State-Level and County-Level Estimates of Health Care Costs Associated with Food Insecurity.

IntroductionFood insecurity, or uncertain access to food because of limited financial resources, is associated with higher health care expenditures. However, both food insecurity prevalence and health care spending vary widely in the United States. To inform public policy, we estimated state-level and county-level health care expenditures associated with food insecurity.MethodsWe used linked 2011-2013 National Health Interview Survey/Medical Expenditure Panel Survey data (NHIS/MEPS) data to estimate average health care costs associated with food insecurity, Map the Meal Gap data to estimate state-level and county-level food insecurity prevalence (current though 2016), and Dartmouth Atlas of Health Care data to account for local variation in health care prices and intensity of use. We used targeted maximum likelihood estimation to estimate health care costs associated with food insecurity, separately for adults and children, adjusting for sociodemographic characteristics.ResultsAmong NHIS/MEPS participants, 10,054 adults and 3,871 children met inclusion criteria. Model estimates indicated that food insecure adults had annual health care expenditures that were $1,834 (95$1,073-2,595, P < .001) higher than food secure adults. For children, estimates were 80 higher, but this finding was not significant (95% CI, -$171 to$329, P = .53). The median annual health care cost associated with food insecurity was $687,041,000 (25th percentile,$239,675,000; 75th percentile, $1,140,291,000). The median annual county-level health care cost associated with food insecurity was$4,433,000 (25th percentile, $1,774,000; 75th percentile,$11,267,000). Cost variability was related primarily to food insecurity prevalence.ConclusionsHealth care expenditures associated with food insecurity vary substantially across states and counties. Food insecurity policies may be important mechanisms to contain health care expenditures

Cost of living, Healthy Food Acquisition, and the Supplemental Nutrition Assistance Program

We tested the hypothesis that high costs of living, such as from high housing rents, reduce the healthfulness of food acquisitions. Using the National Household Food Acquisition and Purchase Survey (2012-13), we examined the relationships between cost of living and food acquisition patterns among both SNAP participants and non-participants (N = 5,414 individuals from households participating in SNAP, 3,863 individuals from non-participating households \u3c185% of the federal poverty threshold, and 5,036 individuals from non-participating households \u3e185% of the federal poverty threshold). Indices for cost of living included county-level Regional Price Parities for major classes of expenditures and the geographic adjustment to the Supplemental Poverty Measure, which is based on rent prices. We regressed the cost of living indices against measures of food acquisitions per person per day in each of several standard food categories, controlling for individual-, household-, and county-level characteristics. Using endogenous treatment effects models to potentially address unmeasured confounders influencing both the propensity to live in high-cost areas and patterns of food acquisition, we observed that higher area-level costs of living were associated with less healthy food acquisitions, including significantly fewer acquisitions of vegetables, fruits, and whole grains, and significantly greater acquisitions of refined grains, fats and oils, and added sugars. Overall, living in a high-cost area was associated with an 11% reduction in the Healthy Eating Index—a composite nutritional index previously associated with obesity, type II diabetes, and all-cause mortality. Additionally, we found that SNAP participation was associated with a significantly improvement in the healthfulness of food acquisitions among persons living in high-cost counties

Impact of Food Insecurity and SNAP Participation on Healthcare Utilization and Expenditures

We tested three hypothesis related to food insecurity and the Supplemental Nutrition Assistance Program (SNAP), America’s largest anti-food insecurity program. We hypothesized that 1)food insecurity would be associated with increased healthcare expenditures, 2)food insecurity would be associated with increased use of emergency department and inpatient services, and 3) SNAP participation would be associated with lower subsequent healthcare expenditures. We used data from the 2011 National Health Interview Survey linked to the 2012-13 Medical Expenditures Panel Survey. We used zero-inflated negative binomial regression to test the relationship between food insecurity and healthcare cost and use. We evaluated the association between SNAP participation and healthcare expenditures using generalized linear regression modeling, near/far matching instrumental variable analysis using state-level variation in SNAP policy as our instrument, and augmented inverse probability weighting. Those with food insecurity had significantly greater estimated mean annualized healthcare expenditures ($6,072 vs.$4,208, p\u3c0.0001), an extra $1,863 in healthcare expenditure per year, or$77.5 billion in additional healthcare expenditure annually nation-wide. Further, food insecurity was associated with significantly greater emergency department visits (Incidence Rate Ratio [IRR] 1.47, 95% Confidence Interval [CI] 1.12 – 1.93), inpatient hospitalizations (IRR 1.47, 95% CI 1.14 – 1.88), and days hospitalized (IRR 1.54, 95% CI 1.06 – 2.24). Across several analytic approaches, we found that SNAP participation was associated with reduced subsequent healthcare expenditures (best estimate: -$1,409; 95$2,694 to -$125). We conclude that food insecurity is associated with increased healthcare costs and use, and SNAP participation is associated with lower subsequent healthcare expenditures

“Now i feel a little bit more secure”: The impact of SNAP enrollment on older adult SSI recipients

In June 2019, California expanded Supplemental Nutrition Assistance Program (SNAP) eligibility to Supplemental Security Income (SSI) beneficiaries for the first time. This research assesses the experience and impact of new SNAP enrollment among older adult SSI recipients, a population characterized by social and economic precarity. We conducted semi-structured, in-depth interviews with 20 SNAP participants to explore their experiences with new SNAP benefits. Following initial coding, member-check groups allowed for participants to provide feedback on preliminary data analysis. Findings demonstrate that SNAP enrollment improved participants’ access to nutritious foods of their choice, contributed to overall budgets, eased mental distress resulting from poverty, and reduced labor spent accessing food. For some participants, SNAP benefit amounts were too low to make any noticeable impact. For many participants, SNAP receipt was associated with stigma, which some considered to be a social “cost” of poverty. Increased benefit may be derived from pairing SNAP with other public benefits. Together, the impacts of and barriers to effective use of SNAP benefits gleaned from this study deepen our understanding of individual-and neighborhood-level factors driving health inequities among low-income, disabled people experiencing food insecurity and SNAP recipients

A study protocol testing pre-exposure dose and compound pre-exposure on the mechanisms of latent inhibition of dental fear

Background: Dental stimuli can evoke fear after being paired - or conditioned - with aversive outcomes (e.g., pain). Pre-exposing the stimuli before conditioning can impair dental fear learning via a phenomenon known as latent inhibition. Theory suggests changes in expected relevance and attention are two mechanisms responsible for latent inhibition. In the proposed research, we test whether pre-exposure dose and degree of pre-exposure novelty potentiate changes in expected relevance and attention to a pre-exposed stimulus. We also assess if the manipulations alter latent inhibition and explore the possible moderating role of individual differences in pain sensitivity. Methods: Participants will be healthy individuals across a wide range of ages (6 to 35 years), from two study sites. Participants will undergo pre-exposure and conditioning followed by both a short-term and long-term test of learning, all in a novel virtual reality environment. The unconditioned stimulus will be a brief pressurized puff of air to a maxillary anterior tooth. Pre-exposure dose (low vs. high) and pre-exposure novelty (element stimulus vs. compound stimuli) will be between-subject factors, with stimulus type (pre-exposed to-be conditioned stimulus, a non-pre-exposed conditioned stimulus, and an unpaired control stimulus) and trial as within-subject factors. Pain sensitivity will be measured through self-report and a cold pressor test. It is hypothesized that a larger dose of pre-exposure and compound pre-exposure will potentiate the engagement of the target mechanisms and thereby result in greater latent inhibition in the form of reduced fear learning. Further, it is hypothesized that larger effects will be observed in participants with greater baseline pain sensitivity. Discussion: The proposed study will test whether pre-exposure dose and compound stimulus presentation change expected relevance and attention to the pre-exposed stimulus, and thereby enhance latent inhibition of dental fear. If found, the results will add to our theoretical understanding of the latent inhibition of dental fear and inform future interventions for dental phobia prevention

Study protocol of an investigation of attention and prediction error as mechanisms of action for latent inhibition of dental fear in humans

Background Evidence suggests that dental anxiety and phobia are frequently the result of direct associative fear conditioning but that pre-exposure to dental stimuli prior to conditioning results in latent inhibition of fear learning. The mechanisms underlying the pre-exposure effect in humans, however, are poorly understood. Moreover, pain sensitivity has been linked to dental fear conditioning in correlational investigations and theory suggests it may moderate the latent inhibition effect, but this hypothesis has not been directly tested. These gaps in our understanding are a barrier to the development of evidence-based dental phobia prevention efforts. Methods Healthy volunteers between the ages of 6 and 35 years will be enrolled across two sites. Participants will complete a conditioning task in a novel virtual reality environment, allowing for control over pre-exposure and the examination of behaviour. A dental startle (a brief, pressurized puff of air to a tooth) will serve as the unconditioned stimulus. Using a within-subjects experimental design, participants will experience a pre-exposed to-be conditioned stimulus, a non-pre-exposed to-be conditioned stimulus, and a neutral control stimulus. Two hypothesized mechanisms, changes in prediction errors and attention, are expected to mediate the association between stimulus condition and fear acquisition, recall, and retention. To ascertain the involvement of pain sensitivity, this construct will be measured through self-report and the cold pressor task. Discussion Dental phobia negatively affects the dental health and overall health of individuals. This study aims to determine the mechanisms through which pre-exposure retards conditioned dental fear acquisition, recall, and retention. A randomized control trial will be used to identify these mechanisms so that they can be precisely targeted and maximally engaged in preventative efforts

Food Insecurity and Suicidal Behaviors Among Us High School Students*

BACKGROUND: Food insecurity (FI) rates in the United States are particularly high among households with children. This research set aims to analyze if high school students experiencing FI had higher risk for mental health and suicidal behaviors. METHODS: Using combined data from 11 states that conducted the 2017 Youth Risk Behavior Survey, a total of 26,962 and24,051 high school students were used to estimate race/ethnicity and sex-stratified prevalence ratios (PRs) from Poissonregression models. A single-question was used to measure the exposure of FI and outcomes of mental health and suicidalbehaviors. RESULTS: Overall, 10.8% of students reported FI. Students experiencing FI had increased risk for all mental health and suicide behavior outcomes, regardless of their race/ethnicity or sex. PRs ranged from 1.9 (95% confidence interval [CI]:1.8, 2.0) to 3.1 (CI:2.7, 3.6). Among males, PRs for the association between FI and all outcomes were highest among non-Hispanic black students(PRs ranged from 2.4 [CI: 1.7, 3.2] to 5.5 [CI: 2.3, 13.3]). Among females, PRs were highest among non-Hispanic white students(PRs ranged from 1.9 [CI:1.7, 2.1] to 3.6 [CI:2.9, 4.5]). CONCLUSIONS:FI is consistently associated with mental health and suicidal behaviors among different subgroups of students

Goal setting in diabetes self-management: Taking the baby steps to success

To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals