, and operational. Opportunities included ease of training and high participant satisfaction. There was high test-retest correlation (r = 0.97) and high correlation between POC results and laboratory results from medical records (r = 0.85). CONCLUSIONS: Community POC testing programs are feasible and relatively accurate, but implementation requires resources and capacity building. TRIAL REGISTRATION: This trial is registered at www.clinicaltrials.gov with identifier NCT02569060, registered October 6, 2015, https://clinicaltrials.gov/ct2/show/NCT02569060.

Diabetes-Related Health Care Utilization and Dietary Intake Among Food Pantry Clients.

Purpose: Consuming a diet appropriate for management of diabetes mellitus (DM) is challenging, particularly for adults with food insecurity (FI). DM-related health care services are thought to support better dietary intake. In this study, we explored associations between DM-related health care utilization and dietary intake among FI adults with DM. Methods: We used cross-sectional, baseline data (collected 2015-2016) from a trial designed to improve glycemic control among adult food pantry clients with DM. We examined intake of vegetables, fruit, sugar-sweetened beverages (SSBs), and desserts using the California Health Interview Survey dietary screener. We then examined adjusted associations between dietary intake and two components of DM-related health care utilization (<12 months vs. ≥12 months ago): self-reported visit to a health care provider for DM management and DM self-management education. Results: Among 523 participants (mean hemoglobin A1c 9.8%; body mass index 34.6 kg/m2; 17.0% uninsured), vegetable intake was more frequent in those reporting recent utilization of health care providers for DM management and DSME-related services (p<0.01), compared with those with less recent use. There was no association between intake frequency of fruit or SSBs and utilization of either DM-related service. Participants more recently utilizing DSME-related services consumed desserts more frequently (p=0.02). Relationships persisted after controlling for DM duration, race/ethnicity, education, health insurance, location, medication adherence, and depression. Conclusions: Among FI patients, DM-related services offered in clinical settings may more effectively increase vegetable consumption than decrease consumption of food and beverage items that can worsen glycemic control. Food pantry settings may provide an opportunity to reinforce dietary messaging.

State-Level and County-Level Estimates of Health Care Costs Associated with Food Insecurity.

INTRODUCTION: Food insecurity, or uncertain access to food because of limited financial resources, is associated with higher health care expenditures. However, both food insecurity prevalence and health care spending vary widely in the United States. To inform public policy, we estimated state-level and county-level health care expenditures associated with food insecurity. METHODS: We used linked 2011-2013 National Health Interview Survey/Medical Expenditure Panel Survey data (NHIS/MEPS) data to estimate average health care costs associated with food insecurity, Map the Meal Gap data to estimate state-level and county-level food insecurity prevalence (current though 2016), and Dartmouth Atlas of Health Care data to account for local variation in health care prices and intensity of use. We used targeted maximum likelihood estimation to estimate health care costs associated with food insecurity, separately for adults and children, adjusting for sociodemographic characteristics. RESULTS: Among NHIS/MEPS participants, 10,054 adults and 3,871 children met inclusion criteria. Model estimates indicated that food insecure adults had annual health care expenditures that were $1,834 (95% confidence interval [CI], $1,073-$2,595, P < .001) higher than food secure adults. For children, estimates were $80 higher, but this finding was not significant (95% CI, -$171 to $329, P = .53). The median annual health care cost associated with food insecurity was $687,041,000 (25th percentile, $239,675,000; 75th percentile, $1,140,291,000). The median annual county-level health care cost associated with food insecurity was $4,433,000 (25th percentile, $1,774,000; 75th percentile, $11,267,000). Cost variability was related primarily to food insecurity prevalence. CONCLUSIONS: Health care expenditures associated with food insecurity vary substantially across states and counties. Food insecurity policies may be important mechanisms to contain health care expenditures.

Nutrition-Focused Food Banking in the United States: A Qualitative Study of Healthy Food Distribution Initiatives.

BACKGROUND: Nutrition-focused food banking is broadly defined as organizational and programmatic efforts to address nutrition-related health disparities among charitable food clients. Additional information is needed to systematically describe how US food banks, as key influencers of the charitable food system, are working to advance nutrition-focused food banking initiatives in their communities. OBJECTIVE: Our aim was to describe food bank leadership-identified organizational strategies, "best practices," and innovative programs for advancing nutrition-focused food banking in the United States. DESIGN: We conducted semi-structured qualitative interviews to elicit information about the nutrition-focused food banking practices and processes being employed by US food banks. PARTICIPANTS/SETTING: Participants comprised a purposive sample of food bank executives (n=30) representing a diverse selection of food banks across the United States. Interviews were conducted between April 2015 and January 2017 at national food bank conferences. ANALYSIS: Two researchers independently reviewed transcripts to identify themes using code-based qualitative content analysis. RESULTS: Executive leader descriptions of specific strategies to support nutrition-focused food banking centered primarily around the following four major themes: building a healthier food inventory at the food bank; enhancing partner agency healthy food access, storage, and distribution capacity; nutrition education outreach; and expanding community partnerships and intervention settings for healthy food distribution, including health care and schools. CONCLUSIONS: Study findings indicate that food banks are implementing a variety of multilevel approaches to improve healthy food access among users of the charitable food system. Further evaluation is needed to assess the reach, scalability, and sustainability of these various approaches, and their effectiveness in reducing determinants of nutrition-related health disparities.

Characteristics of Households of People With Diabetes Accessing US Food Pantries: Implications for Diabetes Self-Management Education and Support.

PURPOSE: The purpose of this study is to explore the associations between food insecurity (FI) and coping strategies of relevance to diabetes self-management among households of people with diabetes (HHDM) who access US food pantry programs. METHODS: The authors conducted a secondary data analysis of HHDM accessing US food pantry programs from the Hunger in America 2014 study (n = 16 826). Weighted analyses included descriptive statistics for household sociodemographics, food pantry service utilization, FI, and coping behaviors. The authors used chi-square and logistic regression to estimate the relationship between FI and coping behaviors. RESULTS: Nearly one-half of HHDM reported visiting food pantries at least 6 times in the past year. Most HHDM were FI, with the majority experiencing the most severe form of FI. Over one-fifth of households reported lacking health insurance. The majority of HHDM reported purchasing inexpensive unhealthy foods to ensure household food adequacy, and many reported watering down food and beverages. The odds of reporting these behaviors significantly increased as FI worsened. CONCLUSION: Food pantries represent an opportunity for the delivery of community-based diabetes self-management education and support programs. These programs should be adapted to address population barriers to self-management and to support access to healthful foods and medical care.

Development and testing of the FRESH Foods Survey to assess food pantry clients' dietary behaviours and correlates.

OBJECTIVE: To use cognitive interviewing and pilot testing to develop a survey instrument feasible for administering in the food pantry setting to assess daily intake frequency from several major food groups and dietary correlates (e.g. fruit and vegetable barriers) - the FRESH Foods Survey. DESIGN: New and existing survey items were adapted and refined following cognitive interviews. After piloting the survey with food pantry users in the USA, preliminary psychometric and construct validity analyses were performed. SETTING: Three US food banks and accompanying food pantries in Atlanta, GA, San Diego, CA, and Buffalo, NY. PARTICIPANTS: Food pantry clients (n 246), mostly female (68 %), mean age 54·5 (sd 14·7) years. RESULTS: Measures of dietary correlates performed well psychometrically: Cronbach's α range 0·71-0·90, slope (α) parameter range 1·26-6·36, and threshold parameters (ß) indicated variability in the 'difficulty' of the items. Additionally, all scales had only one eigenvalue above 1·0 (range 2·07-4·71), indicating unidimensionality. Average (median, Q1-Q3) daily intakes (times/d) across six dietary groups were: fruits and vegetables (2·87, 1·87-4·58); junk foods (1·16, 0·58-2·16); fast foods and similar entrées (1·45, 0·58-2·03); whole-grain foods (0·87, 0·58-1·71); sugar-sweetened beverages (0·58, 0·29-1·29); milk and milk alternatives (0·71, 0·29-1·29). Significant correlations between dietary groups and dietary correlates were largely in the directions expected based on the literature, giving initial indication of convergent and discriminant validity. CONCLUSIONS: The FRESH Foods Survey is efficient, tailored to food pantry populations, can be used to monitor dietary behaviours and may be useful to measure intervention impact.

Effects Of Alternative Food Voucher Delivery Strategies On Nutrition Among Low-Income Adults.

Nutrition assistance programs are the subject of ongoing policy debates. Two proposals remain uninformed by existing evidence: whether restricting benefits to allow only fruit and vegetable purchases improves overall dietary intake, and whether more frequent distribution of benefits (weekly versus monthly) induces more fruit and vegetable consumption and less purchasing of calorie-dense foods. In a community-based trial, we randomly assigned participants to receive food vouchers that differed in what foods could be purchased (fruit and vegetables only or any foods) and in distribution schedule (in weekly or monthly installments, holding total monthly value constant). The use of vouchers for fruit and vegetables only did not yield significantly greater improvements than the unrestricted voucher did in terms of fruit and vegetable consumption or Healthy Eating Index (HEI) score. Weekly vouchers also failed to yield significantly greater improvements than monthly vouchers did. Proposed policies to make assistance more restricted or more frequent, while holding benefit value constant, might not improve nutrition among low-income Americans.