5
Food Insecurity and Hunger

The focus of this session, moderated by Maureen Black, was on research into the interrelationships among food insecurity, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and various health outcomes. Food insecurity is defined as “limited or uncertain availability of nutritionally adequate and safe foods or uncertain ability to acquire acceptable foods in socially acceptable ways.” Hunger (another term used in the following presentations) is defined as the “uneasy or painful sensation caused by a lack of food; the recurrent and involuntary lack of access to food” (Anderson, 1990, pp. 1575–1576). Presenters John Cook and Edward Frongillo each provided background for their research suggestions. Discussant James Weill highlighted some of those suggestions while making a case for emphasizing WIC as a program designed to reduce food insecurity.

FUTURE DIRECTIONS FOR WIC RESEARCH FROM A FOOD SECURITY PERSPECTIVE

Presenter: John T. Cook

Future Context and Environment

To help set the stage for his remarks on a WIC research agenda, Cook identified factors that may influence food security over the coming years. One of the most important factors, according to Cook, will be whether the United States ever develops a meaningful response to global climate change.



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5 Food Insecurity and Hunger The focus of this session, moderated by Maureen Black, was on re- search into the interrelationships among food insecurity, the Special Supple- mental Nutrition Program for Women, Infants, and Children (WIC), and various health outcomes. Food insecurity is defined as “limited or uncertain availability of nutritionally adequate and safe foods or uncertain ability to acquire acceptable foods in socially acceptable ways.” Hunger (another term used in the following presentations) is defined as the “uneasy or painful sensation caused by a lack of food; the recurrent and involuntary lack of access to food” (Anderson, 1990, pp. 1575–1576). Presenters John Cook and Edward Frongillo each provided background for their research suggestions. Discussant James Weill highlighted some of those suggestions while making a case for emphasizing WIC as a program designed to reduce food insecurity. FUTURE DIRECTIONS FOR WIC RESEARCH FROM A FOOD SECURITY PERSPECTIVE Presenter: John T. Cook Future Context and Environment To help set the stage for his remarks on a WIC research agenda, Cook identified factors that may influence food security over the coming years. One of the most important factors, according to Cook, will be whether the United States ever develops a meaningful response to global climate change. 

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 PLANNING A WIC RESEARCH AGENDA Probably the second most important will be whether the United States ever develops a meaningful energy policy. Other factors will include the extent of the economic recovery, the extent of unemployment, the degree to which national food system reforms occur (which relates to obesity), the extent to which global food production responds to demand, and the implementation of health care reform in the United States. From 1999 until 2007, as can be seen in Figure 5-1, the proportion of U.S. households that were food insecure remained fairly stable, as did the racial and ethnic differences in the level of food insecurity. However, the proportion of food-insecure households increased substantially between 2007 and 2008, the first year of the great economic recession. During that year, the estimated number of children younger than 5 years of age living in food-insecure households increased from 3.54 million to 4.85 million (17.1 percent to 23.1 percent, respectively, of all U.S. children under 5 years). Unemployment was one of the major factors underlying this increase. In view of the earlier session on obesity, Cook briefly mentioned re- views of the associations between food insecurity and obesity in children and said that findings from the studies have been mixed. He noted that the prevalence of obesity in children of ages 2 years and older essentially leveled off from 2004 to 2008. 30 32% increase, 25 2007–2008 20 Percent 15 10 5 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 All Households Latino Non-Hispanic Black Non-Hispanic White FIGURE 5-1 Proportion of food-insecure U.S. households (with and without chil- dren) by race and ethnic background, 1999–2008. Figure 5-1.eps SOURCE: USDA/ERS (2000, 2002a, 2002b, 2003, 2004, 2005, 2006, 2007, 2008, 2009).

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 FOOD INSECuRITY AND HuNGER The Face of Food Security Over the Next Decades Cook said that WIC will need to respond to changes in food insecurity over the next decades, but many questions remain regarding what those changes will be, such as: • Will poerty, food insecurity, and demand for food assistance re- main persistently high or decrease? Cook said that he views WIC as a food assistance program that was intended primarily to address the problem of food insecurity. • Will federal and state reenues continue to decline, remain where they are now, or increase? • Will obesity-related health problems maintain pressure for food system reform and for further improements in the WIC food packages? Cook said that he views the use of WIC as a possible way to address the obesity epidemic. Research Needed to Ensure WIC’s Continued Effectiveness Cook offered an extensive list of research topics, a number of which had been addressed in previous sessions: 1. How to reduce barriers to WIC participation; 2. How to assess the effectiveness and the true costs of functional ingredients added by manufacturers to approved WIC foods; 3. How to make more effective use of electronic benefit transfer (EBT) machines in WIC; 4. How WIC can more effectively encourage and support breastfeeding among participating mothers; 5. Ways to increase the use of WIC benefits in farmers markets, community-supported agriculture, and other venues that offer locally produced food; 6. Ways to increase funds available to WIC and to enable all eligible women, infants, and children to participate, with an emphasis on increasing participation by children; 7. Ways to further improve the quality of food purchased with WIC vouchers, especially in the smaller urban food stores that many WIC participants depend upon; 8. How to include oral health screening, fluoride treatment, dental sealant application, and other basic oral-health examination and referrals as part of WIC services, considering that poor oral health is a silent epidemic, especially in the pediatric population;

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 PLANNING A WIC RESEARCH AGENDA 9. How to use WIC to help establish pediatric medical homes for infant and child participants; and 10. Additional, more rigorous evaluations of the effectiveness of WIC in a. Improving birth outcomes and reducing health care costs, b. Improving diet and diet-related outcomes for mothers and children, c. Improving infant feeding practices, d. Improving inter-natal and prenatal health and nutrition status, and e. Improving brain growth and cognitive development. PERSPECTIVES ON WIC RESEARCH Presenter: Edward A. Frongillo, Jr. When the National Nutrition Monitoring System was started, the view was that adverse effects of food insecurity occurred primarily as a function of poor dietary and nutritional status. Now, Frongillo said, it is known that many additional pathways affect well-being and health and help explain why food insecurity affects children’s behavior, ability to learn, and many other aspects of their lives. Prior Research on Food Insecurity and WIC A paper by the U.S. Department of Agriculture Economic Research Ser- vice (USDA/ERS, 2009) found that approximately one-fourth of households that had received WIC benefits in the past 30 days had a food-insecure adult or child. Black et al. (2004) found a similar prevalence of food insecurity among those WIC participants and eligible non-participants who had ac- cess problems. Food insecurity has been associated with a poorer quality diet (Kropf et al., 2007). Bitler and Currie (2005) provided evidence that WIC reaches women and children who are at high nutritional risk. Herman and co-workers (2004) reported a reduction in food insecurity among post- partum women who had enrolled early in pregnancy. Furthermore, two- thirds of the women spent less money on food after enrolling in WIC; for one-third of the women, however, WIC benefits were used to complete the household food budget. Metallinos-Katsaras et al. (2010) also found that the risk of food insecurity with hunger was lower in the postpartum period for women who enrolled during the first or second trimester as opposed to the third trimester and, furthermore, that the risk of food insecurity for children decreased with each additional WIC visit by the mother. 1 The literature review was conducted by Emily Heberlein.

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 FOOD INSECuRITY AND HuNGER Concepts of Food Insecurity Food Insecurity as a Stressor Three models address ways in which participation in WIC could modify the stressor effects of food insecurity: (1) WIC could eliminate the stressor, thereby improving outcomes; (2) WIC could compensate for the stress by providing assistance; or (3) WIC could serve as a buffer that interrupts the pathway between food insecurity and some outcomes. To illustrate his first model (the stress-elimination model), Frongillo discussed outcomes from an innovative program called BRAC’s Ultra Poor program, which targeted the poorest 15 to 20 percent of the population in Bangladesh. The program decreased domestic violence dramatically, improved food security, improved the economic situation, and reduced social constraints. In this example, he said, a reduction in food insecurity accounted for about one-third of the substantial reduction in the distress (depression) of the participating women. Frongillo also noted that early food supplementation of pregnant Ban- gladeshi women was accompanied by a higher mean birth weight and an improved quality of mother-infant interaction, but only among those with a high stress level (high food insecurity). By contrast, a peer-counseling lactation intervention provided more benefit to the women who were less stressed. A possible reason that only the women with lower stress levels benefited is that they were able to pay attention to messages and act on them, whereas the more highly stressed women were not. Synergy Between Tangible Benefits and Behaior Changes Just and Weninger (1997) provide evidence that the societal benefit from WIC and the Farmer’s Market Nutrition Program arises when WIC coupons and information are given together. This work suggests that there may be a synergistic effect between the food voucher and behavior-change- communication components of WIC. A model by Patterson (2002) suggests that an important question to answer is, “How can WIC help families achieve a balance between demands (stressors, strains, daily hassles) and their capabilities (resources, coping behaviors)?” Research Questions Frongillo offered the following list of research questions:

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 PLANNING A WIC RESEARCH AGENDA 1. Does WIC reduce food insecurity, thereby leading to better outcomes? 2. Does WIC buffer the effects of food insecurity? 3. Does the food component of WIC primarily benefit those who are most food insecure? 4. Does the behavior-change-communication component of WIC pri- marily benefit those who are the least food insecure? 5. Does food insecurity need to be reduced by means of the WIC food package before communication to promote behavior change can be effective? 6. Does WIC reduce demands and increase capabilities, and how can WIC best help families balance these two coping strategies? Closing Remarks Frongillo closed his presentation by addressing points made in earlier presentations. 1. If WIC is connected with other programs and providers, the evi- dence from BRAC’s Ultra Poor program suggests that a synergistic effect may occur. That is, the women’s improved access to services and perceived higher social status in the community, combined with WIC benefits, may work together synergistically. 2. One possible outcome to monitor would be maternal–infant inter- actions, which can be measured on a fairly large scale, rather than birth weight, which Frongillo said is resistant to change. 3. Consideration needs to be given to possible gender differences when investigating outcomes among children. RESPONSE Discussant: James Weill WIC’s Purpose Many people believe that the fundamental purpose of WIC is to re- duce food insecurity that results from poverty, both because it should be unacceptable in our affluent society and because that strategy improves maternal and child health. Others believe WIC should be framed mainly as a public health program, in part because the severe hunger and malnu- trition seen in the late 1960s and early 1970s are now uncommon. Weill said that this improvement is in large part due to the success of WIC and its sister nutrition assistance programs, but he asserted that this view of

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 FOOD INSECuRITY AND HuNGER WIC tends to underplay the connections between poverty, food insecurity, and poor health. More people in the WIC age group are struggling financially than when WIC started. Comparing 1973 (essentially when WIC started) and 2007, median income adjusted for inflation decreased 23 percent, from $39,817 to $30,500, for households with children and headed by a person younger than 30 years of age. Moreover, 56 percent of these households had in- comes below 200 percent of the poverty line in 2007 (prior to the great recession). Thus, in many ways, the economic struggle for young families has become worse since WIC began. Weill said that he considers WIC’s role in addressing food insecurity to be just as important now as it was when WIC began. Comments on Research Questions Weill expressed agreement with research questions raised by Cook and Frongillo such as, “Does WIC reduce food insecurity?” and “For which populations does WIC buffer the effects of food insecurity?” Because the neediest subpopulation in WIC is probably the hardest to lift completely out of food insecurity, it is important to acknowledge that reaching that subpopulation is a desirable goal and to identify better ways to measure the positive effects of WIC, including moving families with ery low food security up to low food security. Weill said it is important to examine interactions of WIC with other programs, including the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. Using SNAP as an example, he offered the follow- ing questions: • Do WIC and SNAP together reduce food insecurity or very low food insecurity?; and, if so, • Do they do it more robustly together than in isolation? • Do the results differ for the different populations served by WIC? The combination of WIC and Medicaid is especially important to address, given the phase-in of health care reform and the extension of Medicaid ser- vices to low-income women of childbearing age regardless of their parental or pregnancy status. Other potential research topics include examining the effects of the food package on access to healthful foods in food deserts2 and examining 2 Food deserts are areas (typically rural or inner city areas) in which residents lack access to affordable healthful foods such as fruits, vegetables, whole grains, and low fat milk. Because vendors who participate in WIC must offer a selection of such foods, it would be possible for the food packages to improve access to healthful foods in food deserts.

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 PLANNING A WIC RESEARCH AGENDA whether WIC improves health and reduces obesity by improving food secu- rity. If it is true that improving food security can improve health and reduce obesity, it will be especially useful to examine ways to improve WIC’s effect on food security. GROUP DISCUSSION Moderator: Maureen Black Points made during the group discussion included the following: • The effects of food insecurity may not be immediately visible in young children because those under 3 years of age may not experi- ence effects on their weight or height. • A two-item screen for households at risk for food insecurity was recently validated by Hager and colleagues (2010). One item ad- dresses food, and the other addresses stress and anxiety in the household. The screening tool may be useful in pediatricians’ of- fices and Social Security offices. • The effects of food insecurity on childhood overweight appear to differ according to the maternal pre-pregnancy weight. Large sample sizes of low-income people will be needed to examine the influence of effect modifiers on the relationship between food inse- curity and body weight. SUMMARY OF SUGGESTED RESEARCH TOPICS The research suggestions made during this session focused on ways to increase participation in WIC; to improve its effectiveness and the measure- ment of effectiveness; to examine relationships among WIC, food insecurity, and health outcomes; and to examine relationships among WIC, Medicaid, SNAP, food insecurity, and health outcomes. Studies may need to take into account the degree of food insecurity and how factors such as gender affect food insecurity. REFERENCES Anderson, S.A. 1990. Core indicators of nutritional state for difficult-to-sample populations. Journal of Nutrition 120:1557–1600. Bitler, M. P., and J. Currie. 2005. Does WIC work? The effects of WIC on pregnancy and birth outcomes. Journal of Policy Analysis and Management 24(1):73–91. Black, M. M., D. B. Cutts, D. A. Frank, J. Geppert, A. Skalicky, S. Levenson, P. H. Casey, C. Berkowitz, N. Zaldivar, J. T. Cook, A. F. Meyers, and T. Herren. 2004. Special Supple- mental Nutrition Program for Women, Infants, and Children participation and infants’ growth and health: A multisite surveillance study. Pediatrics 114(1):169–176.

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 FOOD INSECuRITY AND HuNGER Hager, E. R., A. M. Quigg, M. M. Black, S. M. Coleman, T. Heeren, R. Rose-Jacobs, J. T. Cook, S. A. de Cuba, P. H. Casey, M. Chilton, D. B. Cutts, A. F. Meyers, and D. A. Frank. 2010. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics 126(1):e26–e32. Herman, D. R., G. G. Harrison, A. A. Afifi, and E. Jenks. 2004. The effect of the WIC pro- gram on food security status of pregnant, first-time participants. Family Economics & Nutrition Reiew 16(1):21–29. Just, R. E., and Q. Weninger. 1997. Economic evaluation of the Farmers’ Market Nutrition Program. American Journal of Agricultural Economics 79:902–917. Kropf, M. L., D. H. Holben, J. P. Holcomb, Jr., and H. Anderson. 2007. Food security sta- tus and produce intake and behaviors of Special Supplemental Nutrition Program for Women, Infants, and Children and farmers’ market nutrition program participants. Journal of the American Dietetic Association 107(11):1903–1908. Metallinos-Katsaras, E., K. S. Gorman, P. Wilde, and J. Kallio. 2010. A longitudinal study of WIC participation on household food insecurity. Maternal and Child Health Journal. http://www.springerlink.com/content/l12w4171117h5674/fulltext.pdf (published online May 9, 2010, accessed October 21, 2010) Patterson, J. M. 2002. Understanding family resilience. Journal of Clinical Psychology 58: 233–246. USDA/ERS (U.S. Department of Agriculture/Economic Research Service). 2000. Household Food Security in the united States, . Washington, DC: USDA/ERS. http://www.ers. usda.gov/publications/fanrr8/fanrr8.pdf (accessed September 17, 2010). USDA/ERS. 2002a. Household Food Security in the united States, 000. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/fanrr21/fanrr21.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2002b. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/fanrr29/fanrr29.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2003. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/fanrr35/fanrr35.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2004. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/fanrr42/fanrr42.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2005. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/err11/err11.pdf (accessed September 17, 2010). USDA/ERS. 2006. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/Publications/ERR29/ERR29.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2007. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/Publications/ERR29/ERR29.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2008. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/Publications/ERR66/ERR66.pdf (accessed Septem- ber 17, 2010). USDA/ERS. 2009. Household Food Security in the united States, 00. Washington, DC: USDA/ERS. http://www.ers.usda.gov/publications/err83/err83.pdf (accessed September 15, 2010).

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