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LETTER TO THE EDITOR |
Robert J. Karp, MD
Department of Pediatrics
John G. Kral, MD, PhD
Department of Surgery
State University of New York-Downstate Medical Center
Brooklyn, NY 11203
To the Editor.—
Rose and Bodor1 provide data showing that food insecurity is not associated with obesity in kindergarten children; in fact, their data suggest that food insecurity is associated with lower obesity risk. Their work complements that of Hofferth and Curtin,2 which showed that the children at greatest risk for obesity live in families with incomes between 1 and 3 times the poverty level. We suggest that the findings fold into a general theory governing the relation between poverty and malnutrition.3–5 Decreased income available for discretionary spending molds behavior in families with incomes between 1 and 3 times poverty. The need to pay for food, housing, and getting to work will limit the 1 element with cost that is not fixed: food. Generally, in these circumstances, food selection will narrow to those foods containing the most energy at the lowest cost. As detailed most elegantly by Drewnowski et al,6,7 the economic imperative to purchase highly energy-dense foods is part of the adaptation to poverty. Thanks to the low cost of added sugars and fats in the American diet, those foods providing the most energy per dollar are also those that are the most calorie-dense, and experimental studies in adults have shown convincingly that when individuals consume more calorie-dense foods, they take in more total calories per day.8–10 Notably, the Rose and Bodor study reports maternal education and household income to be negatively associated with overweight status,1 in agreement with the preponderance of evidence.
Unlike other variables reflecting poverty (eg, household income, maternal education), the food-security variable does not behave predictably and consistently with regard to its association with obesity; as Rose and Bodor point out, studies examining this association have had mixed results. Perhaps this should not be surprising. Food insecurity is seen as a point on a pathway between food sufficiency and insufficiency; it identifies those poor families who are having the most trouble obtaining sufficient food energy and who, therefore, should be at highest risk for caloric insufficiency and hunger. Thus, one might expect that household food insecurity would predict undernutrition for at least some children and adults. A similar finding for fifth-grade children was reported by Matheson et al,11 who also reported that as payday approached, children's energy intake fell significantly more for those living in food-insecure households. It has also been shown that among food-insecure families, receiving a housing subsidy is associated with a higher mean weight for age and a lower risk of failure to thrive relative to food-insecure families not receiving a housing subsidy, whereas this effect is not seen among food-secure families.12 The role of "weight cycling" in low-income households has also been identified, but to date, its effects have been inadequately explored.13
It would be of great interest to know if the families living with incomes below poverty level and between 1 and 1.85 of poverty level availed themselves of the food-supplementation programs to which they are eligible. Did supplementation affect rates of obesity, and of food insecurity, in the most vulnerable populations? The National Research Council14 suggests that poverty assessments should report supplemental income and support for housing and food expenditures as credits and expenses for maintaining employment as debits.
Thus, the available evidence suggests that in the United States, poverty with cyclic undernutrition exerts pressure to consume obesogenic diets of high energy density when food is available. Food insecurity is a mixed phenomenon that lies in a pathway between abject poverty with undernutrition and food insecurity with cyclic availability, the impact of which will depend on choices/priorities within the family with respect to food distribution, selection, and preparation and availability of resources. Therefore, the mixed results of this study, as contrasted to the very consistent data relating poverty per se and obesity, are not surprising.
Our specific concerns include the following:
REFERENCES
labor/papers/hofferth.pdf. Accessed September 12, 2006
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