Eliminating Food Insecurity in the USA: a Target Trial Emulation Using Observational Data to Estimate Effects on Health-Related Quality of Life.

BACKGROUND: Food insecurity is associated with many aspects of poor health. However, trials of food insecurity interventions typically focus on outcomes of interest to funders, such as healthcare use, cost, or clinical performance metrics, rather than quality of life outcomes that may be prioritized by individuals who experience food insecurity. OBJECTIVE: To emulate a trial of a food insecurity elimination intervention, and quantify its estimated effects on health utility, health-related quality of life, and mental health. DESIGN: Target trial emulation using longitudinal, nationally representative data, from the USA, 2016-2017. PARTICIPANTS: A total of 2013 adults in the Medical Expenditure Panel Survey screened positive for food insecurity, representing 32 million individuals. MAIN MEASURES: Food insecurity was assessed using the Adult Food Security Survey Module. The primary outcome was the SF-6D (Short-Form Six Dimension) measure of health utility. Secondary outcomes were mental component score (MCS) and physical component score (PCS) of the Veterans RAND 12-Item Health Survey (a measure of health-related quality of life), Kessler 6 (K6) psychological distress, and Patient Health Questionnaire 2-item (PHQ2) depressive symptoms. KEY RESULTS: We estimated that food insecurity elimination would improve health utility by 80 QALYs per 100,000 person-years, or 0.008 QALYs per person per year (95% CI 0.002 to 0.014, p = 0.005), relative to the status quo. We also estimated that food insecurity elimination would improve mental health (difference in MCS [95% CI]: 0.55 [0.14 to 0.96]), physical health (difference in PCS: 0.44 [0.06 to 0.82]), psychological distress (difference in K6: -0.30 [-0.51 to -0.09]), and depressive symptoms (difference in PHQ-2: -0.13 [-0.20 to -0.07]). CONCLUSIONS: Food insecurity elimination may improve important, but understudied, aspects of health. Evaluations of food insecurity interventions should holistically investigate their potential to improve many different aspects of health.