write one page summery

Food insecurity, defined as the limited or uncertain availability of nutritionally adequate and safe foods, has been identified as an important public health concern in the United States.1 Results from the most recent Los Angeles County Health Survey (LACHS) indicate that many households in the county experience food insecurity and hunger, a severe form of food insecurity. The survey found that 22% of lower income households (defined throughout this brief as households with annual incomes less than 300% of the federal poverty level (FPL2)) experienced food insecurity in the past year (Table 1). This equates to over 400,000 households with food insecurity, of which 141,000 included someone who had experienced hunger in the past year.

The survey also found large racial/ethnic (Figure 1), geographic (Figure 2), and income disparities among those lower income households experiencing food insecurity. The percentage of lower income households (<300% FPL) found to be food insecure ranged from

a high of 27% in the Metro Service Planning Area (SPA 4) to a low of 17% in the West SPA (SPA 5) (Table 1). By health district, food insecurity ranged from a high of 31% in the Hollywood Health District to a low of 9%* in the San Fernando Health District. Food insecurity was present in 37% of households with incomes below poverty (<100% FPL, Table 1).

1. Nord M, Andrews M, Carlson S. Household food security in the United States, 2002. Food and Rural Economics Division, Economic Research Services, U.S. Department of Agriculture, Food Assistance and Nutrition Research Report No. 35, October 2003.

2. Based on 2002 Federal Poverty Level (FPL) thresholds which for a family of four (2 adult, 2 dependents) correspond to annual incomes of $18,859 (100% FPL), $37,718 (200% FPL), and $56,557 (300% FPL).

FOOD INSECURITY

March 2004

www.lapublichealth.org/

Latino White African-American Asian/Pacific Islander 0

5

10

15

20

25

30

18%

8%

7%

9%

11%

14%

3%

10%

� Food Insecurity with Hunger � Food Insecurity without Hunger

Percentage of Food Insecurity Among Lower Income Households (<300% FPL) by Race/Ethnicity, 2002–03

Antelope Valley

Foothill

Pasadena* Glendale*

North east

Central South west Southeast

San Antonio Inglewood

South Compton

Bellflower

Whittier

Hollywood/ Wilshire

San Fernando*

Alhambra

El MonteEast L.A. Pomona

West Valley

Torrance

Harbor* Long Beach

East Valley

West

Percentage of Food Insecure, Lower Income Households (<300% FPL) by Health District, 2002–03

* Estimate should be viewed with caution because of small numbers.

Additionally, a higher percentage of lower income households with children reported food insecurity (25%) compared to lower income households without children (19%) (Figure 3).

Demographic Characteristics of Respondents Living in Food Insecure Households

The majority of respondents who reported living in lower income, food insecure households were Latino (62%), followed by Whites (18%), African-Americans (12%), and Asians/Pacific Islanders (9%) (Table 2). Also, 46% of the respondents living in lower income, food insecure households had less than a high school education. Other demographic characteristics of persons living in food insecure (vs. secure) households are shown in Table 2.

3. Food Insecurity is a scaled variable based on a series of five questions. [REFERENCE: SJ Blumberg, K Bialostosky, WL Hamilton, and RR Briefel The effectiveness of a short form of the Household Food Security Scale Am J Public Health 1999 89: 1231-1234]

With Children Without Children

Food Insecurity without Hunger

17%

Food Secure 75%

Food Insecurity with Hunger 8%

Food Insecurity with Hunger 8%

Food Insecurity without Hunger

11%

Food Secure 81%

Percentage of Food Insecurity Among Lower Income Households (with or without Children) Below 300% FPL, 2002–03

Food Insecurity Without Hunger Food Insecurity With Hunger Food Insecurity Total Percentage 95% CI Est. # Percentage 95% CI Est. # Percentage Est.#

All Lower Income Households (<300% FPL) 14.1% 13.0–15.1 260,000 7.7% 6.8–8.5 141,000 21.8% 401,000

Households With Children 17.3% 15.8–18.8 160,000 7.5% 6.4–8.5 69,000 24.8% 229,000

Households Without Children 11.0% 9.5–12.4 100,000 8.0% 6.7–9.3 72,000 19.0% 172,000

Federal Poverty Level1

0 to 99% FPL 22.8% 20.6–25.0 131,000 14.1% 12.2–16.0 81,000 36.9% 212,000

100% to 199% FPL 13.7% 11.9–15.4 91,000 5.5% 4.4–6.7 37,000 19.2% 128,000

200% to 299% FPL 6.3% 4.9–7.7 38,000 3.9% 2.8–5.0 23,000 10.2% 61,000

Service Planning Area

Antelope Valley 10.6% 6.7–14.4 6,000 11.8% 7.7–15.8 7,000 22.4% 13,000

San Fernando 13.5% 11.1–15.9 47,000 7.1% 5.2–9.0 25,000 20.5%‡ 72,000

San Gabriel 11.6% 9.3–13.9 36,000 6.7% 4.8–8.5 21,000 18.3% 57,000

Metro 19.8% 16.5–23.0 55,000 7.6% 5.3–9.9 21,000 27.4% 76,000

West 11.3% 7.0–15.6 12,000 *6.1% 2.6–9.5 6,000 17.3%‡ 18,000

South 14.8% 11.7–17.9 32,000 9.3% 6.7–11.8 20,000 24.1% 52,000

East 13.7% 11.1–16.4 33,000 6.4% 4.4–8.4 15,000 20.1% 48,000

South Bay 13.6% 10.9–16.3 40,000 9.0% 6.7–11.4 26,000 22.6% 66,000

‡Totals do not sum due to rounding.

*Estimate should be viewed with caution because of small numbers.

Percentage of Lower Income Households (<300% FPL) That Experience Food Insecurity3 (With Hunger and Without Hunger), 2002–03

Health Characteristics of Respondents Living in Food Insecure Households

Food insecurity and hunger have been associated with increased risk for poor nutritional status and poor health outcomes.4 Research has found that children living in lower income, food insecure households are generally in poorer health, and do worse in school with more absences, tardiness and suspensions.5,6,7 The LACHS found that 41% of respondents living in lower income, food insecure households reported fair or poor health status as compared to 25% of respondents living in lower income food secure households (Table 3). Individuals in

lower income, food insecure households reported almost twice as many poor health days than those in lower income, food secure households (Table 3).

Recent research has also shown that food insecurity is related to obesity.8,9 This association is not intuitive as overweight is often attributed to overeating, and not to hunger and not eating enough (See Sidebar: Food Insecurity and Weight Gain, p.4). LACHS results indicate that a higher percentage of respondents living in lower income, food insecure households were obese (27%) as compared to those living in lower income, food secure households (20%) (Table 3). Additionally, a higher percentage of respondents living in lower income, food insecure households reported physical inactivity (49%), being disabled (30%), and living in a perceived unsafe neighborhood (40%) as compared to respondents living in lower income, food secure neighborhoods (Table 3). Thus, factors such as physical inactivity and living in neighborhoods perceived to be unsafe might put those living in food insecure households at further risk for obesity.

What Can Be Done? Increasing eligibility and participation in the federal

food programs is a first line of defense against food insecurity. The enrollment process to these federal food programs should be more consumer-friendly to remove barriers and stigmas that individuals and families in need of assistance may feel (See Sidebar: Federal Food Programs, p.5).

Los Angeles County has high housing and utility costs, low-paying jobs, inadequate public transportation, and food access problems that may affect the prevalence of food security. Additionally, the decision to make healthy food choices and avoid obesity is impacted by the large amount of advertising and easy accessibility to fast food restaurants. Thus, in addition to the federal programs, local interventions are also needed to help prevent food insecurity and the related problem of obesity.

4. Center on Hunger and Poverty, Heller School for Social Policy and Management, Brandeis University. (2002) The consequence of hunger and food insecurity for children—evidence from recent scientific studies.

5. Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children’s cognitive, academic, and psychosocial development. Pediatrics 108: 44-53, 2001.

6. Kleinman RE, Murphy JM, Little M, Pagano M, Wehler, CA, Regal K, Jellinek MS. Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics 101: 1-6, 1998.

7. Murphy JM, Wehler CA, Pgano ME, Little M, Kleinman RE, Jellinek MS. Relationship between hunger and psychosocial functioning in low-income American children. J American Academy of Child & Adolescent Psychiatry 37: 163-170, 1998.

8. Adams EJ, Grummer-Strawn L & Chavez G. Food Insecurity is associated with increased risk of obesity in California women. Journal of Nutrition 2003.

9. Townsend MS et al. Food insecurity is positively related to overweight in women. Journal of Nutrition 2001; 131: 1738-1745.

Living In Living In Food Insecure Household Food Secure Household Percentage Est. # Percentage Est. #

Race

Latino 61.7% 576,000 50.5% 1,712,000

White 18.1% 169,000 25.1% 852,000

African-American 11.7% 109,000 9.5% 322,000

Asian/Pacific Islander 8.5% 80,000 14.9% 503,000

Education

Less than high school 45.6% 426,000 32.9% 1,113,000

High school 26.4% 247,000 27.0% 915,000

Some college or 19.8% 185,000 25.1% 850,000 trade school

College or 8.2% 77,000 15.0% 508,000 post graduate degree

Citizenship

U.S. 55.9% 524,000 68.3% 2,319,000

Non U.S. 44.1% 413,000 31.7% 1,077,000

Country of Birth

Foreign 58.3% 547,000 51.6% 1,752,000

U.S. 41.7% 391,000 48.4% 1,644,000

Employment Status

Employed 52.7% 481,000 56.8% 1,867,000

Unemployed 7.6% 69,000 3.7% 120,000

Not in labor force 39.7% 362,000 39.5% 1,298,000

Demographic Characteristics of Respondents Living In Food Insecure3 & Food Secure Households, 2002–03

Lower income households and communities need greater access to grocery stores and corner stores that provide healthy, affordable, and nutritionally adequate food. Public transportation between food insecure areas and grocery stores can be increased through policies.

The Los Angeles Alliance for a New Economy (LAANE) has devised strategies to ensure that new developments offer improvements to communities (e.g., good jobs and vital neighborhood services).14 Food pantries and soup kitchens also need to stock nutritious foods for individuals and families. Furthermore, accessible community farmers’ markets and community gardens can be used to increase the availability of fresh, seasonal produce in higher-risk communities.

In order to reduce obesity among the food insecure, increasing opportunities for physical activity should be considered. The Task Force on Community Preventive Services review (www.thecommunityguide.org/pa/pa- ajpm-recs.pdf.) on increasing physical activity in communities recommends six evidenced-based interventions.15 At the community level, these include creating or enhancing access to safe places for physical activity (e.g. parks and bike paths), increasing physical

Food Insecurity and Weight Gain Food insecurity and obesity is a paradox complicated by many factors including genetics, metabolism, behavior, environment and socioeconomic conditions. Possible explanations linking the lack of adequate resources for food and the prevalence of obesity in the food insecure are described below:

Stretching Food Dollars: Many lower income, food insecure households may resort to consuming lower cost foods that are typically lower in nutritional quality and contain higher levels of calories per dollar (e.g., affordable fast-foods for convenience with increased portion size). Research indicates that the quality or variety of food consumed is often compromised before the quantity of food eaten.10

Food Availability: Meats, fish, fresh fruits and vegetables and whole grains are often limited in impoverished neighborhoods, and when available the variety and the quality of items tend to be significantly lower.11,12 This lack of access to a variety of healthy foods limits the ability to make healthy choices.

Overeating: Food insecure households often have periods where the availability of food is limited or uncertain creating episodes of food deprivation. Recent research has shown that food deprivation in humans and food restriction in children produces a tendency toward binge eating behaviors.8 When food is available, individuals in food insecure households may overeat, increasing energy intake and overall weight gain.

Physiological changes: Physiological changes can occur in the body as a result of periods of hunger and consumption of foods low in nutritional value. The body begins to compensate for periodic food and nutrition shortages by becoming more efficient at storing more calories as fat.13

10. Radimer, K.L, Olson, C.M., Greene, J.C., Campbell, C.C., & Habicht, J. (1992). Understanding hunger and developing indicators to assess it in women and children. Journal of Nutrition Education, 24, 36S-45S.

11. Slone, D.C., Diamant, A.L., Lewis, L.B., Yancey, A.K., Flynn, G., Nascimento, L.M., McCarthy, W.J., Guinyard, J.J., and Cousineau, M.R. (2003) Improving the nutritional resources environment for healthy living through community-based participatory research. Journal General Internal Medicine 2003; 18:568-575.

12. Tranquada, J. Supermarket shortage still plagues inner-city los angeles ten years after the 1992 riots, new report shows. 2002. www.oxy.edu/news/articles/020631-supermarket.html

13. Wardlaw, g.M. and Insel, P.M. (1996) Perspectives in Nutrition. Third Edition. New York, NY:WCB/McGraw-Hill.

14. Accountable Development, Los Angeles Alliance for a New Economy. www.laane.org/ad/aboutad.html, visited February 25, 2004)

15. Increasing physical activity. A report on recommendations of the Task Force on community Preventative Services. MMWR Recomm rep. October 26, 2001;50(RR-18):1-14.

Living In Living In Food Insecure Household Food Secure Household

Percentage Est. # Percentage Est. # Health Status

Excellent/Very Good 23.6% 221,000 39.4% 1,335,000

Good 35.6% 333,000 35.7% 1,209,000

Fair/Poor 40.8% 381,000 25.0% 847,000

Poor Health Days+ 11 days 6 days (Average per Month)

BMI

Obese 27.2% 203,000 20.0% 606,000

Overweight 36.0% 269,000 35.8% 1,085,000

Normal 34.8% 260,000 41.5% 1,257,000

Underweight 2.0%* 15,000 2.7% 81,000

Physical Activity

Active (Meets Guidelines) 42.0% 390,000 46.4% 1,565,000

Some Activity 9.5% 88,000 9.1% 305,000 (Does Not Meet Guidelines)

Minimal to No Activity 48.6% 451,000 44.6% 1,503,000 (Sedentary)

Disabled

Yes 29.6% 276,000 18.4% 622,000

No 70.4% 656,000 81.6% 2,760,000

Perceived Neighborhood Safety

Very Safe 15.7% 146,000 27.0% 909,000

Somewhat Safe 44.3% 412,000 49.3% 1,660,000

Somewhat Unsafe 25.1% 233,000 16.1% 542,000

Not at All Safe 15.0% 139,000 7.5% 253,000

+Average number of reported poor physical and/or mental health days in the past month.

*Estimate should be viewed with caution because of small numbers.

Selected Health Characteristics of Respondents Living In Food Insecure3 & Food Secure Households, 2002–03

behavior activity through social support, utilizing individually-adapted health behavior change programs, increasing physical activity in school-based physical education, promoting physical activity in community- wide campaigns, and using point-of-decision prompts to increase physical activity.

Ongoing monitoring of food insecurity along with research about its causes and consequences are necessary to ensure a healthy and well-nourished population. Studies to evaluate changes in conditions that are related to poor health and nutrition as well as food insecurity (e.g., food policies in schools, community food resources) are also important as efforts to address these public health problems move forward.

Federal Food Programs The federal Food Stamp Program, School and Community Nutrition Programs, Special Supplemental Program for Women, Infants and Children (WIC), and the Child and Adult Care Food Program are aimed at improving the nutrition, well-being and food security of in need Americans. Of these programs, WIC is the most utilized in Los Angeles County with 99% of the eligible individuals receiving benefits.16 Although the Child and Adult Care Food Program utilization has increased nationally, local data is not available. The remaining programs are significantly underutilized in the county due to access barriers as described below.

Food Stamp Program: According to recent USDA estimates, the program reaches only approximately half of those who may be eligible across Los Angeles County. Recent legislation reduced several barriers to program utilization, but further food stamp reform needs to be implemented. For example, partnerships with schools, community and faith based organizations should be enlarged and formalized. Efforts should also be made to assist working families by extending office hours into the early evenings. Although the Food Stamp Program helps to improve food security, the average benefit of $84 per month should be increased in an urban setting like Los Angeles County, where the high cost of living causes additional hardship.

School & Community Nutrition Programs: The School Breakfast and Lunch Programs are designed to provide children living below 130% FPL free meals, and those above 130%, but below 185% FPL meals, at a reduced price. Approximately 1,058,000 children in Los Angeles County are eligible to receive free or reduced priced school meals. Although approximately 70% of those children are participating in the National School Lunch Program, less than 30% are participating in the School Breakfast Program.17 This results in an estimated $174,383,000 per year of lost federal resources.17 For information on increasing breakfast opportunities please refer to the Los Angeles Collaborative for Healthy Active Children brief at www.lapublichealth.org/nut/LACOLLAB_Files/lacollab.htm

Summer Food Program: The Summer Food Program helps children obtain food when school is out. Of the 1,252,033 children eligible to receive Summer Food meals, only 310,598 are being fed.18 Increasing program utilization can help to reduce food insecurity among children as well as improve nutritional intake and improve school performance.19,20,21,22

Los Angeles Collaborative for Healthy Active Children is a collaborative made up of nearly 100 stakeholders including representatives of school districts, Head Start providers, health care providers, community-based and faith-based organizations, city and local government agencies, Los Angeles County Departments of Health Services and Parks and Recreation, and non- profit organizations that work to reduce and prevent overweight and increase physical fitness among children and their families in Los Angeles County. This is with support from the County of Los Angeles DHS, Nutrition Program, and the University of California Cooperative Extension, Los Angeles, with funding from the US Department of Agriculture Food Stamp Program. www.lapublichealth.org/nut/LACOLLAB_Files/lacollab.htm

INFO LINE Los Angeles is a nonprofit organization dedicated to helping people find and access health and human services in Los Angeles County. Phone: 800-339-6993 • Food Stamps, L.A. County Health & Nutrition hotline: 877-597-4777 www.infoline-la.org

Los Angeles Regional Foodbank collects and distributes donated food to a network of 1,000 charities located throughout Los Angeles County. Phone: 323-234-3030 or 877-NO-HUNGER www.lafightshunger.org

California Food Policy Advocates is a private nonprofit organization dedicated to improving the health and well being of low-income Californians by increasing their access to nutritious, affordable, and safe food. www.cfpa.net

The Los Angeles Coalition to End Hunger & Homelessness works to eliminate hunger and homelessness through public education, technical assistance, public policy analysis, advocacy, organizing, and community action. They publish the “Peoples’ Guide to Welfare, Health & Other Services” that provides practical information about how to get food, money and other help from government programs and community services. www.lacehh.org (The Peoples’ Guide: www.peoplesguide.org)

on the web

16. Los Angeles County: A profile of poverty, hunger & food assistance. June 2003. California Food Policy Advocates; San Francisco: CA.

17. 2002/2003 Free/Reduced Meals Information: All Schools Reported & 2002-03 County Profile for California School Nutrition Programs (preliminary results). Nutrition Services Division, California Department of Education.

18. Los Angeles County: A profile of poverty, hunger & food assistance. June 2003. California Food Policy Advocates; San Francisco: CA.

19. Gleason, P. & Suitor, C. (2001). Children’s Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. http://www.fns.usda.gov/oane/MENU/Published/CNP/FILES/ChilDiet.pdf

20. Meyers, A.F., Sampson, A.E., Weitzman, M., Rogers, M.L., & Kayne, H. (1989). School Breakfast Program and school performance. American Journal of Diseases and Children 143(10), 1234-1239.

21. Murphy, J.M., Pagano, M.E., Nachmani, J., Sperling, P., Kane, S., & Kleinman, R.E. (1998). The relationship of school breakfast to psychosocial and academic functioning. Archives of Pediatrics & Adolescent Medicine 152(9), 899-907. Abstract available at: http://archpedi.ama-assn.org/issues/v152n9/abs/pnu7508.html

22. Murphy, J.M. & Kleinman, R.E. in collaboration with Project Bread and Boston Public Schools. (2000). “Study Shows Link Between School Breakfast and Academic Achievement.” Summary available at: http://www.projectbread.org/MCHI/mghbreakfaststudy.htm

Presorted Standard

U.S. Postage

P A I D Los Angeles, CA

Permit No. 32365

L. A. County Board of Supervisors Gloria Molina, First District

Yvonne Brathwaite Burke, Second District

Zev Yaroslavsky, Third District

Don Knabe, Fourth District

Michael D. Antonovich, Fifth District

L. A. County Department of Health Services Thomas L. Garthwaite, MD

Director and Chief Medical Officer

Jonathan Fielding, MD, MPH

Director of Public Health and Health Officer

Acknowledgements Paul Simon, MD, MPH, Director, Health Assessment & Epidemiology;

Cheryl Wold, MPH, Chief, Health Assessment Unit;

Health Assessment Unit Staff: Curtis Croker, MPH; Benedict Lee,

PhD; Amy S. Lightstone, MPH; Gigi Mathew, DrPH; Wazim Narain,

MPH; Cynthia Recio; Zhiwei (Waley) Zeng, MD, MPH

We are grateful to Valerie Ruelas, M.S.W., L.C.S.W. for

researching and co-authoring this report.

Special thanks to Johanna Asarian-Anderson, MPH, RD; Cynthia

Harding, MPH; Wendy Schiffer, MSPH; and Anna Long, PhD, MPH;

for their contributions to this report.

Los Angeles County Department of Health Services 313 North Figueroa Street, Room 127 Los Angeles, CA 90012 213-240-7785

The Los Angeles County Health Survey is a periodic, population-based telephone survey that collects information on sociodemographic characteristics, health status, health behaviors, and access to health services among adults and children in the county. The 2002–2003 survey collected information on a random sample of 8,167 adults and 5,995 children. Interviews were offered in English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese. The most recent survey was supported by grants from First 5 LA, the California Department of Health Services through grants to the Family Health, Tobacco Control and Prevention, and Alcohol and Drug Programs, and the Public Health Response and Bioterrorism Preparedness federal grant. The survey was conducted for the Los Angeles County Department of Health Services between October 2002 and March 2003 by Field Research Corporation.

For additional information about the L.A. Survey: www.lapublichealth.org/ha