Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper was well written and I followed it easily. The methods were clear

Minor comments:

Lines 69-70: reads awkwardly to me and am not sure what the intended meaning is

Did you calculate interrater agreement?

Line 336: the 38 is a citation, I assume?

 

Here are some additional notes:   First, the authors did a fantastic job of presenting what and how they did this study. They evaluated the diet quality and household food security at different time points in Massachusetts and focused on the data from low-income individuals. This topic is relevant, particularly right now in the USA because the federal government is making significant effort to change a lot of how they manage programs like SNAP. This is a novel approach and gives insight into the experience of this program’s user experience.   Figure 1 is important because it shows the context in which the data was collected.   The method section is very clear to me. I have several questions about the qualitative data analysis: 

• Did you calculate interrater agreement between coders?
• You chose to analyze the qualitative data from both time points together. Did you consider the differences in responses across the two time points during data immersion? When coding, was coding representation largely the same or were there differences from time 1 to time 2?  The table shows examples across both time points, so I know you looked at them separately in some ways. I would like more info about if the seemed to be differences in responses or not between time points.

  Discussion: I find the limitations discussed to be appropriate and thoughtful.    Conclusion: the conclusion ties together the quant and qual findings    References: range of references included — some more dated but relevant, others more recent.    I do think that having the supplementary table be a regular table would benefit the paper.

Author Response

Comment 1: Reword lines 69-70.

Response 1: Please see the revised sentence below for lines 72-76 (changes underlined):

In particular, while the Thrifty Food Plan had been adjusted for inflation since its inception in the 1970s, the plan had not been modernized to account for significant changes in the food environment, in sociocultural patterns (e.g., the majority of women entering the workforce, less time available for food preparation), and in nutrition research over the past half century[16].

 

Comment 2: Report inter-rater reliability.

Response 2: Thank you for this suggestion. We recognize that inter-rater reliability is a common tool used in qualitative research. However, given that we conducted a reflexive thematic analysis informed by Braun and Clarke guidance, we did not assume there to be a “true” meaning of the data, and thus inter-rater reliability was not aligned with our analysis goals. Rather, we completed an iterative process of coding, reflecting, and discussing our interpretation of the data with the study team.

• Braun and Clarke (2013) Successful Qualitative Research: A Practical Guide for Beginners. SAGE Publications.

To clarify our approach, we added the word reflexive to several places in the manuscript (changes underlined). We also added the Braun 2013 citation to line 248.

Lines 33-34: Reflexive thematic analysis of write-in responses summarized experiences with SNAP.

Lines 86-91: Building on this one prior evaluation of the TFP revision, this study uses a difference-in-differences approach, supplemented by a reflexive thematic analysis of study participants’ written comments about experience with using SNAP, to evaluate differences in adult diet quality and household food security by SNAP participation from before to after the Thrifty Food Plan-related benefit increase among a representative sample of adults with low incomes in one U.S. state (Massachusetts).

Lines 248-249: Next, we conducted a reflexive thematic analysis[34-35] of 204 open-ended responses about respondent’s experiences with using SNAP.

 

Comment 3: Fix citation 38 in line 336.

Response 3: Thank you for catching this typo. We corrected the sentence to read on lines 395-397:

Food prices increased by 3.9% in 2021 with greatest increases beginning in the summer through the end of the calendar year,[36]and inflation rates spiked by 7.5% for consumer items (7% for foods alone) which marked the largest annual increase in decades.[37]

Comment 4: Were there differences in responses across the two time points during data immersion for the qualitative data?

Response 4: Thank you for this question. We opted to analyze the data separately for each time period (pre-increase vs. post-increase) in anticipation of different responses and possible themes; however, during the analysis phase, we found that the themes spanned both time periods as described in the Methods section and as displayed in Table 3.

 

Comment 5: Consider having the supplementary table as a regular table.

Response 5: We moved this supplementary figure to be Figure 3 in the main text.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

 

The manuscript addresses an important and timely topic and is generally well written. The mixed-methods approach is a strong aspect, as it combines statistical analysis with real experiences, making the findings more meaningful.

The introduction is informative, but it could be shorter and more focused. It would help to clearly state what makes this study different from previous research.

The methods are well explained overall. However, the assumptions behind the difference-in-differences approach should be clarified a bit more, especially the parallel trends assumption. A brief note on how missing data might affect the results would also improve clarity.

The results are clearly presented, though some tables are quite dense. Emphasizing the key findings more directly in the text would make it easier to follow. The qualitative results are valuable, but they could be better linked with the quantitative findings.

The discussion is thoughtful and well balanced. The role of inflation is well considered. Expanding slightly on practical or policy implications would strengthen this section.

 

   

Author Response

Thank you reviewing our manuscript. We appreciate your suggestions and have responded below.

Comment 1: Shorten the introduction to make it more focused.

Response 1: Thank you for this suggestion. We trimmed the text in the Introduction and omitted an entire paragraph; however, we were careful not to omit too much text due to Reviewer 3’s request to better explain SNAP, the Thrifty Food Plan, and the U.S. context for international audiences.

Below is the revised Introduction with changes underlined (lines 47-91):

Food insecurity—where a household experiences insufficiency or uncertainty in obtaining adequate food for its members[1]—is a persistent and substantial public health issue. In the United States (U.S.), the prevalence of food insecurity has stubbornly remained above 10% for the last several decades, and racial/ethnic disparities have persisted[2]. Food insecurity is a population health issue given its association with higher healthcare costs[3], mental health conditions[4], and chronic disease including cardiovascular disease, type 2 diabetes, and certain cancers[5]. These chronic conditions are potentially mediated through food insecurity’s adverse effects on diet quality[6], a symptom of the structural barriers to accessing affordable, nutritious food.    

To ameliorate hunger and food insecurity, the federal government operates several nutrition assistance programs, the largest of which is the Supplemental Nutrition Assistance Program (SNAP)[7], formerly known as “food stamps.” In recent years, SNAP has provided more than $100 billion in benefits to income-eligible households to expand their monthly food budgets[8]. Yet, while participation substantially reduces the risk of household food insecurity[9,10],SNAP benefits do not fully close the gap between low-income households’ financial resources and the monthly costs of sufficient, nutritious food for many participating families[11,12]. Nearly half of SNAP participants still report food insecurity[2] and participation in SNAP does not consistently improve diet quality[13].

SNAP benefit amounts are calculated for each household based on its characteristics (e.g., size, income, disability) and a maximum amount given in the U.S. Department of Agriculture’s Thrifty Food Plan, the least costly of four food plans developed by the USDA to outline dietary compositions that meet nutritional needs at various expenditure levels[14]. The Thrifty Food Plan, however, has been long criticized for contributing to the inadequacy of SNAP benefits that prevent households from meeting their nutritional needs[15,16]. In particular, while the Thrifty Food Plan had been adjusted for inflation since its inception in the 1970s, the plan had not been modernized to account for significant changes in the food environment, in sociocultural patterns (e.g., the majority of women entering the workforce, less time available for food preparation), and in nutrition research over the past half century[16].

In the 2018 Farm Bill (The Agriculture Improvement Act of 2018)[17], Congress ordered the U.S. Department of Agriculture to reevaluate the Thrifty Food Plan by 2022 and every five years thereafter. After the release of a revised Thrifty Food Plan in 2021, SNAP-participating households received a 21% increase in benefits, which translated to an increase of approximately $36/month or $1.20/day per person[18]. While increasing food assistance generally reduces food insecurity[19], it is unclear whether this specific increase positively impacted food insecurity and diet quality; only one study has so far evaluated potential impacts of the Thrifty Food Plan revision on food insecurity and diet quality among adults with low-incomes[20].

Building on this one prior evaluation of the Thrifty Food Plan revision, this study uses a difference-in-differences approach, supplemented by a reflexive thematic analysis of study participants’ written comments about experience with using SNAP, to evaluate differences in adult diet quality and household food security by SNAP participation from before to after the Thrifty Food Plan-related benefit increase among a representative sample of adults with low incomes in one U.S. state (Massachusetts).

 

Comment 2: Clearly state what makes this study different from previous research.

Response 2: Thank you for this suggestion. In our effort to shorten the Introduction, we included a brief statement about the one existing study of this specific topic on lines 81-91 (changes underlined):

While increasing food assistance generally reduces food insecurity[19], it is unclear whether this specific increase positively impacted food insecurity and diet quality; only one study has so far evaluated potential impacts of the Thrifty Food Plan revision on food insecurity and diet quality among adults with low-incomes[20].

Building on this one prior evaluation of the Thrifty Food Plan revision, this study uses a difference-in-differences approach, supplemented by a reflexive thematic analysis of study participants’ written comments about experience with using SNAP, to evaluate differences in adult diet quality and household food security by SNAP participation from before to after the Thrifty Food Plan-related benefit increase among a representative sample of adults with low incomes in one U.S. state (Massachusetts).

 

Comment 3: Include an explanation of the assumptions behind the difference-in-differences approach, especially the parallel trends assumption, in the Methods section.

Response 3: We appreciate this suggestion. For the brevity’s sake, we did not elaborate on how each assumption was met. However, we did describe the limitations of our approach relative to some assumptions in our Limitations section. We moved this text to the Methods instead as requested. Please see revised text on lines 231-241 (changes underlined):

We deemed the difference-in-differences approach to be an appropriate analytical approach for our research aims despite being unable to formally test for violation of the parallel trends assumption. However, pre-pandemic trends in diet quality[30] and food security[31] did not differ for households with low incomes that used SNAP and those that did not. Moreover, there is no evidence of exposure to an event during 2020-2022 that would have disproportionately impacted SNAP households vs. non-SNAP households with low incomes that could explain differences in diet quality or food security. For example, while many households with low incomes accessed pandemic-era food assistance programs (e.g., food pantries, food boxes, free school meals)[32,33], program impacts were not expected to differ by household participation in SNAP.

 

Comment 4: Add a brief note on how missing data might affect the results to the Methods section.

Response 4: Thank you for this suggestion. We thought this might be best to include in the Limitations section of the Discussion. Please see added text on lines 455-458:

Last, missing data in our sample, if determined to be systematic, could have prevented our sample from being representative of Massachusetts adults with low incomes.

 

Comment 5: Some tables are quite dense.

Response 5: We reviewed the tables and unfortunately could not locate any text that could be omitted. In a request from Reviewer 3, we omitted many of the acronyms, so we hope this makes the tables easier to read. For Table 3, we wanted to be sure to include a representative quote from each time period (pre-increase and post-increase).

 

Comment 6: Better emphasize main findings in text.

Response 6: Thank you for this suggestion. While we report the main findings in the text (ie, no difference in PDQS or food security), we think it is best to leave the in-depth explanation of the results in Table 2 since the model involves multiple parameters. We think the table notes where we clearly explain the interpretation of each parameter would be too wordy and confusing to include independently in the main text.

For the qualitative component, we provided a succinct explanation of each theme in the main text, while also explaining these themes were found across both time periods (pre- and post- increase). We included at least two representative quotes for each theme in the main text. We believe expanding on these findings in the manuscript text would be a lengthy addition; however, we would be open to expanding the section if the editor advises.

 

Comment 7: Better link the qualitative results with the quantitative findings.

Response 7: Thank you for this suggestion. We added the following paragraph to better link the qualitative and quantitative results from lines 366-380.

We identified several consistencies in the status of adult diet quality and household food insecurity before and after the 21% permanent increase to SNAP benefits across the qualitative and quantitative findings. First, the qualitative findings described in theme 1 (i.e., increased benefits were still not enough to consistently meet household food needs) were also reflected in the results of the difference-in-differences analysis—there were no significant differences in household food security by SNAP participation before the Thrifty Food Plan increase or from before to after the increase. In theme 2, opinions were mixed among SNAP participants as to whether the increased benefits allowed them to purchase nutritious foods. These findings are consistent with the quantitative findings that adult diet quality did not differ by SNAP participation before the Thrifty Food Plan increase or from before to after the increase. In theme 4, the SNAP participants described how increased SNAP benefits were not enough to offset rising food costs and inflation, and thus, still experienced food insecurity. Similarly, additional gains in household food security were not observed among SNAP households compared to SNAP-eligible households in the difference-in-differences analysis.

 

Comment 8: Expand slightly on practical or policy implications.

Response 8: We appreciate this request; however, we want to be careful not to expand too much on the practical and policy implications beyond what we have already included (see lines 408-411, 418-424, 430-438) based on the comments from Reviewer 3 about keeping discussions accessible to those without knowledge of SNAP.

Reviewer 3 Report

Comments and Suggestions for Authors The title is not fit for purpose. Most of the international readership won’t understand the meaning of ’SNAP’.  The title doesn’t point to food or any territory. I have worked in the field of Food Security for 20 yrs outside of the USA & I didn’t have any understand of what the paper was about from the title.    This disclarity continues into the abstract. I got that you were talking about the USA from ‘Massachusetts’, but it is insufficiently clear especially considering that the original ‘Boston’ is on the East coast of England & was a historically important medieval port in the 12^th - 16^th centuries. Your Boston was so named since several of the colony’s leaders came from the original. I guess you can guess my nationality making such points!  Ignore me, but my point really is that it is not sufficiently clear, title or abstract to the international audience - you’ve assumed that the readership will know SNAP & Boston which are not reasonable assumptions in my view.     What we are left with is a study on a one country programme in one state, but the data is drawn around the time of the global pandemic where there was a great deal of 'data noise'.  This 'data noise' really does fundamentally challenge any findings that the paper generates since it cannot be said that the results reflect the increase in SNAP amounts. This point is acknowledged in the paper on p12 and rather draws the value of the whole study findings into question.   There is no attempt made to broaden the discussion making inferences from the findings beyond the specific scheme. I would caution against doing so given the voiced concerns around data validity, however to publish in an international journal some attempt to conceptualise findings and to suggest broader application would be expected.    While the paper is well detailed and academic English is generally clear the over use of acronyms is troubling and makes it difficult to read. Some of this would be hard to avoid, but I found myself having to stop and translate many sentences flipping back and forth to the helpfully provided glossary. Writing out fully would often have enhanced the readability of the paper.  Indeed some acronyms are not included in the glossary and never explained in the paper - I still have no idea what SSBs are, as an example - I don't believe that the meaning of this frequently used acronym is ever made.  This makes me return to my first point. This paper has been written casually, making too many assumptions of the reader. Most won't know what SNAP is, won't automatically assume that the Boston you refer to is in the USA rather than the historic original, and most won't be familiar with your acronyms or know what SSBs are.

Author Response

Comment 1: Revise the title and abstract to be applicable to an international audience.

Response 1: Thank you for this comment. We revised the title as advised for clarity. The new title reads, “Evaluating differences in food security and diet quality from before to after permanent benefit increases to the United States’ largest food assistance program.”We also revised the abstract to better describe the location of the study and to provide context about SNAP. Please see revised text underlined below for lines 20-27:

Background/Objectives: The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States providing income-eligible households with cashlike assistance to spend on food. In October 2021, a historic policy change permanently increased benefit amounts by 21 percent. This study assessed differences in diet quality and food security, supplemented by participant descriptions of using SNAP, among adults with low incomes residing in the state of Massachusettsfrom before (October 2020 – January 2021) to after (December 2021 – February 2022) benefit increases.

We also added U.S. to all table and figure titles.

 

Comment 2: 'Data noise' really does fundamentally challenge any findings that the paper generates since it cannot be said that the results reflect the increase in SNAP amounts. This point is acknowledged in the paper on p12 and rather draws the value of the whole study findings into question.

Response 2: We understand your concern about data noise during the pandemic; however, there have been numerous evaluations of COVID-era safety net policy changes that have still yielded important results, for example:

• Wang G, Collin DF, Karasek D, Hamad R. The 2021 Child Tax Credit and Children's Health and Well-Being: Evidence From a National Longitudinal Study. Milbank Q. 2026 Mar;104(1):116-135. doi: 10.1111/1468-0009.70064. Epub 2025 Dec 10. PMID: 41369253; PMCID: PMC13042757.
• Shafer PR, Gutiérrez KM, Ettinger de Cuba S, Bovell-Ammon A, Raifman J. Association of the Implementation of Child Tax Credit Advance Payments With Food Insufficiency in US Households. JAMA Netw Open.2022;5(1):e2143296. doi:10.1001/jamanetworkopen.2021.43296

Additionally, as outlined in Figure 1, the issuance of federal “emergency allotments” and then removal did not interfere with the timing of the Thrifty Food Plan re-evaluation. We are unaware of any evidence suggesting “uncommon shocks” occurred between SNAP-participants and SNAP-eligible participants relative to food security supports during this time frame. Moreover, we controlled for utilization of other food supports/programs in our analysis to better isolate the association between SNAP increases and study outcomes.  

While we acknowledge the limitation, we do not think this possible noise should preclude our study of this historic policy change. We also believe our qualitative findings support the validity of our findings as there were consistencies with the qualitative data. See response 7 to Reviewer 2.

 

Comment 3: Broaden the discussion to conceptualize findings for an international audience since this is an international journal.

Response 3: Thank you for sharing your perspective on making findings more relevant to international audiences. We want to be careful not to extrapolate findings from our study of SNAP to food assistance programs in other countries with different social safety nets and economic contexts. We have added the following sentence to the Limitations section of the Discussion to explain this on lines 445-447 (changes underlined):

Results also may not be generalizable to SNAP participants outside of Massachusetts and are limited to the U.S. context.

4. Reduce the number of acronyms.

 

We omitted all acronyms in the text except Supplemental Nutrition Assistance Program (SNAP) and PDQS (Prime Diet Quality Score) since we use these terms quite frequently. We used TFP (Thrifty Food Plan) in some Figures due to space constraints.

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

 

I appreciate that you solve all the requirements.

 

Best wishes

Author Response

Thank you for your review!