A Periodical Review of Research and Action
Issue 3 | April 2011
PDF Version | Online Version
In This Issue
New from FRAC -
FRAC Brief: Food Insecurity and Obesity - Understanding the Connections
Reports and Resources
New from FRAC
FRAC Brief: Food Insecurity and Obesity -
Understanding the Connections
While all segments of the population are affected, food insecure and low-income people are especially vulnerable to obesity due to the additional risk factors associated with poverty. Our last newsletter featured a brief on the complicated relationship between obesity and poverty (Do the Data Show a Relationship between Poverty and Obesity? - pdf). Now FRAC is focusing on obesity and food insecurity in a new article, Food Insecurity and Obesity: Understanding the Connections. The article highlights research on food insecurity and obesity, and also explores how food insecure and low-income people are vulnerable to obesity due to the additional risk factors associated with poverty.
What Does the Research Say About Food Insecurity and Obesity?
As more fully detailed in the article, food insecurity and obesity can co-exist in the same individual, family, or community. The research on whether there is a relationship, however, provides mixed results. A number of research studies in the U.S. and abroad have found positive associations between food insecurity and overweight/obesity. Other studies have found no relationship, or even a lower risk of obesity, with food insecurity. Overall, the strongest and most consistent evidence is for a higher risk of overweight/obesity among food insecure women. Although the research for children is not as consistent as it is for women, several studies do find a significant association between food insecurity and overweight/obesity among children.
Why Can Food Insecurity and Obesity Co-Exist?
The fact that food insecurity and obesity are associated (in many studies) for women and children does not necessarily mean they are causally linked to each other. Both food insecurity and obesity can be consequences of low income and the resulting lack of access to enough nutritious food. More specifically, obesity among food insecure people – as well as among low-income people – occurs in part because they are subject to the same influences as other Americans (e.g., more sedentary lifestyles, increased portion sizes), but also because they face unique challenges in adopting healthful behaviors, including:
- Limited resources
- Lack of access to healthy, affordable foods
- Fewer opportunities for physical activity
- Cycles of food deprivation and overeating
- High levels of stress
- Greater exposure to marketing of obesity-promoting products
- Limited access to health care.
Read more (pdf).
National data on child obesity and socioeconomic status.
New data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) demonstrate the complicated, and often inconsistent, relationship between obesity and income in the U.S. Overall, low-income children and adolescents (household income below 130 percent of the federal poverty level) were more likely to be obese than their counterparts of higher income, although the relationship between obesity and income was inconsistent across racial-ethnic groups. The same was true for obesity and education. Obesity rates significantly increased with decreased income among White boys and girls, but no significant trends with income emerged among Black or Mexican-American boys and girls. Although not statistically significant, obesity rates among Mexican-American girls actually were the lowest in the low-income category (16.2 percent) compared to the middle-income (21.8 percent) and high-income (21.0 percent) categories. Furthermore, obesity rates increased at all income and education levels between the 1988-1994 and 2005-2008 surveys. And among all obese children and adolescents, 38 percent were low-income – that is, most obese children and adolescents (62 percent) were not low income.
Source: Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconomic status in children and adolescents: United States, 2005-2008. NCHS Data Brief, 51, 1-8.
National data on adult obesity and socioeconomic status.
The relationship between obesity and income differs by gender and race-ethnicity among adults based on additional analyses from the recent 2005-2008 National Health and Nutrition Examination Survey (NHANES), discussed above with respect to children. Among men, obesity rates were fairly similar across income groups, although they tended to be slightly higher at higher levels of income. In fact, among Black and Mexican-American men, those with higher income were significantly more likely to be obese than those with low-income. Among women, obesity rates tended to increase with decreased income, but this trend was only significant for White women (not Black or Mexican-American women). Obesity rates also increased with decreased education in women, but no significant trend between obesity and education level emerged for men. Similar to children and adolescents, most obese adults (80 percent) were not low-income, and adult obesity rates significantly increased at all income and education levels since the 1988-1994 NHANES survey.
Source: Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconomic status in adults: United States, 2005-2008. NCHS Data Brief, 50, 1-8.
Federal Nutrition Programs and Obesity
Impact of Food Stamp participation on weight-related outcomes.
A new study based on a 2005-2006 national survey of 945 adults highlights the importance of adequate Food Stamp benefit levels in addressing obesity, and also identifies gender differences in weight-related outcomes among program participants. (The survey was conducted before the Food Stamp Program name was changed to the Supplemental Nutrition Assistance Program, or SNAP.) In comparing Food Stamp participants to income-eligible non-participants (controlling for race, age, sex, and education level), Food Stamp participation within the previous year was associated with significantly greater body mass index (BMI) and waist circumference (WC) among women. However, a larger amount of Food Stamp dollars received in the previous month was associated with significantly lower BMI and WC among those women reporting benefit levels. Among male Food Stamp participants, there was no relationship between program participation and BMI or WC, or benefit levels and BMI or WC. In addition, among the full sample of men and women, program participation was associated with significantly fewer meals eaten away from home.
Source: Jilcott, S. B., Liu, H., Dubose, K. D., Chen, S., & Kranz, S. (2011). Food Stamp participation is associated with fewer meals away from home, yet higher body mass index and waist circumference in a nationally representative sample. Journal of Nutrition Education and Behavior, 43(2), 110-115.
Food insecurity, obesity, and food assistance participation in an urban population.
Food assistance programs may play a protective role against obesity among food insecure women, according to a new study set in eight New York City area primary care practices. Of the 558 patients who completed a brief survey, 55 percent received some form of food assistance (i.e., WIC or SNAP), 51.7 percent reported some degree of food insecurity, and 77.3 percent were overweight or obese. Increased levels of food insecurity were significantly associated with increased body mass index (BMI) among women, but not men or children, after adjusting for age, insurance status, language, clinic site, and food assistance participation. Additional analyses revealed that food insecurity was significantly associated with increased BMI in only those women not receiving food assistance.
Source: Karnik, A., Foster, B. A., Mayer, V., Pratomo, V., McKee, D., Maher, S., Campos, G., & Anderson, M. (2011). Food insecurity and obesity in New York City primary care clinics. Medical Care, Epub ahead of print (March 21, 2011).
Food Insecurity and Childhood Obesity
Review of recent studies on food insecurity and childhood overweight/obesity.
Inconsistent results and measurements make it difficult to conclude that food insecurity is associated with overweight/obesity among children and adolescents 2- to 19-years old, although the paradoxical relationship certainly co-exists. This is the main finding of researchers who reviewed 21 studies (20 from the U.S. and one from Canada) published on the topic as of December 2009. More specifically: some studies found that food insecurity was associated with more overweight/obesity, some studies found that food insecurity was associated with less overweight/obesity, and some studies found no association at all. In earlier studies, methodological limitations were partly to blame for mixed results (e.g., small sample sizes, using household food insecurity status as a measure of a child’s food insecurity status). More recent studies overcame many of these limitations and found no association. The authors conclude that more research is needed to clarify the relationship at the population level and to better understand why food insecurity and overweight/obesity co-exist at the individual level for so many children and adolescents.
Source: Eisenmann, J. C., Gundersen, C., Lohman, B. J., Garasky, S., & Stewart, S. D. (2011). Is food insecurity related to overweight and obesity in children and adolescents? A summary of studies, 1995-2009. Obesity Reviews, Epub ahead of print (March 8, 2011).
Food Insecurity and Dietary Behaviors
Relationship between food insecurity and dietary behaviors among low-income adults.
Those who were food insecure consumed diets higher in fruit (including juice) and fat compared to those who were food secure in a study of 1,874 predominantly low-income adults in Rhode Island who volunteered to participate in a nutrition education study and completed a baseline telephone survey as part of the study. Half of participants were food insecure, 85 percent were female, and 55 percent were Hispanic. In analyses that adjusted for age, sex, ethnicity, education, and marital status, those who were food insecure consumed significantly more fruit, although this finding was driven by greater fruit juice intake rather than whole fruit intake. No other significant differences emerged in fruit and vegetable intake by food security status. In analyses that controlled for a variety of demographic characteristics, food insecure participants were less likely to engage in several fat-lowering behaviors, including avoiding fat as a flavoring, modifying meats to be low in fat, and replacing high-fat meats with low-fat alternatives. The authors hypothesize that such lower frequency of fat-lowering behaviors among food insecure respondents could be a result of personal choice, lack of knowledge, the higher cost associated with some of these behaviors, or coping with hunger (e.g., eating the chicken skin for additional calories and to avoid perceived waste).
Source: Mello, J. A., Gans, K. M., Risica, P. M., Kirtania, U., Strolla, L. O., & Fournier, L. (2011). How is food insecurity associated with dietary behaviors? An analysis with low-income, ethnically diverse participants in a nutrition intervention study. Journal of the American Dietetic Association, 110(12), 1906-1911.
Food-related attitudes and behaviors of low-income preadolescent children.
A number of unhealthful and irregular eating patterns emerged – driven, in part, by food insecurity – in focus groups that examined food choices and behaviors, by home, school, and restaurant food environments, among 92 urban, racially diverse, low-income children 9 to 13 years of age in Minnesota. At home and in homeless shelters, children described limited food availability, trying to avoid wasting food, late night eating, and overeating when food was available. At school, most children ate school lunch but many were dissatisfied with meal quality, food safety, and portion sizes. As such, some children periodically skipped the school meal and ate lunch at local fast food restaurants or waited to eat until after school. With regard to restaurants, the children preferred buffets because of the variety of foods that were available in unlimited quantities, and many reported overeating and binge-eating at these establishments. According to the authors, “it appears that some of these low-income children are ‘opportunistic eaters’ who have learned to overeat when food is abundant and tasty.”
Source: Dammann, K. & Smith, C. (2010). Food-related attitudes and behaviors at home, school, and restaurants: perspectives from racially diverse, urban, low-income 9- to 13-year-old children in Minnesota. Journal of Nutrition Education and Behavior, 42(6), 389-397.
Early effects of local wellness policies on healthy eating opportunities in rural Colorado schools.
Local school wellness policies contain vague, weak language, and few evidence-based practices for increasing healthy eating opportunities have been implemented as a result of the policies. These are key findings on the early effects of local wellness policies based on surveys administered to 45 low-income, rural elementary school foodservice managers and principals in Colorado before and after policies were mandated by federal law for all schools participating in the National School Lunch Program. Three key improvements observed between 2005 (before the mandate) and 2007 (after the mandate) were statistically significant increases in the number of: 1) policies stipulating predominantly healthy items be offered in classroom celebrations, 2) fresh fruits offered daily in the cafeteria, and 3) schools using skinless poultry. However, policies were vague and weakly worded, rarely addressed the energy content of foods and beverages, rarely addressed limiting the use of unhealthy ingredients, and (according to foodservice managers during key informant interviews) were not seen as changing lunchroom practices with regard to the nutritional content of meals.
Source: Belansky, E. S., Cutforth, N., Delong, E., Litt, J., Gilbert, L., Scarbro, S., Beatty, B., Romaniello, C., Brink, L., & Marshall, J. A. (2010). Early effects of the federally mandated Local Wellness Policy on school nutrition environments appear modest in Colorado's rural, low-income elementary schools. Journal of the American Dietetic Association, 110(11), 1712-1717.
Relationship between food venue density and obesity in metro and non-metro U.S. counties.
The presence of more food venues per capita was associated with lower county-level obesity rates based on an ecologic study using the USDA’s Food Environment Atlas, although the relationship varied by metropolitan status. In the study, researchers adjusted for natural amenities (e.g., climate), race, age, and household income and examined differences by county metropolitan status (i.e., metro versus non-metro). More supercenters and more supermarkets/grocery stores per capita consistently were associated with lower obesity rates for all U.S. counties as well as metro counties, but no significant relationships emerged for non-metro counties for these two types of food venues. In some statistical models, the presence of more farmers’ markets per capita was associated with lower obesity rates in non-metro counties. No significant relationships were observed for farmers’ markets and obesity in any of the analyses among all U.S. counties or metro counties.
Source: Jilcott, S. B., Keyserling, T., Crawford, T., McGuirt, J. T., & Ammerman, A. S. (2011). Examining associations among obesity and per capita farmers' markets, grocery stores/supermarkets, and supercenters in US counties. Journal of the American Dietetic Association, 111(4), 567-572.
Community-based risks for obesity among youth in the rural Deep South.
Race relations, poverty, and the built environment are among the barriers to maintaining a healthy weight for African American youth in a rural, low-income community in the Deep South. These are key findings from a recent study that examined upstream factors that could influence overweight and obesity risk. Researchers conducted in-depth interviews of 18 African-American community residents who interact with African-American youth in a variety of contexts (e.g., school, church). Participants identified racism and poverty as stressors for the youth in their community, and the researchers note that such external stressors can contribute to obesity. The lack of access to healthful food and physical activity venues were commonly reported by participants, and seen as intersecting with both racism and low socioeconomic status.
Source: Scott, A. J. & Wilson, R. F. (2011). Upstream ecological risks for overweight and obesity among African American youth in a rural town in the Deep South, 2007. Preventing Chronic Disease, 8(1), A17.
Relationship between household or individual psychosocial stressors and childhood obesity.
Social safety net programs that reduce financial stress for families may, by extension, have the added benefit of reducing childhood obesity, according to researchers who reviewed the scientific literature on psychosocial stressors and childhood obesity. As more fully detailed by the researchers, stress can lead to weight gain through metabolic changes in the body and maladaptive coping behaviors (e.g., over-eating, lack of exercise). In 10 of the 11 reviewed studies focused on psychosocial stressors in the household, at least one measure of stress was associated with childhood overweight or obesity, including low self-esteem, financial strain, maternal depression, neglect, maternal stress, and maternal distress. Eight additional studies included in the review focused on psychosocial stressors at the individual level. Depressive symptoms were associated with obesity or greater body mass index in the four studies on depression. In the other four studies at the individual level, increased psychosocial stressors increased the likelihood of being overweight or obese. The findings of the review have “implications for policy in terms of providing more incentive to reduce the stress to which children are exposed on a daily basis.”
Source: Gundersen, C., Mahatmya, D., Garasky, S., & Lohman, B. (2010). Linking psychosocial stressors and childhood obesity. Obesity Reviews, Epub ahead of print (November 3, 2010).
Reports and Resources
The reports and resources highlighted below were chosen because of their focus – in whole or in part – on poverty, low-income, hunger, and/or the federal nutrition programs.
U.S. Department of Agriculture and U.S. Department of Health and Human Services: Dietary Guidelines for Americans, 2010
The U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) jointly released the Dietary Guidelines for Americans, 2010 early this year (2011). Congress has required that the Dietary Guidelines be revised every five years to provide evidence-based guidance to promote health, reduce chronic disease risk, and reduce obesity prevalence among Americans two years of age and older. They serve as the foundation for federal nutrition programs and educational efforts - directing, for example, what is served in school meals, offered in the WIC food package, and included in SNAP/Food Stamp educational materials.
The Dietary Guidelines for Americans, 2010 address the nation’s obesity problem by encouraging Americans to balance calorie intake with physical activity in order to achieve and maintain a healthy weight. The latest edition specifically recommends increasing the consumption of nutrient-dense foods and beverages like fruits, vegetables, and fat-free and low-fat dairy; consuming at least half of all grains as whole grains; and choosing a variety of protein foods (e.g., seafood, lean meat and poultry, beans, unsalted nuts). At the same time, Americans are encouraged to reduce sodium, added sugar, solid fat, and refined grain intake.
Unlike prior editions, this seventh edition includes a Call to Action to support individuals and families in meeting the Dietary Guidelines. One of the three guiding principles of this Call to Action is to “ensure that all Americans have access to nutritious foods and opportunities for physical activity.” To achieve this principle, several strategies are outlined in the report, such as improving access to safe and affordable nutritious foods, promoting participation in the federal nutrition assistance programs to increase food security, and expanding access to grocery stores and other sources of healthy food.
Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2010). Dietary Guidelines for Americans, 2010. 7th Edition. Washington, DC: U.S. Government Printing Office.
Institute of Medicine Workshop Summary: Hunger and Obesity: Understanding a Food Insecurity Paradigm
The Institute of Medicine (IOM) recently released a document summarizing information from an IOM public workshop held in November 2010 in Washington, DC. The workshop explored the relationship between food insecurity and obesity in the United States, the current state of research on this issue, and new data and analyses needed to further understand and address this complicated relationship. A number of experts in the field presented at the IOM workshop, including FRAC’s President Jim Weill. During the workshop, Weill pointed out a variety of positive impacts the federal nutrition programs have on nutrition and health. He pointed also to the types of research needed to deepen the understanding of the intersection of hunger, poverty, obesity, and the federal nutrition programs.
Source: Institute of Medicine. (2011). Hunger and Obesity: Understanding a Food Insecurity Paradigm - Workshop Summary. Washington, DC: The National Academies Press.
Leadership for Healthy Communities Brief: Making the Connection – Linking Economic Growth to Policies to Prevent Childhood Obesity
A new brief from Leadership for Healthy Communities, a national program office of the Robert Wood Johnson Foundation, offers a number of policy recommendations that will jointly stimulate economic growth and contribute to ending childhood obesity. Two of the five overarching themes of these policy recommendations are: addressing local food deserts and improving access to local healthy foods. Specific recommendations outlined in the brief include the following: conduct a food mapping assessment to identify food deserts; provide incentives to promote healthy food retail development in underserved areas; require developments and redevelopments to include healthy food retail in their planning; require stores to accept electronic benefit transfer (EBT) cards for the Supplemental Nutrition Assistance Program (SNAP); and provide subsidies to farmers’ markets that accept EBT cards for SNAP.
Source: Leadership for Healthy Communities. (2011). Making the Connection – Linking Economic Growth to Policies to Prevent Childhood Obesity. Accessed on April 7, 2011.
Let’s Move Toolkit: Let’s Move Cities and Towns – Toolkit for Local Officials
First Lady Michelle Obama has called on mayors and other local elected officials to take a leadership role in the Let’s Move! campaign to end childhood obesity in a generation by becoming a Let’s Move! city or town. To that end, the campaign recently released a toolkit to guide local officials and other key stakeholders in this effort. The toolkit includes ideas for launching a local Let’s Move! campaign, suggestions for policy changes and programs to implement in the local community, and information about available resources. Policy changes outlined in the toolkit include: maximizing participation in the school meals programs and SNAP, encouraging all schools to provide a school breakfast program, and ensuring that residents can access healthy and affordable food through public transportation.
Source: Let’s Move. (2011). Let’s Move Cities and Towns – Toolkit for Local Officials (pdf). Accessed on April 7, 2011.
FRAC Essay: Should soda be excluded from foods food-stamp users can buy?
A recent essay published in CQ Researcher responds to the question: “Should soda be excluded from foods food-stamp users can buy?” FRAC says no, they shouldn’t be restricted, and outlines seven flaws in such a narrow strategy. For instance, there is no evidence that the food stamp (SNAP) program contributes to the U.S. obesity problem, but restrictions on purchases likely would increase stigma and confusion during check-out, possibly leading to a decline in SNAP participation. As noted in the essay, “a narrow strategy of restricting food choice for some vulnerable Americans misses more promising opportunities, such as: supporting SNAP use at farmers’ markets; improving benefit levels so people can afford healthy foods; offering incentives for fruit and vegetable purchases; enhancing SNAP nutrition education; and increasing access to healthy, affordable foods in underserved communities.”
Source: Hartline-Grafton, H. (2010). Should soda be excluded from foods food-stamp users can buy? CQ Researcher, 20(34), 813.
(Copyright CQ Researcher. Reprinted with permission of CQ Press.)
Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute Data Release: Second County Health Rankings
The Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute released its annual County Health Rankings, which rate the overall health of nearly every county in all 50 states as well as the District of Columbia and several other major cities. Unhealthier counties reportedly tend to have less access to healthier foods and higher rates of poverty and unemployment. Using the latest available data, each county was ranked within its state on how healthy people are and how long they live. Counties also were ranked on key factors that influence health, including obesity, access to primary care providers, rates of high school graduation, access to healthier foods, unemployment rates, and the number of children living in poverty.
Source: Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute. (2011). County Health Rankings. Accessed on April 7, 2011.
Centers for Disease Control and Prevention (CDC) Website: Communities Putting Prevention to Work Program
The CDC’s Communities Putting Prevention to Work Program – funded through the American Recovery and Reinvestment Act of 2009 to reduce disease risk and promote wellness for children and adults – recently launched its new website. The site provides tools and resources for community-level change, including those focused on obesity prevention at the local level. For instance, the site offers information on program planning, policy change, media campaigns, and implementation frameworks as well as brief overviews of communities funded through this program.
Source: Centers for Disease Control and Prevention. (2011). Communities Putting Prevention to Work Program. Accessed on April 7, 2011.