The evolution and scope of Medicaid Section 1115 demonstrations to address nutrition: a US survey.

Poor nutrition and food insecurity are drivers of poor health, diet-related diseases, and health disparities in the U.S. State Medicaid Section 1115 demonstration waivers offer opportunities to pilot food-based initiatives to address health outcomes and disparities. Several states are now leveraging 1115 demonstrations, but the scope and types of utilization remain undefined. To fill this gap, we conducted a systematic analysis of state Medicaid Section 1115 applications and approvals available on Medicaid.gov through July 1, 2023. We found that 19 approved and pending 1115 waivers address nutrition, with 11 submitted or approved since 2021. Fifteen states provide or propose to provide screening for food insecurity, referral to food security programs, and/or reporting on food security as an evaluation metric. Thirteen provide or propose to provide coverage of nutrition education services. Ten provide or propose to provide direct intervention with healthy food. The primary target populations of these demonstrations are individuals with chronic diet-sensitive conditions, mental health or substance use disorders, and/or who are pregnant or post-partum. Since 2021, state utilization of Medicaid 1115 demonstrations to address nutrition has accelerated in pace, scope, and population coverage. These findings and trends have major implications for addressing diet-related health and healthy equity in the United States.

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.

A Case for Using Electronic Health Record Data in the Evaluation of Produce Prescription Programs.

Produce prescription programs within clinical care settings can address food insecurity by offering financial incentives through "prescriptions" for fruits and vegetables to eligible patients. The electronic health record (EHR) holds potential as a strategy to examine the relationship between these projects and participant outcomes, but no studies address EHR extraction for programmatic evaluations. We interviewed representatives of 9 grantees of the U.S. Department of Agriculture's Gus Schumacher Nutrition Incentive Grant Program's Produce Prescription Projects (GusNIP PPR) to understand their experiences with and capacity for utilizing EHR for evaluation. Five grantees planned to use EHR data, with 3 main strategies: reporting aggregate data from health clinics, contracting with external/third party evaluators, and accessing individual-level data. However, utilizing EHRs was prohibitive for others due to insufficient knowledge, training and/or staff capacity; lack of familiarity with the Institutional Review Board process; or was inappropriate for select target populations. Policy support for produce prescription programs requires a robust evidence base, deep knowledge of best practices, and an understanding of expected health outcomes. These insights can be most efficiently and meaningfully achieved with EHR data, which will require increased financial support and technical assistance for project operators.

Social Determinants of Health: Underreported Heterogeneity in Systematic Reviews of Caregiver Interventions.

BACKGROUND AND OBJECTIVES: Although most people have some experience as caregivers, the nature and context of care are highly variable. Caregiving, socioeconomic factors, and health are all interrelated. For these reasons, caregiver interventions must consider these factors. This review examines the degree to which caregiver intervention research has reported and considered social determinants of health. RESEARCH DESIGN AND METHODS: We examined published systematic reviews and meta-analyses of interventions for older adults with age-related chronic conditions using the PRISMA and AMSTAR 2 checklists. From 2,707 papers meeting search criteria, we identified 197 potentially relevant systematic reviews, and selected 33 for the final analysis. RESULTS: We found scant information on the inclusion of social determinants; the papers lacked specificity regarding race/ethnicity, gender, sexual identity, socioeconomic status, and geographic location. The majority of studies focused on dementia, with other conditions common in later life vastly underrepresented. DISCUSSION AND IMPLICATIONS: Significant gaps in evidence persist, particularly for interventions targeting diverse conditions and populations. To advance health equity and improve the effectiveness of interventions, research should address caregiver heterogeneity and improve assessment, support, and instruction for diverse populations. Research must identify aspects of heterogeneity that matter in intervention design, while recognizing opportunities for common elements and strategies.

Effect of a Fruit and Vegetable Prescription Program on Children's Fruit and Vegetable Consumption.

INTRODUCTION: Most children in families with low income do not meet dietary guidance on fruit and vegetable consumption. Fruit and vegetable prescription programs improve access to and affordability of health-supporting foods for adults, but their effect on dietary behavior among children is not known. The objective of this study was to describe the extent to which exposure to a fruit and vegetable prescription program was associated with changes in consumption among participants aged 2 to 18. METHODS: We used data from a modified National Cancer Institute screener to calculate fruit and vegetable intake among 883 children who were overweight or had obesity and participated in a 4- to 6-month fruit and vegetable prescription program at federally qualified health centers during 4 years (2012-2015). Secondary analyses in 2017 included paired t tests to compare change in fruit and vegetable consumption (cups/day) between first and last visits and multivariable linear regressions, including propensity dose-adjusted models, to model this change as a function of sociodemographic and program-specific covariates, such as number of clinical visits and value of prescription redemption. RESULTS: We found a dose propensity-adjusted increase of 0.32 cups (95% confidence interval, 0.19-0.45 cups) for each additional visit while holding constant the predicted number of visits and site. An equal portion of the change-score increase was attributed to vegetable consumption and fruit consumption (ß = 0.16 for each). CONCLUSION: Fruit and vegetable prescription programs in clinical settings may increase fruit and vegetable consumption among children in low-income households. Future research should use a comparison group and consider including qualitative analysis of site-specific barriers and facilitators to success.

A Pediatric Fruit and Vegetable Prescription Program Increases Food Security in Low-Income Households.

OBJECTIVE: To assess change in household food security associated with participation in a pediatric fruit/vegetable prescription program. METHODS: The researchers analyzed clinic-based, fruit/vegetable prescription program data for 578 low-income families, collected in 2013-2015, and calculated changes in food security (summative score; high/low/very low; and individual US Department of Agriculture measures). RESULTS: Of participating households, 72% increased their summative score over the course of the program. In adjusted regression models, participants had higher change scores with 5 or 6 clinical visits, compared with 1 or 2 visits (ß = .07; 95% confidence interval, 0.01-0.14), and college education of the primary caretaker, compared with less than college (ß = .05; 95% confidence interval, 0.01-0.09). Select clinic sites (but neither visit nor redemption proportions) significantly contributed to change score variance. All US Department of Agriculture measures saw significant increases. CONCLUSIONS AND IMPLICATIONS: Fruit/vegetable prescription programs may help providers address patients' food insecurity. Further research using experimental designs and implementation science could build the case to incorporate programs into practice.