13
Key Elements, Priorities, and Next Steps

Key Messages Noted by Participants

  • Participants agreed that continued research on food insecurity and obesity is needed to answer the questions policy makers and the public have about how and why the two coexist, and that longer funding cycles will enable important questions to be answered.

  • Such research is important because it will help to guide modifications of food assistance programs and to maintain public support for these programs.

  • Comprehensive analyses of food purchases, acquisitions, and consumption can be achieved by linking data from different sources.

  • Multiple federal agencies are interested in the possible links between food insecurity and obesity.

  • Several participants affirmed that communications research is needed to uncover better ways of framing and disseminating the results of research on food insecurity and obesity.

  • Research on the framing of obesity and food security from an individual perspective needs to be enhanced by more research on community level research in these areas.



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13 Key Elements, Priorities, and Next Steps Key Messages Noted by Participants • Participants agreed that continued research on food insecurity and obesity is needed to answer the questions policy makers and the public have about how and why the two coexist, and that longer funding cycles will enable important questions to be answered. • Such research is important because it will help to guide modi- fications of food assistance programs and to maintain public support for these programs. • Comprehensive analyses of food purchases, acquisitions, and consumption can be achieved by linking data from different sources. • Multiple federal agencies are interested in the possible links between food insecurity and obesity. • Several participants affirmed that communications research is needed to uncover better ways of framing and disseminating the results of research on food insecurity and obesity. • Research on the framing of obesity and food security from an individual perspective needs to be enhanced by more research on community level research in these areas. 177

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178 HUNGER AND OBESITY In the final session of the workshop, several speakers representing gov- ernment agencies and one official from a private foundation summarized the key messages and suggested actions from the previous 2.5 days. The moderator, Patricia B. Crawford, director of the Atkins Center for Weight and Health at the University of California at Berkley, encouraged panelists to reflect on the workshop content and discuss next steps to help increase our understanding of the relationship between food insecurity and obesity. Although much progress has been made in recent years, much more remains to be done, the panelists said. The potential for research and practice to improve the lives of people who struggle with food insecurity and obesity demands redoubled efforts. A PERSPECTIVE FROM THE FOOD AND NUTRITION SERVICE Is there value in continuing to examine the relationship between food insecurity and obesity? “I’m going to say a resounding yes and give you two reasons why that’s the case,” said Carol Olander, director of Family Programs Staff in the Office of Research and Analysis at USDA’s Food and Nutrition Service (FNS), which sponsored the workshop. Rationale for Conducting Research First, a vocal contingent of policy makers and a significant segment of the public cannot fathom how it is possible for people to be both poor and obese. This group asks, if the poor or food insecure are overweight or obese, why do they need additional food or nutrition assistance? “That’s the world I live in,” said Olander. To provide a persuasive and compelling answer to this question, a large body of complicated information needs to be distilled into a succinct message. “I originally thought about having this workshop with the idea that perhaps we would be able to walk out of the room, not necessarily with sound bites, but at least with the armament to move in that direction. That’s not quite the case.” Yet the lack of a succinct message at present demonstrates not only why additional research is needed, said Olander, but also some of the directions in which that research must go. The second reason she cited for looking at the relationship between food insecurity and obesity is that the government has an obligation to demonstrate that it is a good steward of tax dollars. This calls for either a succinct message about the relationship or research aimed at providing that message. Finally, the mission of FNS has evolved from a focus just on hunger to the broader issues of healthful diets and making good food choices. For

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179 KEY ELEMENTS, PRIORITIES, AND NEXT STEPS example, the change in name of the Food Stamp Program to the Supple- mental Nutrition Assistance Program reflects that shift in emphasis. “We’ve moved from being about food assistance programs to being about nutrition assistance programs.” To fulfill this mission, FNS needs to support efforts that respond to both food insecurity and obesity. Olander cited Marlene Schwartz’s concept of “nutritious food insecurity” as an important contribution of the work- shop to meeting this objective. Consideration of both food insecurity and obesity inevitably generates tension. With food insecurity, the emphasis is on more—more resources, more access, more calories. With obesity, the emphasis is on being more selective if not more restrained. Exploring and understanding this funda- mental contrast “is essential to being able to go forward and get the sort of support that is necessary to continue programs that are intended to serve an increasingly large population in this country,” said Olander. Takeaway Messages She cited several takeaway messages that emerged from the workshop: • Further cross-sectional comparisons of overweight and obesity among different populations are not needed. “The additional re- turn for the effort is probably not as worthy as it might be in pursuing some other paths in the research arena.” • Many other factors besides food security mediate the relationship between access to food and obesity. These factors could jointly cause obesity and food insecurity, or they could exert causal influ- ences in either direction. • Many research directions could provide useful information. Ex- amples include ethnographic studies that look at the coping strate- gies that households use; longitudinal and retrospective studies that examine changes in or the persistence of food security and the likelihood that these have cross-generational influences; examina- tion of the source, type, and quality of the foods that a household purchases and consumes; longitudinal research on the relationship of stress and depression to food insecurity and obesity; and case studies that look at how food potentiates the link between food insecurity and obesity, as when the members of a household share food or experience disrupted eating patterns. • Measurement issues remain important, with respect to both so- cioeconomic status and obesity itself, which would seem to be a simple concept but in fact is not straightforward.

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180 HUNGER AND OBESITY FNS is announcing a competitive grants program focused on childhood hunger, said Olander. It also is conducting studies on where people in a household get food, participation in farmers’ markets, and where recipients of Supplemental Nutrition Assistance Program (SNAP) funds spend their resources. For example, a recent study analyzed national data to determine how many different types of stores SNAP recipients go to, how often they shop, and what they spend. The average number of transactions for a household is more than seven per month. Most of the dollars are spent in the first half of the month, with relatively few resources left for the end of the month, and most of the dollars are spent in supermarkets and super- stores. Less than 5 percent of these households never shop in a supermarket or a superstore in the course of a given month. The workshop produced many ideas about how changes to programs could be tested. Examples include alternative SNAP delivery schedules and a focus on family and community wellness. Olander pointed out that legislation can constrain such experiments. Appropriations generally come through very specific line items tied to particular programs, but as legisla- tion at the federal and state levels is reauthorized and otherwise changed, these constraints can be lifted. A PERSPECTIVE FROM THE ECONOMIC RESEARCH SERVICE The interaction between food insecurity and obesity is one element in the larger issue of how to alleviate both. As a result, said Laurian Unnevehr, director of the Food Economics Division of USDA’s Economic Research Service (ERS), understanding this interaction enriches and enlarges work on effective interventions. Linking Different Kinds of Data Unnevehr briefly described the investments USDA has made in linking data of different kinds, which is a way of capturing many characteristics of interest to researchers. For example, efforts are under way to link National Health and Nutrition Examination Survey (NHANES) data with administra- tive data to have a clearer picture of food assistance program participation and benefits. These data also are being linked with price data to have a better measure of the economic environment and how it may influence health out- comes. In addition, spatial data on the food environment from the American Community Survey are being linked with other kinds of data. These various projects are laying the groundwork for a comprehensive survey of food purchases and acquisitions both at home and away from home. The data will cover where the household shops and will be linked to program participation data, providing an opportunity to look at how

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181 KEY ELEMENTS, PRIORITIES, AND NEXT STEPS acquisition might be shaped, for example, by participation in multiple programs. More information on the project is available in the Diet Quality and Food Consumption Briefing Room on the ERS website. Data delivery is expected in 2013 and will be shared with the research community in subsequent years. Food Environment Atlas Unnevehr also briefly mentioned a project on food deserts and the food environment. A Food Environment Atlas provides data at the county level on food deserts as well as what have been called “food swamps”—areas in which large relative amounts of energy-dense snack foods inundate healthful food options (Rose et al., 2009)—and the variety of food choices that may be available in a neighborhood. This project provides a national context for microspatial studies. Intramural Research on Food Insecurity USDA has been supporting intramural research on persistent food inse- curity and the potential limitations of programs to address food insecurity. It also is looking at the relationship between food expenditures and food security, which is particularly important in an era of volatile food prices and economic recession. Another area of long-standing interest is food as- sistance and health outcomes. Understudied questions include the impact of the Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), critical stages in development, and impact of participation in multiple programs on shaping food choices. The result of such research could be “a fuller picture of how policies can play a role in addressing either food insecurity or obesity or both.” Extramural Research on Food Insecurity On the extramural side, USDA was preparing a request for propos- als on the impacts of the recession and the role of food assistance in the broader safety net of social programs. Federal Partnerships for Research on Food Insecurity ERS and FNS are partnering in part to use new tools made available through behavioral economics, which is just one example of potential fed- eral partnerships.

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182 HUNGER AND OBESITY A PERSPECTIVE FROM THE NATIONAL INSTITUTES OF HEALTH Food insecurity is a “hidden phenomenon,” said Wendy Johnson- Askew, public health nutrition and health policy adviser for the Division of Nutrition Research Coordination within the National Institutes of Health (NIH). “Nobody comes out and tells you they don’t have enough money for food.” Surveys may or may not be able to determine what people are experiencing, although obesity can be an objective measurement. The co- existence of food insecurity and obesity can generate confusion for policy makers and members of the public. Even researchers can be hesitant to talk about this relationship if discussions seem to threaten necessary programs. However, exploring the connection is critical, said Johnson-Askew. “We have to be bold, we have to be the advocates, we have to be able to explain to people and steer this conversation so that people get a better understanding of how these two things exist.” Core Measures and Procedures NIH is interested in funding the best research it can fund, she said. Greater than 70 percent of NIH-funded research is investigator-initiated. In light of the mixed results of food insecurity and obesity studies she rec- ommended agreeing on a set of core measures and procedures that can be incorporated in studies to measure the same things in the same way. Some areas of consideration for inclusion in core measures are: Should marginal food security be combined with low and very low food security? Should the population of interest be below 185 percent, 200 percent, or 250 percent of the federal poverty line? Which measures of socioeconomic status should be used in models? Johnson-Askew suggested the following as areas in which more re- search is needed: Communications research. Researchers are not necessarily skilled • at getting their points across to the public and reacting to the public’s questions, said Johnson-Askew. Food choices. Many factors go into these decisions, not just money. • Behavioral economics could make important contributions to how people make these decisions. Food acquisition. We need more information on where people are • getting their food. “Food pantries, though they fill a great niche, are not acceptable ways for families to have to come once a month and get 3 days’ worth of food,” said Johnson-Askew. Social networking. This is a hot topic at NIH, and social networks • undoubtedly influence nutrition behavior.

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183 KEY ELEMENTS, PRIORITIES, AND NEXT STEPS A variety of lenses. Historical trauma, life course perspectives, and • child health are all additional lenses through which to view obesity prevention. NIH has substantial resources that it devotes to nutrition and obesity: 4 percent of the NIH budget goes to nutrition research, representing expen- ditures of $620 million annually, and 8 percent of that is targeted toward obesity. Much of the research funded in the past has been on interventions research. What happens if this one thing is changed? Food insecurity and obesity are very dynamic states. Currently there is a groundswell of interest in systems research, which fits well with the multifactorial nature of obesity and holds promise for helping to understand the relationship between food insecurity and obesity. A PERSPECTIVE FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION Most of the work done by the Centers for Disease Control and Pre- vention (CDC) occurs at the community and state levels, said Commander Heidi Blanck, chief of the CDC’s Obesity Prevention and Control Branch. The CDC division that contains her branch funds adolescent and school health and adult and community health, with an increasing emphasis over time on the environment, policy, and systems approaches. Blanck said that CDC’s portfolio is helping communities make the more healthful choice the easy choice. The goals of CDC include increasing diet quality, increasing physical activity, and reducing obesity. These goals can be met by helping Americans to eat healthfully and live actively. Reducing obesity is a goal, but healthful relationships with the food environment and physical activity are routes to that goal. Unintended Consequences of Policies One thing CDC has examined is possible unintended consequences of policies. For example, will enhanced menu labeling worsen disparities among groups, some of which may not have the education, income, or health literacy to react to healthful incentives? Will emphasis on retail ven- ues, farmers’ markets, or farm-to-school programs enable equitable food choices? It is one thing for government to emphasize the importance of fruits and vegetables and quite another to ensure access to those foods. The administration has been emphasizing programs such as the Fresh Food Financing Initiative to fill the “grocery gap,” but it also has been working

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184 HUNGER AND OBESITY on options that restrict consumption, such as limiting the consumption of sugar-sweetened beverages. Viewing such issues from the perspective of food insecurity has been helpful, said Blanck, because it is a valuable addi- tion to the diet quality perspective. Food Policy Councils and Community Food Security Coalitions Blanck included the importance of food policy councils and community food security coalitions, which are groups of advocates and stakeholders that have the potential to do the following: • Engage in discourse about meeting the needs of multiple groups including agriculture, public health workers, and lower-income individuals; • Provide technical assistance for state and local communities to think about food access and anti-hunger; and • Invest in interventions demonstrated to be effective. The Farm Bill The Centers for Disease Control and Prevention is convening stake- holders to consider public health in the reauthorization of the farm bill. Research on food insecurity and obesity can be a way to bring together people from different areas to work on these broader issues. The National Collaborative on Childhood Obesity Research CDC is part of the National Collaborative on Childhood Obesity Re- search (NCCOR), which has brought together several large public- and private-sector organizations interested in childhood obesity and food security. A PERSPECTIVE FROM PRIVATE FOUNDATIONS For the past 6 years, The California Endowment, which is a private foundation dedicated to improving the health of Californians, has been fo- cused on a community-based, comprehensive obesity prevention initiative, said Marion Standish, director of The California Endowment’s Community Health Program. This initiative has sought to frame the program around the community, not around individuals, which has implications for both research and practice. “We want to move from this narrow frame around outcomes of obesity to these larger frames of community priorities to im- prove health,” she said. One objective is to look carefully at the places where people live. The relationship between food security and place is “profound,” said Standish.

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185 KEY ELEMENTS, PRIORITIES, AND NEXT STEPS Geographic information system (GIS) mapping of poverty, food security, school meal participation, and other measures related to socioeconomic status and food access find enormous geographic concentration. “A good solution solves many problems, and I think in this instance, a focus on place offers us the opportunity to address both food security and obesity simultaneously.” Focus on Prevention Standish expressed the opinion that prevention had not been empha- sized enough in the workshop. Once obesity has taken root, it is hard to undo. How can the problem be shifted upstream to the community factors that contribute to obesity? Communities recognize the importance of the same things researchers do in obesity prevention, including access to health- ful food, safe places to play, and walkable neighborhoods. Policy and systems change requires working with community members and parts of systems. It also requires research to evaluate multisectoral approaches. • Which influences in the community environment offer the most promise for interventions? • To what extent do those influences need to be changed? • How many playgrounds, food stores, or food benefits are neces- sary to make communities food secure and eliminate obesogenic environments? • How can longitudinal research be sustained to assess the long-run impact of policy on behavior? The involvement of the National Institutes of Health in this research would be extremely welcome, said Standish. Currently, the resources to evaluate community change are very limited. GROUP DISCUSSION Moderator: Patricia B. Crawford During the group discussion period, points raised by participants included the following: Funding Cycles The panelists discussed how the typical funding cycle for research at NIH can be harmonized with the study of long-term interventions. One option is to change the funding cycle, although in an institution as large

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186 HUNGER AND OBESITY as NIH that it not easy, said Johnson-Askew. Another option is for NIH to provide support for organizations that can conduct long-term research, such as NCCOR. Foundations also may be able to fill some of the gaps that NIH cannot fill, she said. Improving Program Evaluation Standish pointed to a healthful food initiative that will represent a shared investment between the U.S. Department of the Treasury, USDA, and the Department of Health and Human Services. “There needs to be an evaluation of that initiative that goes beyond did we actually invest in stores or operators to—Did we really deliver healthful food? Did people choose healthful food? Who was choosing healthful food? Where were they coming from to get to those places? . . . I know funders are interested in this as well—a robust, multiagency, coordinated evaluation to address this one very important issue of access to healthful food.” Measuring Community Food Security In response to a question about whether the federal government intends to invest in methods to measure community food security, Blanck said that CDC is sponsoring a survey that will look at how health planners are assessing access to food and water to glean environmental measures that could augment geographical data. CDC also has tools that communities can use for planning and evaluation. Lila Rutten mentioned a new resource developed by the National Cancer Institute called the Grid-Enabled Mea- sures Database, or GEM, which is an online data repository that is based on wiki technologies so that contributors can add what they think are the best measures of nutritional intake, physical activity, and so on. “It’s an opportunity for the scientific community to vet, comment on, and modify those measures.” Communications Research Valerie Tarasuk emphasized the need for communications research. “A lot of the arguments that have been made over the last 3 days around the need for more research on the relationship between food insecurity and obesity have been rooted in concerns about the way in which perceptions about fatness are being used to raise questions about the legitimacy of poor people’s needs for benefits. I would suggest to you that this is not a matter of science, or at least not solely a matter of science. Pouring more money into scientific endeavors to try to elucidate whether or not there is a relationship and what the biological pathways are will probably not be

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187 KEY ELEMENTS, PRIORITIES, AND NEXT STEPS enough to silence those who would raise questions about the legitimacy of benefits for people who are living in poverty.” Standish emphasized that the framework for health issues in the United States is oriented toward self-reliance and individual choice. “To the extent that we are trying to identify [other] factors, it’s an uphill climb unless we have research to help us reframe the discussion.” Standish highlighted the importance of better understanding community food security and factors that influence communities. Edward Frongillo agreed that it is important not only to set a research agenda but to develop a communications strategy based on the findings of research. “If there isn’t a counter narrative, we’re in a position of replacing a narrative that’s out there with nothing. We need to make a story that’s more realistic and more useful to help improve people’s lives.” REFERENCE Rose, D., N. Bodor, C. M. Swalm, J. C. Rice, T. A. Farley, and P. L. Hutchinson. 2009. Deserts in New Orleans? Illustrations of urban food access and implications for policy. Paper presented at Understanding the Economic Concepts and Characteristics of Food Access, Washington, DC, January 23, 2009.

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