Karla L. Hanson

Food insecurity and dietary quality in US adults and children: a systematic review

BACKGROUND Food insecurity is adversely associated with the physical and mental health of adults and children, and the mechanism that underlies this association has been assumed to be dietary intake of lower quality in food insecure than food secure individuals. A thorough understanding of observed associations between food insecurity and dietary quality is needed to test this assumption and may highlight pathways through which to improve the health of food-insecure adults and children. OBJECTIVE We systematically reviewed all evidence of associations between food insecurity and dietary quality and contrasted associations observed in adults and those for children. DESIGN Evidence came from studies that appeared in indexed, peer-reviewed journals and 1) sampled US residents, 2) separately sampled children and adults, 3) contained a measure of food insecurity or food insufficiency, and 4) included at least one measure of dietary quality. RESULTS In adults, 170 associations between food insecurity and dietary quality were tested, and 50 associations (29%) suggested an adverse association. Food-insecure adults consumed fewer vegetables, fruit, and dairy products than did food secure adults and had lower intake of vitamins A and B-6, calcium, magnesium, and zinc. In children, 130 associations were tested, and 21 associations (16%) showed an adverse association. There was substantial evidence of only lower fruit consumption in food-insecure compared with food-secure children. Reporting and publication biases may have contributed to an overestimation of the association between food insecurity and dietary quality. CONCLUSIONS Food insecurity is adversely associated with dietary quality in adults, particularly intakes of nutrient-rich vegetables, fruit, and dairy that promote good health. However, food insecurity was less-consistently associated with lower dietary quality in children. The idea that parents effectively shield their children from compromised dietary quality because of food shortages is supported by the evidence.

Gender, ethnicity, marital status, and body weight in the United States.

Married individuals tend to be heavier than those who are unmarried, particularly men, and individuals in different ethnic categories vary in their involvement in marriage and in their body weights. We examined gender and ethnic differences in relationships between marital status and body weight using cross‐sectional data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) for 3,947 women and 4,019 men. The findings revealed that compared to married men in the same ethnic category, white divorced men, black never‐married men, and all Hispanic men except for widows had lower odds of being overweight. Compared to married women in the same ethnic category, white womens weights did not significantly differ by marital status, black separated women had greater odds of being overweight, and Hispanic never‐married women had lower odds of being overweight. Associations of marriage with body weight appear to be at least partly contingent upon gender and ethnicity, which may reflect larger societal patterns of involvement in marriage, commitment to family, and body‐weight norms and expectations.

Family meals and body weight in US adults

OBJECTIVE Family meals are an important ritual in contemporary societies and many studies have reported associations of family meals with several biopsychosocial outcomes among children and adolescents. However, few representative analyses of family meals have been conducted in samples of adults, and adults may differ from young people in predictors and outcomes of family meal consumption. We examined the prevalence and predictors of adult family meals and body weight outcomes. DESIGN The cross-sectional 2009 Cornell National Social Survey (CNSS) included questions about the frequency of family meals, body weight as BMI and sociodemographic characteristics. SETTING The CNSS telephone survey used random digit dialling to sample individuals. SUBJECTS We analysed data from 882 adults living with family members in a nationally representative US sample. RESULTS Prevalence of family meals among these adults revealed that 53 % reported eating family meals seven or more times per week. Predictive results revealed that adults who more frequently ate family meals were more likely to be married and less likely to be employed full-time, year-round. Outcome results revealed that the overall frequency of family meals among adults was not significantly associated with any measure of body weight. However, interaction term analysis suggested an inverse association between frequency of family meals and BMI for adults with children in the household, and no association among adults without children. CONCLUSIONS These findings suggest that family meals among adults are commonplace, associated with marital and work roles, and marginally associated with body weight only in households with children.

School Meals Participation and Weekday Dietary Quality Were Associated after Controlling for Weekend Eating among U.S. School Children Aged 6 to 17 Years

Prior research has shown positive associations between participation in school meals and some dietary measures, but the evidence is equivocal. Few prior studies have used methodological approaches that address underlying differences in food preferences and health beliefs between school meals participants and nonparticipants, resulting in the potential for selection bias to influence results. This study estimated relationships among school meals participation and weekday energy intake and dietary quality, controlling for weekend dietary intake as a proxy for food preferences and health beliefs. Further, this paper explored how family income moderated these relationships. NHANES data (2003-2008) were analyzed for children aged 6-17 y with reliable dietary recalls for one weekday and one weekend day (n = 2376). Using multivariate linear regression models, we examined weekday-weekend differences in energy intake as a percentage of the estimated energy requirement (%EER) and differences in Healthy Eating Index-2005 (HEI) scores for breakfast and lunch and for the entire day. Overall, school meals participants and nonparticipants had equivalent %EERs and total HEI scores, but participants scored higher for milk and lower for saturated fat and sodium after adjustment for weekend eating. Family income moderated the relationship between school meals participation and HEI. Low-income children who ate school breakfast and lunch had significantly higher total HEI, and total grain, and meat and beans component scores. Conversely, higher income participants had significantly lower scores for total grains, whole grains, and saturated fat. Changes to the content of school meals may differentially affect weekday dietary intake of low-income and higher income participants.

Family dinner frequency, settings and sources, and body weight in US adults

Contemporary families and food systems are both becoming more dynamic and complex, and current associations between adult family meals and body mass index (BMI) are not well understood. This investigation took a new approach by examining diverse settings and sources of food for family dinners in relationship to BMI in a cross-sectional nationally representative survey of 360 US adults age 18-85 living with family members. In this sample, 89% of adults ate family dinners at least 5 days per week and almost all ate family dinners cooked and eaten at home. About half of these adults also ate family dinners at restaurants, fast food places, or ate takeout food at home, and less common were family dinners at homes of relatives or friends. Family dinners eaten at fast food places, but not other settings or sources, were significantly associated with higher BMI. Overall, adult family dinners were commonplace, usually involved home cooking, and when at fast food places may be related with higher adult body weights.

Adult Caregiver Reports of Adolescents’ Food Security Do Not Agree Well With Adolescents’ Own Reports

The accuracy of national statistics on childrens food insecurity depends on the reliability of interview responses by adults. In this study of 395 adolescents ages 15 to 17 in National Health and Nutrition Examination Survey data, adolescents’ self-reported food insecurity was more common than, and only weakly associated with, adult proxy reports of those adolescents’ food insecurity. Adolescents’ dietary quality as measured by the Healthy Eating Index was best when both reports indicated food security, worst when both indicated food insecurity, and intermediate with no systematic difference between the 2 groups when reports disagreed, leaving unanswered the question of which report is more reliable.

Chronic Health Conditions and Depressive Symptoms Strongly Predict Persistent Food Insecurity among Rural Low-income Families

Longitudinal studies of food insecurity have not considered the unique circumstances of rural families. This study identified factors predictive of discontinuous and persistent food insecurity over three years among low-income families with children in rural counties in 13 U.S. states. Respondents reported substantial knowledge of community resources, food and finance skills, and use of formal public food assistance, yet 24% had persistent food insecurity, and another 41% were food insecure for one or two years. Multivariate multinomial regression models tested relationships between human capital, social support, financial resources, expenses, and food insecurity. Enduring chronic health conditions increased the risk of both discontinuous and persistent food insecurity. Lasting risk for depression predicted only persistent food insecurity. Education beyond high school was the only factor found protective against persistent food insecurity. Access to quality physical and mental health care services are essential to ameliorate persistent food insecurity among rural, low-income families.

Marital Status, Marital History, Body Weight, and Obesity

Marital status and marital history are associated with health. Marital history can be represented by the marital trajectory components of timing, transitions, sequence, and duration. We examined whether marital trajectory components add insights beyond marital status in predicting body weight in a retrospective analysis of 3,011 adults. Marital status findings revealed that married men were heavier than separated/divorced men, and never married women were heavier and more often obese than married women. Marital history findings showed that after adjusting for marital status, trajectory measures of age at first marriage, second marriage or second divorce, experiencing widowhood, and duration of separation/divorce were not clearly associated with body weight or obesity. Body weight and obesity appear to be associated with current marital status but not marital history.

Comparison of Preventive Care in Medicaid Managed Care and Medicaid Fee for Service in Institutions and Private Practices

OBJECTIVE To compare preventive screening for children in Medicaid managed care (MMC) with children in Medicaid fee for service (M-FFS) in private and institutional settings. METHODS The sample included randomly selected institutions and private practice physicians in New York City. Within setting, children in MMC and M-FFS were sampled randomly and charts reviewed for immunizations and lead and anemia screening. RESULTS In both institutions and private practices, children enrolled in MMC appeared more likely to be up-to-date than their M-FFS counterparts for immunizations (institution, P <.01; private practice, P <.05), lead screening (institution, P <.01; private practice, P <.01), and anemia screening (institution, P <.01; private practice, P <.01). However, children in MMC had more visits (P <.01) and were followed up for a longer time (P <.01). After controlling for these variables, effects of MMC diminished and only remained significant for screening among private physicians. When considering 10 different attributes of managed care plans, no clear pattern of association with better preventive care services was observed. CONCLUSION The positive effect of managed care on preventive care services was largely explained by more visits and longer follow-up time; however, there were differences between institutions and private practices, with enrollment in MMC associated with some positive effect on screenings in private practices.

Medicaid managed care in New York: problems and promise for childhood immunizations.

New York State is aggressively pursuing mandatory Medicaid managed care. Under managed care, physicians and plans have a defined population for which they are responsible, quality assurance monitoring emphasizes immunization rates along with other preventive services, and population-based incentives are possible. The literature does not offer compelling evidence, however, that immunization coverage is any better in managed care than under fee-for-service. If reimbursement is low and physician capacity insufficient, immunization rates may be considerably worse. In New York, care needs to be taken so that expansion does not outstrip the capacity of managed care plans to absorb additional enrollees.