Chery Smith, PhD, MPH, RD

University of Minnesota

Department of Food Science and Nutrition

IOM Workshop on Food Insecurity & Obesity

November 18, 2010

In 1996-97 we collected data on

people using the Bread Basket

in Manhattan, KSWe found overweight and obesity was higher than the

national norm in that sample of people

Submitted a manuscript to Journal of the American Dietetic Association

A reviewer questioned the findings and asked, “How is that possible?”

It was converted to a “Brief” rather than an original research manuscript.

Bell M, Wilbur L, Smith C. Nutritional status of persons using a local emergency food system program in middle America. J Am Diet Assoc, 1998; 98 (9): 1031-1033.

So how can food insecure

people be obese?

The best way to answer this

question is to use qualitative

research methodology, coupled

with quantitative methodologies.

Using qualitative methodology allows the

investigator to:

TALK with people about an issue

Fill in gaps in the literature that are not

caught through quantitative methodologies

(surveys, measurements, etc.)

It provides FORMATIVE data for survey

development, marketing strategies, and

designing intervention projects

Qualitative Methodology Most

often used include:

Person-to-person interviews

Focus groups

Face-to-face interviewing:

Good for gathering sensitive information

Works well with children and adults and people from various ethnic background

Be sure to include an ice-breaker…something to relax the participant (ie. food models work well)

Requires a skilled and trained interviewer

Time consuming

Focus Group Methodology

Groups should have 4-8 people, depending on the topics to be discussed and the depth of information that you want to collect.

May need to be gender, race, or age-specific.

Avoid having relatives in the same group.

Moderator should be trained and skilled at keeping the conversation going and not allowing one individual to dominate the group.

Always have 2 moderators present. This helps maintain objectivity.

Use first names only and start with an ice-breaker.

Both methods use open-ended

questions

When collecting qualitative data on food

insecurity and obesity take your own

heights and weights after the meeting

(quantitative data)

Self-reported data is not recommended for low-income

groups because of usual over- and under- reporting,

but also because many do not own scales and don’t

know their weights.

Example of quantitative question

regarding food insecurity:

In the last 12 months, were you ever hungry but didn’t

eat because there wasn’t enough money for food?

Yes

no

don’t know

It says “yes” or “no” but not “how” or

“why”

Let’s go back to the food security

question….and ask qualitatively

Tell me about the food situation in your household. What happens when there isn’t enough money to buy food?

What strategies do you use to feed yourself and your family when food is low in the home?

How do you feed your children on days when food is short in the home? Where do you go? How do you select the meal site?

Data generated from a face to face child interview.

When children reported being hungry at night, we asked them to tell us what

happened:

As one child reported, “…I go to sleep and I dream about food that I’m eating…I

dream about ooh, ahhh, I dreamed about hamburgers and carrots and strawberries

and everything else… and then it makes me full when I get up..it makes me, I get, like,

and why do I have a tummy ache?!”

(Richards and Smith, Social Science Medicine: 2007:1577).

You can also ask questions about obesity

or body size

You’ve probably noticed that some people have larger bodies and others have smaller bodies….why do you think that happens?

Or

What do you think of your weight? What influences your body weight?

Do you worry about your weight? Why? Why not?

“it scares me a lot, but it’s still kinda hard to watch

what you eat…even though my brother and sister

passed away, because of their weight. You know I

don’t wanna watch my diet, it’s real hard to watch. I

mean especially when you have a taste for

something and I mean when your body wants it,

you’re just gonna go get it. I start out with a little bit,

then I’ll start eating and once I get into the routine of

eating and it tastes good, then I just keep on eating.

I’ll go OK, I gotta have some more, and then it’s like

oh man, I’m done, I gotta have some more. I just

keep going until I feel like I’m stuffed.”

Analyzing the data Remember that qualitative data cannot be analyzed in the same

way as quantitative data…subjective vs. objective

Qualitative data is an analysis of words, whereas quantitative data is an analysis of numbers.

Be systematic and disciplined in your coding and have two researchers code; this decreases the subjectivity of the data.

Code for ideas independently (you are extracting them from the discussion), then meet and resolve any coding discrepancies.

Look for trends and patterns, identify themes and sub-themes.

Achieve an appropriate “n”…saturation point

(Kruger, 1998)

Analyze the data

Do your analysis in a timely manner

Analysis should be verifiable (someone

else can come to the same conclusion)

Organize the data using NVIVO or another

ethnographic software. We use NVIVO.

Examine the data by body mass index

(BMI)/race/gender/age. Do heavy and lean

children think about food/physical

activity/weight in the same way?

What we’ve learned over time about children and

food insecurity and weight issues:

A history of food deprivation can lead to overeating and

obesity

Current hunger can lead to overeating when tasty food is

available (Smith and Richards, 2008; Richards and Smith, 2007)

55% of homeless youth reported not enough and eat and

25% reported going to bed hungry (Smith and Richards, 2008)

Homeless youth reported overeating, eating disliked food, eating anything,

and eating at friends homes as strategies to cope with food insecurity (Smith

and Richards, 2008)

Many youth reported unhealthy eating behavior because of the types of

foods available in the home (Dammann and Smith, 2010)

Youth reported night eating . Buffets are favored type of restaurant. School

lunches reported as “nasty” (Dammann and Smith, 2010).

The National School Lunch program expedites acculturation for migrant

children (Franzen and Smith, 2009).

From focus group data, models were created (Franzen and Smith, 2009; Richards and Smith, 2007)

What we’ve learned over time about adults and

food insecurity and weight issues:

Parents try to make sure children eat first (Richards and Smith,2006a and 2006b).

Adults have developed strategies to increase food security including: using food

assistance programs, shopping on Saturday when store food samples are plentiful,

overeating when tasty food is availability, shopping smart and thrifty, stealing and

dumpster diving when necessary, asking family and friends for cash/food, pawning items

for cash, selling food stamps, and overeating on Friday evenings at Soup kitchens

because many are closed on Saturday (Richards and Smith , 2006a and 2006b; Smith et al., 2010; Wiig

and Smith, 2009; Eikenberry and Smith, 2005) .

Not all adults want to lose weight; especially true for African American males (Smith and

Richards, in process)….so how can we work with this sample? They will be a challenge.

Different samples view weight differently…older Hmong perceive weight as having money

to eat, better survival in hard times…African Americans and Native Americans are

accepting of larger body sizes….many define “big” differently from Whites (Mulasi-Pokhriyal

and Smith, 2010; Franzen and Smith, 2009; Dammann and Smith, in press).

Both the food environment and personal determinants are important influencers of food

choice (Dammann and Smith, 2010; Dammann and Smith, 2009; Richards and Smith 2006a,b; Smith and Morton,

2009; Smith et al., 2010; Henderickson et al., 2006; Smith et al., 2009)

Food policies at homeless shelters influence eating (Smith et al., 2010; Richards and Smith,

2010; 2007; 2006)

Pop is not the only “problem” food, consumption of high fat meats, milks, and

fried foods contribute excessive calories (Dammann and Smith, 2010; Smith and Richards, in

process).

Quantitative Data Survey questions should be developed using formative data from focus

groups or interviews.

Example of questions created for a child’s survey (n=202 homeless youth 9-18 years) based on data from kid’s interviews (used a 5 pt Likert Scale..always true; kind of true; not sure; kind-of-not true; never true):

If I am hungry, I usually wait until the next meal to eat.

I overeat at mealtimes so I will not be hungry later on.

If I am hungry, I usually wait until the next meal to eat.

I overeat at mealtimes so I will not be hungry later on.

(Smith and Richards, Am J Hum Bio; 2008)

Publications on food insecure populations 1. Damman KW, Smith C. Food-related Environmental, Behavioral, and Personal Factors Associated with

Body Mass Index among Urban, Low-income, African American, American Indian, and Caucasian Women. Am J Health Promotion, 2010, in press.

2. Smith C, Morton LW. Rural Food Deserts: Low Income Perspectives on Food Access in Minnesota and Iowa. J Nutr Educ Behav., 2009, 41:171-187.

3. Dammann KW, Smith C. Food-related attitudes and behaviors at home, school, and restaurants: Perspectives from urban, multi-ethnic, low-income children in Minnesota. J Nutr Ed Behav, 2010; 42(6):389-397.

4. Richards R, Smith C. Investigation of the hunger-obesity paradigm among shelter-based homeless women living in Minnesota. J Hunger Environmental Nutrition, 2010, 5(3):339-359.

5. Dammann KW, Smith C. Race, homelessness, and other environmental factors associated with the food purchasing behavior of low-income women in Minnesota. J Am Diet Assoc, 2010;110(9):1351-1356.

6.Dammann KW, Smith C, Richards R. Low-income, racially diverse mothers’ perceptions of their 9-13 year-old children’s weight status, diet, and health. Maternal Child Health Journal, 2010, in press

7. Smith C, Butterfass J, Rickelle R. Environment influences food access and resulting shopping and dietary behaviors among homeless Minnesotans. Ag and Human Values, 2010, 27(2):141-161.

8. Wiig K, Smith C. The art of grocery shopping on a food stamp budget: Factors influencing the food choices of low-income women as they try to make ends meet. Pub Health Nutrition, 2009, 12 (10):1726-1734.

9. Dammann K, 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 Edu Behav. 2009, 41 (4):242-253.

10. Smith C, Klosterbuer A, Levine A. Military experience strongly influences post service eating behavior and BMI status in American veterans. Appetite. 2009, 52:280-289.

11. Smith C, Richards R. Dietary intake, overweight status, and perceptions of food insecurity among homeless Minnesotan youth. Am J Hum Bio. 2008, 20;550-563.

12. Smith C, Richards R*. Dietary intake, overweight status, and perceptions of food insecurity among homeless Minnesotan youth. Am J Hum Bio. 2008, 20;550-563.

13. Richards R, Smith C. Environmental, parental, and personal influences on food choice, access, and overweight status among homeless children. Soc Sci Med. 2007;65:1572-83.

Publications on food insecure populations

14. Henderickson D, Smith C, Eikenberry N. Low-income individuals face limited fruit and vegetable

access in four Minnesotan communities designated as food deserts. Ag and Human Values. 2006:

23(3):371-383.

15. Richards R, Smith C. Shelter environment and placement in community affects lifestyle factors

among homeless families in Minnesota. Am J Health Promotion, 2006; 21(1):36-44.

16.Eikenberry N, Smith C. Attitudes, beliefs and prevalence of dumpster diving as a means to obtain

food by Midwestern, low-income, urban dwellers. Ag and Hum Values, 2005; 22(2): 187-202.

17. Harala K, Smith C, Hassel C, Galfus P. New Moccasins: Articulating Research Agendas through

Interviews with Faculty and Staff at Native and Non-Native Academic Institutions. J Nutr Ed Behav,

2005; 37(2):67-76.

18. Eikenberry N, Smith C. Healthy eating: Perceptions, motivations, barriers, and promoters in low-

income Minnesota communities. J Am Diet Assoc. 2004;104 (7):1158-1161.

19. Verpi H, Smith C, Reicks M. A qualitative study comparing the needs of food shelf/pantry clients

with behaviors and attitudes of food donors. J Nutr Ed Behav, 2003; 35:6-16.

20. Lautenschlager L, Smith C. Beliefs, knowledge, and values held by inner-city youth about

gardening, nutrition, and cooking. Ag and Hum Values. 2007;24 (2):245-258.

21. Franzen L , Smith C. Differences in Stature, BMI, and Dietary Practices between US born and

Newly Immigrated Hmong Children. Soc Sci Med, 2009, 69:442-450.

22. Bell M, Wilbur L, Smith C. Nutritional status of persons using a local emergency food system

program in middle America. J Am Diet Assoc, 1998;98 (9): 1031-1033.

23. Reimer K, Smith C, Reicks M, Henry H, Atwell J, Thomas R. Child Feeding Strategies Relating to

Fruits and Vegetables According to Stage of Change in African American Women. Pub Health Nutr,

2004;7 (4):505-512