High Food Insecurity
When considering the conclusions and recommendations the authors reached in the High Food Insecurity article, which of them, in your opinion, might be most effective way to remedy the problems outlined in the article and why?
Write a 300+ word response to the prompt above.
High Food Insecurity and Its Correlates Among Families
Living on a Rural American Indian Reservation
Katherine W. Bauer, PhD, MS, Rachel Widome, PhD, MHS, John H. Himes, PhD, MPH, Mary Smyth, MS, Bonnie Holy Rock, BA,
Peter J. Hannan, MStat, and Mary Story, PhD, RD
Food insecurity is defined as the state of either
having limited or uncertain access to food
that is nutritionally adequate, culturally accept-
able, and safe or having an uncertain ability
to acquire acceptable foods in socially accept-
able ways.1 Food insecurity harms childrens
physical, social, and emotional health. Com-
pared with food-secure children, children who
experience food insecurity are less likely to
have a diet that meets recommended guidelines
for nutrition2—4; are more likely to experience
chronic illnesses, acute illness,5,6 psychosocial
problems, and psychiatric distress5,7—9; and are
more likely to have lower academic perfor-
mance.10 There is some evidence to suggest
that food insecurity contributes to overeating
and obesity,11—13 although several studies of
preschool— and grade school—aged children
have not observed associations between food
insecurity and weight status.2,12,14,15 The roots
of food insecurity for a family often lie in
economic factors, such as having insufficient
income, limited wealth, excessive debt, and
high living expenses. However, psychosocial
factors, including maternal mental and physical
health status, domestic violence, parental
cooking and financial skills, parental education
level, and familial social networks, also play
roles in food insecurity.7,16 Additionally, lack of
access to food in their community increases
families likelihood of being food insecure.16
Nationwide in 2009, 21.3% of US households
with children experienced food insecurity dur-
ing the previous year.17
Since the middle of the twentieth century,
substantial changes have occurred in the
availability of and access to healthful food on
American Indian reservations.18,19 Although,
traditionally, American Indian populations
used the land they lived on for hunting and
growing food, and therefore consumed a plant-
based diet supplemented with fish or low-fat
meat, today this is no longer the case.20
American Indians living on reservations often
rely on food—commodity and nutrition assis-
tance programs21,22 and frequently purchase
food from fast-food outlets and small grocery
or convenience stores, which typically have
a limited availability of high-quality produce
and low-fat foods.19
Given the high rates of poverty23 on Amer-
ican Indian reservations and poor food access
on rural reservations, food insecurity and its
health impacts among American Indian fami-
lies living on or near reservations are of great
concern.24,25 Using data from the 2001—2004
Current Population Survey, Gundersen exam-
ined food insecurity among American Indians
living on and those living off reservations and
found that during this period 28% of American
Indian households with children experienced
food insecurity, compared with 16% of non—
American Indian households with children.24
This disparity remained even after adjusting for
education, income, marital status, and age,
suggesting that American Indians had addi-
tional specific risk factors for food insecurity.
Furthermore, American Indians living in non-
metropolitan areas were more likely to be
food insecure than were those living in metro-
politan areasalthough identifying those indi-
viduals specifically residing on or near reser-
vations was not possible with this data set.
Small, reservation-specific studies have exam-
ined food insecurity among selected groups of
American Indians living on reservations, such
as young adults, and have similarly observed
that food insecurity is a prevalent and signifi-
cant problem for these subpopulations.26—28
Although it is clear that a sizable pro-
portion of American Indians experience food
insecurity, the correlates and consequences
of food insecurity among American Indian
families of young children living on or near
reservations are not well understood. To
address this need, we examined the preva-
lence and correlates of food insecurity
among Lakota children and their families
living on the Pine Ridge Reservation in South
Dakota.
Objectives. We sought to better understand the prevalence and conse-
quences of food insecurity among American Indian families with young
children.
Methods. Parents or caregivers of kindergarten-age children enrolled in the
Bright Start study (dyad n = 432) living on the Pine Ridge Reservation in South
Dakota completed a questionnaire on their childs dietary intake, the home food
environment, and food security. We assessed food security with a standard 6-
item scale and examined associations of food insecurity with family sociodemo-
graphic characteristics, parents and childrens weight, childrens dietary pat-
terns, and the home food environment.
Results. Almost 40% of families reported experiencing food insecurity.
Children from food-insecure households were more likely to eat some less
healthful types of foods, including items purchased at convenience stores (P =
.002), and food-insecure parents reported experiencing many barriers to accessing
healthful food. Food security status was not associated with differences in home
food availability or childrens or parents weight status.
Conclusions. Food insecurity is prevalent among families living on the Pine
Ridge Reservation. Increasing reservation access to food that is high quality,
reasonably priced, and healthful should be a public health goal. (Am J Public
Health. 2012;102:13461352. doi:10.2105/AJPH.2011.300522)
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METHODS
We drew data for this study from the
baseline survey of Bright Start, a group-ran-
domized controlled school-based trial to re-
duce excess weight gain among Lakota children
residing on or near the Pine Ridge Reservation
in South Dakota. We recruited all 14 schools
on the reservation (including 1 with 80%
American Indian enrollment just outside the
border) into the study. We distributed letters of
consent to the parents or caregivers (hence-
forth referred to as parents) of all kindergarten
students, inviting them and their child to have
their height and weight measured and for the
parents to complete a survey. We enrolled
2 cohorts of kindergarten students in the study
and collected baseline data in fall 2005 and fall
2006, before randomizing schools to inter-
vention and control conditions. Measurements
were voluntary, and all enrolled students
were eligible to participate. There were no
exclusion criteria, and we allowed children who
did not participate in measurements to partic-
ipate in the intervention activities if parents
agreed. Among the 472 kindergarten students
attending all 14 schools, parental consent was
obtained for 99% of the children, and 97%
of children with parental consent agreed to
participate in the study; therefore, 454 children
(96% of the total eligible) had baseline mea-
surements. Among these 454 children, 432
(95%) parents completed a parent survey and
therefore were included in this study. On the
basis of parent report and school records,
99.3% of children were of American Indian
heritage, with almost all children from the
Oglala Sioux Tribe (Lakota people).
Study Measures
Food security. We assessed food security with
the 6-item short form of the Household Food
Security Scale.29 This scale has been shown to
be valid when compared with the full 18-item
scale included in the Current Population Sur-
vey.30 The 6 items assessed families ability
to obtain food and the behaviors they engaged
in to conserve food over the previous 12 months.
Parents were excluded from analyses if they
had missing data for any of the 6 items (n =
11). We categorized parents who responded in
the affirmative to fewer than 2 items as expe-
riencing food security, those that responded
in the affirmative to 2 to 4 items as experi-
encing low food security, and those that
responded in the affirmative to 5 or more items
as experiencing very low food security.29
Sociodemographic characteristics. Parents an-
swered questions regarding their highest level of
education attained; current marital status; total
household income in the past year including
wages, salaries, social security, public assistance,
unemployment compensation, and child support;
personal relationship with the kindergarten child
enrolled in Bright Start; current work situation;
and whether anyone in their household currently
received food stamps (now known as the Sup-
plemental Nutrition Assistance Program) or
commodity foods (via the Food Distribution on
Indian Reservations program) or were enrolled in
the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC) program.
Ti ole. Ti ole is a Lakota tradition to address
hunger among families within the community.
The phrase can be translated as looking for
a home. The practice involves either going to
another home where there is enough food to
share a meal or inviting another family who
may not have enough food over for a meal. The
food received is often exchanged for help
around the house, such as construction work.
We asked parents a single survey item with
dichotomous (yes or no) response options re-
garding whether in the past 12 months their
family had ever gone ti ole when there was not
enough food.
Childrens body mass index. A team of trained,
local American Indian research staff traveling
to each school took anthropometric measure-
ments. J. H. H. trained team members in an-
thropometric measurements using the proto-
cols that Lohman et al. developed.31 We
measured height to the nearest 0.1 centimeter
using a portable stadiometer (Perspective En-
terprises, Portage, MI). We measured weight
using Tanita scales (model TBF-300) to the
nearest 0.1 kilogram. We calculated age- and
gender-specific body mass index (BMI; defined
as weight in kilograms divided by the square of
height in meters) percentiles,32 and we cate-
gorized children whose BMI was less than the
85th percentile as normal weight, those whose
BMI was equal to the 85th percentile to less
than the 95th percentile as overweight, and
those whose BMI was equal to or greater than
the 95th percentile as obese.33
Parents BMI. The trained research staff
measured parents body weight (kg) and height
(cm) using standardized measurement proto-
cols.31 We categorized parents with BMI less
than 25 as normal weight, those with a BMI
between 25 and 30 as overweight, and those
with a BMI of 30 or greater as obese.34
We did not obtain measured height and
weight for17% of parents in the current sample
(n = 72). For these parents, we imputed BMI
using the parents self-reported height and
weight collected at baseline, self-reported
height and weight collected during the follow-
up measurement period, or measured BMI
collected during the follow-up data measure-
ment period.
Childrens dietary intake. Parents reported
the frequency of their childs consumption of
specific foods and beverages over the past
month. Response categories included never,
1 to 3 times last month, 1 to 2 times a week,
3 to 4 times a week, 5 to 6 times a week, once
a day, and more than once a day. Types of
foods included fruits, vegetables, whole or 2%
milk, nonfat or 1% milk, 100% fruit juice,
and calorically dense savory foods, including
pizza, fry bread, and fried chicken. We also
asked parents the frequency with which their
child consumed food from a fast-food restau-
rant and hot or ready-made food from a con-
venience store or gas station over the past
month. This measure of dietary intake was
used in the Girls Health Enrichment Multi-Site
Studies trial.35 For foods that are commonly
consumed on a daily basis (e.g., fruit, vegeta-
bles, milk), we recoded the response options to
reflect daily intake with never = 0, 1 to 3 times
last month = 0.1, 1 to 2 times a week = 0.2,
3 to 4 times a week = 0.5, 5 to 6 times a
week = 0.8, once a day = 1, and more than
once a day = 2. For foods that are commonly
consumed less than daily (e.g., pizza, fast food,
hot or ready-made food from a convenience
store or gas station), we recoded the response
options to reflect weekly intake with never = 0,
1 to 3 times last month = 0.5, 1 to 2 times
a week = 1.5, 3 to 4 times a week = 3.5, 5 to
6 times a week = 5.5, once a day = 7, and
more than once a day = 9. We calculated total
daily intake of sugar-sweetened beverages by
summing the intake of fruit drinks, energy
drinks, sports drinks, Kool-Aid, and regular
soft drinks, and total intake of sweet and salty
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snacks by summing intake of cake, potato
chips, pretzels, ice cream, donuts, and candy.
Home food availability. We assessed home
food availability with a series of yes or no
questions asking parents to report whether
specific types of fruits, vegetables, beverages,
snacks, and energy-dense foods were available
in their home during the past week. We
adapted this item from the measure of home
food availability that Patterson et al. devel-
oped36 and that was used in the Girls Health
Enrichment Multi-Site Studies trial.35 The
measure has been shown to validly assess
home food availability when compared with
individuals dietary intake, nutrition awareness,
and nutrition-related stage of change.36 We
modified foods assessed by the home food
availability inventory on the basis of pilot
testing the instrument. Trained research staff,
who were members of the tribe, conducted
individual semistructured interviews with
36 parents or caregivers to assess factors such
as the appropriateness of types of foods listed,
response options, and length of time to com-
plete the inventory.
Family food practices. Parents reported the
frequency of family dinners per week and
family fast-food visits per week. Response
options for these questions ranged from never
to 7 or more times a week. We assessed food
shopping with the question, How often do
you (or someone in your household) make
a major food shopping trip? Response options
ranged from more than once a week to less
than once a month, and we recoded these to
reflect shopping trips per week.
Barriers to healthful food in the home. We
asked parents the extent to which they agreed
or disagreed with 8 statements of barriers to
serving healthful food to their families on
a 4-point Likert scale. These items included,
I dont buy many fruits because my family
doesnt like them and I dont buy many
vegetables because they cost too much. We
combined items that assessed barriers for fruits
and vegetables separately.
Statistical Analysis
We used the v2 test to examine associations
between the 3 levels of food security and
sociodemographic characteristics represented
categorically. To examine associations between
food security status and childrens daily or
weekly intake of specific foods, we square-root-
transformed the dietary intake variables to
approximate a Gaussian distribution. We then
developed hierarchical linear regression
models including food security status as the
independent variable and childrens daily or
weekly intake of foods represented continu-
ously as the dependent variable. To account for
potential clustering of behaviors among chil-
dren who attended schools together, we in-
cluded a school-level variable in the regression
models as a random effect. We calculated
adjusted daily or weekly mean intake of specific
foods by level of food security and back-trans-
formed them to obtain the geometrical mean.
If the overall F-statistic was significant, we used
an adjusted Tukey test to highlight sources
of differences between the adjusted means. We
developed similar regression models to exam-
ine associations between food security and
nontransformed, continuous measures of home
food availability, family food practices, and
barriers to healthful food in the home.
RESULTS
Approximately 40% of parents reported that
their households had experienced food inse-
curity within the past 12 months. About a third
of these 124 families (10.5% of all families)
experienced very low food security. Food in-
security was more prevalent among families
with a lower total household income and those
with the parent not currently employed for pay.
We found significant differences in the per-
centage of families receiving food stamps
(P = .002) and having gone ti ole (P < .001) by
families food security status. We did not
observe significant differences in either chil-
drens or parents weight status by food security
status (Table 1).
We observed few differences in childrens
dietary intake by food security status. Children
whose families experienced very low food
security consumed hot food or ready-made
food from a convenience store or gas station
more than twice as often as did children whose
families experienced food security (P = .002),
and food-insecure children consumed pizza
and fried chicken more often than did food-
secure children (Table 2). We did not observe
any differences in families home food avail-
ability or frequency of families fast-food visits,
family meals, or food shopping trips by food
security status (Table 3).
Parents experience of barriers to having
healthful food in the home differed by food
security status. Food-insecure parents were
most likely to agree that there was little
variety of fruit and vegetables where they buy
groceries (P = .003) and were more likely
to report that where they buy groceries the
fruit and vegetables were in poor condition
(P = .03). Food-insecure parents were also
more likely to report that their family does not
like fruits and vegetables (P = .01) and that
it is difficult to find time to cook in the evening
(P = .01; Table 3).
DISCUSSION
We have extended the results of previous
research by demonstrating a high prevalence
of food insecurity among American Indians
and identifying correlates and potential deter-
minants and consequences of food insecurity
such as convenience store use, parents per-
ceptions of barriers to healthful eating, and
participation in ti ole. As previously observed
among American Indian populations, both
those living on and those living off reservations,
food insecurity was common. The prevalence
of food insecurity (39.9%) was nearly twice
as high as that of households with children
nationally.17
We observed few differences in childrens
dietary intake by food security status. How-
ever, children from food-insecure households
consumed hot or ready-made foods from
convenience stores or gas stations more often
than did food-secure children. The differences
observed in childrens intake of pizza and
fried chicken by food security status likely
reflect the ready-made foods that children and
families purchase from these establishments.
Similar positive associations between food in-
security and intake of fried and high-fat foods,
and specifically fried chicken, were seen in
a study of Mexican-born children of migrant
workers in California.37 On the Pine Ridge
Reservation, as in many rural areas,38,39 con-
venience stores and gas stations are common
and provide fast and inexpensive, although
rarely nutritionally adequate, meals for families.
Food-insecure families may be particularly re-
liant on food from convenience stores because
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of the inability to travel to larger grocery stores,
which are farther away, or to budget and plan for
less frequent shopping trips. American Indian
parents may also be more likely to feed their
children high-fat, calorically dense foods because
of their communities histories of food scarcity and
the desire to have heavier children who can
withstand illness and leaner times.20,37,40,41
Among the Lakota Indians participating in
Bright Start, food-insecure families were more
likely to be receiving Supplemental Nutrition
Assistance Program benefits than were food-
secure families, and a higher proportion of
food-insecure families received assistance
through the Food Distribution Program on
Indian Reservations and WIC programs, al-
though the differences across level of food
security were not statistically significant. The
high enrollment in these programs of food-
insecure American Indian families suggests that
improvements to the quantity and quality of
food offered through these programs, as well
as the complementary nutrition education
components, may be important mechanisms
through which to improve the food security
and dietary intake patterns of participating
families. Specifically, a focus on helping parents
reduce their childrens consumption of un-
healthful choices frequently available at con-
venience stores, as well as increasing menu
planning and food budgeting skills, may be
particularly beneficial. Additionally, although
federal food assistance programs are making
progress in the promotion of healthful foods,42
the majority of food retailers on reservations
are convenience stores that do not consistently
stock fresh produce, whole grain products, or
low and nonfat dairy products. To address this
need, policies that encourage larger grocery
stores that have the purchasing power to pro-
vide lower cost fresh foods to open on or near
rural reservations and enable the proprietors
of small grocery and convenience stores to
stock healthful food in an economically viable
manner would help Supplemental Nutrition
Assistance Program and WIC participants
to make the best use of the nutrition assis-
tance services they receive.
In this study, food insecurity was consis-
tently associated with parents perceptions of
barriers to obtaining healthful food for their
families. Several of these barriers are likely
a reflection of families economic limitations;
however, barriers such as family members not
liking fruits and vegetables and not having time
to cook in the evenings have little obvious
association with food access. Although in this
cross-sectional study we cannot ascertain
the causal mechanisms that drive these find-
ings, the consistency with which food-insecure
parents reported barriers to obtaining healthful
food suggests that the accumulation of stress
or experience of depression that often accompanies
TABLE 1Sociodemographic Characteristics and Weight Status of Bright Start Families by
Household Food Security Status: Lakota People, Pine Ridge Reservation, South Dakota,
20052006
Characteristic % (No.)
a
Food
Security,
b
%
Low Food
Security,
c
%
Very Low
Food Security,
d
% P (v2)
Parents educational attainment .09
< high school 23.3 (98) 58.2 28.6 13.3
Completed high school 22.6 (95) 63.2 29.5 7.4
Some college or technical school 35.0 (147) 55.1 29.9 15.0
Completed college or graduate school 19.1 (80) 67.5 30.0 2.5
Parents relationship status .33
Single or never married 30.6 (128) 59.4 30.5 10.2
Married 28.4 (119) 64.7 26.9 8.4
Living in marriage-like relationship 20.3 (85) 65.9 25.9 8.2
Separated, divorced, or widowed 20.8 (87) 49.4 35.6 14.9
Total household income, $ < .001
< 15 000 49.5 (203) 51.2 32.5 16.3
15 00034 999 32.2 (132) 65.2 29.6 5.3
35 000 18.3 (75) 74.7 21.3 4.0
Parents relationship to child .09
Biological or stepmother 67.8 (284) 63.0 27.5 9.5
Biological or stepfather 8.8 (37) 67.6 24.3 8.1
Other 23.4 (98) 48.0 37.8 14.3
Parents employment status .05
Not currently employed for pay 48.1 (202) 54.0 32.7 13.4
Employed part time 9.3 (39) 76.9 20.5 2.6
Employed full time 42.6 (179) 63.1 28.0 8.9
Childs weight status .4
Normal weight 69.8 (289) 58.8 31.8 9.3
Overweight 14.7 (61) 63.9 23.0 13.1
Obese 15.5 (64) 62.5 23.4 14.1
Parents weight status .81
Normal weight 13.8 (58) 60.3 31.0 8.6
Overweight 24.8 (104) 56.7 33.7 9.6
Obese 61.3 (257) 61.1 27.6 11.3
Food support in household, %
Receive food stamps 63.0 (249) 57.0 67.8 83.3 .002
Receive commodities 37.0 (127) 34.1 39.8 50.0 .31
Receive WIC 43.7 (162) 42.9 43.9 47.4 .88
Those having gone ti ole, % 8.7 (36) 1.2 13.2 38.1 < .001
Note. WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
aNo. may vary within descriptive characteristics because of nonresponse.
bTotal % (no.) = 60.1 (253).
cTotal % (no.) = 29.5 (124).
d
Total % (no.) = 10.5 (44).
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food insecurity9,43,44 may contribute to a per-
vasive feeling that feeding ones family health-
fully is a very difficult or even unachievable
goal. These findings suggest a need for food
security programs to not only increase access to
food but also work with families and
communities to address the mental health
concerns that may accompany a history of food
insecurity and increase individuals self-efficacy
for feeding their families healthfully.
A strength of this study is that it is among
the first to examine the correlates of food
insecurity among a rural reservation-residing
American Indian tribe, a population that
experiences high rates of poverty and is at
great risk for nutrition-related chronic dis-
eases. However, this study is not without
limitations. Specifically, the measures of home
food availability we used in this study
assessed only whether a limited number of
foods were available in the home during the
past week and did not determine the quantity
or quality of such foods. Future research
examining food availability among food-in-
secure families in greater detail would benefit
from using a more comprehensive measure of
home food availability and assessing food
availability at multiple points in time, as the
quantity and quality of food in the home are
likely to vary on the basis of proximity to
the time when financial food support is
received.45,46
TABLE 2Parent-Reported Childrens Mean Weekly Dietary Intake by Food Security
Status: Lakota People, Pine Ridge Reservation, South Dakota, 20052006
Food Item
Food
Security
Low Food
Security
Very Low Food
Security Pdf = 2
Fruit, times/d 0.77 0.70 0.56 .08
Vegetables, times/d 0.95 0.86 0.81 .41
French fries or fried potatoes, times/wk 1.72 1.94 1.99 .38
Pizza, times/wk 1.12 1.32 1.68 .03
Fried chicken, times/wk 0.78 1.03 1.16 .04a
Sugar-sweetened beverages, times/d 1.13 1.02 1.31 .23
Sweet and salty snacks, times/d 1.36 1.51 1.49 .45
Skim or 1% milk, times/d 0.13 0.16 0.15 .63
Whole or 2% milk, times/d 0.84 0.80 0.61 .17
Chocolate milk, times/d 0.34 0.31 0.34 .8
Fast food, times/wk 0.81 0.95 0.99 .41
Hot or ready-made foods from a convenience
store or gas station, times/wk
0.64 0.96 1.30 .002
Note. Means and P values derived from square-root-transformed outcome variables. Means with different superscripts are
statistically significantly different using Tukey-Kramer adjusted P < .05.
aBecause the adjusted Tukey-Kramer test is more conservative than the overall F test, the post hoc comparison of means
resulted in no significant differences between means.
TABLE 3Parent-Reported Home Food Availability, Food Practices, and Barriers to Healthful Eating by Food Security
Status: Lakota People, Pine Ridge Reservation, South Dakota, 20052006
Variable Range
Food Security,
Mean
Low Food Security,
Mean
Very Low Food Security,
Mean Pdf = 2
Weekly home food availability
Fruit 0.008.00 5.65 5.80 6.24 .14
Vegetables 0.009.00 6.49 6.29 6.23 .51
French fries or fried potatoes 0.001.00 0.77 0.77 0.81 .8
Sugar-sweetened beverages 0.005.00 2.21 2.43 2.65 .06
Salty snacks 0.003.00 1.42 1.52 1.46 .6
Sweet snacks 0.005.00 2.59 2.92 2.78 .1
Energy-dense foods (e.g., lunch meat, fried meat, ramen noodles) 1.009.00 5.98 6.25 6.42 .19
Family food practices/wk
Fast-food visits 0.005.50 0.80 0.63 0.61 .09
Family meals 0.007.50 6.20 5.95 5.92 .43
Food shopping trips 0.152.00 0.59 0.56 0.45 .13
Barriers to healthful food in the home
a
Little variety of fruit and vegetables 2.95 2.70 2.56 .003
Poor condition of fruit and vegetables 3.07 2.99 2.76 .03
Family doesnt like fruit and vegetables 3.28 3.14 3.03 .01
Fruit and vegetables cost too much 3.24 3.00 2.76 < .001 Difficult to find time to cook in the evening 3.21 2.99 2.91 .01 Not easy to buy food near where I live 2.69 2.45 2.26 .003 Note. Means are statistically significantly different using Tukey-Kramer adjusted P < .05. a strongly agree = 1; strongly disagree = 4. RESEARCH AND PRACTICE 1350 | Research and Practice | Peer Reviewed | Bauer et al. American Journal of Public Health | July 2012, Vol 102, No. 7 Factors at multiple socioecological levels af- fect families experience of food insecurity, from individuals health status and food preparation skills to governmental policies. Specifically among the Lakota people residing on the Pine Ridge Reservation, community- and family- based efforts such as shared gardens, organized transportation to high-quality supermarkets, home economics classes for adults and children that teach skills to create simple and healthful meals, and cooking and canning collectives may increase access to and knowledge about health- ful food while building social networks and social capital in communities, which can buffer the harmful effect that poverty, unemployment, and discrimination have on health.47,48 As the Lakota people specifically have a cultural foundation for sharing food and ensuring that others are fed, community-driven efforts built on the ti ole tradition may be particularly successful. j About the Authors At the time of the study, Katherine W. Bauer, John H. Himes, Mary Smyth, Bonnie Holy Rock, Peter J. Hannan, and Mary Story were with the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN. Rachel Widome is with the Department of Medicine, University of Minnesota, Minne- apolis. Correspondence should be sent to Katherine W. Bauer, PhD, MS, Department of Public Health and Center for Obesity Research and Education, Temple University, 1301 Cecil B. Moore Avenue, Ritter Annex, 9th Floor, Philadel- phia, PA 19122 (e-mail: [emailprotected]). Reprints can be ordered at http://www.ajph.org by clicking the Reprints link. This article was accepted October 23, 2011. Contributors K. W. Bauer conducted the statistical analysis and wrote the article. J. H. Himes, M. Smyth, B. Holy Rock, P. J. Hannan, and M. Story were responsible for the de- velopment, implementation, and evaluation of the Bright Start intervention. All authors contributed to the con- ceptualization of the study and provided significant editing of the article. Acknowledgments The National Heart, Lung, and Blood Institute, National Institutes of Health supported this research (grant 1 R01HL078846). K. W. Bauer was supported by a post- doctoral fellowship from the National Institute of Di- abetes and Digestive and Kidney Diseases, National Institutes of Health (grant T32DK083250). We express thanks to the school administrators, teachers, staff, and parents on the Pine Ridge Reservation for their interest in and support of the Bright Start project. Human Participant Protection The University of Minnesotas institutional review board Human Subjects Committee and the Oglala Sioux Tribal Council and Aberdeen Indian Health Service Area in- stitutional review boards approved all study procedures. References 1. Core indicators of nutritional state for difficult-to- sample populations. J Nutr. 1990;120(suppl 11):1559--- 1600. 2. Kaiser LL, Melgar-Quinonez HR, Lamp CL, Johns MC, Sutherlin JM, Harwood JO. Food security and nutritional outcomes of preschool-age Mexican-American children. J Am Diet Assoc. 2002;102(7):924---929. 3. Melgar-Quionez HR, Kaiser LL. Relationship of child-feeding practices to overweight in low-income Mexican-American preschool-aged children. J Am Diet Assoc. 2004;104(7):1110---1119. 4. Widome R, Neumark-Sztainer D, Hannan PJ, Haines J, Story M. Eating when there is not enough to eat: eating behaviors and perceptions of food among food-insecure youths. Am J Public Health. 2009;99(5):822---828. 5. Weinreb L, Wehler C, Perloff J, et al. Hunge
