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Community and International Nutrition

Low-Income Women's Dietary Intakes Are Sensitive to the Depletion of Household Resources in One Month^1–3,

⁴ Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada M5S 1A8; ⁵ Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada T2N 4N1; and ⁶ Department of Statistics, Purdue University, West Lafayette, IN 47906

^* To whom correspondence should be addressed. E-mail: valerie.tarasuk{at}utoronto.ca.

	ABSTRACT

TOP ABSTRACT Introduction Subjects and Methods Results Discussion LITERATURE CITED

 
Food insecurity affects individuals' dietary intakes, but there have been few direct examinations of changes in individuals' intakes in the context of declining resources. This study examined changes in dietary intake over 30 d following the receipt of income in a sample of low-income, predominantly food-insecure women with children. Data on 182 women who received the bulk of their income in 1 monthly check were drawn from 2 Canadian studies. Equivalent 30-d measures of adult food security were constructed from participants' responses to items on the Radimer-Cornell questionnaire or the U.S. Household Food Security Survey Module. Intake data from multiple 24-h dietary recalls collected over 1 mo were merged. Mixed linear models were used to examine relationships between women's energy, nutrient, and food intakes and the depletion in household resources over 30 d, as indicated by days since the receipt of the household's major source of income. Women's intakes of energy, milk products, and vegetables decreased significantly as the time since they received income increased. When their food security status was considered, women who were food secure or marginally insecure showed no significant within-month patterns, but significant declines in energy, carbohydrate, vitamin B-6, and fruit and vegetable intake were observed for women with moderate or severe adult food insecurity. The food intakes of women in deprived circumstances are sensitive to the decline in household resources following the receipt of a monthly check.

	Introduction

TOP ABSTRACT Introduction Subjects and Methods Results Discussion LITERATURE CITED

Several authors have described the complex relationship between the availability of financial resources in households and their food security (3,7,14,16). It is common for families who receive income on a regular basis but who typically cannot "make ends meet" to describe their food restrictions as cyclic, with food shortages most acute at the end of the month when household resources are exhausted (14,16,17). Monthly cycles in food expenditure and aggregate measures of food intake have been charted in U.S. households receiving food stamps (18), but the dietary manifestations of cyclic declines in household resources more generally are poorly understood. One recent study of Hispanic children in California found significantly decreased energy and meat intakes of children in food-insecure households as payday approached, with the magnitude of the decrease greatest in children in households with more severe food insecurity (13). Given that children's dietary intakes generally appear to be less affected by household food insecurity than adults' (5–8,19), more profound within-month patterns might be expected in adults in the context of food insecurity, but this has not been investigated. Two Canadian studies, one of adults using food assistance programs in Montreal (20) and the other a study of low-income, lone-parent families in Atlantic Canada (19), examined patterns in intake over a 1-mo period to represent a financial cycle. Neither study found a significant trend in adults' energy or nutrient intakes across the month (19,20), although declined nutrient intakes in children were reported in the Atlantic study (19). However, neither analysis differentiated in individuals by food security status.

Understanding how household food insecurity relates to adults' dietary intake behaviors is particularly important in the context of a growing body of research linking food insecurity to increased risk of overweight and obesity. Although not all studies have documented this association (21,22), several have reported increased prevalence of overweight and obesity in women in food-insecure (23–29) and food-insufficient households (4). Others have reported significant associations for adults not differentiated by sex (30,31). It is not clear that food insecurity actually precipitates weight gain (28,32), but one explanation frequently posited to account for the increased likelihood of overweight and obesity in adults (or adult women, at least) in food-insecure households is that food insecurity predisposes people to a feast and famine pattern of eating, whereby they overeat when resources are replete and then endure periods of relative food deprivation as they await their next influx of income or food stamps (23,26,27,33). Apart from anecdotal reports (33,34) and some evidence of disordered eating patterns in women in food-insecure settings (10,11,27), however, there is little empirical evidence of this phenomenon.

We undertook a direct examination of changes in individuals' dietary intakes over time as household resources declined, using a merged sample of low-income, predominantly food-insecure women who received the bulk of their income in 1 monthly check. We examined women's food, energy, and nutrient intakes over 30 d in relation to the number of days since their receipt of income and compared within-month intake patterns in women with different levels of adult food insecurity during the month.

	Subjects and Methods

TOP ABSTRACT Introduction Subjects and Methods Results Discussion LITERATURE CITED

 
Dietary intake and food security data for this analysis were drawn from 2 Canadian studies of low-income women: a study of women using emergency food assistance programs in Toronto and a study of lone-parent mothers in the Atlantic provinces. Both studies received ethical approval from their respective university ethics review boards. This secondary analysis of data was confirmed by these boards as requiring no further ethical review. The results of the original studies have been published previously (14,15,19,35,36), as has 1 examination of the merged data (37). We draw on data from the merged sample here to maximize the number of participants available for the examination of within-person variation.

Participants in the Toronto study were women recruited on a first-come, first-served basis when they sought food assistance from a sample of 21 emergency food hamper programs in that city. Participants were interviewed in person 3 times, ideally over a 30-d period. They provided sociodemographic information and, at each interview, identified the most recent date(s) when income from social assistance, wages, employment insurance, child support, child tax benefits, or other major sources had been received. This included any checks paid directly to the participant as well as sources of income received by other members of the household. In addition, the women completed interviewer-administered 24-h dietary intake recalls at each interview, and at the end of the 3rd interview, they responded to a modified version of the U.S. Household Food Security Survey Module (HFSSM), administered to assess food insecurity over the previous 12 mo and 30 d (38). Only 5 questions were asked with reference to the previous 30 d and these were used to measure 30-d food security status in Toronto participants. Data were collected between May 1996 and April 1997. The final sample included 153 nonpregnant women, aged 19–48 y, all with at least 1 child <15 y. For 145 of the women, all 3 dietary recalls were conducted within a 30-d period. Although poverty and lone motherhood were not inclusion criteria, 99% of the sample reported incomes below the poverty line (39) and 65% were lone mothers (36).

Participants in the Atlantic study consisted of lone mothers living with at least 2 children under the age of 14 y in Atlantic Canada (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland) whose household income was less than or equal to the Statistics Canada Low-Income Cut-Off for the residential district (40). Network sampling was used for difficult-to-sample populations (41) to create 12 community clusters from participants who were referred by personnel working for parent resource centers, public health units, community organizations, and other subjects (snowball sampling). Data were collected from participants between February 1999 and February 2000 and included sociodemographic questions, the calendar date(s) when women received checks for their main sources of income (i.e. social assistance, employment insurance, child support, child tax benefits, etc.), and the Radimer-Cornell Questionnaire to Estimate the Prevalence of Hunger and Food Insecurity (11) for the past year on the first interview and weekly for the 3 subsequent interviews. Women's dietary intakes were assessed using 4 24-h dietary intake recalls spread over 4 consecutive weeks; the first recall was administered in person and subsequent recalls were conducted by telephone. The Atlantic Study included 141 women (12 pregnant or lactating), aged 19–46 y, who all met the inclusion criterion of living alone with at least 2 children <14 y; completed assessments of food insecurity during the month were available for 136 participants.

While the Radimer-Cornell Questionnaire is both conceptually similar to, and shares some questions with, the HFSSM, results on the 2 instruments cannot be directly compared, because each instrument also includes unique items. Furthermore, the HFSSM provides both a scale score and a food security classification from item responses, while the Radimer-Cornell questionnaire provides food insecurity status classifications separately for adults and for the household but does not provide a scale score (36,38). For the purposes of this study, equivalence was established between the 30-d food security measures in the 2 surveys using statistical methods based on the Rasch item response theory model (42,43). A preliminary analysis indicated that equivalence could not be established reliably for the household (i.e. combined adult-child-item) measures in the 2 surveys. On the other hand, equivalence was readily established between the adult measures and we therefore used the adult 30-d food insecurity scales for this study. The internal validity of each scale was first tested using Rasch-model-based item-fit statistics, and initial item and scores and household scores for each raw score were calculated using standard joint maximum likelihood methods. Equivalence between the 2 scales was then established based on the 2 items with identical cognitive content in the 2 surveys: "respondent ate less than she thought she should" and "respondent was hungry but did not eat." The item severity scores for these 2 items in the Atlantic scale were set equal to those of the Toronto scale and proportional adjustments were made to the remaining Atlantic items and to the Atlantic scale household scores corresponding to each raw score. Three cut-points were then specified at equal severity levels on the 2 scales to differentiate food security or marginal food insecurity, moderate food insecurity, and severe food insecurity (Supplemental Table 1).

Prior to merging the dietary intake data from these 2 datasets, steps were undertaken to minimize systematic differences in intake estimates arising from methodological effects. We excluded 55 respondents from the Atlantic study because of a previously documented interviewer bias that led to underreporting of dietary intake for these women (44). In addition, to eliminate the potential for differences in intake estimates arising from the use of different data processing systems, the dietary recall data from the Atlantic Study, initially analyzed using Food Smart Millennium Professional Edition nutrient analysis program (Sasquatch Software), were reentered into the Canadian Dietary Information system (45), the food composition database used to compute nutrient values for the Toronto study.

To describe women's energy intake patterns in relation to the monthly flow of income into the household, group mean energy intakes were computed over 3-d intervals for the 30 d following receipt of income and then plotted in relation to time for the 3 subgroups defined by food insecurity status. To ensure that the observations within each time interval were independent, only the first observation (i.e. the 1 closest in time to the receipt of a check) was included in intervals where a woman had more than 1 observation. Because of the difficulty arranging interviews with participants at the very end of the month, we had fewer observations during this period. Nonetheless, only 20% of the group means presented on the graph were constructed from fewer than 10 observations. It should be noted that the graph represents a depiction of patterns across the sample overall; it doe not chart the intake of any 1 woman.

To determine the relationship between women's daily intakes of energy, nutrients, and foods and the depletion of household resources, indicated by days since receipt of a monthly income check, a series of mixed linear models were constructed. The linear relation between time since income receipt and intake was examined first adjusting only for study (i.e. a binary variable denoting the original study from which the observations were drawn) and then adjusting for the 3-level categorical variable for adult food insecurity status and several sociodemographic variables found through prior analyses to relate to intakes in this sample (37). These included presence of a male partner in the household, woman's education (high school or less vs. some postsecondary education), woman's racial/cultural background (white, African Canadian, racially visible immigrant, aboriginal, or other/not stated), number of children (1, 2, 3, or 4), age of oldest child (4 y, 5–9 y, 10 y), and the receipt of any employment income during the month. All covariates were entered as fixed effects. Finally, mixed linear modeling was applied to test the linear trends within 2 strata defined by adult food insecurity status, again including "study" as a covariate. The moderate and severe categories of food insecurity were combined for this analysis.

In addition to total energy intake, we examined women's intakes of fat, carbohydrate, protein, vitamin A, vitamin C, vitamin B-6, niacin, riboflavin, thiamin, calcium, zinc, iron, and magnesium using the mixed linear models described above. To assess food intake patterns, foods were grouped as grain products, fruits and vegetables, milk products, and meat and meat alternates [following the definitions and serving sizes outlined in Canada's Food Guide for Healthy Eating (46)]. To explore the nature of observed differences in the fruit and vegetable group, this food group was further subdivided into fruits, potatoes, and other vegetables. Potatoes were separated out because of their common use as a low-cost staple in some households in this study.

We applied maximum likelihood methods to estimate parameters in these mixed linear models. Because this method assumes that the distribution of the dependent variable is normal, the distributions of all intake variables were reviewed and Box-Cox transformations applied (after adding a small constant to all observations for variables that included 0 intakes) to ensure that all intake variables approximated normal distributions. In all mixed linear models, the covariance between 2 d of intake data for any 1 woman was assumed to be 0, because the dietary intake recall interviews were all conducted on nonconsecutive days, but the intervals between days varied. Prior to conducting these analyses, we applied ANOVA to assess the effect of 2 other possible influences on observed within-person variation in energy and nutrient intakes: day of week, and in the Atlantic study, mode of interview (i.e. telephone or in person). Because no significant effects were observed, neither day of week nor mode of interview was included in the mixed linear models.

For purposes of the analyses outlined here, only women who reported receiving all or almost all of their income in a single check on 1 d during 30 d of observation were included. Forty-four women (18 from the Toronto sample and 26 from the Atlantic sample) who received income more or less frequently than once per month were excluded, because any patterns of dietary intake in relation to the receipt of financial resources among these women could be expected to follow shorter or longer cycles than 1 mo. Consistent with this hypothesis, preliminary analyses revealed that including these women in the analyses biased results toward the null. Thus, results are reported for 182 women (127 from the Toronto sample and 55 from the Atlantic sample), with a total of 601 d of intake data recorded over a 30-d period.

All statistical analyses were conducted using SAS/PC Version 9.1 (SAS Institute). Because of our low statistical power to observe effects in within-person variation, we reported both significant effects (P < 0.05) and marginally significant effects (0.10 > P > 0.5).

	Results

TOP ABSTRACT Introduction Subjects and Methods Results Discussion LITERATURE CITED

 
A summary of the sociodemographic characteristics and food insecurity status of study participants included in this analysis appears in Table 1. Most women had 1 or 2 children living at home and most were lone parents. Almost all were reliant on social assistance benefits (welfare) for the bulk of their income, but 6 women reporting receiving employment insurance benefits and 26 also reported that their household had obtained some money from employment over the month. Two-thirds of respondents were classed as having moderate or severe adult food insecurity.

View larger version (13K): [in this window] [in a new window]   FIGURE 1  Energy intake (MJ/d) for women over 30 d following receipt of monthly income by adult food security status. Within subgroups defined by food security status, the number of observations used to calculate the mean intake for an interval ranged from 2 (for moderately food-insecure women on d 27–29) to 40 (for severely food-insecure women on d 3–5). The mean number of observations used was 19.3 for the food-secure/marginally insecure group (median 19), 12 for the moderately food-insecure group (median 12.5), and 22 for the severely food-insecure group (median 22).

	Discussion

TOP ABSTRACT Introduction Subjects and Methods Results Discussion LITERATURE CITED

One interpretation of our findings is that the categorization of a woman as moderately or severely food insecure is itself a marker of how her dietary intake responds to perturbations in household resources. In other words, the woman's food security status reflects her resilience or vulnerability to dietary compromise when household resources diminish. In this study, women whose intakes exhibited less change in the context of declining resources were more food secure than those whose intakes showed deterioration over the month. While more research is clearly warranted to confirm this interpretation, relatively severe food insecurity in adult women with children may be characterized by the sensitivity of their dietary intakes to declining household resources over time.

This study does not purport to describe a representative population of low-income women with children but rather to describe, in a purposively assembled cohort of such women, the relationship between within-person variation in dietary intake and the monthly receipt of income. The data upon which our observations are based were drawn from 2 earlier studies conducted at different times, with samples from different recruitment bases and different parts of the country. Strengths of this study include: the multiple 24-h food recalls available for these women over a 1-mo period, rendered directly comparable by reentry of data into the same nutrient analysis software; contemporaneous measures of food insecurity over the month; a range of severity in food insecurity across the sample; and knowledge of the exact date on which monthly income was received so that intakes could be classified by days since income receipt. However, the study is not without limitations.

Depletion of household resources was examined only in terms of the number of days since major sources of household income had been received. Actual revenue and expenditures throughout the month were not documented consistently across the 2 studies, so we could not quantify the actual flow of cash resources into and out of these households. As well, detailed information on the amounts and timing of food assistance and other in-kind sources of supports that might have influenced women's dietary intakes on particular days of the month were not tracked consistently across both studies. Further, we were limited to the examination of adult food insecurity, using an index developed through the creation of a common metric for the 2 studies; this index likely includes misclassification error, although we have no way to gauge the extent of this problem nor the direction of bias. Moreover, while it could be argued that adult food insecurity was more appropriate than a household measure for assessing women's own experiences of food insecurity over the 30 d because the latter measure is sensitive to the ages of the children in the household (47,48) and the ages of children varied considerably in households in our sample, it would have been desirable to examine within-person variation in intakes in relation to household food security as well.

Our analysis was also likely affected by reporting errors in women's dietary intake recalls and by the limited number of days of intake data available for analysis. The plausibility of reported intakes relative to estimated energy expenditure (49,50) could not be explored because of the absence of height and weight data for Atlantic study participants. Moreover, the examination of temporal patterns in individuals' dietary intakes is complicated by the instability in individual-level estimates of day-to-day variation based on small numbers of days of intake data (51). Having only 3 or 4 d of intake data per woman over a single month likely limited our ability to discern within-month patterns, particularly for micronutrients that are known to have high intraindividual variation (51–53). In addition, the relatively few women in each of the 3 levels of food insecurity analyzed here limited the statistical power of our stratified analyses. The fact that we have been able to identify significant within-month patterns despite these limitations suggests that women's intakes must indeed be responsive to changes in household resources and that this responsiveness is intimately linked to their food security status.

It is noteworthy that we have documented significant within-month declines in energy, milk products, and vegetable intake in relation to time since the receipt of income in a sample of women with children, 97% of whom were dependent upon social assistance for their income. The inadequacy of social assistance benefit levels in Canada has been extensively documented (54–58), as has the increased vulnerability of social assistance recipients to problems of food insecurity (22,30,59–61). Our findings provide further evidence of this vulnerability. Across the sample overall and within the subgroups reporting greater food insecurity, we can see evidence of deterioration in women's dietary intakes as their monthly allowances are spent and they await the next welfare check. Given the research suggesting that women in severely resource-constrained circumstances will deprive themselves of food as a means to spare their children from deprivation (3,19,62,63), women's food intakes are likely more sensitive to dwindling household resources than are the intakes of other family members. However, it would be naïve to assume that children's food intakes are unaffected in such circumstances, particularly given the recent study by Matheson et al. (13) that showed significant declines in the intakes of children in food-insecure households as payday approached.

In an effort to explain observed associations between food insecurity and adult obesity, several authors have suggested that food insecurity may predispose individuals to "feast and famine" patterns of eating (23,26,27,33). This concept implies a recurrent pattern of above-normal intakes (feasts) followed by below-normal intakes (famine), with cycling following the periodic flow of income resources into the household. The results of our mixed linear modeling support the notion of a resource-based cyclical pattern in intakes, particularly for women in the most food-insecure states. We lack the data to examine women's intakes in relation to weight status or changes in weight over time, but our plot of women's energy intakes over time provides little indication of feast and famine behaviors. The mean energy intake of women with severe food insecurity spiked during the first 2 d following receipt of income, but this intake (7.66 MJ or 1830 kcal/d) is lower than the estimated energy requirements for all but very small, sedentary women (64). Thus, the spike in intake is perhaps best interpreted not as evidence of feasting, but rather as the 1 time in the month when the women's intakes come closest to meeting their needs. While mean intakes were lower over the remainder of the month, whether the levels observed are indicative of a famine phase is debatable. The mean intake levels of women with moderate food insecurity over the 30 d also do not suggest feast or famine. It is possible that some individuals did exhibit feast and famine patterns of eating that could not be discerned through an examination of group mean intake levels during the month. However, the number of days of intake data per woman in this study was insufficient to support a detailed examination of intake patterns at the individual level.

It has also been suggested that food insecurity may predispose individuals to weight gain, as the lack of funds to purchase a healthy diet leads to the overconsumption of less expensive but more energy-dense foods (65–67). Given that all of the women in our sample were low income, diets high in inexpensive, energy-dense foods but low in fruits and vegetables were likely the norm, even for those not experiencing food insecurity. Although women experiencing less severe levels of food insecurity may have engaged in compensatory consumption of cheaper, more energy-dense foods to maintain energy equilibrium as household resources declined, we have no direct evidence of this. Further, the decline in both energy and carbohydrate intakes in women with moderate or severe food insecurity suggests that whatever potential they possessed to maintain energy intakes by altering the composition of their diets must have been exhausted. Indeed, the pattern of persistently low levels of energy intake for most of the month in women with severe food security could predispose them to weight loss. This would be consistent with the observation that, in some populations, severe food insecurity increases the odds of being underweight (27,31).

We conclude that the daily food intakes of women in deprived circumstances are sensitive to the state of their household resources, declining as resources become depleted. We have too little data to speculate upon the physiological implications of such intra-month cyclic variations in intake, but an examination of the patterns of decline between women with different levels of food insecurity indicates that this is not an innocuous situation. The declines in intake in women experiencing moderate or severe food insecurity suggests that they live tenuously in need of their next income infusion. Anything that threatens those funds, or the use of those funds for food purchases, must threaten their nutritional health.

	ACKNOWLEDGMENTS

 
We are indebted to Mark Nord for assistance with the statistical assessment of the food security measures in the two surveys.

	FOOTNOTES

 
¹ Supported by the CIHR-NSHRF-Dairy Farmers of Canada regional partnership program grant no. 62216.

² Author disclosures: V. Tarasuk, L. McIntyre, and J. Li, no conflicts of interest.

³ Supplemental Table 1 is available with the online posting of this paper at jn.nutrition.org.

Manuscript received 18 September 2006. Initial review completed 3 November 2006. Revision accepted 11 June 2007.

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