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Article

Nutrient Intake of Food Bank Users Is Related to Frequency of Food Bank Use, Household Size, Smoking, Education and Country of Birth¹

Linda Jacobs Starkey², Katherine Gray-Donald and Harriet V. Kuhnlein^*

School of Dietetics and Human Nutrition and ^* Centre for Indigenous Peoples' Nutrition and Environment, McGill University, Macdonald Campus, Quebec H9X 3V9 and Department of Epidemiology and Biostatistics, McGill University, Montreal

²To whom correspondence should be addressed.

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
The number of individuals and families accessing food assistance programs has continued to grow throughout the 1990s. Despite the increased health risk among low-income people, few studies have addressed nutrient intake throughout the month or at the end of the month when food and financial resources are thought to be compromised, and no study has described dietary status of a random sample of food bank users. Nutrient intakes of adult female and male food bank users in metropolitan Montreal, Quebec, Canada, were monitored week-by-week over a month by dietitian-administered 24-h recall interviews. A total of 428 participants from a stratified random sample of 57 urban area food banks completed all four interviews. Mean energy intake, as an indicator of diet quantity, was similar to other adult populations (10.2 ± 4.8 and 7.9 ± 3.6 MJ for men and women, respectively, age 18–49 y) and not related to sociodemographic variables except the expected biological variation of age and sex. Macronutrient intake was stable throughout the month. Overall median intakes of calcium, vitamin A, and zinc were below recommended levels for all age and sex groups. Intakes of several micronutrients were related to frequency of food bank use, household size, smoking, education, and country of birth. High nutrient intake variability characterized these adult food bank users.

KEY WORDS: • food security and nutrient intake • urban food banks and nutrition • urban food security • food bank users' nutrient intake • food bank users' diet

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Increasing numbers of people continue to turn to food banks and soup kitchens for personal and family food assistance (Davis and Tarasuk 1994 , Jacobs Starkey 1994 ). In Canada, a 20% increase in the number of food banks was seen from 1992 to 1996 (Canadian Association of Food Banks 1997 ). Recent reports from the United States show that the demand for these and other forms of emergency food assistance continues to grow (Kendall and Kennedy 1998 ).

The term "food bank" initially referred to a central collection and distribution center that provided bulk food to local food relief programs; the local food depot or food pantry then gave food assistance directly to those in need. Today the media, community workers, and the clients themselves most often refer to the local food assistance sites as food banks; we use the term food bank in the local food relief context. The food bank obtains emergency food supplies from a central collection center, market discards, or food company donations; augments supplies through purchases from fund-raising drives or from food donations by residents of communities (Riches 1989 ; Vozenilek 1998 ); and gives the collected food to those in need of it. Emergency food bags were found to vary greatly in the amount of nutrients they provide (Jacobs Starkey and Kuhnlein 1996 ), and the food bank system was criticized as providing limited nutritional support in a community (Riches 1989 ).

Despite the concern for food security and nutrient intake adequacy among urban food assistance recipients (Jacobs Starkey et al. 1995 , Kendall et al. 1996 , Radimer et al. 1990 , Wolfe et al. 1996 ), most studies provide only a snapshot of the food assistance program participants from a single interview or from synthesis of focus group discussions (Badun et al. 1995 , Hargrove et al. 1994 , Smith and Hoerr 1992 , Tarasuk and MacLean 1990 ). Few studies of food bank users address nutrient intake throughout the month, looking at week-to-week variation in food intake, or at the end of the month when the time since income was received is greatest and food and financial resources are considered to be most limited. Taren et al. (1990) reported the number of servings of different food items per week decreased during the last week of the month; however, second or third servings of the same food were not counted. Other studies have been limited by the use of small convenience samples (Emmons 1986 , Villalon 1998 ).

Increased health risk among low-income people is well documented; nutritional status is one indicator of wellness, and an important health monitoring parameter (Margetts and Jackson 1993 , Najman 1993 ). Definitive nutrient intake data are not available from difficult-to-sample populations, such as emergency food recipients. The need for greater understanding of obesity, protein-energy malnutrition, iron, vitamin A, and folate status among these people, as well as diet variety, was expressed (Anderson 1990 ). Further, two priorities from the International Conference on Nutrition are relevant to food assistance programs in industrialized countries: 1) to assess, analyze, and monitor nutrition situations; and 2) to improve household food security (Food and Agriculture Organization 1995 ).

We investigated the week-by-week over the income month food and nutrient intakes of adult Quebec female and male food bank users, to describe the overall nutrient intake and to characterize the variation in ability to meet nutrient recommendations as the month progressed. An earlier publication described the sociodemographic characteristics of the study group (Jacobs Starkey et al. 1998 ). The objectives of this analysis were threefold: 1) to assess the average diet over a month (mean of four recalls) and determine correlates of poor overall intake; 2) to describe any decline in intake over the income month and determine for which clients this decline was most pronounced; and 3) to describe the characteristics of clients who had the most highly variable diet over the income month, as this may reflect food insecurity.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Food depot and client enrollment.

Fifty-seven community organizations (sites) whose primary purpose was to direct food aid to clients were identified from a census of 167 agencies receiving supplies from a central food bank in metropolitan Montreal. Sites were stratified into three groups based on the number of people served per month: small sites (n = 21) provided food to <100 clients per month, medium (n = 20) 100–499, and large sites (n = 16) served >500 people per month, for a total of >22,000 people served each month. A total of 20 individual sites were randomly selected in numbers proportionate to their representation of food banks of that size, and clients were then systematically selected at each site, based on the percentage of people served in each stratum (5.5% small, 20.7% medium, and 73.8% from large sites). A random number was generated each sampling day to designate the first client to be interviewed; after completion of that interview, the next person in line was approached for an interview, and so forth.

Participating clients signed a consent form. Eligibility criteria were 18 y of age or older, from a household of known address within two bus transfers from the food assistance site, and spoken English or French in the home unless an interpreter was available. Clients entered the study at any time during the month, when they came to the food bank to obtain supplies; only one respondent per household was enrolled. Based on when study participants received their income, largely as one social assistance check per month, we determined whether they were in income-week 1, 2, 3 or 4 of the month. Income-week served as an indicator of financial risk (more money at hand in income-week 1 than income-week 4). Interviews were conducted in winter (>NOREF>February to April 1995) when disposable income for food was expected to be most limited by other seasonal costs. All procedures were approved by the McGill University Ethics Committee.

Measurement sequence.

Once enrolled, while still at the food bank, clients completed a dietitian-administered structured questionnaire, including self-reported height and weight, and initial 24-h dietary recall interview. They were interviewed weekly thereafter at home or other convenient location, to complete three additional 24-h recalls. Thus, each person who completed the study was interviewed a total of four times. These clients were paid an honorarium ($25) at the final visit. All days of the week were represented in the recall data.

Repeated in-person 24-h recalls were used because preliminary work revealed a number of food assistance recipients without a telephone or with access only to a common-use telephone. Trained dietitian-interviewers used household food portion models to enhance correct estimation of portion size and decrease respondent bias. Clients were asked if they had visited a food bank in the interval since the previous interview; however, data on the source of foods consumed were not collected during the recall interviews.

Data analysis.

Each 24-h recall was coded by the dietitian who conducted the interview, using food codes representing the Canadian Nutrient File (The Food Processor, Version 5.03; ESHA Research, Salem, OR). The software program selected was reported to be appropriate for the nutrients analyzed (Lee et al. 1995 ). The percentage contribution of protein, fat, and carbohydrate to energy intake was determined for each income-week and compared to the Nutrition Recommendations for Canadians (Minister of National Health and Welfare 1990 ).

The contribution of recalled food to the food groups of Canada's Food Guide to Healthy Eating (Health and Welfare Canada 1992 ) was determined using serving sizes provided in the Guide. Volume and dimensions were converted to gram weights, as needed. For comparison with the Quebec Nutrition Survey (Santé Québec 1995 ), servings for the meat and alternatives group were calculated using 60 g of meat, fish, or poultry; 200 mL of canned beans; and 50 mL of peanut butter.

Mean energy and nutrient intake over the four recalls was calculated. ANOVA, stratified for age and gender, followed by Tukey's multiple comparison test, was used to compare mean intakes by income-week (Hatcher and Stepanski 1994 ). Mean intakes of the number of food servings for each of the food groups of Canada's food guide to healthy eating (Health and Welfare Canada 1992 ) were compared to minimum recommended intake levels for each food group. To investigate the relationship between overall intake of nutrients and correlates of intake, continuous variables were analyzed using multiple regressions. Change in energy and nutrient intake (from income-week 1 to income-week 4) was divided into quintiles; the association of these quintiles with sociodemographic variables was assessed using the chi-square test of independence. To assess whether greater day-to-day variability in energy intake was associated with different levels of intake of any of the micronutrients, the mean intakes per energy variability quintile were compared using ANOVA. Differences at the level of P < 0.05 were considered significant. Statistics were generated using SAS/STAT 6.11 (SAS Institute, Cary, NC).

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Client profile.

A total of 60% or 490/816 clients approached were enrolled, 57.2% of women and 62.9% of men. Sociodemographic data obtained upon enrollment are described elsewhere (Jacobs Starkey et al. 1998 ). Briefly, clients' mean age was 41 y with mean body mass index (BMI)³ of 27 ± 11 (kg/m²); 43% were born in Canada. The most common regions of origin for non-Canadian clients were Eastern Europe, South America, and the Caribbean. Refugees represented 16% of clients enrolled in the study. Weekly or biweekly food bank visits were reported by 36.9% of clients.

All four 24-h recall interviews were completed by 428 (87.3%) subjects (219 men and 209 women): 23 from small, 89 from medium, and 316 from large food assistance sites. Among these food assistance recipients, men and women were equally represented (51.2 and 48.8%, respectively); 77.6% were in the 18–49-y-old age group; 63.1% were single, separated, or widowed; and 66.6% had completed high school or post-secondary studies. Twice as many men as women (49.2 vs. 27.4%) had a technical, college, or university education. The total number of people fed in a household (mean 2.4 ± 1.5) was higher when women versus men presented themselves at the food bank (P < 0.0001), 2.8 ± 1.6 versus 2.1 ± 1.4, respectively. Eighty-three percent of food bank users who completed the study received income as social assistance benefits.

Of the 62 dropouts from the study, 59.7% were men. In comparison to the completing adults, dropouts were younger (mean age 38 vs. 41 y, P < 0.05), lived in smaller households (2.2 ± 1.4 vs. 2.4 ± 1.6, P < 0.05), and shopped more often for food (4.5 ± 2.8 vs. 3.4 ± 2.7 times per week, P < 0.05) than clients who completed the study. Dropouts also reported spending more on smoking ($9.33 ± 10.38 vs. $6.01 ± 9.84, P < 0.01).

Dietary intake status and energy intakes.

Energy intakes (means of 4 d) (Table 1) of male and female food bank clients were similar to the general Quebec population (Santé Québec 1995 ). Further, whereas the vast majority of people received money once a month as a social assistance check, there was no decline in mean energy intake over the income-month (Table 2). Mean energy intake varied with age and gender (P < 0.01) in the expected directions, being higher for men and the younger food bank clients. Whereas energy intake variation was high, as evidenced by large standard deviations, it is unlikely that the food bank users chronically lacked enough to eat. Self-reported height-weight data indicated that <6% of subjects had a BMI below 20, 66% between 20–27, and 28% had a BMI 28 kg/m². There could be a concern that food bank users, entering the study in any income-week, would report lower intakes in later interviews as a result of interview fatigue thus obscuring trends over the month. There were no differences in energy intakes analyzed by visit (week-by-week from the time people entered the study, regardless of income-week).

To further examine the week-to-week variability in energy intake, quintiles of the coefficient of variation of energy intake were formed (data not shown). There were no differences in the mean (4 d) energy intake by quintile of variation in energy intake. For men, mean energy intake at the lowest quintile of variability (13%) was 10.2 MJ, similar to the 10.4 MJ obtained by those with the highest variability in energy intake (65%). Multivariate analysis of the correlates of variability in energy intake indicated that the week-to-week variability in energy intake was higher among smokers (P < 0.002) and among Canadian-born clients (P < 0.02) and lower when more people usually ate together (P < 0.004). Age and gender were not associated with variability of intake. The correlates of variability of intake from week-to-week appeared to reflect lifestyle, whereas the correlates of mean energy intake over the 4-wk period were age and sex, indicators of biological variability between subjects.

Food group servings.

The proportion of food bank users who met the minimum recommended number of servings from Canada's food guide to healthy eating (Health and Welfare Canada 1992 ) (Table 3 ) was similar to the general Quebec population (Santé Québec 1995 ). The proportion of clients who met minimum intake recommendations for milk products was lower than for Quebecers in general; only 32.5% of Quebecers and 21% of food bank clients met the recommended intakes. Mean intake of milk products (data not shown) was below the recommended minimum of two servings for all age and sex groups; mean intakes of the other three food groups exceeded the recommended minimum number of servings.

With the exception of calcium, mean nutrient intakes (4 recalls) (Table 1) met the Recommended Nutrient Intakes (RNI), levels thought to meet the needs of most healthy people (Murray and Beare-Rogers 1990 ). Mean calcium intakes were below the RNI for women aged 18–49 y and both men and women aged 50+ years. Analysis of food group data support these observations (Table 3) .

Mean nutrient intakes by income-week (Table 2) showed very little change over the month; nutrient intake was not influenced by how close clients were to their next check. It is possible that our participants obtained food bank provisions before running out of food, thus maintaining a stable intake over the weeks. ANOVA revealed an effect for income-week only for one nutrient, calcium [F(3,1272) = 3.08; P < 0.03]. Calcium intake was not consistent over time; during weeks 1 and 3 intakes were significantly lower than during weeks 2 and 4 (P < 0.04) for all age and sex groups.

Mean nutrient intake was also not different by quintile of energy intake variability; those people with the most erratic daily eating pattern obtained micronutrients similar to their more energy-consistent peers.

Correlates of nutrient intake.

Multivariate correlates of nutrient intake were identified (Table 4). Overall intakes (means of 4 d) were regressed on the linear combination of age, sex, country of origin, education level, civil status, number of people fed, frequency of using the food bank, telephone costs, rent payment, and smoking. Civil status and rent payment showed no relationship to nutrient intake (P > 0.05) and were deleted from the final models. As expected, men had a higher intake than women for energy (2.1 MJ) and all nutrients, with the exception of vitamins A and C. Food bank clients not born in Canada (58.8% of subjects) had higher intakes of folate (P < 0.0002) and vitamin C (P < 0.001). Similarly, education was positively associated with intake of folate (P < 0.008), vitamin C (P < 0.01), and vitamin A (P < 0.001).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
This is the first report of monthly (week-to-week) nutrient intake of a random sample of food bank users and the first paper to define correlates of usual nutrient intake. Study participants appeared to achieve a level of nutrition not unlike the general Quebec population, but under the restraint of a lower income. Variation in energy intake from week-to-week was substantial and was associated with lifestyle factors, but was not associated with lower overall intake of energy or other nutrients.

The 60% enrollment success in this study compares favorably with other large scale studies in Canada (69%) and the United States (61%) (Santé Québec 1995 ; US Department of Health and Human Services and US Department of Agriculture 1986 ). The <13% dropout rate over four contacts was not unreasonable.

Mean energy intakes below recommended levels (Murray and Beare-Rogers 1990 ), such as we found for food bank users, was also reported by Badun et al (1995) in a low-income group in Ontario and by Dowler and Calvert (1995) among lone-parents in Britain. Nonetheless, our study participants did not have low mean BMI. Although Kendall et al (1996) hypothesized that occasional bingeing behaviors may predispose food-insecure individuals to obesity, we found the distribution of BMI among food bank users to be similar to the general Quebec population (Santé Québec 1995 ) .

The mean of four 24-h dietary recalls is considered valid to represent the overall nutrient intake of a group (Bingham 1991 ). Mean energy intakes in this study were higher than reported in other low-income groups, for example, by Crotty et al (1992) using weighed food records and by Dowler and Calvert (1995) using two 24-hour recalls. Energy intakes reported in the NHANES III report (US Department of Health and Human Services 1994) and in the Quebec Nutrition Survey (Santé Québec 1995 ) were similar to those in the present study for women and older men. Men aged 18–49 y in both of these surveys had higher mean energy intakes than food bank users; however, the low income subgroup in the Quebec survey had lower energy intakes than food bank users (US Department of Health and Human Services 1994, Santé Québec 1995 ).

Peterkin et al (1982) reported that food stamp program participants in the US meet the recommended daily allowance (RDA) for calcium, iron, magnesium, vitamin A, thiamin, and vitamin C less often than their nonpoor peers. Badun et al (1995) also found calcium, folate, and zinc intake of a small sample of Canadian low-income people to be below recommended levels. Although Levine (1996) found that economic resources are a determinant of zinc status, in our study zinc intake by food bank users was higher in most age/sex groups than that reported in two Quebec surveys (Ghadirian et al. 1995 , Santé Québec 1995 ). Lower zinc intakes (<7.5 mg/d) were found for lower income participants in NHANES II, which were attributed to food selection rather than a low energy intake (Mares-Perlman et al. 1995 ). These latter results are supported by analysis of Canadian family food expenditure data: Campbell and Horton (1991) found an increased proportion of households with lower protein, iron, folate, and calcium levels among those with lower income. Interpretation of iron intake data must also consider food source. Gibson (1994) , upon reporting a study where 44% of iron came from pasta, rice, cereal and bread, cautioned that meal composition may be an important variable for study in vulnerable groups. Given that over 70% of the food bank users had mean meat & alternatives food group intake above the minimum recommended number of servings, their mean zinc and iron intakes above RNI levels were not unexpected.

Mean intakes of folate, vitamin C, iron, thiamin, zinc, and vitamin A were higher in the present study than recently reported for other low-income groups (Crotty et al. 1992 , Dowler and Calvert 1995 , Santé Québec 1995 ). Fruit and vegetable intake (important for sources of folate) is related to both income (Myres and Kroetsch 1978 ) and education (Rogers et al 1995 ). Low-income women in Maryland reported spending little time on cooking and revealed barriers to fruit and vegetable consumption as preference for other food, time and effort required, perishability, and cost (Trieman et al., 1996 ). Given the declining earnings of young men and increasing income gaps between higher- and lower-income Canadians (Morissette 1997 ), the challenge to have an adequate food budget is likely to affect even more people in the future. Stitt et al. (1995) found a 53% difference in the regularity of fresh fruit and vegetable consumption when comparing high and low income groups in Britain. Education level reported in our study group was reflected in mean folate intakes meeting recommended levels, except among older men.

Food bank users in this study who were not born in Canada had higher folate intakes; this may reflect a greater consumption of raw food or of meals that require cooking from raw ingredients. Dowler and Calvert (1995) found that nonwhite respondents' higher nutrient intake could be related to a greater dietary diversity; a more consistent habit of cooking from fresh, raw ingredients; and a less likelihood of smoking. Diets with higher diversity scores are more likely to meet nutrient intake recommendations, and diet diversity is associated with higher income and education (Kant et al. 1991 ).

Heavy smoking has been reported to be negatively associated with attitudes about healthy eating (Smith et al. 1997 ). From 7-d weighed food records of British adults, Margetts and Jackson (1993) determined that, while there was little difference in total food energy between smokers and nonsmokers, the smokers had lower fiber, iron, carotene, and ascorbic acid intakes. Our results among low-income smokers show a similar pattern.

Mean calcium intake of participants in this study was below levels reported for French Canadian men and women (Ghadirian et al. 1995 ), for low-income men (Myres and Kroetsch 1978 ), and for adult women entering a food bank study (Villalon 1998 ). Intakes of men and women aged 50+ y were similar to those reported in the Quebec Nutrition Survey, while younger food bank users had intakes below their provincial age counterparts (Santé Québec 1995 ). Low-income Quebecers' mean intake of calcium (Santé Québec 1995 ) was similar to that of the food bank users in this study. In an early study of food stamp program participants in the US, Peterkin et al. (1982) reported that households meeting the RDA for calcium consumed more milk, vegetables, and grain products, an area for further investigation among young food bank clients. The need to augment emergency food supplies with milk products was previously documented (Jacobs Starkey 1994 ).

Comparative data on variability in nutrient intake are limited. The coefficient of variation for energy intake of male food bank users aged 18–49 y was higher than reported by Beaton et al. (1979) (47.3 vs. 35.8%, respectively), as was the variability for six other nutrients: protein, fat, calcium, iron, thiamin, and vitamin C. Using the example of calcium variability in adults, that of food bank users (76.4%) was similar to low income Quebecers (72.4%) and higher than that reported in the US (49.7%) (Beaton et al. 1983 , Santé Québec 1995 ). The response of within-person variance to both environmental and biological pressures (Tarasuk and Beaton 1991 ) is at play. It may be that the high variation in food bank users' intake protects, in the short term, from overall low intakes.

Food bank users in this study most often reported use of the food bank as a community service (Jacobs Starkey et al. 1998 ), had a fixed address, and were able to carry the provisions received. The homeless and other poor groups who are less mobile, such as single parents with large families and the frail elderly, are not well represented by these data.

The nutrient intake of adult food bank users is not worse than the general Quebec population. Energy intake was sufficient and was unrelated to clients' social circumstances. Five important correlates of nutrient intake in the study population were determined: frequency of food bank use, household size, smoking, education, and country of birth. These data may be important to health professionals to target nutrition information and intervention activities with food bank clients.

	FOOTNOTES

 
¹ Financial Support of Health Canada, National Health Research Development program, is acknowledged (Grant #6605–4092).

² Abbreviations used: BMI, body mass index; RE, retinol equavalents; RDA, recommended daily allowance; RNI, recommended nutrient intakes.

Manuscript received July 23, 1998. Initial review completed September 24, 1998. Revision accepted December 22, 1998.

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