Health and Hunger in America Hilary Seligman, MD, MAS Division of General Internal Medicine San...

Health and Hunger in Health and Hunger in AmericaAmerica

Hilary Seligman, MD, MASHilary Seligman, MD, MASDivision of General Internal MedicineDivision of General Internal Medicine

San Francisco General Hospital, UCSFSan Francisco General Hospital, UCSF

April 16, 2009April 16, 2009

Learning ObjectivesLearning Objectives

1.1. To understand the concept of food To understand the concept of food insecurity and how it relates to hungerinsecurity and how it relates to hunger

2.2. To understand multiple mechanisms by To understand multiple mechanisms by which food insecurity may predispose which food insecurity may predispose adults to chronic diseaseadults to chronic disease

3.3. To understand implications of food To understand implications of food insecurity for the clinical management of insecurity for the clinical management of chronic diseasechronic disease

HungerHunger

““The uneasy or painful sensation caused The uneasy or painful sensation caused by a lack of food, the recurrent and by a lack of food, the recurrent and involuntary lack of access to food.” involuntary lack of access to food.” (LSRO)(LSRO)

HungerHunger

““The uneasy or painful sensation caused The uneasy or painful sensation caused by a lack of food, the recurrent and by a lack of food, the recurrent and involuntary lack of access to food.” involuntary lack of access to food.” (LSRO)(LSRO)

“Eating? That no longer has importance for me; I cannot even say what is hunger anymore. Oh I feel my empty stomach but I am not hungry; I have no more appetite.” (Hamelin, 2002)

Food InsecurityFood Insecurity

The limited or uncertainThe limited or uncertain– availability of nutritionally adequate and safe availability of nutritionally adequate and safe

foods orfoods or– ability to acquire acceptable foods in socially ability to acquire acceptable foods in socially

acceptable ways acceptable ways (LSRO)(LSRO)

Multi-Dimensional ConceptMulti-Dimensional Concept

Anxiety that food Anxiety that food budget is inadequatebudget is inadequate

Experience of running Experience of running out of food without out of food without money to buy moremoney to buy more

Perceptions that food Perceptions that food is inadequate in is inadequate in quality or quantityquality or quantity

Adjustments to Adjustments to normal food usenormal food use

Reduced food intakeReduced food intake

Physical sensation of Physical sensation of hungerhunger

Weight lossWeight loss

Progression of Food InsecurityProgression of Food Insecurity

11.1% of American households = 13.0 million households

(23.8 million adults and 12.4 million children)

4.1% of American households = 4.7 million households

(8.2 million adults and 691,000 children)

Food Insecurity is Associated with Food Insecurity is Associated with PovertyPoverty

Food Insecurity Food Insecurity ≠ ≠ PovertyPoverty

Household budget requirements differHousehold budget requirements differFood insecurity is aFood insecurity is a measure of need measure of need in one particular areain one particular area- About a third of households with incomes - About a third of households with incomes

<130% FPL<130% FPL- Half of food insecure households have - Half of food insecure households have

incomes >130% of the FPLincomes >130% of the FPL

All studies cited have adjusted for All studies cited have adjusted for povertypoverty

Nord, EIB 25.

Worsening ProblemWorsening Problem

Consumer Price Index for Food*Consumer Price Index for Food*– 2007, increased 4% (highest annual increase since 2007, increased 4% (highest annual increase since

1990)1990)– 2008, increased 6%2008, increased 6%

Survey by Feeding America, 2008Survey by Feeding America, 2008– >80% of food banks couldn’t meet demand without >80% of food banks couldn’t meet demand without

reducing operations or amount of food distributedreducing operations or amount of food distributed

Enrollment in Food Stamps (SNAP) now Enrollment in Food Stamps (SNAP) now surpasses previous record set in 1994surpasses previous record set in 1994

*CPI=price of a standard market basket of goods representing the typical purchases of a typical urban consumer

Worsening Problem: Worsening Problem: CPI For for FoodCPI For for Food

Risk Factors for Food InsecurityRisk Factors for Food Insecurity

Single parent household (Single parent household (30% with 30% with female parentfemale parent; 18% with male parent); 18% with male parent)

African-American (22%) or Latino (20%)African-American (22%) or Latino (20%)

Household with children (16%) Household with children (16%)

Urban (13% vs. 9% rural)Urban (13% vs. 9% rural)

Nord, 2008.Source: ERS using data from the Dec 2007 Current Population Survey Food Security Supplement

Food Insecurity in Clinical SettingsFood Insecurity in Clinical Settings

13-23% of patients in urban, safety net 13-23% of patients in urban, safety net ED’s reported not eating for an entire day ED’s reported not eating for an entire day during the prior 12 months during the prior 12 months (Kersey; Biros)(Kersey; Biros)

41% of patients receiving care in 41% of patients receiving care in community health clinics in Louisiana and community health clinics in Louisiana and and Chicago and Chicago (Seligman)(Seligman)

SFGH General Medicine ClinicSFGH General Medicine Clinic

Latino patients with diabetes Latino patients with diabetes

““How often during the last 12 months were How often during the last 12 months were you in a situation that the food you bought you in a situation that the food you bought just didn’t last and you didn’t have money just didn’t last and you didn’t have money to buy more?” to buy more?” – Often 9%Often 9%– Sometimes 34%Sometimes 34%– Never 56%Never 56%

Seligman, unpublished data.

43%

Health Consequences in ChildrenHealth Consequences in Children

More frequent infections (URI’s, ear infections), More frequent infections (URI’s, ear infections), stomachaches, headaches, fatiguestomachaches, headaches, fatigue

Iron-deficiency anemiaIron-deficiency anemia

Impaired cognitive function & lower school Impaired cognitive function & lower school achievementachievement

Higher rates of aggression, hyperactivity, Higher rates of aggression, hyperactivity, anxiety, and passivityanxiety, and passivity

Increased need for mental health servicesIncreased need for mental health services

Increased hospitalization ratesIncreased hospitalization rates

Mild Food Insecurity is Associated Mild Food Insecurity is Associated with Obesity In Womenwith Obesity In Women

0

1

2

3

Food Secure (ref) Insecure, Mild Insecure, Severe

Od

ds

of

BM

I>30

kg/m

2

Seligman, JGIM, 2007.Adjusted for age, race/ethnicity, parity, income, education, and physical activity. All women < 300% FPL.

Mean BMI=28.9

Mean BMI=28.9

Mean BMI=30.9

*

Difference = 11.4 pounds for avg height woman in US

Food Insecurity & Food Insecurity & Overweight/Obesity in WomenOverweight/Obesity in Women

Olson, 1999Olson, 1999 Randomly selected women Randomly selected women of childbearing age in rural of childbearing age in rural NY, n=193NY, n=193

BMI 28.2 vs. 25.6 BMI 28.2 vs. 25.6 (p<0.05)(p<0.05)

Townsend, Townsend, 20012001

Population-based (CSFII),Population-based (CSFII),

n=4509n=4509

AOR=1.3 (1.1-1.5)AOR=1.3 (1.1-1.5)

Adams, 2003Adams, 2003 California Women’s Health California Women’s Health Survey, n=8169Survey, n=8169

AOR 1.4 (1.0-1.8) in AOR 1.4 (1.0-1.8) in whites, 1.5 (1.1-1.9) in whites, 1.5 (1.1-1.9) in othersothers

Kaiser, 2004Kaiser, 2004 Latina women in CA, n=559Latina women in CA, n=559 AOR 1.98 (1.1-3.5)AOR 1.98 (1.1-3.5)

VanEenwyk, VanEenwyk, 20032003

WA BRFSS Social Context WA BRFSS Social Context Model, n=3252Model, n=3252

AOR 1.3 (1.0-1.8)AOR 1.3 (1.0-1.8)

Basiotis, 2003Basiotis, 2003 NHANES III, n=5241NHANES III, n=5241 58% vs. 47% overweight58% vs. 47% overweight

Hypotheses for the Hypotheses for the Food Insecurity-Obesity LinkFood Insecurity-Obesity Link

Dietary ChangesDietary Changes

Behavioral adaptation to binge-fast cyclesBehavioral adaptation to binge-fast cycles

StressStress

GenesGenes

Furst, 1996.

P. Basiotis and M. Lino. 2002.

The Obesity-Hunger Paradox

Copyright ©2004 The American Society for Nutrition Drewnowski, A. et al. Am J Clin Nutr 2004;79:6-16

Relation between the energy density of selected foods and energy costs (¢/MJ)

Putnam, 2002.

Increase in Retail Price of Food Increase in Retail Price of Food Groups, 1985-2000Groups, 1985-2000

Putnam, 2002.

Roots of Food Insecurity in the US Roots of Food Insecurity in the US are Economic or Socialare Economic or Social

Putnam, 2002.

A Production & Distribution A Production & Distribution Problem in the US?Problem in the US?

Food Insecurity & Dietary IntakeFood Insecurity & Dietary Intake

Decreased dietary varietyDecreased dietary variety““We only have one food on our plate.” We only have one food on our plate.” (Hamelin, 2002)(Hamelin, 2002)

“ “The same stuff always comes back.” The same stuff always comes back.” (Hamelin, 2002)(Hamelin, 2002)

““Like oatmeal, you can eat that for breakfast, lunch, or Like oatmeal, you can eat that for breakfast, lunch, or dinner.”dinner.” (Wolfe, 1998) (Wolfe, 1998)

Increased consumption of calorically-dense Increased consumption of calorically-dense foods (refined grains, added sugars/fats)foods (refined grains, added sugars/fats)Reduced intake of fruits, vegetables, and Reduced intake of fruits, vegetables, and milk/dairymilk/dairyReduced micronutrient intake (riboflavin, niacin, Reduced micronutrient intake (riboflavin, niacin, B6, B12, magnesium, iron, zinc, calcium)B6, B12, magnesium, iron, zinc, calcium)

Bhattacharya, 2004; Kendall, 1996; Olson, 1999; Tarasuk, 2001; Tarasuk, 1999; Dixon, 2001; Lee, 2001

DAIRY

EG

GS

M

EA

T

FRESH PRODUCE

“Shopping in the Middle of the Grocery Store”

•Highly refined/processed foods

•Added fat/sugar

•Added salt

•Bread, pasta, other carbohydrates

•Juices and soft drinks

Hypotheses for the Hypotheses for the Food Insecurity-Obesity LinkFood Insecurity-Obesity Link

Dietary ChangesDietary Changes

Behavioral adaptation to binge-fast cyclesBehavioral adaptation to binge-fast cycles

StressStress

GenesGenes

Episodic Overconsumption & Episodic Overconsumption & UnderconsumptionUnderconsumption

Food insecurity is cyclical & episodicFood insecurity is cyclical & episodic– Monthly food stamps (“The Food Stamp Monthly food stamps (“The Food Stamp

Cycle”) or pay checksCycle”) or pay checks– Seasonal variationSeasonal variation– Periodic, unforeseen expendituresPeriodic, unforeseen expenditures

Food insecure households food insecure 7 Food insecure households food insecure 7 months of the year on averagemonths of the year on average

““The last week of each month, it is The last week of each month, it is an internal panic.”an internal panic.”

Hamelin, Soc Sci Med, 2002; Taren, AJPH, 1990.

Cyclic Food Restriction Cyclic Food Restriction in Animal Studiesin Animal Studies

Prefer calorically dense foodsPrefer calorically dense foods

Hoard foodHoard food

Become aggressiveBecome aggressive ““When I don’t have enough, I become aggressive or rude When I don’t have enough, I become aggressive or rude

or angered with my children.”or angered with my children.” (Hamelin, 2002)(Hamelin, 2002)

Increased body fatIncreased body fat

Decreased lean muscle massDecreased lean muscle mass

Quicker weight gain with refeedingQuicker weight gain with refeedingTownsend, 2001; Dietz, 1995.

Behavioral Adaptation to Cyclic Behavioral Adaptation to Cyclic Food RestrictionFood Restriction

Adults who episodically underconsume Adults who episodically underconsume overconsume during food adequacy overconsume during food adequacy (Urbszat (Urbszat

2002, Polivy 1996)2002, Polivy 1996)

Food obsessionsFood obsessions

““I buy a big five-pound block of cheese I buy a big five-pound block of cheese twice a month and when that first comes twice a month and when that first comes into the house, you know, it’s like into the house, you know, it’s like everybody’s sort of ravenous after everybody’s sort of ravenous after stuff….”stuff….”

““Towards the first part, the first half of the Towards the first part, the first half of the month they always eat probably more month they always eat probably more than they should, ‘cause they get so than they should, ‘cause they get so excited.”excited.”

Olson, 2007.Olson, 2007.

Hypotheses for the Food Insecurity-Hypotheses for the Food Insecurity-Obesity LinkObesity Link

Dietary ChangesDietary Changes

Behavioral adaptation to binge-fast cyclesBehavioral adaptation to binge-fast cycles

StressStress

GenesGenes

Chronic StressChronic Stress

Food insecurity is associated with very Food insecurity is associated with very high levels of anxiety, worry, & sorrowhigh levels of anxiety, worry, & sorrow

Chronic stress is associated with Chronic stress is associated with adiposity, particularly visceral adiposityadiposity, particularly visceral adiposity

“When I see my cupboard becoming empty, I wonder how am I going to fill it again and I get panicky.”

“I was so scared that my son would be taken away.”

Hamelin, 2002

Hypotheses for the Food Insecurity-Hypotheses for the Food Insecurity-Obesity LinkObesity Link

Dietary ChangesDietary Changes

Behavioral adaptation to binge-fast cyclesBehavioral adaptation to binge-fast cycles

StressStress

GenesGenes

The Thrifty Gene HypothesisThe Thrifty Gene Hypothesis

When food is unpredictable, it is adaptive When food is unpredictable, it is adaptive to efficiently accumulate fat during food to efficiently accumulate fat during food plenty so that it will be in abundance plenty so that it will be in abundance during food scarcityduring food scarcity

Evolutionary AdvantageEvolutionary Advantage

Slide from Marilyn Townsend.

Food Insecurity is Associated with Food Insecurity is Associated with Diabetes (Men & Women)Diabetes (Men & Women)

SecureSecure Insecure, Insecure, MildMild

Insecure, Insecure, SevereSevere

FBS, mg/dLFBS, mg/dL 99.999.9 101.0101.0 106.9*106.9*

FBS>126, %FBS>126, % 7.07.0 7.07.0 15.9**15.9**

Adjusted Adjusted odds of DModds of DM

RefRef 1.01.0 3.9**3.9**

(1.8-8.4)(1.8-8.4)

Adjusted for BMI, age, gender, race, education, income, insurance, & marital status. Sample restricted to adults <300% FPL.

Seligman et al.

Evolutionary advantageEvolutionary advantage

During starvation, muscle protein is consumed to During starvation, muscle protein is consumed to produce energy for brain…but you need your produce energy for brain…but you need your muscles to hunt & gather!muscles to hunt & gather!

Peripheral insulin resistance reduces loss of Peripheral insulin resistance reduces loss of muscle protein, but also may result in diabetes muscle protein, but also may result in diabetes (Reaven, 1998)(Reaven, 1998)

Acute starvation has been linked to diabetes Acute starvation has been linked to diabetes (Netherlands, 1944-45)(Netherlands, 1944-45)

Effect-CauseEffect-Cause

2001 per capita OOP HC expenditures 2001 per capita OOP HC expenditures higher for adults with diabetes ($1329) higher for adults with diabetes ($1329) than heart disease ($1103), HTN ($961), than heart disease ($1103), HTN ($961), or cancer ($1023) or cancer ($1023) (Bernard, 2001)(Bernard, 2001)

Qualitative & quantitative data indicates Qualitative & quantitative data indicates adults don’t buy food to pay for meds, or adults don’t buy food to pay for meds, or don’t buy meds to pay for food don’t buy meds to pay for food (Hunt, 1998; Biros, (Hunt, 1998; Biros, 2005; Kersey, 1999)2005; Kersey, 1999)

Food Insecurity and DiabetesFood Insecurity and Diabetes

““The end of the month, I start getting out of food…but I The end of the month, I start getting out of food…but I have to eat something, ‘cause if I don’t eat behind my have to eat something, ‘cause if I don’t eat behind my [insulin] shot, that shot will make you so sick. I just eat [insulin] shot, that shot will make you so sick. I just eat anything I can find during that time just to keep me from anything I can find during that time just to keep me from getting sick.” getting sick.” (Wolfe, 1998)(Wolfe, 1998)

““Snow boots or insulin or groceries this week?” Snow boots or insulin or groceries this week?” (Hamelin, (Hamelin, 2002)2002)

Food Insecurity & HypoglycemiaFood Insecurity & Hypoglycemia

61% of diabetics in an urban, safety net hospital 61% of diabetics in an urban, safety net hospital experienced hypoglycemia annually experienced hypoglycemia annually (Nelson, 1998)(Nelson, 1998)

– 1/3 of episodes were attributed to the inability to 1/3 of episodes were attributed to the inability to afford food afford food

Diabetics in community health centers (n=40), Diabetics in community health centers (n=40), 38% food insecure 38% food insecure (Seligman, unpublished)(Seligman, unpublished)

– More likely to report a hypoglycemic reaction because More likely to report a hypoglycemic reaction because of an inability to afford food (AOR 11.6, p=0.04) of an inability to afford food (AOR 11.6, p=0.04)

– More likely to visit ER due to a hypoglycemic reaction More likely to visit ER due to a hypoglycemic reaction (AOR 8.6, p=0.09)(AOR 8.6, p=0.09)

– More likely to put off purchasing blood testing More likely to put off purchasing blood testing supplies so they would have enough money for food supplies so they would have enough money for food (AOR 17.2, p=0.02)(AOR 17.2, p=0.02)

Food Insecurity is Associated with Food Insecurity is Associated with Poor Diabetes Control (HbA1c>7%)Poor Diabetes Control (HbA1c>7%)

SecureSecure Insecure, Insecure, MildMild

Insecure, Insecure, SevereSevere

%% 46.446.4 63.063.0 68.068.0

Adjusted odds of Adjusted odds of poor controlpoor control

RefRef 1.71.7

(0.9-3.1)(0.9-3.1)

2.82.8

(1.0-7.2)(1.0-7.2)

Adjusted for BMI, age, gender, race, education, income, insurance, & marital status. Sample restricted to adults <300% FPL.

Seligman et al.

Glycemic ControlGlycemic Control

Mean HbA1c among patients with Mean HbA1c among patients with diabetes (n=40) seeking care in diabetes (n=40) seeking care in community health clinics in Louisiana and community health clinics in Louisiana and ChicagoChicago

Food SecureFood Secure 7.7%7.7%

Food InsecureFood Insecure 9.2%*9.2%*

* p=0.05

Food Insecurity Is Associated with Food Insecurity Is Associated with Poorer Health StatusPoorer Health Status

0

10

20

30

40

50

Excellent Very Good Good Fair/Poor

%

Secure Insecure, Mild Insecure, Severe

Adjusted for age, gender, race, education, income, insurance, & marital status.

Seligman et al.

******

*** ***

******

*

***

Food Insecurity & Clinical Evidence Food Insecurity & Clinical Evidence of Hypertensionof Hypertension

SecureSecure Insecure, Insecure, MildMild

Insecure, Insecure, SevereSevere

%% 1818 2222 2222

Adjusted Adjusted oddsodds

RefRef 1.41.4

(1.1-2.0)(1.1-2.0)

1.41.4

(1.0-1.9)(1.0-1.9)

Adjusted for BMI, age, gender, race, education, income, insurance, & marital status. Sample restricted to adults <300% FPL.

Seligman et al.

Food insecure patients report difficulty affording low-sodium foods appropriate for patients with hypertension or CHF. (Wolfe, 1998)

Food Insecurity & HyperlipidemiaFood Insecurity & Hyperlipidemia

SecureSecure Insecure, Insecure, MildMild

Insecure, Insecure, SevereSevere

%% 3232 4343 4242

Adjusted Adjusted oddsodds

RefRef 1.61.6

(0.9-2.8)(0.9-2.8)

1.41.4

(0.9-2.4)(0.9-2.4)

Adjusted for BMI, age, gender, race, education, income, insurance, & marital status. Sample restricted to adults <300% FPL.

Seligman et al.

Implications for Clinical Implications for Clinical ManagementManagement

Ask Ask patients about food insecuritypatients about food insecurity– ““In the past month, was there any day when In the past month, was there any day when

you or anyone in your family went hungry you or anyone in your family went hungry because you did not have enough money for because you did not have enough money for food?” food?” (Kleinman, 2007)(Kleinman, 2007)

Implications for Clinical Implications for Clinical Management: Dietary CounselingManagement: Dietary Counseling

Stress portion control rather than dietary Stress portion control rather than dietary substitutionssubstitutionsFarmers’ markets Farmers’ markets – Bayview Hunters Point: Wed AM, summer months, 3Bayview Hunters Point: Wed AM, summer months, 3rdrd

and Galvezand Galvez– Mission: Sat all day, year-round, junction of 101 & 280Mission: Sat all day, year-round, junction of 101 & 280

Frozen (not canned) fruits and vegetablesFrozen (not canned) fruits and vegetables

Implications for Clinical Implications for Clinical ManagementManagement

For patients with type 2 diabetes, useFor patients with type 2 diabetes, use oral oral hypoglycemics/insulin with a hypoglycemics/insulin with a short half-short half-lifelifeRefer eligible patients for supplemental Refer eligible patients for supplemental food assistance & address stigma openlyfood assistance & address stigma openly– Food Stamps (SNAP)Food Stamps (SNAP)– Elder nutrition programsElder nutrition programs– Meals on WheelsMeals on Wheels

Food Stamps BenefitsFood Stamps Benefits

31.6 million people/month in 9/08 (highest 31.6 million people/month in 9/08 (highest participation level on record)participation level on record)

Average monthly benefit = $2.87/dayAverage monthly benefit = $2.87/day

General eligibility:General eligibility:– Income <130% FPL & < $2000 in the bankIncome <130% FPL & < $2000 in the bank– Lawful, permanent residents (green card)—with some Lawful, permanent residents (green card)—with some

exceptions (need photo & fingerprinting)exceptions (need photo & fingerprinting)– If 18-49 yo, able-bodied, and don’t have kids, capped If 18-49 yo, able-bodied, and don’t have kids, capped

at 3/36 months unless working 20+ hours per weekat 3/36 months unless working 20+ hours per week

USDA, Food & Nutrition Service

http://www.fns.usda.gov/fsp/applicant_recipients/eligibility.htm#income

Frontline Issues in Nutrition Assistance; Hunger Report 2006.

http://www.dss.cahwnet.gov/research/res/pdf/foodtrends/FS05jun07.pdf. Accessed September 2007.

The 7-Day Food Stamp Challenge: The 7-Day Food Stamp Challenge: $21$21

Oregon Governor Ted Kulongoski (D), Oregon Governor Ted Kulongoski (D), Representatives James McGovern (D-Representatives James McGovern (D-Mass.) and Jo Ann Emerson (R-Mo.), and Mass.) and Jo Ann Emerson (R-Mo.), and others others

If you invest LOTS of time in Internet If you invest LOTS of time in Internet research and in cooking beans and ground research and in cooking beans and ground meat, you will do fine. If you don’t…meat, you will do fine. If you don’t…

7-Day Food Stamp Challenge7-Day Food Stamp Challenge“Within a half hour of being in that [grocery] store, I was no longer looking at calorie content. I wasn’t looking at fat. I was looking at the price tag.”“It’s been terrible. I feel lousy. I’m tired, irritable. I’m hungry all the time, and I just don’t feel like myself.”“I don’t have enough energy to go to work.”“It is hard to concentrate when you’re hungry.”

Food Research and Action Center, Food Research and Action Center, www.frac.orgwww.frac.org, summarizes the , summarizes the blogsblogs

$10 Voucher for Fresh $10 Voucher for Fresh Fruits/VegetablesFruits/Vegetables

Breastfeeding mothers receiving WIC in Breastfeeding mothers receiving WIC in LA (n=454)LA (n=454)

Redemption rates 90.7% for farmers’ Redemption rates 90.7% for farmers’ market and 87.5% for supermarketmarket and 87.5% for supermarket

Herman, 2006

Biweekly Delivery of Market Biweekly Delivery of Market BasketsBaskets

Low-income, elderly recipients of Meals on Low-income, elderly recipients of Meals on Wheels (n=100)Wheels (n=100)

Increase in f/v consumption in intervention Increase in f/v consumption in intervention arm = 1.04 servings/dayarm = 1.04 servings/day

% of intervention ppts eating 5+ servings % of intervention ppts eating 5+ servings f/v daily: 22% at baseline, 39% at f/uf/v daily: 22% at baseline, 39% at f/u

Difference between daily f/v consumption Difference between daily f/v consumption intervention vs. control = 1.31 (p<0.001)intervention vs. control = 1.31 (p<0.001)

Johnson, 2004.

Copyright ©2003 American Society for Nutrition

French, S. A. J. Nutr. 2003;133:841S-843S

Fruit Sales as a Function of Price

“Low price”= 50% price reduction; two secondary school cafeterias

Copyright ©2003 American Society for Nutrition French, S. A. J. Nutr. 2003;133:841S-843S

Low-Fat Snack Sales as a Function of Price

12 worksite & 12 secondary school vending machines

Thank You!Thank You!

hseligman@medsfgh.ucsf.eduhseligman@medsfgh.ucsf.edu