Household Crowding and Food Insecurity Among Inuit Families With School-Aged Children in the Canadian Arctic

Objectives. We examined the relation of household crowding to food insecurity among Inuit families with school-aged children in Arctic Quebec.Methods. We analyzed data collected between October 2005 and February 2010 from 292 primary caregiver–child dyads from 14 Inuit communities. We collected information about household conditions, food security, and family socioeconomic characteristics by interviews. We used logistic regression models to examine the association between household crowding and food insecurity.Results. Nearly 62% of Inuit families in the Canadian Arctic resided in more crowded households, placing them at risk for food insecurity. About 27% of the families reported reducing the size of their children’s meals because of lack of money. The likelihood of reducing the size of children’s meals was greater in crowded households (odds ratio = 3.73; 95% confidence interval = 1.96, 7.12). After we adjusted for different socioeconomic characteristics, results remained statistically significant.Conclusions. Interventions operating across different levels (community, regional, national) are needed to ensure food security in the region. Targeting families living in crowded conditions as part of social and public health policies aiming to reduce food insecurity in the Arctic could be beneficial.Inadequate housing conditions (e.g., crowding and structural damage) are prevalent among First Nations and Inuit communities in Canada and elsewhere.1 In Nunavik, the Inuit homeland in Arctic Quebec, Canada, the government promoted the relocation of many Inuit families to fledgling communities during the 1950s. Relocated families were moved to small, poorly heated and insulated accommodations. Since then, different programs have been designed by the federal, provincial, territorial, and regional governments to address the housing problem in Nunavik and across the Canadian Arctic.2 At present, more than 90% of the Nunavik population has reported living in social (subsidized) housing.3 In this region, social housing units are allocated locally through a point-based system set according to specific criteria, so that applicants most in need are given first priority (e.g., families with lower income, with young children, and living in overcrowded dwellings).2 Rent is set according to household income, while also considering the cost of living.4 Thus, in Nunavik, housing tenure does not differentiate between households on the basis of financial security or income level, given that nearly all of the population resides in social housing. Such organization rather highlights the high degree of financial need throughout this population and a limited private residential market unattainable by most of the population.Household overcrowding, generally defined as more than 1 person per room,5 is particularly problematic in Nunavik. According to Statistics Canada, 49% of the 2006 population lived in overcrowded houses.5 Often, overcrowding is approached as a consequence of economic difficulties. Living in smaller homes or in shared accommodation has been known as a way to lower living costs to dedicate the available financial resources to other basic necessities.6 In such situations, overcrowded households may experience higher food insecurity as a result of a precarious economic situation. In the particular case of Nunavik, however, crowding is a direct consequence of an underlying, and persistent, lack of housing. Household crowding in Nunavik is not only a product of financial difficulties but also an effect of the rapidly growing and young population. Between 2001 and 2006, the population in Nunavik increased by 12% compared with 4% for the province of Quebec. During the past 3 decades, the population has doubled from 5860 in 1986 to 12 090 in 2011.7 In 2008, it was estimated that more than 900 new housing units were needed, but only 239 units were constructed.8 The housing backlog is further compounded by high costs of construction and short building seasons.The housing situation in Nunavik and throughout the Canadian Arctic raises concerns, in terms of both public health and the health of each individual resident, especially that of children.9–14 Indeed, studies have shown that household crowding is associated with poorer respiratory health, especially among children.12,15 In crowded dwellings, the lack of privacy and the difficulty of withdrawing from (unwanted) social interactions may limit the ability of controlling one’s home situation and lead to “overarousal.”16 Household crowding also has been identified as eliciting chronic stress responses in adults,17 anger and depression18 with possible repercussions on behaviors,19–22 withdrawal,23 and reduced social support24 that, we contend, could influence household food insecurity.Food insecurity occurs when it is not possible to obtain safe, sufficient, and nutritiously adequate foods for a healthy life in socially and culturally acceptable ways.25–27 Studies have shown that in a situation of food insecurity, adults generally first reduce their own food consumption. As the situation becomes more severe, children’s diets also will be reduced, particularly in low-income households with single mothers.28,29 In 2012, 14% of the households in Canada experienced food insecurity.30 In Canadian Arctic communities, food insecurity is high: 62.2% and 31.6% of children live in food-insecure households in Nunavut and Northwest Territories, respectively.30 In Nunavik, the proportion of Inuit children experiencing food insecurity reached 30% in 2006.31 Studies emphasize that a reduction of the quality in diet and nutrient intake resulting from food insecurity is linked to various health issues in children, including poor health,25,32–34 developmental delays,35 and poor mental health.36Access to food products supplied from southern regions of Quebec comes at a very high cost to Nunavik, with an average price 57% higher than in the provincial capital.37 Despite efforts to redress this situation, food costs remain very high and often inaccessible to many Nunavik families who must resort to reducing the amount of food supplies or buying products of lower nutritional quality,38 which compromises health and well-being.36,37,39In a study conducted among low-income families in the United States, Cutts et al.40 found a higher risk of food insecurity and child food insecurity in households with higher housing insecurity. In their study, crowding and multiple moves were considered as indicators of housing insecurity. This association was independent of maternal and family characteristics such as education and household employment. In a recent study involving Inuit households from Nunavut, in the eastern Canadian Arctic, Huet et al.41 reported higher food insecurity among Inuit living in overcrowded households and in houses requiring major repairs. This observation, however, was based on bivariate associations between housing conditions and food insecurity and did not account for other factors such as socioeconomic conditions. These studies nonetheless suggest that food insecurity is not only explained in terms of low socioeconomic status and poverty.40,42We examined whether household crowding was associated with food insecurity among Inuit families with school-aged children, independently of socioeconomic disadvantage.     

Socioeconomic Status,Food Security,and Dental Caries in US Children: Mediation Analyses of Data From the National Health and Nutrition Examination Survey, 2007–2008

Objectives. We examined associations of household socioeconomic status (SES) and food security with children’s oral health outcomes.Methods. We analyzed 2007 and 2008 US National Health and Nutrition Examination Survey data for children aged 5 to 17 years (n = 2206) to examine the relationship between food security and untreated dental caries and to assess whether food security mediates the SES–caries relationship.Results. About 20.1% of children had untreated caries. Most households had full food security (62%); 13% had marginal, 17% had low, and 8% had very low food security. Higher SES was associated with significantly lower caries prevalence (prevalence ratio [PR] = 0.77; 95% confidence interval = 0.63, 0.94; P = .01). Children from households with low or very low food security had significantly higher caries prevalence (PR = 2.00 and PR = 1.70, respectively) than did children living in fully food-secure households. Caries prevalence did not differ among children from fully and marginally food-secure households (P = .17). Food insecurity did not appear to mediate the SES–caries relationship.Conclusions. Interventions and policies to ensure food security may help address the US pediatric caries epidemic.Tooth decay (dental caries) is the most prevalent disease worldwide and the most common pediatric disease in the United States.1,2 From 1999 to 2004, the prevalence of untreated tooth decay was 24.5% for children aged 6 to 11 years and 19.6% for adolescents aged 12 to 19 years.3 Untreated tooth decay can lead to difficulties eating and sleeping, pain, the need for invasive restorative treatment, emergency department visits and inpatient hospitalizations, poor quality of life, systemic health problems, and, in rare cases, death.4–7 To date, most public health efforts aimed at addressing the pediatric caries epidemic have focused on tooth-level interventions (e.g., topical fluorides, dental sealants). Although disparities in oral health are considered a measure of social injustice,8 comparatively less research has been conducted on the social determinants of pediatric oral health.9Low socioeconomic status (SES), one of the strongest determinants of caries in children,10–12 is associated with food insecurity,10–17 defined as inadequate access to food resulting in food shortages, disrupted eating patterns, and hunger.18 Food insecurity, in turn, is associated with oral health–related behaviors, including increased fermentable carbohydrate intake,19,20 a risk factor for dental caries.21,22 The American Dietetic Association recognizes the link between nutrition and oral health,23 and numerous studies have drawn associations between dietary factors and disparities in dental caries.24 Collectively, these studies suggest that food insecurity is related to caries and is a potential mechanism linking SES and caries, but these relationships have not yet been evaluated empirically. We used nationally representative data from the United States to test 3 hypotheses: (1) food insecurity is positively associated with untreated dental caries, (2) food insecurity mediates the SES–caries relationship, and (3) food insecurity mediates the SES–caries relationship differentially for children from higher- versus lower-SES households.     

Feeding a Family in a Recession: Food Insecurity Among Minnesota Parents

Objectives. We assessed current levels of food insecurity among a large, diverse sample of parents and examined associations between food insecurity and parental weight status, eating patterns, and the home food environment.Methods. Project F-EAT (Families and Eating and Activity Among Teens) examined the home food environments of adolescents. Parents and caregivers (n = 2095) living with adolescents from the Minneapolis–St. Paul, Minnesota school districts completed mailed surveys during a 12-month period in 2009–2010. We performed our assessments using multivariate regressions.Results. Almost 39% of the parents and caregivers experienced household food insecurity, whereas 13% experienced very low food security. Food insecurity was significantly associated with poorer nutrition-related variables such as higher rates of parental overweight and obesity, less healthy foods served at meals, and higher rates of binge eating. Food-insecure parents were 2 to 4 times more likely to report barriers to accessing fruits and vegetables.Conclusions. Food insecurity was highly prevalent. Environmental interventions are needed to protect vulnerable families against food insecurity and to improve access to affordable, healthy foods.The United States is experiencing the most severe economic collapse since the Great Depression.1,2 By historical standards, unemployment levels remain extremely high3; low-income families, who have been disproportionately burdened by the recession, are struggling to make ends meet.4,5 This financial struggle often results in increased levels of food insecurity—the lack of consistent access to healthy, affordable food.1 Current national estimates suggest 16% of US adults and 25% of US children are food insecure.1,6Common household responses to having inadequate resources for food include food budget adjustments, reduced food intake, and alterations in types of food purchased. Nutrient-dense foods (e.g., fruits, vegetables, whole grains, and lean meats) are significantly more expensive per calorie than are energy-dense foods (e.g., soft drinks, salty and sugary snacks, and pastries).7,8 Thus, studies have shown that in households experiencing food insecurity, food variety tends to decrease and the consumption of energy-dense foods tends to increase.9 A study in Minnesota found that food-insecure youths were more likely to eat fast food and less likely to consume breakfast and family meals than were food-secure youths.10 Poor dietary intake resulting from household food insecurity has been associated with numerous health problems, such as higher rates of diabetes, stress and depression, and hospitalization.11–15 Although the literature is inconsistent,16 food-insecure households, particularly those headed by single mothers, have been found to have higher rates of overweight and obesity.17–19 The concurrent prevalence of obesity and food insecurity is often referred to as the hunger–obesity paradox.20,21Households with children are more likely to be food insecure than are households without children.19,22 Studies have shown that parents, especially mothers, tend to restrict their own intake so enough food will be available for their children.23,24 Additionally, communities of color and immigrant communities experience significantly higher rates of food insecurity compared with the national average.25–27Given the shifts in the economic well-being of the United States, we assessed the current prevalence of food insecurity across sociodemographic characteristics among parents in a large, ethnically diverse population in Minnesota. To better describe implications of current food insecurity among parents, we also examined associations between food insecurity and parental weight status and eating patterns as well as measures of the home food environment.     

Relationship Between Past Food Deprivation and Current Dietary Practices and Weight Status Among Cambodian Refugee Women in Lowell, MA

Objectives. We investigated Cambodian refugee women''s past food experiences and the relationship between those experiences and current food beliefs, dietary practices, and weight status.Methods. Focus group participants (n = 11) described past food experiences and current health-related food beliefs and behaviors. We randomly selected survey participants (n = 133) from a comprehensive list of Cambodian households in Lowell, Massachusetts. We collected height, weight, 24-hour dietary recall, food beliefs, past food experience, and demographic information. We constructed a measure of past food deprivation from focus group and survey responses. We analyzed data with multivariate logistic and linear regression models.Results. Participants experienced severe past food deprivation and insecurity. Those with higher past food-deprivation scores were more likely to currently report eating meat with fat (odds ratio [OR] = 1.14 for every point increase on the 9-to-27–point food-deprivation measure), and to be overweight or obese by Centers for Disease Control and Prevention (OR = 1.28) and World Health Organization (OR = 1.18) standards.Conclusions. Refugees who experienced extensive food deprivation or insecurity may be more likely to engage in unhealthful eating practices and to be overweight or obese than are those who experienced less-extreme food deprivation or insecurity.Since 2000, almost 500 000 refugees have resettled in the United States, with tens of thousands arriving annually.¹ In addition to their high rates of mental health disease resulting from the turmoil they are fleeing,^2–4 refugees have higher rates of heart disease, hypertension, and diabetes than do other immigrant groups and native-born Americans.^2,3,5,6 The high rates of chronic disease are likely related to multiple factors. Refugees may have suffered physiological damage during stress and war,⁷ and traumatic stress may have increased their risk of cardiovascular disease and stroke.⁸The increased rates of chronic disease may also be related to changes in food consumption. In a postconflict environment with plentiful food, people may adopt harmful eating behaviors that affect health both directly and through increased weight.^9–14 World War II prisoners of war who experienced highest trauma and food deprivation also reported the highest rate of binge-eating behaviors 50 years after the war.¹⁵ Holocaust survivors reported lifelong binge eating and preoccupation with food, including worrying about food availability and hoarding.¹⁶Uneven access to food is associated with higher rates of overweight and obesity and weight gain in the United States,^9–13 possibly because it may lead to excessive consumption of food in times of plenty.^9,11,13,14 Refugees who experienced food deprivation or insecurity and who currently have abundant access to food may approach food in ways that increase risk for overweight and obesity. African refugees reported eating high-status foods, such as meat and steak, more often in the United States than in their native countries.¹⁷ Hmong refugees indicated that they purchased and ate food they knew to be unhealthful because it was very affordable in the United States.¹⁸ Studies of Vietnamese, Hmong, and Cambodian refugees reported high preference for steak.^19–21 Although food security has been well-defined,²² to our knowledge, there is no existing quantitative measure of variation in the past food deprivation experiences of refugees.Cambodian refugees stand out as a potential refugee model for examining how past experiences of food deprivation or food insecurity affect current food beliefs, dietary practices, and weight. Cambodian refugees survived high levels of trauma and food deprivation in their home countries,³ and both trauma²³ and food deprivation or insecurity are experienced by most refugees.²⁴ Cambodian refugees also have disproportionately high rates of chronic disease,⁵ as do other refugee groups.^3,6,25Our research sheds some light on the food experiences of Cambodian refugees from 1975 through arrival in the United States (1980s through mid-1990s), develops and validates a measure of past food deprivation to allow measurement of potential effects on current dietary practices, and tests for relationships between severity of past food deprivation and current food beliefs. We also discuss implications for refugee communities.     

Feed First,Ask Questions Later: Alleviating and Understanding Caregiver Food Insecurity in an Urban Children’s Hospital

Objectives. We estimated the prevalence of caregiver hospital food insecurity (defined as not getting enough to eat during a child’s hospitalization), examined associations between food insecurity and barriers to food access, and propose a conceptual framework to inform remedies to this problem.Methods. We conducted a cross-sectional study of 200 caregivers of hospitalized children in Chicago, Illinois (June through December 2011). A self-administered questionnaire assessed sociodemographic characteristics, barriers to food, and caregiver hospital food insecurity.Results. Caregiver hospital food insecurity was prevalent (32%). Caregivers who were aged 18 to 34 years, Black or African American, unpartnered, and with less education were more likely to experience hospital food insecurity. Not having enough money to buy food at the hospital, lack of reliable transportation, and lack of knowledge of where to get food at the hospital were associated with hospital food insecurity. The proposed conceptual framework posits a bidirectional relationship between food insecurity and health, emphasizing the interdependencies between caregiver food insecurity and patient outcomes.Conclusions. Strategies are needed to identify and feed caregivers and to eradicate food insecurity in homes of children with serious illness.In 2009, a pediatric hospital chaplain, distressed by signs of hunger among her patients’ caregivers, shared her concerns with physician leaders of an effort to improve local urban health conditions. She related her observations of hungry parents asking nurses, residents, and medical students for food. She witnessed the kindness of many providers who shared their own sandwich or a few dollars. She also described what she perceived to be a loss of dignity on the part of the person asking for food and the painful resignation of those who were unable to help. She worried that caregiver hunger could be an impediment to a child’s recovery.Food insecurity is a major public health problem in the United States. One in 5 US households with children is food insecure.1 Household food security is defined as having “access at all times to enough food for an active, healthy life for all household members.”1^(p4),2 Acute symptoms of household food insecurity include hunger, depression, fatigue, and lack of control.3–6 Furthermore, people with household food insecurity can experience “alienation” and related feelings including “embarrassment and shame” and a sense of “powerlessness.”3 A qualitative study reported that adults and children with household food insecurity have difficulty concentrating and an impaired ability to learn.4 Hungry children are more likely to suffer from psychosocial problems, receive special education services, and fail a grade.7The long-term outcomes of food insecurity include increased risk of poor physical and mental health in children8–11 and adults.12,13 Food insecurity is also associated with poor disease management and medication nonadherence.12,14,15 The prevalence of household food insecurity has been assessed in inpatient and outpatient populations; the prevalence in these populations frequently exceeds national population-based averages.16–20Although household food insecurity is a known risk factor for poor health, chronic disease, and hospitalization in children,10,11,21,22 very little is known about the patterns and prevalence of food insecurity in the hospital setting. Results from a single qualitative study of 24 caregivers of hospitalized children found that among the personal, financial, and social costs of a child’s hospitalization, “parents experienced difficulty providing themselves with adequate and affordable food and drink. . . .”23^(p748) We found no published studies examining how the symptoms of food insecurity might be associated with a caregiver’s ability to play an active role in the care of a hospitalized child. Little evidence was found to inform a rapid, sustainable remedy to the problem of food insecurity among caregivers of hospitalized children.At the time the chaplain approached us, the hospital’s policy permitted social workers to provide 1 free food tray per stay to families in need, regardless of the length of the patient’s stay. The chaplain’s concerns were validated by other professionals with experience as providers, caregivers, or both in the children’s hospital. Given the acuity of the situation, we opted for a “feed first, ask questions later” approach in alignment with the ethical principle of beneficence in research24 and the principles of our community-engaged research model.25 We marshaled medical students, other faculty, hospital personnel, and existing relationships with the Greater Chicago Food Depository to deploy the area’s first hospital-based food pantry.After we implemented the food pantry, we launched a study to test the hypothesis that food insecurity among caregivers of hospitalized pediatric patients (“hospital food insecurity”) would be prevalent and associated with potentially mutable barriers to food access. We used these empirical findings to develop a conceptual framework to facilitate future study of the impact of hospital food insecurity on pediatric health and health care outcomes.     

The Supplemental Nutrition Assistance Program,Food Insecurity,Dietary Quality,and Obesity Among US Adults

Objectives. We examined whether Supplemental Nutrition Assistance Program (SNAP) participation changes associations between food insecurity, dietary quality, and weight among US adults.Methods. We analyzed adult dietary intake data (n = 8333) from the 2003 to 2010 National Health and Nutrition Examination Survey. Bivariate and multivariable methods assessed associations of SNAP participation and 4 levels of food security with diet and weight. Measures of dietary quality were the Healthy Eating Index 2010, total caloric intake, empty calories, and solid fat; weight measures were body mass index (BMI), overweight, and obesity.Results. SNAP participants with marginal food security had lower BMI (1.83 kg/m²; P < .01) and lower probability of obesity (9 percentage points; P < .05). SNAP participants with marginal (3.46 points; P < .01), low (1.98 points; P < .05), and very low (3.84 points; P < .01) food security had better diets, as illustrated by the Healthy Eating Index. Associations between SNAP participation and improved diet and weight were stronger among Whites than Blacks and Hispanics.Conclusions. Our research highlights the role of SNAP in helping individuals who are at risk for food insecurity to obtain a healthier diet and better weight status.Food insecurity, broadly defined as having limited access to adequate food,1 is associated with increased stress levels and reduced overall well-being.2 In addition, food insecurity has been shown to diminish dietary quality and affect nutritional intake and has been associated with chronic morbidity (e.g., type 2 diabetes, hypertension) and weight gain.1,3–5 In 2012, approximately 14.5% of US households (17.6 million households) experienced food insecurity, of whom 5.7% (7.0 million households) experienced very low food security (i.e., reduction in food intake).6 The Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, is the largest government assistance program in the United States and seeks to alleviate food insecurity in US households.7 SNAP has the potential to mitigate the adverse effects of food insecurity on health outcomes not only through attenuating food insecurity but also by enhancing the dietary quality of its participants.8,9Although cross-sectional studies have found no significant differences in food insecurity levels between SNAP participants and nonparticipants,10,11 in a longitudinal study, Nord observed a 28% reduction in the odds for very low food security among households that remained on SNAP throughout the year relative to those who left before the last 30 days of the year.12 In addition, studies by Leung and Villamor13 and Webb et al.14 found that independent of food insecurity, SNAP participation is associated with the increased likelihood of obesity, and other studies have observed lower dietary quality specifically among SNAP participants.15,16 Kreider et al. used partial identification bounding methods to take into account the endogenous selection and misreporting of SNAP enrollment and found that SNAP reduced the prevalence of food insecurity, poor general health, and obesity among children.17Thus, the interrelationships among SNAP participation, food insecurity, dietary quality, and weight status warrant further investigation to inform SNAP programming, policy, and outreach to ultimately improve the health and well-being of SNAP participants. We explored these relationships in data from the National Health and Nutrition Examination Survey (NHANES) over multiple years. We aimed to determine mitigating effects SNAP participation might have on the association of food insecurity with dietary quality and obesity among a nationally representative sample of US adults.     

High Food Insecurity and Its Correlates Among Families Living on a Rural American Indian Reservation

Objectives. We sought to better understand the prevalence and consequences of food insecurity among American Indian families with young children.Methods. Parents or caregivers of kindergarten-age children enrolled in the Bright Start study (dyad n = 432) living on the Pine Ridge Reservation in South Dakota completed a questionnaire on their child’s dietary intake, the home food environment, and food security. We assessed food security with a standard 6-item scale and examined associations of food insecurity with family sociodemographic characteristics, parents’ and children’s weight, children’s dietary patterns, and the home food environment.Results. Almost 40% of families reported experiencing food insecurity. Children from food-insecure households were more likely to eat some less healthful types of foods, including items purchased at convenience stores (P = .002), and food-insecure parents reported experiencing many barriers to accessing healthful food. Food security status was not associated with differences in home food availability or children’s or parents’ weight status.Conclusions. Food insecurity is prevalent among families living on the Pine Ridge Reservation. Increasing reservation access to food that is high quality, reasonably priced, and healthful should be a public health goal.Food insecurity is defined as the state of either having limited or uncertain access to food that is nutritionally adequate, culturally acceptable, and safe or having an uncertain ability to acquire acceptable foods in socially acceptable ways.1 Food insecurity harms children’s physical, social, and emotional health. Compared with food-secure children, children who experience food insecurity are less likely to have a diet that meets recommended guidelines for nutrition2–4; are more likely to experience chronic illnesses, acute illness,5,6 psychosocial problems, and psychiatric distress5,7–9; and are more likely to have lower academic performance.10 There is some evidence to suggest that food insecurity contributes to overeating and obesity,11–13 although several studies of preschool– and grade school–aged children have not observed associations between food insecurity and weight status.2,12,14,15 The roots of food insecurity for a family often lie in economic factors, such as having insufficient income, limited wealth, excessive debt, and high living expenses. However, psychosocial factors, including maternal mental and physical health status, domestic violence, parental cooking and financial skills, parental education level, and familial social networks, also play roles in food insecurity.7,16 Additionally, lack of access to food in their community increases families’ likelihood of being food insecure.16 Nationwide in 2009, 21.3% of US households with children experienced food insecurity during the previous year.17Since the middle of the twentieth century, substantial changes have occurred in the availability of and access to healthful food on American Indian reservations.18,19 Although, traditionally, American Indian populations used the land they lived on for hunting and growing food, and therefore consumed a plant-based diet supplemented with fish or low-fat meat, today this is no longer the case.20 American Indians living on reservations often rely on food–commodity and nutrition assistance programs21,22 and frequently purchase food from fast-food outlets and small grocery or convenience stores, which typically have a limited availability of high-quality produce and low-fat foods.19Given the high rates of poverty23 on American Indian reservations and poor food access on rural reservations, food insecurity and its health impacts among American Indian families living on or near reservations are of great concern.24,25 Using data from the 2001–2004 Current Population Survey, Gundersen examined food insecurity among American Indians living on and those living off reservations and found that during this period 28% of American Indian households with children experienced food insecurity, compared with 16% of non–American Indian households with children.24 This disparity remained even after adjusting for education, income, marital status, and age, suggesting that American Indians had additional specific risk factors for food insecurity. Furthermore, American Indians living in nonmetropolitan areas were more likely to be food insecure than were those living in metropolitan areas—although identifying those individuals specifically residing on or near reservations was not possible with this data set. Small, reservation-specific studies have examined food insecurity among selected groups of American Indians living on reservations, such as young adults, and have similarly observed that food insecurity is a prevalent and significant problem for these subpopulations.26–28Although it is clear that a sizable proportion of American Indians experience food insecurity, the correlates and consequences of food insecurity among American Indian families of young children living on or near reservations are not well understood. To address this need, we examined the prevalence and correlates of food insecurity among Lakota children and their families living on the Pine Ridge Reservation in South Dakota.     

The Association Between Food Insecurity and Inflammation in the US Adult Population

Objectives. To expand the understanding of potential pathways through which food insecurity is associated with adverse health outcomes, we investigated whether food insecurity is associated with nutritional levels, inflammatory response, and altered immune function.Methods. We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (1999–2006) with 12 191 participants. We assessed food insecurity using the US Department of Agriculture food security scale module and measured clinical biomarkers from blood samples obtained during participants’ visits to mobile examination centers.Results. Of the study population, 21.5% was food insecure. Food insecurity was associated with higher levels of C-reactive protein (adjusted odds ratio [AOR] = 1.21; 95% confidence interval [CI] = 1.04, 1.40) and of white blood cell count (AOR = 1.36; 95% CI = 1.11, 1.67). White blood cell count partly mediated the association between food insecurity and C-reactive protein.Conclusions. These findings show that food insecurity is associated with increased inflammation, a correlate of chronic diseases. Immune response also appears to be a potential mediator in this pathway.An estimated 17 million US households were food insecure in 2008, representing a particularly vulnerable subpopulation of Americans.1 Food insecurity reflects the uncertainty of having or the inability to acquire adequate food intake for all household members1 and stems in large part from the lack of sufficient resources to obtain adequate food intake. Income level has been strongly correlated with food insecurity, with low-income families more likely to experience food insecurity.1,2 However, income and poverty do not fully predict food insecurity, suggesting other factors, such as the ability to effectively budget available resources, are important in determining an individual’s propensity to be food insecure. Identifying additional risk factors for food insecurity may provide targets for prevention among at-risk populations.Numerous studies in the United States have demonstrated that food insecurity is associated with adverse health outcomes, including diabetes, hypertension, and cardiovascular disease.3–7 The mechanisms by which food insecurity predisposes one to chronic diseases, however, have not been well studied but are hypothesized to include shifts in dietary quantity and quality.8 Recent literature has established a seemingly paradoxical relationship between food insecurity and obesity in the United States.9–12 It is thought that food insecurity induces individuals to obtain foods that provide a higher caloric value per dollar spent; subsequently, these high-calorie diets lead to obesity and the associated adverse health outcomes.4,5 However, this model does not account for alternative pathways whereby food insecurity may lead to poor health through undernourishment. For example, those with food insecurity may be able to obtain less food altogether or may experience increased psychological stress, leading to reduced net caloric intake and, ultimately, chronic disease risk from undernourishment. By expanding our understanding of all the potential pathways through which food insecurity is associated with adverse health outcomes, we can develop more effective public health programs.It is possible that the stress and shifts in dietary patterns that characterize food insecurity incite an inflammatory state and alter immune function in food-insecure individuals. This hypothesis may account for why body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) does not fully mediate the relationship between food insecurity and diabetes as well as why food-insecure households do not have significantly different energetic intakes.4,5,8 C-reactive protein (CRP), a systemic and nonspecific inflammatory marker, has been linked to health conditions such as diabetes, peripheral arterial disease, and cardiovascular disease.13–18 Specific nutritional markers, including vitamin A, vitamin B12, and folate, have been identified in biological and epidemiological studies as associated with inflammatory states and innate immune function and increased risk of some infections.19–27 Therefore, nutritional status and its impact on inflammation and immunological processes may help explain how food insecurity influences health outcomes, such as diabetes and cardiovascular disease.Using a representative sample of the United States, we assessed sociodemographic predictors of food insecurity. In addition, we tested the hypothesized association between food insecurity and increased inflammation as measured by CRP levels. We further hypothesized that food insecurity may be associated with poorer nutritional status—as measured by levels of key nutrients—and an increased susceptibility to infection—as captured by white blood cell count, which could then lead to immune system activation and increased inflammation. Nutrients and white blood cell count may be mediators on the pathway from food insecurity to increased inflammation.     

US Housing insecurity and the health of very young children

Objectives. We investigated the association between housing insecurity and the health of very young children.Methods. Between 1998 and 2007, we interviewed 22 069 low-income caregivers with children younger than 3 years who were seen in 7 US urban medical centers. We assessed food insecurity, child health status, developmental risk, weight, and housing insecurity for each child''s household. Our indicators for housing insecurity were crowding (> 2 people/bedroom or > 1 family/residence) and multiple moves (≥ 2 moves within the previous year).Results. After adjusting for covariates, crowding was associated with household food insecurity compared with the securely housed (adjusted odds ratio [AOR] = 1.30; 95% confidence interval [CI] = 1.18, 1.43), as were multiple moves (AOR = 1.91; 95% CI = 1.59, 2.28). Crowding was also associated with child food insecurity (AOR = 1.47; 95% CI = 1.34, 1.63), and so were multiple moves (AOR = 2.56; 95% CI = 2.13, 3.08). Multiple moves were associated with fair or poor child health (AOR = 1.48; 95% CI = 1.25, 1.76), developmental risk (AOR 1.71; 95% CI = 1.33, 2.21), and lower weight-for-age z scores (–0.082 vs −0.013; P = .02).Conclusions. Housing insecurity is associated with poor health, lower weight, and developmental risk among young children. Policies that decrease housing insecurity can promote the health of young children and should be a priority.In the United States, as in other countries, housing is considered a strong social determinant of health.¹ Poor housing conditions have been linked to multiple negative health outcomes in both children and adults. The Department of Health and Human Services has defined housing insecurity as high housing costs in proportion to income, poor housing quality, unstable neighborhoods, overcrowding, or homelessness.² Crowding in the home and multiple moves from home to home have clear negative associations for children. Crowding is negatively associated with mental health status,³ ability to cope with stress,⁴ child and parent interaction,⁵ social relationships,³ and sleep.³ It also increases the risk for childhood injuries,⁶ elevated blood pressure,⁵ respiratory conditions,⁷ and exposure to infectious disease.⁷ Adults⁸ and children⁹ living in crowded households are less likely to access health care services than are those in noncrowded households, and families with multiple moves are less likely to establish a medical home and seek out preventive health services for their children than are securely housed families.¹⁰In older children and adolescents, a history of multiple moves has been associated with mental health concerns,¹¹ substance abuse,¹² increased behavior problems,¹³ poor school performance,^13,14 and increased risk of teen pregnancy.¹⁵ Multiple moves in childhood can have lifelong impact, as evidenced by higher rates of adverse childhood events,¹⁶ lower global health ratings in adulthood,¹⁷ and increased mental health and behavior concerns lasting through adolescence and into adulthood.¹⁶ Grade-school children with more than 2 school moves are 2.5 times more likely to repeat a grade,¹⁸ and adolescents who experience school moves are 50% more likely not to graduate from high school.¹⁹Access to affordable housing is likely to reduce the chances that a family will live in crowded conditions or make multiple moves within a short period of time. Since the Housing Act of 1937 was passed,²⁰ 30% of monthly adjusted income has been used as the threshold for affordable housing costs. But affordability by this definition is becoming increasingly less common. In 2008, half of renter households paid more than 30% of their income in rent, and nearly a quarter paid more than 50%.²¹ Increases in unemployment and the poverty rate since 2008 have likely increased the number of families living in housing that they are hard pressed to afford. Although poverty is higher among young children than among any other age group,²² little is known about the effects of housing insecurity on very young children who are considered housed, albeit precariously. We examined the health, developmental, and anthropometric correlates of housing insecurity among children younger than 3 years, using crowding and multiple moves as indicators.     

Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans��A Qualitative Approach

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.     

Medication Prescribing Practices for Older Prisoners in the Texas Prison System

Objectives. We sought to assess appropriateness of medication prescribing for older Texas prisoners.Methods. In this 12-month cross-sectional study of 13 117 prisoners (aged ≥ 55 years), we assessed medication use with Zhan criteria and compared our results to prior studies of community prescribing. We assessed use of indicated medications with 6 Assessing Care of Vulnerable Elders indicators.Results. Inappropriate medications were prescribed to a third of older prisoners; half of inappropriate use was attributable to over-the-counter antihistamines. When these antihistamines were excluded, inappropriate use dropped to 14% (≥ 55 years) and 17% (≥ 65 years), equivalent to rates in a Department of Veterans Affairs study (17%) and lower than rates in a health maintenance organization study (26%). Median rate of indicated medication use for the 6 indicators was 80% (range = 12%–95%); gastrointestinal prophylaxis for patients on nonsteroidal anti-inflammatories at high risk for gastrointestinal bleed constituted the lowest rate.Conclusions. Medication prescribing for older prisoners in Texas was similar to that for older community adults. However, overuse of antihistamines and underuse of gastrointestinal prophylaxis suggests a need for education of prison health care providers in appropriate prescribing practices for older adults.More than 1 in 100 Americans are incarcerated in a US prison or jail¹ and older prisoners are among the most rapidly growing correctional populations.^1–4 With high rates of chronic disease,^5–7 older prisoners cost on average 2 to 3 times more than younger prisoners to incarcerate.^1,8 Yet prisons are often ill-equipped to care for older prisoners with complex medical problems, such as functional or cognitive impairments.^9–12 This is largely because older adults have substantively different health care needs than younger adults who have traditionally been the focus of prison health care.¹² Despite the increasing numbers and cost of older prisoners, research about the quality of geriatric care in prisons is sparse.One important difference in the care of younger and older adults is medication prescribing.^13,14 Older adults often require medications for multiple chronic diseases, whereas younger adults typically require short-term medications for acute injuries or infection. Although older patients are at increased risk for medication-related adverse events leading to morbidity, mortality, and high costs,^15,16 underuse of indicated medications can deny older adults improved quality and length of life.¹⁵ Despite the safety concerns and high cost associated with inappropriate medication use in older adults, little is known about medication prescribing practices for older prisoners.We assessed medication prescribing practices among older prisoners in the Texas Department of Criminal Justice (TDCJ)—one of the nation''s largest state prison systems. Since 1994, when the TDCJ implemented an academic-based managed care system run by the University of Texas Medical Branch, it has reported substantial improvements in health care and has been proposed as a nationwide model.^17,18 It is unknown if this improved quality has extended to elements of care of the older prisoners, such as medication prescribing quality.     

Evaluation of the New York City Breakfast in the Classroom Program

Objectives. We determined the impact of Breakfast in the Classroom (BIC) on the percentage of children going without morning food, number of locations where food was consumed, and estimated calories consumed per child.Methods. We used a cross-sectional survey of morning food consumed among elementary school students offered BIC and not offered BIC in geographically matched high-poverty-neighborhood elementary schools.Results. Students offered BIC (n = 1044) were less likely to report not eating in the morning (8.7%) than were students not offered BIC (n = 1245; 15.0%) and were more likely to report eating in 2 or more locations during the morning (51.1% vs 30%). Overall, students offered BIC reported consuming an estimated 95 more calories per morning than did students not offered BIC.Conclusions. For every student for whom BIC resolved the problem of starting school with nothing to eat, more than 3 students ate in more than 1 location. Offering BIC reduced the percentage of students not eating in the morning but may contribute to excess calorie intake. More evaluation of BIC’s impact on overweight and obesity is needed before more widespread implementation.Food insecurity and obesity are both serious concerns in urban, low-income communities,1 particularly for children. Food insecurity occurs “whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain.”2 According to the US Department of Agriculture, in 2010, 11.3% of US children lived in households with food insecurity (reporting mainly reductions in quality and variety of children’s meals), and 1.3% were affected by very low food security (termed “food security with hunger” before 2006).3Obesity is a major public health problem among children nationally4,5 and in New York City (NYC).6 Nearly 21% of public school students aged 5 to 14 years are obese.6 Obesity levels are higher among low-income children who qualify for free school meals (23.4%) than among those who do not (18.9%).7 Paradoxically, obesity often occurs among children with food insecurity. Therefore, any effort to address food insecurity should also address obesity.On any given day, between 12% and 34% of children and adolescents report skipping breakfast.8 Eating breakfast may improve short-term memory and academic performance, particularly in undernourished children.8 The national school breakfast program was established in 1966 and permanently authorized in 1975 to provide for students in need of adequate nutrition in the morning.9 Through local departments of education, the school breakfast program provides meals to youths living below 130% of the federal poverty level.9 However, breakfast consumption among youths has declined since 1965.10 In NYC, more than 70% of public school students qualify for free or reduced-price meals. The NYC Department of Education serves more than 800 000 meals each day, using rigorous guidelines initiated in 2005,11 and has introduced initiatives to increase participation in school meals, such as providing universal free breakfast in the cafeteria to all students, regardless of family income and, more recently, providing breakfast in the classroom (BIC) in some schools.BIC is a program intended to serve those who do not or are unable to take advantage of before-school breakfast in the cafeteria. BIC was piloted in selected public school classrooms in NYC at the discretion of school principals starting in January 2008. In the 2009–2010 school year, a number of elementary schools in low-income NYC neighborhoods initiated BIC, consisting of 4-item breakfasts delivered to classrooms and offered to students by their teacher. Breakfast items included milk, cereal, fruit or 100% fruit juice, and 1 additional item, such as carrot bread or string cheese. By January 2010, approximately 19% of approximately 1500 NYC schools served BIC in some or all classrooms.Given the coexisting problems of food insecurity and obesity, our goal was to determine the impact of BIC on the potential to both reduce breakfast skipping and increase calorie consumption. Specifically, we evaluated whether BIC was associated with any of the following changes in children’s morning food consumption: percentage who did not eat, eating locations, and estimated calories consumed.     

The Effect of Household Smoking Bans on Household Smoking

Objectives. Because household smoking levels and adoption of domestic smoking rules may be endogenously related, we estimated a nonrecursive regression model to determine the simultaneous relationship between home smoking restrictions and household smoking.Methods. We used data from a May–June 2012 survey of Philadelphia, Pennsylvania, households with smokers (n = 456) to determine the simultaneous association between smoking levels in the home and the presence of home restrictions on smoking.Results. We found that home smoking rules predicted smoking in the home but smoking in the home had no effect on home smoking restrictions.Conclusions. Absent in-home randomized experiments, a quasi-experimental causal inference suggesting that home smoking rules result in lower home smoking levels may be plausible.Secondhand smoke (also known as “passive smoking” or “environmental tobacco smoke”) is a health hazard for children and adults.1–5 Institutional, city, or national smoking restrictions reduce smoking prevalence and the average consumption of smokers while naturally limiting exposure to secondhand smoke.6–11 At the household level, the research focus has been on the efficacy of household bans on indoor smoking to reduce nonsmokers’ and children’s exposure.12–18 Many studies have found that smokers in households with smoking bans or restrictive smoking rules smoke fewer cigarettes than smokers in households with no bans or rules.19–23 This relationship appears to suggest that household smoking restrictions are effective in reducing household smoking. But do household bans really reduce household smoking? Unfortunately, this situation is not the same as when smoking bans are implemented in bars,24,25 hospitals,26 prisons,27 schools,28 or countries.29,30 In all of these examples, the bans are introduced independently of the prevalent smoking levels of the institution, city, or country because passive smoking exposure is seen as an important health hazard that requires an administrative or legislative response.In households, this analogy does not necessarily hold. Household smoking could be negatively related to household smoking bans because smokers who smoke fewer cigarettes or households with little smoking may implement a household smoking ban whereas heavier smokers or households with multiple smokers could not do so.23,31 In this situation, household smoking bans are endogenous32 relative to household smoking, which implies that household smoking levels cause the smoking ban, not the reverse. To determine which explanation is correct, an experiment that implemented a household ban randomly in regard to household smoking levels would be appropriate.14,33,34 Under experimental conditions, the ban would be independent of household smoking levels and the effect of implementing a household smoking ban on smoking could be unambiguously estimated.     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

The California Endowment's Healthy Eating, Active Communities Program: A Midpoint Review

Objectives. We conducted a midpoint review of The California Endowment''s Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing children''s environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising.Methods. We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in children''s attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers.Results. Children''s environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the program''s implementation.Conclusions. HEAC sites successfully changed children''s food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.Childhood obesity is at epidemic levels in the United States. More than 1 in 7 children and adolescents aged 6 to 17 years are considered obese.¹ Additionally, disparities in obesity rates exist among ethnic groups. Black, Hispanic, and Native American children and adolescents have higher rates of diabetes and obesity than do White children and adolescents.¹ Poor diet and inadequate physical activity have been linked to obesity and preventable chronic illnesses.^2,3 Overweight and obese children may develop a number of risk factors for chronic disease and are increasingly diagnosed with diseases that have historically had their onset in adulthood, such as type 2 diabetes, hypertension, and high cholesterol.⁴Most strategies to prevent or reduce childhood obesity have focused on individual behavior modification and pharmacological treatment, with limited success.⁵ Current research suggests that childhood dietary habits and physical activity levels are influenced by a variety of environmental factors,⁶ such as increasing portion sizes,^7–10 increasing availability of fast food and soft drinks,^11–20 availability of soda and unhealthy food on school campuses,^21–29 curtailment or elimination of physical education and recess in schools,³⁰ insufficient or inadequate parks and recreational facilities,³¹ public policy favoring personal transportation over mass transit,^32–39 limited access to healthy foods and ready availability of unhealthy foods,^37,40–44 and disproportionate advertising of low-nutrient-dense foods and sedentary activities to children and their families.^25,45–49Many of these factors are exacerbated in low-income communities, where healthy and affordable food options and safe opportunities for physical activity are noticeably absent.^40,42 These factors are contributing to high levels of diseases related to nutrition and physical activity among Black and Latino populations.^34,40,42,50A better understanding of the underlying factors that lead to obesity has led to the emergence of a new type of initiative that seeks to reduce childhood obesity by making environmental improvements that promote healthy eating and physical activity, rather than focusing on changing individual eating and activity patterns. Although this type of environmental intervention is relatively new, early results are encouraging.^51–53 It has been demonstrated that better access to healthy foods and opportunities for physical activity results in healthier diets and increased physical activity: people in the presence of supermarkets eat more fruits and vegetables,^40,42,54 and when a venue for physical activity is available, people are more likely to be physically active.^34,55To help prevent obesity and type 2 diabetes among children and adolescents, the Healthy Eating, Active Communities (HEAC) program was established to promote public health environmental change in 6 California communities. We conducted a midpoint review of HEAC''s progress to assess how well these communities were translating models for change into on-the-ground practices resulting in real improvements in the food and physical activity opportunities available to low-income children and families.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).