Opportunities to Promote Food and Nutrition Security as the Federal Public Health Emergency Ends.

This JAMA Forum discusses key changes to the social safety net after the COVID-19 public health emergency ends and provides information regarding the ways health care professionals can support individuals experiencing food and nutrition security.

Food insecurity and the role of food assistance programs in supporting diet quality during the COVID-19 pandemic in Massachusetts.

Background: Economic and supply chain shocks resulting from the COVID-19 pandemic in 2020 led to substantial increases in the numbers of individuals experiencing food-related hardship in the US, with programs aimed at addressing food insecurity like the Supplemental Nutrition Assistance Program (SNAP) and food pantries seeing significant upticks in utilization. While these programs have improved food access overall, the extent to which diet quality changed, and whether they helped mitigate diet quality disruptions, is not well understood. Objective: To evaluate food insecurity, food pantry and/or SNAP participation associations with both diet quality as well as perceived disruptions in diet during the COVID-19 pandemic among Massachusetts adults with lower incomes. Methods: We analyzed complete-case data from 1,256 individuals with complete data from a cross-sectional online survey of adults (ages 18 years and above) living in Massachusetts who responded to "The MA Statewide Food Access Survey" between October 2020 through January 2021. Study recruitment and survey administration were performed by The Greater Boston Food Bank. We excluded respondents who reported participation in assistance programs but were ineligible (n = 168), those who provided straightlined responses to the food frequency questionnaire component of the survey (n = 34), those with incomes above 300% of the federal poverty level (n = 1,427), those who completed the survey in 2021 (n = 8), and those who reported improved food insecurity (n = 55). Current dietary intake was assessed via food frequency questionnaire. Using Bayesian regression models, we examined associations between pandemic food insecurity, perceived disruption in diet, diet quality, and intakes of individual foods among those who completed a survey in 2020. We assessed interactions by pantry and SNAP participation to determine whether participation moderated these relationships. Results: Individuals experiencing food insecurity reported greater disruption in diet during the pandemic and reduced consumption of healthy/unhealthy foods. Pantry participation attenuated significant associations between food insecurity and lower consumption of unhealthy (b = -1.13 [95% CI -1.97 to -0.31]) and healthy foods (b = -1.07 [-1.82 to -0.34]) to null (unhealthy foods: -0.70 [-2.24 to 0.84]; healthy foods: 0.30 [-1.17 to 1.74]), whereas SNAP participation attenuated associations for healthy foods alone (from -1.07 [-1.82 to -0.34] to -0.75 [-1.83 to 0.32]). Results were robust to choice of prior as well as to alternative modeling specifications. Conclusion: Among adults with lower incomes, those experiencing food insecurity consumed less food, regardless of healthfulness, compared to individuals not experiencing food insecurity. Participation in safety-net programs, including SNAP and pantry participation, buffered this phenomenon. Continued support of SNAP and the food bank network and a focus on access to affordable healthy foods may simultaneously alleviate hunger while improving nutrition security.

Food insecurity and the role of food assistance programs in supporting diet quality during the COVID-19 pandemic in Massachusetts

Background Economic and supply chain shocks resulting from the COVID-19 pandemic in 2020 led to substantial increases in the numbers of individuals experiencing food-related hardship in the US, with programs aimed at addressing food insecurity like the Supplemental Nutrition Assistance Program (SNAP) and food pantries seeing significant upticks in utilization. While these programs have improved food access overall, the extent to which diet quality changed, and whether they helped mitigate diet quality disruptions, is not well understood. Objective To evaluate food insecurity, food pantry and/or SNAP participation associations with both diet quality as well as perceived disruptions in diet during the COVID-19 pandemic among Massachusetts adults with lower incomes. Methods We analyzed complete-case data from 1,256 individuals with complete data from a cross-sectional online survey of adults (ages 18 years and above) living in Massachusetts who responded to "The MA Statewide Food Access Survey” between October 2020 through January 2021. Study recruitment and survey administration were performed by The Greater Boston Food Bank. We excluded respondents who reported participation in assistance programs but were ineligible (n = 168), those who provided straightlined responses to the food frequency questionnaire component of the survey (n = 34), those with incomes above 300% of the federal poverty level (n = 1,427), those who completed the survey in 2021 (n = 8), and those who reported improved food insecurity (n = 55). Current dietary intake was assessed via food frequency questionnaire. Using Bayesian regression models, we examined associations between pandemic food insecurity, perceived disruption in diet, diet quality, and intakes of individual foods among those who completed a survey in 2020. We assessed interactions by pantry and SNAP participation to determine whether participation moderated these relationships. Results Individuals experiencing food insecurity reported greater disruption in diet during the pandemic and reduced consumption of healthy/unhealthy foods. Pantry participation attenuated significant associations between food insecurity and lower consumption of unhealthy (b = −1.13 [95% CI −1.97 to −0.31]) and healthy foods (b = −1.07 [−1.82 to −0.34]) to null (unhealthy foods: −0.70 [−2.24 to 0.84];healthy foods: 0.30 [−1.17 to 1.74]), whereas SNAP participation attenuated associations for healthy foods alone (from −1.07 [−1.82 to −0.34] to −0.75 [−1.83 to 0.32]). Results were robust to choice of prior as well as to alternative modeling specifications. Conclusion Among adults with lower incomes, those experiencing food insecurity consumed less food, regardless of healthfulness, compared to individuals not experiencing food insecurity. Participation in safety-net programs, including SNAP and pantry participation, buffered this phenomenon. Continued support of SNAP and the food bank network and a focus on access to affordable healthy foods may simultaneously alleviate hunger while improving nutrition security.

Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children.

BACKGROUND: This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families. METHODS: Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443). RESULTS: During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31). CONCLUSIONS: Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03334669 , Registered October 2017.

Caregivers' Perceived Impact of WIC's Temporary Cash-Value Benefit (CVB) Increases on Fruit and Vegetable Purchasing, Consumption, and Access in Massachusetts.

Responding to the COVID-19 pandemic, the American Rescue Plan (2021) allowed state agencies of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) the option of temporarily increasing the Cash-Value Benefit (CVB) for fruit and vegetable (FV) purchases. To examine the impact of this enhancement on WIC caregiver experience, the MA WIC State Office invited 4600 randomly selected MA WIC caregivers to complete an online survey (February-March 2022). Eligible adults had at least one child, had been enrolled at least a year, and were aware of the increase. Of those who opened the screener (n = 545), 58.9% completed it (n = 321). We calculated the frequencies of reporting increased FV outcomes and tested whether responses differed by race/ethnicity, market access, and food security. Most caregivers perceived the CVB increase to benefit FV purchasing (amount and quality, 71.0% and 55.5%), FV consumption (offered to children and personally consumed, 70.1% and 63.2%), and satisfaction with the WIC food package (37.1% reported improved satisfaction, pre- vs. post-increase). Probability of reporting improved outcomes was not found to differ by race/ethnicity, market access, or food security. CVB increases may pose important implications for dietary behaviors and satisfaction with WIC. Policymakers should consider making this increase permanent.

Costs, Reach, and Benefits of COVID-19 Pandemic Electronic Benefit Transfer and Grab-and-Go School Meals for Ensuring Youths' Access to Food During School Closures.

Importance: School meals are associated with improved nutrition and health for millions of US children, but school closures due to the COVID-19 pandemic disrupted children's access to school meals. Two policy approaches, the Pandemic Electronic Benefit Transfer (P-EBT) program, which provided the cash value of missed meals directly to families on debit-like cards to use for making food purchases, and the grab-and-go meals program, which offered prepared meals from school kitchens at community distribution points, were activated to replace missed meals for children from low-income families; however, the extent to which these programs reached those who needed them and the programs' costs were unknown. Objective: To assess the proportion of eligible youths who were reached by P-EBT and grab-and-go meals, the amount of meals or benefits received, and the cost to implement each program. Design, Setting, and Participants: This cross-sectional study was conducted from March to June 2020. The study population was all US youths younger than 19 years, including US youths aged 6 to 18 years who were eligible to receive free or reduced-price meals (primary analysis sample). Exposures: Receipt of P-EBT or grab-and-go school meals. Main Outcomes and Measures: The main outcomes were the percentage of youths reached by P-EBT and grab-and-go school meals, mean benefit received per recipient, and mean cost, including implementation costs and time costs to families per meal distributed. Results: Among 30 million youths eligible for free or reduced-price meals, grab-and-go meals reached an estimated 8.0 million (27%) and P-EBT reached 26.9 million (89%). The grab-and-go school meals program distributed 429 million meals per month in spring 2020, and the P-EBT program distributed $3.2 billion in monthly cash benefits, equivalent to 1.1 billion meals. Among those receiving benefits, the mean monthly benefit was larger for grab-and-go school meals ($148; range across states, $44-$176) compared with P-EBT ($110; range across states, $55-$114). Costs per meal delivered were lower for P-EBT ($6.46; range across states, $6.41-$6.79) compared with grab-and-go school meals ($8.07; range across states, $2.97-$15.27). The P-EBT program had lower public sector implementation costs but higher uncompensated time costs to families (eg, preparation time for meals) compared with grab-and-go school meals. Conclusions and Relevance: In this economic evaluation, both the P-EBT and grab-and-go school meal programs supported youths' access to food in complementary ways when US schools were closed during the COVID-19 pandemic from March to June 2020.

Feeding Children and Maintaining Food Service Operations during COVID-19: A Mixed Methods Investigation of Implementation and Financial Challenges.

The United States Department of Agriculture (USDA) National School Lunch and Breakfast Programs are critical for the health and food security of U.S. schoolchildren, but access to these programs was disrupted by COVID-19 pandemic-related school closures in spring 2020. While temporary policy changes to the programs enabled school food authorities (SFAs) to pivot towards distributing meals throughout their communities instead of within school buildings, SFAs faced complex challenges during COVID-19 with minimal external support. This mixed methods study investigates the implementation and financial challenges experienced by twelve of the largest urban SFAs in the U.S. during COVID-19. We conducted semi-structured interviews with SFA leaders and analyzed alongside quantitative financial data. We found that SFAs reconfigured their usual operations with nearly no preparation time while simultaneously trying to keep staff from contracting COVID-19, accommodate stakeholders with sometimes competing priorities, and remain financially solvent. Because student participation was much lower than during regular times, and revenue is tied to the number of meals served, SFAs saw drastic decreases in revenue even as they carried regular operating costs. For future crises, disaster preparedness plans that help SFAs better navigate the switch to financially viable community distribution methods are needed.

A Safety Net Unraveling: Feeding Young Children During COVID-19.

The emergence of COVID-19 in the United States led most states to close or severely limit the capacity of their early child-care and education (ECE) programs. This loss affected millions of young children, including many of the 4.6 million low-income children who are provided free meals and snacks by their ECE programs through support from the federal Child and Adult Care Food Program (CACFP).Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to continue distributing food to children, early evidence suggests that most ECE programs did not have the capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps created by this loss.Critical steps are needed to repair our nation's fragile ECE system, including greater investment in CACFP, to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and beyond.