Protocol for the Support Application for Food PAntrieS trial: design, implementation, and evaluation plan for a digital application to promote healthy food access and support food pantry operations.

Introduction: Food-insecure households commonly rely on food pantries to supplement their nutritional needs, a challenge that was underscored during the COVID-19 pandemic. Food pantries, and the food banks that supply them, face common challenges in meeting variable client volume and dietary needs under normal and emergency (e.g., pandemic, natural disaster) conditions. A scalable digital strategy that has the capacity to streamline the emergency food distribution system, while promoting healthy food options, managing volunteer recruitment and training, and connecting to emergency management systems in times of need, is urgently required. To address this gap, we are developing a working mobile application (app) called the Support Application for Food PAntrieS (SAFPAS) and will evaluate its feasibility and impact on food pantry staff preparedness, stocking, and client uptake of healthful foods and beverages in two urban United States settings. Methods: This paper describes the protocol for a randomized controlled trial of the SAFPAS mobile application. We will conduct formative research in Baltimore, Maryland and Detroit, Michigan to develop and refine the SAFPAS app and increase scalability potential to other urban settings. Then we will test the app in 20 food pantries in Baltimore randomized to intervention or comparison. The impact of the app will be evaluated at several levels of the emergency food system, including food pantry clients (n = 360), food pantry staff and volunteers (n = 100), food pantry stock, and city agencies such as the local food bank and Office of Emergency Management. The primary outcome of the SAFPAS trial is to improve the healthfulness of the foods received by food pantry clients, measured using the Food Assessment Scoring Tool (FAST). Post-trial, we will conduct additional formative research in Detroit to prepare the app for scale-up. Discussion: We anticipate that SAFPAS will improve alignment in the supply and demand for healthy foods among food pantry clients, food pantries, and city agencies which supply food in Baltimore. Real-time, bidirectional communication between entities across the system allows for increased situational awareness at all levels during normal and emergency operations. By conducting formative research in Detroit, we hope to increase the scalability of the SAFPAS app to additional settings nationwide. Clinical trial registration: NCT87654321. https://classic.clinicaltrials.gov/ct2/show/NCT05880004.

Construct validity of the Charitable Food Nutrition Index.

Background: Food pantries are an important source of food for those facing food insecurity. The Charitable Food Nutrition Index (CFNI) was developed for research and practice to measure the nutritional quality of assortments of foods in this setting. Objective: The study assessed the construct validity of the CFNI using secondary data from a group-randomized food pantry intervention in Minnesota. Methods: The CFNI was calculated for each client cart post-intervention (n = 187; 85 intervention, 102 control). CFNI scores were based on the proportion of items in each client cart ranked "green," "yellow," or "red" using the Healthy Eating Research Nutrition Guidelines for the Charitable Food System. An implementation score assessing intervention fidelity was measured for each pantry (n = 11; 5 intervention, 6 control) based on the four intervention subcomponents: aesthetics/use of space; healthy food prominence and appeal; unhealthy food de-emphasis; and stocking standards. Mixed linear models were used to test whether: (a) client carts from pantries in the intervention condition had higher CFNI scores than those in the control condition, and (b) higher implementation scores were associated with higher CFNI scores. Results: In adjusted models, clients from intervention group pantries had higher CFNI scores, reflecting a healthier assortment of foods compared with clients from control group pantries (p = 0.022). CFNI scores were positively associated with greater fidelity to the intervention (p = 0.020). Conclusions: The CFNI was sensitive enough to detect the effects of the intervention in the expected directions. These findings support its construct validity and utility as a measure in the charitable food system.

Evaluating a Campus Food Pantry's Potential Impact on Nutrition Security using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework.

Background: Campus food pantries are uniquely positioned to promote health equity with the foods they make accessible to food-insecure students. Objectives: This study assessed the implementation and effectiveness of a client-choice campus food pantry to understand its potential impact on nutrition security and to inform future implementation. Methods: This observational study was designed using the reach, effectiveness, adoption, implementation, and maintenance framework, leveraging administrative data collected from a client-choice campus food pantry at a large Midwest university from August 2020 to May 2022. Pantry staff tracked student usage and item inventory. Items were analyzed for specific nutrients using the Nutrition Data System for Research. The mean nutrients and servings per food group distributed per visit were calculated and compared with dietary recommendations (effectiveness). Characteristics of pantry operation and setup were detailed (adoption). The percentage of openings with adequate stock to meet distribution guidelines was determined (implementation). Descriptive statistics were calculated, and multiple linear regressions determined whether significant changes in nutrients and food were distributed based on distribution guidelines and stock available. Results: Effectiveness: Vitamin D, fruits, vegetables, and whole grains were below 3 d of the recommended intake for all students, and energy, fiber, potassium, vitamin A, and grains were low for male students. Adoption: The pantry was established through a collaboration with a pre-existing community food pantry and operates as a 501(c) and is managed by campus recreation staff. Implementation: The pantry supplied enough produce for 72% of openings to meet distribution guidelines and enough dairy for 63% of openings. Conclusions: The food and nutrients distributed in limited amounts are consistent with those underconsumed according to the Dietary Guidelines for Americans. More research is needed to understand how pantry implementation can best support nutrition security through the adequate distribution of key nutrients and food groups.

Food Pantry Clients' Needs, Preferences, and Recommendations for Food Pantries: A Qualitative Study.

A qualitative formative approach was used to explore food pantry clients' needs, preferences, and recommendations regarding food received from food pantries. Fifty adult clients of six Arkansas food pantries were interviewed in English, Spanish, or Marshallese. Data analysis used the constant comparative qualitative methodology. In choice and minimal choice pantries, three themes emerged: clients need increased quantities of food, particularly more proteins and dairy; clients desire higher quality food, including healthy food and food not close to expiration; and clients desire familiar foods and food appropriate for their health needs. System level policy changes are needed to address clients' recommendations.

Evaluation of US Department of Agriculture Foods Programs for Households Using Nutrition Guidelines for the Charitable Food System.

BACKGROUND: US Department of Agriculture (USDA) Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) are designed to provide nutritious foods at no cost to income-eligible individuals in the United States. OBJECTIVE: Our aim was to evaluate the nutritional quality of the foods available from 3 USDA Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) according to the Healthy Eating Research (HER) Guidelines for the Charitable Food System. DESIGN: Review of the nutritional information of the foods available from USDA Foods programs for households was performed. Using the HER Guidelines, foods were categorized into a 3-tiered system (ie, choose often/green; choose sometimes/yellow; choose rarely/red) based on levels of saturated fat, sodium, and added sugar per serving, and presence of whole grains. SETTING: All unique foods available from The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program (n = 152) for fiscal year 2022 were evaluated. MAIN OUTCOME MEASURES: Nutritional quality of the foods available from USDA Foods programs for households according to the HER guidelines was measured. Foods were ranked green, yellow, red, or not ranked. STATISTICAL ANALYSES PERFORMED: The proportion of foods in each HER Guidelines' rank was calculated across the 3 USDA Foods programs for households and by each program. RESULTS: The majority of USDA Foods were ranked green (57.3%) or yellow (35.5%). A small number of items were ranked red (3.3%) or were unranked condiments or cooking staples (3.9%). CONCLUSIONS: The USDA Foods available in the household programs were primarily fruits and vegetables; lean proteins; whole grains; and low-fat dairy products that were consistent with national dietary guidelines. There is some room for improvement, and adjustments in the specifications for certain items are recommended to strengthen the nutritional value of the foods provided through these important federal programs.

A food bank program to help food pantries improve healthy food choices: mixed methods evaluation of The Greater Boston Food Bank's Healthy Pantry Program.

BACKGROUND: The Greater Boston Food Bank's (GBFB) Healthy Pantry Program (HPP) is an online training that teaches food pantry staff to implement behavioral nudges (e.g., traffic-light nutrition labels, choice architecture) to promote healthier client choices. This study assessed if HPP was associated with healthier food bank orders by food pantries and identified implementation facilitators and barriers. METHODS: This mixed methods study collected quantitative data from a matched cohort of 10 HPP food pantries and 99 matched control food pantries in eastern Massachusetts that allow clients to choose their own food, and qualitative data from structured individual interviews with 8 HPP pantry staff. A difference-in-differences analysis compared changes in percentage of pantries' food bank orders (by weight) of foods labeled green/yellow (healthier choices) and fresh produce from baseline to 6 and 10 months between HPP and control pantries. Interviews were coded for implementation facilitators and barriers. RESULTS: Before starting HPP, green-yellow ordering was 92.0% (SD 4.9) in control and 87.4% (SD 5.4) in HPP pantries. Participation in HPP was not associated with changes in green-yellow or fresh produce ordering at 6 or 10 months. HPP implementation facilitators included HPP training being accessible (sub-themes: customizable, motivating) and compatible with client-choice values. Barriers included resource limitations (sub-themes: staff shortage, limited space) and concerns about stigmatizing client food choices with use of labels for unhealthy foods. CONCLUSIONS: An online program to help pantries promote healthier client choices was not associated with changes in how much healthy food pantries ordered from the food bank, suggesting it did not substantially change client choices. Implementation challenges and high baseline healthy ordering may have influenced HPP's effectiveness.

Validating a Nutrition Ranking System for Food Pantries Using the Healthy Eating Index-2015.

In 2020, charitable food organizations began adopting Healthy Eating Research (HER) nutrition guidelines, which rank individual foods in tiers (e.g., green, yellow, or red) based on each food's nutrient profile. This study aimed to validate this HER tier-ranked system against the Healthy Eating Index-2015 (HEI) and develop a formula to summarize the percentages of tier-ranked foods in an overall nutritional quality index that correlated with HEI. Using secondary data of foods selected by clients in 16 Minnesota food pantries (n = 503 "client carts"), we generated an HEI score and percentages of green, yellow, and red foods for each cart. As validation, we tested the association between HEI scores and the percentages of tier-ranked foods and compared the means of the tier-ranked variables using quintiles of the HEI scores. HEI scores were positively associated with percentages of green foods and negatively associated with percentages of red foods. Next, we used statistical learning to generate weights to maximize the correlation of the tier-ranked variables and the HEI scores and used these weights to create an index. The index demonstrated a moderate-to-strong correlation with HEI and can be used as a single measure to summarize the overall nutritional quality for sets of tier-ranked foods.

A randomized study of food pantry environment-level change following the SuperShelf intervention.

The charitable food system is rapidly evolving. Interventions that target the food pantry environment and use behavioral economics are in high demand, but can be difficult to implement in a low-resource setting. This is an analysis of secondary, environment-level outcomes in a food pantry intervention (SuperShelf); the study evaluates whether the intervention resulted in measurable changes to the food pantry environment and improved diet quality of the food available to clients, compared with a control group of food pantries. Eleven food pantries were randomized to an intervention (n = 5) or control (n = 6) condition and completed baseline and one-year follow-up measures between 2018 and 2020. The intervention addressed healthy food supply and the appeal of healthy foods using behavioral economics. Assessments included manager surveys, intervention fidelity, food inventory, and food supply tracked over 5 days. Measures included change in intervention fidelity (range 0-100) with four subcomponents; Healthy Eating Index scores (HEI-2015, range 0-100) with 13 subcomponents; and Food Assortment Scoring Tool scores (FAST, range 0-100). Descriptive analyses and t-tests examined pre-post changes within and between intervention arms. Average fidelity scores increased from baseline to follow-up in the intervention group compared with the control group (p < .001), as did FAST scores (p = .02). Average HEI-2015 Total scores increased in the intervention group by 6.3 points and by 1.6 points in the control group, but the difference in change between groups was not statistically significant (p = .56). The intervention was implemented with high fidelity at five sites, with some evidence of change in the nutritional quality of the food available on the shelf to clients.

Impact of Enhanced Food Pantry Services on Food Security among Adults with Diabetes Using a Crossover Study Design.

Food banks and pantries provide food to millions of food-insecure households each year. However, there has been limited research to understand the extent to which they improve food security. This is a secondary, prespecified analysis of a randomized controlled trial (ClinicalTrials.gov ID: NCT02569060). We examined whether an enhanced food bank intervention impacted the food security status of adults with diabetes. Using a crossover design, participants (n = 568) were randomly assigned to receive the intervention (usual pantry services plus twice-monthly diabetes-specific food boxes, diabetes self-management education, health care referrals, and glucose monitoring) or 6 mo of usual services. Results demonstrate a statistically significant improvement in food insecurity among participants following the intervention phase compared with the control phase (mean: 0.49-point decrease; 95% CI: 0.21, 0.77; P = 0.0006). This finding adds to evidence that the charitable food system plays an important role in mitigating short-term food insecurity for adults with diabetes.

US state variations in food bank donation policy and implications for nutrition.

Food insecurity has increased dramatically in 2020 as a result of the COVID-19 public health and economic crisis. Many more families in the United States are turning to the charitable food system to help meet their needs. However, little is known about the policies that influence food bank donations and whether they promote healthy food donations. The purpose of this study was to explore state variation in food donation policies and secondarily to assess whether policies promoted the donation of healthy foods and beverages. We reviewed donation policies for all states in the United States and Washington, DC (hereafter "states") in fall 2020. Two reviewers independently assessed donation policies using two legal databases; we reconciled discrepancies via team discussion. We then grouped them into 10 distinct categories based on common purpose and theme. We identified 252 state policies from 51 states. Policies fell into all 10 categories. The largest category was "liability protection," with all states having a policy in this category. The second largest category was date labeling; 32 states had requirements or policies restricting the donation of past-dated foods. However, across all categories, we found that only two policies explicitly promoted the donation of healthy foods and beverages. Although all states had some policies governing food donations, few promoted healthier foods and beverages. States could encourage healthy donations through policy to help ensure that all families have access to nutritious foods and beverages.

Food pantries select healthier foods after nutrition information is available on their food bank's ordering platform.

OBJECTIVE: In the USA, community-based food pantries provide free groceries to people struggling with food insecurity. Many pantries obtain food from regional food banks using an online shopping platform. A food bank introduced a visible nutrition rank (i.e. green, yellow or red) onto its platform. The hypothesis was that pantry orders would increase for the healthiest options (green) and decrease for the least healthy options (red). DESIGN: Interrupted time series (ITS) analysis of a natural experiment. Monthly data included nutrition ranks of available inventory and itemised records of all products ordered during the 15-month baseline period and 14-month intervention. SETTING: A New England food bank. PARTICIPANTS: The twenty-five largest food pantries in the network based on pounds of food ordered. RESULTS: Descriptive analyses of 63 922 pantry ordering records before and after the visible ranks identified an increase in the proportion of green items ordered (39·3-45·4 %) and a decrease in the proportion of red items ordered (10·5-5·1 %). ITS analyses controlling for monthly changes in inventory available and pantry variables indicated that average monthly orders of green items increased by 1286 pounds (P < 0·001) and red orders decreased by 631 pounds (P = 0·045). Among the largest changes were increases in orders of fresh produce, brown rice, low-fat dairy and low-fat meats and decreases in orders of sugary juice drinks, canned fruit with added sugar, higher fat dairy and higher fat meats. CONCLUSIONS: This promising practice can support system-wide efforts to promote healthier foods within the food banking network.

Gratitude, resignation and the desire for dignity: lived experience of food charity recipients and their recommendations for improvement, Perth, Western Australia.

OBJECTIVE: The present study explored recipients' perceptions of food charity and their suggested improvements in inner-city Perth, Western Australia. DESIGN: In-depth interviews were conducted with charitable food service (CFS) recipients. Transcripts were thematically analysed using a phenomenological approach. SETTING: Interviews were conducted at two CFS in inner-city Perth. SUBJECTS: Fourteen adults. RESULTS: The recipients' journeys to a reliance on CFS were varied and multifactorial, with poverty, medical issues and homelessness common. The length of time recipients had relied on food charity ranged from 8 months to over 40 years. Most were 'grateful yet resigned', appreciative of any food and resigned to the poor quality, monotony and their unmet individual preferences. They wanted healthier food, more variety and better quality. Accessing services was described as a 'full-time job' fraught with unreliable information and transport difficulties. They called for improved information and assistance with transport. 'Eroded dignity' resulted from being fed without any choice and queuing for food in public places, often in a volatile environment. 'Food memories and inclusion' reflected a desire for commensality. Recipients suggested services offer choice and promote independence, focusing on their needs both physical and social. CONCLUSIONS: Although grateful, long-term CFS recipients described what constitutes a voluntary failure. Their service improvement recommendations can help meet their nutritional and social needs. A successful CFS provides a food service that prioritises nutritious, good-quality food and individual need, while promoting dignity and social inclusion, challenging in the current Australian context.