Food as Medicine

In a recently released issue of Pediatrics, Sonik et al examined whether Supplemental Nutrition Assistance Program (SNAP) participation is associated with emergency department (ED) use among children WITH low-income (10.1542/peds.2022-058247). In other words, does receiving SNAP (formerly known as the Food Stamp Program) reduce the likelihood of utilizing the ED? The authors further sought to understand whether that association was ‘mediated’ by household food hardship and child health status, and/or ‘moderated’ by special health care needs (SHCN) status.

The terms ‘moderator’ and ‘mediator’ should not put you off from reading this excellent article. Basically, what moderators and mediators can do is better explain the relationship between 2 variables (in this research, between SNAP participation and ED use) to get a “fuller picture of the real world.”¹ To explain further, “a mediating variable (or ‘mediator’) explains the process through which two variables are related, while a moderating variable (or ‘moderator’) affects the strength and direction of that relationship.”¹ This makes intuitive sense because SNAP participation by itself is not obviously linked to use of the ED, but when we consider that SNAP participation is driven by food insufficiency, and food insufficiency is related to child health,² and poor child health could potentially lead to ED use, this “chain” of ‘mediators’ connects SNAP participation and ED use. With respect to SHCN status as a possible ‘moderator’, it makes intuitive sense that an important question is whether this association would be stronger for children whose medical status is more precarious than those without chronic health problems?

The authors conducted a secondary analysis of data from 2016-2019 of the National Survey of Children’s Health, a nationally representative sample of US children, and included those living in households with income at or below 150% of the federal poverty level, since these children were most likely to be SNAP-eligible. A total of 24,900 children were included, of whom 6,644 were those with SHCN and 18,345 were without SHCN. Exposure to food hardship was measured with a single food insufficiency question, and parent-reported child health status, asked on a 5-point scale, was dichotomized as “excellent” versus “very good”, “good”, “fair” or “poor.” The main outcome was ED utilization, defined by one or more versus no ED visits in the prior year. The study results, in short, showed that SNAP participation was a really good thing.  SNAP was associated with lower likelihood of household food hardship, non-excellent health and at least one ED visit in the past year. And as the authors hypothesized, SHCN status did moderate this association with each outcome larger (more impactful) for those with, versus without, SHCN.

This brief summary is just to whet your appetite for reading the article itself, which explains this work clearly and in depth. Little prior research has been done on the relationship between SNAP participation and health care utilization in children, or in differing populations of children, so this work has huge implications for federal policy as well as for pediatricians. With respect to policy, this research is evidence that SNAP has significant health benefits, which has the potential to drive advocacy for this and like programs. With respect to the work we do in our offices, I believe it is a call to action: we must not only screen for food insufficiency, but then act on the results, know about local resources and government benefits, and empower and assist families in enrolling when eligible, through referral to social work or case managers. If one does not have ready resources, here is the impetus to find and engage the assistance needed to help families with food insecurity. After reading this article, let us know what you are already doing and/or plan to do on this important topic!

References

1. Bhandari P. Mediator vs. Moderator Variables | Differences & Examples. Scribbr. March 1, 2021, revised December 5, 2022. https://www.scribbr.com/methodology/mediator-vs-moderator/ Accessed 12/19/2022
2. Thomas MMC, Miller DP, Morrissey TW. Food Insecurity and Child Health. Pediatrics. 2019 Oct;144(4):e20190397