key: cord-0074642-tve9hgsq authors: Oronce, Carlos Irwin A.; Miake-Lye, Isomi M.; Begashaw, Meron M.; Booth, Marika; Shrank, William H.; Shekelle, Paul G. title: Interventions to Address Food Insecurity Among Adults in Canada and the US: A Systematic Review and Meta-analysis date: 2021-08-06 journal: JAMA Health Forum DOI: 10.1001/jamahealthforum.2021.2001 sha: 1d185a13e8eb571ce897a59c35828132e8d312de doc_id: 74642 cord_uid: tve9hgsq IMPORTANCE: Inadequate access to food is a risk factor for poor health and the effectiveness of federal programs targeting food insecurity, such as the Supplemental Nutrition Assistance Program (SNAP), are well-documented. The associations between other types of interventions to provide adequate food access and food insecurity status, health outcomes, and health care utilization, however, are unclear. OBJECTIVE: To review evidence on the association between food insecurity interventions and food insecurity status, clinically-relevant health outcomes, and health care utilization among adults, excluding SNAP. DATA SOURCES: A systematic search for English-language literature was performed in PubMed Central and Cochrane Trials databases (inception to January 23, 2020), the Social Interventions Research and Evaluation Network database (December 10, 2019); and the gray literature using Google (February 1, 2021). STUDY SELECTION: Studies of any design that assessed the association between food insecurity interventions for adult participants and food insecurity status, health outcomes, and health care utilization were screened for inclusion. Studies of interventions that described addressing participants’ food needs or reporting food insecurity as an outcome were included. Interventions were categorized as home-delivered food, food offered at a secondary site, monetary assistance in the form of subsidies or income supplements, food desert interventions, and miscellaneous. DATA EXTRACTION AND SYNTHESIS: Data extraction was performed independently by 3 reviewers. Study quality was assessed using the Cochrane Risk of Bias Tool, the ROBINS-I (Risk of Bias in Non-Randomized Studies of Interventions) tool, and a modified version of the National Institutes of Health’s Quality Assessment Tool for Before-After Studies With No Control. The certainty of evidence was based on GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and supplemented with mechanistic and parallel evidence. For outcomes within intervention categories with at least 3 studies, random effects meta-analysis was performed. MAIN OUTCOMES AND MEASURES: Food insecurity (measured through surveys; eg, the 2-item Hunger Vital Sign), health outcomes (eg, hemoglobin A(1c)), and health care utilization (eg, hospitalizations, costs). RESULTS: A total of 39 studies comprising 170 605 participants were included (8 randomized clinical trials and 31 observational studies). Of these, 14 studies provided high-certainty evidence of an association between offering food and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.53; 95% CI, 0.33-0.67). Ten studies provided moderate-certainty evidence of an association between offering monetary assistance and reduced food insecurity (pooled random effects; adjusted odds ratio, 0.64; 95% CI, 0.49-0.84). There were fewer studies of the associations between interventions and health outcomes or health care utilization, and the evidence in these areas was of low or very low certainty that any food insecurity interventions were associated with changes in either. CONCLUSIONS AND RELEVANCE: This systematic review with meta-analysis found that providing food and monetary assistance was associated with improved food insecurity measures; however, whether it translated to better health outcomes or reduced health care utilization was unclear. We included all studies that evaluated a food insecurity intervention and included health outcomes or food insecurity as an outcome measured at the person-level. We defined a food insecurity intervention as a program or policy that either directly addresses food needs or improves the ability to obtain food. We also included studies if investigators explicitly stated that the intervention's objective was to address participants' food insecurity or if the study measured food insecurity as a study outcome. Therefore, an intervention could be included if it improved household financial resources, but was not designed to address food insecurity as its primary goal, and the study measured its association with food insecurity. We excluded studies on the Program for Women, Infants, and Children (WIC), which are established interventions with a voluminous literature. Because we were most interested in clinically oriented health outcomes, we excluded studies that only reported fruit and vegetable intake as the sole outcome. We rejected publications that employed community-level metrics as well as those that were descriptive narrative studies. As our focus was interventions applicable to the United States, we excluded studies conducted in low-and middle-income countries, in addition to those that took place in Western countries outside of the U.S. and Canada. Some studies in Canada were focused on indigenous populations unique to the country and we excluded these given limited generalizability. Finally, we also excluded studies focusing on children and adolescents, such as school lunch programs, as the focus of the sponsor was adults with food insecurity. While pediatric food insecurity interventions may also have impact on adults since food insecurity is often measured at the household-level, we sought to focus on interventions that could be widely targeted to adults. As mentioned in the main body of the manuscript, we conducted a random-effects meta-analysis and pooled results of studies in the same intervention category. The random effects meta-analysis takes into account the between-study variation as well as the variation across studies. Prior to conducting the meta-analysis, we performed an exploratory meta-regression to assess the association of 3 variables on outcomes: study design, baseline degree of food insecurity, and intervention type. Bivariate meta-regressions were done controlling separately for each of the three variables. Studies grouped as "miscellaneous studies" were not pooled and were not included in the meta-regressions. Outliers were assessed and removed from all pooled results and meta-regressions. None of the variables examined had statistically significant evidence of a differential association. Food insecurity interventions included provision of food, monetary assistance, food desert interventions, and a miscellaneous category. The food provision interventions were further categorized as those delivering food to the program participant and those where participants went to a secondary site to receive the intervention. We expand below on the results of studies evaluating the effectiveness of food provision interventions on reducing food insecurity. Providing Food Delivered to Home Among the six studies that provided home delivered food, 25,34,47-49, 63 one was a small randomized trial of medically tailored meals, in which dieticians designed meals to address patients' nutritional needs based on their medical conditions (e.g. diabetes or HIV). In this pilot randomized cross-over trial, 44 individuals were enrolled to receive either immediate home delivery of medically tailored meals for 12 weeks (through an organization called Community Servings) or delayed delivery and usual care before crossing over to the "on-meals" arm. This study found that 42% of those receiving meals were food insecure versus 62% of those who were not receiving home-delivered medically tailored meals, compared to the baseline food insecurity prevalence of 71-80% 25 . There were 5 studies comprising home delivery of non-medically tailored food (Table 1) . One provided food to families in motel shelters, but found no changes in food insecurity 49 . Four other studies examined the same intervention-home delivered meals under the Older Americans Act Nutrition Program (OAANP) or "Meals on Wheels". These included Before-After studies from multiple states and a nationally-representative cross-sectional study 34, 47, 48, 63 . The three Before-After studies found that home delivered meals were associated with reduced food insecurity. The cross-sectional study, which used a matched comparison group of Medicare beneficiaries, did not observe a difference in food insecurity 63 . Ten studies examined interventions where food was provided at a secondary location and were differentiated by degree of tailoring towards the patients' comorbidities-medically tailored meals, medically tailored or appropriate food boxes, or other (no further individualization, see Table 1 ). One intervention provided medically tailored meals at a distribution site. Meals provided 100% of daily calorie needs to individuals living with HIV or diabetes. The evaluation used a Before-After without control design and found that those receiving medically tailored meals for a 6month period experienced a statistically significant increase in food security from 10% to 54% Medically tailored groceries (i.e. "diabetic diet" groceries, not individually prescribed) One RCT and 3 observational studies evaluated medically tailored grocery interventions (Table 1 ). These interventions targeted populations with common cardiometabolic conditions, including obesity, hypertension, and diabetes. The RCT was conducted across 3 states and included 568 diabetic individuals with an HbA1c of at least 7.5% randomized to control or a bundled intervention of diabetes self-management education, primary care referral, and diabetesappropriate food boxes provided twice monthly 26 . Food insecurity at the end of the 6-month trial was 60% in the intervention group versus 69% in the control, corresponding to a relative risk reduction of 15% in multivariate analysis (p=0.04). In a Before-After study evaluating a bundle of a diabetes-appropriate food box, patient education, and components of the Diabetes Prevention Program, the intervention was associated with a significant reduction in food insecurity from 44% to 29% (p<0.001) 37 . Remaining Before-After studies included providing food boxes aligned with the Dietary Approaches to Stopping Hypertension (DASH) diet and food prescriptions for fruits, vegetables, and pre-approved items that the patient could select 36,39 . The latter was associated with a statistically significant decrease in food insecurity from 100% food insecurity to 6% 36 . "Healthy eating" Groceries (i.e. more fruits and vegetables) Two studies, both RCTs, examined food provision interventions that were not medically tailored but intended to encourage healthy food intake in general 28,29 . One RCT evaluated a single site employer-based program of 60 participants 28 . Participants received 8 community supported agriculture boxes over 4 months containing vegetables, fruit, eggs, and content to encourage use of the groceries, like recipes and food storage tips. The other RCT examined a multifaceted food provision program implemented in a high poverty area in Connecticut at a local food pantry 29 . Participants selected their groceries, received support towards their individual goals of food security and self-sufficiency, and were connected with services to address unmet social needs. Only the first study had a statistically significant effect with an 89% reduction in the odds of food insecurity. The latter study showed a small reduction through 9 months, which was diminished and no longer statistically significant at 12 months (p=0.12). Three observational studies provided non-medically tailored food to older adults (Table 1) . These included two studies that evaluated group meal programs under the OAANP 48, 63 . Two studies observed a reduction in food insecurity associated with food provision 40,48 . Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries Sustainable' Rather Than 'Subsistence' Food Assistance Solutions to Food Insecurity: South Australian Recipients' Perspectives on Traditional and Social Enterprise Models Lunch at the library: examination of a community-based approach to addressing summer food insecurity. 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