PROJECT SUMMARY/ABSTRACT More than 34 million people experience food insecurity in the US, and 1 in 3 households with low incomes are food insecure. A growing body of evidence suggests that food insecurity is associated with higher rates of cardiovascular disease and mortality. Therefore, efforts to improve food insecurity may be critical to improving cardiovascular health in low-income adults. During the first months of the COVID-19 pandemic, food insecurity increased dramatically among low-income adults. In response, the federal government took unprecedented steps to expand benefits through the Supplemental Nutrition Assistance Program (SNAP). These policy actions provided emergency allotments that collectively doubled the average SNAP benefit – the largest-ever increase. However, SNAP emergency allotments were recently de-implemented across 32 US states on March 2023, with some states electing to do so much earlier (2021), resulting in a significant increase in food insecurity. Many policy experts believe that this reduced investment in SNAP benefits could not only impede low-income families’ ability to purchase healthy foods, but may also create competing financial demands that have adverse spillover effects. For example, low-income families may be forced to choose between spending limited financial resources on food instead of important health care services and may also find it more challenging to afford (and adhere to) important medications, which could collectively worsen cardiovascular health. However, these hypotheses have not been rigorously tested to date. The time-staggered way in which SNAP emergency allotments were de-implemented across US states provides a rare and unique opportunity to estimate the causal effects of changes in SNAP benefits, and to elucidate the pathways by which food insecurity impacts cardiometabolic health. In this proposal, will use a unique combination of national datasets, including survey data from NHIS, biometric & laboratory data from NHANES, and administrative claims data from Medicaid and Medicare to accomplish three aims. In Aim 1 we will determine changes in food insecurity among low-income adults, including those with diet-sensitive cardiometabolic risk factors, during and following the pandemic. In Aim 2, we will leverage the natural experiment created by some US states ending SNAP emergency allotment policies much earlier than others to evaluate their impact on health care access and affordability, the prevalence, treatment, and control of cardiometabolic risk factors, and self-reported health. In Aim 3, we will determine whether the de-implementation of SNAP emergency allotment policies led to changes in the incidence of acute cardiovascular events (myocardial infarction, heart failure, stroke), as well as associated outcomes. This research will advance our understanding of changes in food insecurity among millions of low- income adults, elucidate pathways by which food insecurity impacts cardiovascular health, and provide critical evidence on the spillover and health effects of SNAP benefits. Our work could have major public health implications, and inform policy strategies to improve food security, cardiovascular health, & equity nationwide.

PROJECT NARRATIVE Food insecurity increased sharply at the onset of the COVID-19 pandemic, and in response, the federal government took unprecedented steps to increase nutrition benefits (emergency allotments) for millions of low- income Americans through the Supplemental Nutrition Assistance Program (SNAP). A growing body of evidence suggests that food insecurity is associated with cardiovascular health, and so in this proposal, we will: (1) examine changes in food insecurity among low-income adults, including those with cardiometabolic risk factors, during and following the pandemic; (2) elucidate the pathways by which food insecurity impacts cardiometabolic health; and (3) estimate the spillover and health effects of SNAP benefits. To do so, we will leverage a natural experiment that occurred during the pandemic when US states de-implemented SNAP emergency allotments to estimate their impact on health care access and affordability, the prevalence, treatment, and control of cardiometabolic risk factors, and the incidence acute cardiovascular events.