Food Insecurity and Body Mass Index: A Longitudinal Mixed Methods Study, Chelsea, Massachusetts, 2009-2013

Introduction Cross-sectional studies show an association between food insecurity and higher body mass index (BMI), but this finding has not been evaluated longitudinally. Patient perspectives on food choice in resource-constrained environments are not well understood. The objective of this study was to evaluate the longitudinal association between food insecurity and BMI. Methods This mixed methods study used both a retrospective matched cohort and focus groups. For the quantitative analysis, all patients in a community health center who reported food insecurity from October 2009 through March 2010 (n = 457) were followed through August 2013 and compared with controls matched by age, sex, and race/ethnicity (n = 1,974). We evaluated the association between food insecurity and change in BMI by using linear, mixed effects longitudinal models. The qualitative analysis included patients with food insecurity, stratified by BMI. Qualitative data were analyzed by using open coding and grounded theory. Results The mean age of participants was 51 years; 61% were women, and 73% were Hispanic. Baseline BMI was similar in food insecure participants and matched controls. After adjustment in longitudinal analyses, food insecurity was associated with greater increase in BMI (0.15 kg/m(2) per year more than controls, P <.001). Themes identified in 4 focus groups included attitudes and knowledge about food, food access, and food practices. Participants with BMI of 30 kg/m(2) or less highlighted skills such as budgeting and portion control. Conclusion Food insecurity is associated with increase in BMI. The skills of food insecure participants who were not obese, such as portion control and budgeting, may be useful in weight management interventions for vulnerable patients.