Research Brief

Diet Quality is Low among Female Food Pantry Clients inEastern AlabamaPatricia Duffy, PhD1; Claire Zizza, RD, PhD2; Jocelynn Jacoby, RD, BS3; Francis A. Tayie, PhD4

1DepartmeAL2Departme3DepartmeCity, KS4DepartmePleasant, MThis studyHuman ScAddress foRural Soci844-5629; F�2009 SOdoi:10.1016

414

ABSTRACT

Objective: Examine diet quality, food security, and obesity among female food pantry clients.Design: Cross-sectional study.Setting: A food pantry in Lee County, Alabama.Participants: Fifty-five female food pantry clients between 19 and 50 years of age.Main Outcome Measure(s): Diet quality using United States (US) Department of Agriculture HealthyEating Index (HEI-2005), adult obesity (Body Mass Index [BMI] $ 30 kg/m2), household food security(US Department of Agriculture Module).Analysis: Analysis of variance and multivariate models.Results: Diet quality of the women was generally poor, with a mean HEI of a 43 on a 100 point scale.Having low education level (less than a high school degree) and being a smoker were related to lower over-all diet quality. Sixty-seven percent of the clients were obese while 65% percent were food insecure.Conclusions and Implications: Food pantry clients are characterized by high levels of food insecurity,obesity and poor diet quality. Smoking was associated with food insecurity and low diet quality. Increasedoutreach efforts to improve nutrition education and to help food pantry clients stop smoking could bebeneficial.KeyWords: food pantry, diet quality, obesity, food insecurity, smoking (JNutr Educ Behav. 2009;41:414-419.)

INTRODUCTION

According to the most recent reportfrom the United States Department ofAgriculture (USDA), about 11% ofUnited States (US) households arefood insecure, meaning that all house-hold members did not have access atall times to enough food for an active,healthful life.1 Food insecurity hasbeen linked to a number of adverse out-comes, including overweight and obe-sity in adult women.2,3

Food-insecure households mayturn to federal food assistance pro-grams (eg, food stamps, school lunch,

nt of Agricultural Economics and Ru

nt of Nutrition and Food Science, Ant of Dietetics and Nutrition, The U

nt of Human Environmental StudIwas funded by the Alabama Agriculiences, Auburn University.r correspondence: Patricia Duffy, Pology, 202 Comer Hall, Auburn Uax: (334) 844-5639; E-mail: pduffy@CIETY FOR NUTRITION EDUC/j.jneb.2008.09.002

or the Special Supplemental NutritionProgram for Women, Infants, andChildren [WIC]) or emergency food as-sistance from a food pantry, a locallyrun organization that provides grocer-ies for clients to prepare and consumeat home. Research on food pantry cli-ents is not extensive, but researchersconsistently find that clients tend tobe women with very low incomes,low educational attainment, and highlevels of self-reported food insecu-rity.4-6

Previous dietary research on foodpantry clients has generally focusedon nutrient intake or single-food con-

ral Sociology, Auburn University, Auburn,

uburn University, Auburn, ALniversity of Kansas Medical Center, Kansas

ies, Central Michigan University, Mount

tural Experiment Station and the College of

hD, Dept of Agricultural Economics andniversity, Auburn, AL 36849; Phone: (334)acesag.auburn.eduATION

Journal of Nutrition Education and Beh

sumption, with findings indicatingthat intakes may be inadequate.7-9 Afocus on nutrient intake or food con-sumption is limited, however, becauseindividuals consume combinations offood items. Diet quality is complexand multidimensional, and subse-quently, individualsdonot consistentlymeet or fail to meet all nutrient- andfood-based recommendations.10 Mea-sures of diet quality assess compliancewith dietary recommendations overa range of food- and nutrient-basedcomponents. To the authors’ knowl-edge, there are no previously publishedreports regarding the overall diet qual-ity of food pantry clients.

This present study explores the dietquality, body mass index (BMI), andsmoking status of adult female clientsof a food pantry in Lee County, Ala-bama. This study focuses on womenclients because the overwhelmingmajority of clients at this site are femaleand because the association betweenfood insecurityand overweight is stron-gest in women.3 It was expected thatdiet quality in general would be poorand that smoking would be associatedwith a lower quality diet, whereas par-ticipation in the federal food assistanceprograms (food stamps, WIC) would be

avior � Volume 41, Number 6, 2009

Journal of Nutrition Education and Behavior � Volume 41, Number 6, 2009 Duffy et al 415

associated with a better quality diet.Results from this study can inform fu-ture research and outreach effortsamong this vulnerable, food-needypopulation.

STUDY DESCRIPTIONParticipants

Women, who were neither pregnantnor lactating, 19-50 years of age, weresolicited as volunteer respondents fora pilot study at the pantry site in Marchand April 2006. Enumerators went tothe pantry site during its regular operat-inghoursandapproachedtheclientsonsite to obtain a convenience sample.About 90% of those approached agreedto participate. The purpose of the studywas explained to the 55 participants,who then completed an informedconsent form. The survey instrument,study protocol, and informed consentdocument were approved by the Au-burn University Institutional ReviewBoard for Human Subject Research.Trained interviewers administered thesurvey instrument, the 24-hour dietaryrecall, and conducted the anthropomet-ric measurements. All interviews wereconduced in English in a private roomat the food pantry site. Questions onthe survey instrument were read to par-ticipants so that literacy levels of theparticipants wouldnot affect the results.

Healthy Eating Index

The Nutrition Data System for Re-search (NDS-R) (version 2005, Nutri-tion Coordinating Center, Universityof Minnesota, Minneapolis, MN) wasused to collect a 24-hour recall frompantry clients. NDS-R is a computer-based software program that usesa multiple-pass method and providesa standardized interview through a se-ries of prompts. A 24-hour recall is wellsuited for low literacy populations. Us-ing the information from the 24-hourrecall, scores for Healthy Eating In-dex-2005 (HEI-2005) were constructedfor each woman. The HEI-2005 isa measure of overall diet quality thatwas created by the USDA.10 This indexmeasures the degree to which an indi-vidual is following the Dietary Guide-lines for Americans 2005 andincludes 12 food- and nutrient-basedcomponents. The food-based compo-nents include amounts of total fruit

(includes 100% juice); whole fruit(not juice); total vegetables; dark greenand orange vegetables and legumes;total grains; whole grains; milk; meatand beans; and oils. The nutrient-based components include intakes ofsaturated fat; sodium; and caloriesfrom solid fat, alcohol, and addedsugar (SoFAAS).

Food-level results from the NDS-Rsystem were reported in terms of serv-ings as found in the 1992 USDA FoodGuide Pyramid. Serving informationwas converted to cups and ounces forcomparison to the HEI-2005 standard.The food components do not always di-rectly represent food items as eaten. Allfood-based components include fooditems that are ingredients in mixedfood products. The more in-depth taskwas disaggregating mixed food items.For example, the authors calculatedthe ounces of grain one subject con-sumed when she reported eating a cob-bler that contained pie crust. Some ofthese values were supplied by USDApersonnel. HEI-2005 standards for allfoodcomponentsandthe sodiumcom-ponent are on a 1000 kcal basis, andthese also had to be calculated fromthe dietary information.

Of the 55 participants, 48 providedusable 24-hour diet recalls. Five did notcomplete the diet recall because theyhad to leave the site before the diet re-call could be conducted. Another hadnot consumed anything but waterthe previous day, because of a dentalhealth problem. Finally, one womanhad implausible diet recall resultsthat appeared to be enumerator error.

Smoking Status

Respondents were asked orally if theyhad smoked at least 100 cigarettes intheir lifetime and whether they cur-rently smoked cigarettes every day,some days, or not at all. Respondentswho reported smoking every day orsome days were classified as currentsmokers. Respondents who reportedthat they did not currently smokecigarettes at all were classified as non-smokers.Because so few(5 respondents)of those who do not smoke currently re-ported smokingat least 100cigarettes intheir lifetime, a separate analysis couldnot be conducted for former smokers.Former smokers were thus groupedwith nonsmokers in this study.

Socioeconomic Survey,Food Security Status, andAnthropometric Measurements

Respondents were also asked orallybasic demographic questions abouttheir age, education, ethnicity, andincome. Household income wasmeasured as a categorical variable, inincrements of $5,000. Respondentswere asked whether they or anyoneelse in their household currently re-ceived food stamps or benefits underthe WIC. They were also asked ifthey had health insurance.

The food security status of thehousehold was measured with the 10adult-based questions selected fromthe full 18-question USDA food secu-rity module.1 Respondents with noaffirmative answers were classified asfully food secure. Those with 1 or 2affirmative answers were classified asmarginally food secure. Those with 3to 5 affirmative answers were classi-fied as having low food security. Thosewith 6 or more affirmative answerswere classified as having very lowfood security.1 Following Bickel andassociates, a continuous scale variablewas also created from the responses.11

This scale ranges from a value of 0 forno affirmative responses to 7.9 for 10affirmative responses. All participantscompleted socioeconomic surveys,most with complete answers to allquestions, although 5 respondents re-ported they did not know the level oftheir household income.

Weight and height were measuredusing a Tanita electronic scale (TanitaWB-300MH; Tanita Corp., ArlingtonHeights, IL). Body mass index (weightin kg/height in m2) was calculated us-ing the average of duplicate heightand weight measurements. Partici-pants were classified as normalweight, BMI 18.5-24.9; overweight,BMI 25.0-29.9; or obese, BMI $ 30.No participant had a BMI below 18.5.

Analysis

Data were analyzed by using SAS soft-ware (version 9.1.3, SAS Institute, Inc.,Cary, NC). Descriptive statistics(means, proportions) were calculatedto describe the overall characteristicsof the sample. One-way analysis ofvariance was conducted to examinethe differences in HEI-2005 scores

Table 1. Characteristics of Participants, Lee County Food Pantry Clients, 2006

Characteristic n %Adult weight status

Underweight (BMI< 18.5) 0 0Normal weight (BMI 18.5-24.9) 6 10.9Overweight (BMI 24-29.9) 12 21.8Obese (BMI 30-39.9) 25 45.5Severely obese (BMI over 40) 12 21.8

Food security statusFull food security 7 12.7Marginal food security 12 21.8Low food security 15 27.3Very low food security 21 38.2

Ethnicity

White 19 34.5Black 33 60.0Other 3 5.5

Healthy Eating Index-2005*0-25 5 10.426-50 29 60.451-78 (sample maximum) 14 29.2

Other InformationCurrent smoking 21 38.2No health insurance 23 41.8Food Stamps 28 50.9WIC 14 25.4

BMI indicates body mass index; HEI, Healthy Eating Index; WIC, The SpecialSupplemental Nutritional Program for Women, Infants, and Children.*Higher values of HEI are associated with a more health-promoting diet; althoughno absolute cut-offs exist, scores below 50 generally indicate a diet that is nothealth-promoting.

416 Duffy et al Journal of Nutrition Education and Behavior � Volume 41, Number 6, 2009

across the following categorical vari-ables: smoking, food security status,education level, and participation inWIC or food stamps. Analysis of vari-ance was also used to test the differ-ences in adult food security scalescore and BMI among smokers andnonsmokers.

Regression techniques were usedto analyze the joint relationship offood security, education, age, ethnic-ity, participation in governmentfood programs, and smoking to theoverall HEI-2005 score as well as itscomponents. Explanatory variablesin the regression models were smok-ing, education, age, race, adult foodsecurity, adult food security scale,current participation in WIC, andcurrent participation in the FoodStamp Program. All variables wereincluded as categorical 0-1 dummyvariables in the regression analysisexcept for age, which was a continu-ous variable measured in years, andthe adult food security scale. The

education dummy variable took thevalue of 1 if the respondent did nothave a high school education or theequivalent and the value 0 otherwise.Income was measured as a categoricalvariable, and all women surveyed re-ported very low incomes; there wasthus very little variation in the vari-able, and it was not included in theregression.

Standard ordinary least squares(OLS) regression was used for HEI-2005. The dependent variable wastested for normality using the Kolmo-gorov-Smirnov test, and the nullhypothesis of normality could notbe rejected at the 5% level. Manydata points take the value 0 for theHEI-2005 components; thus use oftobit models, a maximum likelihoodmethod that accounts for the dis-continuity, is preferred to OLS forthe subcomponents.12 Because of theexploratory nature of this study andthe relatively small sample size, signif-icance is reported at the 10% level.

SUMMARY OF FINDINGSCharacteristics of Participants

The mean age of respondents was 34.4.All respondents had incomes belowthe federal poverty thresholds. Be-cause income is reported categorically,the exact relationship of household in-come to the poverty level could not bedetermined. However, it could be de-termined that between 60% and 70%of respondents are living in deep pov-erty, defined as less than half the fed-eral poverty threshold. About 45% ofrespondents were single parents, and24% reported having less than a highschool education/GED. Other charac-teristics of the respondents are sum-marized in Table 1. High rates ofoverweight and obesity and highlevels of food insecurity were found.About 35% of respondents were foodsecure, including 13% who were fullyfood secure and 22% who were mar-ginally food secure. About 65% of therespondents reported some level offood insecurity, with 38% reportingvery low food security. About 42% ofrespondents had no health insurance.Thirty-eight percent of the respon-dents currently smoked, comparedwith a state average of about 20% forwomen in Alabama,13 and 9% wereformer smokers. About half of thewomen reported receiving foodstamps, and about 25% received bene-fits from WIC.

HEI-2005

Diet quality was generally poor. Ofthe 48 women who completed the24-hour diet recall, none scored above80 on the HEI-2005, and only 29%scored above 50. Detailed informationabout the HEI-2005 scores, includingscores on the subcomponents, isreported in Table 2. The majority ofrespondents reported no fruit con-sumption, no whole fruit consump-tion, no whole grain consumption,and no consumption of dark greenor orange vegetables or legumes. Theonly category in which most respon-dents received the maximum scorewas for meat and beans.

Analysis of Variance

Significant differences were found be-tween BMI and current smoking, and

Table 2. HEI-2005 by Components, Lee County Food Pantry Clients, 2006 (n¼ 48)

PossibleRange Mean Median

% ScoringMinimum

% ScoringMaximum

Total fruit 0-5 1.4 0.0 66.7% 20.8%Whole fruit 0-5 1.1 0.0 75.0% 16.7%Total vegetables 0-5 2.6 2.7 25.0% 20.8%Dark green and

orange vegetablesand legumes

0-5 1.0 0.0 68.8% 12.5%

Total grains 0-5 3.4 4.0 12.5% 37.5%Whole grains 0-5 1.1 0.0 68.8% 10.4%Milk 0-10 3.4 1.4 41.7% 14.6%Meat and beans 0-10 8.3 10.0 10.4% 70.8%Oils 0-10 1.6 0.0 58.3% 4.2%Saturated fat 0-10 4.4 3.9 25.0% 12.5%Sodium 0-10 3.6 2.5 29.2% 8.3%SoFAAS 0-20 11.1 10.4 12.5% 8.3%Total HEI score 0-100 42.8 40.8

HEI indicates Healthy Eating Index; SoFAAS, calories from solid fat, alcohol, andadded sugar.

Table 3. Mean Marginal Effects ofExplanatory Variables onComponents of HEI-2005,Lee County Food PantryClients, 2006

WIC:Marginal effect on

whole fruit1.31

Marginal effect onwhole grain

1.53

Food Stamps:

Marginal effect on sodium 1.94Low education:

Marginal effect onwhole fruit

�1.99

Marginal effect onwhole grain

�2.38

Marginal effect on milk �3.10Marginal effect on sodium �2.15

Smoking:Marginal effect on total

grain�1.10

Marginal effect on wholegrain

�1.33

Marginal effect on meat �2.65African American:

Marginal effect on totalgrain

�1.06

Age (per year):Marginal effect on whole

grain0.07

HEI indicates Healthy Eating Index;WIC, The Special SupplementalNutritional Program for Women, In-fants, and Children.Note: Mean marginal effects ob-tained from tobit models, reportingthe expected change in the ob-

Journal of Nutrition Education and Behavior � Volume 41, Number 6, 2009 Duffy et al 417

between adult food security scale andcurrent smoking. Mean BMI for cur-rent smokers was 31.6 compared to35.5 for respondents who did notsmoke currently (P¼.05). Mean foodsecurity scale score was 4.9 for currentsmokers, compared to 3.3 for thosewho did not currently smoke(P¼.02). No significant differenceswere found between HEI-2005 andfood security status, HEI-2005 andcurrent smoking, HEI-2005 and loweducation, and HEI-2005 and partici-pation in food stamps and/or WIC.

served value of the subcomponentscore with respect to a change inthe independent variable. Onlythose marginal effects associatedwith explanatory variables with sig-nificant parameter estimates at the10% level are reported.

Associations between HEI-2005and Other Variables Measured

In the regression analysis, smokingwas found to be associated witha 9.8-point decrease in HEI-2005 score(P¼.07), whereas having less thana high school degree was found todecrease HEI-2005 by 11.1 points(P¼.05). The overall F test for themodel of HEI-2005 was not significant,however. Smoking was negatively as-sociated with whole grain (P¼.03)and meat (P¼.02) subscores and nega-tively associated with total grain(P¼.08) subscores. WIC was found tohave a positive impact for whole fruit(P¼.09) subscores and a positive im-pact for whole grain (P¼.04) sub-scores. Food stamps were found to

have a positive impact on the sodium(P¼.05) subscore. Low education wasnegatively associated with the HEI-2005 subscores for whole grain(P¼.02) and milk (P¼.03) and nega-tively associated with the whole fruit(P¼ 0.07) and sodium (P¼.06) sub-scores. Age was positively associatedwith whole grain (P¼.08) subscores.Being black was negatively associatedwith the total grain subscore (P¼.05)but did not affect milk subscores inthis sample. Milk subscores in generalwere very low, which may explain thelack of significance for race. Becauseof the estimation technique used, theregression parameters cannot be usedto directly measure the impact onHEI-2005 subcomponents. Mean mar-ginal effects of all significant explana-tory variables are reported in Table 3.The marginal effects report the changein the expected value of the observedvalues of the dependent variable,with respect to a unit change in an ex-planatory variable.12

DISCUSSION

This study found that food pantryclients in eastern Alabama reportedhigh rates of obesity, high rates offood insecurity, and poor diet quality.Smoking was associated with in-creased probability of food insecurity

and with lower diet quality. Foodstamps and WIC participation werenot positively associated with higherdiet quality but were positively relatedto specific subcomponents of the HEI-2005. Care should be taken in inter-preting results for the diet quality sub-components, however, as a relativeincrease in one area could be associ-ated with a relative decrease in otherareas.

418 Duffy et al Journal of Nutrition Education and Behavior � Volume 41, Number 6, 2009

Little previous research specificallyaddressed the dietary and otherhealth-related behaviors of food pan-try clients. A few studies have exam-ined nutrient intake of pantryclients, however. Starkey and associ-ates investigated the nutrient intakesof adult food bank users in metropoli-tan Montreal, Quebec, Canada, overa 1-month period and found thatmedian nutrient intakes of calcium,vitamin A, and zinc did not meet rec-ommended nutrient intake levels.7 Ina related paper, Starkey and associatesexamined macronutrient intakes ofCanadian pantry clients and foundthat, as a percentage of energy intake,protein, fat, and carbohydrate intakesapproximated health recommenda-tions.14 Tarasuk and Beaton foundthat female pantry clients in Toronto,Canada who reported hunger in theirhouseholds also reported lower in-takes of a number of nutrients.8 Thispresent study provides evidence thatthe overall dietary quality amongfood pantry clients is suboptimal.

Starkey and associates found thatsmoking was negatively related tointakes of 5 nutrients (folate, pro-tein, vitamin C, iron, and thiamin)for the pantry clients in Canada.7

Among the Alabama pantry clients,smoking was found to negatively af-fect overall dietary quality. Foodsecurity status among the Alabamafood pantry clients was also signifi-cantly and negatively related tosmoking. These results provide inde-pendent evidence supporting recentwork by Armour and associates,who showed that smoking was nega-tively related to household foodsecurity in a national sample oflow-income adults.15

Although overweight and obesityhave increased in all adult popula-tions, rates of obesity have remainedhighest for those with low incomeand low education, with the link be-tween low incomes and overweightespecially strong for women.16-18

Thus it is not surprising that food pan-try clients in this study were found tohave high rates of overweight andobesity. In their urban Kansas sample,Bell and associates found that about17% of food pantry clients were un-derweight and 49% were obese.9

They concluded that food pantry cli-ents were at higher risk of malnutri-tion than the general population.

The high prevalence of obesity,smoking, and poor diet quality sug-gests that Alabama pantry clients arelikely to experience health problems.The lack of health insurance amongmany pantry clients surveyed (42%of the sample) is especially troublingin this light.

LIMITATIONS

Although results of this study indi-cate that food pantry clients havepoor quality diets and high rates ofobesity and smoking, the sample issmall and may not be representative.Another limitation is that the dataused in this analysis are from a single24-hour dietary recall and may notrepresent usual intake, especiallygiven that the 24-hour period oc-curred immediately before the clientscame to the food pantry. The presentresults are also limited because the in-vestigators did not capture intakes onall days of the week and seasons ofthe year, or over the range of time en-compassing periods both before andafter receipt of the pantry food. Amore extensive sample of pantry cli-ents over a broader geographic areais needed to ascertain whether pantryclients in general exhibit high levelsof obesity and smoking and poordiet quality. Further, because all re-spondents in this study were pantryclients, no conclusions can be drawnas to whether food pantry clients hadworse diets or higher rates of obesitythan other low-income women inthe study area.

IMPLICATIONS FORRESEARCH ANDPRACTICE

Most food pantry clients are both low-income and food insecure, a popula-tion well-served by nutrition outreachprograms. More specific knowledgeabout their diet quality will help pan-try directors and nutrition counselorstarget these efforts more effectively.Also, if pantry clients have higherthan average rates of smoking, andsmoking is linked to self-reportedfood insecurity for a broader range ofpantry clients, smoking cessation pro-grams may be of special benefit topantry clients. A greater understand-ing of the social causes of poverty

and food insecurity could also begained from increased researcher con-tact with this population.

ACKNOWLEDGMENTS

The authors gratefully acknowledgeMartha Faupel and Elsie Lott foraccommodating this study; KristinMarcoe for assistance in deriving theHEI-2005 scores; and Marinia Irimia-Vladu, Alicia Gaines, Kristen Postell,and Alexi Thompson for assistancewith data collection.

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