The USDA Supplemental Nutrition Assistance Program (SNAP) provides food and financial assistance to food-insecure individuals and families. In the midst of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, SNAP benefits evolved. Policy changes and federal legislation expanded SNAP eligibility, raised benefit levels, and introduced program waivers that enabled online ordering to reduce participants' exposure to community-acquired SARS-CoV-2. Although rapid expansion of SNAP benefits in the online space represents significant progress for federal food assistance, changes also introduced unforeseen partiality in how benefits and services were accessed and utilized, as illustrated by 2 populations and regions in the early months of the SARS-CoV-2 pandemic: low-income older adults in rural Alabama and low-income Hispanic adults in urban California. Opportunities exist to build on the recent progress in SNAP, while also ensuring continued inclusiveness of eligible persons. Efforts should be informed by evidence that supports equitable access to federal food assistance.

Background

Dietary energy density, or energy available in relation to gram intake, can inform disease risk.

Objective

The objective of this study was to investigate the association between baseline dietary energy density and risk of incident type 2 diabetes in postmenopausal women.

Design

Dietary energy density, weight status, and type 2 diabetes incidence were prospectively characterized in a large cohort of postmenopausal women participating in one or more clinical trials or an observational study.

Participants/setting

The study involved 161,808 postmenopausal women recruited to the Women's Health Initiative observational study or clinical trials at 40 centers across the United States between 1993 and 1998.

Main outcome measures

The primary outcome was incident type 2 diabetes.

Statistical analyses performed

The association between dietary energy density quintiles and incident diabetes was tested using Cox proportional hazards regression.

Results

A total of 143,204 participants without self-reported diabetes at enrollment completed baseline dietary assessment and were followed for 12.7±4.6 years. Risk of diabetes developing was 24% greater for women in the highest dietary energy density quintile compared with the lowest after adjusting for confounders (95% CI 1.17 to 1.32). Body mass index (calculated as kg/m²) and waist circumference mediated the relationship between dietary energy density and diabetes. In waist circumference-stratified analysis, women in dietary energy density quintiles 2 to 5 with waist circumferences >88 cm were at 9% to 12% greater risk of diabetes developing compared with women with waist circumference ≤88 cm.

Conclusions

In this prospective study, a higher baseline dietary energy density was associated with higher incidence of type 2 diabetes among postmenopausal women, both overall, and in women with elevated waist circumference.

Objective

We performed a secondary analysis to evaluate the effect of the Women's Health Initiative dietary intervention on incident diabetes and diabetes treatment in postmenopausal women.

Research design and methods

A total of 48,835 women were randomized to a comparison group or an intervention group that underwent a behavioral/nutritional modification program to decrease fat and increase vegetable, fruit, and grain intake for an average of 8.1 years. Ninety-three percent of participants completed the intervention, and 71% participated in active follow-up through 30 September 2015 (median 17.3 years). We measured time to development of treated diabetes and progression from oral antihyperglycemic agents to insulin. Serum glucose and insulin were measured in a subsample of women (N = 2,324) at baseline and years 1, 3, and 6.

Results

During the trial, intervention group women had lower rates of initiation of insulin therapy (hazard ratio [HR] 0.74 [95% CI 0.59, 0.94]; P = 0.01). Moreover, women with baseline waist circumference ≥88 cm (P interaction = 0.01) and worse metabolic syndrome scores (P interaction = 0.02) had the greatest reduction in risk of initiating insulin therapy. The decreased risk from the intervention was present during the cumulative follow-up (HR 0.88 [95% CI 0.78, 0.99]; P = 0.04). In participants with measured biomarkers (5.8% subsample) who had baseline glucose <100 mg/dL, the intervention reduced the risk of developing glucose ≥100 mg/dL by 25% (odds ratio 0.75 [95% CI 0.61, 0.93]; P = 0.008). Adjustment for weight change did not alter the results.

Conclusions

In this secondary analysis, a dietary intervention in postmenopausal women aimed at reducing fat and increasing intake of vegetables, fruits, and grains did not increase risk of diabetes and may have slowed progression.