8
Socioecological Perspectives: The Institutional Level

Key Messages Noted by Participants

  • The growth of the local and organic foods movement could serve as a model for making changes in food assistance programs.

  • Emergency food systems such as food banks, pantries, soup kitchens, and shelters are facing the challenge of a changing food system.

  • Changes in public- and private-sector food programs could have substantial nutritional benefits for the populations they serve.

The most encompassing level from a socioecological perspective is the institutional level, because institutions help to create the environments that shape household and individual behaviors. These institutions create the macroeconomic, taxation, and policy conditions that may contribute to the coexistence of food insecurity and obesity, noted Katherine Alaimo, who moderated the session on institutional factors at the workshop. In particular, food assistance programs and emergency feeding systems, which were the primary focus of the session, can have a profound effect on the lives of low-income and food-insecure people.



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8 Socioecological Perspectives: The Institutional Level Key Messages Noted by Participants • The growth of the local and organic foods movement could serve as a model for making changes in food assistance programs. • Emergency food systems such as food banks, pantries, soup kitchens, and shelters are facing the challenge of a changing food system. • Changes in public- and private-sector food programs could have substantial nutritional benefits for the populations they serve. The most encompassing level from a socioecological perspective is the institutional level, because institutions help to create the environments that shape household and individual behaviors. These institutions create the macroeconomic, taxation, and policy conditions that may contribute to the coexistence of food insecurity and obesity, noted Katherine Alaimo, who moderated the session on institutional factors at the workshop. In particu- lar, food assistance programs and emergency feeding systems, which were the primary focus of the session, can have a profound effect on the lives of low-income and food-insecure people. 115

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116 HUNGER AND OBESITY THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) AND THE AGRICULTURAL SYSTEM Researchers often treat food-insecure households as optimizers, said Sonya Jones, assistant professor in the Department of Health Promotion, Education, and Behavior at the University of South Carolina. These house- holds work hard to save their money, they do the best they can when they have shortfalls, and they are rational in their decisions. A better way to think about these families may be through the lens provided by the recent book Nudge: Improving Decisions About Health, Wealth, and Happiness (Thaler and Sunstein, 2008). Subtle clues in society and the environment, such as putting more healthful foods in the front of a buffet or rearranging the items in supermarkets, can influence choices in important ways. “We need to challenge ourselves to be more expansive than a traditional, economic maximizing approach in thinking about food insecurity,” said Jones. In her work in South Carolina, Jones has been moving toward a model that incorporates family adaptation and adjustments. Families have de- mands and structures, the hassles of everyday life, and the chaos and unpredictability that tend to come with food insecurity. Families balance liabilities against their assets and capabilities. They understand the demands and stresses of their lives and adapt or adjust. They use family management strategies such as maintaining a family meal time or going out for fast food to feel like a normal family. When families are able to achieve this balance, they are resilient—they are able to maintain healthful diets, positive parent- ing, and healthful food routines. When imbalances arise, maladaptation can occur. Families can have obesogenic diets, disrupted food routines, and lack of parental monitoring or engagement. “The qualitative work we have done suggests that this might be a promising way to understand and intervene on food insecurity,” said Jones. Features of SNAP An institution can be seen as an organization with rules and policies that affect a person’s behavior. By that measure, the Supplemental Nutrition Assistance Program (SNAP) fits the definition of an institution, because it affects people’s behavior when they participate. The Food Stamp Act of 1977 describes the program’s original intent as • To strengthen the agricultural economy; • To help to achieve a fuller and more effective use of food abun- dances; and

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117 SOCIOECOLOGICAL PERSPECTIVES: INSTITUTIONAL LEVEL • To provide for improved levels of nutrition among low-income households through a cooperative federal-state program of food assistance to be operated through normal channels of trade. The program still supports the agricultural economy, injecting about $50 billion into the food economy in 2010, almost double the level of 5 years ago. It also supports low-income people, who can qualify for the program by meeting one of several financial or nonfinancial criteria. Partici- pants are required to complete a significant amount of paperwork, which represents a demand on families, said Jones. They also can be subject to the stigma of participation, may find benefits to be inadequate, or can choose inappropriate foods that lead to obesity. “Families are trying to be resilient in the face of crisis, and they use programs that might be adding to their demands.” Balanced against these demands are the adaptive assets of having ad- ditional money to purchase food, receiving nutritional education from the Supplemental Nutrition Assistance Program for Education (SNAP Ed), and establishing healthful family routines. The challenge, said Jones, is to use re- search about these programs to channel support in the most effective ways. SNAP and Obesity With regards to obesity, research has shown that women who par- ticipate in SNAP have a small increase in the risk of obesity (Townsend et al., 2001; Gibson, 2003, 2006). Food-insecure women also may undergo changes in meal patterns (Zizza et al., 2008). Jones and Frongillo (2006) found a small increase in weight gain when participating in the food as- sistance programs—“maybe a 10 percent increase in risk.” As with any large institution, SNAP has multiple effects, some of which are positive and some negative. One way to view this problem is through what researchers call the “multiple streams theory.” Multiple problems such as obesity, hunger, and increasing agricultural yield are attacked with very broad solutions, such as “taking care of poor people” or “reducing the size of government.” As Jones said, “The solutions are driving the problems, or the politics are driving the problems, rather than the other way around.” In addition, said Jones, agriculture is a classic example of an “iron tri- angle” where policy makers, interest groups, and bureaucracies are tightly linked in making policy. This makes it very difficult to change the agricul- tural system, of which SNAP is a part. One promising change in the past 20 years, Jones added, has been the growth of the local and organic foods movement, which has used the growth of a market sector and local advo-

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118 HUNGER AND OBESITY cacy to make policy changes. “This is a model that we need to think about learning from,” she said. Research Considerations Jones suggested several future research directions: • Use family systems theory to integrate program evaluation research. • Use policy analysis to understand how new “solutions” change problems and politics. Examples include taxes on sugar-sweetened beverages, changes in food subsidies, and the development of local food economies. • Conduct experiments that help families develop resilience, set food procurement standards for retailers participating in programs, and keep food assistance dollars local. ADDRESSING OBESITY THROUGH THE EMERGENCY FOOD SYSTEM Food banks, which originated in the 1960s, were originally intended to be used for emergencies and to help people in disasters, said Tom Slater, executive director of the Food Bank of Central New York, which is part of the Feeding America network of 200 food banks across the United States. Food banks glean, purchase, store, and distribute foods to their subsidiary emergency food programs (EFPs) such as food pantries, soup kitchens, and shelters. Food banks are the equivalent in the commercial food distribution system of wholesalers, while EFPs are equivalent to food retailers in that they receive food from a variety of sources, including but not limited to food banks, and distribute food directly to recipients. The number of food banks increased significantly in the 1980s. Over the past few years they have continued to grow and have served many people who suffer from chronic food insecurity. Slater said that 82 percent of food pantries, 67 percent of soup kitchens, and 80 percent of shelters have seen an increase since 2006 in the number of recipients who come to their programs. Food Banks and a Changing Food System In recent years, many food banks have faced the challenge of a chang- ing food system. They have lost significant food donations, which typically come from food manufacturers, grocers, farmers, and individuals. Informa- tion technology has increasingly made it possible for food manufacturers to make just enough food that they can sell. Also, the rise of dollar stores and

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119 SOCIOECOLOGICAL PERSPECTIVES: INSTITUTIONAL LEVEL drug stores selling food has created lost opportunities for food banks, while donations to food banks of energy-dense foods with minimal nutritional value have increased, noted Slater. The role of food banks as major food suppliers to food-insecure and nutritionally vulnerable people necessitates consideration of the nutritional impact of food donation and distribution policies and practices, said Slater. “If we are going to change behaviors, we not only have to educate but we have to change the environment in which people are getting food.” The Food Bank of Central New York distributed more than 11 mil- lion pounds of food in 2009, which is equal to more than 23,000 meals every day. With four registered dietitians on staff, it has been conducting an in-depth discussion within the organization of how to change the way it works. The Hunger Prevention Nutrition Assistance Program within the New York State Department of Health, which is a major funder of the food bank, is very supportive of this process. Food banks tend to accept every food donation that is offered, said Slater, because even if the donation is not healthful, food banks may be concerned that rejecting certain items might preclude people from making future donations. When a solicitor from Slater’s food bank went to Pepsi to talk about the nutritional value of its donations, Pepsi responded that it would be glad to provide noncarbon- ated beverages. “That was a huge barrier to overcome that we could have a dialogue with our donors and perhaps come to a better understanding.” No-Soda/No-Candy Policy In 2004 the Food Bank of Central New York implemented a no-soda and no-candy policy. The policy was very controversial in the emergency food network. “I went on a series of debates across the country with John Arnold, the food bank director from Michigan, to talk about whether we should have policies that would exclude foods,” Slater said. “Those against exclusion policies argued that clients may want or need specific food items and food banks should not limit their choices. We responded that we are not saying that people shouldn’t have soda or candy. We are saying that it is affordable and accessible in their neighborhoods.” Food banks also spend considerable time and money picking up products that are not health- ful; when the Food Bank of Central New York considerably reduced the amount of soda distributed, it prevented a potential 3,300 pounds of weight gain among its clients. Perspectives of Bank Recipients Since the policy was instituted, the Atkins Center on Weight and Health at the University of California at Berkeley has conducted an evaluation to

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120 HUNGER AND OBESITY assess the policy’s impact, the preferences of emergency food recipients, and the perceptions of food pantry directors. Recipients were asked to rank the importance of various considerations on a four-point scale. Ninety-eight percent indicated that having nutritious food available to choose at a food pantry was important or very important. Ninety-four percent reported that taste was also an important or very important consideration when choosing food for their households. Seventy percent did not place a prior- ity on receiving snacks, reporting that it was somewhat or not important to them. Ninety-four percent placed a high priority on the availability of staple items. Recipients also ranked items they would like to get at a food pantry. Meat, poultry, and fish; vegetables; and fruit received the three highest ranks. Snacks, soda, and candy were the three least preferred items. “These find- ings helped validate the Food Bank of Central New York’s original no-soda/ no-candy policy and can help shape future nutrition policies,” said Slater. More than 70 percent of food recipients said that they preferred fresh fruit rather than frozen or canned fruit, and 51 percent said they preferred to receive fresh vegetables rather than frozen or canned. Perspectives of Food Pantry Directors About 80 percent of directors said they “strongly agree/somewhat agree” and 20 percent said they “strongly disagree/somewhat disagree” with the statement “the role of the food pantry is to provide healthy items only.” Only about twenty-seven percent said they “strongly agree/somewhat agree” with the statement “the role of the food pantry is to provide a va- riety of foods including soda and candy,” with about 74 percent indicating that they “strongly disagree/somewhat disagree” with that statement. Most of the directors surveyed were familiar with the Food Bank of Central New York’s policy of no soda and no candy and had come to agree with it. Directors reported that inconsistent availability is the greatest barrier to providing fresh fruits and vegetables. The costs of meat, poultry, fish, refrigerated milk, and whole wheat bread also were identified as barriers to distribution, as was the inability to store milk and fresh fruit properly. This study revealed several important points, Slater said. The biggest challenges to providing preferred foods are not attitudinal; instead, they re- late to cost, inconsistent availability, and storage capacity. Recipients’ prefer- ences can be used to guide food donors, purchasers, program directors, and dietitians when determining the product mix to distribute as well as what types of foods may need promotion. “Findings from this study should be used to support internal discussions regarding improvement of the infrastructure of food pantries to help support the improvement of foods distributed at food pantries,” Slater concluded.

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121 SOCIOECOLOGICAL PERSPECTIVES: INSTITUTIONAL LEVEL Building the Infrastructure Since 2004 the Food Bank of Central New York has put more than a million dollars into refrigerators, freezers, and shelving to handle differ- ent kinds of food. Its staple items are now meat, poultry, fish, fresh fruits and vegetables, and frozen vegetables. It has set up a million-dollar line of credit so that food pantries can draw on the bank throughout the year. The 276 emergency food programs it serves can choose on a monthly basis the type of foods they want to distribute. It has partnered with neighborhood stores so that people can redeem milk vouchers for 1 percent or skim milk and food banks do not have to store and distribute as much milk. Of the people surveyed in the territory served by the bank, 97 percent were happy with the quantity of food that they received, 98 percent were happy with the quality of the food they received, and 95 percent said that they were treated with respect. The Food Bank of Central New York can be “a model for the na- tion,” said Slater. The Feeding America network has begun to source and track nutritious food. Slater is working with the network to define a meal as containing three to five food groups, rather than simply 1.3 pounds of food, the definition used in the past. The provision of funding from the New York State Department of Health, rather than the Department of Social Services, means that the Food Bank of Central New York can focus on health. It also works with recipients to ensure that they get the government benefits to which they are entitled. A full-time staff member works with the emergency food programs to assess why individuals come into the network and to address their needs, whether paying a heating bill, feeding a new baby, or applying for SNAP. “It is critical that we partner with the government so that . . . we can have a comprehensive approach.” Research Considerations Slater identified the following questions: • To what extent can the emergency food system change nutrition and procurement policies to meet the demand of recipients? • To what extent would the infrastructure of the emergency food system need to change to accommodate more healthful foods? Is this sustainable? • Do recipients, directors, food bank staff, and nutrition experts define nutritious food similarly? • How do inventory improvements in the emergency food system affect recipients’ overall diet quality?

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122 HUNGER AND OBESITY DISAGREEMENTS OVER THE RATIONALE FOR STUDYING FOOD INSECURITY AND OBESITY In the final presentation of the session on institutional factors, Diego Rose, professor in the Department of Community Health Sciences at Tulane University, raised several provocative questions as a way of helping people think more deeply about the topic of the workshop. Rose began by asking whether it made sense to focus on the relation- ship between food insecurity and obesity. Because both food insecurity and obesity are major social problems and because relatively little is known about how to improve either, Rose suggested that it would make more sense to focus energies on each problem separately. The Obesity Problem Obesity is strongly associated with poverty, even more so than with food security. For those working on the problem of obesity, it would make more sense to focus on the poor, rather than the narrower subset of the food insecure. Surveys show that 43 percent of the poor are food insecure, leaving 57 percent who are not food insecure. “Do we want to exclude them if we are concerned about obesity?” Rose asked. Similarly, only about 10 percent of overweight children are food in- secure, but about a quarter of overweight children are poor. “Maybe we would have more of an impact if we worked on poor people rather than food-insecure people.” If one is concerned about obesity, the other problem Rose mentioned is that focusing on the narrower food insecurity-obesity linkage removes physical activity from consideration. Of course, physical activity level is a key determinant of obesity. Yet being physically active in poor neighbor- hoods, for example, can be difficult because of crime, difficulty accessing playgrounds, and other issues. Leaving out physical activity gives an in- complete picture of the factors contributing to obesity, particularly among the poor. The Food Security Problem Just as with obesity, food insecurity is a major problem in its own right that requires solution. Thus, for those concerned with solving the problem of food insecurity, it can be misleading to focus only on those food-insecure people who are overweight or obese, because that would exclude one-third to two-thirds of the food-insecure population. “Why muddy it up with looking at just those who are overweight?”

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123 SOCIOECOLOGICAL PERSPECTIVES: INSTITUTIONAL LEVEL Other Considerations Rose said that focusing on the relationship between food insecurity and obesity may detract from our real concerns, which are to reduce food inse- curity and to reduce obesity. Even in isolation, these objectives are very dif- ficult, both for researchers and for policy makers. Intervention science can be more effective if one outcome at a time is studied. Focusing on whether institutions affect the relationship between food insecurity and obesity de- tracts from the more pressing concerns of how we influence institutions to reduce food insecurity or how we influence institutions to reduce obesity. Furthermore, policy makers understand the importance of reducing food insecurity or reducing obesity, but emphasizing the relationship between the two may obscure the importance of each goal. Rose asked whether we might be analyzing ourselves out of relevance by focusing too narrowly on this complex relationship. Rose also wondered whether some emphasized the relationship between food insecurity and obesity as a way of justifying food assistance programs to U.S. taxpayers. Rose argued that this wasn’t necessary because “food” assistance programs had modernized to become “nutrition” assistance programs—offering nutrition education and better access to healthful foods. GROUP DISCUSSION Moderator: Katherine Alaimo During the group discussion period, points raised by participants included the following: The Rationale for Studying Food Insecurity and Obesity Researchers need to understand the relationship between food insecu- rity and obesity because the public blames poor people for having obese children, said one participant. By delineating mechanisms that link food insecurity and obesity, researchers can help explain the association. Another pointed out that the public may come to the conclusion that food assistance programs promote obesity, which can reduce support for these programs. Research on the links between poverty, food insecurity, and obesity can reduce public confusion about this issue. Similarly, rates of obesity vary among regions and ethnic groups in the United States, and research can help delineate the reasons for this variation. Rose agreed in part with these observations. He pointed out that many people blame the obese for their condition. Research can reveal the

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124 HUNGER AND OBESITY socioecological contributors to obesity, which might shift blame more ap- propriately. A benefit of focusing on food insecurity and obesity is what this workshop provides: a way to bring creative, interdisciplinary researchers together to devise solutions that would not necessarily be considered from a single disciplinary perspective, he said. Food Quality in the Emergency Food System Several participants commented on the efforts of food banks around the country to improve the nutritional quality of the foods they distribute. As the result of a recent initiative in California, for example, 60 percent of the food going into the food bank system now consists of fruits and vegetables. Changes in advocacy and communication also have been made, and other states are adopting these changes, just as other state food banks have adopted changes pioneered in New York State. In response to a question about how he has managed to have so many nutritionists on the staff of the Food Bank of Central New York, Slater responded that he has been able to hire four nutritionists by convincing government of the importance of their positions. “We need to hold [govern- ment] accountable to help fund this, and we need to show them that it is critical that we do it from a nutritional standpoint.” Redefining “Success” of Food Distribution Michelle Berger from the Feeding America network remarked that her organization is working with member organizations on both food insecurity and nutritional insecurity. It also is considering such issues as how to define success beyond the distribution of particular quantities of food. “What does success look like in the emergency feeding system beyond just pounds?” REFERENCES Gibson, D. 2003. Food stamp program participation is positively related to obesity in low income women. Journal of Nutrition 133(7):2225-2231. Gibson, D. 2006. Long-term food stamp program participation is positively related to simul- taneous overweight in young daughters and obesity in mothers. Journal of Nutrition 136(4):1081-1085. Jones, S. J., and E. A. Frongillo. 2006. The modifying effects of food stamp program partici- pation on the relation between food insecurity and weight change in women. Journal of Nutrition 136(4):1091-1094. Thaler, R., and C. Sunstein. 2008. Nudge: Improving decisions about health, wealth, and happiness. Ann Arbor, MI: Caravan Books. Townsend, M. S., J. Peerson, B. Love, C. Achterberg, and S. P. Murphy. 2001. Food insecurity is positively related to overweight in women. Journal of Nutrition 131(6):1738-1745. Zizza, C. A., P. A. Duffy, and S. A. Gerrior. 2008. Food insecurity is not associated with lower energy intakes. Obesity 16(8):1908-1913.