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ethnic disparities
Appetite xxx (2017) 1e6
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Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities Daphne C. Hernandez a, *, Layton M. Reesor a, Rosenda Murillo b a
University of Houston, Department of Health and Human Performance, 3875 Holman St., Garrison Gymnasium Rm 104, Houston, 77204-6015, TX, USA University of Houston, Department of Psychological Health and Learning Sciences, 3657 Cullen Blvd, Stephen Power Farish Hall, Houston, 77204-5029, TX, USA
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 January 2017 Accepted 11 July 2017 Available online xxx
The majority of the food insecurity-obesity research has indicated a positive association among women, especially minority women. Less research has been conducted on men, and the findings are inconsistent. The aim was to assess whether gender and race/ethnic disparities exists between the food insecurity and overweight/obesity relationship among adults ages 18e59. We used the cross-sectional 2011 and 2012 National Health Interview Survey data (N ¼ 19,990). Three or more affirmative responses on the 10-item USDA Food Security Scale indicated food insecure experiences. Self-reported height and weight were used to calculate body mass index according to the Centers for Disease Control and Prevention. Multivariate logistic regression models were stratified by gender and race/ethnicity to estimate the association between food insecurity and overweight/obesity controlling for several demographic characteristics. Adults on average were 36 years of age (51% female; 56% white, 27% Hispanic, and 17% black), 27% were food insecure, and 65% were overweight/obese. Food insecurity was most prevalent among blacks and Hispanics, regardless of gender. A greater percentage of food insecure women were overweight/obese compared to food secure women among all race/ethnicity groups; while similar proportions of white, black, and Hispanic men were overweight/obese irrespective of their food security status. In covariateadjusted models, food insecurity was associated with a 41% and 29% higher odds of being overweight/ obese among white and Hispanic women, respectively. Food insecurity was not related to overweight/ obesity among black women nor among white, black, and Hispanic men. The complex relationship between food insecurity and obesity suggests a need to investigate potential behavioral and physiological mechanisms, and moderators of this relationship. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Hispanics Hunger National Health Interview Survey Nutrition Obesity
1. Introduction Sixty-nine percent of U.S. adults are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014). While the overweight and obesity prevalence rates are similar among Hispanic women (77%) and Hispanic men (79%), there are disparities in the overweight or obesity prevalence rate among white women (63%) compared to white men (71%) and black women (82%) compared to black men (69%) (Ogden et al., 2014). For the past decade there has been an increasing trend in obesity among women, and a consistent elevated, but not increasing, obesity trend among men (Flegal, Kruszon-Moran, Carroll, Fryar, & Ogden, 2016). The concern with
* Corresponding author. E-mail address: [email protected] (D.C. Hernandez).
the increasing and elevated obesity trends is that they are associated with severe health consequences. Obesity has been associated with arthritis, diabetes, hypertension, and high cholesterol (Mokdad et al., 2003). Consequently, the obesity-related comorbidities are associated with the staggering cost of health care (Finkelstein, Trogdon, Cohen, & Dietz, 2009), more so than smoking and or problem drinking (Sturm, 2002). The negative health and financial consequences associated with obesity has resulted in researchers focusing on how sources of stress within the family environment may be a contributor (Hernandez & Pressler, 2014, 2015; Hernandez, Pressler, Dorius, & Mitchell, 2014). Food insecurity, or the lack of availability or access to healthful food because of insufficient money or other resources (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2016), is a type of financial stress within the family environment that often coexists with obesity. Roughly 13% (i.e. 16 million) of adults
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D.C. Hernandez et al. / Appetite xxx (2017) 1e6
experience food insecurity in the U.S, with greater disparities observed among women, and black and Hispanic households (Coleman-Jensen et al., 2016). The research that has focused on the association between food insecurity and obesity has primarily found a positive association among adult women (Franklin et al., 2012; Gooding, Walls, & Richmond, 2012; Hanson, Sobal, & Frongillo, 2007; Martin & Lippert, 2012; Pan, Sherry, Njai, & Blanck, 2012; Townsend, Peerson, Love, Achterberg, & Murphy, 2001; Wilde & Peterman, 2006), especially among Mexican American women (Kaiser, ~ onez, Fujii, & Crawford, 2004; Smith, Townsend, Melgar-Quin Colon-Ramos, Pinard, & Yaroch, 2016). The dearth of research examining race/ethnic differences in the food insecurity-obesity association is stronger among race/ethnic minority adult women compared to white adult women (Adams, Grummer-Strawn, & Chavez, 2003). On the other hand, less research has been conducted on adult men, and the findings are not consistent. Two studies have found positive yet non-significant results (Gooding et al., 2012; Pan et al., 2012). One study found positive and significant effects but small in magnitude compared to findings focused on food insecure women (Wilde & Peterman, 2006), while another study found the association to vary by the level of food insecurity (Hanson et al., 2007). The scarcity and inconsistent findings has resulted in few studies investigating race/ethnic differences in the relationship between food insecurity and obesity among adult men. The purpose of this study was to determine whether these association between food insecurity and obesity differs by race/ ethnicity among adult women and men ages 18e59. We hypothesized a positive and significant association between food insecurity and overweight or obese status among minority (black and Hispanic) women, and positive yet non-significant findings among white women, and white, black, and Hispanic men. It is necessary to identify the subpopulations at risk for experiencing the food insecurity-overweight/obesity relationship so that mechanisms and moderators can be investigated and later policies and programs addressing food insecurity and obesity can be adjusted accordingly. 2. Methods The 2011 and 2012 person, family, and sample adult files from National Health Interview Survey (NHIS) data was employed for this study (N ¼ 210,006). The National Center for Health Statistics (NCHS), which is part of the Centers for Disease Control and Prevention (CDC) conducts this cross-sectional survey annually. A multistage probability sample survey design is used to acquire a nationally representative sample of the US non-institutionalized civilian population. For individuals included in the survey, demographics and health of all family members are obtained. Within each family, an adult 18 years of age or older is selected at random and interviewed to obtain additional information. Additional details about the NHIS survey can be found elsewhere (National Center for Health Statistics). The sample was restricted to only include adults 18e59 years of age (162,265 cases excluded), who were of a normal weight (BMI ¼ 18.5) or higher (759 cases excluded), and not pregnant (681 cases excluded). The cut off at age 59 was used because the Administration on Aging refers to individuals over the age of 60 as older adults and oversees the provisions of the Older Americans Act, which provides special services and programs designed to assist these individuals to live independently (Adminstration for Community Living, 2015). Although food insecurity rates are substantially higher among low-income households (i.e. <200% FPL), households slightly above the low-income status also experience food hardship (Gundersen & Garasky, 2012; Gundersen, Kreider, & Pepper, 2011; Hernandez, 2015). For this reason the sample was
restricted to adults who were less than or equal to 299% of the federal poverty line (FPL) (23,187 cases excluded). Further, only adults who identified their race/ethnicity status as non-Hispanic white, non-Hispanic black or Hispanic were included due to low response rates among other racial groups (1933 excluded). Last, only adults with data on all variables of interest were included in the analytic sample (1191 excluded). The final sample consisted of 19,990 adults. This study was approved by the University of Houston’s Institutional Review Board. 2.1. Measures Body Mass Index (BMI). Height (feet and inches) and weight (pounds) were self-reported and used to calculate BMI (kg/m2). Participants’ BMI was then categorized as normal weight (BMI ¼ 18.5e24.9) or overweight/obese (BMI 25.0) based on the standards developed by the CDC (Centers for Disease Control and Prevention, 2015). The BMI categories were then used to create the dichotomous dependent variable used to predict overweight/ obese. Food Insecurity. The 10-item USDA Food Security Scale was used to assess adult food security status. Affirmative responses to three or more items indicated that that the participant experienced food insecurity; affirmative responses to two or fewer items suggested that the participant was food secure (Coleman-Jensen et al., 2016). Gender and Race/ethnicity. Gender and race/ethnicity (nonHispanic white, non-Hispanic black, Hispanic) were self-reported by participants. Covariates. Demographic characteristics were included as covariates in all models to control for factors that may be related to food insecurity as well as overweight/obesity. Characteristics included: age (years), marital status (single vs. married/cohabitating), nativity (foreign born vs. native born), education [less than high school diploma (reference), high school diploma, associates degree, bachelors degree or more], employment (unemployed vs. employed), household income based on the Federal Poverty Line (FPL) [0.00e0.99 FPL (reference), 1.00e1.99 FPL, 2.00e2.99 FPL], health insurance status [private (reference), public, no coverage], physical activity (self-reported weekly minutes of moderate to vigorous activity), and region [South (reference), West, Midwest, Northeast]. 2.2. Analytic plan Using STATA SE version 13.0 statistical software weighted descriptive and multivariate regression models were conducted. To account for the complex sampling design of NHIS and survey weights, survey procedures were used. A series of multivariate logistic regression models were conducted where overweight/ obesity status was regressed onto food insecurity status, controlling for demographic characteristics. All models were stratified by gender and race/ethnicity status. 3. Results Sixty-five percent of the adults were classified as overweight/ obese, 27% were classified as food insecure, 51% female, 56% white, 17% black, and 27% Hispanic (Table 1). Adults were approximately 36 years of age, primarily born in the U.S. (78%), low-income (69%, <1.99 FPL), and with a high school diploma or more (78%). Fifty percent of the adults were married/cohabiting (50%), over half were employed (57%), and health insurance varied with 40% having private insurance, 24% having public insurance, and 36% having no coverage. A greater percentage of black women were overweight/obese,
Please cite this article in press as: Hernandez, D. C., et al., Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities, Appetite (2017), http://dx.doi.org/10.1016/j.appet.2017.07.010
D.C. Hernandez et al. / Appetite xxx (2017) 1e6
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Table 1 Weighted descriptive statistics for study variables for the analytic sample and by gender and race/ethnicity [M (SE) or %].
Dependent Variable Continuous body mass index Normal weight Overweight/obese Independent Variables Food security status Food secure Food insecure Gender Male Female Race/ethnicity White Black Hispanic
Analytic Sample (n ¼ 19,990)
Females (n ¼ 11,143) White Black Hispanic (n ¼ 5215) (n ¼ 2641) (n ¼ 3287)
Significant White Black Hispanic Differences (p < 0.05) (n ¼ 4568) (n ¼ 1527) (n ¼ 2752)
28.47 (0.07)
30.44 (0.19) 27% 73%
28.52 (0.15)
B > W, H H > W
35% 65%
28.09 (0.16) 44% 56%
34% 66%
73% 27%
76% 24%
65% 35%
70% 30%
49% 51%
0% 100%
0% 100%
56% 17% 27%
100% 0% 0% 36.34 (0.27)
Demographic Covariates Age (years) 36.03 (0.14)
Significant Differences (p < 0.05)
B, H > W B > H
28.15 (0.12) 33% 67%
28.59 (0.21) 32% 68%
27% 73%
H > W, B
B > W, H H > W
77% 23%
66% 34%
74% 26%
B > W, H H > W
0% 100%
100% 0%
100% 0%
100% 0%
0% 100% 0%
0% 0% 100%
100% 0% 0%
0% 100% 0%
0% 0% 100%
36.56 (0.33)
35.42 (0.28)
W, B > H
36.44 (0.29)
36.09 (0.42)
34.70 (0.25)
W, B > H
56% 44%
B > W, H H > W
50% 50%
62% 38%
38% 62%
W > H, B > W, H
63% 37%
B > W, H > W, B
5% 95%
12% 88%
64% 36%
H > W, B B > W
40%
B > W, H > W, B
15%
24%
43%
B > W, H > W, B
47%
W, B > H
59%
60%
45%
W, B > H
7% 5%
W, B > H W > B, H B > H
10% 12%
7% 7%
6% 5%
W > B, H W > B, H
51% 49%
H>W
40% 60%
51% 49%
29% 71%
W > H, B > W, H
41% 39% 20%
B > W, H > W H > W, B W > B, H
27% 36% 37%
35% 36% 28%
33% 43% 25%
B, H > W H > W, B W > B, H B > H
26% 26% 48% 243.72 (10.64)
W > B, H B > H B > W, H H > W, B W > B, H
48% 20% 32% 414.16 (17.03)
35% 25% 40% 417.95 (26.92)
28% 17% 55% 401.47 (25.91)
W > B, H B > H W > H, B > H, W B > W, H > W, B
37% 41% 8% 14%
B > W, W > B, W > B, B > W,
35% 20% 31% 15%
60% 8% 18% 13%
36% 42% 10% 12%
B > W, H W > B, H > W, B W > B, H B > H W>H
Marital status 50% 52% 74% Singlea Married/ 50% 48% 26% cohabitating Nativity status Foreign borna 22% 5% 10% Native born 78% 95% 90% Education Less than high 22% 12% 18% school diplomaa High school 55% 57% 60% diploma Associates degree 10% 13% 12% Bachelors degree 12% 14% 8% or more Employment status 43% 46% 48% Unemployeda Employed 57% 54% 54% Household income based on Federal Poverty Line (FPL) 0.00e0.99 FPLa 32% 29% 44% 1.00e1.99 FPL 37% 36% 35% 2.00e2.99 FPL 30% 35% 21% Health insurance coverage Privatea 40% 49% 35% Public 24% 24% 38% No Coverage 36% 26% 28% Physical activity 340.07 (7.62) 290.65 250.13 (minutes) (10.68) (13.29) Region a South 40% 36% 59% West 23% 18% 7% Midwest 23% 32% 18% Northeast 14% 14% 17% a
Males (n ¼ 8847)
H H > B, W HB>H H
28.39 (0.13)
Reference category in regression models. W ¼ white; B ¼ black; H ¼ Hispanic.
followed by Hispanic women. Among the men, a greater percentage of Hispanics were overweight/obese. Food insecurity was most prevalent among blacks and Hispanics, regardless of gender. A greater percentage of Black women and men were single. Hispanic women and men displayed several socio-economic disadvantages compared to their peers. A higher percentage of Hispanic women and men were foreign born and lacked health insurance. They also had the lowest levels of education. Black and Hispanic women and men were more likely to have incomes below the poverty line (i.e. 0.00e0.99 FPL), while white women and men were more likely to be two times or more above the poverty line (i.e. 2.00e2.99 FPL). A greater percentage of food insecure women were overweight/
obese compared to food secure women among all race/ethnicity groups (Table 2, Panel A). Among males, similar proportions of food insecure men were categorized as overweight/obese compared to food secure men among all race/ethnicities (Panel B).
3.1. Multivariate regression models In Table 3 the multivariate logistic regression models predicting the association between food insecurity and overweight/obese are presented. Among white women, those who were food insecure were at 41% higher odds of being overweight/obese. Similarly, among Hispanic women, those who were food insecure were 29%
Please cite this article in press as: Hernandez, D. C., et al., Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities, Appetite (2017), http://dx.doi.org/10.1016/j.appet.2017.07.010
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D.C. Hernandez et al. / Appetite xxx (2017) 1e6
Table 2 Weighted descriptive statistics for body mass index by gender and food security status [M (SE) or %]. Panel A: Females (n ¼ 11,143) White (n ¼ 5215)
Black (n ¼ 2641)
Hispanic (n ¼ 3287)
Food secure n ¼ 3937 Food insecure n ¼ 1278 Food secure n ¼ 1710 Food insecure n ¼ 931 Food secure n ¼ 2294 Food insecure n ¼ 993 29.51 (0.33)*** 35% 65%***
Continuous body mass index 27.64 (0.16) Normal weight 46% Overweight/obese 54%
30.18 (0.24) 29% 71%
30.96 (0.34) 24% 76%*
28.09 (0.17) 36% 64%
29.51 (0.28)*** 28% 72%***
Panel B: Males (n ¼ 8847) White (n ¼ 4568)
Black (n ¼ 1527)
Hispanic (n ¼ 2752)
Food secure n ¼ 3582 Food insecure n ¼ 986 Food secure n ¼ 1013 Food insecure n ¼ 514 Food secure n ¼ 1998 Food insecure n ¼ 754 Continuous Body Mass Index 27.88 (0.13) Normal weight 34% Overweight/obese 66%
29.10 (0.26)*** 30% 70%
28.36 (0.22) 33% 67%
29.05 (0.40) 31% 69%
28.25 (0.15) 27% 73%
28.79 (0.27) 26% 74%
***p < 0.001; *p < 0.05.
Table 3 Weighted logistic regressions predicting the association between food insecurity and overweight/obese vs. normal weight. Panel A: White (n ¼ 9,783)
Food security status Food secure Food insecure
Female n ¼ 5,215
Male n ¼ 4,568
1.00 1.41 (1.17e1.70)***
1.00 1.12 (0.93e1.34)
Panel B: Black (n ¼ 4,168)
Food security status Food secure Food insecure
Female n ¼ 2,641
Male n ¼ 1,527
1.00 1.18 (0.93e1.51)
1.00 1.23 (0.91e1.68)
Panel C: Hispanic (n ¼ 6,039)
Food security status Food secure Food insecure
Female n ¼ 3,287
Male n ¼ 2,752
1.00 1.29 (1.04e1.61)*
1.00 1.10 (0.83e1.44)
Note: Odds ratios and 95% Confidence Intervals are presented. The odds ratio represents the increasing in odds for one unit of food insecurity. Models were conducted on pooled 2011 and 2012 National Health Interview Survey data. All models include covariates described in Table 1, and the dependent variable does not include the underweight category. ***p < 0.001; *p < 0.05.
higher odds to being overweight/obese. Food insecurity status did not predict overweight/obese status among black women. Among males, food insecurity was not predictive of overweight/obese status for any race/ethnicity.
4. Conclusion The purpose of this study was to examine the gender and race/ ethnic differences in the association between food insecurity and overweight/obesity among adults ages 18e59. Findings indicate that there are gender and race/ethnic disparities in how food insecurity influences higher weight status. Specifically, a greater percentage of black and Hispanic women were overweight/obese and food insecure compared to white women. Yet, food insecurity was a predictor of overweight/obesity among white and Hispanic women, but not black women. The positive and significant association between food insecurity and overweight/obesity for white and Hispanic women is similar to prior studies that have found a positive and significant association (Franklin et al., 2012; Gooding et al., 2012; Hanson et al., 2007; Martin & Lippert, 2012; Pan
et al., 2012; Townsend et al., 2001; Wilde & Peterman, 2006). In the current study, a greater proportion of white, black, and Hispanic food insecure women were overweight/obese compared to their food secure peers. However, the discrepancy between the percentage of adult women that were overweight/obese by food security status was larger for white and Hispanic women compared to black women. This larger discrepancy may be a reason for the significant positive association found in the regression models that controlled for various confounding factors among white and Hispanic adult women. On the other hand, the association between food insecurity and overweight/obesity was positive but non-significant for white, black, and Hispanic men, which is similar to prior research (Gooding et al., 2012; Pan et al., 2012). Similar to black and Hispanic women, black and Hispanic men were more likely to experience food insecurity compared to white men. However, the proportion of white, black, and Hispanic food insecure men that were overweight/obese did not significantly differ from the proportion of white, black, and Hispanic food secure men that were overweight/ obese. The lack of discrepancy could be a reason for the nonsignificant findings. Another reason for the lack of findings could be based on the measurement of food insecurity. The Food Security Scale measures food scarcity (e.g., “food bought did not last”, “cut the size of meal or skipped meal”) and anxiety over food scarcity (e.g., “worried food would run out”) (Coleman-Jensen et al., 2016). Typically, men have not been responsible for food shopping and preparation (McIntosh & Zey, 2013) and may have never had to resort to the strategies women use to reduce food shortages. For example, women have reported sending their children to a friend/relative's house for a meal, pawning possessions to have money for food, and putting off a bill to have money for food as methods to increase food supplies (Tarasuk, 2001). In addition, food insecure women feed themselves lower quality food (Basiotis & Lino, 2003; Champagne et al., 2007; Kaiser et al., 2003; Tarasuk, McIntyre, & Li, 2007). Thus, men may be aware that food scarcity exists in the household, but they may not be aware as to the level of severity that women acknowledge. Consequently, men may have less anxiety compared to women about where the next meal will come from. The differences in anxiety levels could be contributing to differences in physiological responses to stress that are associated with obesity (Carroll, Phillips, & Der, 2008; Yudkin, Kumari, Humphries, & Mohamed-Ali, 2000). Although non-significant findings were found among the adult male sample, it is necessary to continue to include men in food insecurity studies as a way to understand the underlying
Please cite this article in press as: Hernandez, D. C., et al., Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities, Appetite (2017), http://dx.doi.org/10.1016/j.appet.2017.07.010
D.C. Hernandez et al. / Appetite xxx (2017) 1e6
mechanisms and moderators that contribute to overweight/obesity among women but not men. Including questions about the division of labor in households regarding food shopping and preparation, along with physiological measures associated with obesity, may provide insight as to the underlying mechanisms and moderators contributing to the gender disparities observed in the food insecurity-overweight/obesity relationship. Although the NHIS data provides information on a large diverse sample making it feasible to investigate gender and race/ethnic differences in the association between food insecurity and obesity, there are limitations to the data. Due to the cross-sectional design of the NHIS, causality between food insecurity and obesity cannot be inferred. The cross-sectional design of the study also prevents the investigation into the duration of food insecurity experiences over a period of several years. Previous research has indicated that it is repeated experiences with poverty that places individuals at risk for obesity (Hernandez & Pressler, 2014; Wells, Evans, Beavis, & Ong, 2010; Ziol-Guest, Duncan, & Kalil, 2009). Thus, measures of childhood poverty, along with yearly measures of food insecurity as an adult, may provide further insight into why gender and race/ ethnic disparities exist. Last, height and weight are self-reported in the NHIS data, which introduces biased BMI estimates compared to direct measurements. The estimates are biased in different directions for women and men. While women have a tendency to overestimate their height and underestimate their weight, men overestimate their height and weight (Merrill & Richardson, 2009). Despite this concern, self-reported height and weight have been included in various epidemiological studies (Spencer, Appleby, Davey, & Key, 2002). 4.1. Implication Just as the American Academy of Pediatrics has recommended screening for food insecurity as a part of wellness visits (Gitterman et al., 2015), adults should be screened during their annual checkups. Identifying adults who may be at risk or are currently experiencing food insecurity is necessary so that patients receive the appropriate resources, such as information for the nearest food pantry. For medical facilities that provide comprehensive health care services, assisting patients with applying for federal nutrition assistance programs, such as the Supplemental Nutrition Assistance Program which has been shown to be effective in reducing food insecurity (Gundersen & Ziliak, 2015; Ratcliffe, McKernan, & Zhang, 2011), could also be another preventative measure. The findings suggest that gender and race/ethnic disparities exist in the food insecurity and obesity relationship. Specifically, food insecurity and obesity are positively and significantly correlated among white and Hispanic women but not among black women and white, black, and Hispanic men. Thus, the complex relationship between food insecurity and obesity suggests a need to investigate potential behavioral and physiological mechanisms and moderators of this relationship. Funding No funding support. Author contributions DCH conceived the design of the study and supervised all aspects of the study reported in this manuscript. RM managed the data, and LR analyzed the data. All authors were involved in data interpretation and writing the paper. All authors had final approval of the submitted version.
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Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities Daphne C. Hernandez a, *, Layton M. Reesor a, Rosenda Murillo b a
University of Houston, Department of Health and Human Performance, 3875 Holman St., Garrison Gymnasium Rm 104, Houston, 77204-6015, TX, USA University of Houston, Department of Psychological Health and Learning Sciences, 3657 Cullen Blvd, Stephen Power Farish Hall, Houston, 77204-5029, TX, USA
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 January 2017 Accepted 11 July 2017 Available online xxx
The majority of the food insecurity-obesity research has indicated a positive association among women, especially minority women. Less research has been conducted on men, and the findings are inconsistent. The aim was to assess whether gender and race/ethnic disparities exists between the food insecurity and overweight/obesity relationship among adults ages 18e59. We used the cross-sectional 2011 and 2012 National Health Interview Survey data (N ¼ 19,990). Three or more affirmative responses on the 10-item USDA Food Security Scale indicated food insecure experiences. Self-reported height and weight were used to calculate body mass index according to the Centers for Disease Control and Prevention. Multivariate logistic regression models were stratified by gender and race/ethnicity to estimate the association between food insecurity and overweight/obesity controlling for several demographic characteristics. Adults on average were 36 years of age (51% female; 56% white, 27% Hispanic, and 17% black), 27% were food insecure, and 65% were overweight/obese. Food insecurity was most prevalent among blacks and Hispanics, regardless of gender. A greater percentage of food insecure women were overweight/obese compared to food secure women among all race/ethnicity groups; while similar proportions of white, black, and Hispanic men were overweight/obese irrespective of their food security status. In covariateadjusted models, food insecurity was associated with a 41% and 29% higher odds of being overweight/ obese among white and Hispanic women, respectively. Food insecurity was not related to overweight/ obesity among black women nor among white, black, and Hispanic men. The complex relationship between food insecurity and obesity suggests a need to investigate potential behavioral and physiological mechanisms, and moderators of this relationship. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Hispanics Hunger National Health Interview Survey Nutrition Obesity
1. Introduction Sixty-nine percent of U.S. adults are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014). While the overweight and obesity prevalence rates are similar among Hispanic women (77%) and Hispanic men (79%), there are disparities in the overweight or obesity prevalence rate among white women (63%) compared to white men (71%) and black women (82%) compared to black men (69%) (Ogden et al., 2014). For the past decade there has been an increasing trend in obesity among women, and a consistent elevated, but not increasing, obesity trend among men (Flegal, Kruszon-Moran, Carroll, Fryar, & Ogden, 2016). The concern with
* Corresponding author. E-mail address: [email protected] (D.C. Hernandez).
the increasing and elevated obesity trends is that they are associated with severe health consequences. Obesity has been associated with arthritis, diabetes, hypertension, and high cholesterol (Mokdad et al., 2003). Consequently, the obesity-related comorbidities are associated with the staggering cost of health care (Finkelstein, Trogdon, Cohen, & Dietz, 2009), more so than smoking and or problem drinking (Sturm, 2002). The negative health and financial consequences associated with obesity has resulted in researchers focusing on how sources of stress within the family environment may be a contributor (Hernandez & Pressler, 2014, 2015; Hernandez, Pressler, Dorius, & Mitchell, 2014). Food insecurity, or the lack of availability or access to healthful food because of insufficient money or other resources (Coleman-Jensen, Rabbitt, Gregory, & Singh, 2016), is a type of financial stress within the family environment that often coexists with obesity. Roughly 13% (i.e. 16 million) of adults
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experience food insecurity in the U.S, with greater disparities observed among women, and black and Hispanic households (Coleman-Jensen et al., 2016). The research that has focused on the association between food insecurity and obesity has primarily found a positive association among adult women (Franklin et al., 2012; Gooding, Walls, & Richmond, 2012; Hanson, Sobal, & Frongillo, 2007; Martin & Lippert, 2012; Pan, Sherry, Njai, & Blanck, 2012; Townsend, Peerson, Love, Achterberg, & Murphy, 2001; Wilde & Peterman, 2006), especially among Mexican American women (Kaiser, ~ onez, Fujii, & Crawford, 2004; Smith, Townsend, Melgar-Quin Colon-Ramos, Pinard, & Yaroch, 2016). The dearth of research examining race/ethnic differences in the food insecurity-obesity association is stronger among race/ethnic minority adult women compared to white adult women (Adams, Grummer-Strawn, & Chavez, 2003). On the other hand, less research has been conducted on adult men, and the findings are not consistent. Two studies have found positive yet non-significant results (Gooding et al., 2012; Pan et al., 2012). One study found positive and significant effects but small in magnitude compared to findings focused on food insecure women (Wilde & Peterman, 2006), while another study found the association to vary by the level of food insecurity (Hanson et al., 2007). The scarcity and inconsistent findings has resulted in few studies investigating race/ethnic differences in the relationship between food insecurity and obesity among adult men. The purpose of this study was to determine whether these association between food insecurity and obesity differs by race/ ethnicity among adult women and men ages 18e59. We hypothesized a positive and significant association between food insecurity and overweight or obese status among minority (black and Hispanic) women, and positive yet non-significant findings among white women, and white, black, and Hispanic men. It is necessary to identify the subpopulations at risk for experiencing the food insecurity-overweight/obesity relationship so that mechanisms and moderators can be investigated and later policies and programs addressing food insecurity and obesity can be adjusted accordingly. 2. Methods The 2011 and 2012 person, family, and sample adult files from National Health Interview Survey (NHIS) data was employed for this study (N ¼ 210,006). The National Center for Health Statistics (NCHS), which is part of the Centers for Disease Control and Prevention (CDC) conducts this cross-sectional survey annually. A multistage probability sample survey design is used to acquire a nationally representative sample of the US non-institutionalized civilian population. For individuals included in the survey, demographics and health of all family members are obtained. Within each family, an adult 18 years of age or older is selected at random and interviewed to obtain additional information. Additional details about the NHIS survey can be found elsewhere (National Center for Health Statistics). The sample was restricted to only include adults 18e59 years of age (162,265 cases excluded), who were of a normal weight (BMI ¼ 18.5) or higher (759 cases excluded), and not pregnant (681 cases excluded). The cut off at age 59 was used because the Administration on Aging refers to individuals over the age of 60 as older adults and oversees the provisions of the Older Americans Act, which provides special services and programs designed to assist these individuals to live independently (Adminstration for Community Living, 2015). Although food insecurity rates are substantially higher among low-income households (i.e. <200% FPL), households slightly above the low-income status also experience food hardship (Gundersen & Garasky, 2012; Gundersen, Kreider, & Pepper, 2011; Hernandez, 2015). For this reason the sample was
restricted to adults who were less than or equal to 299% of the federal poverty line (FPL) (23,187 cases excluded). Further, only adults who identified their race/ethnicity status as non-Hispanic white, non-Hispanic black or Hispanic were included due to low response rates among other racial groups (1933 excluded). Last, only adults with data on all variables of interest were included in the analytic sample (1191 excluded). The final sample consisted of 19,990 adults. This study was approved by the University of Houston’s Institutional Review Board. 2.1. Measures Body Mass Index (BMI). Height (feet and inches) and weight (pounds) were self-reported and used to calculate BMI (kg/m2). Participants’ BMI was then categorized as normal weight (BMI ¼ 18.5e24.9) or overweight/obese (BMI 25.0) based on the standards developed by the CDC (Centers for Disease Control and Prevention, 2015). The BMI categories were then used to create the dichotomous dependent variable used to predict overweight/ obese. Food Insecurity. The 10-item USDA Food Security Scale was used to assess adult food security status. Affirmative responses to three or more items indicated that that the participant experienced food insecurity; affirmative responses to two or fewer items suggested that the participant was food secure (Coleman-Jensen et al., 2016). Gender and Race/ethnicity. Gender and race/ethnicity (nonHispanic white, non-Hispanic black, Hispanic) were self-reported by participants. Covariates. Demographic characteristics were included as covariates in all models to control for factors that may be related to food insecurity as well as overweight/obesity. Characteristics included: age (years), marital status (single vs. married/cohabitating), nativity (foreign born vs. native born), education [less than high school diploma (reference), high school diploma, associates degree, bachelors degree or more], employment (unemployed vs. employed), household income based on the Federal Poverty Line (FPL) [0.00e0.99 FPL (reference), 1.00e1.99 FPL, 2.00e2.99 FPL], health insurance status [private (reference), public, no coverage], physical activity (self-reported weekly minutes of moderate to vigorous activity), and region [South (reference), West, Midwest, Northeast]. 2.2. Analytic plan Using STATA SE version 13.0 statistical software weighted descriptive and multivariate regression models were conducted. To account for the complex sampling design of NHIS and survey weights, survey procedures were used. A series of multivariate logistic regression models were conducted where overweight/ obesity status was regressed onto food insecurity status, controlling for demographic characteristics. All models were stratified by gender and race/ethnicity status. 3. Results Sixty-five percent of the adults were classified as overweight/ obese, 27% were classified as food insecure, 51% female, 56% white, 17% black, and 27% Hispanic (Table 1). Adults were approximately 36 years of age, primarily born in the U.S. (78%), low-income (69%, <1.99 FPL), and with a high school diploma or more (78%). Fifty percent of the adults were married/cohabiting (50%), over half were employed (57%), and health insurance varied with 40% having private insurance, 24% having public insurance, and 36% having no coverage. A greater percentage of black women were overweight/obese,
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Table 1 Weighted descriptive statistics for study variables for the analytic sample and by gender and race/ethnicity [M (SE) or %].
Dependent Variable Continuous body mass index Normal weight Overweight/obese Independent Variables Food security status Food secure Food insecure Gender Male Female Race/ethnicity White Black Hispanic
Analytic Sample (n ¼ 19,990)
Females (n ¼ 11,143) White Black Hispanic (n ¼ 5215) (n ¼ 2641) (n ¼ 3287)
Significant White Black Hispanic Differences (p < 0.05) (n ¼ 4568) (n ¼ 1527) (n ¼ 2752)
28.47 (0.07)
30.44 (0.19) 27% 73%
28.52 (0.15)
B > W, H H > W
35% 65%
28.09 (0.16) 44% 56%
34% 66%
73% 27%
76% 24%
65% 35%
70% 30%
49% 51%
0% 100%
0% 100%
56% 17% 27%
100% 0% 0% 36.34 (0.27)
Demographic Covariates Age (years) 36.03 (0.14)
Significant Differences (p < 0.05)
B, H > W B > H
28.15 (0.12) 33% 67%
28.59 (0.21) 32% 68%
27% 73%
H > W, B
B > W, H H > W
77% 23%
66% 34%
74% 26%
B > W, H H > W
0% 100%
100% 0%
100% 0%
100% 0%
0% 100% 0%
0% 0% 100%
100% 0% 0%
0% 100% 0%
0% 0% 100%
36.56 (0.33)
35.42 (0.28)
W, B > H
36.44 (0.29)
36.09 (0.42)
34.70 (0.25)
W, B > H
56% 44%
B > W, H H > W
50% 50%
62% 38%
38% 62%
W > H, B > W, H
63% 37%
B > W, H > W, B
5% 95%
12% 88%
64% 36%
H > W, B B > W
40%
B > W, H > W, B
15%
24%
43%
B > W, H > W, B
47%
W, B > H
59%
60%
45%
W, B > H
7% 5%
W, B > H W > B, H B > H
10% 12%
7% 7%
6% 5%
W > B, H W > B, H
51% 49%
H>W
40% 60%
51% 49%
29% 71%
W > H, B > W, H
41% 39% 20%
B > W, H > W H > W, B W > B, H
27% 36% 37%
35% 36% 28%
33% 43% 25%
B, H > W H > W, B W > B, H B > H
26% 26% 48% 243.72 (10.64)
W > B, H B > H B > W, H H > W, B W > B, H
48% 20% 32% 414.16 (17.03)
35% 25% 40% 417.95 (26.92)
28% 17% 55% 401.47 (25.91)
W > B, H B > H W > H, B > H, W B > W, H > W, B
37% 41% 8% 14%
B > W, W > B, W > B, B > W,
35% 20% 31% 15%
60% 8% 18% 13%
36% 42% 10% 12%
B > W, H W > B, H > W, B W > B, H B > H W>H
Marital status 50% 52% 74% Singlea Married/ 50% 48% 26% cohabitating Nativity status Foreign borna 22% 5% 10% Native born 78% 95% 90% Education Less than high 22% 12% 18% school diplomaa High school 55% 57% 60% diploma Associates degree 10% 13% 12% Bachelors degree 12% 14% 8% or more Employment status 43% 46% 48% Unemployeda Employed 57% 54% 54% Household income based on Federal Poverty Line (FPL) 0.00e0.99 FPLa 32% 29% 44% 1.00e1.99 FPL 37% 36% 35% 2.00e2.99 FPL 30% 35% 21% Health insurance coverage Privatea 40% 49% 35% Public 24% 24% 38% No Coverage 36% 26% 28% Physical activity 340.07 (7.62) 290.65 250.13 (minutes) (10.68) (13.29) Region a South 40% 36% 59% West 23% 18% 7% Midwest 23% 32% 18% Northeast 14% 14% 17% a
Males (n ¼ 8847)
H H > B, W HB>H H
28.39 (0.13)
Reference category in regression models. W ¼ white; B ¼ black; H ¼ Hispanic.
followed by Hispanic women. Among the men, a greater percentage of Hispanics were overweight/obese. Food insecurity was most prevalent among blacks and Hispanics, regardless of gender. A greater percentage of Black women and men were single. Hispanic women and men displayed several socio-economic disadvantages compared to their peers. A higher percentage of Hispanic women and men were foreign born and lacked health insurance. They also had the lowest levels of education. Black and Hispanic women and men were more likely to have incomes below the poverty line (i.e. 0.00e0.99 FPL), while white women and men were more likely to be two times or more above the poverty line (i.e. 2.00e2.99 FPL). A greater percentage of food insecure women were overweight/
obese compared to food secure women among all race/ethnicity groups (Table 2, Panel A). Among males, similar proportions of food insecure men were categorized as overweight/obese compared to food secure men among all race/ethnicities (Panel B).
3.1. Multivariate regression models In Table 3 the multivariate logistic regression models predicting the association between food insecurity and overweight/obese are presented. Among white women, those who were food insecure were at 41% higher odds of being overweight/obese. Similarly, among Hispanic women, those who were food insecure were 29%
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Table 2 Weighted descriptive statistics for body mass index by gender and food security status [M (SE) or %]. Panel A: Females (n ¼ 11,143) White (n ¼ 5215)
Black (n ¼ 2641)
Hispanic (n ¼ 3287)
Food secure n ¼ 3937 Food insecure n ¼ 1278 Food secure n ¼ 1710 Food insecure n ¼ 931 Food secure n ¼ 2294 Food insecure n ¼ 993 29.51 (0.33)*** 35% 65%***
Continuous body mass index 27.64 (0.16) Normal weight 46% Overweight/obese 54%
30.18 (0.24) 29% 71%
30.96 (0.34) 24% 76%*
28.09 (0.17) 36% 64%
29.51 (0.28)*** 28% 72%***
Panel B: Males (n ¼ 8847) White (n ¼ 4568)
Black (n ¼ 1527)
Hispanic (n ¼ 2752)
Food secure n ¼ 3582 Food insecure n ¼ 986 Food secure n ¼ 1013 Food insecure n ¼ 514 Food secure n ¼ 1998 Food insecure n ¼ 754 Continuous Body Mass Index 27.88 (0.13) Normal weight 34% Overweight/obese 66%
29.10 (0.26)*** 30% 70%
28.36 (0.22) 33% 67%
29.05 (0.40) 31% 69%
28.25 (0.15) 27% 73%
28.79 (0.27) 26% 74%
***p < 0.001; *p < 0.05.
Table 3 Weighted logistic regressions predicting the association between food insecurity and overweight/obese vs. normal weight. Panel A: White (n ¼ 9,783)
Food security status Food secure Food insecure
Female n ¼ 5,215
Male n ¼ 4,568
1.00 1.41 (1.17e1.70)***
1.00 1.12 (0.93e1.34)
Panel B: Black (n ¼ 4,168)
Food security status Food secure Food insecure
Female n ¼ 2,641
Male n ¼ 1,527
1.00 1.18 (0.93e1.51)
1.00 1.23 (0.91e1.68)
Panel C: Hispanic (n ¼ 6,039)
Food security status Food secure Food insecure
Female n ¼ 3,287
Male n ¼ 2,752
1.00 1.29 (1.04e1.61)*
1.00 1.10 (0.83e1.44)
Note: Odds ratios and 95% Confidence Intervals are presented. The odds ratio represents the increasing in odds for one unit of food insecurity. Models were conducted on pooled 2011 and 2012 National Health Interview Survey data. All models include covariates described in Table 1, and the dependent variable does not include the underweight category. ***p < 0.001; *p < 0.05.
higher odds to being overweight/obese. Food insecurity status did not predict overweight/obese status among black women. Among males, food insecurity was not predictive of overweight/obese status for any race/ethnicity.
4. Conclusion The purpose of this study was to examine the gender and race/ ethnic differences in the association between food insecurity and overweight/obesity among adults ages 18e59. Findings indicate that there are gender and race/ethnic disparities in how food insecurity influences higher weight status. Specifically, a greater percentage of black and Hispanic women were overweight/obese and food insecure compared to white women. Yet, food insecurity was a predictor of overweight/obesity among white and Hispanic women, but not black women. The positive and significant association between food insecurity and overweight/obesity for white and Hispanic women is similar to prior studies that have found a positive and significant association (Franklin et al., 2012; Gooding et al., 2012; Hanson et al., 2007; Martin & Lippert, 2012; Pan
et al., 2012; Townsend et al., 2001; Wilde & Peterman, 2006). In the current study, a greater proportion of white, black, and Hispanic food insecure women were overweight/obese compared to their food secure peers. However, the discrepancy between the percentage of adult women that were overweight/obese by food security status was larger for white and Hispanic women compared to black women. This larger discrepancy may be a reason for the significant positive association found in the regression models that controlled for various confounding factors among white and Hispanic adult women. On the other hand, the association between food insecurity and overweight/obesity was positive but non-significant for white, black, and Hispanic men, which is similar to prior research (Gooding et al., 2012; Pan et al., 2012). Similar to black and Hispanic women, black and Hispanic men were more likely to experience food insecurity compared to white men. However, the proportion of white, black, and Hispanic food insecure men that were overweight/obese did not significantly differ from the proportion of white, black, and Hispanic food secure men that were overweight/ obese. The lack of discrepancy could be a reason for the nonsignificant findings. Another reason for the lack of findings could be based on the measurement of food insecurity. The Food Security Scale measures food scarcity (e.g., “food bought did not last”, “cut the size of meal or skipped meal”) and anxiety over food scarcity (e.g., “worried food would run out”) (Coleman-Jensen et al., 2016). Typically, men have not been responsible for food shopping and preparation (McIntosh & Zey, 2013) and may have never had to resort to the strategies women use to reduce food shortages. For example, women have reported sending their children to a friend/relative's house for a meal, pawning possessions to have money for food, and putting off a bill to have money for food as methods to increase food supplies (Tarasuk, 2001). In addition, food insecure women feed themselves lower quality food (Basiotis & Lino, 2003; Champagne et al., 2007; Kaiser et al., 2003; Tarasuk, McIntyre, & Li, 2007). Thus, men may be aware that food scarcity exists in the household, but they may not be aware as to the level of severity that women acknowledge. Consequently, men may have less anxiety compared to women about where the next meal will come from. The differences in anxiety levels could be contributing to differences in physiological responses to stress that are associated with obesity (Carroll, Phillips, & Der, 2008; Yudkin, Kumari, Humphries, & Mohamed-Ali, 2000). Although non-significant findings were found among the adult male sample, it is necessary to continue to include men in food insecurity studies as a way to understand the underlying
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mechanisms and moderators that contribute to overweight/obesity among women but not men. Including questions about the division of labor in households regarding food shopping and preparation, along with physiological measures associated with obesity, may provide insight as to the underlying mechanisms and moderators contributing to the gender disparities observed in the food insecurity-overweight/obesity relationship. Although the NHIS data provides information on a large diverse sample making it feasible to investigate gender and race/ethnic differences in the association between food insecurity and obesity, there are limitations to the data. Due to the cross-sectional design of the NHIS, causality between food insecurity and obesity cannot be inferred. The cross-sectional design of the study also prevents the investigation into the duration of food insecurity experiences over a period of several years. Previous research has indicated that it is repeated experiences with poverty that places individuals at risk for obesity (Hernandez & Pressler, 2014; Wells, Evans, Beavis, & Ong, 2010; Ziol-Guest, Duncan, & Kalil, 2009). Thus, measures of childhood poverty, along with yearly measures of food insecurity as an adult, may provide further insight into why gender and race/ ethnic disparities exist. Last, height and weight are self-reported in the NHIS data, which introduces biased BMI estimates compared to direct measurements. The estimates are biased in different directions for women and men. While women have a tendency to overestimate their height and underestimate their weight, men overestimate their height and weight (Merrill & Richardson, 2009). Despite this concern, self-reported height and weight have been included in various epidemiological studies (Spencer, Appleby, Davey, & Key, 2002). 4.1. Implication Just as the American Academy of Pediatrics has recommended screening for food insecurity as a part of wellness visits (Gitterman et al., 2015), adults should be screened during their annual checkups. Identifying adults who may be at risk or are currently experiencing food insecurity is necessary so that patients receive the appropriate resources, such as information for the nearest food pantry. For medical facilities that provide comprehensive health care services, assisting patients with applying for federal nutrition assistance programs, such as the Supplemental Nutrition Assistance Program which has been shown to be effective in reducing food insecurity (Gundersen & Ziliak, 2015; Ratcliffe, McKernan, & Zhang, 2011), could also be another preventative measure. The findings suggest that gender and race/ethnic disparities exist in the food insecurity and obesity relationship. Specifically, food insecurity and obesity are positively and significantly correlated among white and Hispanic women but not among black women and white, black, and Hispanic men. Thus, the complex relationship between food insecurity and obesity suggests a need to investigate potential behavioral and physiological mechanisms and moderators of this relationship. Funding No funding support. Author contributions DCH conceived the design of the study and supervised all aspects of the study reported in this manuscript. RM managed the data, and LR analyzed the data. All authors were involved in data interpretation and writing the paper. All authors had final approval of the submitted version.
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Please cite this article in press as: Hernandez, D. C., et al., Food insecurity and adult overweight/obesity: Gender and race/ethnic disparities, Appetite (2017), http://dx.doi.org/10.1016/j.appet.2017.07.010