USDA Economic Research Service Small Grants Program

Summary of Findings

2006-2007 Summary of Findings

2005-2006 Summary of Findings

2004-2005 Summary of Findings

2003-2004 Summary of Findings

2002-2003 Summary of Findings

2001-2002 Summary of Findings

2000-2001 Summary of Findings

1999-2000 Summary of Findings

  • Do Food Stamps, Food Label Use and Nutrition Knowledge Affect Dietary Quality Among Low-Income Adults: Results from the 1994-1996 CSFII/DHKS, Rafael Perez-Escamilla, Ph.D., University of Connecticut
  • Factors Mediating the Use of Food Assistance Programs and Coping Strategies that Improve Food Security and Nutritional Well-Being Among the Low-Income Hispanic Population, Grace Marquis, Ph.D., Iowa State University
  • Unsafe Food Acquisition Practices Used by Limited Resources Individuals, Debra Palmer-Keenan, Ph.D. and Sylvia Ridlen, Ph.D.,
    Rutgers University
  • Food Stamps, Ethnicity, and Nutrient Supplements: Associations with Food Intake and Knowledge, Attitudes, and Beliefs about Nutrient Supplement Use, David Pelletier, Ph.D., Cornell University
  • Etiology of Iron Deficiency and Iron Deficiency Anemia Among Children Aged 12 months, Sheri Zidenberg-Cherr, Ph.D., University of California, Davis

1998-1999 Summary of Findings

The direct economic effects of a policy to provide government subsidized price discounts for the purchase of fruit and vegetable by food stamp recipients.

Karen M. Jetter, University of California Agricultural Issues Center

Background

 

The purpose of this study is to evaluate the direct benefits and costs to consumers and producers from changes in prices, consumption and production, of a policy to offer government price discounts on fresh fruit and vegetables to food stamp recipients. Increased consumption of fruit and vegetables has been linked to a decrease in dietary related chronic diseases such as heart disease, diabetes and some cancers.  Low socioeconomic status (SES) is strongly associated with higher rates of obesity and high rates of the leading causes of illness and death.  Diet may play an important mediating role in explaining socioeconomic disparities in health status.  Consequently, developing cost effective policies that lead to higher consumption of fruit and vegetables may have a significant impact on the incidence of chronic disease among persistent food stamp recipients.

 

Targeted assistance has been shown to be more efficient at bringing about dietary changes than more general assistance programs. Therefore, a targeted food assistance program such as price discounts on fruit and vegetables may provide substantial benefits to low-income consumers.   Providing a price discount of 25% also directly benefits food stamp consumers through lowering the prices that they pay for fruit and vegetables.  However, a price discount may cause equilibrium market prices to rise for fruit and vegetables, benefiting growers, but making other consumers worse off.

 

Methods

 

The analysis involves using a model of the U.S. fruit and vegetable industry to determine how market prices and quantities change in response to a shock to the system, such as a price discount for one group of consumers.  The model lays out a series of demand and supply equations in log-differential form.  The demand side of the model contains equations for four different consumer groupings:  fruit and vegetable home consumption by food stamp recipients, away from home consumption by food stamp recipients, consumption by other low-income consumers who are below 130 percent of the poverty level but not on food stamps, and all other higher income consumers.  Consumption by food stamp recipients is done separately for food consumed at home as it is assumed that consumers would most likely use food stamps to purchase food from grocery stores for home consumption. 

 

The supply side of the model contains equations for net U.S. trade (U.S. imports minus U.S. exports), market quantity supplied from the agricultural marketing sector (processors and handlers), and production supplied to the marketing sector from growers in California and the rest of the U.S.  The result is a model that links supply and demand in the final market to supply and demand in the marketing sector, and ultimately, to growers’ production decisions.  The solution to the system of equations is the percentage change in retail and grower prices, final quantity demanded by each consumer group in the study, imports and exports, and production by growers in each region.  The percentage changes in prices were used to estimate the changes in economic surplus for growers in California and the Rest of the U.S (RUS), marketing sector, consumers and the tax payer cost of the program.  The model was estimated for 38 commodities.  The commodities included in the study were those for which a complete data set was available.

 

Findings/Discussion

 

Current consumption of all fruit and vegetables is 18.1 cups for food stamp recipients, 16.2 cups for people living below 1.3 of the poverty ratio, but who are not receiving food stamps, and 18.5 cups for people living above 1.3 of the poverty ratio.  While the consumption of fruit and vegetables is similar between food stamp and higher income consumers, both groups are falling below the 24.5 minimum recommended servings for adults in the 2005 Dietary Guidelines for Americans. 

 

Table 1.  Changes in consumption and estimates of benefits and costs for each group.

Weekly Consumption in cup equivalents

Group

Current

Total

Current total for 38 items

New total

for 38 items

Percentage change in consumption

Costs & Benefits

($ millions)

Food stamp

18.1

13.7130

14.4242

5.19

653

Home consumption

 

8.7430

9.4559

8.15

654

Away from home consumption

 

4.9700

4.9683

-0.034

-0.9

Low Income

16.2

13.3525

13.3474

-0.0382

-5

HigherIncome

18.5

15.2565

15.2507

-0.0378

-49

Tax payer costs

 

 

 

 

-681

Growers - California

 

 

 

 

23

Growers - RUS

 

 

 

 

26

Marketing sector

 

 

 

 

13

 

Current consumption of fruits and vegetables for the 38 commodities examined in this study is 13.71 cups for food stamp consumers, 13.35 cups for other low-income consumers and 15.25 cups for higher income consumers.  The price discount will cause home consumption of fruit and vegetables by food stamp recipients to increase by 8.15% to 9.46 cups, but decrease consumption of away from home consumption due to higher market prices by 0.034%.  The net result is an increase in total consumption of fruits and vegetables by 5.19%.  Because other low-income consumers and higher-income consumers are affected by higher market prices, their consumption falls slightly by about 0.038%.  The price discount increases consumer surplus for food stamp recipients, but lowers it for the other two groups.

 

The 5.19% increase in fruit and vegetable consumption by food stamp recipients will increase food stamp program costs by $681 million. Producer surplus increases for California growers by $23 million, growers in the rest of the U.S. by $26 million, and the suppliers of marketing inputs by $13 million.  These benefits notably exclude the benefits of increased health status, which is the subject of future research. 

A Longitudinal Study of Food Insecurity on Overweight in Preschool Children

 

Elizabeth Metallinos-Katsaras, Simmons College, Jan Kallio, Massachusetts Department of Public Health, Aviva Must and Parke Wilde, Tufts University and Kathleen Gorman, University of Rhode Island.

 

Background

 

Childhood overweight and household food insecurity (HFI) represent urgent public health problems in the United States. Food insecurity is the lack of access to enough food for an active healthy life that results from the limited or uncertain access to nutritionally adequate and safe foods in socially acceptable ways. Low income households are more likely be food insecure and paradoxically low income adults, specifically women, are more likely to be overweight. In children, however, studies of this association have yielded conflicting results; perhaps because study designs (i.e., cross-sectional versus longitudinal) and populations (i.e. ages and income levels) have varied. Additionally, most of the prior work did not examine this association in the most relevant population: low income households.

 

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) serves low income women and children at high nutritional risk. Anthropometric, sociodemographic and other health-related data are routinely collected. The purpose of this research is to: 1) examine the effect of WIC participation on HH food security status in women and children, and 2) assess the relationship between HFI with/without hunger in infancy and later childhood weight status in 2 to 5 year-old WIC participants. Strengths of this study lie in the use of the large and diverse WIC population on which longitudinal anthropometric and food security data are available.

 

Methods

 

This longitudinal study includes data collected from 2001-2006 on children and their mothers who participated in Massachusetts WIC. WIC data are collected every 6 months and prepared for submission to CDC for inclusion in the Pregnancy and Pediatric Surveillance Systems. The addition of household (HH) food security measures to the WIC management information system was undertaken as part of a previously CDC funded cooperative agreement granted to the Massachusetts Department of Public Health (1996-2000). Inclusion of the full length food security module was not feasible due to time constraints. For this study, a subscale to measure food security status, was used. It addressed the following areas: 1) not having enough money to buy food for a balanced meal, 2) adults cutting the size of or skipping meals, 3) frequency of cutting meal size or skipping meals, and 4) adults not eating for a whole day. HH food security status was defined by the number of positive (“yes”) responses to the questions: food security = 0 positive responses; HFI without hunger = 1–2 positive responses; and, HFI with hunger = 3–4 positive responses.

 

HH food security status at both time points were combined to create a dynamic food security variable comprising the following categories: persistently food insecure, food insecure at first visit and secure at the second, food secure at the first visit and insecure at the second, and persistently food secure (referent). The age- and sex-specific body mass index (BMI) percentile and z-score of children was based on their directly measured height and weight relative to the CDC growth reference. At-risk for overweight and overweight were defined, as recommended, as sex specific BMI-for-age of > 85th and >95th percentiles, respectively.

 

Multinomial logistic regression was used to assess the relationship between duration of WIC participation and HH food security status (e.g., food secure, HFI without hunger and HFI with hunger) at the last visit for women (n=21,863) and children (57, 377) adjusting for race, maternal education, household size, and initial HH food security status. Both general linear model and logistic regression techniques were used to examine the relationship between HH food security status at the first and last visit and child weight status. Children meeting the following criteria were included (n=25,186): 1) first visit data available, 2) first WIC visit at age < 12 months, 3) at least 4 WIC visit data available, 4) complete data on HH-food security status at first and last visit and on covariates (birth weight, age, sex, race/ethnicity, maternal education, household size and maternal weight status), 5) child of non-Hispanic White, Hispanic, Black non-Hispanic or Asian race/ethnicity, and 6) complete anthropometric data at both time points and age 24-60 months, 7) Birth weight of the child available.

 

Findings/Discussion

 

The association between duration of WIC participation and HH food security status depends on HH food security status at the initial visit. For both women and children from initially (i.e. at first WIC visit) food secure HHs there was no effect of WIC duration on later HH food security status. On the other hand, among women who were from HHs that were initially food insecure with hunger, early prenatal certification into WIC produced the greatest improvement in HH food security status by the post-partum period. Among children who were from initially food insecure HHs (with or without hunger), longer WIC participation was associated with the greatest improvements in their HH’s food security status.

 

Preliminary results suggest that the relationship between HH food security status and children’s weight status is dependent on other factors. Significant effect modification (p < .05) in the fully adjusted model was noted for the dynamic HFI variable and the following: maternal education, maternal pre-pregnancy weight status, and child’s birth weight. Thus, analyses were adjusted or stratified by each of these variables. Stratification of the analyses by birth weight, using a median split for this sample (3,291.5 g), yielded a significant association between HH-food security status and weight status among children whose birth weight was less than the median (but not those > the median). Persistent HFI was associated with a 27% higher odds (p < .01) of attaining a BMI-for-age > 85th %tile and a 31% greater odds (p < .01) of becoming overweight by the time they were 2-5 years old compared to children whose HHs were persistently food secure. Among children whose mother’s pre-pregnancy weight classified them as overweight or obese (i.e. BMI > 25), persistent HFI was associated a 22% higher odds (p < .01) of their children attaining a BMI-for-age > 85th %tile and a 19% greater odds (p < .05) of 2-5 year old children becoming overweight compared to those whose HH were persistently food secure. No association was found among those children whose mothers’ pre-pregnancy weight was normal.

 

From a policy perspective, these findings suggest that getting mothers enrolled into WIC earlier in pregnancy could reduce later risk of overweight among their children by improving HH food security status once their child is born. The results also imply that certain sub-groups of children are particularly vulnerable to the adverse effects of HH-food insecurity on overweight risk; thus targeting these groups may be necessary.

Dietary behaviors that promote over consumption: Food insecurity is not associated with lower energy intakes

 

Claire Zizza and Patricia Duffy, Auburn University, and Shirley Gerrior, Cooperative State Research, Education, and Extension Service, US Department of Agriculture

 

Background

 

Findings from the Current Population Survey indicate that in 2006, 11% of households in the United States were food insecure (FI). Food insecurity has been associated with obesity, heart disease, diabetes, high blood pressure and food allergies. Despite this vulnerability, very little attention has been given to the diet of FI individuals. This study was undertaken to further the understanding of the dietary behaviors of FI individuals. Specifically this study determined the number of daily snacks and meals consumed by men and women in different levels of food security. In addition, the energy contribution, the energy density, and the food group sources of those snacks and meals were calculated.

 

Methods

 

National Center for Health Statistics' (NCHS) NHANES for 1999-2000 provides information about people’s consumption of foods and nutrients, as well as extensive health-related data, and information about Americans’ demographic and socioeconomic characteristics. The NHANES 1999-02 contains the 18-item Food Security Survey Module (FSSM), which has been shown to be a stable, robust, and reliable measurement tool. The NHANES 1999-02 Food Security data are released in four categories: Food secure (FS), marginally food secure (MFS), food insecure without hunger (FIWOH), and food insecure with hunger (FIWH). Because adults were the focus of this analysis, the adult measure rather than the household measure was used.

 

For the 1999-02 NHANES, individuals’ dietary intakes were collected through an interviewer-administered 24-h dietary recall method. Energy intakes used for this analysis were obtained from the NHANES dataset. The number of meal occasions and snacking occasions were calculated over the entire 24-h for each individual. The energy contributions per snack and per meal, and the total energy contributions of snacks and meals, were calculated. In addition, the relative caloric contributions of food groups were calculated. Due to the differences in the treatment of beverages, it has been recommended that energy density values be calculated using only food items. Although beverages were included in all previous calculations, they were excluded from measurements of energy density. For this analysis the energy density of food items alone was calculated by dividing the total energy from foods (kcal) by the weight (g) of the foods.

 

The analytical sample for this work is the subset of individuals from whom the adult-level FSSM was collected. Individuals were screened into the FSSM using the USDA food adequacy indicator and/or income. Women who were pregnant and/or breastfeeding were excluded. Again adults were the focus of this research so those individuals > 18 y old were examined. To avoid including older individuals, many of whom have low energy intakes, respondents > 60 y old were excluded. Because prior research has found differences in obesity patterns among food insecure men and women, men and women were examined separately (women n=2707; men n=2933). Multivariate linear regression analyses were used to examine the relationship between food security status and dietary outcomes while controlling for age, race-ethnicity, education, and income. In all models, food secure individuals were the comparison group. To account for characteristics of the NHANES dataset, STATA (Version 10, College Station, TX) was used.

 

Findings/Discussion

 

Daily total energy intakes were not different for FI individuals however, there were considerable differences regarding their meal and snack behaviors. FIWOH and FIWH women had significantly fewer meals than FS women. The mean energy contribution of each meal and the total energy contributed from snacking were both significantly greater for FIWOH women than for FS women. Among men, the daily number of meals was significantly decreased whereas the daily number of snacks and the total energy from snacking were significantly higher for FIWOH men than for FS men. Among both men and women, the energy density of meal foods was not significantly different. Among women, the energy density of snack foods was also not different; however, among men those that were FIWOH consumed snack foods that had a significantly lower energy density than those that were FS.

 

The major sources of energy during meal occasions were similarly ranked for women and men. For men and women, the grain group was the predominate source, followed by meat, poultry, fish, egg and mixtures. The third largest source was the sugars, sweets and beverages group for men and women. Among women the sugars, sweets and beverages contribution ranged from 14% in both the MFS and FIWH to 16% in the FIWOH. Among men, the sugars, sweets and beverages relative contribution to meal energy was 16%, 19%, 18% and 21% for FS, MFS, FIWOH and FIWH respectively. Conversely, the major source of energy for snacking was the sugar, sweets, and beverages for both men and women. Among women sugar, sweets and beverages contributed 34%, 39%, 36% and 37% to snacking energy among FS, MFS, FIWOH and FIWH respectively. Among FIWH men, the sugar, sweets and beverages group contributed more than half their snacking energy. Grain products and dairy products are the next largest sources of energy during snacking for both men and women.

 

This study provides evidence that skipping meals can be associated with diets that are adequate and possibly more than adequate in energy. An increase in meal size and the energy obtained by snacking appears to compensate for a reduced meal frequency. Thus focusing solely on total energy intake would miss important consequences of food insecurity. Nutrition interventions aimed at FI audiences should target snack behaviors. For example, dairy products were a leading source of snacking energy and thus messages could emphasize the benefits of low-fat dairy products. For men, who consume a large portion of their snacking energy from sugars, messages could emphasize the sweetness of fruits.

Intra-Household Allocation and Consumption of WIC Approved Foods

Ariun Ishdorj, Helen H. Jensen and Justin Tobias, Iowa State University

 

Background

 

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of USDA’s major food assistance programs with benefits targeted to the needs of qualifying women, infants and young children in the household. Vouchers provide for specific amount and types of foods designed to enhance the intake of key nutrients needed by the targeted individuals.  Although the vouchers are issued to an individual, once acquired, the food items are available to share in the household.  Reallocation of program benefits in response to a program targeted towards individuals would lead to smaller than expected gains to the recipient of the transfer and larger than expected intake by non-targeted individuals in the program household.

The overall goal of the research reported here is to carefully examine intake of program-determined foods by household members in order to better understand targeting of food benefits and spillover of WIC program effects within the household. In order to clearly identify the effect of the food program, it is important to account for endogenous program participation – that is, an eligible household’s choice to participate in the program. The specific application is to household allocation of WIC approved foods, and uses dairy products as the example food.

Methods

The empirical analysis used data from the USDA Continuing Survey of Food Intake by Individuals (CSFII) 1994-96. These data allowed tracking food consumption of targeted WIC recipients and other members of the same household. All individuals who lived in households that had income less than or equal to 200 percent of the poverty income level and that included at least one member of a WIC targeted group (pregnant, lactating or post-partum women and children of age 1 through 4 years old) were included in the analyses. The threshold of 200 percent of the poverty income level was selected to account for some variability in income that makes it more likely that a household may become income eligible. Infants were not included in the analysis. This selection process led to an analytical data set that included 1018 program-eligible households with 2421 individuals.

All individuals in the selected households were assigned to one of the four mutually exclusive groups: targeted individuals in WIC households, non-targeted individuals in the same households, targeted individuals in non-WIC households and non-targeted individuals in non-WIC households.  The WIC targeted group included children of age 1 through 4 years old and pregnant, lactating or postpartum women; the non-targeted group includes other adults and children of age five and older. Households in the sample were identified as WIC eligible by meeting the income criterion and having at least one targeted individual living with them. Although several foods are included in the program packages, only intake of milk and cheese, measured in calcium-equivalence, was used here. The dairy products were widely consumed and represent a significant share of the foods provided in the WIC package for children and women.

The estimation model accounted for the household’s decision to participate in the WIC program, included as a probit equation, and the calcium intake of the individuals in the household, included as a tobit equation. The system with the two equations was estimated jointly using Bayesian methods. Demographic variables for age, gender, race/ethnicity, education level, and other variables useful in determining the WIC participation decision such as household size and income, were also included. The estimation resulted in predicted intake values for calcium conditioned on being in one of the four assigned groups based on program participation and target group status. The predicted values allowed comparison between intake of individuals in the four groups and assessment of likely redistribution of program foods.

 

Findings/Discussion

Several factors play a role in determining household participation in WIC. Large households, households with infants, those that participate in the Food Stamp Program, and those in the South were more likely to participate in the program. Preliminary results of the joint estimation for consumption of calcium from dairy products show that targeted individuals in WIC households consumed higher amounts of calcium from dairy products than did individuals in the other three groups. This outcome supports the objective of the WIC program to increase intake of targeted foods. Another finding was that the consumption of dairy foods by non-targeted individuals in WIC households was no greater than the consumption of similar non-targeted individuals in non-WIC households. Hence there was no evidence that the WIC program improved the intakes of the non-targeted WIC household members.

The WIC program is designed to improve diets of participating individuals in order to assure better health. The preliminary evidence suggests that in the period of study (1994-96), program participants did have greater intakes of dairy foods. Were there other program-induced effects for others in the household? These effects might have come from reallocation of program-provided foods within the household, from the indirect effect of providing increased resources to the household that resulted in changes in foods consumed by all members of the household, or from changes in diets due to nutrition education. In the case of dairy products, there is no evidence that the program benefits were reallocated or enhanced calcium intake of individuals not targeted by the program. Further examination of the case of dairy products and of different foods will help to clarify the source and types of intra-household allocation of other program benefits.

 

 

Policy implications of WIC or food stamp program participation on children’s diet quality and the risk for childhood obesity

Sibylle Kranz and Jill Findeis, Pennsylvania State University

 

Background

Federal food programs, such as the Supplemental Food Program for Women, Infants and Children (WIC) and the Food Stamp Program target low-income families and provide foods to the individuals who are participating. Foods and nutrient associated with health outcomes and of particular interest in the child population are the need to increase the dietary intake of fruits, vegetables, dairy and calcium, and whole grains while decreasing the consumption of added sugar. The dietary intake recommendations for these foods have changed in the recent past and are included in the newly proposed WIC food package in an effort to improve child nutrition.

Dietary intake during childhood is not only an important predictor of children’s health during childhood but dietary intake patterns track into adulthood. Hence, the development of healthy eating patterns early in life is an important tool to prevent chronic diseases such as diabetes and cardiovascular disease in adults. Due to the obesity epidemic affecting adults but also children, federal nutrition programs are not only a venue to increase the availability of food in low-income families but may also increase the access and consumption of high quality foods to prevent the development of obesity other chronic diseases.

Current research indicates that children participating in WIC are more likely to meet the dietary intake recommendations for nutrients than non-participants. WIC participation has also been shown to improve children’s eating patterns, significantly reducing the amount of snacking and the intake of added sugar from snacks, reducing overall added sugar intake, and increasing the likelihood of meeting the Dietary Reference Intake (DRI) for dietary fiber.

 

Methods

There is no single food or nutrient that might be representative of total diet quality, thus, a composite diet quality assessment score was developed and updated to reflect the latest federal dietary intake recommendations. The Revised Children’s Diet Quality Index (RC-DQI) includes 12 individual nutritional components and one item to indicate overall energy balance to determine the quality of the average dietary intake in children ages 2-18 years old. Dietary intake of added sugars, total fat, specific fatty acids (linoleic acid, linolenic acid, EPA, and DHA), total grains, whole grains, fruits, vegetables, 100% fruit juice, dairy, and iron was used to determine whether children consume optimal levels of these key nutrients and foods. In addition, a energy balance component consisting of two sub components was introduced to express the ratio between children’s actual and ideal energy intake (as estimated using the age and gender specific Estimated Energy Requirements (EER) of the Dietary Reference Intakes (DRI)) as well as the average number of hours spent watching TV compared to the recommendation for TV and computer time released by the American Academy of Pediatrics.

Socio-economic, nutrition, and medical examination data of children 2-18 years old (n=7,546) of the National Health and Nutrition Examination Survey (NHANES) 1999-2002 were employed to examine the diet quality in the American children. All analysis was conducted using STATA 9.2, which allowed the correction for the complex survey design and sampling techniques to maintain the nationally representative character of the data.

 

Findings

Total RC-DQI point scores ranged from 0-82 and younger children had better diet quality than teenagers. Four percent of preschoolers had between 90 and 100 percent of the possible RC-DQI points and only 10% scored less than 50% of the possible points. School-age children and teenagers scores on average much lower and none of either age group scored more or equal to 90 % of the possible points but 46 of the 12-18 year olds and 31% of the 6-11 year old children scored less than 50% of the possible points.

Validation of the index showed that increasing RC-DQI scores, representing better diet quality were associated with improved values of indicators of overall health, such as obesity status and blood cholesterol and total triglyceride levels.

To examine whether federal food program participation predicted whether American children were at risk to be overweight or overweight we conducted a multivariate regression using nationally representative data for children ages 2-18 years old (NHANES 1999-2002) controlling for children’s age, gender, physical activity level, ethnic group, household income, preschool and school attendance, and school breakfast and school lunch participation.

Results indicate that WIC participation significantly improved children’s overall diet quality. In addition, in children who were income-eligible for WIC (<1.3 PIR), the risk for being overweight was reduced by 40% compared to children who were income eligible but did not participate in the program. In food stamp eligible children (PIR<1.3), the effect was even more beneficial, in that children who participated in WIC were 57% less likely to be overweight than children in the same income group who did not participate in WIC.

Due to the dual problem of malnutrition along with over-consumption of energy and lack of physical activity, public policy on nutrition programs must be re-evaluated on a regular basis to ensure that the assistance provided addresses both of these important issues. Our data indicates that the WIC program has a significant impact on young children. WIC participation does not only improve preschooler’s diet quality but also decreases the risk for childhood obesity. Encouraging WIC participation in the low-income population may be an effective public policy strategy to help prevent childhood obesity and therefore reduce the risk of chronic diseases not only during childhood but also later in life.

 

Feeding Practices of Childcare Staff in CACFP-Funded Centers

Madeleine Sigman-Grant; Elizabeth Christainsen; George Fernandez, University of Nevada, Reno

 

Background

As one of USDA’s food assistance entitlement programs, the Child and Adult Care Food Program (CACFP) provides nutritious meals and snacks to 2.9 million low-income American children, by reimbursing eligible childcare providers. CACFP also has suggested written feeding guideline policies to foster a supportive feeding environment, including allowing children to serve themselves. Interestingly, these guidelines are congruent with recommendations to prevent childhood overweight. Moreover, they support the concept of Satter’s division of responsibility. This concept assumes adults are responsible for selecting, preparing and offering healthful foods as well as determining when and where meals and snacks are served. On the other hand, children are responsible for how much they eat, or whether they eat at all—control of food intake.

Thus, in addition to being a partner in combating childhood hunger, CACFP can play a significant role in establishing healthy eating habits, promoting self-regulation of food intake, and supporting self-sufficiency. Moreover, since low-income households are at high risk for obesity, CACFP-funded centers can play a role in modulating childhood overweight.

While some information exists regarding food selection in CACFP-funded centers, little is known about the feeding environment in these centers. This unique study compares reported implementation of feeding policies in childcare centers that receive CACFP funding to non-funded centers who serve low-income children. Additionally, it explores issues facing CACFP funded centers who encounter very hungry children. This study answers the following questions:

  1. Do centers serving low-income children receive CACFP funding?
  2. What challenges do CACFP-funded centers face in response to feeding children coming into centers exhibiting signs of extreme hunger?
  3. Do staff members in centers receiving CACFP funds and training report providing more opportunities that support the promotion of healthy eating and feeding behaviors espoused to prevent childhood obesity in young children than staff in centers not CACFP-funded?

 

Methods

Questions 1 and 3 were answered using quantitative data gathered from responses to a previously conducted survey – About Feeding Children (AFC). A stratified (by census density and state) random sampling method was used to identify 1,600 centers (400 from each state) within California, Colorado, Idaho and Nevada to receive mailed questionnaires. Responses were received from 574 centers (470 directors and 1210 staff). Interview data from 49 AFC staff as well as from 11 experts knowledgeable in CACFP was used to qualitatively explore question 2.

 

Findings/Discussion

Of centers responding to the AFC survey, 61% reported serving low-income families. Of these, 125 centers served meals and snacks, with significantly more receiving CACFP funding (66% vs. 34%, p<.01). Center location stratification revealed some centers in the poorest communities (i.e. the first quartile) do not participate in CACFP (24% with poverty rates ranging between 14.5% to 39.6% and 35% with median incomes ranging from $20,129 to $33,193). One could speculate that if eligible centers are aware of the program, they may not choose to enroll due to the arduous application process and/or the cumbersome record keeping required.

A pattern emerged regarding very hungry children entering CACFP-funded childcare. Both providers and experts stated that some children do not receive sufficient food or food of healthful nutritional quality over the weekend. Thus, early in the week (especially Mondays), some children enter centers in an apparent state of extreme hunger. Although this study could not determine if these children lived in food insecure households, they displayed behaviors reflective of that situation by acting out, being irritable, lacking concentration, and expressing an overwhelming desire to eat. Staff and experts state these children need and want more than the one serving of food for which the center is reimbursed, resulting in unmet hunger. In some centers, these children remain hungry until the next eating occasion, as second helpings were not prepared. Other centers meet the increased hunger by maintaining a stock of food provided by food banks or purchased without CACFP reimbursement.

In general, CACFP-funded centers were more likely than unfunded centers to report practices consistent with feeding guidance and with an overall environment purported to support self-regulation of food intake in children. CACFP funded staff allowed children more involvement in determining what to eat, the order in which to eat and how much to eat. Interestingly, staff in both funded and non-funded centers did not believe it was extremely important to teach children how to serve themselves food (52%) as much as they did to teach social skills (75%), conversational skills (72%), table manners (76%) and motor skills (using spoons and cups) (72%). This is reflected in the frequency of teaching so that 42% always taught children how to serve foods as compared to always teaching social skills (75%), conversations skills (79%), motor skills (83%) and table manners (84%). However, requiring self-service may not work for all CACFP-funded centers, even Head Start Centers, since some centers receive foods preplated.

In summary, this study suggested several strategies that CACFP could implement in response to both child hunger and overweight. For those centers who serve extremely hungry children, CACFP needs to reconsider the reimbursement policy. For example, additional quantities of food could be prepared for Mondays and Tuesdays when children enter centers most hungry and on Fridays to accommodate weekends, where food is scarce. CACFP reimbursement policies also may not coincide with obesity research. Reimbursement allows for a specified amount of food per child. However, research suggests that children self-regulated their food intake. Implicit in this suggestion is that some children will eat less than the reimbursed serving size whereas others will need to eat more. In theory, for most centers, sufficient quantities of food would be available for all. In reality, this may not happen, especially in centers with very hungry children. Finally, CACFP could specify funds to be set aside to train all CACFP-funded staff, directors and sponsors on the role CACFP can play in child overweight prevention and in setting up a supportive feeding environment. However, none of these strategies will help low-income children if eligible centers do not enroll in the CACFP program. Increased outreach efforts and reduced paperwork may entice centers, especially those in the poorest neighborhoods, to seek program benefits.

Educational Intervention to Modify Bottle-feeding Behaviors Among Formula Feeding Mothers in the WIC Program: Impact on Infant Formula Intake, Weight Gain and Fatness
Kathryn Dewey (PI), Jane Heinig, Katie Kavanagh-Prochaska

Summary

Background

One of the key factors associated with child obesity is a rapid rate of weight gain during infancy. Infant feeding practices are a major contributor to early rapid weight gain. Formula-fed infants consume more energy and gain weight more rapidly than breastfed infants, even during the first few months of life. Recent evidence indicates that there is a long-term effect of infant feeding on body fatness, with children and adolescents who were breastfed being 20-30% less likely to be overweight than children who were formula-fed. The mechanisms underlying these differences are not well understood. One possibility is that the composition of infant formulas has a stimulatory effect on intake and growth, although recent data from one of our own studies suggest that neither the protein content or quality nor the potential renal solute load of formula is the trigger. Another possibility is that it is bottle-feeding, not the composition of the milk in the bottle, that is more important. It has been hypothesized that infants are born with the ability to self-regulate their energy intake. The bottle-feeding caregiver may miss the infant’s satiety cues, or encourage the infant to empty the bottle. Our objective was to evaluate whether formula-feeding caregivers who are encouraged to be more sensitive to their infants’ satiety cues, and to adopt feeding practices similar to those of breastfeeding mothers, will in fact alter their feeding practices, and whether this results in 1) a lower volume of formula consumed at 4 months of age, and 2) a less rapid rate of weight gain from ~1-2 to 4 months of age

Methods

This project was a double-blind, randomized educational intervention trial with exclusively formula-feeding caregivers in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Sacramento County. Some of the ideas for this intervention came about as a result of focus groups conducted with WIC mothers in the spring of 2003, which revealed that overfeeding of formula-fed infants is common in this population.

The intervention group received education promoting awareness of early satiety cues and discouraging the use of large bottles (> 6 oz) before 4 mo of age, and the control group received standard nutrition education regarding introduction and feeding of solid foods. After initial screening, caregivers completed a baseline 2-day formula intake record, and were then randomized to attend either the intervention or control nutrition education class. Subjects were stratified by infant sex and maternal language (English or Spanish) and were randomized using computer-generated stratified random lists with a block size of 4. All subjects who attended the class were then followed for no less than 2 months post-class. Formula intake records were again completed at 2 weeks post-class and at ~ 3.5 mo of age. At baseline and at ~ 4 mo of age, infant anthropometry was completed. To identify under- or over-dilution of formula, caregivers were asked to provide samples of prepared formula at baseline and at the end of the study.

Results and Discussion

Of the 836 caregivers screened at the two clinic sites, 214 were eligible and 104 were willing to participate in the study. The most common reason for refusal was lack of time. Access barriers to participation included lack of transportation to the nutrition education class, uncertainty regarding ability to attend the class, and family or personal problems. Of the 104 women who agreed to participate, 101 completed the baseline questionnaire and 61 completed the first formula intake record. The remainder (n = 43) did not complete the baseline intake record and therefore were not included in the randomized trial. In most of these cases, the research staff was never able to reconnect with the caregivers, even after multiple attempts.

Of the 61 caregivers who completed the first intake record and were randomized, 17 never attended the nutrition education class (16 had been scheduled for the class but did not show up even after repeated re-scheduling). Of the 44 caregivers who attended the nutrition education class, 40 caregivers completed the final formula intake record, and 38 of these attended the final measurement session. Among the 40 caregivers who completed the final intake record, there were no significant differences between intervention and control groups in maternal age, education, BMI, number of children or ethnicity, or infant birth weight, sex, or formula intake at baseline.

There were no significant differences between groups in formula intake at the second record or at the end of the study, even after controlling for infant age at baseline, baseline intake, sex, birth weight, and time in the study. There were also no significant differences between groups in bottle-feeding behaviors at baseline or at the final intake record, including the mean percentage of bottles emptied, the percentage of subjects who emptied the bottle at more than 50% of feedings, and the percentage of bottles offered that were greater than 6 oz. Bottle-emptying increased in both groups over time (from ~50% to ~60% of feedings), as did the use of bottles > 6 oz (from < 5% to ~17% of subjects).

There were no significant differences between groups in infant weight, length or the sum of skinfold thickness at baseline, after controlling for age and sex. However, by the end of the study, infants in the intervention group were heavier and longer than those in the control group, even after controlling for age at measurement, sex, baseline weight or length and time in study. In addition, the sum of skinfold thickness was greater among infants in the intervention group than in the control group after controlling for age at measurement 1, time in study, sex, and sum of skinfold thickness at baseline.

Response to the nutrition education class and follow-up phone call, and to the key messages, was overwhelmingly positive. Most caregivers in the intervention group could accurately repeat the key messages and the demonstrations used to transmit them, and felt that they were easy to comply with and to share with friends and family. However, this did not appear to translate into behavioral change.
The adult learning technique used for this intervention was designed to be used in a group setting, but 95% of the classes were conducted with just one caregiver because of no-shows. Although the caregivers seemed to appreciate the one-on-one nature of the classes, the lack of group facilitation may be one reason for not achieving changes in feeding practices. Other possibilities include 1) inadequate reinforcement of messages; 2) insufficient depiction of and/or practice with identifying satiety cues in human infants; 3) not intervening early enough in the feeding relationship to support and foster inherent infant self-regulation; 4) not following caregivers long enough to detect a potential change in bottle-feeding behaviors, and 5) other barriers to responsive feeding related to the desire for infants to cry infrequently and sleep more.

Conclusion

In summary, the results of this study indicate that formula intakes of infants in this population are quite high – probably reflective of overfeeding - and that modifying bottle-feeding behaviors to prevent overfeeding is a challenging task. The more rapid growth of infants in the intervention group is difficult to explain, given that there were no significant differences in the intake variables. The final sample size was quite small, and caregivers participating in the project were not representative of the WIC population in general, which limits the conclusions that can be drawn. However, even though caregivers did not report a difference in intake or bottle-feeding behaviors, the educational intervention was successful in improving knowledge and awareness of the key messages. Further research is needed to understand the attitudes and life circumstances that are constraints to changing infant feeding behaviors.

Household food security, dietary intake, and obesity among a sample of recently arrived Liberian refugees receiving food assistance
Craig Hadley

There are currently 10 million individuals in the world who meet the United Nation’s definition of a refugee; that is an individual who is unable to return to their country of birth because of a well founded fear of persecution. Typically these are individuals who are forced to flee their homes because of civil wars, and are therefore exposed to violence, torture, loss of family and assets. Each year, approximately seventy thousand refugees are eligible to be resettled in the USA through the Department of State's refugee resettlement program. A majority of research on refugees resettled in western countries has focused on health status at the time of entry (Entzel et al., 2003) or mental health (Fazel et al., 2005). Studies focusing on other dimensions of health and well-being in the post-resettlement period are, however, currently lacking. This is unfortunate because concern has been raised that resettled refugees may face barriers to entry into the health care system, quality housing, and quality dietary intake. This research project investigated several dimensions of health and well-being among a sample of West African refugees living in a medium sized city in the northeast region of the USA. A specific focus was on the social and economic determinants of household food insecurity.

Food insecurity occurs whenever adequate and safe foods are not available or the ability to acquire such foods is limited or uncertain (Bickel et al., 2000). Conceptually, food insecurity is a more direct measure of inadequate or unreliable dietary supply than is low-income because it more closely taps into the phenomena of interest (Frongillo, 1999). Food insecurity represents a public health concern and is a useful index of health and well-being because it is associated with poverty, ill health, poor dietary intake (e.g., low intake of fruits and vegetables), limited social capital, depressive disorders, and, paradoxically, overweight and obesity among females (Alaimo et al., 2002; Alaimo et al., 2001; Cook et al., 2004; Himmelgreen et al., 2000; Townsend et al., 2001). Refugees resettled from developing countries are hypothesized to be at elevated risk of food insecurity because they initially face high levels of un/under employment, language barriers, shopping difficulties, and tremendous shift in the budget and management of household resources. Our objective was to test for hypothesized associations between measures of food insecurity and indicators of economic standing, knowledge and practice of budget management strategies, and measures of acculturation including language ability and time since arrival.

A variety of ethnographic and survey methods were employed in this project. For the survey, a non-probability sample was used and 101 West African caretaker-child pairs were enrolled (there were no refusals). At baseline, mean household size was 5 individuals, 1-2 of whom were under the age of five years. Caretakers were on average 30 years of age with a range from 18 to 74 years of age. The women had been in the USA for an average of 22 months, (SD 16). Just over half of the women (59%) interviewed had a high school education or higher, and 57% were currently employed. Half of caretakers reported the mean household income as less than $1000 per month, and 64% of caretakers reported their own income as less than $1000 per month. Nearly all caretakers had participated in the FSP at some point since their arrival (98%), and approximately 48% of caretakers were currently participants.

Approximately 53% of caretakers’ responses indicated that they and members of their households had experienced periods of food insecurity during the six months prior to the interview. This 53% was comprised of 37% who experienced food insecurity with no indication of hunger, and 16% whose responses to the USDA food insecurity scale indicated food insecurity with hunger. The mean food insecurity score on the continuous scale, indicating severity, was 3.6 (SD 3.4). The modified-USDA scale showed acceptable internal consistency (Cronbach’s alpha =0.85). A majority of caretakers responded that they had experienced food insecurity prior to arriving in the USA (90%).

In bivariate statistical tests, the occurrence and severity of food insecurity was associated with the both economic and socio-cultural factors. Households that scored lower on several measures of financial security scored significantly higher on the food insecurity scale. Similarly, respondents who were current participating in the Food Stamp Program experienced greater food insecurity. Informal social support appeared to be protective against food insecurity, although the effect was weak. Two measures of acculturation, language use and shopping difficulty, were also associated with greater food insecurity. Those respondents who reported difficulty with understanding people and who reported more difficulty shopping scored higher on the food insecurity scale. These bivariate relationships disappeared in a multivariate regression model when the time since arrival in the USA was entered as a factor. This commonly used measure of acculturation was the most important explanatory variable in this study and explained approximately 13% of the variation in food insecurity (p=0.001).

Other noteworthy results include:
1. The prevalence of overweight and obesity among caretakers approaches 65%. This appears to be considerably higher than found in the sending population.
2. Participation in the Food Stamp Program declined sharply with time lived in the USA
3. The percent of the sample that reported being employed increased sharply with time in the USA.

Although based on a non-probability sample, our findings suggest that food insecurity is an important public health problem in this vulnerable population, particularly during the first year in the USA. The distribution of food insecurity is consistent with theoretically derived predictions and ethnographic reports from caseworkers and refugees. The results also highlight the important role that economics and acculturation appear to play in protecting against food insecurity. Confidence in the results is further enhanced by the concordance between these findings and the limited data from other groups resettled in other industrial countries. From a programmatic standpoint the results suggest that traditional measures of self-sufficiency, such as employment, may not be reliable indicators alone. Rather, measure of income coupled with measures of food insecurity may provide a more accurate picture of the health and well-being of a family. Importantly, despite agency objectives of achieving self-sufficiency within the first six months, these data suggest that families may still be struggling two or three years after resettlement.

The prevalence and existence of food insecurity, as identified through qualitative and quantitative methodologies, also suggests that nutrition education programs should be further integrated in to the resettlement orientation that all refugees are expected to undergo upon arrival in their new home. The Expanded Food and Nutrition Education Program (EFNEP) through its hands-on didactic approach may be a useful program to promote money management strategies to ensure that food stamps reach through the whole month. This, along with education geared towards dietary change, may improve food insecurity as well as intake of key micronutrients; the latter may be particularly important given high levels of iron deficiency anemia in sending countries. The data on overweight and obesity from this refugee sample also suggest worrying trends which may be combated through behavioral change programs in the area of physical activity and dietary intake.

References
Alaimo K, Olson CM, Frongillo EA. 2002. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. J. Nutr. 132(4):719-725.
Alaimo K, Olson CM, Frongillo EA, Jr. 2001. Low family income and food insufficiency in relation to overweight in US children: is there a paradox? Arch Pediatr Adolesc Med 155(10):1161-7.
Bickel G, Nord M, Price C, Hamilton W, Cook J. 2000. Guide to measuring food insecurity, revised 2000. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service.
Cook JT, Frank DA, Berkowitz C, Black MM, Casey PH, Cutts DB, Meyers AF, Zaldivar N, Skalicky A, Levenson S and others. 2004. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr 134(6):1432-8.
Entzel PP, Fleming LE, Trepka MJ, Squicciarini D. 2003. The health status of newly arrived refugee children in Miami-Dade County, Florida. Am J Public Health 93(2):286-8.
Fazel M, Wheeler J, Danesh J. 2005. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet 365(9467):1309-14.
Frongillo EA. 1999. Validation of Measures of Food Insecurity and Hunger. J. Nutr. 129(2):506-.
Himmelgreen D, Pérez-Escamilla R, Segura-Millán P, Gonzalez A, Singer M, Ferris A. 2000. Food insecurity among low-income Hispanics in Hartford, Connecticut: implications for public health policy. Human Organization 59(3).
Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. 2001. Food insecurity is positively related to overweight in women. J. Nutr. 131(6):1738-1745.

Validation Study of a Diet Adequacy Screening Tool for Participants in the Older Americans’ Act Nutrition Program
Beth Rabinovich (PI) and Suzanne W. McNutt

Background

The Older Americans Act (OAA), enacted in 1965, and since reauthorized 14 times, established the Administration on Aging (AoA). The goals of the OAA are to provide services to older individuals with the greatest economic and social need, especially to low-income minorities and residents of rural areas. The AoA funds a network of state units on aging and area agencies on aging (AAA) to coordinate a comprehensive array of home and community-based services to persons 60 years and older that enable them to remain in their own homes.

Together, the congregate and home delivered meals programs constitute the largest proportion of funding for any service under Title III of the Older Americans Act. AAAs administer the nutrition program, and contract with providers to prepare and deliver the meals. Sites for the congregate meals program include senior centers, schools, and senior housing facilities.

The purpose of this study was to validate a Diet Screening tool developed by representatives of state and area agencies on aging that participated in the Performance Outcomes Measures Project (POMP) under the auspices of AoA. The starting point was the nutrition screening initiative (NSI), which the network uses for administrative reporting to AoA. The POMP grantees modified the NSI to more accurately reflect areas over which the network had some influence. The questions on the Diet Screener expanded the NSI by asking clients to report the number of servings of foods they usually eat in a day in each major food group, and omitting questions on alcohol consumption, over-the-counter and prescription drugs, and dental problems that interfered with eating.

The study served to evaluate a diet adequacy scoring system developed in POMP to measure the impact of the nutrition program. The adequacy score assigns the client to one of three categories: “Adequate” (=17), “Marginal” (16-l1), and “Poor” (<11) diet. The score measures the participants’ food intake against the U.S. Department of Agriculture Food Guide Pyramid, published with the Dietary Guidelines for Americans, 2000.

Methods

To evaluate the validity of the POMP Diet Screener, which asks about food behavior and usual intake for seven foods and food groups, we compared it to the Diet History Questionnaire (DHQ), a food frequency questionnaire (FFQ) developed and validated by the National Cancer Institute (NCI). The DHQ asks about usual intake over the past year for more than 130 foods.

We recruited congregate meals clients in South Bend, Indiana and Montgomery County, Maryland who had completed the Diet Screener, to participate in the validation study. Approximately one month later an interviewer administered the food frequency questionnaire by telephone. A staff member entered the data from the Diet Screener into an Access database, and scanned the FFQ using a specific diet calculation program. The Diet*CALC software developed by NCI yielded nutrient and food group intake estimates from the DHQ. Analyses included range checks of all data elements to check for possible outliers, and the calculation of adequate servings of food groups and Diet Adequacy scores for each participant. We then compared the adequate serving sizes of the Diet Screener to that of the DHQ, the criterion measure. Finally, we compared the diet adequacy scores obtained from the two methods.

Results

The majority of the participants were white females, age 75 and older, living alone, with household incomes below $20,000. This is similar to the demographic profile of participants nationwide.

The Diet Screener performed well compared to the DHQ in estimating intakes from the Vegetable and Dairy groups. However, it underreported the number of servings from the Fruit category by 31 and 35 percent and Grain category by 29 to 45 percent (males and females, respectively). It also over reported the number of servings of Meats/Beans for males and females by 30 and 40 percent.

Almost 90 percent of males and females met the “Adequate” standard for number of meals per day using the Diet Screener (this information was not captured on the DHQ). For all food groups except Meat/Beans, however, fewer participants reported an adequate number of servings using the Diet Screener compared to the DHQ. In addition, while 37 percent of men and more than 23 percent of women reported adequate Grain servings on the DHQ, none reported an adequate number of servings on the Diet Screener.

Results suggested that the Diet Screener incorrectly categorized participants downward compared to the DHQ. The screener classified more than 38 percent of males, and almost 40 percent of females as having “Poor” diets, whereas the DHQ classified only about 20 percent of males and 23 percent of females into the same category.

Discussion

To better understand and monitor the diet adequacy of older Americans in the AoA Nutrition Program, and to provide directed nutritional counseling, it is imperative to have a simple measure that is quick to administer, can be used repeatedly, and is cost effective. Brief screening instruments have been designed and used by many researchers to minimize respondent burden and quickly identify individuals most at risk and in need of behavior change. However, designing an accurate, yet short diet screener is not a simple task. A number of studies have shown that quick screeners are prone to underreporting and misclassification. While the POMP project area agencies refined the food questions in the NSI to capture dietary intake in more detail (suggesting more accuracy), the results of this study are in general agreement with earlier findings – the POMP Diet Screener misreports number of servings for most food groups and misclassifies congregate meals clients as having “Poor” diets. There are a number of possible explanations for these findings. First, they could be related to people’s perceptions of what they eat. A USDA study found that older respondents overestimated their meat/bean, dairy, fruit, and vegetable intakes and underestimated their grains when using a screener to report intake. Second, they could be associated with problems with measuring diets among the elderly -- memory, comprehension, literacy, special diets, and dentition can all contribute to inaccurate reporting. And third, the questionnaire design may have caused respondents to over or under report their foods. The POMP Diet Screener has the potential to be a useful tool for the AoA Nutrition Program to inform the diet adequacy of its clients and measure the impact of the program on their dietary status. The results of this study provide valuable information for refining this simple tool to measure diet adequacy in an elderly population. Future work needs to be considered that focuses on cognitive and focus group testing to better understand the abilities of the elderly population to complete a self-administered instrument about their diet.

Adapting EFNEP to Meet the Changing Needs of Food-Assistance Eligible Families: Investigating the Results of Program Responses to Welfare Reform

Katherine Dickin, Ph.D. and Jamie Dollahite, Ph.D., R.D., Cornell University

Background and Research Objective: This research was designed to investigate how the Expanded Food and Nutrition Education Program (EFNEP) has adapted to keep services for low-income participants relevant, accessible, and effective during the period of welfare reform. EFNEP’s adaptation strategies were examined using qualitative assessment of the experiences of EFNEP personnel combined with quantitative analysis of the trends in program monitoring data on implementation and outcomes.

Highlights of Research Methods: In-depth interviews were conducted with state EFNEP coordinators and selected county or regional EFNEP supervisors in 3 states. Six focus group discussions with EFNEP paraprofessional Community Nutrition Educators (CNEs) and 2 interviews with key informants were conducted in one state. Verbatim transcripts were analyzed qualitatively. A national dataset of selected program variables for the period of 1997-2003 was created from state-level data excerpted from the national EFNEP monitoring system. Regression analysis was used to examine trends over time in program implementation and outcomes at the national and state levels. The authors also compared the characteristics of a sub-sample of ten states with the strongest trends (5 positive, 5 negative) in behavior change score, a measure of the proportion of program graduates reporting an improvement in dietary practices between program entry and completion.

Preliminary Findings: EFNEP personnel reported that families transitioning to work continued to need EFNEP but had little time to attend nutrition education classes. Poor working parents who have less time for food preparation and acquisition need information on managing food resources, preparing quick healthy meals for home and work, and making good choices when eating out. To reach these participants, EFNEP collaborated with other agencies to deliver services to groups formed for other purposes, offered programs on weekends or evenings, and identified new audiences. Collaborating agencies included adult education and English language programs, residential programs addressing various needs (e.g. domestic abuse, homelessness, mental disabilities, and drug rehabilitation), welfare-to-work training programs, and occupational groups (e.g. daycare providers). CNEs now teach more groups and the audiences are more diverse and include mandated audiences who must attend an agency’s program to avoid sanctions (such as loss of TANF benefits). Sustained collaborations with agencies serving similar populations and interested providing nutrition education to their clients were critical to successful adaptation. This was difficult in some rural areas where few agencies were available to collaborate with EFNEP and low population density and lack of transportation limited attendance at group educational sessions.
Most personnel felt that EFNEP was adapting successfully to reach and serve potential participants. The most important disadvantages of inter-agency collaboration were constraints on the number and length of lessons, resulting in less time for education and hands-on activities like cooking. Some personnel were concerned that shorter program duration and group methods could reduce impact. To preserve program quality some sites enforced standards for minimum length and frequency of lessons and provided extra individual or home-study lessons for people needing more information and support. Training CNEs to work with new audiences, revising curricula to focus on priority topics, and sub-dividing large groups were other strategies to protect effectiveness. Such strategies required resources and were not practiced equally in all sites. Supervisors varied along a continuum from “compromisers”, primarily concerned with program survival and maintenance of large caseloads, to “negotiators-innovators” employing strategies designed to ensure both high participation rates and program quality. The majority of respondents in this study were “negotiators-innovators” but the few examples of “compromisers” suggest the need to evaluate how a focus on reaching large numbers of participants affects program impact, particularly in the context of limited program resources.

Analysis of national EFNEP monitoring data confirmed many of the qualitative findings. From 1999-2003, the number of participants/year and the number of front-line staff decreased significantly. The proportion of participants reached by group (rather than individual) methods increased sharply from under 60% in 1997 to almost 72% in 2002 - 2003. Characteristics of EFNEP participants also changed. From 1997 to 2003 there was a significant reduction in the proportion of participants living in rural areas or small towns, an increase in the proportion of Hispanics, and a decrease in the proportion of African Americans. Trends in behavior change at the state level were not significantly associated with other changes over time and did not indicate that program adaptations have negatively affected outcomes. Nationally, the percent of graduates reporting an improvement in dietary behavior between program entry and completion remained relatively constant, although trends in individual states varied widely. The rate of program completion increased, probably due to inclusion of more mandated participants and changes in graduation criteria associated with group methods. Few differences were found between the sub-groups of states with the strongest positive or negative trends in behavior change. Both groups included states using relatively more and less group methods and covering more and less rural populations. The “upward trend” states had much larger programs (federal EFNEP allocations) than the “downward trend” states, suggesting a possible contribution of economies of scale to program success.

Implications for food assistance programs and future research: EFNEP has developed innovative strategies to adapt to welfare reform and to contribute to the success of this policy by helping families practice healthy nutrition and resource management as they transition to work. Staff of EFNEP and similar programs can learn from these successful strategies and EFNEP’s capacity to adapt should be leveraged to respond to other trends influencing the health of low income families, such as the obesity epidemic. While the trends identified in this study occurred during the era of welfare reform, EFNEP was also influenced by other socioeconomic and policy conditions during this period. Continued funding constraints have implications for program access, quality, intensity, and duration as EFNEP struggles to “do more with less”. Adaptations to reach more participants are essential but programs also need adequate resources to provide the amount and quality of nutrition education that will be effective in promoting healthy dietary practices. Compromises in the name of efficiency could eventually reduce benefits to rural residents and other hard-to-reach or hard-to-teach audiences.

These analyses illustrate how EFNEP’s extensive program monitoring system can be used to assess changes in program implementation and behavior change outcomes. Despite collection of data on many useful indicators, national-level analyses are limited by constraints of resources, personnel and data format. Minimal additional investment could substantially increase the usefulness of these data for guiding programs and policy by making available a national dataset that integrates multiple years of EFNEP and includes disaggregated raw data.

The interpretation of research results would be greatly enhanced if program monitoring data were complemented by an external EFNEP evaluation of contrasting program approaches and multiple outcomes among participants and non-participants. Future research should assess the impact of the “best practices” identified by this study as likely to contribute to program efficiency and effectiveness. Our results suggest that certain state programs achieve good outcomes with large caseloads and follow-up research should examine the program characteristics and strategies related to their success.

Are Economic Incentives Useful for Improving Dietary Quality Among WIC Participants and their Families

Dena Herman, Ph.D., M.P.H., R.D., Gail G. Harrison, Ph.D., UCLA Jonsson Comprehensive Cancer Center, Eloise Jenks, M.Ed., R.D., Public Health Foundation Enterprises, WIC Program, Abdelmonem A. Afifi, Ph.D., UCLA School of Public Health

Dietary quality, for which the best single index for American adults is fruit and vegetable intake, is a powerful protective factor for various common chronic diseases including several of the major causes of premature death and disability. Low income is well established as a risk factor for poor dietary quality in the US. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program provides an ideal context for investigating means to improve fruit and vegetable consumption in a vulnerable population. The WIC program was designed and developed prior to the time that the relationship of fruit and vegetable intake to chronic disease risk was well established, and the foods were selected to provide supplements of the nutrients that at that time were thought to be most limiting in the diets of women and children – namely protein, calcium, vitamin A and vitamin C. Recently there has also been considerable discussion about adding fruits and vegetables to the WIC food “package” but the potential cost is substantial. A recent report by the Institute of Medicine (IOM) reviewed the current public health context for the development of WIC’s food packages and proposed criteria for the selection of food items to be included. Fruits and vegetables were among the food groups considered to be of highest priority. We investigated whether providing supplemental financial support specifically for purchase of fresh fruits and vegetables would result in high uptake of the supplement and if the individuals would continue to consume more fruits and vegetables after financial support was removed.

We used a non-equivalent control group design to provide vouchers for fresh fruit and vegetable purchase to low-income women participating in the PHFE WIC program in Los Angeles, CA. We recruited 602 women who were enrolling for postpartum services at three selected WIC program sites (approximately 200 per site) in Los Angeles. Sites were assigned to intervention with vouchers redeemable at a local supermarket; intervention with vouchers redeemable at a nearby year-round farmers’ market; and a control site with a minimal non-food incentive for participation in interviews. Vouchers were issued bimonthly, at the level of US$10 /week. Interventions were carried out for six months, and participants’ diets were followed for an additional six months following the intervention. Quantitative 24-hour dietary recalls were conducted at four interviews for all participants; in addition, at the intervention sites two extra interviews spaced two months apart were held to obtain information on the fruits and vegetables purchased with the vouchers. Specifically, participants were asked to respond to the question “What did you buy with your fruit and vegetable coupons last week?” Voucher redemption rates were obtained from scanned data from the supermarket’s corporate headquarters. In the farmers’ market condition, vouchers presented for purchase were collected by the farmers’ market manager and turned into the city government’s accounting department for tallying; vouchers were then mailed to the study’s research staff who re-counted the redeemed vouchers and logged the tallies into an electronic database.

In all, US$44,000 worth of vouchers were issued for the supermarket and US$44,960 for the farmers’ market. Redemption rates were 90.7% for the farmers’ market and 87.5% for the supermarket. Overall, participants reported purchasing 27 and 26 different fruits, and 34 and 33 different vegetables in the farmers’ market and supermarket outlets respectively. Five fruits and five vegetables accounted for about 70 percent of the items reported for each group, with only minor differences in items. The ten most frequently reported items were oranges, apples, bananas, peaches, grapes, tomatoes, carrots, lettuce, broccoli and potatoes. A larger number of item purchases were reported for the farmers’ market condition although the total number of types of fruits and vegetables did not differ significantly between the two conditions.

Participants in the intervention conditions increased their consumption of fruits and vegetables with use of the supplement and sustained that increase six months after the intervention was completed. At baseline, participants at the farmers market site reported eating 2.2 servings/1000 kcal on average, at the supermarket site 2.9 servings/1000 kcal and at the control site 2.6 servings/1000kcal. Six months post-intervention, this same comparison was made and the increase in fruit and vegetable intake reported by the intervention sites was sustained. Both the farmers market and supermarket sites reported eating 4.0 servings of fruits and vegetables/1000 kcal on average, while the control site reported eating 3.1 servings/1000 kcal on average. The difference in consumption between each of the intervention sites and the control site was statistically significant even after adjusting for multiple comparisons. These results were identical when evaluating consumption of fruits and vegetables excluding beans and potatoes and fruits and vegetables excluding juices. Increases in vegetable consumption were primarily responsible for the overall increases in fruit and vegetable intake.

We conducted a linear regression analysis using baseline demographics, government program participation, body composition, food security status, reported energy intake, reported fruit and vegetable intake, infant feeding method, and treatment site to explore which of these factors was associated with fruit and vegetable intake six months post-intervention. We found that higher reported intake of fruits and vegetables six months post-intervention was associated with reported fruit and vegetable intake at baseline, preference for speaking Spanish, and being a participant at either the farmers market site or the supermarket site when compared to the control site.

In conclusion, the variety of choices of fruits and vegetables exhibited in this study leads us to conclude that low-income consumers make wise, varied and nutritious choices from available produce and that the potential for dietary improvement with a targeted subsidy that allows free choice within the fresh produce category is significant. Neither the supermarket nor the farmer’s market found the study particularly burdensome, but rather were positive about their participation and no specific barriers arose to redemption of the vouchers by participants or retailers. In addition to the economic intervention, we attribute the high intake of fruits and vegetables in this study to the large proportion of Latinos included. The study participants’ sustained intake of fruits and vegetables may also be reflective of the positive cultural habits that they have retained as well as the timing of the study at a critical point in the life course.

The Links Between Food Insecurity, Food Program Participation, and Overweight Status in Children: Evidence from Early Childhood Longitudinal Survey

Donald Rose, Ph.D., and Nick Bodor, Ph.D., Tulane University School of Public Health

Obesity is the most pressing nutritional problem in the United States. There is strong evidence of increased risk of poor health outcomes, such as cardiovascular disease, diabetes, and cancer, due to this condition. Moreover, close to two-thirds of the U.S. adult population is overweight or obese. The latest evidence also confirms dramatically increasing trends in the prevalence of overweight among children.

While there is little controversy about the proximal determinants of overweight status - that is, an imbalance between energy intake and expenditure - there is considerable complexity in the framework of distal factors that give rise to this imbalance. An emerging area of research is concerned with the relationship between household food insecurity and obesity. While it may seem like a paradox, several mechanisms could explain this relationship. Food insecurity could lead to an overweight status, if individuals overcompensate for periods when food is scarce, so that overall intake is greater. Weight cycling could also make the body more efficient in utilizing dietary energy, and thus over the long-run lead to an increased weight. Finally, energy-dense foods are often less expensive, so that food insecure households who can't afford to eat balanced meals or who must rely on a few kinds of low-cost foods, may have an overall greater energy intake.

Various studies have explored the food insecurity-weight status relationship empirically. There is apparent agreement of studies on adult women; most show a positive association between food insecurity and the probability of being overweight. However, no clear pattern has emerged when considering the food insecurity-overweight link in children. Some authors have suggested that the issue in children is unresolved, because of limitations, including sample size, of previous datasets. Thus our objective in this research project is to test the hypothesis that household food insecurity is positively associated with overweight status in children.

We carry this out with an analysis of data collected in the Department of Education's Early Childhood Longitudinal Survey-Kindergarten Cohort (ECLS-K). The ECLS-K is a large nationally representative survey of children, begun with the kindergarten class of 1998-99. The survey collected measured heights and weights on children twice per year in the kindergarten and first grade, the full 18-item USDA food insecurity module in the Spring of 1999, and a rich set of variables on the home and school environments of these children. We used the Centers for Disease Control and Prevention's algorithms for assigning BMI-for-age percentiles to each child's measurements. Children with a BMI that was greater than or equal to the 95th percentile of their sex-specific BMI-for-age chart were considered overweight. In addition to this indicator, we created a dichotomous variable indicating “risk of overweight,” a CDC term for children with a BMI greater than or equal to the 85th percentile of their BMI-for-age chart. We used the standard dichotomous variable for food insecurity, which simply indicated whether the household was food insecure (i.e. either with or without hunger) or not.

Weight status is known to be affected by a number of biological and socio-economic factors. In order to control for potentially confounding variables we developed multi-variate logistic regression models in which the dependent variable was a dichotomous indicator of overweight status. Independent variables included our measure of household food insecurity and a full set of control variables, including: age, sex, and birthweight of the child; schooling of the mother; income, region, and urbanization of the household; as well as family meal patterns and child activity patterns. All analyses used ECLS-K weighting variables and accounted for the clustered nature of the sample, by using jackknife replicate methods to estimate standard errors.

Our main finding is that household food insecurity, when modeled with appropriate controls, is not associated with a higher prevalence of overweight among young school children and, if anything, seems inversely associated with weight status.

We believe our finding is relatively robust, since we found similar results a cross a range of different models. We tried dichotomous (food secure, insecure) and trichotomous (food secure, insecure without hunger, insecure with hunger) expressions of the food security variable and also used dichotomous and trichotomous expressions for child food insecurity. We also analyzed models with different expressions of the dependent variable, using "risk of overweight" as an indicator in one model, and simply body mass index, in continuous form, in another. We did a cross-section analysis based on data collected in the Spring of the child's kindergarten year. It should be noted that parents reported on household status in the 12 months previous to the interview, so a food insecure condition would have, in effect, preceded the child's weight status. Still, we tested whether food insecurity in the Spring of 1999 was predictive of overweight status a year later and found that it was not. We also tested whether household food insecurity in 1999 was predictive of a high weight gain over the next year and found an inverse association.

If for most young children, food insecurity is not associated with overweight status, our nation's most serious nutrition problem, does it mean that we should stop paying attention to food insecurity? Certainly not. In addition to concerns for equity of access to food, there are strong arguments for reducing food insecurity based on society's interest in improving the productivity of its next generation. A growing literature focused on children has found that food insecurity or hunger is associated with negative academic outcomes and poor psychosocial functioning at school, adverse health outcomes, and poor mental health.

It may mean, however, that food insecurity is less relevant for those whose main concern is to address the child obesity problem. For interventions that depend on low-cost social marketing techniques or for environmental change strategies that affect large groups of people, targeting of these program resources would be better accomplished with indicators other than food insecurity. For example we estimated that of all the overweight children in the ECLS-K sample 10 percent came from food insecure households, whereas 24 percent came from households in poverty. Thus targeting overweight prevention would be more appropriately focused on a general population of the poor than of the food insecure.

Household Food Insecurity, Food Assistance Program Participation, and the Use of Preventive Medical Care

Gail G. Harrison, Ph.D., University of California, Los Angeles

Research Objective and Policy Relevance. The objective of the present work was to examine, within the 2001 California Health Interview Survey, relationships between household food insecurity and non-utilization or postponement of primary and secondary preventive medical care. Among adults with diagnosed chronic disease requiring ongoing management (diabetes, heart disease, high blood pressure, asthma, and arthritis) we examined relationships between food insecurity and reported postponement or foregoing of prescribed care, including prescription drugs, recommended medical tests and treatment, and other medical care. We hypothesized that food insecurity would predict low rates of utilization of preventive health services and for adults with chronic diseases, poorer disease management as indexed by postponement or failure to get needed care. We further hypothesized that these relationships would be stronger for adults in households with children, and that health insurance and participation in food assistance programs would mitigate these relationships. If food insecurity contributes to increased medical care costs and ill health, the argument is strengthened for effective food security safety nets for the low-income population.

Contribution to Existing Research. It is well established that some types of preventive medical services reduce morbidity and save health care costs. Particularly for individuals with chronic disease, effective clinical preventive services have been shown to markedly improve outcomes. For the individual with a chronic disease that requires ongoing medical, nutritional or pharmacological management, foregoing or postponing medical care of the purchase of necessary drugs and supplies may result in increased rates of complications and poorer outcomes. There is now a considerable descriptive literature on food insecurity at the household level, indicating that the management of scarce resources in the face of food insecurity and hunger often results in sacrificing or postponing other basic needs. There has been to date little attention to food insecurity in relation to use of medical care; there is indication both from a hospital based study1 and a national sample2 that among adult diabetics, food insufficiency is associated with higher complication rates, poorer disease management, and increased medical care utilization.

Highlights of Research Methods. The California Health Interview Survey (CHIS) is the largest state health survey conducted in the United States . It is to our knowledge the only large database from the US that incorporates both a measure of household food security and extensive data on use of preventive medical services as well as health insurance status and data on food and other public program participation. CHIS is a telephone survey, modeled in part after the National Health Interview Survey. In the 2001 survey, data were collected from 55,428 households. Individual interviews were completed for one adult per household and from one adolescent (aged 12-17) and with a parent on behalf of one child under 11 years when these were present in the household, resulting in 55,428 adult interviews, 5801 adolescents and 12,592 parents about a child under 11 years. The survey was conducted in six languages (English, Spanish, Mandarin, Vietnamese, Hmong, and Korean). The basic statewide sample was selected through a random-digit dial process, and certain ethnic groups were over-sampled to yield stable estimates. The food security measure that was utilized is the six-item screener that has been derived from the 18-item federal instrument. Food security questions were only asked of adults residing in households with per capita incomes <200% of the federal poverty level. . Throughout our analyses, we utilized data weighted by the CHIS data access system to represent statewide population, using SUDAAN. We examined distributions and bivariate relationships; multivariate logistic regression analysis was utilized to examine predictors of key dependent variables.

Preliminary Findings. The prevalence of food insecurity among this population of low-income adults (incomes <200% of the federal poverty level) was 28.3%; 8.3% reported food insecurity with hunger. More than one-quarter (28.9%) had no current health insurance, and for younger adults (<65 years of age) the figure was higher at 35.6%. Food stamp participation was only 10.2% among individuals in households with incomes below 130% poverty; WIC participation was higher, with 58.5% of income-eligible (<185% poverty) of pregnant women reporting their own or their child’s participation.

Use of basic preventive medical services. Contrary to our hypothesis, there was no consistent relationship between living in a food-insecure household and several basic preventive indicators – including having a medical home, having had a flu shot in the last year, and several screening indicators including mammograms, Pap smears, stool blood tests and bone density screening. There was a significant association of food insecurity with never having had a PSA test in men over 40, with never having had a blood cholesterol check, and with never having had endoscopic colon cancer screening.

Utilization of medical care. Food insecure adults reported significantly higher utilization of medical care, including number of doctor visits in the previous year and having utilized an emergency room in the previous year. Dental care, on the contrary, showed lower utilization, with adults in households reporting hunger more likely to have had their last