Article
EvaluationofDietQuality,PhysicalHealth,andMentalHealth BaselineDatafromaWellnessInterventionforIndividuals
LivinginTransitionalHousing
CallieMillward 1,KyleLyman 2,SoonwyeLucero 2,JamesD.LeCheminant 2,CindyJenkins 3,KristiStrongo 4 , GregorySnow 5 ,HeidiLeBlanc 3,LeaPalmer 4 andRickelleRichards 2,*
1 DepartmentofNutritionalSciences,ThePennsylvaniaStateUniversity,UniversityPark,PA16802,USA; cjm8279@psu.edu
2 DepartmentofNutrition,Dietetics&FoodScience,BrighamYoungUniversity,Provo,UT84602,USA; lyman444@student.byu.edu(K.L.);soonwyel@gmail.com(S.L.);james_lecheminant@byu.edu(J.D.L.)
3 ExtensionHomeandCommunityDepartment,UtahStateUniversityExtension,UtahStateUniversity, Logan,UT84322,USA;cindy.jenkins@usu.edu(C.J.);heidi.leblanc@usu.edu(H.L.)
4 DepartmentofNutrition,Dietetics&FoodSciences,UtahStateUniversity,Logan,UT84322,USA; kristi.strongo@usu.edu(K.S.);lea.palmer@usu.edu(L.P.)
5 DepartmentofStatistics,BrighamYoungUniversity,Provo,UT84602,USA;snow@stat.byu.edu
* Correspondence:rickelle_richards@byu.edu;Tel.:+1-801-422-6855
Abstract
AcademicEditor:Javier Aranceta-Bartrina
Received:28June2025
Revised:29July2025
Accepted:1August2025
Published:6August2025
Citation: Millward,C.;Lyman,K.; Lucero,S.;LeCheminant,J.D.;Jenkins, C.;Strongo,K.;Snow,G.;LeBlanc,H.; Palmer,L.;Richards,R.Evaluationof DietQuality,PhysicalHealth,and MentalHealthBaselineDatafroma WellnessInterventionforIndividuals LivinginTransitionalHousing. Nutrients 2025, 17,2563. https:// doi.org/10.3390/nu17152563
Copyright: ©2025bytheauthors. LicenseeMDPI,Basel,Switzerland. Thisarticleisanopenaccessarticle distributedunderthetermsand conditionsoftheCreativeCommons Attribution(CCBY)license (https://creativecommons.org/ licenses/by/4.0/).
Background/Objectives:Theaimofthisstudywastoevaluatebaselinehealthmeasurements amongtransitionalhousingresidents(n =29)participatinginan8-weekpilotwellnessintervention. Methods:Researchersmeasuredanthropometrics,bodycomposition,muscular strength,cardiovascularindicators,physicalactivity,dietquality,andhealth-relatedperceptions.Researchersanalyzeddatausingdescriptivestatisticsandconventionalcontentanalysis. Results:Mostparticipantsweremale,White,andfoodinsecure.MeanBMI(31.8 ± 8.6kg/m2), waist-to-hipratio(1.0 ± 0.1males,0.9 ± 0.1females),bodyfatpercentage(25.8 ± 6.1%males, 40.5 ± 9.4%females),bloodpressure(131.8 ± 17.9/85.2 ± 13.3mmHg),anddailystepcounts exceededrecommendedlevels.Absolutegripstrength(77.1 ± 19.4kgmales,53.0 ± 15.7kg females)andperceivedgeneralhealthwerebelowreferencestandards.TheHealthyEating Index-2020score(39.7/100)indicatedlowdietquality.Commonbarrierstohealthyeating werefinancialconstraints(29.6%)andlimitedcooking/storagefacilities(29.6%),aswellasto exercise,physicalimpediments(14.8%). Conclusions:Residentslivingintransitionalhousing havelessfavorablebodycomposition,diet,andgripstrengthmeasures,puttingthematriskfor negativehealthoutcomes.Wellnessinterventionsaimedatpromotingimprovedhealth-related outcomeswhileaddressingcommonbarrierstoproperdietandexerciseamongtransitional housingresidentsarewarranted.
Keywords: homelessness;transitionalhousing;SNAP-Ed;nutritioneducation;dietquality; physicalactivity;health;wellnessintervention;foodsecurity;bodycomposition
1.Introduction
HomelessnessintheUnitedStates(U.S.)hasbeenassociatedwithlesshealthydiets, includinglowerthanrecommendedintakesoffiber,calcium,vitaminsAandC,fruits, andvegetables[1–5].Limitationsinphysicalfunctioninghavealsobeenobservedamong individualsexperiencinghomelessnessandhavecontributedtolowphysicalactivity
levels[6].Negativehealthoutcomesrelatedtopoordietaryintakeandphysicalactivity showninthispopulationhaveincludedcardiovasculardiseaseandobesity[7–9].
Althoughpaststudieshaveattemptedtoprovideacomprehensivehealthriskassessmentinthispopulation,themeasurementsusedinthesestudieshaveshownlimitations. Forexample,manystudiesevaluatingdietaryintakehavefocusedonnutrientandfood groupintakeratherthanoveralldietquality[1–5,10].Dietqualityconsidersanindividual’s foodintakeincomparisonwithdietaryrecommendations,whichoffersamorecomplete viewintoapopulation’snutritionalstatus[11].AlthoughHoisingtonetal.[12]evaluated dietqualityamongthoseexperiencinghomelessness,thestudypopulationfocusedonU.S. veteransexperiencinghomelessness,whoseexperiencesmaydifferfromthegeneraladult populationexperiencinghomelessness.
Toevaluatebodycompositioninthispopulation,researchershavereliedonBody MassIndex(BMI)[2,4,8,9].FewstudieshavepairedBMIwithmorespecificmeasuresof bodycomposition,suchaswaistcircumferenceorwaist-to-hipratios[4],whichhavebeen showntobebetterindicatorsofhealthriskthanBMIalone[13,14].Muscularstrength hasbeenpreviouslyassessedamongadultsexperiencinghomelessnessinIreland[6]and Mexico[15]usinghandgripstrength,whichhasbeenshownasanindicatorofgeneral health[16].However,thismeasureremainsunexploredintheU.S.
Limitationsfrompreviousstudiesmeasuringphysicalactivitylevelshaveincluded relyingonqualitativereportsofphysicalactivityoronlymeasuringVO2max[6,17].AlthoughonestudyintheU.S.utilizedaccelerometers,thepurposewasrelatedtoevaluating theeffectivenessofaninterventionaimedatincreasingphysicalactivity,nottoevaluate normalday-to-dayliving[18].Collectively,thesemethodshavepreventedresearchersfrom gaininginsightsaboutday-to-dayphysicalactivitypatternswithinthispopulation.
Researchersfromthepresentstudysoughttoaddressthelimitationsidentifiedinthe previousstudiesbyincorporatingamorecomprehensivesetofquantitativeandqualitative measuresintoapilotwellness(definedbytheauthorsashealthyeatingandphysical activitypatternsaimedatpromotinghealthandwell-being)interventionstudyamong adultslivingintransitionalhousingunitsatalocalhomelessresourcecenter.Theaimof thepresentstudywastoevaluatebaselinemeasurementsfromthepilotinterventionstudy includingdietquality,bodycomposition(fatmass,fat-freemass,bodyfatpercentage), handgripstrength,accelerometer-basedphysicalactivity,bloodpressure,heartrate,blood oxygenationlevels,health-relatedqualityoflife,depression,anxiety,stress,andperceived barrierstohealthyliving.Thebreadthofmeasurementstaken,alongwiththeuseof validatedequipmentandmeasurementapproaches,willprovideamorecompleteand accurateviewoftransitionalhousingresidents’healthstatusthanhasbeenpublished previouslyinasinglestudy.Researchersandpractitionerscanusethiscomprehensiveset ofdatatomoreeffectivelytailorinterventionstoaddresshealthconcernsidentified.In thepresentpilotinterventionstudy,wehypothesizedthattransitionalhousingresidents wouldhavelessfavorablenutritionandhealth-relatedmeasurements.
2.MaterialsandMethods
2.1.StudyDesignandPopulation
Researchersutilizedcross-sectionaldatacollectedfromtransitionalhousingresidents whotookpartinan8-weekwellnesspilotinterventionstudyatalocalhomelessresource center.ResearchersimplementedanadaptedSupplementalNutritionAssistanceProgram Education(SNAP-Ed)curriculum[19]throughoutthe8-weekperiod,withmeasurements takenbeforetheintervention(week1),immediatelypost-intervention(week10),andtwo monthspost-intervention(week18).Thepresentstudyreportsbaselinedatacollectedfrom fourcohortsbyresearchersbetweenSeptember2022andJanuary2024.
Eligibilitycriteriaincludedbeing18+yearsold,English-speaking,andresidinginthe transitionalhousingunits.Recruitmentoccurredthroughpostingfliersandinpersonat aweeklyhousemeeting.Writteninformedconsentwasobtainedfromallparticipantsat baseline,beforemeasurementsweretaken.Participantsreceived$10cashforcompleting thebaselineassessment.UtahStateUniversity’sInstitutionalReviewBoardapprovedthis study(Protocol#12210,approved5May2022,through15January2029).
2.2.DataCollectionandMeasures
2.2.1.TrainingProtocol
Researchersreceivedtrainingoncivilrights,privacyrights,trauma-informedmethods[20],anddatacollectiontechniques.Datacollectiontrainingemphasizedparticipant autonomy,offeringoptionsforsurveycompletioninprivateand/orverbalformatsand theabilitytoscheduleappointmentsconvenienttoparticipants[20].Bodymeasurement trainingemphasizedsensitivity,detailingprocedures,seekingpermission,andrefraining fromcommentaryonmeasurements[20].
2.2.2.Demographics
Participantsprovidedinformationaboutage,sex,race,andethnicity.
2.2.3.FoodSecurity
ParticipantscompletedtheU.S.DepartmentofAgriculture’s(USDA)Six-ItemShort FormoftheFoodSecuritySurveyModule[21].ResearchersusedtheUSDAscoringcriteria toclassifyfoodsecurity[21].
2.2.4.BodyTemperature,HeartRate,andBloodOxygenation
BodytemperaturewasmeasuredwithaTherma9Pro(Oxiline,LLC.,Miami,FL, USA).APulse7Pro(Oxiline,LLC.,Miami,FL,USA)fingertippulseoximeterwasplaced onparticipants’indexfingerfor10–15stodetermineheartrate(bpm)andbloodoxygen levels(%).Normallevelswereconsidered97–99 ◦Fforbodytemperature[22],60–100bpm forrestingheartrate[23],and95–100%forbloodoxygenation[24].
2.2.5.BloodPressure
Participantssatwithbothfeetonthegroundforfiveminutesbeforethemeasurement[25].Theaneroidsphygmomanometer(AmericanDiagnosticCorporation,Hauppauge,NY,USA)cuffwasplacedaroundtheupperleftarm,andthestethoscopeover thebrachialarteryunderthecuff.Thecuffwasinflatedtoamaximumof180mmHg andreleasedgraduallyat2–3mmHgpersecond.Thefirstclearsound(Phase1Korotkoff sound)indicatedsystolicbloodpressure,whilethefinaldistinctsoundbeforemuffling (PhaseIVKorotkoff)indicateddiastolicbloodpressure[25].Bloodpressurecategorieswere basedonrecommendationsfromtheAmericanHeartAssociation[26].
2.2.6.Anthropometrics
Heightwasmeasuredusingaportablestadiometer(Seca,Hamburg,Germany)withoutshoestothenearest0.1cm.Weightwasmeasuredinnormalclothing,withoutshoes, usingaportabledigitalscale(BefourInc.,Saukville,WI,USA)accurateto ±0.1kg.BMIwas calculated(kg/m2),withclassificationsdesignatedasunderweight(<18.5),healthyweight (18.5–24.9),overweight(25.0–29.9),andobese(≥30.0)[27].Waistandhipcircumference weremeasuredattheumbilicusandwidestportionofthebuttocks,respectively,usinga spring-loadedGulickmeasuringtape(BlueJay).Twomeasurementsforeachparameter weretakenpersite,withtheaveragereported.Waist-to-hipratios(waistcircumference/hip
circumference)werecomparedwithrecommendedranges:<0.9formalesand<0.8for females[28].
2.2.7.BodyComposition
Bioelectricalimpedanceanalysis(Tanita,Tokyo,Japan)providedestimatedfatmass (lbs),fat-freemass(lbs),andbodyfatpercentage.Bodyfatmassindex(BFMI,fatmass [kg]/height[m]2)andfat-freemassindex(FFMI,fat-freemass[kg]/height[m]2)calculationsandinterpretationwerebasedonKyleetal.[29].Bodyfatpercentagewascompared withsex-andage-specificrecommendedrangesasoutlinedbyKyleetal.[29].
2.2.8.MuscularStrength
AJamarHydraulicHandDynamometer(PattersonMedical,Warrenville,IL,USA) measuredhandgripstrength,whichisanindexofoverallhealth[30]andphysicalfunction[31].Participantssqueezedthedynamometeratmaximaleffortwiththeirelbowat arightangle[31].Thehighestmeasurefrombothhandswassummedforabsolutegrip strength(kg)andthendividedbyBMItocalculaterelativegripstrength(kg/BMI)[31]. ValueswerecomparedwiththosereportedbyLawmanetal.[31]foradultmales(absolute gripstrength,89.7 ± 0.8kgandrelativegripstrength,3.2 ± 0.1kg/BMI)andfemales (absolutegripstrength,56.1 ± 0.5kgandrelativegripstrength,2.0 ± 0kg/BMI).
2.2.9.PhysicalActivity
Todeterminephysicalactivity,tri-axialActigraphaccelerometers(wGT3X-BT+)(Pensacola,FL,USA)wereused.Accelerometersarecommonlyreportedinresearchstudies[32]. Eachparticipantworetheaccelerometeronthenon-dominantwristforaperiodof7days. Accelerometersallowfortheintensityofactivitytobedetermined.However,giventhe variabilityinwrist-wornaccelerometerintensitycutpointsreportedinpreviousstudies andthelackofvalidatedintensitycutpointsforthepopulationusedinthepresentstudy, wereportonlyaveragestepsperday.Limitationsofwrist-wornintensitycutpointsare discussedindetailbyGaoetal.[33].Stepcountswerecomparedtolevelsshowntoreduce all-causemortalityinadults(6000–10,000)[34].
2.2.10.DietQuality
DietqualitywasassessedusingtheNationalCancerInstitute’sAutomatedSelfAdministeredDietaryAssessmentTool(ASA24)[35]andtheHealthyEatingIndex-2020 (HEI-2020)[36].TheHEI-2020measureddietqualitybasedonalignmenttotheDietary GuidelinesforAmericansandyieldedatotalscorebetween0and100,withhigherscores indicatingbetterdietquality[11,36].TheaveragescoreamongthegeneralUSadult populationrangesfrom57to61[37].
2.2.11.Health-RelatedQualityofLife(HRQOLSF-36)
Participants’perceptionsofhealthwerebasedonresponsestotheeightdomains oftheHRQOLSF-36[38].ScoresforeachdomainwerecomparedtoguidelinesrecommendedbytheRANDCorporation[38]:Physicalfunctioning,70.6 ± 27.4;rolelimitationsduetophysicalhealth,53.0 ± 40.8;rolelimitationsduetoemotionalproblems, 65.8 ± 40.7;energy/fatigue,52.2 ± 22.4;emotionalwell-being,70.4 ± 22.0;socialfunctioning,78.8 ± 25.4;pain,70.8 ± 25.5;andgeneralhealth,57.0 ± 21.1.
2.2.12.DASS-42
TheDepressionandAnxietyStressScale(DASS)-42included14itemsineachsubscale fordepression,anxiety,andstress[39].Responseoptionswere0=didnotapplytomeatall, 1=appliedtometosomedegree,orsomeofthetime,2=appliedtometoaconsiderable
degree,oragoodpartoftime,and3=appliedtomeverymuch,ormostofthetime. Scoresweretotaledbysubscale,withsummedscoresclassifiedintonormal(depression, 0–9;anxiety0–7;stress,0–14),mild(depression,10–13;anxiety,8–9;stress,15–18),moderate (depression,14–20;anxiety,10–14;stress,19–25),severe(depression,21–27;anxiety,15–19; stress,26–33),andextremelysevere(depression,28+;anxiety,20+;stress,34+)[39].
2.2.13.CreateBetterHealthSurvey
ParticipantscompletedanonlineQualtrics(Provo,UT,USA)surveyusingaresearcher’siPadthatincludedquestionsaboutstretchingfoodbudgets,foodvariety,nutritionlabelusage,grocerylistusage,foodsafetyadherence,andmealadjustments.Likertscaleresponseoptionswere1(never)to5(always).Perceivedbarrierstohealthyeating andphysicalactivityweremeasuredviaopen-endedquestions.
2.3.DataAnalysis
ResearchersuseddescriptivestatisticsforLikert-scaledsurveyitems,physicalmeasurements,HRQOLSF-36,DASS-42,anddemographicsusingIBMSPSS,v.28,andfor HEI-2020andphysicalactivityusingR(RCoreTeam,2023).ProgrammingfromtheNationalCancerInstitutewasusedtocalculateHEI-2020scores[40].ActiLifesoftwarev6.13.6 (Actigraph,Pensacola,FL,USA)wasutilizedtoinitialize,download,andprocessphysical activitydata.Physicalactivitydatawereoriginallycollectedin10sepochsbutconverted to60sepochsintheActiLifesoftware.Weexcludedanydaysthatdidnotreachatleast 18hofweartime(75%)[41],aswellasparticipantswhodidnothaveatleast2daysof usabledata.UsingtheActilifesoftware,stepcountsweredetermined.Subject-weighted meanscoreswerecalculated.Wenotedthatoneparticipanthadanunusuallyhighstep count(78,961stepsperday).WenoteintheResultstheaveragestepcountsandstandard deviationswithandwithoutthisparticipant.
Fortheopen-endedquestions,researchersusedaconventionalcontentanalysis adaptedfromHseihandShannon[42].Tworesearchersindependentlyreviewedsurveyresponseslikeanarrativetobuildacodebook.Researchersindependentlycodedthe dataonMicrosoftExcel(Microsoft365subscription)usingthecodebook.Researchers comparedcodingandreconciledanydiscrepancies,withathirdresearcherresolvingany unresolveddifferences.Totalscoresandpercentageswerecalculatedtoidentifythemost prevalentbarriers.
3.Results
Mostparticipantsidentifiedasmale,between55and64yearsold,andWhite,and wereclassifiedashavingloworverylowfoodsecurity(Table 1).
Table1. Baselinedemographicsoftransitionalhousingresidentsparticipatinginawellnessinterventionprogramatalocalhomelessresourcecenter(n =29).
Total, n (%)
Sex
Male17(58.6)
Table1. Cont.
35–447(24.1)
45–544(13.8)
55–6411(37.9)
65+2(6.9)
Hispanic/Latino a Yes4(14.8)
No23(85.2)
Race b
AmericanIndian/AlaskanNative1(3.8)
Black/AfricanAmerican1(3.8)
White23(88.5)
Other c 1(3.8)
FoodSecurity ad
HighorMarginal8(29.6)
Low13(48.1)
VeryLow6(22.2)
Total, n (%)
a Missingdata, n =2. b Missingdata, n =3,andresponsesnotselected:Asian,NativeHawaiian,orPacificIslander. c OtherresponsesincludedMexicanAmerican(n =1). d DatacollectedusingtheU.S.HouseholdFoodSecurity SurveyModule:Six-ItemShortForm[21].
AsshowninTable 2,themeanbaselinemeasurementforbloodpressurewas 132 ± 17.9/85 ± 13.3mmHg;BMIwas31.8 ± 8.6kg/m2;waist-to-hipratiowas 1.0 ± 0.1formalesand0.9 ± 0.1forfemales;andbodyfatmassindexwas 7.7 ± 3.1formalesand15.3 ± 7.7forfemales.Themeanabsolutehandgripstrengthwas 77.1 ± 19.4kgformalesand53.0 ± 15.7forfemales.Theaveragenumberofsteps perdaytakenbyparticipantswas14,334.0 ± 14,297.8stepsforallparticipantsand 11,524.3 ± 3951.6stepswhenasingleoutlierwasremoved.
Table2. Baselinemeasurementsoftransitionalhousingresidentsparticipatinginawellnessinterventionprogramatalocalhomelessresourcecenter(n =29).
PhysicalMeasurementsMeanStd.Dev.ReferenceStandards a Temperature(F)97.71.097–99
RestingHeartRate(bpm)86.813.060–100
Oxygenation(%)96.22.095–100
BloodPressure
Systolic(mmHg)131.817.9<120
Diastolic(mmHg)85.213.3<80
BMI(kg/m2) 31.88.618.5–24.9
Waist-to-HipRatio0.90.1
Male1.00.1<0.9(M) Female0.90.1<0.8(F)
Table2. Cont.
PhysicalMeasurementsMeanStd.Dev.ReferenceStandards a
BodyFat(%)
Male25.86.119.8 ± 5.4(M,allages)
18–39years25.63.218.3 ± 4.8(M,18–39years)
40–59years26.19.220.5± 5.3(M,40–59years)
60+years25.43.224.0 ± 5.3(M,60+years)
Female40.59.428.7 ± 6.4(F,allages)
18–39years36.610.926.5 ± 5.1(F,18–39years)
40–59years44.46.028.3 ± 5.8(F,40–59years)
60+years----35.2 ± 6.3(F,60+years)
BodyFatMassIndex(kg/m2)
Male7.73.14.9 ± 1.8(M,allages)
18–39years7.71.54.3 ± 1.5(M,18–39years)
40–59years8.34.65.1 ± 1.7(M,40–59years)
60+years6.91.66.2 ± 1.9(M,60+years)
Female15.37.76.6 ± 2.4(F,allages)
18–39years13.89.25.7 ± 1.7(F,18–39years)
40–59years16.86.46.6 ± 2.2(F,40–59years)
60+years----9.1 ± 2.9(F,60+years)
Fat-freeMassIndex(kg/m2)
Male21.22.319.1 ± 1.4(M,allages)
18–39years22.11.119.0 ± 1.3(M,18–39years)
40–59years21.33.019.4 ± 1.4(M,40–59years)
60+years19.92.119.1 ± 1.6(M,60+years)
Female20.43.715.9 ± 1.3(F,allages)
18–39years20.84.315.6 ± 1.1(F,18–39years)
40–59years20.03.516.2 ± 1.3(F,40–59years)
60+years----16.2 ± 1.7(F,60+years)
AbsoluteGripStrength(kg) b
Male77.119.489.7 ± 0.8(M)
Female53.015.756.1 ± 0.5(F)
RelativeGripStrength(kg/BMI) b
Male2.70.83.2 ± 0.5(M)
Female1.60.62.0 ± 0.02(F)
PhysicalActivity c
Stepscounts(perday)14,334.014,297.86000–10,000
Stepscounts(perday)*11,524.33951.66000–10,000
F=Fahrenheit;bpm=beatsperminute;BMI=BodyMassIndex;F=female;M=male; a Referencestandards forthefollowingmeasuresare:bodytemperature[22];restingheartrate[23];bloodoxygenation[24];systolic anddiastolicbloodpressure[26];BMI[27];sex-specificwaist-to-hipratio[28];sex-andage-specificbodyfat percentage[29];sex-andage-specificbodyfatindexandfat-freemassindex[29];sex-specificabsoluteandrelative gripstrength[31];anddailystepcount[34]; b missingdata, n =1(male); c missingdata, n =5;*with n =1 outlierremoved.
Table 3 displaystheHEI-2020data.Fortheadequacycomponents,outof5maximum points,meanscoreswere1.4fortotalfruit,1.3forwholefruit,2.4fortotalvegetables, 1.9forgreensandbeans,4.2forproteinfoods,and1.5forseafoodandplantproteins. Outof10maximumpoints,themeanscoreswere0.8forwholegrains,6.3fordairy,and 1.2forfattyacids.Formoderationcomponents,outofamaximumof10points,themean scoreswere6.2forrefinedgrains,3.9forsodium,and7.2foraddedsugars.Themeantotal HEI-2020scorewas39.7(outofamaximum100points).
Table3. HealthyEatingIndex-2020componentsoftransitionalhousingresidentsparticipatingina wellnessinterventionprogramatalocalhomelessresourcecenter(n =29).
HEI-2020ComponentsMaximumHEIScoreMeanScoreStd.Dev. Adequacy
TotalFruits51.41.9
WholeFruits51.32.1
TotalVegetables52.42.0 GreensandBeans51.92.2
WholeGrains100.81.7 Dairy106.33.5
TotalProteinFoods54.21.5
SeafoodandPlantProteins51.52.1
FattyAcids101.22.6 Moderation
RefinedGrains106.23.6
HEI=HealthyEatingIndex.
Themeanscoreforparticipants’generalhealthwas52.9 ± 29.8(Table 4).Meanscores fordepression,anxiety,andstresswere8.6 ± 8.7,9.3 ± 9.3,and10.9 ± 9.5,respectively. Participantsscoredlowestonvariety(2.3 ± 1.5)andfollowingfoodsafetyrecommendations (2.5 ± 1.5)andhighestonadjustingmealstousefoodsalreadyavailableathome(3.7 ± 1.1) andstretchingfooddollars(3.1 ± 1.5,Table 4).Perthequalitativedata,themostcommon barrierstohealthyeatingwerefinancialconstraints(29.6%)andlimitedcooking/storage facilities(29.6%),aswellastoexercise,physicalimpediments(14.8%).
Table4. Perceptionsofhealth-relatedbehaviorsamongtransitionalhousingresidentsparticipating inawellnessinterventionprogramatalocalhomelessresourcecenter(n =29).
MeanStd.Dev. ReferenceStandards/ Classifications
Health-RelatedQualityofLife(SF-36) a,b
Table4. Cont.
ReferenceStandards/ Classifications
Energy/fatigue51.721.252.2 ± 22.4 Emotionalwell-being61.918.770.4 ± 22.0
DASS-42 c,d
Depression8.68.7
Normal=0–9
Mild=10–13
Moderate=14–20
Severe=21–27
Extremelysevere=28+ Anxiety9.39.3
Normal=0–7
Mild=8–9
Moderate=10–14
Severe=15–19
Extremelysevere=20+ Stress10.99.5
Normal=0–14
Mild=15–18
Moderate=19–25
Severe=26–33
Extremelysevere=34+
CreateBetterHealthItems d
Istretchmyfooddollarssothereisfoodto lasttheentiremonth. a 3.21.5-Ichooseavarietyoffoodsbasedon MyPlaterecommendations. a 2.31.5-Iusethenutritionfactslabelto makefoodchoices. a 2.61.3-Ishopwithagrocerylist. a 3.01.5-IfollowUSDAfood safetyrecommendations. e 2.51.5-IadjustmealstousefoodsIalready haveathome. e 3.71.1--
DASS=DepressionAnxietyStressScale;USDA=UnitedStatesDepartmentofAgriculture. a Missingdata, n =2; b referencestandardsfromRAND[38]; c scoresaresummedacrossitemsmeasuringdepression,anxiety, andstress[39]; d missingdata, n =3; e responsesbasedona5-pointLikertscale:1=never,2=seldom, 3=sometimes,4=usually,and5=always.
4.Discussion
Thepurposeofthepresentstudywastocomprehensivelyevaluatebaselinehealth measuresamongpeoplelivingintransitionalhousingunitswhoparticipatedinapilot wellnessinterventionatalocalhomelessresourcecenter.Restingheartrate,bloodoxygenationlevels,andbodytemperaturewereallinnormalorrecommendedranges[22,24]. Meanbaselinemeasurementswerehigherthanrecommendationsforbloodpressure,BMI, waist-to-hipratio,andbodyfatpercentage,whereashandgripstrengthandoveralldiet qualitywerelowerthanthereferencestandards[11,26–28,31,36,43].Averagestepsperday werehigherthanotherUSadults[34].Qualitativedataindicatedthatthemainbarriersto healthyeatingwerefinancesandlimitedcooking/storagefacilities,andforexercisewere
physicalimpediments.Collectively,theseresultsindicatedlessfavorablehealthriskfactors amongthosetransitioningoutofhomelessness.
Theassessmentofbodycompositioninthepresentstudyindicatedlessfavorable measures,basedonrecommendations[27,28],withparticipantshavingahighaverage waist-to-hipratio,indicatingcentralobesity,andanobeseBMI.Duetothenatureoffood insecurityinindividualslivinginahomelesssituation,ithascommonlybeenbelieved thatthispopulationwouldstrugglewithbeingunderweight[8].Thisisnotinfactthe case,as57%ofchronicallyhomelessadultsinaTsaiandRosenheck[8]wereoverweight orobese,withwomenhavingthehighestriskforobesity.Otherstudiesamongadults experiencinghomelessnessorresidingintransitionalhousingunitshavesimilarlyshown ahighfrequencyofobesity[2,4,9].Theresultsfromthepresentstudyfurthersupported thesepreviousfindings,includingahigherproportionoffemalesclassifiedasobesethan males[9].However,thisstudyprovideduniqueinsightsonchronicdiseaseriskthroughassessingwaist-to-hipratio,fatmassandfat-freemass,andhandgripstrength,whichwereall outsiderecommendedhealthyrangesand/orlessfavorablecomparedtoresearchsamples amongUSadults[28,29,31].Further,althoughdiseaseprevalencewasnotmeasuredinthe presentstudy,participantshadhigher-than-normalbloodpressure(132/85mmHg)[26]. Previousresearchhasshownahighprevalenceofhypertensioninpeopleexperiencing homelessness[7];thus,theelevatedbloodpressureamongparticipantsinthisstudywas notsurprising.Inthepresentstudy,thecombinationofelevatedbloodpressurewiththe adversebodycompositionmeasuressuggestsanevenhigherpotentialriskforpoorchronic diseasehealthoutcomesamongthispopulation[14,44,45].
LowermeanabsoluteandrelativegripstrengthcomparedtothegeneralUSadult populationwasfoundinthepresentstudy,suggestingpoorermusclestrengthandthus higherriskforfrailtysyndrome,whichistypicallyassociatedwithagingandriskfor adversehealthoutcomes[31,46].Priortothepresentstudy,handgripstrengthhasnotbeen studiedamongU.S.adultsexperiencinghomelessness.However,twostudieshavebeen publishedonhandgripstrengthinthispopulationoutsideoftheU.S.[6,15].Inthestudy doneinIreland,themeangripstrengthofpeopleexperiencinghomelessnesswasfoundto bemuchlowerthanthegeneralpopulation,eventhoughtheywereofayoungerage[6]. InMexico,itwasfoundthatthemeasureddominanthandgripstrength(34.8kg)wasata levelthatindicatedfrailtysyndrome,aconditiontypicallyassociatedwithagingadults andpeoplewithchronicillnesses[15].Similardominanthandgripstrengthwasnotedin thepresentstudy,suggestingfurtherevidenceofpotentialriskforadversehealthoutcomes inthispopulation.
Qualitativedatashowedthatthebiggestbarrierstophysicalactivityforparticipants werephysicalimpediments.Itispossiblethatparticipantsinthisstudywerethinking ofmoreformalmethodsofphysicalactivity,suchasexercisingatagym,ratherthan walking,whenansweringthisquestion.Participantswereawareofbeinggivenfree localrecreationcentermembershipaspartofparticipatinginthestudy,sothismayhave alsoinfluencedhowparticipantsthoughtaboutphysicalactivity.Oritispossiblethat participantshadtowalkdespitephysicallimitationsbecauseitwastheparticipants’mode oftransportation[47,48].
However,itisinterestingtonotethataccelerometer-derivedstepcountstendedtobe higherthanaverageamongparticipantsinthissample.Ina2022meta-analysisofstepsper dayandall-causemortalityinU.S.adults,medianstepsperdayamongthehighestquartile was10,901andassociatedwithsignificantlylowerriskofall-causemortalitythanthe lowestquartile[34].Weareuncertainhowhigheractivityinthepresentstudyinfluences overallhealthortheexactreasonswhyactivityishigher.Nevertheless,itmaybearesult ofavarietyoffactors(e.g.,transportationoptions).
Thefindinginthepresentstudyoflowdietqualityamongadultslivingintransitionalhousingisnotsurprising,giventhatpreviousresearchinpopulationsexperiencing homelessnesshasshownthemtohavealownutrientandfoodgroupintake[1,3,48]. Hoisingtonetal.[12]foundaloweroverallHEI-2020score(64.0)amongU.S.adultveteransexperiencinghomelessnesscomparedtothosenotexperiencinghomelessness.The presentstudyfoundanevenloweroverallHEI-2020thantheHoisingtonetal.[12]study, suggestingevenpoorerdietqualityamongageneraladultpopulationexperiencinghomelessnessandincreasedriskofnegativehealthimplications[49].Thelessfavorablephysical measurementsfromthepresentstudy,combinedwiththelowdietqualityobserved,are likelytoputtheseindividualsatevenhigherriskforchronicdisease[50].
Potentialreasonsfortheoveralldietqualityofparticipantsinthepresentstudybeing belowthenationalnormmayberelatedtothehighrateoffoodinsecurityobservedand thebarrierstohealthyeatingidentifiedbyparticipants.Thisstudyfoundthatoftheparticipantssurveyed,about70%werefoodinsecure,whichisnotsurprisingbasedonprevious researchinthispopulation[51,52].Withfoodinsecurity,itislogicalthatdietqualitywould alsobelow,givenquestionswithintheUSDA’sSix-ItemShortFormaskaboutbeingable toconsumebalancedmealsandhavingenoughfood[21].Beyondthis,participantsin thepresentstudyprovidedqualitativedataonbarrierstohealthyeating,withresponses suggestingpotentialenvironmentalreasonsforthislowerdietquality.Inthetransitional housingunitswhereparticipantsinthepresentstudyresided,therewere26unitsformales and12unitsforfemales,witheachresidentareaincludingonesmall,sharedkitchenwith onefull-sizedfridgeandsharedcabinets,thuslikelycontributingtoparticipants’perceptionsoflimitedspacetostorefood.Participantsinthepresentstudywerealsounableto utilizecookingtoolssuchasastoveorknivesandwerelimitedtoamicrowaveandbasic utensils.Similarenvironmentalconstraintsinahomelessshelterhavepreviouslybeen identifiedamongtransitionalhousingresidentsinMinneapolis,Minnesota[48],suggesting thesebarriersarecommonexperiencesamongthoseexperiencinghomelessnessintheU.S. Givenpreviousresearchhasfoundsoupkitchensandsheltersasacontributingfactorto obesityamongchronicallyhomelessadults[2,4],thismayalsohelptoexplainthehigh meanBMIobservedinthepresentstudy.
Interestingly,theparticipants’perceptionsofgeneralhealthinthepresentstudywere belowtheaverageforU.S.adults,butonlybyaboutfourpoints[38].Thiswasunexpected consideringthehighratesoffoodinsecurity,poorerbodycompositionmeasures,elevated bloodpressurelevels,andlowdietqualityobservedinthepresentstudy.Oneexplanation forthismaybethatifparticipantspreviouslylivedinunhousedconditions(e.g.,car,street, etc.)beforetransitioningintoatemporaryshelteratthelocalhomelessresourcecenter, accessingfoodinparticipants’currentlivingsituationhasimproved,alongwithfeelings ofstability.Inthepresentstudy,participantsalsohadaccesstoanon-sitemedicalclinic, whichmayhavecontributedtogeneralhealthscoresnottoofarbelowUSadults.
Arecentmeta-analysisstudyindicatedthat67%ofadultsexperiencinghomelessness hadbeendiagnosedwithamentalhealthdisorder,suggestingthesedisordersarecommonlyfoundinthispopulation[53].Inthepresentstudy,participants’responsesindicated meanscoreswithinthenormalrangefordepressionandstress,andinthemildrangefor anxiety.Thislackofconsistencywiththemeta-analysismaybeexplainedbythesmall samplesizeinthispilotstudy,theself-reportednatureoftheinstrumentusedinthepresent studyratherthanamedicaldiagnosis,andthemeta-analysisincludingamorevariedset ofmentalhealthdisordersthanthepresentstudy.
Thisstudyhasseverallimitations.First,duetothenatureofitbeingapilotstudy, thesamplesizeissmall.Thislimitedtheauthors’analyticalapproachtodescriptive statistics.Thisalsopreventedauthorsfromstratifyingabsoluteandrelativegripstrength
byco-morbidities(e.g.,BMI)andage,aswasperformedbyLawmanetal.[31].Future studieswithlargersamplesizesareneededtoevaluateassociationsbetweenvariables. Second,itwasonlyperformedatonegeographicallocation,withthesampleidentifying mostlyasmaleandWhite.Thus,theresultsmaynotbesimilartothoseexperiencing homelessnessatotherlocationsacrosstheU.S.oramongmorediverseaudiences.Infuture studies,tocollectdatafromamorediversesample,researchersshouldrecruitparticipants frommultiplegeographicalareasandfromavarietyofcommunityagenciesproviding servicesforunhousedandtemporarilyhousedindividuals.Third,participantswerenot askedabouttransportationaccess,soitisunknownwhethertheirmainmodalitywasby foot,publictransit,and/orprivatetransportation,whichwouldhaveofferedinsightinto thehighstepcount.Fourth,theterm“physicalactivity”wasnotdefinedinthesurveys. Thus,participantswerelefttointerpretthetermontheirown,andthewaytheyanswered thisquestionmayhavevariedbasedonthatinterpretation.Lastly,theASA24wasonly collectedononedayatbaseline,whichdoesnotaccountforday-to-dayvariationsobserved inindividuals’dietsandtherebylimitsitsgeneralizability[10].Futureresearchshould considercollectingmultipledaysofdietaryrecalltoenhancetheaccuracyofdietquality measurementsamongtransitionalhousingresidents.
5.Conclusions
Individualstransitioningoutofhomelessnesshavelessfavorablehealthmeasures relatedtobodycomposition,muscularstrength,anxiety,anddietquality.Limitedfinances andcooking/storagefacilitiespresentedchallengesfortransitionalhousingresidentsto consumeahealthyeatingpattern.Althoughphysicalimpedimentswerebarriersidentified bytransitionalhousingresidentsinbeingphysicallyactive,accelerometerdatasuggested residentswerehighlyactive.Futureinterventionsthataretailoredtoaddresstheunique challengesfacedbytransitionalhousingresidentsareneededtopromoteoptimalhealth amongthispopulation.
AuthorContributions: Conceptualization,J.D.L.,C.J.,K.S.,H.L.,L.P.andR.R.;methodology,J.D.L., C.J.,K.S.andR.R.;formalanalysis,C.M.,J.D.L.,G.S.andR.R.;datacuration,C.M.,K.L.,S.L., J.D.L.,C.J.,K.S.andR.R.;writing—originaldraftpreparation,C.M.,K.L.,S.L.,J.D.L.andR.R.; writing—reviewandediting,C.J.,K.S.,G.S.,H.L.andL.P.;fundingacquisition,J.D.L.,C.J.,K.S.and R.R.Allauthorshavereadandagreedtothepublishedversionofthemanuscript.
Funding: ThisresearchwasfundedbytheAssociationforUtahCommunityHealthandtheCommunityFoundationofUtah.
InstitutionalReviewBoardStatement: ThestudywasconductedinaccordancewiththeDeclaration ofHelsinkiandapprovedbytheInstitutionalReviewBoardofUtahStateUniversity(protocolcode #12210anddateofapproval,5May2022).
InformedConsentStatement: Informedconsentwasobtainedfromallsubjectsinvolvedinthestudy.
DataAvailabilityStatement: Therawdatasupportingtheconclusionsofthisarticlewillbemade availablebytheauthorsonrequest.
ConflictsofInterest: Theauthorsdeclarenoconflictsofinterest.Thefundershadnoroleinthedesign ofthestudy;inthecollection,analyses,orinterpretationofdata;inthewritingofthemanuscript;or inthedecisiontopublishtheresults.
Abbreviations
Thefollowingabbreviationsareusedinthismanuscript: U.S.UnitedStates
BMIBodyMassIndex
SNAP-EdSupplementationNutritionAssistanceProgramEducation
USDAUnitedStatesDepartmentofAgriculture
ASA24AutomatedSelf-AdministeredDietaryAssessmentTool
HRQOLHealth-RelatedQualityofLife
DASSDepression,Anxiety,StressScale
SPSSStatisticalPackagesforSocialScientists
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