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Health Disparities

HD: Food Security (2011)

Citation:

Brewer DP, Catlett CS, Porter KN, Lee JS, Hausman DB. Physical limitations contribute to food insecurity and the food insecurity-obesity paradox in older adults at senior centers in Georgia. Journal of Nutrition for the Elderly. 2010; 29: 150-169.

PubMed ID: 20473810
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To explore the relationship of obesity and physical limitations with food insecurity among Georgians participating in the Older Americans Act (OAA) congregate meal site program.

Inclusion Criteria:
  • 50 years of age or older
  • Attendance at included senior centers in Georgia
  • Signed informed consent.
Exclusion Criteria:
  • Less than 50 years of age
  • Not selected as a participant at a participating senior center
  • No informed consent
  • 194 participants were excluded after data collection due to:
    • Missing data for height, weight, waist circumference, joint pain, arthritis, physical function, disability, education, self-reported health and food insecurity assessed by the survey
    • Race or ethnicity other than black or white
    • Younger than 60 years of age
    • BMI less than 18.5kg/m2.
Description of Study Protocol:

Recruitment

Recruited from one of 40 selected senior centers. 

Design

Convenience sample of participants at 40 senior centers were interviewed by trained staff who read the questions to participants and recorded their responses. A modified six-item US household food insecurity survey was conducted. Body mass index (BMI) and waist circumference (WC) were measured or self-reported. Physical function was assessed using the Short Physical Performance Battery.

Statistical Analysis

  • Data analyzed using Statistical Analysis System version 9.1
  • Frequencies, medians, ranges and Spearman correlation coefficients were calculated
  • Mann-Whitney U-test used to assess the relationship between food insecurity and BMI, WC and total physical function
  • Relationships with categorical variables assessed with Chi-square analysis
  • Multivariate and forward stepwise logistic regression analyses. 
Data Collection Summary:

Timing of Measurements

Information obtained during interview:

  • US household food insecurity survey
  • Body weight, height and waist circumference were measured 
  • Physical limitations measured by self-reported arthritis, joint pain and disability
  • Short Physical Performance Battery.

Dependent Variables

Food insecurity measured by US household food insecurity survey with one point for each affirmative response.

Independent Variables

  • BMI calculated using weight measured by scale or self-reported and height measured with tape measure or self-reported by participant
  • Waist circumference was measured with tape measure
  • Physical limitations were measured by self-reported arthritis, joint pain and disability and the Short Physical Performance Batter.

Control Variables

  • Age
  • Gender
  • Race or ethnicity
  • Education
  • Self-reported health.
Description of Actual Data Sample:
  • Initial N: 815 participants
  • Attrition (final N): 621 participants (515 females, 106 males)
  • Age: 76 years (range 60 to 79) based on final N of 621 participants
  • Ethnicity: 63.6% white, 36.4% black based on final N of 621 participants
  • Anthropometrics:
    • BMI among 621 participants 28.3kg/m2 (18.9 to 61kg/m2)
    • 194 excluded participants had lower average BMI, 27.7kg/m2 (P≤0.05), as compared to 621 included participants 
    • Men of the included group had higher WC, 41 inches, as compared to the excluded group, 38 inches (P≤0.05)
    • Higher prevalence of WC class I obesity (17.8% vs. 9.4%, P≤0.001) and WC class II obesity (14.1% vs. 8.9%, P≤0.001)
  • Location: Multiple senior centers in Georgia.
Summary of Results:

 Key Findings

  • Participants with food insecurity were
    • Younger (P≤0.0001)
    • More likely to be black than white (P≤0.0001)
    • Had higher BMI (P≤0.0001)
    • Higher prevalence of high WC (P≤0.001)
    • More likely to have arthritis (P≤0.001), joint pain (P≤0.01) and weight related disability (P≤0.0001)
  • Food insecurity was not significantly associated with BMI class I obesity
  • Insecurity was significantly associated with BMI class II obesity in model one but not associated with insecurity when physical limitations were added (models two and three)
  • Food insecurity was significantly associated with WC class I obesity in model one and model three but not model two when all physical limitations were assessed
  • Food insecurity was significantly associated with WC class II obesity in all models
  • Reported weight related disability and arthritis was consistently and significantly associated with a two-fold increase in the risk of being food insecure.
  Age Ethnicity Obesity Arthritis Joint Pain Physical Function Disability Self-reported Health

BMI Class I Model One

0.56 (0.33 to 0.94)

P<0.05

3.43 (2.23 to 5.26) 

P<0.001

1.42 (0.9 to 2.21)          
BMI Class I Model Two 0.54 (0.32 to 0.93)

3.49 (2.23 to 5.45)

P<0.001

0.95 (0.58 to 1.560 1.67 (0.87 to 3.24) 1.15 (0.62 to 2.14) 1.25 (0.71 to 2.21)

2.40 (1.38 to 4.15)

P<0.01

1.36 (0.87 to 2.13)

BMI Class I Model Three

0.52 (0.34 to 0.85)

P<0.05 

3.69 (2.39 to 5.68)

P<0.001 

 

2.01 (1.16 to 3.50)

P<0.05

   

2.41 (1.46 to 3.97)

P<0.01

 
BMI Class II Model One

0.58 (0.35 to 0.98)

P<0.05

3.38 (2.20 to 5.19)

P<0.001 

1.96 (1.19-3.22)

P<0.01 

         
BMI Class II Model Two

0.57 (0.34 to 0.97)

P<0.05

3.39 (2.18 to 5.29)

P<0.001

1.27(0.74-2.21)

1.64 (0.85 to 3.16) 1.13 (0.61 to 2.11) 1.25 (0.70 to 2.21) 

2.16 (1.25 to 3.74)

P<0.01

1.35 (0.86 to 2.12) 
BMI Class II Model Three

0.57 (0.34 to 0.95)

P<0.05

3.69 (2.39 to 5.68)

P<0.001

 

2.01 (1.16 to 3.50)

P<0.05

   

2.41 (1.46 to 3.97)

P<0.001

 
WC Class I Model One 

0.58 (0.35 to 0.97)

P<0.05

3.53 (2.3 to 5.43)

P<0.001

2.09 (1.34 to 3.25)

P<0.01

         
WC Class I Model Two  0.59 (0.35 to 1.01) 

3.47 (2.22 to 5.41) 

P<0.001

1.54 (0.96-2.48) 1.59 (0.82 to 3.07)  1.16 (0.62 to 2.16)  1.21 (0.68 to 2.15) 

2.09 (1.23 to 3.56)

P<0.01

1.29 (0.82 to 2.03)
WC Class I Model Three   

3.77 (2.44 to 5.81)

P<0.001

1.66 (1.05-2.62)

P<0.05

1.84 (1.06 to 3.21)

P<0.05 

   

2.26 (1.35 to 3.78)

P<0.01 

 
WC Class II Model One 0.62 (0.37 to 1.03) 

3.46 (2.24 to 5.35)

P<0.001 

3.42 (2.01-5.8)

P<0.001 

         
WC Class II Model Two  0.63 (0.37 to 1.07) 

3.42 (2.19 to 5.35)

P<0.001 

2.51 (1.43 to 4.39)

P<0.01

1.54 (0.8 to 2.99)

1.21 (0.65 to 2.25) 

1.18 (0.66 to 2.1)

1.89 (1.1 to 3.25)

P<0.5 

1.29 (0.81 to 2.03) 
WC Class II Model Three   

3.64 (2.35 to 5.64)

P<0.001

2.79 (1.63 to 4.78)

P<0.05 

1.84 (1.05 to 3.21)

P<0.05 

   

2.04 (1.21 to 3.43)

P<0.01

 

Model one: Logistic regression analyses that included age, gender, ethnicity, education and obesity.

Model two: Logistic regression analysis that included all model one variables and arthritis, joint pain, physical function, disability and self-reported health.

Model three: Forward stepwise logistic regression analysis that included for selection all model two variables, only the OR for variables that met the criteria for retention in the models are shown.

Other Findings

  • Gender and education not associated with food insecurity
  • Race consistently and significantly associated with food insecurity
  • Older age was associated with a significantly lower risk of food insecurity in some models.
Author Conclusion:
  • Major findings of the study were that the bivariate analyses indicated that food insecurity was significantly associated with all of the class I and class II obesity-related and physical-limitation-related measures except for physical function
  • Multivariate analyses revealed that food insecurity was consistently and significantly associated with being black, having a high WC and reporting weight-related disability
  • The study demonstrated that the food insecurity-obesity paradox exists in older adults attending senior centers in Georgia and that obesity, weight-related disability and being black are associated with food insecurity.
Funding Source:
Government: Georgia Division of Aging Services, Georgia Area Agencies on Aging
University/Hospital: Department of Food and Nutrition and the Georgia Agricultural Experimentation of University of Georgia
Reviewer Comments:
  • Convenience sample used
  • Numerous exclusion criteria.
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? N/A
  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? N/A
  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")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  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? N/A
  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.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  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? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  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? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  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? N/A
  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? Yes
  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)? N/A
  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? Yes
  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