USDA Food and Nutrition Service 

The Office of Analysis, Nutrition and Evaluation 

Family Programs Report No. FSP-04-PO 

Obesity, Poverty, and 

Participation in Nutrition 

Assistance Programs 

United States Food and February 2005

Department of Nutrition Family Programs 

Agriculture Service Report No. FSP-04-PO 

Obesity, Poverty, and Participation in Nutrition 

Assistance Programs 

Authors: 

Paul Linz 

Michael Lee 

Loren Bell 

Submitted by: Submitted to: 

ALTA Systems, Inc. Office of Analysis, Nutrition and Evaluation 

9302 Lee Highway USDA, Food and Nutrition Service 

Suite 401 3101 Park Center Dr., 10th Floor 

Fairfax, VA 22031 Alexandria, VA 22302-1500 

Project Director: Michael G. Lee Project Officer: Sharron Cristofar 

Funding for this report was provided through the USDA Food and Nutrition Services Office of Analysis, Nutrition 

and Evaluation under Contract 53-3198-2-018, Task No. 43-3198-3-3714. ALTA Systems, Inc. and its subcontractor, HSR, Inc., summarized extant research material on the topic and invited subject matter experts to 

participate in a discussion panel to address the questions discussed in this report. The findings herein represent the 

independent consensus of the panel as presented to the USDA/FNS. 

This report is available on the Food and Nutrition Service web site: http://www.fns.usda.gov/oane

Suggested Citation: 

U.S. Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and 

Evaluation, Obesity, Poverty, and Participation in Food Assistance Programs, FSP-04-PO, 

Project Officer, Sharron Cristofar. Alexandria, VA: 2004 
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and 

activities on the basis of race, color, national origin, gender, religion, age, disability, political 

beliefs, sexual orientation, or family status. Persons with disabilities who require alternative

means for communications of program information (Braille, large print, audiotape, etc.) should 

contact USDA’s TARGET Center at (202)720-2600 (voice and TTD). To file a complaint of 

discrimination, write USDA Director, Office of Civil Rights, Room 326-W, Whitten Building, 

14th and Independence Avenue, S.W., Washington, DC 20250-9410 or call (202) 720-5964 

(voice and TTD). USDA is an equal opportunity provider and employer. 

i
ACKNOWLEDGMENTS 

Many people contributed in significant ways to the preparation of this report. We 

received valuable comments from several people at the Food and Nutrition Service of the U.S. 

Department of Agriculture, including Sharron Cristofar, Ted Macaluso, Steven Carlson, Pat 

McKinney, Jay Hirschman, Judy Wilson, as well as Peter Basiotis of the Center for Nutrition 

Policy and Promotion; and Jay Variyam of the USDA Economic Research Service. We also

benefited from a variety of contributions from an outstanding expert panel for the study. The

expert panel consisted of Adam Drewnowski, at the University of Washington, Center for Public

Health and Nutrition, Edward A. Frongillo, Jr. at the Cornell University, Diane Gibson, at the 

Baruch College of the City University of New York (CUNY), Sonya Jones, at the University of

Tennessee, Christine Olson, at the College of Human Ecology at Cornell University, Barry 

Popkin, at the Population Center & School of Public Health, University of North Carolina, and 

Peter Rossi, Professor Emeritus at the University of Massachusetts at Amherst. The panel 

developed a consensus statement addressing the two major objectives of the project by assessing 

the methodological strengths and limitations of current research findings. Tanya Willingham 

and Kim Lee coordinated all the logistics for the meeting in Washington and worked tirelessly to 

assure that everything went smoothly. The literature research was aided considerably by Laura

Sternesky and Rebecca Ledsky. Finally, Paul Linz helped immensely conducting additional

research and skillfully producing the report. We gratefully acknowledge these contributions and 

accept sole responsibility for any remaining errors or omissions in the report. 

ii

TABLE OF CONTENTS 

EXECUTIVE SUMMARY ........................................................................................................... vi 

1. INTRODUCTION .................................................................................................................. 1 

2. PROJECT DESCRIPTION..................................................................................................... 2 

RESPONSE TO QUESTION 1 .......................................................................................... 6 

Combined Effects of Participation in Multiple Food assistance Programs ...................... 10 

RESPONSE TO QUESTION 2 ........................................................................................ 11 

Limitations of the Previous Research and Needs for Future Research............................. 11 

3. PANEL RECOMMENDATIONS........................................................................................ 15 

4. SUMMARY.......................................................................................................................... 20 

APPENDIX A: LITERATURE REVIEW DATA ELEMENT DEFINITIONS......................... 1 

APPENDIX B: BIBLIOGRAPHY ................................................................................................ 1 

iv
v
EXECUTIVE SUMMARY 

In September 2003, the U. S. Department of Agriculture (USDA) Food and Nutrition

Service (FNS) contracted with ALTA Systems to conduct a project with the goal of providing a

comprehensive overview of the relationship between poverty, program participation and obesity by

conducting an in depth literature review; and convening an expert panel. The project goals were to

(1) Critically review existing studies and other literature to determine if there is a sound 

empirical basis for identifying a relationship among poverty, participation in food assistance

programs, and overweight/obesity; (2) If the existing research was not found to be conclusive, 

identify what research approaches, including data sources, would be necessary and feasible to fill 

the knowledge gaps. 

FNS provides food assistance benefits through 15 programs. This network of programs 

plays an important role in providing a nutrition safety net that ensures low-income American 

families have access to a healthy and nutritious diet. Many low-income individuals are both obese

and participants in one or more of FNS’ food assistance programs. This project focused on the

four largest food assistance programs. These four programs accounted for approximately 90% of

FNS’ food assistance expenditures in FY2003. 

• Food Stamp Program (FSP): Benefits across the country are tied to the cost of a low-cost 

nutritious diet sufficient to sustain an active, healthy life. 

• Special Supplemental Nutrition Program for Women, Infants and Children (WIC): 

Food packages are tailored to specific nutrition requirements. 

• National School Lunch Program (NSLP) and the School Breakfast Program (SBP):

Set nutrition standards for school meals served to America's children. 

A panel of experts was convened in Washington DC on March 2nd and 3rd, 2004. The 

panel represented a cross section of individuals with demonstrated expertise in areas of research 

design and development, social research methodology, nutrition, obesity, food assistance 

programs, food insecurity and poverty. The meeting provided a forum for critical assessment of 

the research literature as well as a discussion of issues related to poverty, food assistance 

program participation, and overweight/obesity. The panel was tasked to develop a consensus

statement addressing the two major objectives of the project. Using the literature review as a 

starting point for discussion, the panel assessed the methodological strengths and limitations of 

current research findings. 

A rigorous review of the research literature was conducted to identify relevant 

information pertaining to the relationship among poverty, participation in food assistance 

programs and overweight/obesity. A major criterion for the research studies was that they

considered FNS program participation in their examination of the relationship (including 

existence and direction of causality) between overweight and/or obesity and poverty. The panel 

proposed that the relationship between poverty (as measured by multiple socioeconomic factors) 

and overweight/obesity was a critical issue that must be explored before addressing the impact of 

program participation. Therefore, research literature germane to that issue was included for 

discussion as it provided important contextual information and background for the panel 

discussions. Additional studies suggested by panel members related to issues such as food 

insecurity, dietary intake and food environment were also included in the reference base. 

vi
The research studies selected were abstracted and organized by category. An evidencebased matrix was constructed to facilitate comparison of strengths and weaknesses of the 

research design as well as to provide a brief overview of the content. The panel identified twelve

research studies, eleven published in peer-reviewed journals that met enough of the criteria to 

merit further discussion during the panel’s meeting. Based on the identified research, their 

individual professional and academic research experience and their focused discussions, the

panelists were asked to address the following questions during the panel discussions: 

Question 1: Does a sound empirical basis exist for determining the relationship among 

overweight/obesity, poverty, and participation in the four major FNS food assistance programs—

specifically the Food Stamp Program (FSP), the Special Supplemental Nutrition Program for 

Women, Infants, and Children (WIC), the National School Lunch Program (NSLP) and the 

School Breakfast Program (SBP)?

Question 2: In the absence of existing research that can empirically support a causal 

relationship, what research approaches, including data sources, are necessary and feasible to fill 

any knowledge gaps? Which research issues are/are not feasible to address using existing data? 

What new data may be required? What measurement and analysis issues are relevant and how 

can they be resolved? What additional research questions are pertinent given the existing 

knowledge regarding the relationship of poverty, food assistance program participation, and 

overweight/obesity? 

Response to Question 1

The panel concluded that to be able to determine the relationship between obesity and food

assistance program participation, it is necessary to consider the difficulties and complexity 

of separating the effects of poverty from the potential effects of food assistance on any 

health or social outcome including obesity. The challenge is in controlling for the effects of 

poverty, which is highly correlated with program participation. Because of the strength of the

existing research on this point, it is imperative that this established association be presented as

the first point in their consensus statement. 

The panel also concluded that the sparse research that has been published provides no

consistent evidence of association and no evidence of a causal relationship between the four

major FNS food assistance programs and overweight. Previous research has provided 

some information on components of the relationship, but no study has fully addressed the 

issues related to research design, such as selection bias, and measurement issues. There is 

no published research that considers the relationship between participation in the WIC program 

and maternal obesity. There is no published research that provides evidence of a consistent 

relationship between participation in NSLP and SBP and overweight/obesity. The published 

research on Food Stamps indicates there is some association between program participation and 

overweight/obesity; but there is no evidence of causality. Only one study looked at the combined 

effects of participation in multiple programs on overweight/obesity among individual family 

members. Jones (2003) measured the effects of participating in NSLP, SBP and FSP and found 

no additive effect above the effects of any one program. However, it is not known if the 

combined impact of multiple program participation has any impact on overweight/obesity, or if

vii
there are countervailing effects of multiple program participation on overweight/obesity among 

family members. 

Response to Question 2

The panel concluded that new research is needed to determine the relationship between 

participation in nutrition assistance programs and overweight/obesity. Because the 

relationships among poverty, nutrition assistance program participation and obesity are complex, 

the panelists suggested the importance of creating designs or methods to identify these

relationships so that the true effects of food assistance programs can be appropriately measured. 

They cautioned against conducting new research without a greater understanding of all the 

possible impacts of participation in food assistance programs; regard to the magnitude of the

issue and the opportunity costs for those research dollars. Panel members also emphasized the 

need for future research to consider the simultaneous effects of all three major elements—

nutrition assistance program participation, poverty, and obesity—on one another. They 

cautioned that limiting the scope of research to the investigation of strict associations between 

just two of the elements might miss the larger reality. 

Panel’s Recommendations:

All types of studies should be given equal priority in consideration by FNS. Although 

recognizing that a randomized controlled trial is the “gold standard” in terms of research design, 

the panel agreed that this approach is probably not feasible because it would not be ethical to 

deny entitlement programs to anyone including control subjects in a study of food assistance 

programs in the United States. 

Research efforts should include a mix of small in-depth studies beginning with exploratory 

research approaches that are informative about the relationship and can provide a 

justification for moving to designs that are more expensive. These studies are useful in 

identifying the likely mechanisms, cultural dimensions and local and regional variations that 

contribute to the understanding of the complexity of the relationship. 

Large-scale longitudinal studies are needed to provide the best possible evidence of the

timing and direction of any relationship between program participation and obesity. The 

generalizability of findings is extremely important. Small, local, special population studies are 

excellent first steps in a research program but have to be followed by large scale research that 

can provide credible estimates relating to the entire target population of participants. 

Methodological issues have weakened the current research and need to be controlled for in 

future research. The available data for examining an association between obesity and

participation in food assistance programs has several limitations. Sampling issues included 

sample size, over sampling of some groups, and whether or not conducting a number of small

studies would be sufficient to draw any conclusions. The panel agreed that a national sample

would be the ideal but that a mix of small and large studies might be able to capture important 

information to support future national research. Data collection issues included a discussion of 

personal interviews vs. phone interviews, the length of time between initial and follow-up 

interviews, the length of time a population should be followed; and how to maximize response 

rates. It was decided that a longitudinal study lasting four years would capture enough data.

viii
While no single type of study may provide the definitive answer to the issue, various types

of studies can contribute to our overall understanding of the problem and offer potential 

solutions. The panel identified four approaches that might be successful in adding to the 

knowledge about this relationship. 

• Use natural opportunities for controlled trials, including taking advantage of new 

approaches to program delivery in nutrition assistance programs; 

• Add features and questions into existing longitudinal and other studies by incorporating 

questions and measurements related to obesity including height, weight, dietary intake, 

program participation, and relevant control variables; 

• Initiate smaller in-depth studies that focus on specific target populations of limited size to 

help clarify specific aspects of the relationship between obesity and program

participation; and 

• Identify and use existing data sets that have not been fully exploited to understand causal 

relationships. 

The panel also identified potential research opportunities and challenges. Since each of the 

four programs examined has unique issues and opportunities associated with program rules and 

structure, the research suggestions were program specific: 

• FSP: A challenge to conducting FSP research of this kind is participation dose which 

makes it difficult to follow recipients over a meaningful period of time. Another major 

measurement challenge is the household being the unit of analysis making it difficult to 

measure FSP food distribution by individual. Possible research efforts could be designed 

to take advantage of research opportunities such as a natural intervention through food 

stamp outreach programs for eligible non-participants. Researchers could track people 

that join the program after an outreach effort, to determine potential effects of program 

participation. In addition, panelists noted that the FSP offers the opportunity to intervene 

through family intervention and nutrition education to determine whether such 

interventions change the outcome when food program participation is kept constant. 

• National School Lunch and School Breakfast: These programs present challenges to

designing appropriate research efforts. There are multiple components and diverse

delivery systems within each program which would make it necessary to sample on the

school or district level in order to have a consistent delivery system or, alternatively, to 

include detailed controls for type of delivery system. Even when sampling on a school or 

district level, there will be issues related to variation in school meal content across 

districts. The biggest research challenge is measuring intake of school meals and the 

degree to which they contribute to overweight or obesity. The federally funded portion 

of meals provided is only one component of the food environment in the schools. 

A possibility for a research study could include incorporating more variability in the 

contents of school lunches like programs that are being developed in school districts that 

promote healthy eating. It may be possible to build some measures of total food intake 

through studies that examine food waste. Another potential research opportunity is to 

examine dietary changes in low-income children who are moved to higher income 

schools through school choice and/or voucher experiments. 

ix
• WIC: Challenges to research on the relationship between participation in the WIC 

Program and overweight/obesity include several measurement issues. It is difficult to

know who is consuming the WIC food in a given household. Since the focus of WIC is 

on the participant (pregnant woman or child), it is difficult to know whether a study is 

measuring the effect of program benefits on the persons for whom they are intended. 

• There are several opportunities for conducting research on the relationship between 

participation in the WIC Program and overweight/obesity. WIC has multiple

program components (e.g., food package, health care, nutrition education) that can be 

manipulated to see how the nature of the local program (e.g., tailoring of food 

packages, referral to health services, etc.) can affect outcomes and quality measures. 

• WIC also offers the opportunity to examine issues related to postpartum weight 

loss—women are on the program for a limited time after their child’s birth (except for 

breastfeeding women) but their infants participate for up to a year afterward, and 

children can participate up to age 5. With minimal effort, it may be possible to obtain 

ongoing weight gain/loss and diet information from mothers when they bring their 

children in for assessment/voucher pickup. However, selection issues would still 

exist. Those women who choose to stay on the program may be different from those 

who don’t. 

• Another opportunity would be to examine how variance in the type of providers, such 

as programs that are well integrated with primary/preventative health care might 

compare to programs operated by social service agencies. This might allow for

examining the variance in service delivery approach as a factor, as well as providing

comparison/control groups. 

The panelists concluded by highlighting a number of issues/questions related to 

measurement that had been discussed during the meeting and should be addressed in 

future research designs. 

How should impact on weight be measured? For example, should change in weight be 

the major factor measured, or should outcomes such as a person becoming

overweight/obese after program entry or a person staying overweight/obese without 

measurable improvement be considered? It is also important that measurement issues

be considered in the context of the length of time it would normally be necessary to 

capture data to reflect these changes. 

How should program participation be modeled? Should it be a yes or no question in 

terms of participation within a specific time period? How the level of should need be 

accounted for, since nutrition assistance programs may have a differential effect 

depending on the degree of deprivation a family is experiencing? How should 

different and/or additive effects of participating in multiple programs be accounted

for? How should the episodic nature of program participation be factored into

research designs?

How should selection bias be examined? Of particular importance are factors such as 

changes in household composition and its impact on decisions related to food and 

diet, or stress-related factors such as losing or changing jobs, divorce, or family 

illness?

How can, and should community level data and neighborhood effects be included?

x
Does a child’s height and weight provide enough information for infants and young 

children? Traditionally, weight management has not been an issue before 24 months 

of age, but this situation may change because of the trends we have been seeing in the

overweight/obesity “epidemic.” The panel concurred that this is an important factor 

to consider. Panelists concurred that information on how children have been fed 

could also be important. Are they being breastfed? For how long? When are they 

starting solid food? Are they being fed on demand?

xi
1. INTRODUCTION 

In September 2003, the U. S. Department of Agriculture (USDA) Food and Nutrition 

Service (FNS) contracted with ALTA Systems, Inc. to conduct a project with the goal of

providing a comprehensive overview of the relationship between poverty, program participation and 

obesity by conducting an in depth literature review; and convening an expert panel. The project

goals were to: (1) Conduct a critical review of existing studies and other literature to determine if 

there is a sound empirical basis for identifying a relationship among poverty, participation in

food assistance programs, and overweight/obesity; and (2) If the existing research was not found 

to be conclusive, identify what research approaches, including data sources, would be necessary 

and feasible to fill the knowledge gaps

Many low-income individuals are both obese and participants in one or more of the 15 

food assistance programs operated by FNS. This network of programs plays an important role in

providing a nutrition safety net that ensures low-income American families have access to a healthy 

and nutritious diet. This project focused on the four largest food assistance programs. These four

programs accounted for approximately 90% of FNS’ food assistance expenditures in FY2003.

• Food Stamp Program (FSP): Benefits across the country are tied to the provision of a 

low-cost nutritious diet sufficient to sustain an active, healthy life. 

• Special Supplemental Nutrition Program for Women, Infants and Children (WIC): 

Food packages are tailored to specific nutrition requirements. 

• National School Lunch Program (NSLP) and the School Breakfast Program (SBP): 

Sets nutrition standards for school meals served to America's children. 

Obesity is a major public health concern. It is a risk factor for chronic diseases such as 

coronary heart disease, certain types of cancer, stroke, diabetes, hypertension, and osteoporosis 

(LSRO 1995). Of even more concern is that medical professionals are now seeing children with

these conditions that were once associated only with adults (Hassink, 2003; Freedman, 2002). 

1
2. PROJECT DESCRIPTION 

Expert Panel: 

A panel of experts was convened in Washington DC on March 2-3, 2004. The panel 

represented a cross section of individuals with demonstrated expertise in areas of research design

and development, social research methodology, nutrition, obesity, food assistance programs, 

food insecurity, and poverty. 

Panel Member and 

Affiliation 

Areas of Expertise 

Adam Drewnowski, M.D., PhD 

University of Washington, Center for 

Public Health and Nutrition. 

Dietary choices and food preferences, obesity and eating 

disorders, dietary quality assessment, and nutrient intake. 

Edward A. Frongillo, Jr. PhD

Division of Nutritional Sciences, 

Cornell University, New York. 

Food insecurity, anthropometric assessment hunger and poverty.

Extensive experience in the evaluation of the effectiveness of

food assistance programs.

Diane Gibson, PhD Baruch College 

of the City University of New York. 

(CUNY). 

Issues surrounding poverty and obesity. Strong familiarity with 

food assistance programs, especially regarding the relationship 

between the Food Stamp program and obesity in low-income 

individuals. 

Sonya Jones, PhD University of 

Tennessee, Knoxville, Tennessee. 

The social determinants of healthy eating, community-based 

nutrition issues, and longitudinal effects of poverty on weight

gain and overweight/obesity. 

Christine Olson, PhD, R.D 

Division of Nutritional Sciences, 

Cornell University, New York.

Her area of expertise is in obesity and relationships of health 

behaviors (eating, physical activity, pregnancy weight gain),to 

body weight in women, infants and children. She also studies 

the measurement and consequences of hunger and food 

insecurity among low-income populations. She is experienced 

in food insecurity research and in nutrition outcomes in food 

assistance programs. 

Barry Popkin, PhD Population Center 

& School of Public Health, University of

North Carolina, Chapel Hill, North 

Carolina. 

Expertise is in obesity area, focused on understanding patterns 

and determinants of dietary, physical activity and obesity

patterns among adolescents and adults. Active in US and global 

food and nutrition areas, and large-scale program and policy

initiatives addressing obesity and other nutrition-related noncommunicable disease. He has strong ties to food assistance

programs, and is knowledgeable in the policy issues related to 

nutrition and disease prevention. 

Peter Rossi, Ph D Professor Emeritus, 

University of Massachusetts at Amherst. 

He is also the Director of Evaluation 

Design and Analysis, a consulting firm. 

Sociology and evaluation. The author of Feeding the Poor: An 

Analysis of Five Federal Nutrition Programs., he is also the

prime author (with Lipsey and .Freeman) of Evaluation: A 

Systematic Approach. He brings a strong research background 

in food assistance outcome research and in research methods. 

2
The meeting provided a forum for critical assessment of the research literature as well as

a discussion of issues related to poverty, food assistance program participation, and 

overweight/obesity. The panel was tasked to develop a consensus statement addressing the two 

major objectives of the project. Using the literature review as a starting point for discussion, the 

panel assessed the methodological strengths and limitations of current research findings. 

Literature Review:

A rigorous review of the research literature was conducted to identify relevant 

information pertaining to the relationship among poverty, participation in food assistance 

programs and overweight/obesity. Sources included journals, government reports, books, 

unpublished manuscripts and dissertations, presentations and personal communication with 

researchers and experts in the field who have conducted or were currently conducting related 

research. Empirical research was favored over opinion. Opinion pieces selected were included

only if they referenced scientific studies as the basis of their conclusions. 

The major criterion for the research studies was that they considered FNS program 

participation in their examination of the relationship (including existence and direction of

causality) between overweight and/or obesity and poverty. An evidence-based matrix was

constructed to facilitate comparison of strengths and weaknesses of the research design as well as

to provide a brief overview of the content. The data elements were: (1) purpose of study; (2) 

type of study; (3) food program referenced; (4) data source; (5) measurement; (6) sample type; 

(7) sample size; (8) study design; (9) geographic location of study; (10) population studied; (11) 

definition of obesity/overweight; (12) key findings; (13) study limitations; and (14) 

recommendations for further research. The search was limited to articles in English referencing 

3
studies conducted in the United States between 1994 and 2004. (See Appendix A for a more 

detailed description of the approach used to generate the research literature for the project). 

Initially, thirty-four research articles met the criteria for inclusion and formed the

reference base for the panel discussions. They were abstracted and organized by category. The

panel was provided with the annotated bibliography, data matrix and complete copies of all 

material that had been identified. Additional studies suggested by panel members were also 

included in the reference base. The panel agreed that the relationship between poverty (as 

measured by multiple socioeconomic factors) and overweight/obesity was a critical issue that 

must be addressed before addressing the impact of program participation. Therefore, the 

research literature germane to that issue was included for discussion as it provided important 

contextual information and background for the panel discussions. 

The panel edited and revised the matrix and annotated reference list based on their review 

of these materials. Twelve research studies (eleven published in peer-reviewed journals) were 

identified that met enough of the criteria to merit further discussion during the panel’s meeting in 

March 2004. These are identified in the following table. Other sources were used as background 

and justification of positions taken during the discussions. 

4
FSP

Gibson D (2004) Long-term food stamp program participation is differentially 

related to overweight in young girls and boys Journal of the 

American Society for Nutritional Sciences, 134(2): 372-379 

Gibson D (2003) Food stamp program participation is positively related to obesity in

low income women Journal of Nutrition, 133:2117-2118 

Hofferth SL, and S Curtin (2004) Do Food Programs Make Children Overweight? Working Paper 

Jones S, Jahns L, Laraia B,

and B Haughton 

(2003) Lower risk of overweight in school-aged food insecure girls who 

participate in food assistance: results from the panel study of 

income dynamics child development supplement Archives of

Pediatric and Adolescent Medicine, 157(8) 780-4 

Townsend M, Peerson J, 

Love B, Achterberg C, and 

S Murphy 

(2001) Food insecurity is positively related to overweight in women 

Journal of Nutrition, 131(6): 1738-45 

WIC

Center for Disease Control 

(CDC) 

(1996) Nutritional status of children participating in the Special 

Supplemental Nutrition Program for Women, Infants, and

Children--United States, 1988-1991 Morbidity and, Mortality 

Weekly Rep, 45(3): 65-9 

Cole N (2001) The prevalence of overweight among WIC children WIC010PCOM U S Department of Agriculture, Food and Nutrition

Services, Office of Analysis, Nutrition and Evaluation 

Mei Z, Scanlon K, 

Grummer-Strawn L, 

Freedman D, Yip R, 

Trowbridge F

(1998) Increasing prevalence of overweight among US low-income

preschool children: the Centers for Disease Control and Prevention 

pediatric nutrition surveillance, 1983 to 1995 Pediatrics, 101(1): 

E12 

NSLP and SBP

Gordon A, Devaney B, & J 

Burghardt 

(1995) Dietary-effects of the national school lunch program and the school 

breakfast program American Journal of Clinical Nutrition, 61(1): 

S221-S231 

Hofferth SL, and S Curtin (2004) Do Food Programs Make Children Overweight? Working Paper 

Jones S, Jahns L, Laraia B,

and B Haughton 

(2003) Lower risk of overweight in school-aged food insecure girls who 

participate in food assistance: results from the panel study of 

income dynamics child development supplement Archives of

Pediatric and Adolescent Medicine, 157(8) 780-4 

Melnik T, Rhoades S, 

Wales K, Cowell C, and W 

Wolfe 

(1998) Overweight schoolchildren in New York City: prevalence 

estimates and characteristics International Journal of Obesity and

Related Metabolic Disorders, 22(1): 7-13 

Wolfe W, Campbell C, 

Frongillo E, Haas J, and 

T Melnik 

(1994) Overweight schoolchildren in New York State: prevalence and 

characteristics American Journal of Public Health, 84(5): 807-13 

5
The panelists were asked to use the identified research, their individual professional and 

academic research experience and their focused discussions to address the following questions

during the panel meeting: 

Question 1: Does a sound empirical basis exist for determining the relationships among 

overweight/obesity, poverty, and participation in the four major FNS food assistance

programs—specifically the Food Stamp Program (FSP), the Special Supplemental

Nutrition Program for Women, Infants, and Children (WIC), the National School

Lunch Program (NSLP) and the School Breakfast Program (SBP)?

Question 2: In the absence of existing research that can empirically support a causal 

relationship, what research approaches, including data sources, are necessary and 

feasible to fill any knowledge gaps? Which research issues are/are not feasible to 

address using existing data? What new data may be required? What measurement 

and analysis issues are relevant and how can they be resolved? What additional 

research questions are pertinent given the existing knowledge regarding the 

relationships of poverty, food assistance program participation, and 

overweight/obesity? 

RESPONSE TO QUESTION 1 

Question 1: Does a sound 

empirical basis exist for 

determining the relationship 

among overweight/obesity, 

poverty, and participation in

the four major FNS food

assistance programs—

specifically the Food Stamp 

Program (FSP), the Special 

Supplemental Nutrition 

Program for Women,

Infants, and Children (WIC),

and the National School

Lunch Program (NSLP)/

School Breakfast Program 

(SBP)?

A. Poverty, as measured by household income, has been 

established to be associated with obesity in some population 

groups in the United States 

The potential mechanisms underlying the observed links 

between obesity and different measures of socioeconomic status may 

include biological pathways, family, social and cultural factors, as

well as the characteristics of food environments. Life events such as 

change in marital status, loss of job, death in the family may lead 

normal weight persons to change behaviors that could increase the 

6
risk of change in weight status (Stunkard and Sorenson, 1993; Wolfe, Sobal , Olson, Frongillo 

1997; Gortmaker 1993). Neighborhood effects such as living in areas with depressed economic

conditions, inner city or rural areas with high unemployment levels; and low wage employment

opportunities have similar effects. For example, results from contemporary research in 

neurobiology suggest stresses resulting from such events may lead to changes in weight and 

promote central adiposity through hormonal changes (Dallman, 2003). 

Before any conclusive statements about the relationship between obesity and 

participation in food assistance programs can be made, multiple indices of low socioeconomic 

status (e.g., low educational level, income, household assets, and occupation) and socio-cultural 

factors associated with increased risk of obesity in most population groups, must be taken into 

account. (Drewnowski, 2004). 

Both physical activity and nutrition must be addressed to reduce the prevalence of 

obesity. Recent data from Australia, the United States and Europe show increased self-reported 

energy intake associated with obesity, The effect of increased energy intake is compounded by 

sedentary lifestyles (Stubbs and Lee 2004). Environmental factors may play an important role 

influencing physical activity (Booth SL, et al 2001). Wilson (2004) compared perceptions of 

access and safety for physical activity among residents who were stratified as low or high SES. 

Respondents from low-SES areas reported engaging in less PA based on CDC recommendations. 

They reported higher perceptions of neighborhood crime, unattended dogs, unpleasantness of 

neighborhoods, untrustworthy neighbors, and less access to public recreation facilities (Wilson et 

al 2004). 

7
To determine this relationship, it is necessary to consider the difficulties and complexity

of separating the effects of poverty from the potential effects of food assistance on any health or

social outcome including obesity. The challenge is in controlling for the effects of poverty, 

which is highly correlated with program participation. Because of the strength of the existing 

research on this point, the panel decided that it was imperative that this established association be 

presented as the first point in their consensus statement. 

Highest rates of obesity occur among groups with low income and low education 

(Gortmaker 1993; Galobardes 2000; Sobal and Stunkard 1989, Jeffery and French 1996, Jeffery, 

French, and Spry 1991, Sobal 1991, Stunkard 1996 Zhang and Wang 2004). In white females

for example, the research suggests an association between poverty and an increased risk of

obesity beginning in adolescence. In males however, research suggests that poverty is associated 

with a decreased risk of obesity. Sobal and Stunkard (1989), who summarized a great deal of 

previous literature about SES and overweight and obesity found an inconsistent relationship 

across studies for men. For example, while it would be expected, and some data supports the 

hypothesis of low SES and obesity in males, in some population groups, African American and 

Mexican males in particular, the relationship between socioeconomic status and the risk of 

obesity seems to go in the opposite direction – that is, low socioeconomic status of these two 

groups is associated with a decreased risk of obesity. 

B. The sparse research that has been published provides no consistent evidence of 

association. There is no evidence that there is a sound empirical basis of a causal 

relationship among any of the four major FNS food assistance programs and 

overweight or obesity. 

Previous research has provided some information on components of the relationship, but 

no study has fully addressed the issues related to research design, such as selection bias, and 

measurement. There is no published research that considers the relationship between

8
participation in the WIC program and maternal obesity. Several studies (CDC 1996; Mei et al., 

1998; Rose et al., 1998; Wilde et al., 2000; Cole, 2001; Siega-Riz 2004) examined the 

relationship between child participation in WIC and height and/or weight status. All were

descriptive studies restricted to WIC participants. None addressed obesity issues. There is no 

published research that provides evidence of a consistent relationship between participation in

NSLP and SBP and overweight/obesity (Gordon et al., 1995; Wolfe et al., 1994; Melnik et al., 

1998; Jones et al., 2003). 

The published research on Food Stamps indicates there is some association between 

program participation and overweight/obesity; but there is no evidence of causality. The best

available information regarding the relationship between women’s participation in the Food 

Stamp Program and obesity is from studies by Gibson (2003) and Townsend et al. (2001). Both 

were somewhat limited in their ability to support definitive conclusions about the relationship 

between women’s participation in food assistance programs and obesity. 

Gibson, using nationally representative data from the 1985 to 1996 waves of the National 

Longitudinal Survey of Youth 1979, found that both current participation and long-term

participation in the Food Stamp Program were significantly related to an increased risk of obesity 

for low-income women. However the data does not contain elements that would support an indepth examination of participation patterns nor to accurately classify non-participant households 

as potentially eligible. The study does not control or account for food insecurity which is an 

important intervening variable that has the potential to confound the main effect. The inclusion 

of factors that take into account unobserved differences across individuals which do not vary 

over time, was not thought to fully account for potential differences between participants and 

non-participants related to both obesity and program participation (e.g., specific life events such 

as depression). In addition, although Gibson’s study included long-term data related to program

participation, it did not look at the incidence of weight gain but rather measured obesity at a 

single point in time. 

9
Townsend et al., using national data from the 1994-1996 Continuing Survey of Food 

Intakes by Individuals, similarly found that participation in the Food Stamp Program was

associated with an increased risk of overweight in women. Although controlling for food 

insecurity, the study relied on cross-sectional data, which does not allow for a determination of 

causality. 

Few papers have considered the relationship between men and children’s participation in

the FSP and obesity. Gibson (2004) used the National Survey of Youth 1979 Child Sample to 

examine the relation between long-term Food Stamp Program participation and overweight in 

children and found an increased risk of overweight among young girls whose families participate 

in the Food Stamp Program. There is a negative and weakly significant relationship between 

long-term FSP participation and overweight for young boys. In contrast, using the 1997 Panel 

Study of Income Dynamics Child Development Supplement, Jones (2003) found a lower risk of 

overweight in school-aged food-insecure girls who participate in food assistance. However, this 

study does not have measures of food insecurity. 

No studies were identified that link program participation to dietary change and in turn to 

change in weight status. Although there are studies identified that demonstrated that

participation in the FSP increased total caloric intake and had a significant effect on the

availability of food energy at the household level, they did not address individual weight gain 

and obesity (Currie, 2003; Fox et al., 2004; Hamilton and Rossi, 2002; Cuellar, 2003; Wilde et 

al., 2000; Gleason, 2000). 

Combined Effects of Participation in Multiple Food assistance Programs

Although some of the studies referenced above have simultaneously considered the 

effects of participation in the FSP, WIC, and the NSLP and SBP on the dietary intakes of 

10
households, only one has looked at the combined effects of participation in multiple programs on 

overweight/obesity among individual family members. Jones (2003) measured the effects of 

participating in NSLP, SBP and FSP and found no additive effect above the effects of any one

program. However, it is not known if the combined impact of multiple program participation has

any impact on overweight/obesity, or if there are countervailing effects of multiple program 

participation on overweight/obesity among family members. 

RESPONSE TO QUESTION 2 

The expert panel concluded that new research is needed to determine the relationship 

between participation in nutrition assistance programs and overweight/obesity and offered 

several suggestions as to how FNS might proceed. Because the relationships among poverty,

nutrition assistance program participation, and obesity are complex, the panelists suggested the 

importance of creating designs or methods to identify these relationships so that the true effects 

of food assistance programs can be appropriately measured. 

They cautioned against conducting new research without a greater understanding of all 

the possible impacts of participation in food assistance programs; regard to the magnitude of the

issue and the opportunity costs for those research dollars. Panel members also emphasized the 

need for future research to consider the simultaneous effects of all three major elements—

nutrition assistance program participation, poverty, and obesity—on one another. They 

cautioned that limiting the scope of research to the investigation of strict associations between 

just two of the elements might miss the larger reality. 

Limitations of the Previous Research and Needs for Future Research

The available research for examining an association between obesity and participation in 

food assistance programs has several limitations. The panel began their discussion by 

11
identifying methodological issues that have weakened the current research and need to be 

addressed in future research. 

Selection bias: This critical issue needs to be addressed and controlled for. It is a result 

of the systematic error in creating or defining comparison groups that differ in observed and nonobserved measures. This source of error may influence results and thus limit the level of

confidence of the results. The panel discussed some of the sources of selection bias that is

present in the current research on the relationship among food assistance programs, poverty and 

obesity. 

• An important potential source of selection bias is the individual’s propensity to 

participate in a program. The decision to participate is complex and can be 

conceptualized in terms of its cost (both economic and social) and benefit. 

• Individuals may learn about and apply for food stamps through their contact with other 

social assistance programs resulting in a higher food stamp participation rate than similar 

individuals. For example, those whose health conditions lead them to the Medicaid 

system and referral to WIC. Conversely, those individuals who are not at nutritional risk 

but are similar on other characteristics would not be included for participation in that 

program. 

Data and Measurement Issues: Data sources used in recent research were designed to 

approach other, often related, issues but were generally not focused on the complexity of the 

obesity-food assistance relationship and other factors, and often did not take into account or 

completely control for potential sources of measurement error. 

Most of the data sources currently used in the studies reviewed used aged data that may 

not completely reflect the current relationship between obesity and program 

participation.

12
Few studies have identified and tracked control populations so that meaningful 

comparisons could be made between participants and non-participants. The nonparticipants in the data sets that have been used do not necessarily represent a 

reasonable comparison group to participants (even with the use of statistical controls) 

and therefore better statistical controls are necessary. 

Participation needs to be accurately defined. Accurate characterizations of eligibility,

enrollment, “dose” of participation both in terms of time and level of benefit, local 

program aspects that influence participation (e.g., universal free breakfast or WIC 

packages) are needed. None of the studies adequately addressed measures of 

exposure to the program. Participation is most often measured as a survey question;

which does not provide enough data to fully evaluate and categorize level of program

participation.

Another source of measurement error that can lead to misclassification of low-income

non-participants is based on incomplete information about eligibility criteria not 

associated directly with household income. Many data sources include information 

on income but do not include information on assets or other sources of capitol (such 

as unreported income). Also little attention is usually paid to the way income is 

calculated in the data base as opposed to how the program computes income for 

eligibility purposes (individual vs. household; monthly vs. annual). 

Benefits provided to the household complicate the assessment of the effects of these 

programs on individuals since the division of program benefits among family

members is not usually measured. There are indirect benefits to the household when 

the unit of analysis is the individual and similarly to the individual when the unit of

analysis is the household. Food distributed within the household is often treated as 

available capital that can be leveraged and not always based on household availability 

or the individual’s participation. 

Design Issues: Since experimental methods have not been used, estimates of the effects 

of program participation on dietary outcomes may be biased by unobserved differences between 

participants and non-participants. As no causal model can be constructed, we are confined to 

discussion of measures of association. 

13
An important factor that is not usually taken into account involves physical and financial 

access to healthier diets. The structure of food prices is such that energy dense foods, 

often containing refined grains, added sugars or added fats represent the lowest cost

option to the consumer. In contrast, the recommended healthier diets are likely to 

cost more. Computer modeling of optimal diets at a minimum cost led to energy

dense fat-rich diets that were similar in composition to those consumed by the poor

(Drewnowski, 2004; Nestle, 1998). 

Continued selection of low-cost energy-dense but nutrient-poor foods may have 

metabolic consequences. In clinical and laboratory studies, high energy density and

the high palatability of sweets and fats were associated with higher energy intakes

and, in some cases, weight gain. The observed association between economic 

deprivation and obesity may involve the low cost and good taste of energy dense 

foods (Drewnowski, 2004; Darmon 2003; Leibtag and Kaufman 2003). 

The challenges of understanding how food assistance might change dietary intake, and 

therefore body weight, limit the ability to make causal links between food assistance 

and obesity, were those links to exist. Dietary intake is difficult to adequately collect. 

It is even more difficult to attribute intake to specific economic or program resources

using the available data sources. Perceptions of body weight and health vary by 

ethnic and cultural background, as does acceptability of program participation.

Therefore, the impact of food assistance on food consumption and body weight has to 

be understood in the appropriate ethno-cultural context. Measures of heritage, 

acculturation and region are important to understanding this relationship as well (Lin,

Huang and French, 2004; Gordon-Larsen, Adair and Popkin, 2003). 

14
3. PANEL RECOMMENDATIONS 

Although recognizing that a randomized controlled trial is the “gold standard” in terms of 

research design, the panel agreed that this approach is probably not feasible since it would not be 

ethical, and not allowable in the United States, to deny entitlement programs to anyone including 

control subjects in a study of food assistance programs. Ideally, such a study would include 

variation in levels of benefit or service, which is not legally possible within the FNS programs, 

and might only be obtained by setting up experimental programs outside the U.S. An alternative 

approach would be to conduct a non randomized controlled trial using a regression discontinuity 

design. It controls for selection bias by comparing three groups – non-eligibles, eligible nonparticipants and participants. Including non-eligibles improves the comparability between the 

two groups of interest. Since the eligibility rule is based on a variable that can be expressed as 

being continuous, the impact on participants on the margin between eligibility and non-eligibility 

is identifiable independent on self selection factors. (Heckman 1995) 

All types of studies should be given equal priority in consideration by FNS. The panel 

suggested that research efforts should include a mix of small in-depth studies beginning with 

exploratory research approaches that are informative about the relationship and can provide a 

justification for moving to more expensive designs. These studies are useful in identifying the

likely mechanisms, cultural dimensions and local and regional variations that contribute to the 

understanding of the complexity of the relationship. 

Large-scale longitudinal studies are needed to provide the best possible evidence of the

timing and direction of any relationship between program participation and obesity. The

generalizability of findings is extremely important. Small, local, special population studies are 

excellent first steps in a research program but have to be followed by large scale research that 

15
can provide credible estimates relating to the entire target population of participants. The

required variables for large-scale studies are, at a minimum, valid, reliable, and long-term 

measures of the following: weight and height; food insecurity; multiple detailed information on 

income and how it is calculated for each program; marital status; employment status; household 

income; program participation data, propensity to seek help/assistance (which should include 

such elements as duration and participation cycles), level of benefit; poverty level, food

insecurity, social demographic characteristics of various target populations, and detailed dietary 

intake data with some physical activity measures (including those associated with work, travel, 

and leisure activity). Other variables to consider in such studies may include: measures of 

individual food expenditures, measures of household assets (savings, net worth, etc.), nutritional 

knowledge, measures of self-efficacy, and other variables that may provide a more complete 

picture of program participation and confounding factors. 

Panelists raised a number of issues regarding the nature of samples to be included in 

future research, including sample size, whether or not there should be over sampling of some

groups, and whether or not conducting a number of small studies would be sufficient to draw any 

conclusions. They agreed that a national sample would be the ideal but that a mix of small and 

large studies might be able to capture important information to support future national research. 

Panelists also discussed different methods of data collection, such as: personal interviews 

vs. phone interviews; the length of time between initial and follow-up interviews; the length of

time a population should be followed; and how to maximize response rates. It was decided that a 

longitudinal study lasting four years would capture enough data. 

Although there was some discussion about databases that might be modified to capture 

the additional data needed for determining the relationship between nutrition assistance and

16
obesity, no database could be identified that currently includes all of the appropriate data

elements and follows them longitudinally. The panel agreed that more exploration of existing

databases is needed to determine what is available, what is usable, and what can be modified 

and/or supplemented to capture the data necessary to determine a relationship between nutrition

assistance program participation and obesity. 

While no single type of study may provide the definitive answer to the question, various 

types of studies can contribute to our overall understanding of the problem and offer potential 

solutions. The panel identified four alternative approaches that might be successful in adding to 

the knowledge about this relationship: 

• Use natural opportunities for controlled trials, including taking advantage of new 

approaches to program delivery in nutrition assistance programs; 

• Add features and questions into existing longitudinal and other studies by incorporating 

questions and measurements related to obesity such as height, weight and dietary intake, 

program participation, and relevant control variables; 

• Initiate smaller in-depth studies that focus on specific target populations of limited size to 

help clarify specific aspects of the relationship between obesity and program

participation; and 

• Identify and use existing data sets that have not been fully exploited to understand causal 

relationships. 

The panel identified several potential research opportunities. Since each of the four

programs we examined has unique issues and opportunities associated with program rules and 

structure, the research suggestions were program specific: 

FSP: A natural intervention could occur through food stamp outreach programs for

eligible non-participants. Researchers could track people that join the program after an outreach 

effort, to determine potential effects of program participation. In addition, panelists noted that 

the FSP offers the opportunity to intervene through family intervention and nutrition education to 

17
determine whether such interventions change the outcome when food program participation is 

kept constant. 

National School Lunch and School Breakfast: These programs present challenges to 

designing appropriate research efforts. There are multiple components and diverse delivery 

systems within each program which would make it necessary to sample on the school or district

level in order to have a consistent delivery system or, alternatively, to include detailed controls 

for type of delivery system. Even when sampling on a school or district level, there will be

issues related to variation in school meal content across districts. 

The largest obstacle is involved in measuring intake of school meals the degree to which 

they contribute to overweight or obesity. The federally funded portion of meals provided is only 

one component of the food environment in the schools. 

A possibility for a research study could include incorporating more variability in the 

contents of school lunch like programs that are being developed in school districts that promote 

healthy eating. It may be possible to build some measures of total food intake through studies 

that examine food waste. Another potential research opportunity is to examine dietary changes 

in low-income children who are moved to higher income schools through school choice and 

voucher experiments. 

WIC: There are several opportunities for conducting research on the relationship 

between participation in the WIC Program and overweight/obesity. WIC has multiple program

components (e.g., food package, health care, nutrition education) that can be manipulated to see 

how the nature of the local program (e.g., tailoring of food packages, referral to health services, 

etc.) can affect outcomes and quality measures. 

18
WIC also offers the opportunity to examine issues related to postpartum weight loss—

women are on the program for a limited time after their child’s birth (except for breastfeeding 

women) but their infants participate for up to a year afterward, and children can participate up to 

age 5. With minimal effort, it may be possible to obtain ongoing weight gain/loss and diet 

information from mothers when they bring their children in for assessment/voucher pickup. 

However, selection issues would still exist. Those women who choose to stay on the program 

may be different from those who don’t. 

Another opportunity would be to examine how variance in the type of providers, such as 

programs that are well integrated with primary/preventative health care might compare to 

programs operated by social service agencies. This might allow for examining the variance in 

service delivery approach as a factor, as well as providing comparison/control groups. 

Challenges to research on the relationship between participation in the WIC Program and

overweight/obesity include several measurement issues. As mentioned earlier, it is difficult to 

know which persons are eating the WIC food in a given household. Since the focus of WIC is on 

the participant (pregnant woman or child), it is difficult to know whether a study is measuring 

the effect of program benefits on the persons for whom they are intended. 

19
4. SUMMARY 

Many low-income individuals are both obese and are participants in one or more of FNS’

food assistance programs. The sparse research that has been published provides no consistent 

evidence of association and no evidence to conclude that there is a sound empirical basis of a 

causal relationship among any of the four major food assistance programs and 

overweight/obesity. 

The relationship among food assistance programs and overweight/obesity among 

participants is complex and requires a research approach that takes into account other 

contributing factors. One of the most important of these is poverty, which has already been 

established as associated with overweight/obesity for some groups. 

Previous research has provided some information on components of the relationship, but 

no study has fully addressed the issues related to research design, such as selection bias, and 

measurement issues. The available data used for examining an association between obesity and 

participation in food assistance programs has several limitations. It was designed to approach 

other, often related, issues but was generally not focused on the complexity of the obesity-food 

assistance relationship and other factors, and often did not take into account or completely

control for potential sources of design or sampling error. A comprehensive randomized control 

trial (“gold standard”) design is probably not possible because of cost, ethical and/or potential 

legal issues. Therefore, less direct methods for approaching the question would be more 

realistic. 

The panel identified four alternative approaches that might be successful in adding to the

knowledge about this relationship. 

20
• Use natural opportunities for controlled trials, including taking advantage of new 

approaches to program delivery in nutrition assistance programs; 

• Add features and questions into existing longitudinal and other studies by incorporating 

questions and measurements related to obesity, including height, weight and dietary 

intake, program participation, and relevant control variables; 

• Initiate smaller in-depth studies that focus on specific target populations of limited size to 

help clarify specific aspects of the relationship between obesity and program

participation; and 

• Identify and use existing data sets that have not been fully exploited to understand causal 

relationships. 

The panelists concluded by highlighting a number of issues/questions related to 

measurement that had been discussed during the meeting and should be addressed in future 

research designs. 

How should impact on weight be measured? For example, should change in weight be 

the major factor measured, or should outcomes such as a person becoming

overweight/obese after program entry or a person staying overweight/obese without 

measurable improvement be considered. It is also important that measurement issues

be considered in the context of the length of time it would normally be necessary to 

capture data to reflect these changes. 

How should program participation be modeled? Should it be a yes or no question in 

terms of participation within a specific time period? How should the level of need be 

accounted for, since nutrition assistance programs may have a differential effect 

depending on the degree of deprivation a family is experiencing? How should 

different and/or additive effects of participating in multiple programs be accounted

for? How should the episodic nature of program participation be factored into

research designs?

How should selection bias be examined? Of particular importance are factors such as 

changes in household composition and its impact on decisions related to food and 

diet, or stress-related factors such as losing or changing jobs, divorce, or family 

illness?

How can, and should community level data and neighborhood effects be included?

21
Does a child’s height and weight provide enough information for infants and young 

children? Traditionally, weight management has not been an issue before 24 months 

of age, but this situation may change because of the trends we have been seeing in the 

overweight/obesity “epidemic.” The panel concurred that this is an important factor 

to consider. Panelists concurred that information on how children have been fed 

could also be important. For example: Are they being breastfed? For how long?

When are they starting solid food? Are they being fed on demand?

22
APPENDIX A: LITERATURE REVIEW DATA ELEMENT DEFINITIONS1

Selected sources were abstracted and entered into an evidence-based matrix. The data elements

contained in the matrix are described below. 

Purpose of Study: The purpose and/or hypothesis to be tested were assessed. 

Type of Study: Studies were classified as being primarily original research or analysis of 

secondary data, a research summary or literature review, or an opinion or news commentary. 

Food Program Referenced: Which, if any, food assistance programs were referenced, namely, 

Food Stamps, WIC, or National School Lunch or School Breakfasts Programs. 

Data Source: If given, the primary source of data, as well as the time period covered by the data 

was also recorded. Further information on what type of data were utilized, i.e., survey, focus

group, interview, diary, physical measurements, or other, was also collected. 

Measurement: The type of data measurement was assessed—either longitudinal, defined as 

having measurements over time, including time series data, or cross-sectional, with measurement

at only one point in time. 

Sample Type: Studies were characterized as having either representative or convenience 

samples. It was noted whether the sample was considered representative of the U.S. or another 

specific population, e.g., a specific city or country. 

Sample Size: If applicable, sample size was recorded. 

Study Design: Studies were assessed as to whether they employed an experimental, controlled 

trial design, or other (e.g., a literature review). 

 

1

 HSR, subcontractor to ALTA systems, Inc., prepared the literature review and data matrix. 

A-1
Geographic Location of Study: It was noted whether the study included a population from a

specific state or city, and urban or rural areas. 

Population Studied: Demographic characteristics of the study population, including race, 

gender, socioeconomic status, ethnicity and age, were assessed. 

Definition of Obesity/Overweight: Where applicable, the definitions of obesity and overweight 

as used in the study were recorded. 

Key Findings: The major conclusions of the study were summarized. 

Study Limitations: Limitations in the data, design, assumptions, or other aspects of the study, as 

identified by the authors and/or abstractor, were recorded. 

A-2
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