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Evaluating Effectiveness of Food Pantry Programs to Improve Client Nutrition and Food Security:

A Systematic Review

By

Meredith Carroll

A Master’s Paper submitted to the faculty of the University of North Carolina at Chapel Hill

in partial fulfillment of the requirements for the degree of Master of Public Health in

the Public Health Leadership Program

Chapel Hill

Spring 2020

Advisor

Second Reader

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Abstract

Background: Food pantries are a common resource for low-income families in the

United States. Traditionally, food pantries supplied canned and processed goods. More

recently, food pantries have expanded their focus offering interventions to improve

nutrition and food security. We conducted a systematic review to assess the impact of

food pantries on client nutrition and food security.

Methods: A single reviewer searched SCOPUS from 2005 to 2019. Food pantry studies

with nutrition and food security outcomes were included. Quality of studies was

assessed using GRADE criteria.

Results: One hundred fifteen titles were identified from a SCOPUS search. Of those, 55

met criteria for review and 12 articles met full inclusion criteria. Food pantries were

associated with improved nutrition and food security. Quality of data were assessed as

moderate to poor.

Conclusions: Food pantries improve nutrition and food security among clients. More

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Introduction

Food insecurity, defined as the inability to provide adequate household food and

supplies, affects upwards of 15 million households across the United States, can lead to

negative health effects such as malnutrition (low quality food lacking in nutritious value),

food constraint (hunger), obesity, chronic disease, and even long-term psychological

effects associated with deprivation. (Coleman-Jensen et al., 2018) Studies have linked

food insecurity to increased risk of diabetes leading to lifelong effects (Hartline-Grafton,

2017). Hunger and food insecurity are not synonymous. Although hunger can be a side

effect of food insecurity, it is not a guaranteed outcome. Healthy People 2020 defines

low food security as “Reports of reduced quality, variety, or desirability of diet. Little or

no indication of reduced food intake.” Being food insecure indicates poor diet quality

due to unavailability of funds, access to food and food sources, or other resources, but

does not always indicate hunger (Office of Disease Prevention and Health Promotion,

2020). However, poor diet quality can lead to many long-term effects and debilitating

health and mental conditions, as outlined below.

Food insecurity often goes hand in hand with low nutrient intake and high

instances of obesity among food insecure persons, most prevalently seen in women.

This correlation can be explained by the types of food most commonly available for the

food insecure – foods high in fat and calorie content. Many food insecure people fall

below the poverty line and are unable to afford healthy items such as fresh vegetables,

fruit, food high in fiber, and lean meats. (Mello et al., 2010) A 2002 study found persons

living in a house of severe food insecurity were 2.1 times more likely to develop

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with high caloric values and poor nutritional value (Seligman et al., 2007). Food

insecurity can also lead to hunger and inadequate nutrition. Insufficient food intake and

poor nutrition can severely stunt the growth of a child, create difficulties with learning

and cognitive skills in children, and create the burden for senior citizens and head of

households to choose between providing adequate nutrition or critical health care

services. (Hunger in America, 2020). The negative effects of long-term food insecurity

are robust and require a strong solution.

The National Office of Disease Prevention and Health Promotion describes

numerous factors affecting food security status of families and creating temporary or

long-term food insecurity within a household, including unemployment, neighborhood

conditions, and transportation. Short or long-term unemployment can cause lack of

money and resources to provide food and other necessary household items. Long-term

unemployment can devastate a household’s ability to acquire adequate nutrition,

medical care, and other necessary items. Neighborhood conditions can affect access to

adequate nutrition. Many food insecure households live in areas known as food deserts,

or communities that lack affordable and readily available nutritious food. Another barrier

to accessing nutritious food is transportation. Often public transportation does not exist

in more rural areas, and many of these households do not have access to a car and

cannot access or afford adequate bus, train, or alternate transportation to stores outside

of the immediate area (Office of Disease Prevention and Health Promotion, 2020).

Healthy People 2020 also notes food insecurity varies by race, ethnicity and disability

status.

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or more of the three largest federal food and nutrition assistance programs: the

Supplemental Nutrition Assistance Program (SNAP); the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC); and the National School Lunch

Program (NSLP). (Coleman-Jensen et al., 2018) The SNAP program, formerly known

as the Food Stamp Program, is the largest and serves over 46 million Americans

annually. The program bases the amount of assistance received on several factors

including household size, household income, number of people and ages in a

household, and other benefits received. Qualifying households receive monthly SNAP

benefits through vouchers or Electronic Benefit Transfer [EBT] cards and can shop for

qualifying items at authorized food retailers including grocery stores, convenience

stores, and even farmers markets. (Caswell & Yaktine (Eds.), 2013). The WIC program

is specifically designed to provide specialized assistance for pregnant, breastfeeding,

and postpartum women, as well as infants and children up to age five. This program is

also income-based and qualifying persons must fall within the federal poverty

guidelines. Nutrition risks must be identified by qualifying persons such a physician or

nutritionist. Benefits for WIC recipients include food packages and resources,

breastfeeding support, immunization screenings and referrals, plus additional services

as determined per state. (U.S. Department of Agriculture, 2019). The National School

Lunch Program provides free and reduced-price meals/lunch to approximately 100,000

schools and residential programs. Children qualify for NSLP free lunches when their

household incomes fall below 130 percent of poverty and reduced lunch when

household incomes fall between 130 and 185 percent of poverty. In 2018, research

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received more of their food and nutrient intake from school meals than did other

children” (Guthrie & Ralston, 2019). Households coming out of food assistance

programs such as those described above are especially susceptible to food insecurity

and the need to visit emergency food providers. Even though leaving the program

typically means they have had an increase in income and no longer fall below the

poverty line qualifying them for these programs, they may still have months of unpaid

bills and other expenses to pay that prevent them from putting adequate food on the

household table. (Nord & Coleman-Jensen, 2010) According to a 2019 article by Rivera,

Maulding, and Eicher-Miller, SNAP-Ed programs have been proven to significantly

increase household food security (p<0.01) and improve nutrition related behaviors

including eating more fruits and vegetables (p<0.05) but requires more research around

the ability for these programs to impact important dietary outcomes. WIC programs

show similar effectiveness. A 2017 article demonstrated WIC participation reduced food

insecurity by at least 8.7 percentage points for infants (p=0.14) and by at least 5.1

points for children aged one through four (p=0.17). Although WIC guidelines point

families to nutritious foods, there is little evidence on the effectiveness of WIC programs

to improve nutrition (Kreider, Pepper, and Roy, 2016). A 2017 study of food assistance

programs showed no significant improvements associated with SNAP and NSLP related

to food security or nutrition in school aged children (Nguyen et al., 2017).

Private food supplemental organizations and systems also play a valuable role in

providing hunger relief and supplementation to public assistance programs for food

insecure households. (Gunderson et al., 2016). These “front line” private supplemental

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annually serve 46.5 million Americans. (Weinfeld, 2014). The private food assistance

network, created in response to emergency situations, has evolved into a program of

chronic assistance for low-income individuals and families living in food insecure

households. This network has expanded over the years to provide free food access to

households needing to supplement food supplied through public food assistance

programs, especially in years when the federal government has cut food stamp

programs. (Daponte & Bade, 2006) These organizations, including but not limited to

food banks, food pantries, and soup kitchens, are now accessed on a regular basis due

to high demand and need of food insecure persons across the U.S. (Berner, Ozer, &

Paynter, 2008)

Food pantries and banks began as food emergency organizations to meet the

immediate needs of families in emergent situations, and the primary focus was on

donations typically in the form of canned or other processed goods. As more families

find themselves in need of food assistance on a more consistent basis, food pantries

are shifting from emergency service to regularly utilized food programs. (Feeding

America, 2011) This shift has highlighted the lack of nutritious offerings typically

provided by food banks and pantries, as well as the need for additional services to

benefit families in need (Liu et al., 2019). Food Pantry users typically show high rates of

malnutrition due to lack of quality shelter, access to nutritious foods, barriers to

consistent health care, unemployment and overall lack of money, illiteracy, substance

abuse, and domestic conflict (Greenberg M, Greenberg G, & Mazza, 2010). A

systematic review in 2019 revealed that food pantries have the potential to improve

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implementing pantry-based interventions. A 2019 review of 12 food pantry interventions

by An et al. found all 12 improved food security and diet quality among low-income

families. The studies reviewed also saw improvements in nutrition knowledge, cooking

skills, and health outcomes. The researchers discuss shortcomings of the interventions

studied, including food pantry difficulty with sustainability due to issues with personnel

and funding.

Since food pantry programs with interventions may be difficult to sustain, we

sought to understand the effects of food pantry programs lacking interventions. We

conducted a review to explore the question, “What is the level of evidence for

effectiveness of food pantries to improve food security and nutrition outcomes among

low-income families in the United States?”

Methods

This systematic review sought to discover what the literature currently says about

the effectiveness of food pantries to promote food security and increased nutrition

among low-income families in the United States. Through an initial literature search, a

study question for this review was determined as, “What is the level of evidence for

effectiveness of food pantries to improve food security and nutrition outcomes among

low-income families in the United States?” Food security is defined as the ability to

provide household with food and necessary resources. Nutrition outcomes include diet

quality and increased nutritional knowledge and behaviors.

A single reviewer conducted an electronic search of the SCOPUS database for

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following keywords: "food bank" OR "food pantries" OR "food pantry" AND nutrition OR

health OR healthy. Studies focusing primarily on interventions and outcomes beyond

nutrition and food security of clients were excluded unless they also discussed these

key topic areas.

Each study included in the review met inclusion requirements outlined in Table 1

below. Studies were included that discussed outcome measures related to nutrition and

food security within food pantry settings. Traditional food pantry programs and food

pantries implementing healthy pantry interventions were included. For this study,

intervention is defined as “an act performed for, with or on behalf of a person or

population whose purpose is to assess, improve, maintain, promote or modify” food

insecurity and nutrition (WHO, 2020). All food pantry practices fall under this definition,

but in order to differentiate between studies in this review, “traditional” food pantries are

defined as those with no additional services beyond providing food, and pantries with

“interventions” will be defined as those pantries that include additional programming,

included but not limited to client choice, educational nudges, and cooking

demonstrations. Articles included in this study were limited to those published after

2005 to ensure the most up-to-date data and to provide new information.

Inclusion Criteria Exclusion Criteria

Food pantry studies focused on nutrition and food

security Incomplete studies; abstracts

Studies occurred in the United States Published prior to 2005

Studies set in general population Studies focused on a specific population subset Outcome measures were reported Focused on assessment tools with no outcomes

Interventions unrelated to food pantries

Table 1: Inclusion Criteria for Literature Search for Articles on Effectiveness of Food Pantries

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for consideration. Those articles which met all inclusion criteria and were not duplicates

were pulled for full text review. Articles included presented outcome measures of food

security, nutrition and diet quality, or both. Several articles were pulled in full text review

stage after discovering the study was set either fully or partially outside of the United

States. A majority of the articles excluded after full review showed promising information

but did not include exclusive results related to the aforementioned outcome measures

studied in this review.

Results from each study were summarized for comparative review and to

recheck inclusion and exclusion criteria (Table 2). The following information was

summarized for each article: the primary focus, year published, limitations and bias, a

brief description and main findings, and whether each article provided outcome

measures for nutrition or food security of food pantry clients.

The quality of data was assessed using the Grading of Recommendations

Assessment, Development, and Evaluation (GRADE) framework. The GRADE tool

designates all observational studies as low quality and randomized control trials as high

quality. These levels of quality can then be marked up based on three factors (large

magnitude of effect, dose-response gradient, and control of residual confounding would

increase magnitude of effect) or downgraded based on five factors (limitations or bias,

inconsistency, indirectness, imprecision, and publication bias). Quality is then assessed

across studies for each main outcome measure (nutrition and food security) to give a

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Study Design Quality of Evidence Lower if Higher if

Randomized trial High Risk of bias

-1 Serious -2 Very serious

Inconsistency -1 Serious -2 Very serious

Indirectness -1 Serious -2 Very serious

Publication Bias -1 Likely -2 Very likely

Large Effect +1 Large +2 Very large

All plausible confounding +1 Would reduce a demonstrated effect or

+1 Would suggest a spurious effect when results show no effect Moderate

Observational study Low

Very low

Figure 1: Quality Assessment Criteria, *Adapted from Guyatt et al.

Results

This search resulted in 115 articles, 72 of which were reviewed after screening

for duplicates (n=2), interventions based outside the U.S. (n=38), and articles published

prior to 2005 (n=3). A total of 72 records related to nutrition and food security of food

pantry clients were pulled from the initial review. Of those,17 abstracts were excluded

upon review, 55 full articles were assessed for their eligibility and 12 studies were

assessed suitable for inclusion in this systematic review. Six articles were unavailable to

be reviewed in full due to access issues. The most common reason for exclusion of

studies was lack of outcome measures related to nutrition and/or food security, making

them ineligible for comparison. Figure 2 below showcases all exclusion reasons for the

60 studies excluded from this review.

Of the 12 studies reviewed, 9 included overviews of nutrition-driven interventions

and 3 focused on the nutrition and food security of clients who frequent traditional food

pantries. A summary table of selected information from the studies is included below in

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Aiyer and colleagues trialed a food prescription program with two school-based

clinics and one Federally Qualified Health Center in Harris County, Texas (Aiyer et al.,

2019). Participants received 30 pounds of fresh produce and healthy non-perishable

items every 2 weeks for up to 12 visits, at a cost of $12.20 per redemption. This study

resulted in a self-reported decrease in food insecurity of 94% over the 6-month period.

Though nutrition was not explicitly measured, participants received large quantities of

fresh produce, healthy non-perishables, and nutrition education materials to take home.

The Rhode Island Community Food Bank implemented a 6-week cooking

program that provided nutrition education, guidance on healthy shopping/eating habits,

and healthy cooking strategies to participants. Flynn and colleagues developed the

6-week “Raise the Bar” program after implementing the Thrifty Food Plan (a minimal-cost

meal plan based on the 2005 Dietary Guidelines for Americans) which included 6-weeks

of cooking classes, as well as 6-months of follow-ups with monthly in-person visits. The

study found overall improved nutrition and food security. Variety of vegetable

consumption increased 15% (p<.01) and variety of fruit consumption increased 37%

(p<.01) at follow-up. During follow-up participant interviews, 78% reported eating more

vegetables and 44% reported eating more fruit. Food insecurity decreased from

baseline to follow-up, but the observed effect was not statistically significant (Flynn,

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Year Publishe

d Lead Author Setting and Sample Size Limitations Description Main Findings

2019 Aiyer, J Two school-based clinics and one Federally Qualified Health Center in north Pasadena, TX 172 total participants No control

Self-reported food security data, lack of dietary-intake data, small sample size, and lack of control group

Participating clinics/FQHCs collaborated with food pantry/banks to create and implement a food prescription program. Food pantries were client-choice and were open during weekdays and weekends to best serve prescription clients. Prescriptions helped guide clients in pantry food choices and pantries created welcoming and helpful environments to guide clients.

Food insecurity (self-reported) decreased 94% over the 6-month program (quantitative and qualitative data) (p<0.01).

2013 Flynn, M Rhode Island (RI) Community Food Panty 63 total participants No control

Incomplete data collection (dietary intake)

Raising the Bar on Nutrition is a 6-week cooking program at the RI Community Food Pantry. This program teaches healthy shopping/eating habits along with cooking strategies for healthier living. Strategies are based on The Thrifty Food Plan and 2005 Dietary Guidelines for Americans. Food Insecurity Scores (FIS), BMI and waist circumference, fruit and vegetable intake, and details on food purchases including grocery receipts were collected and measured.

FIS score ≥ 3 is considered food insecure; 48% (n = 30) scored 3 or higher at baseline vs 33% (n = 21) at follow-up (P = .09). There was a 15% increase in variety of vegetable consumption (p<.01) and a 37% increase in variety of fruit consumption (p<.01) at follow-up. In follow-up interviews, 78% reported eating more vegetables, and 44% reported eating more fruit. 2019 Rublee, M Food pantries across

Maine

41 intervention 95 control

Self-reported behavior data, small pool of participants, possible contamination bias

Trained volunteers led an educational nutrition program with food pantry residents. The program was 4-months and included classes and cooking demonstrations, surveys, and follow-up with these trained volunteers. Interventions and education at this level influence healthful decisions but demonstrated statistically insignificant changes.

Participants in intervention self-reported improved food security and nutrition behavior.

No statistical difference between control and intervention groups

2018 Wright, B.N. Food pantries across six states: Indiana, Michigan, Missouri, Nebraska, Ohio and South Dakota 455 total participants No control

Limited study (pre/post one food pantry visit), no data on other food sources, monetary incentive given

An observational cohort study comprised of a paired, before-and-after design with a pantry visit as the intervention. This study was used to evaluate single-day dietary intake patterns before and after visiting a food pantry among food-secure and food-infood-secure pantry clients. A significant increase in mean energy intake was observed those classified as food insecure.

Small increase in food security while no significant increase in nutrition. Increased quantity but not overall dietary improvement due to lack of fresh fruits and vegetables.

2019 Liu, Y Food pantries across Central Indiana

270 total participants No control

English speaking clients only, no adjustment between data for choice and non-choice pantries

A cross-sectional study of emergency food pantry use, household food security, diet quality, and chronic disease and related conditions of adult food pantry users in Indiana.

Clients who visited food pantries more than once a month had a Healthy Eating Index (HEI-2010) total score 5.2 points higher (p=0.03) and a Total Protein Foods component score 0.4 point higher (p=0.05) than those who visited pantries less often *Did not measure food security.

2017 Carpenter, L Central Florida Early care and education (ECE) programs

Small pilot, variations in catering options and cost, self-reported data

A catered food bank program for families involved in three ECE programs within 20 miles of Second Harvest food pantry in Central Florida.

Nutrition of food was measured for baseline (parent prepared) and follow-up (catered meals), and parents reported children eating foods they hadn’t

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Table 2: Summary of Articles Describing Effectiveness of Food Pantries Included in this Study

2013; Cooke, 2007). Year

Publishe

d Lead Author Setting and Sample Size Limitations Description Main Findings

2019

Bush-Kaufman, A Key informants in the food pantry community within the 13 western US states 43 total participants No control

No significant

limitations Qualitative review of hunger relief organizations across the western US to see what makes a "healthy" environment and what interventions these organizations are using and seeing improvements with.

Many of these interventions, like the FreshPlace model and nudges, client choice with additional resources, and others seem to increase healthy offerings and increase customer/user satisfaction but can be difficult to implement due to increased volunteer and donation/ buying needs. Qualitative study only, no significance levels listed. *Did not measure food security. 2016 Wilson,

N.L.W. New York State food pantry 205 back treatment 238 front treatment 255 unboxed treatment 188 boxed treatment

Diversity of product differs for people at front and back of line (as well as on diff days)

Pilot testing different "nudges" of targeted food in a client-choice pantry. This especially focused on promoting items like protein bars instead of other sweet snack items (to especially help those clients diagnosed with diabetes)

Placing healthier items in the original packaging at the front of the line has an odds ratio of 4.7 (95% CI=2.3, 9.9) over placing the product at the end of the line out of the original package, controlling for queue number. These simple nudges can increase the interest in targeted food items and are feasible for any food pantry. *Did not measure food security. 2013 Robaina, K.A. Food Pantries across

Hartford, CT

212 total participants No control

Self-reported data, survey not tested for validity, participant variability, Block screener doesn’t specify serving size

Block food frequency screener was used to measure fruit/vegetable consumption; as food insecurity increased, fruit/vegetable consumption decreased; most food-insecure clients visits pantries on average once per week and also supplemented diet with soup kitchen visits and other charitable food sources; those with decreased food security were much less likely to consume fruits, vegetables, and other nutritious options.

Clients who frequent food pantries typically show high BMIs, low food security, and low consumption of fruits and vegetables. However, frequent visits to food pantries can help improve self-reported nutrition (p=0.04) but does not seem to improve food security.

2013 Yao Community Cupboard clients within the Northern Illinois Food Bank

205 intervention 204 control

Quasi-experimental, limited resources, groups not

randomized (based on food pantry use)

Intervention group sampled a chicken and whole-grain dish then given the ingredients and recipe to prepare at home. This group participated in verbal interviews before intervention and 1 week and 1 month after the intervention. Control group were able to sample dish as well but did not receive bag with recipe and ingredients.

"Increased self-efficacy in control group, participants in the intervention group were 2.8 times more likely to agree that their family had consumed more whole grains over the past month (OR = 2.75; p=0.001). *Did not measure food security.

2013 Martin, K Food Pantries across Hartford, CT 113 intervention 115 control

Lack of participant variability, high cost program, self-reported data

FreshPlace intervention with quarterly follow-ups for 12 months. The intervention group received a client-choice pantry, monthly meetings with a project manager for motivational interviewing, and targeted referrals to community services.

Those participating in FreshPlace were less than half as likely to experience very low food security, gained 4.1 points in self- sufficiency scores, and averaged 2 points higher in fruit and vegetable consumption than those in the control group (all outcomes p<0.01). 2019 Stein, E.C. A food pantry in

Bridgeport, CT 128 T1 intervention 160 T2 intervention 160 control

Non-randomization, no follow-up data, no specific data on tasting of prepared foods from demonstrations

Intervention group 1 (T1) received recipe tastings only, Intervention group 2 (T2) received recipe tastings plus ingredient bundles, and Control group received no intervention. The intervention was conducted over 3 weeks (a total of 9 days as pantry was open 3 days/week). Food selection was measured but no follow-up interviews were conducted.

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Researchers in Maine conducted a 4-month quasi-experimental design

comparing two food pantries. One pantry served as the control, and participants at the

intervention pantry received educational lessons as well as necessary cooking

equipment to cook demonstrated meals at home (e.g. strainers for rinsing food). Both

groups completed intense surveys at the conclusion of the intervention period and while

the comparison group showed no statistically significant improvements, the intervention

group demonstrated improved food security and nutrition behavior through both high

intent to use resources and behavior change (p ≤ .05). (Rublee et al., 2019).

Carpenter and colleagues reported on a community project to provide healthy

meals to children in early care and education programs using food bank catering. A

12-month cooperative study was done by a food bank in Central Florida in partnership with

four early and child education programs. The goal of the program was to gauge the

nutrition of home prepared meals and test the feasibility of providing catered meals to

participating family to improve health and nutrition. The program also helped with

healthy strategies (e.g. portion control). Nutrition was measured based on average

amount of calories, fat, and saturated fat, and parents reported children eating foods

they hadn’t previously eaten. The results of this study showed that parent prepared

meals had 28% more calories, 20% more fat, and 30% more saturated fat, (p<0.05)

than catered meals. Parent interviews indicated that catered meals influenced home

prepared foods including replicating favorite items and rethinking portion size. Parent

interviews also indicated nutrition education and convenience of prepared meals were

viewed favorably and had positive influences on food choices and portion sizes of home

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The study by Bush-Kaufman explored food pantry capacity and selection in

implementing healthy food pantry policies as well as challenges faced by the pantries in

implementing these interventions. Although pantry participant outcome measures were

not collected, this study was included as it explored pantry staff capacity and perception

of programs as well as outcome measures related to increased availability of nutrition

education and healthy foods for pantry clients. Authors of this study concluded that food

pantry interventions were incredibly helpful in improving overall nutrition of foods and

nutrition education provided to clients and that partnering with nutrition and dietetics

practitioners saw the most successful outcomes (Bush-Kaufman et al., 2019).

Wilson and colleagues reported on a study exploring cost-effective way to

encourage client choice of healthier items. They placed healthier options, such as

granola and yogurt bars, at the back of the dessert aisle and collected data on how

many clients self-selected these healthier options, then they placed the same options at

the front of the aisle, and compared the results. The added nudge of placing healthier

options in their original packaging at the front of the dessert line greatly improved the

odds ratio of self-selection of those items (OR of intervention = 4.7; 95% CI = 2.3, 9.9;

p<0.05). This study shows low-cost nudges can be an effective way for food pantries to

encourage the selection of targeted, healthier foods (Wilson et al., 2016).

In a quasi-experimental study in northern Illinois, Yao and colleagues utilized

cooking demonstrations, recipe kits with ingredients needed for a whole grain recipe

and samples in food pantry settings. Those in the intervention group received education

focusing on the message, “make half your grains whole,” and received a bag of food

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card. This intervention focused on increasing self-efficacy of pantry clients to select

more whole grains and improve overall nutrition. Both intervention and control groups

were able to taste the dish and completed telephone surveys as follow-up. Participants

of the intervention group were 2.8 times more likely to agree that their family had

consumed more whole grains in the past month (OR = 2.75; p<0.01). The study also

saw a self-reported increase in self-efficacy to select whole grains in both the

intervention and control groups. (Yao et al., 2013)

Martin and colleagues assessed an intervention in Hartford Connecticut with a

focus on examining the impact of the intervention on food security. This intervention

called FreshPlace includes multiple components: “a client-choice model pantry, monthly

meetings with a project manager for motivational interviewing… and targeted referrals

to community services.” For outcome measures, the USDA Food Security Module,

Missouri Community Action Family Self-Sufficiency Scale, and the Block Food

Frequency Screener were utilized. At follow-up those participating in FreshPlace were

less than half as likely to experience very low food security (p<0.01), had increased

self-sufficiency scores, and averaged higher in fruit and vegetable consumption than those

in the control group. (Martin et al., 2013)

Stein and colleagues conducted a study in at a food pantry in Bridgeport,

Connecticut to compare the selection of targeted healthy food items between three

groups: recipe tastings only (T1), recipe tastings and provided ingredient bundles to

recreate recipes at home (T2), and a control group with no intervention. The study was

conducted over a 3-week period and a total of 9 days. The pantry was open three days

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Those who visited the pantry on Mondays were in the control group, on Wednesdays

were in T1, and on Fridays were T2. Selections of targeted healthy food items were

measured, and those in the T2 group were approximately three times as likely to select

the targeted foods than the control, and twice as likely to select as the T1 group. There

was no significant difference between the control and T1 (recipe only) group. For all

three nutritional choices promoted, significant increases were seen (p<0.001). This

study shows that unobtrusive, low-cost nudges such as recipe cards and ingredient

bundles can be effective measures in encouraging clients to select targeted foods.

Wright and colleagues reported results from an observational cohort study across

6 states: Indiana, Michigan, Missouri, Nebraska, Ohio and South Dakota that examined

nutrition and food security of pantry clients. This study had a paired, before and after

pantry visit design. In each state two pantries were chosen, one as the “control” pantry

and one as the “intervention” pantry based on factors such as availability of client

choice, number of clients and food served. A small increase in self-reported food

security was observed by pantry clients, but overall diet quality was poor. Although a

statistically significant increase in amount of fruits (p <0.001) and vegetables (p =

0.0003) consumed by food insecure households who visited a pantry was found, overall

diet quality did not show a significant increase post pantry visit (p = 0.21). (Wright et al.,

2018)

Liu and colleagues reported results from a cross-sectional study of food pantry

use in central Indiana. Recruited pantry clients were surveyed about pantry use,

household food security, diet quality, and chronic disease and related conditions.

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self-reported healthier eating habits, increased consumption of fruits and vegetables, and

increase in proteins compared to those who visited pantries less often. Authors utilized

the Healthy Eating Index (HEI-2010) score for comparison of healthy eating habits and

found clients who visited pantries more than once a month had an HEI-10 score 5.2

points higher (p = 0.03) than others. Food security was not measured within this study

(Liu et al., 2019).

A convenience sample of food pantry clients in Hartford, Connecticut were

studied by Robaina and Martin to examine food security, assessed using the USDA

Food Security Module, fruit and vegetable consumption, assessed using the Block Food

Frequency Screener. The study found most food-insecure clients visits pantries on

average once per week and supplemented their diet with soup kitchen visits and other

charitable food sources; those with decreased food security were much less likely to

consume fruits, vegetables, and other nutritious options.

Table 3 below summarizes the studies discussed and highlights the findings

related to our study question. Of the 12 studies reviewed, 11 measured nutrition of

pantry clients: 10 of which showed improved outcome measures and only one of which

showed no difference in baseline and follow-up. Three studies reviewed traditional food

pantries with no intervention. Of those studies, one showed no change but two showed

improvement in nutrition after visiting the pantry. Each food pantry implementing a

healthy food intervention (and measuring nutrition) showed some improvement in client

nutrition before and after pantry intervention. Typically, nutrition information was

self-reported and based on fruits, vegetables, and proteins consumed before and after

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measurements included healthy eating index scores, self-reported ability and desire to

continue healthy eating habits, and the calorie and fat intake of meals.

Outcomes of food security were measured in six of the reviewed studies: five of

which showed improved outcome measures and one of which showed no change

between baseline and follow-up. Of the three studies that reviewed traditional food

pantries, two measured food security: one showed an improvement and one showed no

change. Each of the four pantries implementing a healthy food intervention and

measured food security saw a self-reported improvement in pantry clients. Food

security was typically measured through a research-based questionnaire, but the exact

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Study Description of Intervention Findings relevant to Perception of Program Health Outcomes

Clients Staff Nutrition Food Security

Aiyer, 2019 Food prescription program Positive perception of program and selection of products and education provided from pantry prescription distributions throughout program; misunderstandings around how many times they could redeem prescriptions and distribution hours were not always convenient

Collaboration between clinics and pantries is key for this program; lack of clear

communication caused issues and created extra work in the form of extra reminder and follow-up calls

n/a Improved

Flynn, 2013 Cooking & nutrition education Clients reported improved cooking skills and comfort with cooking, perception of “healthy” food vs costs was altered

Cooking demonstrations were simple and quick; would need more research to learn fidelity of continued program

Improved Improved

Rublee, 2019 Educational nutrition program Clients reported increased food security as well as improved knowledge of basic cooking and nutrition habits; appreciated the educational tips such as "incorporating whole grains, like rolled oats, into meals”

Simple to implement, providing necessary cooking equipment was essential to clients fulfilling the program and utilizing education

Improved Improved

Wright, 2018 None; Observational cohort study n/a n/a No difference Improved

Liu, 2019 None; Cross-sectional pantry study Food-insecure clients tend to visit food pantries multiple times per month to fully supplement their

diet n/a

Improved n/a

Carpenter, 2017 Catered food bank program Parent interviews: positive experience; catered food influenced home food prep; could become expensive

High perceived benefits for clients; expense and donations can be an issue; toolkits were created

Improved n/a

Bush-Kaufman, 2019 Healthy environment review

n/a Interventions were helpful in food pantry settings and partnering with nutrition and dietetics practitioners was most helpful

Improved n/a

Wilson, 2016 “Nudges” of targeted foods n/a n/a Improved n/a

Robaina, 2013 None; Block food frequency screener Food insecure pantry clients visited pantries on

average once per week Improved quality of food is needed, including increased refrigeration units to provide fresh produce to clients

Improved No Change

Yao, 2013 Nutrition Education on whole grains Increased education on making healthy meals plus the ability to taste a sample improved client knowledge and desire to cook healthy

Volunteer staff need to be trained to orally

communicate whole grains education Improved n/a Martin, 2013 FreshPlace intervention

n/a There is a cost associated with a project- manager to implement FreshPlace and provide volunteer and staff training

Improved Improved

Stein, 2019 Ingredient bundle intervention n/a Community members, chefs, pantry director and staff were all consulted on ingredients and recipes to include and target in the study

Improved n/a

Table 3: Summary of Key Findings and Outcome Measures Related to Effectiveness of Food Pantries

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Table 4 demonstrates use of the GRADE method to determine quality of data in this study. The first outcome

measure discussed is nutrition and includes a mix of observational studies and randomized control trials (RCT’s), starting

it between low and moderate quality. The large effect demonstrated within articles by Flynn and Wilson pushes this

GRADE quality score up to a solid moderate. The second outcome measure, food security, includes half as many studies,

all of which are observational. Starting at low, the quality worsens due to serious limitations and imprecision found

throughout the six studies. Robaina and Martin both show serious study limitations: survey data on food security was not

tested for validity and high cost of program can have a large impact and bias on food insecure homes, respectively.

Imprecision is shown by Wright et al: they showcase a low number of events where food security was measured and

therefore confidence in this data is extremely low.

Study data on nutrition outcomes are assessed as moderate quality. The studies reporting nutrition outcome

data(Flynn, Rublee, Wright, Liu, Carpenter, Bush-Kaufman, Wilson, Robaina, Yao, Martin, and Stein) include both

randomized control trials and observational studies with control group and do not qualify to be downgraded. There were

some limitations applied for this measure, as well as inconsistent reporting of data collected, however, not enough to

qualify as serious.

Study data on food security are assessed as very low quality. The studies are primarily observational studies and

do not qualify for rating up (Aiyer, Flynn, Rublee, Wright, Robaina, and Martin). There were serious limitations and risk of

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caused reviewers to mark down for imprecision.

Table 4. Summary of Findings for Main Results Comparison Effect of food pantry use on nutrition and food security of clients

Population: adults >18 who frequent food pantries as a primary or secondary source of food Settings: food pantries across the United States

Intervention: food pantry use Comparison: standard No of

Participants

(Studies) Studies Included Design Limitations or bias Inconsistency Indirectness Imprecision Publication Bias

Studies that Contributed to Upgrading

Studies that Contributed to

Downgrading Quality of the evidence (GRADE) Comments Nutrition

3,294

(11) Flynn, Rublee, Wright, Liu, Carpenter, Bush-Kaufman, Wilson, Robaina, Yao, Martin, and Stein

Observational Study + four RCT’s

No serious

limitations No serious inconsistency No serious indirectness No serious imprecision Undetected Flynn, Rublee, Wilson, Yao, and Martin

none moderate Some limitations throughout but does not affect efficacy. RCT’s upgraded. Food Security

1,266

(6) Aiyer, Flynn, Rublee, Wright, Robaina, and Martin

Observational

Study only Serious limitations No serious Inconsistency No serious indirectness Serious imprecision Undetected none Robaina, Martin, and Wright

very low Serious limitations of self-reported data and scale

*GRADE Quality Scale (Siemieniuk & Guyatt, 2018)

Very Low The true effect is probably markedly different from the estimated effect Low The true effect might be markedly different from the estimated effect Moderate The authors believe that the true effect is probably close to the estimated effect High The authors have a lot of confidence that the true effect is similar to the estimated effect

Discussion

Study results demonstrate healthy food pantry interventions have an overall positive effect on both nutrition and

food security of pantry clients, and even just visiting a food pantry can improve diet quality and nutrition of food insecure

households. Simple interventions and pantry changes such as implementing client choice, nudges toward targeted foods,

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interventions due to too few studies.

Previous studies have suggested more research should be done around sustainability of healthy pantry

interventions, and this review confirms that conclusion. The study done by Wright and colleagues on traditional food

pantries in rural Midwestern America was the only study with negative findings on client nutrition. This could be due to

limitations of survey structure and the incentive of a $10 grocery store gift card that could have been used to purchase

items unable to be found in the pantry. However, this could also be due to the selection of items offered at the included

pantries or the structure of how clients receive products (pre-boxed vs. client choice). (Wright et al., 2018) Overall, there

was significant improvement in nutrition and slight improvement in overall food security.

In this study, food pantries were less effective in showing improvement to food security among pantry clients.

However, only 6 of the 12 included studies measured food security of pantry clients, and of those 83% saw an

improvement in food security over the course of the study. Food security is primarily self-reported, and there could be

some perception bias in the reported information. The one study that showed no change in food security was a food

pantry study with no intervention, and the self-reported surveys allowed introduction of social response bias (Robaina &

Martin, 2013). However, even though there was an increase in overall food security, many clients who frequent food

pantries with or without interventions are still considered to be food insecure (Liu, 2019). In addition, many traditional

pantry structures struggle with providing and keeping nutritious foods such as fresh produce, which strongly effect client

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programming covered in this study, it is unclear whether this is a reliable way to address food insecurity in food pantry

populations. Given varied outcome measures collected, inconclusive results, and studies still in action and yet to report on

data, it is not conclusive that food pantries and healthy initiatives are truly responsible for improved nutrition and food

security.

Many of the articles highlighted benefits beyond those measured in this study. The study by Liu et al. concluded

that low income families who utilize food pantries multiple times per month are likely to have better diet quality than those

who do not supplement diets with pantry visits. This indicates that implementation of healthy interventions in food pantries

has the potential to create a larger impact on nutrition. Many interventions in this study, including the FreshPlace program

and the study to improve selection of targeted items via simple nudges helped reduce the stigma for utilizing food pantries

through packaging of products and the “shopping” experience as a whole (Wilson et al., 2016) . The FreshPlace model

takes steps to dignify the food pantry process by calling its clients “members” and allowing them to shop at the pantry up

to twice per month.

Additionally, client-choice pantries such as the FreshPlace model allows for self-efficacy and the selection of

cultural and dietary-specific needs of clients. (Martin et al., 2013) Pantries promoting interventions from client-choice to

interactive programs and cooking demonstrations have the capacity to improve the social and emotional experience of

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food in each category but can select what they and their family prefer. This type of pantry also promotes the availability of

fresh fruits and vegetables, increasing overall capacity for nutrition. (Remley et al., 2013)

There can be many challenges when food pantries supply healthier options to clients, whether through

interventions or simply requesting more nutritious donations. These challenges can make research on this subject more

difficult, as many studies and interventions are unable to be continued, leading to low availability of research in this area

and of longer, higher quality studies. Challenges include lack of capacity to handle wide-scale implementation of

interventions as well as increased cost associated with some initiatives. A lack of capacity can also be attributed to the

spaces some food pantries occupy and other environmental factors, as pantries sometimes lack refrigeration for proper

storage and sinks for hand and produce washing. These limiting factors can prevent some pantries from implementing

some interventions and from stocking healthier items like fresh fruits and vegetables. (Bush-Kaufman, 2019) Many of the

interventions discussed in this study required both increased volunteer and/or staff capacity and an added cost to the

pantry itself and/or the client, which can sometimes be an insurmountable barrier for program continuation (Carpenter et

al., 2017). Although the overall results of this study were positive and suggest a correlation between food pantry use and

improved nutrition and food security, these challenges suggest it may not be a viable solution to either outcome measure

due to supply issues. Unfortunately, there may not be a one size fits all solution to this issue. It is important to continue to

monitor the effectiveness of food pantries as long as they remain a key supplement to low-income family’s diets. Policy

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pantry practices can flourish and become sustainable.

Limitations

This study was limited in scope, as only 12 articles fit the criteria and differed in specific outcomes measured. Many

articles pulled for review had relevant information but did not include specific outcome measures of nutrition and/or food

security, and therefore had to be eliminated. Several articles found reported on current programs and interventions that do

not yet have outcome measures to report but will in the coming years. In addition, only one search database was utilized

for this study, and a widened search might have yielded further studies to include. Time became a limiting factor for using

only one search engine for this paper.

Conclusion

This study presents modest evidence of improved nutrition in food pantry users, especially in those food pantries

implementing healthy interventions, confirming data shown in an article by An et al. However, due to a low number of

studies including traditional food pantries, we were unable to answer the original question of overall effectiveness of food

pantries on nutrition and food security. Additional research needs to be done in this area to see the full effects of pantries

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food resource for low-income U.S. families then it would be helpful to continue to monitor their effect on food security and

nutrition. In addition, community-based programs that provide resources, educational material, and knowledgeable staff to

food pantries should be continually studied and monitored.

More research needs to be done around the continued effectiveness of food pantries to promote food

security and increased nutrition for clients. Most, if not all, food pantry clients also receive public food benefits through

programs such as SNAP, WIC, and NSLP (Coleman-Jensen et al., 2018). It would be helpful to explore why none of these

programs or interventions, including the use of food pantries, are enough to effectively lower rates of food insecurity

across the U.S. The use of some programs can hinder a client’s ability to utilize another (e.g. some food pantries don’t

allow client access more than once per month, and additional restrictions can apply to those accessing other food

assistance programs).

One difficulty found when conducting this research was the lack of standard measures across pantries for both

nutrition and food security. Though the studies reviewed here presented outcome measures, they differed in the specific

items measured and varied between client self-reported and staff/volunteer-taken measurements. Additionally, information

was not always provided on any training or lack thereof for data collection. Future comparison would be made simpler and

more concrete if common measures were standardized across pantries and future studies. One reason for these varying

degrees of measurement could be contributed to the ever-changing standards and measurements of health and nutrition

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Even with the positive results found in this study, many families frequenting food pantries can still be considered

food insecure (Coleman-Jensen et al., 2018), which possibly indicates a larger problem that needs to be addressed

outside the scope of this study. More information around the relationship of food insecurity and poor diet with social

determinants of health in low-income families should be further studied.

The interventions reviewed in this study varied greatly in implementation, target goals, resources needed, and

outcomes measured. We recommend that additional studies be done with a critical eye to see why certain interventions

work best in certain communities. There may not be one intervention that works best for all communities, as there are

many factors that influence outcome. Challenges of food pantries and client populations may also vary by community,

changing the outcomes of interventions tested. As we continue to work on this issue of food security and nutrition, it is

imperative that we allow data to guide where we go next.

Addendum

As we were concluding this study, we were in the middle of a worldwide pandemic caused by COVID 19. With

many businesses unable to operate due to social distancing, 26 million Americans reported job loss as of mid-April 2020,

causing numbers of food insecurity to soar into unprecedented amounts. In the midst of our current situation, food

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need (Abou-Sabe et al., 2020). Now, more than ever, there is a renewed focus on food security related prevention. We

can harness this newfound focus towards food assistance programs, which must include food pantries: they support the

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