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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. As listeners of this podcast and readers of health affairs likely already know, the April issue of health affairs is dedicated entirely to the intersection of food, nutrition, and health. When we think about those topics as circles on a Venn diagram, where they overlap is really where it gets interesting. It's where research and study can sharpen our focus and it's where difficult questions typically arise, especially for policymakers charged with assessing the potential impact and efficacy of various policy interventions aimed at improving people's health and well-being.
Rob Lott:For health affairs and our authors, the goal is to inform those decisions with evidence. But what happens when the evidence is mixed and what happens when different interventions pose trade offs for individuals, communities and society at large? That's the subject of today's health podocy. I'm here with Doctor. Mary Katherine Poole, a postdoctoral research fellow at Harvard University's Chan School of Public Health.
Rob Lott:She's the lead author of an article on the April issue of Health Affairs. It's a rapid review aimed at understanding and comparing economic assistance models to improve food security and diet quality. This is some really important work and I can't wait to dig in. Doctor. Mary Katherine Poole, welcome to A Health Odyssey.
Mary Kathryn Poole:Thank you so much for having me.
Rob Lott:So Doctor. Poole, bear with me here, but can you tell me if I'm even thinking about this correctly in the first place? Because I think there are multiple issues at play here, right? Multiple public policy challenges. One challenge is that people might not be able to put enough food on the table.
Rob Lott:Another challenge is that however much food is on the table, it might not be very good for them or good for their health. And another challenge is basically in a word poverty, right? Too many people struggling with low or no income, which of course contributes to and is exacerbated by food insecurity and diet quality. So is that a fair take? And if so, maybe you can talk about how we as a society have tried to address those challenges.
Mary Kathryn Poole:Yeah, I think it's definitely a fair take. And as you alluded to, you know, these issues often co occur in the same populations and are often very much intertwined. And so The US has made significant efforts through the years to help address these issues of food insecurity and diet quality on population level. So one in four Americans have been reached by a USDA program of some kind, which are generally geared towards offering food and nutrition assistance. So in terms of the primary interventions that on the federal level have been implemented through the years, some of the programs take the approach of offering cash like assistance that can be spent on food with the idea that if if families have this assistance at each month, they can put that towards food to help alleviate food insecurity.
Mary Kathryn Poole:And then some programs also take the approach of providing food directly to families. The majority of the programs I'll talk about today take the cash like approach of putting resources in the pockets of families to use on food. But within these federal programs, some, you know, focus only on food security and then some try to focus on food security and diet quality. So an example, most people are familiar with SNAP, the Supplemental Nutrition Assistance Program, and that's the largest kind of food security program in the country where households receive cash like benefits each month that they can use to spend on food. There's also the program the second largest program is called WIC, which takes a more integrated approach of providing cash like assistance to pregnant mothers and their infants and children through the first years of life.
Mary Kathryn Poole:But there's nutrition restrictions incorporated into that program. So the families can use the funds to purchase food, but they have to meet certain guidelines. And then WIC also incorporates kind of wraparound services with nutrition counseling. So it's much more of a diet quality and health focused program as well.
Rob Lott:Can you say a little bit about what some of those dietary restrictions are the program?
Mary Kathryn Poole:Yeah. So with WIC, you know, the mission of the program is to help pregnant women and young children get a healthy start to life. And so there's a WIC food package that has been developed based on the latest nutrition science. And within that package are foods that are demonstrated to help fuel healthy growth and development. So fruits and vegetables, whole grains, limiting things that might be harmful like too much sugary drinks and refined carbohydrates and those types of things.
Rob Lott:So it's against this backdrop that you conducted a review, synthesizing the evidence around these different interventions. Hopefully, that those findings then allow us to make some comparisons. Can you say a little bit about how this review sort of represents an advance over what we already know about these programs? Why was this a good time to do this review and sort of what were you hoping to learn new from that process?
Mary Kathryn Poole:Yeah, so the evidence for these large federal nutrition assistance programs is pretty robust for their effectiveness. Like we know that SNAP does a great job at helping to improve food security. We know that WIC is equally as effective as for food security and nutrition. And and there are many other smaller programs that also have strong evidence. However, the the trends in food insecurity and diet quality are persistent or and poor nutrition are are persistent in the country.
Mary Kathryn Poole:And so there's been increasing attention, I think, with the pandemic, which really highlighted some of the challenges many Americans have in accessing food and having enough food to lead a healthy life. I think it became more a part of, like, daily conversation and dialogue in the public. And then I think there's also been more dialogue in the policy arena around, like, how how do we address these persistent trends and what's the right approach? So is it, you know, increasing and expanding upon what we're already doing or is there a need for new kind of interventions or solutions? So these conversations have been happening a lot in the policy world and then also in the research world.
Mary Kathryn Poole:And there are several policy timely policy discussions going on right now related to, you know, SNAP benefits, either increasing or decreasing benefit amounts or adding nutrition restrictions. And so as a team, we felt like with all of the discussion in the last few years and also a lot of innovation that happened during the pandemic around helping to get food to people, we wanted to take a look at the evidence and see, like, where do we stand now and how can a review of this evidence potentially inform current policy decisions.
Rob Lott:Okay. I I understand that the farm bill is up for renewal later this year and some of these programs fall under that bill. So was that also one sort of one piece of the the elements on the calendar that inspired this review?
Mary Kathryn Poole:Yes, for sure. The farm bill authorizes SNAP and has a lot of implications for how SNAP and SNAP adjacent programs are operated. So that was a big piece of it. And then we saw in 2021, SNAP was the benefit amount was increased for the first time in many, many years. It was a 21% benefit increase.
Mary Kathryn Poole:It was permanent permanently to the benefits and there have been discussions about, you know, taking that back or whatnot. So I think there's just a definite need to understand, you know, how well these programs are working and which way policymakers might want to go for for helping American people.
Rob Lott:Okay. Well, let's dig in. Can you tell us a little bit about some of your top line findings? And I'm curious in what ways perhaps this synthesis may have confirmed your suspicions or conversely how it may have surprised you.
Mary Kathryn Poole:Sure. So we basically compared the existing evidence that had been published since 02/2008. So we wanted to include studies that were most relevant to our current economy. And we looked for studies that evaluated either increases to existing cash like food assistance programs or nutrition incentive programs, which are typically providing like a fruit and vegetable voucher of some sort to help encourage nutritious choices. And then we compared these programs both to unconditional cash transfers, which have been implemented in many low and middle income countries for decades, but there's been a growing interest in The US in recent years to see if, you know, does putting just more cash in American's pockets help improve their overall health and well-being?
Mary Kathryn Poole:So there have been a lot of pilot studies in recent years. So we we reviewed the evidence for across these three different types of of economic approaches and overwhelmingly, we found that the strongest evidence for impacts on food security was for increasing benefits to existing programs or introducing new food assistance programs. There were some really great studies that were in this category that had really good impacts on these outcomes. And then we found that the nutrition incentive programs prompted small increases in fruit and vegetable intake pretty consistently, but less so for food security, which makes sense since it's often much smaller incentive than receiving a monthly benefit from SNAP or a similar program. And then the evidence for the unconditional cash transfer pilots that we reviewed was actually quite limited.
Mary Kathryn Poole:So there have been a lot of pilot studies but a lot of them did not meet our inclusion criteria. So we didn't really walk away with any type of policy implication for that type of program, but we still think it's warranted to continue research in that area because it does have the potential to overcome some of the barriers that we know exist to participating in food assistance programs that have been well documented.
Rob Lott:Great. Well, I want to hear a little more about the policy implications of your findings. But before we go there, why don't we go to an ad break? And we're back. I'm here with doctor Mary Katherine Poole from Harvard University talking about her recent article in Health Affairs April issue, all about the evidence around economic assistance models to improve food security and diet quality.
Rob Lott:Doctor. Poole, can you say a little bit about the state of the research that you examined? How good is the research out there? Is there something about this field that lends itself to high quality research or maybe conversely, what's particularly challenging about doing this kind of research that might make it hard to draw some conclusions in a review like this?
Mary Kathryn Poole:Yeah, so we were able to include 23 studies in our review, which 19 of those we rated as fair to good quality studies. So they all had a comparison group or they were randomized controlled trials. So that's really, you know, the gold standard for evaluations in this setting. I'd say the evidence overall was strong and we learned a lot from the studies that we did review. I think some of the limitations were that some of the studies used like repeated cross sectional data rather than a longitudinal study where they were able to follow the same people over time.
Mary Kathryn Poole:So that makes it a little more difficult to have as much confidence in the effect that you're seeing from the results. And then one of the major challenges that we noticed in some of the studies is finding a comparable group for your comparison group to the intervention group. And I think that speaks to the nature of some of how food research is sometimes conducted. And you know, if there's a policy change that occurs and you want to look at it very quickly, you know, a quick pre post study for evaluating impacts, it's really hard to just start primary data collection that quickly. Like you have to usually find grant funding and takes a lot of time and resources.
Mary Kathryn Poole:And so often we rely on secondary data, which is still very useful, but is not always the strongest for having the most confidence in the outcomes that you're seeing.
Rob Lott:Okay, so going back to sort of your top line findings that you mentioned before the break, I'm curious sort of what's the next step? Let's say you're talking to a policymaker who's trying to make sense of your article and what would you point them to in terms of maybe opportunities for improving the status quo?
Mary Kathryn Poole:I would say that a big takeaway for me was that the programs that we do have in place are working really well and that cuts to them or removing programs that are serving so many families would be very detrimental to food security and nutrition. I'd also say that, you know, I think there's so many views on this topic and people have a lot of ideas about what, you know, there's controversies around like what should be done, should it be more about nutrition restrictions or should it be, you know, increasing benefits or should it be more about individual behavior like nutrition education? I'd say it's easy to get lost in those debates. And I think just looking back to the evidence and seeing like, you know, from this review and many others that have come before it, like increasing the benefit amounts to establish programs does have the potential to improve health for people. I'd say another thing that I think is important when having these discussions is, you know, remembering the kind of lived experiences of people who are engaged and enrolled in these programs because, you know, food is something we all do, but it's very complex and there's, you know, social and emotional and environmental components.
Mary Kathryn Poole:And so while it can be easy for us to, think we understand a certain a certain pro, program experience, I think having good, like qualitative research involved in this conversation is so important because it really brings out participant voices and they can cast a lot of light onto like what it's like to participate in a program and what they think could make it better and help their family have more food and have a healthier diet.
Rob Lott:Wow. So great advice for policymakers and folks in this space in general. I'm wondering if you could now maybe speak to your fellow researchers as well as probably those funding the research about where you'd like to see the field go next. Where should researchers turn? What are the biggest gaps in this space that need addressing?
Mary Kathryn Poole:Yes, I think that there needs to be more studies that directly compare these different intervention approaches. So that was kind of a unique spin of our paper is that while there have been systematic reviews that looked just at WIC and WIC outcomes, we really wanted to try to compare these different approaches side by side. So I think there are a few studies that we did review actually. There were two by Lisa Harnack that were really interesting where she compared, you know, effects of receiving SNAP like benefits without restrictions, SNAP like benefits with restrictions and then nutrition incentives. So I think those kinds of studies are really interesting because it's often mimicking like what someone might be experiencing in the real world because often families are enrolled in multiple programs.
Mary Kathryn Poole:And so being able to parse out like what are the different effects and, you know, comparative effects between these programs is important. I think another important thing for the research community is trying to use, you know, validated and consistent measures of food insecurity and nutrition. We found a lot of studies in our review that might have been eligible to be included, but often didn't use a measure that we could compare to a lot of the gold standard measures of these outcomes. So trying to do that moving forward, think will be helpful. And then I think also thinking about other health outcomes in this work is important.
Mary Kathryn Poole:So yes, you know, diet and food security are critically important, but you know, how does that relate to mental health and physical health and overall well-being? I think the more studies we can incorporate those outcomes to paint a better picture of the large impact these programs can have.
Rob Lott:Wonderful. Well, Doctor. Mary Katherine Poole, you so much for taking the time to be here today and tell us all about your paper. Appreciate you joining us.
Mary Kathryn Poole:Thank you so much.
Rob Lott:And to our listeners, thank you for tuning in. If you enjoyed this episode, recommend it to a friend, subscribe, and tune in next week. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.