Challenges and Opportunities for Equity in US School Meal Programs: A Scoping Review of Qualitative Literature Regarding the COVID-19 Emergency.

The emergency school meals program provided free meals to children in the United States (US) during COVID-19-related school closures. This scoping review aims to synthesize the existing qualitative empirical evidence published between March 2020 and January 2023 on the operations and utilization of emergency school meal programs during the pandemic. Qualitative, US-based peer-reviewed literature was collected from three sources: (1) parent review of all federal nutrition assistance programs; (2) systematic search of four databases; and (3) manual search of grey literature. Identified scientific articles and grey literature reports (n = 183) were uploaded into Covidence and screened for duplicates and inclusion/exclusion criteria. Our final sample included 21 articles/reports, including 14 mixed methods and seven qualitative-only projects. Articles spanned all U.S. states. Articles had similar research questions to understand school meals and/or general food access during COVID-19, with an emphasis on long-term policy implications. Hybrid deductive/inductive analytic coding was used to analyze data, utilizing domains from the Getting to Equity Framework (GTE). GTE considers multi-level factors that influence nutrition behavior while centering more equitable pathways to improve nutrition security and reduce adverse health. Findings were sorted into two categories: operational challenges during the pandemic and solutions to address inequities in school meal distribution during and after the pandemic, particularly during school closures such as summers or future emergencies. Key challenges related to supply chain issues, safety, and balancing families' needs with limited staff capacity. Programs addressed equity by (a) reducing deterrents through federally issued waivers and increased communications which allowed the serving of meals by programs to families who previously did not have access, (b) building community capacity through collaborations and partnerships which allowed for increased distribution, and (c) preparing and distributing healthy options unless barriers in supply chain superseded the effort. This review highlights the importance of emergency school meal programs and provides insights into addressing challenges and promoting equity in future out-of-school times. These insights could be applied to policy and practice change to optimize program budgets, increase reach equitably, and improve access to nutritious meals among populations at highest risk for nutrition insecurity.

The Impact of the COVID-19 Pandemic on the Experiences and Operations of Sponsors of the Summer Food Service Program in Maryland, USA: A Multiphase Mixed Methods Study.

During the COVID-19 pandemic, the Summer Food Service Program (SFSP) was allowed to operate in untraditional non-summer months to ensure children did not lose access to free and reduced-priced nutritious meals when schools were mandated to close in the United States. This study assessed the impact of the pandemic on the operations and experiences of Summer Food Service Program (SFSP) sponsors in the state of Maryland during the COVID-19 pandemic in 2020 (Phase I) and 2021 (Phase II). This study used a multiphase explanatory sequential mixed methods design with qualitative prioritization. Maryland SFSP sponsors completed an online survey (Phase I: n = 27, Phase II: n = 30), and semi-structured in-depth interviews were conducted with a subset of sponsors who completed the survey (Phase I: n = 12, Phase II: n = 7). Inductive and deductive analyses were used for qualitative data, and descriptive statistics were used for quantitative data. The COVID-19 pandemic caused SFSP sponsors to change their operations. Sponsors were primarily concerned about staff safety/burnout and decreased participation. Sponsors perceived waivers implemented by the United States Department of Agriculture to be crucial in enabling them to serve meals to children during the pandemic. The findings from our study support advocacy efforts to permanently implement waivers and provide free school meals for all children.

A Call for Consistent Screening and Measurement of Adolescent Food Insecurity.

This Viewpoint discusses the need for accurately screening for and measuring adolescent food insecurity.

The Role of Accurate Self-Assessments in Optimizing Mate Choice.

Individuals are thought to seek the best possible romantic partner in exchange for their own desirability. We investigated whether individuals' self-evaluations were related to their partner choices and whether the accuracy of these self-evaluations was associated with mating outcomes. Participants (N = 1,354) took part in a speed-dating study where they rated themselves and others on mate value and indicated their willingness to date each potential partner. Individuals were somewhat accurate in their self-evaluations, and these self-evaluations were associated with individuals' revealed minimum and maximum standards for a potential partner, but not the number of partners they were interested in. Participants who overestimated their mate value were accepted by an equivalent number of partners compared with under-estimators, but the over-estimators were choosier and thus ended up with fewer (but similarly attractive) reciprocal matches. Results support social exchange theory and the matching hypothesis, and contrast findings that self-enhancement facilitates positive social outcomes.

Strategies to Improve Adolescent Food Security from the Perspectives of Policy Advocates, Parents, and Adolescents.

This study explored strategies to improve adolescent food security using semi-structured in-depth interviews with 9 policy advocates, 12 parents and 15 adolescents aged between 17 and 20 years, living in households who were eligible for the Supplemental Nutrition Assistance Program in 2020. This study was part of a larger evaluation of adolescent food insecurity conducted in Baltimore, Maryland, USA during the COVID-19 pandemic. Three key strategies arose during analysis-improving federal nutrition assistance programs for households, federal nutrition assistance programs for individual adolescents, and leveraging school programs and resources. Respondents described concordant views regarding the role of the Supplemental Nutrition Assistance Program in supporting households but held discordant views about the role of other federal programs, such as the school nutrition programs and Pandemic Electronic Benefit Transfer program. The results of this study provide important insights about policy and programmatic supports that may assist adolescents to acquire food for themselves and their families. Future research should test how federal programs and policies specifically impact food security and nutrition for adolescents.

Diet Quality and Contextual Factors Influencing Food Choice among Adolescents with Food Security and Food Insecurity in Baltimore City.

This study evaluated differences in overall diet quality, diet quality components, and food-related contextual factors between adolescents with food security and those with food insecurity. Mixed methods analysis was conducted on data from three 24-h dietary recalls from 61 adolescents ages 14-19 years old living in Baltimore, Maryland, USA in 2020-2021. All adolescents were sampled from households eligible for the Supplemental Nutrition Assistance Program in 2020. There were no significant differences in overall diet quality or components between adolescents with food security and those with food insecurity in this sample, except for seafood and plant proteins, which was higher for adolescents with food insecurity. Qualitative analysis found that adolescents were largely influenced by their parents and the home food environment, and that workplace environments enabled adolescents to eat foods high in refined grains, sugar, and saturated fat. These findings provide insight about the experiences of low-income adolescents during times when they are home for prolonged periods (i.e., emergency school closures, summer, and winter breaks). Programs and policies that aim to improve healthy food access may positively impact adolescent food security and diet quality, and it is important to ensure that healthy foods are available and accessible to adolescents in the places where they spend the most time. Multilevel interventions in the home, school, and workplace may be most effective in encouraging healthy eating behaviors among adolescents.

Patterns of Food Assistance Program Participation, Food Insecurity, and Pantry Use among U.S. Households with Children during the COVID-19 Pandemic.

This study aims to describe differences in participation in the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women and Children (WIC), and school meal programs by household characteristics prior to and during the pandemic, and to examine the association of program participation with food security status and food pantry use. We analyze secondary data (n = 470) from an online survey collected in July/August 2020 using weighted multiple logistic regression models. Participation in SNAP declined among households with children in the first four months of the pandemic, while participation in WIC increased slightly, and participation in school meals remained unchanged. There were significant differences in SNAP, WIC, and school meal programs use by race/ethnicity, income, and urbanicity before and during the pandemic. Food insecurity prevalence was higher among SNAP participants at both periods but the gap between participants and non-participants was smaller during the pandemic. Pantry use and food insecurity rates were consistently higher among federal nutrition assistance program participants, possibly suggesting unmet food needs. These results highlight the need for increased program benefits and improved access to food, particularly during periods of hardship.

Serving Summer Meals During the COVID-19 Pandemic: A Case Study of 2 Summer Food Service Program Sponsors in Maryland.

BACKGROUND: The Summer Food Service Program (SFSP) provides free and nutritious meals to children under age 18 during out-of-school times. During the COVID-19 pandemic, Maryland sponsors served over 9.5 million meals to children through an expanded version of the SFSP. This study aimed to explore and compare the factors that enabled 2 SFSP sponsors in Maryland to dramatically increase meals distribution during the pandemic. METHODS: Sponsors were selected based on their responses in the larger study and demographic characteristics of the area in which they served. Semi-structured in-depth interviews were conducted over Zoom-4 interviews with Sponsor A (3 interviews with the sponsor, 1 interview with their vendor) and 1 interview with Sponsor B. Qualitative data were analyzed inductively and deductively. Participation data from 2019 and 2020 were obtained from the Maryland State Department of Education and analyzed. RESULTS: Despite their differences in organization type and geographic region, they identified similar facilitators to their success-communication with the community and utilization of the United States Department of Agriculture-issued waivers. CONCLUSIONS: Strengthening community communication networks and permanently integrating more flexibility into regulation of the SFSP may increase meals participation during future out-of-school times.

The Impact of Waivers on Summer Meal Participation in Maryland.

BACKGROUND: The Summer Food Service Program (SFSP) is a federally funded program that serves free, nutritious meals during the summer months. In 2019, 6 federal waivers that previously helped sponsors serve meals were rescinded. The purpose of this mixed methods study was to assess the impact of the waiver rescission on the experiences of SFSP sponsors in Maryland. METHODS: This study analyzed responses from Maryland SFSP sponsors in a quantitative online survey and linked meal participation data for 2018 and 2019 (n = 29) and in-depth interviews (n = 11) about their experiences serving summer meals. RESULTS: Most respondents reported that the waiver rescission significantly impacted their experience serving meals, including increases in workload, spending and staffing; reductions in meal types (eg, breakfast); fewer meals served; and changing closed sites to open. Sponsors expressed desire for the state to apply for waivers on behalf of all SFSP sponsors in future years. CONCLUSION: The federal rescission of USDA summer meals waivers created substantial barriers for sponsors. To address the issues created by policy decisions, school food authorities and other SFSP should continue to work with researchers and antihunger advocates to share their experiences in order to shape state programs and policies.

A Multi-Site Analysis of the Prevalence of Food Insecurity in the United States, before and during the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic profoundly affected food systems including food security. Understanding how the COVID-19 pandemic impacted food security is important to provide support and identify long-term impacts and needs. OBJECTIVE: The National Food Access and COVID research Team (NFACT) was formed to assess food security over different US study sites throughout the pandemic, using common instruments and measurements. This study presents results from 18 study sites across 15 states and nationally over the first year of the COVID-19 pandemic. METHODS: A validated survey instrument was developed and implemented in whole or part through an online survey of adults across the sites throughout the first year of the pandemic, representing 22 separate surveys. Sampling methods for each study site were convenience, representative, or high-risk targeted. Food security was measured using the USDA 6-item module. Food security prevalence was analyzed using ANOVA by sampling method to assess statistically significant differences. RESULTS: Respondents (n = 27,168) indicate higher prevalence of food insecurity (low or very low food security) since the COVID-19 pandemic, compared with before the pandemic. In nearly all study sites, there is a higher prevalence of food insecurity among Black, Indigenous, and People of Color (BIPOC), households with children, and those with job disruptions. The findings demonstrate lingering food insecurity, with high prevalence over time in sites with repeat cross-sectional surveys. There are no statistically significant differences between convenience and representative surveys, but a statistically higher prevalence of food insecurity among high-risk compared with convenience surveys. CONCLUSIONS: This comprehensive study demonstrates a higher prevalence of food insecurity in the first year of the COVID-19 pandemic. These impacts were prevalent for certain demographic groups, and most pronounced for surveys targeting high-risk populations. Results especially document the continued high levels of food insecurity, as well as the variability in estimates due to the survey implementation method.

Feasibility of using mobile point-of-sale technology in Baltimore City corner stores tracking sales: A brief report.

Small food retail stores in many underserved urban settings keep no electronic records, making documentation of program impact on sales difficult to obtain. We examined the feasibility of introducing a point-of-sale tablet (POST) application to track sales of foods and beverages in Baltimore City corner stores. A sample of four geographically and ethnically diverse corner store owners were trained to use POST to track sales of 14 items for eleven days. Feasibility was documented via a structured survey and open-ended interviews. POST had high economic and cultural acceptability, operability, and perceived sustainability, regardless of language differences or familiarity with mobile technology. All store owners reported willingness to use POST again. It is feasible to train corner store owners to use a point-of-sale application for sales monitoring. An upcoming trial will help to ensure that POST provides sufficient value added for corner store owners.

A Scoping Review of the Use of Indigenous Food Sovereignty Principles for Intervention and Future Directions.

Indigenous food sovereignty (IFS) represents a community-led movement with potential to reduce health inequities, but no scoping review of the impact of taking an IFS approach on intervention research has been conducted. This review sought to: 1) describe intervention studies that employ IFS principles, and 2) describe the impact of studies using IFS principles on food access, eating patterns, diet quality, physical activity, and health. Through a literature review, 4 IFS principles were identified: 1) community ownership, 2) inclusion of traditional food knowledge, 3) inclusion and promotion of cultural foods, and 4) environmental/intervention sustainability. Twenty intervention studies published between January 1, 2000 and February 5, 2020 were included. Most of the studies that scored high in IFS principles saw a positive impact on diet. This review found evidence supporting the value of IFS principles in the development, implementation, and evaluation of health interventions for Indigenous communities.

Exploring the Reasons for Low Usage and Informing Strategies to Improve Use of a Nonprofit Grocery Store in Baltimore City.

Introducing new grocery stores into low-income communities has been a focus of policy efforts to improve the food environment. Yet, evidence of the impact of this strategy on diet and health outcomes is inconsistent. In Baltimore, a not-for-profit grocery store was opened by the Salvation Army in March 2018 with the goal of improving healthy food access. Unfortunately, the store has so far failed to attract sufficient customers. This study explored the reasons for low usage from the perspective of community members and staff members. A qualitative, formative research study was conducted at the store, which included semi-structured interviews (n = 21), direct observations (n = 8), and sociodemographic surveys (n = 152). Reasons for low store usage included high prices, confusion regarding the nature of the store, and lack of product variety. Reducing prices, increasing community engagement, and using promotional materials were all recommended strategies to increase usage. The Salvation Army is interested in potentially opening other nonprofit grocery stores. The results of this study will be used to help the Salvation Army refine their nonprofit grocery store model and in their future planning.

Fruit and Vegetable Intake and All-Cause Mortality in a Chinese Population: The China Health and Nutrition Survey.

This study was to investigate the association of long-term fruit and vegetable (FV) intake with all-cause mortality. We utilized data from the China Health and Nutrition Survey (CHNS), a prospective cohort study conducted in China. The sample population included 19,542 adult respondents with complete mortality data up to 31 December 2011. Cumulative FV intake was assessed by 3 day 24 h dietary recalls. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause mortality. Covariates included sociodemographic characteristics, lifestyle factors, health-related factors, and urban index. A total of 1409 deaths were observed during follow-up (median: 14 years). In the fully adjusted model, vegetable intake of the fourth quintile (327~408 g/day) had the greatest negative association with death compared to the lowest quintile (HR = 0.63, 95% CI: 0.53-0.76). Fruit intake of the fifth quintile (more than 126 g/day) had the highest negative association (HR = 0.24, 95% CI: 0.15-0.40) and increasing general FV intake were also negatively associated with all-cause mortality which demonstrated the greatest negative association in the amount of fourth quintile (HR = 0.59, 95% CI: 0.49-0.70) compared to the lowest quintile. To conclude, greater FV intake is associated with a reduced risk of total mortality for Chinese adults. High intake of fruit has a stronger negative association with mortality than differences in intake of vegetables. Our findings support recommendations to increase the intake of FV to promote overall longevity.

Healthy Food Retail during the COVID-19 Pandemic: Challenges and Future Directions.

Disparities in dietary behaviors have been directly linked to the food environment, including access to retail food outlets. The Coronavirus Disease of 2019 (COVID-19) pandemic has led to major changes in the distribution, sale, purchase, preparation, and consumption of food in the United States (US). This paper reflects on those changes and provides recommendations for research to understand the impact of the pandemic on the retail food environment (RFE) and consumer behavior. Using the Retail Food Environment and Customer Interaction Model, we describe the impact of COVID-19 in four key areas: (1) community, state, tribal, and federal policy; (2) retail actors, business models, and sources; (3) customer experiences; and (4) dietary intake. We discuss how previously existing vulnerabilities and inequalities based on race, ethnicity, class, and geographic location were worsened by the pandemic. We recommend approaches for building a more just and equitable RFE, including understanding the impacts of changing shopping behaviors and adaptations to federal nutrition assistance as well as how small food business can be made more sustainable. By better understanding the RFE adaptations that have characterized the COVID-19 pandemic, we hope to gain greater insight into how our food system can become more resilient in the future.

Environmental enteric dysfunction pathways and child stunting: A systematic review.

BACKGROUND: Environmental enteric dysfunction (EED) is commonly defined as an acquired subclinical disorder of the small intestine, characterized by villous atrophy and crypt hyperplasia. EED has been proposed to underlie stunted growth among children in developing countries. A collection of biomarkers, organized into distinct domains, has been used to measure different aspects of EED. Here, we examine whether these hypothesized relationships, among EED domains and between each domain and stunting, are supported by data from recent studies. METHODOLOGY: A systematic literature search was conducted using PubMed, MEDLINE, EMBASE, Web of Science, and CINAHL between January 1, 2010 and April 20, 2017. Information on study objective, design, population, location, biomarkers, and results were recorded, as well as qualitative and quantitative definitions of EED. Biomarkers were organized into five EED domains, and the number of studies that support or do not support relationships among domains and between each domain with stunting were summarized. RESULTS: There was little evidence to support the pathway from intestinal permeability to microbial translocation and from microbial translocation to stunting, but stronger support existed for the link between intestinal inflammation and systemic inflammation and for intestinal inflammation and stunting. There was conflicting evidence for the pathways from intestinal damage to intestinal permeability and intestinal damage to stunting. CONCLUSIONS: These results suggest that certain EED biomarkers may require reconsideration, particularly those most difficult to measure, such as microbial translocation and intestinal permeability. We discuss several issues with currently used biomarkers and recommend further analysis of pathogen-induced changes to the intestinal microbiota as a pathway leading to stunting.