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H Brief List of Recurring Workshop Discussions1 The presenters at the workshop put forth a wide variety of research considerations to help further our understanding of the relationship be- tween food insecurity and obesity. Participants also had the opportunity to comment on the research considerations and present new ideas. Recurring themes are compiled and condensed below as a guide to the wide range of issues discussed at the workshop. The themes are organized by topics that arose during the workshop, which differ from the session titles. The over- view provides general themes and is followed by recurring research topics, measures, and methods to improve our understanding of the relationship between food insecurity and obesity. The following list does not reflect priorities or group consensus. OVERVIEW Food insecurity negatively impacts health and well-being in adults and children—beyond any potential association with obesity. The importance of continuing to facilitate improvements in food insecurity status among individuals, households, and communities was underscored by participants throughout the workshop. 1 The list, prepared by the rapporteurs and based on the workshop discussions, reflects sug- gestions made by presenters, discussants, panelists and other workshop participants in relation to the workshop’s focus. It was prepared for the convenience of the reader. It should not be construed as representing recommendations or consensus statements, nor is it reflective of all topics or the entire breadth of the discussions. 235

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236 HUNGER AND OBESITY Understanding the potential pathways by which food insecurity and obesity may be associated can help inform intervention strategies. Research- ers may consider analysis, framework, and understanding of the relation- ship between food insecurity and obesity given that a high percentage of the population is overweight or obese. Bringing together varied academic disciplines such as public health, nutrition, psychology, sociology, and economics, and encouraging research collaborations across organizations can make valuable contributions in- cluding expanding methodologies and frameworks used to examine the relationship. RESEARCH TOPICS A Life Course Perspective • Impacts of food insecurity during critical periods of development such as fetal development and child growth and development, in- cluding examining the association and mechanisms of deprivation in childhood and obesity later in life. • Whether specific factors are more or less influential on the relation- ship during different points in infancy and childhood. • Other critical periods of development. • The relationship in aging/older adults. Environmental Factors • Access to healthful foods including the impact of supermarket ac- cess, transportation access, and various sources of foods. • Food marketing, including the impact on diet quality. • Foods served and consumed in schools and childcare programs, including strategies to design and implement higher nutritional standards and other strategies to improve the quality of foods. • Competitive foods, including the impact on healthful choices and participation in free or reduced-price school meals. Institutional Factors • Taxation of less healthful foods. • Broader social policies such as agricultural subsidies. • Food assistance programs, including the impact of Supplemental Nutrition Assistance Program benefit distribution on behaviors and benefit modifications to improve choices, free or reduced-priced school meals, and summer meals programs.

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237 BRIEF LIST OF RECURRING WORKSHOP DISCUSSIONS Mediators, Moderators, and Effect Modifiers • A multitude of factors potentially influence the relationship be- tween food insecurity and obesity. The importance of identifying additional factors beyond the ones listed below was also noted. • Stress was mentioned in nearly every session—including both phys- iological and psychological stress; being food insecure and/or living in a low-resource environment may be stressful and conversely, stress may impact food insecurity status. • Other potential factors recurring throughout the workshop in- cluded poverty, diet quality, maternal/caregiver mental health, in- fant feeding and parenting behaviors, gender, age, violence, social support, and physical activity. RESEARCH MEASURES Food Insecurity • Variance of food insecurity measures across individuals within a household. • Does the current food insecurity measure capture the experience of children? • Impact of depression on the assessment of food insecurity. • The concept of food-insecure neighborhoods or environments. • The episodic nature of food insecurity, including the frequency and duration of food insecurity, the determinants of food insecurity episodes, and how periodic food insecurity influences behaviors. • Differences between those with persistent and those with periodic food insecurity. • Examination of food security at the individual, household, and community level. Obesity • Challenges of measuring obesity in children less than 2 years of age. • Incorporation of alternative measures of assessing body fat, such as DXA, into studies, noting that it may not be practical in some studies. • The relationship of the multiple factors related to obesity among food secure individuals.

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238 HUNGER AND OBESITY Socioeconomic Disparities • Improved measures of socioeconomic status. • The impact of race and ethnicity on health outcomes. • Variance of social, economic, and geographic factors on food inse- curity and obesity. RESEARCH METHODS Data Collection • Expand and combine data collection methods. • Consider geographic information system and other electronic map- ping techniques to track food insecurity, obesity, and other poten- tially related factors such as poverty and food access. • Pair electronic mapping with on-the-ground research. • Consider qualitative methods such as ethnographic studies and photovoice. • Incorporate qualitative methods into ongoing quantitative research. • Engage community members in data collection and interpretation. Research Types • Communications research including identifying improved ways of framing and disseminating results of food insecurity and obesity research; creating and disseminating messages to motivate different populations, including (but not limited to) those served by SNAP, to make healthful food choices. • Evaluation research including evaluating approaches to encourage behavior change in purchasing and consuming healthful foods. Research Designs • Prospective and retrospective studies to better understand topics such as how food insecurity early in life shapes longer-term eating behaviors, intergenerational impacts, and acculturation, and to identify mediators and moderators and examine changes in or the persistence of food insecurity. • Intervention studies or experimental studies to examine causality and to better understand program effectiveness.

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239 BRIEF LIST OF RECURRING WORKSHOP DISCUSSIONS Data Analysis • Link data from different sources to enable analysis of key variables together. • Assess interactions to identify effect modifiers. • Use advanced statistical analysis such as structural equation modeling.

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