Azusa Saigusa, Maki Inoue, Pablo Monsivais, Roseann Torkelson, Ruiwen Qin , Shih-hui Yang

1. Exploring the links between Food Insecurity and Obesity Azusa Saigusa, Maki Inoue, Pablo Monsivais, Roseann Torkelson, Ruiwen Qin, Shih-hui Yang

2. How is Food Insecurity defined? • Food Insecurity (FI): Limited or uncertain availability of nutritionally adequate or limited or uncertain ability to acquire acceptable foods in socially acceptable ways. - Food Insecurity may or may not co-exist with hunger • Hunger: Uneasy or painful sensation caused by a lack of food. - Food insecurity may relate to involuntary hunger resulting from not being able to afford enough food.

3. How is FI measured? • The U.S. Census Bureau began implementing the first Food Security Supplement to its Current Population Survey in 1995. • Validated questionnaire that consists of 18 questions • Surveys conducted in person or by telephone • Measures a persons experience over the preceding 12 months • National data for FI have been collected since 1995.

4. Single Item Scale

5. 18 Scale Items

6. FI & Obesity Prevalence Food Insecurity - Households with incomes below the poverty line - Households with children under 18 - Women - Hispanic or African-American - The South and West, and central cities Obesity - Poor to low income adults - Women in low income households - African-American and Hispanic

7. FI is linked to overweight & obesity… why? How? • 1995 First publication of the potential association • (Dietz et al. ) • Townsend et al. • 2004 Kaiser et al. Limitations - Discrepancy in measurement tools - Few response variables 　 - Cross-sectional analyses

8. What are the features of FI? • Anxiety that the household food budget or food supply may be insufficient to meet basic needs • The experience of running out of food, without money to obtain more • Perceptions by the respondent that the food eaten by household members was inadequate in quality or quantity • Adjustments to normal food use, substituting fewer and cheaper foods than usual • Instances of reduced food intake by adults in the household, or consequences of reduced intake such as the physical sensation of hunger or loss of weight • Instances of reduced food intake, or consequences of reduced intake, for children in the household

9. Proposed Mechanisms • Physiological factors • Psychological factors • Socioeconomic factors

10. Fluctuations in eating habits could result in the body becoming a more efficient user of energy, meaning that the individual could increase in weight without eating more calories. Physiological Mechanisms Energy restriction only produces a transient hypothyroid-hypometabolic state, which normalizes on return to energy-balanced conditions.

12. Dallman et al, Endocrinology 2004

14. PsychologicalMechanism “Food Stamp Cycle” : food acquisition cycle which synchronizes with food stamp distribution 42% of food stamp month households conduct grocery shopping once per month or less. Parke.et.al.Amer. J. Agr. Econ. 82, Feb. 2000: 200-213

15. Disordered Eating Periods without food could cause individuals to overeat when food is available. - Minnesota study - Dieters, prisoners of war, and children with food restrictive parents High prevalence of obesity among low-income women - Mothers in low-income families sacrifice their own nutrition in order to give more food to their children.

16. EconomicMechanism • Energy density V.S. Energy cost Energy-dense foods cost less • Diet quality People consume less fats and refined sugar as their incomes increases

17. EconomicMechanism • The prevalence of fast food restaurants The density of fast food restaurants is much higher in poorest areas. • Supersizing: Value-for-money

18. What are we doing about this? Food aid programs are targeted to populations who experience FI Education WIC education Food Stamp education EFNEP Other Programs Head Start

19. The Foods Stamp Program of the USDA • Target population & goals: • The cornerstone of the Federal food assistance programs. FSP enables low-income (135% of poverty or less) families to buy nutritious food with coupons and Electronic Benefits Transfer (EBT) cards. • Services: • Food coupons and Electronic Benefits Transfer (EBT) cards. • Nutrition education: The Food Stamp Nutrtition Education Program, aimed at helping FSP participants make healthy choices within a limited budget. • Relation to food insecurity and obesity: • 88% of recipients are at or below the poverty line (2001) • Nationally, 50% of households on the FSP are food insecure (1999)

20. The National School lunch Program of the USDA • Target population & goals: • NSLP provides children from low-income households (180% of poverty or less) with nutritionally balanced meals for free or reduced prices. • Services: • 26 million children served each day (2003). • Lunches provide 1/3 of daily energy intake and must meet the recommendations of the Dietary Guidelines for Americans • Relation to food insecurity and obesity: • Participating students are disproportionately black and Hispanic and more likely than non participating students to live in either urban or rural areas, rather than in the suburbs. The local unemployment rate is higher, on average, in the areas where certified students live than in the areas where noncertified students live (1992).

21. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Target population & Goals: • Safeguard the health of low-income(180% or less) women, infants, and children up to age 5 who are at nutrition risk Services: • Health screening, Nutrition and health education, Breastfeeding support • Farmers Market Nutrition Program • Healthy Community Project; Moses Lake Relation to food insecurity and obesity: • 53% of WIC participants are food insecure • focus on the maintenance of pregnant and postpartum women and children’s ideal body weight for the prevention of obesity.

22. Expanded Food and Nutrition Education Program (EFNEP) Target population and Goals: • To assist low-income families and youth to acquire the knowledge, skills, attitudes, and behaviors necessary for nutritionally sound diets • To contribute to personal development and the improvement of total family diet and nutritional welfare Services: • Lessons on nutrition, cooking skills, food safety, and food budgeting Relation to food insecurity and obesity: • Focus on population who are most likely to be food insecure • Help the higher risk population balance food resources and avoid obesity

23. Head Start Target population: - Pregnant women and children from birth to age 5 from low-income families Services: - Daily nutritious meals - Opportunities for social, emotional, and intellectual growth - Connects children to a health care source Goal: - Increase the school readiness of young children in low-income families Relation to food insecurity and obesity: - As high as 48.8% participating households are food insecure - 9.6-28% participating kids are overweight. Screen obesity problems. - Promotes breastfeeding.

24. Food insecurity Grocery stores; Free/low cost physical activity facilities Environment: Fast food outlets Assistance programs; Different methods to distribute food assistance. Psychological factors: Food acquisition cycle; Disordered eating Different price balance of healthy foods and energy dense foods - + Physiological factors: Stress Education: Wise choice of foods; Financial planning; Food preparation and storage of fresh foods Food choices: Cheap foods; Energy dense; High in sugar and fat; Palatable Research: Understanding of mechanisms: Other possible strategies Obesity/Overweight