Food Insecurity and Overweight in WIC Clients

1. Food Insecurity and Overweight in WIC Clients A Community Nutrition Project by University of Washington Students Winter 2005

2. Food insecurity • Food insecurity (FI): Occurs whenever the availability of nutritionally adequate and safe foods, or the ability to acquire acceptable foods in socially acceptable ways, is limited in socially acceptable ways is limited or uncertain.1 • Prevalence of FI: • US: 11.0%2 • WIC clients: 53.7%1 • FI in King county -- BRFSS survey results1 • Percent of adults concerned about having enough food for themselves or their families in the past 30 days: • Seattle: 5.5%; North: 4.7%; East: 2.7%; South: 4.6%

3. The FI-obesity link • People in poor to low income households are more likely to be obese than people in higher income households • The association of food insecurity and obesity is more prevalent in women than in men, and more prevalent in African-American and Hispanic populations than in other ethnic groups3,4,5,6,7

4. Socioeconomic and Environmental Factors • People with FI have limited food choices due to their financial constraints • Cheaper foods are often energy dense and higher in refined sugar and fat8 • Higher density of fast food outlets in low income communities9

5. Psychophysiological factors • People with FI have elevated levels of stress • Chronic stress can result in a series of physiological events that lead to impaired energy balance regulation: increased food intake and reduced energy expenditure10 • Periods of hunger or fear of hunger lead to overeating when food is available, which can lead to an increased total energy intake11 • Food acquisition cycle in low-income households: 42% of food stamp households conduct grocery shopping ≤1 time per month12

7. Conducting focus groups inWIC clinics Focus groups: a common qualitative research tool used to generate data from a small group of a selected population.13 • 6 focus groups at 3 WIC sites • Participation: 2-8 participants per group, total 30 females • Locations: Eastgate , Kent Alder Square, and Renton • Date: February 18, 2005 • Eligibility: WIC clients; at least 18 years old; English speaking

8. Conducting Focus Groups inWIC Clinics (cont.) • Recruitment: UW students introduced the study and gave flyers to potential participants at each site for two weeks before the focus groups session • Incentive: $25 gift certificate for participation in the discussion • Data analysis:transcriptions were analyzed and coded based on common themes -- four overarching themes were identified

9. Overview of focus groups questions • Goal: to obtain clients' perspective & suggestions about the link between FI and overweight • The questions are divided into two parts: • Food insecurity • Healthy weight

10. Sample focus group questions • How do you think a child’s health is affected by not having enough food? • What do you think are some reasons why some families have trouble having enough food to feed their families? • If you knew someone (a friend) who was worried about running out of food, what are some things you would tell her to do? • If you were in the situation of running out of food and not having enough money for food for you and your children, what could WIC do that would be most helpful? • People who don’t have money to buy enough food, compared to those that do, are more likely to be overweight. What do you think could be the cause of this? • If a woman on WIC wanted help with her weight after having a baby, what could WIC offer or provide that would be most helpful to her? This is only a partial list of all the questions asked.

11. Main findings14 Participants indicated that they know the differences between healthy and unhealthy foods – it is other factors that are leading to becoming overweight • Lack of time and financial resources • Stress and fear of hunger • Poor quality of food in emergency food programs • Lack of exercise resources

12. Lack of financial and time resources • Participants identify cheaper foods as “bad” foods and “healthy” foods as expensive foods • “Bad” foods are also more convenient and easy to prepare “Sometimes when people don’t have enough money to buy food, then that makes them prone to go get whatever is cheaper...” “People are so pressed for time, they have to fit so many things into the day, you have all these dollar menus and everything and you don’t want to get out of the car so you are looking for things that are only drive-thru.”

13. Stress and fear of hunger • Participants identified a relationship between stress, hunger, and overweight • A fear of future hunger can lead to overbuying and overeating food now “Food hording; oh yes!!! Because when you don’t think you’re going to have enough you buy too much, and you will end up eating it.” “[S]ometimes you just eat because you’re stressed out, so you get ice cream...you keep eating and eating ‘cause you don’t have enough food, you don’t have any food so you just want to eat. That makes you feel better.”

14. Poor quality of food in emergency food programs • Participants look to emergency food assistance programs to get enough food to feed their families, in cases where the WIC amount wasn’t enough • They often perceive food from these sources to be junk food, the consumption of which leads to becoming overweight “[W]hen you run out of food and go down to the food banks they load you up with donuts and bread and it’s hard to balance your diet that way.”

15. Lack of exercise resources • Participants recognize exercise as being part of a way to address the problem of overweight • They would like more information and resources for themselves and for their children, and some would like a health professional to give the information “I didn't know that there were certain things I could do with him when he was 3 months old, like swimming or whatever or like that, that could have stopped him from being in the 97th percentile.”

16. WIC focus group findings compared to the existing literature • New relationships identified: • Use of emergency food programs in addition to using WIC, may contribute to overweight because of the poor food quality in some of these programs • Lack of resources can prevent people from exercising, although participants recognize that exercise is an effective way to prevent overweight • In addition to a lack of financial resources, leading to the purchase of cheaper, “bad” foods, people lack the time to prepare healthier meals and find it more efficient to purchase these foods

17. Recommendations • Increasing access to and education about nutrition and physical activity addresses the concerns raised by the focus group participants • Increasing access to and expanding existing services will also address the main problems identified in the focus groups

18. Recommendations for Access • Increase flexibility of WIC benefits • Selection should incorporate alternatives for food allergies and cultural preferences • Consider increasing the number of stores clients are able to purchase food from • Implement EBT system for clients to be able to use WIC benefits more flexibly • Establish a network of organizations that offer nutrition and physical activity programs and activities, so that referrals can be made for sites that are most appropriate and convenient for each mother and child

19. Recommendations for Education Nutrition: • Offer suggestions for increasing food variety and give recipes to make “quick,” healthy meals • Hold workshops and create booklets about meal planning and budgeting Physical Activity: • Provide information about exercise for mothers and age-appropriate information about exercise for children • Offer post-partum workout videos

20. Suggested interventions for WIC • Continue advocating for use of EBT cards to purchase WIC food items to make food acquisition more flexible for clients • Improve nutrition education by providing practical cooking demonstrations about how to cook culturally appropriate recipes on a budget • Increase the availability of physical activity groups that parents and children can do together • Provide information on low-cost physical activity resources available in the community

21. References • DiGiorgio, L. & Oberg, D. WIC & Food Insecurity: UW Community Nutrition – 531. Powerpoint Presentation. January 7, 2005. • ERS. Household Food Security in the United States, 2003. www.ers.usda.gov/publications/fanrr42/ • Olson CM. Nutrition and health outcomes associated with food insecurity and hunger. J Nutr. 1999;129(2S Suppl):521S-524S. • Adams EJ, Grummer-Strawn L, Chavez G. Food Insecurity is Associated with Increased Risk of Obesity in California Women. J Nutr. 2003;133:1070-1074. • Kaiser LL, Townsend MS, Melgar-Quinonez HR, Fujii ML, Crawford PB. Choice of instrument influences relations between food insecurity and obesity in Latino women. Am J Clin Nutr. 2004;80:1372-1378. • Alaimo K, Olson CM, Frongillo EA Jr. Low Family Income and Food Insufficiency in Relation to Overweight in US Children: Is there a paradox? Arch Pediatr Adolesc Med. 2001;155:1161-1167. • DOH. The Health of Washington State-Nutrition. www.doh.wa.gov/HWS/doc/RPF/RPF_Nut.doc • Drewnowski A, Specter SE. Poverty and obesity: the role of energy density and energy costs. Am J Clin Nutr. 2004;79:6-16. • Reidpath DD, Burns C, Garrard J, Mahoney M, Townsend M. An ecological study of the relationship between social and environmental determinants of obesity. Health Place. 2002;8:141-5. • Bjorntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obes Rev. 2001;2:73-86. • Frogillo AE, Olson MC, Rauschenbach SB, Kendall A. Nutritional consequences of food insecurity in a rural New York State county. University of Wisconsin-Madison, Institute for Research on Poverty. Discussion paper. 1997:1120-1197. • Parke E Wilde, Christine K Ranney. The monetary food stamp cycle: Shopping frequency and food intake decisions in an endogenous switching regression framework. Am J Agric Econ. 2000;82:200-213. • Krueger, RA. Moderating Focus Groups. from Focus Group Kit. Sage Publications. 1998. • Nutrition 531: Community Nutrition. University of Washington. “Analysis Summary: WIC Focus Groups.” 2005.

22. Thank you!