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Health Disparities

HD: Food Security (2011)


Dammann KW, Smith C. Factors affecting low-income women's food choices and the perceived impact of dietary intake and socioeconomic status on their health and weight. J Nutr Educ Behav. 2009 Jul-Aug; 41 (4): 242-253.

PubMed ID: 19508929
Study Design:
Descriptive Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To qualitatively examine the thoughts, feelings and perceptions of low-income women regarding:

  • Food choice within limited financial resources
  • Reasons for choices made despite negative consequences of a calorie-dense diet on weight status and health
  • The degree to which they believe their diet, health and weight status are influence by their socio-economic status.
Inclusion Criteria:

Low-income mothers or female guardians of at least one child aged nine years to 13 years were recruited within a 20-mile radius of St. Paul, Minnesota, via flyers at community sites and homeless shelters.

Exclusion Criteria:

Approximately one-third of participants were actively recruited from homeless shelters in order to ensure representation of this population. Otherwise, there were no exclusion criteria.

Description of Study Protocol:


  • Participants were recruited via flyers posted at community sites including libraries, Supplemental Program for Women, Infants and Children (WIC) offices, grocery stores and food shelves and pantries
  • Additional participants were actively recruited from homeless shelters. 


  • 14 focus groups were held with questions framed in Bandura's Social Cognitive Theory of human behavior as triadic, dynamic and reciprocal interaction between behavior, personal factors and evironmental influences
  • Each focus group was recorded and transcribed with common themes and discussions analyzed comparative to participants' reported age, race, socio-economic status and measured Body Mass Index (BMI).
Statistical Analysis

Demographics and health questionnaire results were analyzed for means and frequency using Statistical Package for Social Sciences, version 12.0 (SPSS Inc., Chicago, IL, 2003). 

Data Collection Summary:

Timing of Measurements

Data was collected at one-time focus group with height and weight measurements as well as participant survey.

Dependent Variables

  • Diet valuation
  • Health perception
  • Environmental situation.

Independent Variables

  • Age
  • Race
  • Income
  • Education
  • Employment
  • Food stamp use
  • Household size
  • Number of children in the household.
Description of Actual Data Sample:
  • Initial and final N: 92 females
  • Age: Mean, 37 years
  • Ethnicity: African-American (N=47), Native American (N=25), white (N=12), Hispanic (N=2) and other (N=6)
  • Other relevant demographics: 84% of participants received food stamps
  • Anthropometrics: 75% overweight or obese
  • Location: St. Paul, Minnesota, USA.
Summary of Results:

Key Findings

  • Economics of Food Choice were impacted by food stamp participation, employment and participation in other federal food assistance programs. Price was the most important component of food purchasing decisions.
  • Multiple Roles of Mothers (or Female Guardians) included discussion of influence on eating habits of the entire household related to nutrition knowledge and cooking skills of the participants
  • Impact of Environmental Situation on food choice and eating behavior include the household set-up (or lack thereof), social connections and access to food shopping locations.
  • Impact of poverty on diet and health revealed that participants did have many diet-related health conditions, but did not select foods for their health; they considered quantity was more important than quality food choices and an overall disconnect between diet and health was found.

Other Findings

  • Participants felt that food stamps were not sufficient to supply food through the month and did not understand the program to be a "supplement" to their food budget
  • Homeless participants tended to eat together more often than those who were not homeless but had less storage or cooking ability
  • Most participants rated the diet quality and health of their children as higher or better than their own.
Author Conclusion:
  • Food choices and the potential impact on the weight and health status of low-income women and their families is a complex area for study
  • Environmental factors may supercede personal choices with regard to low-income women's eating behavior.
Funding Source:
Government: Minnesota Food Stamp Nutrition Education Program
University/Hospital: Agricultural Experiment Station of the University of Minnesota
Reviewer Comments:
  • The qualitative format of this study is difficult to report
  • The researchers attempted to collect participant input in an organized manner, but it is difficult to quantify.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? Yes
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? No
  7.1. Were primary and secondary endpoints described and relevant to the question? No
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? No
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? No
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  8.6. Was clinical significance as well as statistical significance reported? No
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes