1. Is food insecurity related to obesity among people with disabilities in Oregon? Liz Adams, PhD, RD; Rie Suzuki, PhD; Willi Horner-Johnson, PhD; Kim Hoffman, PhD

2. Definitions Food security All household members have access at all times to enough food for an active, healthy life Food Insecurity Limited or uncertain availability of nutritionally adequate and safe foods, and limited or uncertain ability to acquire acceptable foods in socially acceptable ways Life Sciences Research Office, S.A. Andersen, ed., "Core Indicators of Nutritional State for Difficult to Sample Populations," The Journal of Nutrition, Vol. 120, 1990, 1557S-1600S

3. Food Security

4. Measurement of Food Insecurity Food insecure households: Worry their food will run out before they get money to buy more Report that the food they bought did not last and they didn’t have money to get more Report that they couldn’t afford to eat balanced meals

5. Constructs of Food Insecurity Qualitative: using unsafe, nutritionally inadequate, culturally unacceptable foods Quantitative: inability to obtain sufficient amounts of food Social: accessing foods in socially unacceptable ways Psychological: feelings of deprivation, lack of choice; fear, anxiety

6. Prevalence of Food Insecurity 2005 All US households 11.4 % Income –Below poverty level36.0% –Under 185% FPL28.3% –185% FPL and over 5.2 % H ousehold Composition –With children, <18 15.6 % –Female head, no spouse, w children, 30.8% –Male head, no spouse17.9% With Elderly6.0% ERS, Current Pop Survey, 2005

7. Prevalence of Food Insecurity 2005 Race-ethnicity –African American22.4% –Hispanic17.9% –White 8.2% –Other 9.6% Region of US –Northeast9.1% –Midwest11.1% –South 12.0% –West 10.8% ERS, Current Pop Survey, 2005

8. Rates of Food Insecurity and Hunger in Oregon and U.S. More than one tenth (11.9%) of Oregon households are food insecure, and 3.9% of Oregon households reported very low food security. The national averages are 11.4% and 3.8%, respectively, for 2003-05 (Nord et al./USDA, 2005)

9. Emergency Food Boxes Distributed (Oregon Food Bank)

11. Most Adult Recipients of Emergency Food are Working, Retired, or Disabled Hunger Factors Assessment Survey, OFB, 2006

12. Health and Nutrition Outcomes Associated with Food Insecurity Poor diet, nutritional status & obesity (Kendall 1997, Dixon 2001, Townsend 2001, Wilde 2006) Poor health & mental health (Vozoris 2003, Seifert 2005) Poor control chronic disease (Nelson 2001) Disability (Gulliford 2003, Bernell 2005)

13. Nutritional Consequences of Food Insecurity in a Rural New York County Studied 193 women from rural NY State Body mass index significantly higher for women from food insecure households 37% of women from food insecure households were classified as obese, vs 26% from food secure households Food insecurity related to obesity after controlling for income, education, single parent, & employment Frongillo EA. 1997, Discussion Paper 1120-97, Inst Research on Poverty

14. Food Insecurity is Positively Related to Overweight in Women Continuing Survey of Food Intake of Individuals Prevalence of overweight increased with FI: –food secure (34%) –mildly food insecure (42%) –moderately food insecure (51%) Mildly food insecure women were 30% more likely vs food secure to be overweight (OR adj =1.3) Food insecurity was a significant predictor of obesity among women, but not men Townsend M, 2001. J Nutr; 131:1738-45 CSFII 1994-96 (n=4,509)

15. Individual Weight Change Associated with Household Food Security Status Used NHANES data from 1999-2002 (n=4549 f, 4202 m) Compared with women in food secure households (HH) women from –marginally secure HH were more likely to be obese (OR=1.58) –insecure HH without hunger were more likely to be obese (OR=1.78) Compared with men in food secure HH, –men from marginally secure HH were more likely to be obese (OR=1.43) Wilde P, J Nutr, 2006

16. Research Question How does food insecurity relate to obesity risk for people with disabilities (PWD)?

17. Methods Cross sectional study 2005 Oregon BRFSS data Participants with complete data were included (n=4496) Disability status categorized based on BRFSS core disability questions Food security status was categorized using the US Core Food Security Module

18. Disability Questions The following questions are about health problems or impairments you may have. Are you limited in any way in any activities because of physical, mental, or emotional problems? (Yes, No, Don’t know / Not Sure, Refused) Do you now have any health problems that require you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Include occasional use or use in certain circumstances.

19. Analysis Analysis was carried out to describe prevalence of obesity by food security and disability status. Logistic regression was carried out to assess the relationship between food security status and obesity (BMI>30 kg/m 2 ) for people with disabilities Analyses were carried out using SUDAAN software

20. Race/Ethnicity of Population

21. Prevalence of Food insecurity and Disability in Oregon

22. Results Food insecurity and obesity were more common for PWD (22.9% and 36.3%) vs. others (12.0% and 21.5%) Food insecurity (OR=1.43) and disability (OR=1.84) both predicted increased obesity risk Obesity risk related to food insecurity did not differ by disability status (interaction ns)

23. Prevalence of Food insecurity and obesity for people with and without disability * * Chi Square, p<.05 *

24. Conclusions Increased prevalence of food insecurity and overweight indicates need for strategies to promote food security and a healthy weight for people with disabilities. The relationship between food insecurity and obesity needs to be better understood.

26. Questions Used To Assess the Food Security of Households in the CPS Food Security Survey 1.“We worried whether our food would run out before we got money to buy more.” [often, sometimes, or never true for you in the last 12 months?] 2. “The food that we bought just didn’t last and we didn’t have money to get more.” [often, sometimes, or never true for you in the last 12 months?] 3.“We couldn’t afford to eat balanced meals.” [often, sometimes, or never true for you in the last 12 months?] 4.In the last 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food? (Yes/No) 5.If yes to Question 4, How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? 6.In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food? (Yes/No) 7.In the last 12 months, were you ever hungry, but didn’t eat, because you couldn’t afford enough food? (Yes/No) 8.In the last 12 months, did you lose weight because you didn’t have enough money for food? (Yes/No) 9.In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food? (Yes/No) 10.If yes to Question 9, How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?

27. Questions 11-18 are asked only if the household included children under 18 years old 11.“We relied on only a few kinds of low-cost food to feed our children because we were running out of money to buy food.” Was that often, sometimes, or never true for you in the last 12 months? 12.“We couldn’t feed our children a balanced meal, because we couldn’t afford that.” Was that often, sometimes, or never true for you in the last 12 months? 13.“The children were not eating enough because we just couldn’t afford enough food.” Was that often, sometimes, or never true for you in the last 12 months? 14.In the last 12 months, did you ever cut the size of any of the children’s meals because there wasn’t enough money for food? (Yes/No) 15.In the last 12 months, were the children ever hungry but you just couldn’t afford more food? (Yes/No) 16.In the last 12 months, did any of the children ever skip a meal because there wasn’t enough money for food? (Yes/No) 17.(If yes to Question 16) How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months? 18.In the last 12 months did any of the children ever not eat for a whole day because there wasn’t enough money for food? (Yes/No)