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

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

Produce prescription projects: Challenges, solutions, and emerging best practices - Perspectives from health care providers.

Produce prescription projects are becoming increasingly common. This study explores perspectives and experiences of a sample of health care providers throughout the United States participating in implementing produce prescription projects with funding from the United States Department of Agriculture. Surveys (N = 34) were administered to collect demographic and descriptive data. Subsequently, individual key-informant interviews with participating health care providers (N = 16) were conducted via videoconference. Participants in this study included physicians and clinical staff (e.g., nursing, nutrition, social work) who work at health care organizations that facilitate a produce prescription project. Interview transcripts were coded using thematic qualitative analysis methods. Four cross-cutting key themes emerged. First, interviewees shared operational challenges, including lack of time/staff, difficulty with provider/patient engagement (some related to COVID-19), steep "trial and error" learning curve, and formidable barriers related to data sharing and research-related requirements (e.g., Institutional Review Board approvals). Second, interviewees elucidated their solutions, lessons learned, and emerging best practices as a response to challenges (e.g., importance of having a full-time paid staff member to manage PPR within clinic). Third, interviewees expressed satisfaction with produce prescription projects, particularly related to positive patient experiences (e.g., improved clinical outcomes and improved food security). Fourth, interviewees also shared appreciation for rigorous program evaluation to establish sustained funding and advance policies. However, they contextualized this appreciation within challenges outlined regarding collecting and sharing patient-related data outcomes. Findings provide emergent best practices and inform additional resources that are needed to sustainably implement and rigorously evaluate produce prescription projects.

Additional Fruit and Vegetable Vouchers for Pregnant WIC Clients: An Equity-Focused Strategy to Improve Food Security and Diet Quality.

Women with low household income and from racial/ethnic minority groups are at elevated risk of food insecurity. Food insecurity during pregnancy is associated with overall less healthy diets, lower intake of the pregnancy-supportive nutrients iron and folate, and significant variations in diet across the course of a month. The goal of this study was to explore the impact of an ongoing $40/month supplement for fruits and vegetables (F&Vs) provided to pregnant people enrolled in the Special Supplemental Nutrition Program for Women and Children (WIC). Our primary outcome was food insecurity using the USDA 6-item survey, and our secondary outcome was dietary intake of F&Vs based on the 10-item Dietary Screener Questionnaire. Participants in intervention and comparison counties completed surveys at enrollment and approximately three months later (n = 609). Mean ± SD food insecurity at baseline was 3.67 ± 2.79 and 3.47 ± 2.73 in the intervention and comparison groups, respectively, and the adjusted between-group change from baseline to follow-up in food insecurity was 0.05 [95% CI: −0.35, 0.44] (p > 0.05). F&V intake (in cup equivalents) was 2.56 ± 0.95 and 2.51 ± 0.89 at baseline in the two groups, and the adjusted mean between-group difference in changes from baseline was −0.06 [−0.23, 0.11] (p > 0.05). Recruitment and data collection for this study coincided with the most intensive of America's COVID relief efforts. Our results may indicate that small increases in highly targeted food resources make less of a difference in the context of larger, more general resources being provided to individuals and households in need.

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

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

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.

Survey Fraud and the Integrity of Web-Based Survey Research.

Compared to traditional paper surveys, online surveys offer a convenient, efficient, and socially distant way to conduct human subjects research. The popularity of online research has grown in recent decades. However, without proper precautions, false respondents pose a serious risk to data integrity. In this paper, we describe our research team's own encounter with survey fraud, steps taken to preserve the integrity of our study, and implications for future public health research.

Dietary Management of Heart Failure: DASH Diet and Precision Nutrition Perspectives.

Heart failure (HF) is a major health care burden increasing in prevalence over time. Effective, evidence-based interventions for HF prevention and management are needed to improve patient longevity, symptom control, and quality of life. Dietary Approaches to Stop Hypertension (DASH) diet interventions can have a positive impact for HF patients. However, the absence of a consensus for comprehensive dietary guidelines and for pragmatic evidence limits the ability of health care providers to implement clinical recommendations. The refinement of medical nutrition therapy through precision nutrition approaches has the potential to reduce the burden of HF, improve clinical care, and meet the needs of diverse patients. The aim of this review is to summarize current evidence related to HF dietary recommendations including DASH diet nutritional interventions and to develop initial recommendations for DASH diet implementation in outpatient HF management. Articles involving human studies were obtained using the following search terms: Dietary Approaches to Stop Hypertension (DASH diet), diet pattern, diet, metabolism, and heart failure. Only full-text articles written in English were included in this review. As DASH nutritional interventions have been proposed, limitations of these studies are the small sample size and non-randomization of interventions, leading to less reliable evidence. Randomized controlled interventions are needed to offer definitive evidence related to the use of the DASH diet in HF management.

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

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

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

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

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

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