Cumulative environmental stress and emerging cardiometabolic risk during childhood.

OBJECTIVE: To prospectively evaluate the relationship between cumulative environmental stress and cardiometabolic risk in middle childhood, and to examine whether hair cortisol, a measure of hypothalamic pituitary adrenal-axis activity, mediates this relationship. METHODS: In a cohort of children from low-income households (n = 320; 59% Hispanic, 23% Black, body mass index (BMI) percentile >50th at enrollment), environmental stressors including family and neighbourhood factors representing disadvantage/deprivation, and cortisol concentrations from hair samples, were measured over five timepoints beginning when children were 2-4 years old. Cardiometabolic risk factors (i.e., BMI, blood pressure, lipids, blood sugar, C-reactive protein) were measured at the final timepoint when children were 7-11 years of age. RESULTS: In adjusted logistic regression models, greater cumulative environmental stress was associated with a higher likelihood of elevated cardiometabolic risk in middle childhood (p = 0.01). Children from minoritized racial/ethnic groups had a higher prevalence of both stressors and cardiometabolic risk factors. Cumulative environmental stress was associated with higher hair cortisol concentrations (p < 0.01). However, hair cortisol was not directly associated with cardiometabolic risk factors and did not explain the association between environmental stress and cardiometabolic risk in causal mediation analysis. CONCLUSIONS: The influence of cumulative stress on cardiometabolic health can be observed in middle childhood and may contribute to cardiometabolic health disparities, highlighting the importance of public health interventions to mitigate disadvantage.

The Relationship between Household SNAP Participation, Parent Feeding Styles, and Child Eating Behaviors.

This cross-sectional analysis of the Minnesota Now Everybody Together for Amazing Healthful Kids (NET-Works) study evaluated whether SNAP participation was associated with specific parental feeding styles and child eating behaviors. Associations between parent-reported feeding styles and child eating behaviors and SNAP participation were examined using multiple linear regression analyses and responses from 534 parent/child dyads (49.1% female children, 91.7% female parents). SNAP participation was not associated with specific feeding styles or child eating behaviors when adjusting for food insecurity, timing in SNAP cycle, and other covariates in this large, ethnically and racially diverse sample of predominantly mothers and preschool-aged children. Other factors, such as food insecurity, not SNAP participation, may influence parental feeding and child eating behaviors, and screening by health care providers is recommended.

Effects of Inclusion of Food Purchase Restrictions and Incentives in a Food Benefit Program on Diet Quality and Food Purchasing: Results From a Randomized Trial.

BACKGROUND: There is interest in reshaping the Supplemental Nutrition Assistance Program (SNAP) to better support family nutrition. OBJECTIVE: The Grocery Assistance Program Study (GAPS) for Families evaluated the effects of prohibiting using program funds for the purchase of certain sugary foods on the nutritional quality of foods purchased and consumed by program participants. DESIGN: A randomized experimental trial was carried out with participants randomized to one of three food benefit conditions. Baseline and follow-up measures collected included interviewer-administered 24-hour dietary recalls, food purchase receipts, food security, height, and weight. PARTICIPANT/SETTING: Adult-child dyads in households eligible for SNAP but currently not enrolled were recruited from the Minneapolis/St Paul MN metropolitan area from May of 2018 through May of 2019. A total of 293 adult-child dyads received the intervention as allocated. Of these dyads, 233 adults completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 20.5%. A total of 224 children completed follow-up measures and met criteria for inclusion in the analytic sample, resulting in an attrition rate of 23.5%. INTERVENTION: Participants were randomized to 1 of 3 conditions: restriction (not allowed to buy sugar-sweetened beverages [SSB], sweet baked goods, or candy with program funds); restriction paired with incentive (30% incentive for fruits and vegetables [FV] purchased with funds); and control (funds provided with no restrictions or incentives). Funds were provided on a 4-week cycle for 20 weeks via a study-provided debit card. MAIN OUTCOME MEASURES: The primary outcome was the Healthy Eating Index (HEI)-2015 total score. Additional outcomes included selected HEI-2015 component scores; energy intake; food security; body weight; and purchasing of SSB, sweet baked goods, candies, fruits, and vegetables. STATISTICAL ANALYSIS: Linear regression analyses were conducted with change in the outcome regressed on treatment condition for the primary outcome analyses. RESULTS: No differences were observed between conditions in change in the nutrition and food security measures examined. Purchases of SSB and sweet baked goods and candies significantly differed by experimental condition. Purchase of restricted foods was lower at follow-up in the restriction and restriction paired with incentive conditions compared with the control condition. For example, spending on SSB at follow-up was significantly lower in the restriction ($2.66/week) and restriction paired with incentive ($2.06/week) conditions in comparison with control condition ($4.44/week) (P < 0.0003 and P < 0.0001, respectively). CONCLUSIONS: This study failed to find evidence in support of prohibiting the purchase of sugary foods with food program funds as a strategy to improve program participant nutrition, even when paired with an FV incentive. Research carried out in the context of the SNAP program is needed for a more robust evidence base.

Body Mass Index Trajectories and Biomarkers of Cardiometabolic Risk in Children from Low-Income and Racially and Ethnically Diverse Households.

Background: This study examined the associations between BMI trajectories and emerging cardiometabolic risk (CMR) in children living in low-income and racially and ethnically diverse households in the United States. Methods: Data were drawn from NET-Works randomized intervention trial and NET-Works 2 prospective follow-up study (N = 338). BMI was measured across 6 follow-up visits and biomarkers of cardiometabolic risk (CMR) at the sixth visit. Group-based trajectory modeling identified child BMI trajectories. Adjusted multivariable linear regressions evaluated the associations between BMI trajectories and CMR. Results: We identified two BMI trajectories: 25% followed a trajectory of steep BMI increase, and 75% followed a moderate decreasing BMI trajectory over time. Relative to children in the moderate decreasing trajectory, children in the increasing trajectory had higher adjusted mean levels of C-reactive protein [CRP; 3.3; 95% confidence interval (CI): 1.6 to 5.0], leptin (63.1; 95% CI: 44.3 to 81.8), triglycerides (35.4; 95% CI: 22.1 to 48.6), triglyceride/high-density lipoprotein (HDL) ratio (1.2; 95% CI: 0.8 to 1.6), hemoglobin A1c (HbA1C; 0.1; 95% CI: 0.03 to 0.2), fasting glucose (1.8; 0.1 to 3.5) and insulin (8.8; 95% CI: 6.5 to 11.0), overall CMR score (0.7; 95% CI: 0.5 to 0.9), and lower adiponectin (-1.3; 95% CI: -2.5 to -0.1) and HDL (-10.8; 95% CI: -14.3 to -7.4). Conclusions: Children with high BMIs early in childhood were more likely to maintain an accelerated BMI trajectory throughout childhood, which was associated with adverse CMR in pre-adolescence. To advance health equity and support children's healthy weight and cardiovascular health trajectories, public health efforts are needed to address persistent disparities in childhood obesity and CMR.

NET-Works paediatric obesity prevention trial: 66 month outcomes.

BACKGROUND AND OBJECTIVES: The NET-Works trial (2012-2018) randomized 534 children ages 2-4 years at baseline and their caregivers to either a 3-year multicomponent obesity prevention intervention or a control group. This research examined treatment effects on body mass index and other outcomes at 66 months. METHODS: Parent-child dyads (n = 338) who agreed to participate in a 66 month measurement visit were measured for child BMI, physical activity, diet, and cardiometabolic risk factor variables. RESULTS: At 66 months, no significant treatment effects were observed on BMI (Effect = -0.38; 95% CI = -1.13, 0.37). Subgroup results were consistent with the NET-Works 36 month results. Children with overweight at baseline in the intervention group gained significantly less BMI versus children with overweight in the control group (Effect = -1.28; 95% CI = -2.48, -0.07). Among Hispanic children, those in the intervention gained significantly less BMI than those in the control group (Effect = -1.04; 95% CI = -1.97, -0.11). CONCLUSIONS: Evidence suggests that early intervention with children at highest risk for obesity, using community-based, multicomponent, multisetting interventions, may be effective in reducing excess weight gain and obesity among certain subgroups of children. The intervention appeared to be effective in slowing BMI gain 66 months after randomization among children who were already overweight at ages 2-4 years and among children of Hispanic ethnicity.

Is economic hardship associated with young children's cortisol levels?

Economic hardship during childhood has been linked to poor physical and mental health. This study examines cross-sectional and longitudinal associations of a summed economic hardship score of poverty, food insecurity, and financial hardship with hair cortisol in young children. Data from 24-month (Time 1, mean age 5 years) and 36-month (Time 2, mean age 6 years) follow-up from the NET-Works obesity prevention trial (NET-Works, NCT0166891) were used. Hair cortisol measures obtained at each time point were log-transformed and regressed on economic hardship at Time 1 and a cumulative economic hardship from Time 1 to Time 2, using generalized linear regressions. All models were adjusted for child age, sex, race/ethnicity, and intervention (prevention vs. control) arm. The final analytic sample sizes ranged from 248 to 287. Longitudinal analyses indicated that for every 1-unit higher economic hardship score at Time 1, hair cortisol at Time 2 follow-up was on average 0.07 log-picograms per milligram (pg/mg) higher (95% confidence interval [CI]: 0.01, 0.13). For every 1-unit increase in the cumulative economic hardship score between Time 1 and 2, there was a 0.04 log-pg/mg (95% CI: 0.00, 0.07) average higher level of hair cortisol at Time 2 follow-up. Results show suggestive but limited evidence for an association between economic hardship and cortisol in young children.

Household Income, Cortisol, and Obesity During Early Childhood: A Prospective Longitudinal Study.

OBJECTIVE: To prospectively evaluate the relationship between household income, children's cortisol, and body mass index (BMI) trajectories over a 3-year period in early childhood. STUDY DESIGN: Household income, child hair cortisol levels, and BMI were measured at baseline, 12-, 24-, and 36-month follow-up visits in the Now Everybody Together for Amazing and Healthful Kids (NET-Works) Study (n = 534, children ages 2-4 years, and household income <$65 000/year at baseline). Relationships were examined between very low household income (<$25 000/year) at baseline, income status over time (remained <$25 000/year or had increasing income), cortisol accumulation from hair samples, and BMI percent of the 95th percentile (BMIp95) trajectories using adjusted linear growth curve modeling. Households with baseline income between $25 000 and $65 000/year were the reference group for all analyses. RESULTS: Children from very low-income households at baseline had annual changes in BMIp95 that were higher (P < .001) than children from reference group households (0.40 vs -0.62 percentage units/year). Annual increases in BMIp95 were also greater among children from households that remained very low income (P < .01, .34 percentage units/year) and among those with increasing income (P = .01, .51 percentage units/year) compared with the reference group (-0.61 percentage units/year). Children from households that remained very low income had higher hair cortisol accumulations (0.22 pg/mg, P = .02) than reference group children, whereas hair cortisol concentrations of children from households with increasing income (0.03 pg/mg) did not differ significantly from the reference group. Cortisol was not related to BMIp95. CONCLUSIONS: The economic circumstances of families may impact children's BMI trajectories and their developing stress systems, but these processes may be independent of one another.

Race/ethnicity and age associations with hair cortisol concentrations among children studied longitudinally from early through middle childhood.

A total of 513 children were included in this secondary analysis of data from the NET-Works trial of low income children at risk for obesity. The purpose of the analysis was to examine HCC longitudinally over 5 assessments from early through middle childhood with the goal of i) determining if there were racial/ethnic differences in HCC, and if so, how early in childhood these differences could be observed; and (ii) whether racial/ethnic differences in HCC reflected structural and family-level indicators of disadvantage. The sample consisted of children from diverse racial/ethnic backgrounds: Black, including Hispanic Black (N = 156), non-Hispanic White (N = 67) and Non-Black Hispanic (N = 290) children. As the largest group, the last group was used as the reference group in analyses. Structural and family-level indicators of disadvantage, including the neighborhood child opportunity index (COI), family income, and parent perceived neighborhood safety, were collected at each assessment. The results showed higher HCC among Black children beginning as early as 2-4 years of age than non-Black Hispanic children who did not differ from non-Hispanic White children. Although family income and COI were lower for children from minoritized racial-ethnic backgrounds, entering these measures as covariates did not reduce the difference in HCC between Black children and the other two groups. The results also showed that HCC initially decreased with age and then plateaued, with no evidence that this pattern differed by race/ethnicity. Because of the potential health risks of chronically elevated cortisol concentrations, these data argue for increased attention to the myriad of factors (oppressive structures, systems, and interpersonal experiences) that likely contribute to elevated cortisol levels among Black children.

Household food insecurity and obesity risk in preschool-aged children: A three-year prospective study.

BACKGROUND: Household food insecurity (FI) is a pressing social, economic and public health issue. However, little is known regarding the effect of FI exposure during the first few years of life, the most active postnatal time for neurobiological and physiological development, on patterns of weight gain during early childhood. It is also unknown whether dietary quality would serve as a pathway through which FI affects children's weight development. METHOD: This was a secondary data analysis from a three-year randomized clinical trial with five hundred and thirty-four parent/child dyads. Household FI in the past year was reported by parents at baseline when children were 2-4 years of age using the USDA Household Food Security Survey Module-Six Item Short Form. Children's dietary quality at baseline was measured by the US Department of Agriculture Healthy Eating Index (HEI). Child body mass index (BMI) was measured following standardized protocols at baseline and 12-, 24-, and 36-month follow-up. A latent growth curve model was used to examine 1) the association between baseline FI and sex-and-age-adjusted BMI z-scores in children and 2) the HEI pathway between the FI- BMI association. RESULTS: FI early in life was associated with higher baseline BMI z-scores. Children who had higher BMI at baseline maintained their higher BMI status over the next three years. Children's dietary intake quality did not explain the association between baseline FI and BMI z-scores. CONCLUSION: Early exposure to FI was associated with higher BMI in children as early as two years of age, setting them up for an increased likelihood of persistently high BMI-for-age in later childhood. These data suggest that the first few years may be a critical time for developing obesity risk, calling for policy and practices designed for early intervention of food insecurity.

The relative contributions of adiposity and activity levels to physical performance in children with excess weight.

OBJECTIVE: This study examined predictors of physical performance, a key aspect of quality of life, in children with excess weight. METHODS: Participants were 269 children aged 6-12 years with a body mass index above the 85th percentile. Children completed a standardized physical performance task capturing lower extremity strength, balance, and gait speed. Height, weight, and waist circumference were objectively measured, and daily moderate-vigorous physical activity (min/day) and sedentary time (% of day) were assessed with a 7-day accelerometer protocol. RESULTS: Physical performance task completion averaged 15.0 (SD = 2.5) seconds. Children with higher body mass index z-scores and waist circumferences had significantly longer task completion times. The task took 1.8 additional seconds per 1.0 body mass index z-score (p < .001), and 1.2 additional seconds for every 20 cm higher waist circumference (p < .001). Daily moderate-vigorous physical activity and sedentary time were unrelated to physical performance, and did not moderate its associations with the adiposity measures. CONCLUSION: Among children with excess weight, physical performance declines with increasing levels of total and central adiposity. Daily activity levels do not moderate this association. Interventions that directly target weight reduction would likely yield the greatest improvement in physical performance in children with overweight or obesity.

Attenuated efficacy of pediatric obesity treatment during the COVID-19 pandemic.

OBJECTIVE: This study examined whether the efficacy of a standard-of-care pediatric obesity treatment was affected by the COVID-19 pandemic. METHODS: Analyses leveraged data from an ongoing pediatric obesity treatment trial involving 230 lower-income, urban children aged 6 to 12 years. Mixed-effects regression models compared children who participated in a 12-month weight-management intervention before versus during the COVID-19 pandemic on change from baseline in BMI z score (ΔzBMI) at 3, 6, 9, and 12 months. RESULTS: The observed pattern of ΔzBMI was significantly different before versus during the pandemic (χ2 = 22.73, p < 0.0001). Children treated before the pandemic maintained an average weight loss of -0.06 ΔzBMI at 12 months, whereas children treated during the pandemic steadily gained weight over time, averaging a net gain of 0.11 ΔzBMI at 12 months (χ2 = 34.99, p < 0.0001). Treatment session completion did not differ before versus during the pandemic (60.4% vs. 55.7%, respectively; p = 0.30) or account for differences in ΔzBMI. CONCLUSIONS: Similar reductions in intervention efficacy may be anticipated in other pediatric obesity treatment trials conducted during the COVID-19 pandemic. Many families that have struggled with managing their child's weight during this period may need encouragement to continue engaging in structured weight management as society renormalizes.

Assessing effect heterogeneity of a randomized treatment using conditional inference trees.

Treatment effect heterogeneity occurs when individual characteristics influence the effect of a treatment. We propose a novel approach that combines prognostic score matching and conditional inference trees to characterize effect heterogeneity of a randomized binary treatment. One key feature that distinguishes our method from alternative approaches is that it controls the Type I error rate, that is, the probability of identifying effect heterogeneity if none exists and retains the underlying subgroups. This feature makes our technique particularly appealing in the context of clinical trials, where there may be significant costs associated with erroneously declaring that effects differ across population subgroups. Treatment effect heterogeneity trees are able to identify heterogeneous subgroups, characterize the relevant subgroups and estimate the associated treatment effects. We demonstrate the efficacy of the proposed method using a comprehensive simulation study and illustrate our method using a nutrition trial dataset to evaluate effect heterogeneity within a patient population.

The impact of financial incentives and restrictions on cyclical food expenditures among low-income households receiving nutrition assistance: a randomized controlled trial.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) is the largest anti-hunger program in the United States. Two proposed interventions to encourage healthier food expenditures among SNAP participants have generated significant debate: financial incentives for fruits and vegetables, and restrictions on foods high in added sugar. To date, however, no study has assessed the impact of these interventions on the benefit cycle, a pattern of rapid depletion of SNAP benefits that has been linked to worsening nutrition and health outcomes over the benefit month. METHODS: Low-income households not currently enrolled in SNAP (n = 249) received benefits every 4 weeks for 12 weeks on a study-specific benefit card. Households were randomized to one of four study arms: 1) incentive (30% incentive for fruits and vegetables purchased with study benefits), 2) restriction (not allowed to buy sugar-sweetened beverages, sweet baked goods, or candy using study benefits), 3) incentive plus restriction, or 4) control (no incentive or restriction). Weekly household food expenditures were evaluated using generalized estimating equations. RESULTS: Compared to the control group, financial incentives increased fruit and vegetable purchases, but only in the first 2 weeks after benefit disbursement. Restrictions decreased expenditures on foods high in added sugar throughout the benefit month, but the magnitude of the impact decreased as the month progressed. Notably, restrictions mitigated cyclical expenditures. CONCLUSIONS: Policies to improve nutrition outcomes among SNAP participants should consider including targeted interventions in the second half of the month to address the benefit cycle and attendant nutrition outcomes. TRIAL REGISTRATION: ClinicalTrial.gov, NCT02643576 . Retrospectively registered December 22, 2014.

Randomized Informational Intervention and Adult Park Use and Park-Based Physical Activity in Low-Income, Racially Diverse Urban Neighborhoods.

BACKGROUND: Neighborhood parks are important locations to encourage and stimulate physical activity (PA) among the urban population. This study aims to evaluate the impact of an informational intervention on adult park use and PA behaviors in 3 low-income, racially diverse urban neighborhoods in Minneapolis, MN. METHOD: The study employed a household-level randomized controlled trial and collected baseline and follow-up data from 171 participants. Within each neighborhood, participants were randomized to an informational intervention or to a no-intervention comparison. Intervention households received monthly, neighborhood-specific newsletters about park-based PA opportunities, park program brochures, trail maps, and activity guides. RESULTS: The average treatment effect of the newsletter intervention was positive yet moderated by respondent age. For a 20-year-old resident, treatment was associated with 0.97 (P < .05) additional park visits and 31.24 (P < .05) additional minutes of park-based PA over a 3-day recall period. For 40-year-old respondents, these positive effects are smaller at 0.36 (P < .05) additional visits and 4.66 (P < .05) additional minutes, respectively. CONCLUSIONS: An intervention to increase awareness about park-based PA opportunities and benefits increased self-reported park visits and in-park PA among adults who lived in low-income, racially diverse neighborhoods.

Associations between shopper impulsivity and cyclical food purchasing: Results from a prospective trial of low-income households receiving monthly benefits.

Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. Proposed interventions targeting the benefit cycle often focus on impulsive decision-making. However, it remains unclear whether shopper impulsivity is associated with food purchasing behavior. Using data from a prospective trial, we evaluate whether shopper impulsivity is associated with food purchasing behavior before and after households receive nutrition assistance. In this study, 249 low-income households in the Minneapolis-St. Paul, Minnesota, metropolitan area received monthly benefits for three months. Overall impulsivity and impulsivity subtraits of the primary shopper was assessed using the Barratt Impulsiveness Scale-11. Both total food expenditures and expenditures for two specific categories (fruits and vegetables, and foods high in added sugar) were evaluated. Generalized estimating equations were used to model household expenditures as a function of week since benefit distribution, impulsivity, and their interaction. Results showed that during the benefit period, food expenditures were cyclical and patterned by impulsivity. Shoppers with greater overall impulsivity spent $40.62 more in week 1 (p < 0.001). While more impulsive shoppers spent more on foods high in added sugar throughout the month (p < 0.05 for all weeks), no patterns were observed for fruits and vegetables. These findings suggest that greater impulsivity exacerbates cyclical food purchasing behavior. The impact of shopper impulsivity is especially notable for expenditures on foods high in added sugar. SNAP educational interventions to mitigate the benefit cycle may be strengthened by focusing on more impulsive shoppers and on strategies to reduce impulsive purchases of foods high in added sugar.

Designing online grocery stores to support healthy eating for weight loss.

OBJECTIVES: The current study aimed to identify features to include in online grocery stores to support healthful food purchasing by those striving to lose weight. DESIGN: A Value Proposition Design approach was used to gain shopper insights, devise potential online grocery store features and obtain feedback on these features. SETTING: Telephone interviews were conducted to gain insight into shoppers' needs and perceptions. Results were used by the research team to identify potential online grocery shopping features that may support healthful purchase decisions, and interviews were conducted with a different sample of shoppers to gather feedback on features. PARTICIPANTS: Insight (n 25) and feedback (n 25) interviews were conducted with convenience samples of adults trying to lose weight. RESULTS: Participants were primarily female, white, college educated and with obesity or overweight. Online grocery features devised by the research team based on findings from the insight interviews included (1) shopping cart nutrition rating tool; (2) healthy meal planning tool; (3) interactive healthy eating inspiration aisle and (4) healthy shopping preference settings option. Findings from the feedback interviews indicated that the healthy meal planning tool, healthy shopping preference settings option and shopping cart nutrition rating tool features were positively rated by most participants. CONCLUSIONS: There are multiple features grocers should consider including in their online stores to attract and support customers striving to eat healthy for weight loss.

Three-Year Changes in Low-Income Children's Physical Activity: Prospective Influence of Neighborhood Environment and Parent Supportive Behavior.

Objectives: To prospectively evaluate parent supportive behaviors (PSB) for child physical activity (PA) and neighborhood environment variables on changes in child PA over 3 years. Study design: Secondary data analysis of the Now Everybody Together for Amazing and Healthful Kids-Works study with 534 parent-child (age 2-4 years) dyads randomized to a community-based pediatric obesity prevention intervention for 3 years (92% retention). PSB and neighborhood environmental variables were examined in relation to changes in child moderate-to-vigorous PA (MVPA), light and sedentary activity, and screen time. Child and parent accelerometry data were collected at visit 0, 12, 24, and 36 months. Mixed multivariate models were used to examine independent and interactive effects of parent-level and neighborhood-level variables on changes in child PA outcomes. Results: PSB significantly interacted with visit on change in child MVPA (ß = 0.12) and sedentary behaviors (ß = -0.18). Over 3 years, a 1-unit increase in PSB was associated with an average increase of 4.3 minutes/day of MVPA and an average decrease of 6.5 minutes/day of sedentary time. Significant main effects were observed for PSB and 3-year change in child screen time (ß = -0.05). The children of parents with higher PSB at baseline watched an average of 1.8 fewer minutes/day of screen time compared with parents with lower baseline PSB. Neighborhood-level variables were not significantly associated with changes in child PA outcomes. Conclusions: Parents who increase their supportive behaviors for their child's PA have children who are more physically active and less sedentary over time. Interventions to increase preschool-age children's PA may enhance their effectiveness by targeting parents' supportive behaviors for their child's PA.

Trends in cyclical food expenditures among low-income households receiving monthly nutrition assistance: results from a prospective study.

OBJECTIVE: Supplemental Nutrition Assistance Program (SNAP) benefits are rapidly depleted after distribution. This phenomenon, known as the benefit cycle, is associated with poor nutrition and health outcomes. However, to date, no study has evaluated trends in food expenditures before and after households receive benefits using prospective data, and whether these trends vary by household characteristics. DESIGN: Generalised estimating equations were used to model weekly household food expenditures during baseline (pre-benefit) and intervention months by vendor (restaurants and food retailers). Food retailer expenditures were further evaluated by food category (fruits and vegetables and foods high in added sugar). All expenditures were evaluated by household composition, demographics and economic means. SETTING: Minneapolis-St. Paul, Minnesota, metropolitan area. PARTICIPANTS: Low-income households (n 249) enrolled May 2013-August 2015. RESULTS: Weekly food retailer expenditures did not vary during baseline (pre-benefit), but demonstrated a cyclical pattern after households received benefits across all household characteristics and for both food categories, particularly for fruits and vegetables. Households with greater economic resources spent more throughout the month compared with those with fewer resources. Households with lower food security status experienced more severe fluctuations in spending compared with more food secure households. CONCLUSIONS: Cyclical food purchasing was observed broadly across different household characteristics and food categories, with notable differences by household economic means and food security status. Proposed SNAP policy changes designed to smooth food expenditures across the benefit month, such as increased frequency of benefit distribution, should include a focus on households with fewest resources.

Assessment of Interrater Reliability of the Emergency Severity Index After Implementation in Emergency Departments in Jamaica Using a Learning Collaborative Approach.

INTRODUCTION: In 2016, the Ministry of Health in Jamaica selected the Emergency Severity Index as the triage tool to be used nationally. This study evaluated the effectiveness of this approach by assessing the interrater reliability among new users trained with minimal resources by 2 experienced trainers, 1 local and 1 international. METHODS: A retrospective case series review was conducted within an online learning collaborative framework. After completion of the training, the participants from each of the 19 clinical sites were asked to submit 2 triage cases per month for blinded review by the expert trainers. The triage categories assigned by each reviewer were compared with those assigned by the newly trained Emergency Severity Index providers. A weighted kappa value was calculated to assess the degree of agreement between the sites and the expert trainers. RESULTS: A total of 166 cases were received over the study period. Participation in the learning collaborative was consistently below 50%. The interrater reliability between the expert trainers (κ = 0.48) as well as between each scorer and each accident and emergency department site (κSF = 0.33, κPT = 0.26) was low, although there was improvement over the study period. Incomplete triage documentation limited raters' ability to assign triage categories and assess interrater reliability. DISCUSSION: Despite a rigorous implementation process, the interrater reliability of the Emergency Severity Index skills of Jamaican emergency nurses and doctors when compared with that of the 2 experts was poor. Several areas were identified for strengthening. Considerations for the implementation of the Emergency Severity Index in countries outside of the US were also discussed.