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*
Department of Nutritional Sciences and The Cooperative Extension System, University of Connecticut, Storrs, CT 06269-4017;
Hispanic Health Council, Inc., Hartford, CT;
**
Connecticut Children’s Medical Center, Hartford, CT and
St. Francis Hospital, Hartford, CT
3To whom correspondence should be addressed.<. >
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • children • dietary intake • food security • Food Stamp Program • Hispanic • Latino • micronutrients
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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$20 billion/y. Although this food
assistance program receives more funding from the federal government
than other food assistance programs, such as the Supplemental Food
Program for Women, Infants, and Children (WIC) (Rush 1986), much less is known about its effectiveness in
alleviating child hunger and malnutrition (Ohls and Beebout 1993
).
Studies that compared FSP households with similar households that were
not participating in FSP have shown that an additional $1 of food
stamps increases food purchases by 20 to 50 cents and that FSP
increases nutrient availability levels by 15–20% for the average FSP
household (Ohls and Beebout 1993
). These data suggest
that both dietary quantity and quality are positively related to
participation in FSP. A recent analysis of the 1989–1991 Continuing
Survey of Food Intake by Individuals (Rose et al. 1998
)
documented in a sample of predominantly non-Hispanic white or black
children that food stamps were associated, independent of WIC exposure,
with improved dietary intake among children aged 1–4 y. In particular,
this study documented higher intakes of iron, zinc and
water-soluble vitamins among children who were exposed to FSP. The
average increase in iron and zinc intake associated with FSP was 12.3
and 9.2% of the respective preschooler’s recommended daily allowance.
As a result of welfare reform, FSP will lose $5 billion/y in funding
over the coming years. This serious funding reduction is likely to have
a negative impact on the nutritional status of children
(Pérez-Escamilla and Koppel 1997
,
Pérez-Escamilla et al. 1997
, Wise et al. 1999
). Thus, it is important to examine existing evidence and
to conduct studies that will allow for a better understanding of the
impact of FSP on children’s nutrition and health status.
A recent study conducted in inner-city Hartford, CT, suggests that
FSP buffers the negative impact of poverty on food security
(Himmelgreen et al. 2000
). The proportion of households
classified as having a preschooler who had experienced hunger was
fivefold higher in those households in which food stamps lasted for <1
month than in households in which food stamps lasted for the entire
month.
Although these previous studies provide evidence suggestive of a positive impact of FSP, they were not designed to examine in detail the potential nutritional benefits offered by this program to preschoolers. The overall goal of the present report was to examine the impact of FSP on the food security and dietary intake of low-income children from Hartford, CT, who are enrolled in WIC.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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This study was approved by the human subjects review committees of the University of Connecticut, the Connecticut Children’s Medical Center and St. Francis Hospital in Hartford, CT. The study compared the food security and nutritional status of Hartford preschoolers whose caretakers reported being enrolled in FSP (FS, n = 59) with those of their counterparts who reported not being enrolled in FSP (NFS, n = 40). The main reasons reported by the NFS group for not receiving food stamps at the time of the study were "high income" (55%) and welfare reform (22%). The survey instrument was not sufficiently sensitive to fully clarify the "high income" response, and it is quite likely that this was often reported as a result of real or perceived eligibility changes linked to welfare reform (i.e., 75% of the NFS group had previously received food stamps). Eighty-five percent of the sample participants were recruited while in the pediatric clinic waiting areas of the Connecticut Children’s Medical Center, and 15% were recruited at St. Francis Hospital. These are the two largest hospitals in the city of Hartford and serve >90% of the study target population. Children’s caretakers were recruited if: 1) the child was between 18 mo and 5 y old and 2) the child reportedly received WIC benefits at the time of the study or during the year preceding it. The mother and grandmother of one child were independently recruited for the study. Through a subsequent telephone follow-up, it became clear that the grandmother was the meal preparer and primary caretaker of the child. Thus, only the data reported by the grandmother of this child were included in the analyses.
After their informed consent was obtained, subjects were scheduled for
a 90-min interview in their households. The survey instrument was
adapted from a previous instrument specifically designed by the
principal investigator’s research group to assess the food security
and nutritional situation of Latino preschoolers living in Hartford, CT
(Kris-Etherton and Burns, 1998
). The survey was
pretested extensively between September and December 1998. Formal data
collection began on February 24, 1999, and ended on August 6, 1999.
Data were collected by three bicultural/bilingual Hispanic interviewers
and by four English-speaking nutrition graduate students. All
interviewers were trained by and standardized against the field
coordinator (L.H.).
Survey instrument
Socioeconomic and demographic conditions. A battery of questions were used to assess the demographic and socioeconomic conditions of the household, including monthly income, respondent’s level of education, availability of 11 household appliances, availability of a telephone and an automobile, through the child’s caretaker and employment status. Demographic indicators included household neighborhood, household size, respondent’s ethnicity, respondent’s relationship to child and children’s age and gender.
Dietary intake. The preschooler’s dietary intake was assessed with one 24-h recall and one "short" and one detailed food frequency questionnaire (FFQ). The 24-h recall was completed in four stages. In the first stage, a complete list was obtained of all foods and beverages consumed during the preceding day. In the second stage, detailed descriptions of all of the beverages consumed, including cooking methods and brand names, were recorded together with the time and place of consumption. In the third stage, estimates were obtained of the amounts of all foods and beverages consumed. Portion sizes were measured with models that represented common household utensils. Finally, in the fourth stage, the food recall was reviewed to ensure that all items had been recorded correctly. The short FFQ included 14 items and the detailed version included 106 items broken down as follows: 12 fruits, 17 vegetables, 14 meats, 7 "fish/seafood," 10 mixed dishes, 8 dairy, 16 "breads, pasta and cereals," 15 "snacks, sweets and desserts," 6 drinks and 1 vitamin supplement. The detailed FFQ was developed and pretested with input from community members who represented various ethnic groups (n = 5). Spearman correlation coefficients for each of the food groups on the short and detailed FFQ were r = 0.512 (P < 0.001) for fruits, r = 0.584 (P < 0.001) for legumes, r = 0.545 (P < 0.001) for vegetables, r = 0.483 (P < 0.001) for dairy products, r = 0.528 (P < 0.001) for "high-fat/processed sugar" snacks and r = 0.548 (P < 0.001) for "sodas/artificially flavored drinks."
Food assistance and social program participation. Data were collected on current and past participation and patterns of use of the programs AFDC/TANF, WIC program, FSP and emergency food assistance.
Hunger and food insecurity.
Hunger and food insecurity were assessed with the 10-item
Radimer/Cornell hunger scale (Kendall et al. 1996
,
Radimer et al. 1992
). These 10 items were further
collapsed into the following four mutually exclusive categories: food
secure, household food insecure, adult food insecure and child
hunger (Kendall et al. 1996
).
Food purchasing. Data were collected regarding specific foods bought with food stamps, type of stores at which foods were bought (corner store, medium-size versus large supermarket), money spent per month on groceries and mode of transportation to get to the stores.
Infant-feeding practices. Women were asked to remember whether they breastfed the study child and, if so, for how long and the reasons for discontinuation. Data on weaning age, types of weaning foods and mode of feeding were also collected through this survey.
Maternal and child anthropometry.
Standard recommended procedures (World Health Organization 1995
) were followed to assess maternal and child weights and
heights. Measurements were also obtained of women’s triceps skinfolds
and children’s head circumference. All measurements were obtained in
duplicate. Forty-four children did not allow the interviewer to
measure their length, so complete anthropometric data are available for
only 55 of the 99 study children.
Maternal and child health status. Respondents were asked to rate their health and that of the study child and to report whether either of the two had experienced any of 11 health conditions listed in the survey.
Caretaker nutrition knowledge. A battery of questions were included to assess the respondents’ knowledge of and self-efficacy with food labels.
Statistical analyses
The 10-item Radimer/Cornell hunger scale was used to classify
households and individuals within four mutually exclusive food
insecurity categories as described by Kendall et al. (1996).
Nutrient intakes were derived from the 24-h recall data
using The Minnesota Data Base (Nutrient Data System, Version 4.02). The
FFQ were analyzed with SPSS-compatible software written for this
study. Because the detailed FFQ did not add additional information,
only the data from the 14-item FFQ are included here.
Statistical analyses were conducted with SPSS for Windows (Version
8.0). Descriptive characteristics were compared between groups using
Student’s t test for continuous variables and
2 tests for categorical variables. Levels of
food insecurity were compared using the 2 test
according to food stamp status. Nutrient intakes derived from a single
24-h recall and food group intakes derived from the 14-item FFQ were
compared between groups (i.e., FS versus NFS) with use of the
nonparametric Mann-Whitney U test.
Multivariate logistic regression was used to examine the associations between: 1) "how long food stamps last" and food insecurity, 2) nutrient intake and food stamp status and 3) food group intake and food stamp status after controling for key confounders that differed between FS and NFS subjects. The last two sets of analyses were adjusted for household income, caretaker’s education, children’s country of birth (United States versus Puerto Rico/other) and access to an automobile. Monthly food stamp duration analyses were adjusted for monthly food stamp allotment and education. Income and access to an automobile were not included as covariates in this analysis because they are determinants of the amount of household food stamp benefits. All dietary outcomes were tested in the multivariate analyses. For both nutrient and food intake, the median split was used to define the dichotomous variables used in these analyses. Categorization of dietary variables using median cut points was chosen to avoid cells with unacceptably small sample sizes. Because of the public health relevance of iron intake, further multivariate analyses were conducted to determine whether NFS children were significantly more likely to have intakes below the 20th percentile of the iron intake distribution. The associations between independent and outcome variables are presented as odds ratios (OR) and their respective 95% confidence intervals (CI). Associations were considered statistically significant if the 95% CI excluded the value of 1.0.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Respondents were an average of 27.6 ± 9.8 y old, with
the vast majority being female, and 93% reported to be the main meal
preparers. Eighty-four percent identified themselves as Hispanic,
and 93% of them identified themselves as Puerto Rican. Sixteen percent
identified themselves as either African American (n = 6), black Caribbean (n = 2) or white (n
= 3). The vast majority were either the biological parent or
grandparent. Only 18% reported to be married, and only 39% of the
children’s fathers lived in the household. In contrast with these
demographic characteristics, which were similar among FS and NFS
groups, those receiving food stamps were associated with a lower
socioeconomic status (P < 0.05). The FS respondents
were less likely to have finished high school, more likely to earn
<$1000 per month, less likely to have access to an automobile and more
likely to have ever received food stamps. About one of every five
respondents reported to be receiving WIC benefits for themselves at the
time of the study. Children were on average 2.7 ± 0.6 y old,
exactly half were girls and 86% were born in the United States.
According to their caretakers, all of the study children had received
WIC at some point during the previous year, and 95% were receiving it
at the time of the study (Table 1
). Sixteen percent of the caretakers assessed the health of their
children as fair/poor, 51% as good and only 33% as excellent, and
there were no significant differences between groups.
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The average monthly food stamp allotment was $260 for an average household size of 4.3 individuals. This food stamp allotment represented 96% of the reported monthly food expenditure. Caretakers reported that food stamps last an average of 3 wk. As expected, almost no one (n = 1) reported buying vitamins with food stamps. The vast majority of respondents (90%) strongly disagreed that the use of food stamps altered the types of foods they bought.
Food insecurity
The levels of food insecurity did not differ between the
FS and NFS groups (Table 2
). Food security was significantly higher and adult food insecurity was
significantly lower in those households in which food stamps lasted the
entire month than in households in which they lasted <4 wk. The
association between monthly food stamp duration and food security
remained (OR 0.10 for <4 wk versus 4 wk, 95% CI 0.02–0.56) even
after adjustment for amount of monthly food stamp allotment in dollars
(1.01, 1.00–1.02) and caretaker’s level of formal education (0.43 for
less than high school versus high school or higher, 0.11–1.64).
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Nutrient intakes.
FS preschoolers had a higher energy-adjusted intake of thiamin,
niacin, vitamin B-6 and iron (Table 3
). In the multivariate analyses, food stamp participation was
significantly associated with above-median energy-adjusted intakes
for vitamin B-6, folate and iron (Table 4
). Thiamin intake was marginally associated (P = 0.055)
with food stamp use. Multivariate analyses also showed that NFS
children were more likely than FS children to have an iron consumption
of <8 mg/d (OR 3.73, 95% CI 1.09–12.80).
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). The positive association between food stamps and consumption of
"sodas and artificially flavored beverages" became marginal
(P = 0.056) after controlling for socioeconomic
covariates (Table 6
).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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). The present study, however, suggests that this
is not the case in this community, because food stamps were indeed the
major source for food purchases in these households. This is
particularly important to document at a time when the benefits of the
current strong economy have not translated into improvements in the
food security situation of low-income households in the United
States (Nord et al. 1999
).
The results from this study derived from a predominantly Hispanic
sample suggest that FSP is associated with the food security of the
households in which the study preschoolers lived. In particular, the
monthly duration of food stamps appears to be an independent predictor
of food security. This finding is fully consistent with a previous
study conducted by our group with Hispanic children in Hartford
(Himmelgreen et al. 2000
) and with a study conducted
with Caucasians in rural upstate New York (Olson et al. 1997
). The original contribution from this study is the finding
that this association remained even after controlling for the
caretaker’s level of formal education and monthly food stamp
allotment. Thus, there may be other factors, such as efficiency of
household budget management, that are in part responsible for this
finding. This suggests that household food security could be improved
through "home economics" interventions, including nutrition
education, budgeting and menu planning. To our knowledge, there is no
national nutrition survey that currently asks the question, "In an
average month, how long do food stamps last in your household?" Thus,
we strongly encourage this question to be included in future
surveys.
The finding that the intakes of iron and some water-soluble
vitamins were higher among food stamp recipients is in close agreement
with the 1989–1991 Continuing Survey of Food Intake by Individuals
(CSFII) secondary data analyses from Rose et al. (1998)
.
In fact, the types of nutrients that appear to respond to food
stamps were remarkably similar in both studies. This implies that FSP
is associated with nutrient intake among Hispanic as well as
non-Hispanic children. There are important differences in the
design and the strength of the inferences that can be made from this
study and the secondary data analyses by Rose et al. (1998)
. First, the CSFII analyses are based on a national
survey that was not designed to specifically answer the question of
interest (i.e., influence of food stamps on food security and nutrient
intakes of low-income children). For example, the analyses
controlled for WIC participation statistically rather than by study
design, as we did in our project. Thus, our research design is more
reliable for understanding this relationship. Second, the CSFII
analyses involve data collected years before welfare reform was
discussed and enacted. Third, those analyses are based on a sample in
which Hispanic children are well underrepresented. In fact, those
analyses do not provide any meaningful information about Puerto Rican
children, who are among the most disadvantaged in the United States.
Fourth, in our study, we document that food stamp use was associated
not only with iron intake above the median but also with less
likelihood of suboptimal consumption of this micronutrient. This
finding deserves careful attention (Brown and Pollitt 1996
), because iron deficiency anemia is highly prevalent in
this pediatric population (Moran et al. 1999
).
The consumption of "sodas and artificially flavored beverages" tended to be higher among FS children. This implies that nutrition education may be needed to improve the food choices made by food stamp recipients.
Study limitations
The main methodological limitation of the present study is its nonexperimental design. Because of its observational nature, a conclusive causal link cannot be made between food stamp use and improved food security and child nutrition outcomes. It is important to underscore, however, that because of welfare reform, a significant proportion of controls were in fact very low-income households that lost their ability to receive food stamps, providing a unique opportunity to have a "comparable" control group in the study. The food security inferences derived from these analyses are based on monthly food stamp duration (i.e., include only the FS group) rather than on a comparison of food security between food stamp and non–food stamp recipients. Thus, those results must be interpreted with caution.
The external validity of this study also must be put into context. For study design purposes, our project was based on a sample of preschoolers who actively participated in WIC. In addition, children were recruited from pediatric clinics that offer an array of public health and social services to their low-income clients. Thus, it is not surprising that the average nutrient intakes of the children who were not receiving food stamps appear to be adequate. Therefore, the public health meaning of these findings must await further research, although the iron consumption findings suggest that FSP may indeed prevent the suboptimal intake of essential micronutrients such as iron.
Nutrient intakes were determined with a single 24-h recall, which is valid for a comparison of average nutrient intakes between groups but may lead to attenuation of associations in regression analyses. The fact that bivariate associations between nutrient intakes and food stamp status persisted in multivariate analyses despite the likely attenuation effect attests to the strength of the association between food stamp use and specific nutrient intakes. We cannot, however, rule out the possibility that we could have missed true associations as a result of attenuation.
In conclusion, these results suggest that FSP is associated with the food security of inner-city households and with children’s micronutrient intakes. Finally, the greater soda consumption associated with food stamps suggests that nutrition education is needed to maximize the nutritional value of foods purchased with food stamps.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Funded by the U.S. Department of Agriculture Economic Research Service through the University of California at Davis (Research Agreement K-981834-03) and the Connecticut Family Nutrition Program
4 Abbreviations used: AFDC, Aid to Families with Dependent Children; CI, confidence interval; CSFII, Continuing Survey of Food Intake by Individuals; FFQ, food frequency questionnaire; FS, receiving food stamps; FSP, Food Stamp Program; NFS, not receiving food stamps; OR, odds ratio; TANF, Temporary Assistance to Needy Families; WIC, Supplemental Food Program for Women, Infants, and Children.
Manuscript received April 3, 2000. Initial review completed May 28, 2000. Revision accepted August 3, 2000.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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2. Himmelgreen, D. A., Pérez-Escamilla, R., Segura-Millán, S., Peng, Y. K., Gonzalez, A., Singer, M. & Ferris, A. (2000) Food insecurity among low-income Hispanics in Hartford, Connecticut: Implications for public health policy. Hum. Org. 59: (in press).
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6. Nord M., Jamison K, Bickel G. Prevalence of Food Insecurity and Hunger, by State, 1996–1998 1999:1-18 U.S. Department of Agriculture, Office of Analysis, Nutrition, and Evaluation, Food and Nutrition Service Washington, D.C.
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