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Articles

Household Food Insecurity with Hunger Is Associated with Women’s Food Intakes, Health and Household Circumstances^{1 ,2}

Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 3E2 Canada

	ABSTRACT

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
This study investigated food intake patterns and contextual factors related to household food insecurity with hunger among a sample of 153 women in families seeking charitable food assistance in Toronto. Women in households characterized by food insecurity with severe or moderate hunger over the past 30 d (as assessed by the Food Security Module) reported lower intakes of vegetables and fruit, and meat and alternatives than those in households with no hunger evident. Women were more likely to report household food insecurity with hunger over the past 12 mo and 30 d if they also reported longstanding health problems or activity limitations, or if they were socially isolated. The circumstances that women identified as precipitating acute food shortages in their households included chronically inadequate incomes; the need to meet additional, unusual expenditures; and the need to pay for other services or accumulated debts. Women who reported delaying payments of bills, giving up services, selling or pawning possessions, or sending children elsewhere for a meal when threatened with acute food shortages were more likely to report household food insecurity with hunger. These findings suggest that expenditures on other goods and services were sometimes foregone to free up money for food, but the reverse was also true. Household food insecurity appears inextricably linked to financial insecurity.

KEY WORDS: • food insecurity • hunger • food intake • poverty

	INTRODUCTION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
In recent years, it has become apparent that food scarcity and food deprivation are problems among the poor in many affluent Western nations. Variously referred to as hunger, food poverty, food insufficiency and household food insecurity, the problem has been described by nutrition researchers in Canada, the United States, the United Kingdom, Australia and New Zealand (1 –17) . Although some qualitative studies have been conducted to elucidate the day-to-day experiences of families struggling to cope with problems of hunger and food insecurity (18 –24) , the primary focus of nutrition research in this area has been on the development of survey instruments to quantify experiences of food insecurity and deprivation at an individual or household level (25 –35) . The characterization of this particular aspect of "nutritional state" (36) represents an important advance in our field. However, the development of sound policies and programs to address food insecurity hinges not only on its measurement but also on a thorough understanding of the problem.

A study of food insecurity and nutritional vulnerability among women in families seeking help from charitable food assistance programs in Toronto (37 ,38) provided an opportunity to examine women’s food and nutrient intakes in relation to a comprehensive, contemporaneous measure of household food security status and to investigate the settings and circumstances associated with reports of household food insecurity with hunger. Almost all of the study participants reported some food insecurity over the preceding 12 mo, and 57% reported food insecurity with severe or moderate hunger over the previous 30 d (37) (as measured by the Food Security Module (27 ,31 ,39) . In this sample, severity of household food insecurity appeared unrelated to sociodemographic characteristics (37) . Women who reported household food insecurity with hunger in the past 30 d were found to have systematically lower intakes of energy and a number of nutrients during this period (38) . The associations persisted even when other economic, sociocultural and behavioral influences on dietary intake were taken into account (38) . Interestingly, when nutrient intakes were expressed per MJ, only vitamin A intake per MJ was associated with 30-d food security status (38) . The finding suggests that the observed differences in nutrient intakes were primarily a function of the lower food intakes of women in households characterized by food insecurity with hunger, rather than systematic differences in food selection. However, the results highlighted the need for a separate analysis of food intake data in relation to food security status.

The present study represents a further analysis of data from this sample of women in families using charitable food assistance programs. It builds on previous analyses in three important ways as follows: 1) women’s reported food intakes are examined in relation to contemporaneous household food insecurity with hunger; 2) the relationships between 12-mo and 30-d household food insecurity with hunger and women’s self-reported health, social isolation and social support are assessed; and 3) the women’s descriptions of the circumstances precipitating acute food shortages and actions in response to impending food shortages are examined.

	SUBJECTS AND METHODS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
A detailed description of the sampling, recruitment and dietary intake assessment procedures appears elsewhere (38) . Briefly, study participants were recruited on a "first come, first serve" basis from a stratified, random sample of 21 emergency food hamper programs in Toronto. Women were deemed eligible if they were age 19–49 y, nonpregnant, had at least one child <15 y old in their household, had used a food hamper program at least one other time in the past 12 mo and possessed sufficient fluency in English to participate in oral interviews. Participation was voluntary and confidential. The study protocol was approved by the Human Subjects Review Committee at the University of Toronto.

A total of 450 women were approached to participate in this study, but 226 were deemed ineligible (most because they did not have children living with them). Of the 224 potentially eligible women approached, 43 declined to participate, 23 agreed but subsequently failed to participate in the first interview and 5 were interviewed but later dropped from the study because of data quality concerns or personal crises. A final sample of 153 women was achieved, reflecting a participation rate of 68.3% (153/224). Comparison of the demographic profile of study participants with the profile of women with children that emerged from a large client survey of food hamper programs in this region indicated that the sample was comparable to this subgroup of the larger client population (personal communication, W. Husbands, 1997).

Three in-person interviews were conducted with each participant. The interviews were held on nonconsecutive days, typically scheduled on different days of the week and spanning the 3 wk after recruitment. All women in the sample completed all three interviews, with 95% (n = 145) completing the interviews within a 31-d period.

Each interview included a 24-h dietary intake recall [described in detail elsewhere (38) ] and an interviewer-administered questionnaire. In the first interview, questions focused on household demographics and living circumstances. In the second interview, self-rated health [a variable that relates to other measures of physical and mental health (40 ,41) ] was assessed, and participants were asked to describe any longstanding health problems and activity limitations they had. To obtain an indication of social isolation, participants were asked how often they felt "isolated and alone." Their access to emotional and instrumental forms of social support was assessed in terms of the availability of a confidante and the availability of someone to "help in a time of need" (42) . In the third interview, household food insecurity was assessed using the Core Food Security Module (27 ,31 ,39) , with the omission of one item regarding perceived weight loss related to food deprivation. Participants were also asked if they had used five resource augmentation strategies (i.e., purchasing food on credit, sending children to a friend or relative’s home for a meal, selling or pawning possessions, giving up services such as telephone or cable TV and delaying bill payments) when food and money for food were lacking in the past 12 mo. These strategies were identified from previous research with similar populations (23 ,31 ,34 ,39) .

Because such extreme levels of food insecurity were being reported by some study participants, a decision was made after 2 mo in the field to add a series of open-ended questions in the third interview to enable fuller exploration of the context within which food shortages arose. Participants were asked if in the last 12 mo they had ever "had very little food and no money to buy any" (an item drawn from the Radimer/Cornell hunger scale (32 ,34) . Those responding affirmatively (104 of the 116 women asked) were then asked to describe the experience and the circumstances leading up to it. Open-coding was used to summarize the responses. Almost all (98%) of the women who responded affirmatively to this question were subsequently classified as experiencing household food insecurity over the past 12 mo, and 74% were classified as food insecure with severe or moderate hunger.

All statistical analyses were performed using SAS/PC Version 6.12 for Windows (SAS Institute, Cary, NC). Stratification effects were not accounted for in any of the analyses presented here because ANOVA revealed no differences in key variables (i.e., measures of food security status) across strata.

Household food security status over the past 12 mo and 30 d was determined from responses to the Food Security Module (31 ,39) . To adjust for the omission of one scale item, participants’ responses were scaled by rerunning the Rasch model using BIGSTEPS Version 2.60 (MESA, Chicago, IL) and anchoring the model with the item calibrations developed by Hamilton et al. (39) . In addition to the calculation of continuous variables for severity of household food insecurity over 12 mo and 30 d, a three-level categorical variable denoting severity over the past 30 d and a four-level variable denoting severity over the past 12 mo were constructed using the criteria developed by Hamilton et al. (39) . Severity is defined in terms of the frequency and duration of food deprivation reported for adults and children over the time frame of interest. In both scales, households classified as food insecure with moderate hunger are typically characterized by reports of reduced food intakes among adults. Households classified as food insecure with severe hunger are typically characterized by reports of reduced food intakes among children and more severe reductions in adults’ intakes. The 30-d scale differs from the 12-mo scale in that it does not include a sufficiently broad range of questions to permit differentiation between food secure households and those experiencing relatively "mild" levels of food insecurity.

To examine relationships between contextual variables and severity of household food insecurity, dichotomous variables were constructed from the categorical variables to differentiate between households reporting hunger (moderate or severe) and those not reporting hunger over the past 12 mo and past 30 d. The odds of reporting hunger given a particular condition or behavior were then calculated using PROC LOGISTIC. Women reporting household food insecurity with moderate or severe hunger were treated as a single group because preliminary analyses revealed few discernible differences between these groups in relation to the contextual variables examined here (possibly due to sample size limitations). The Pearson correlation between severity of 12-mo household food insecurity (as indicated by the continuous scale score) and the number of different resource augmentation strategies any one woman reported using was examined using PROC CORR.

In the analyses presented here, participants’ responses to the questions on social isolation and social support were dichotomized into those reporting the phenomenon "most of the time" or "some of the time" vs. those reporting it "rarely" or "never." To enable fuller interpretation of these variables, -squared (PROC FREQ) tests were conducted to examine the relationships between the measures of social isolation, social support, and single parenthood included in this study.

The 24-h dietary recall data were analyzed in the 1996 version of the Canadian Dietary Information System for food intake analysis (43) . The 147 basic food categories generated from this system were further collapsed into five broad food groups, corresponding to the food groups in Canada’s Food Guide to Healthy Eating, i.e., grain products; vegetables and fruit (including juices); milk products; meat (includes fish, poultry, eggs) and alternatives (i.e., nuts, seeds, legumes); and other foods (44 ,45) . "Other" foods were foods that did not clearly fall into one of the other groups, e.g., water, fats, oils, sweets, soft drinks, salty or high fat snack foods, coffee or tea. Women’s 3-d mean numbers of servings from each group of foods were calculated, using standard serving sizes (44) . The normality of these distributions was assessed using the Shapiro-Wilk statistic. The relationship between food group intakes and 30-d food security status was examined using ANOVA (PROC GLM), with the food group variables first transformed to better approximate normality, using log or square-root transformations. To examine the relationship between household food security status and women’s food selection patterns, the ANOVA was repeated with 3-d mean energy intake included as a covariate to control for differences in total food intake. To explore the possibility that potato consumption might be influencing the observed association between vegetables and fruit and food security status, these analyses were repeated for vegetables and fruit excluding potatoes. To ensure a comparison of contemporaneous measures, only women who had completed all three 24-h recalls within the period over which their 30-d food security status had been assessed (n = 145) were included in the analyses of food intake variables.

	RESULTS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
Sample characteristics.

A full description of the sample is presented elsewhere (37) . Participants ranged in age from 19 to 48 y (mean age 33 ± 7 y ) and varied widely in terms of ethnoracial identity and educational attainment. Sixty-five percent were single parents. Household size ranged from 2 to 10, with a median of 3 persons per household. The median number of children per household was 2. Most (69.9%) households were supported by social assistance programs (welfare); 14.4% were supported by a combination of welfare payments and employment incomes; 9.8% received income from employment only; the remaining 5.9% relied on savings or received income from employment insurance, student loans or other sources. Most households lived in poverty, with 90% of reported household incomes falling below two thirds of the Statistics Canada Low-Income Cut-Offs (the "poverty line") (46) . Other indications of poverty in the sample include the observation that 17% of households did not have telephone service at the time of the study, and only 23% had access to a car for grocery shopping.

One hundred forty-three of the 153 women in this study (94%) reported some degree of household food insecurity over the past 12 mo, with 36 (24%) reporting food insecurity with no hunger evident, 66 (43%) reporting moderate hunger and 41 (27%) reporting severe hunger (37) . In the past 30 d, 54 households (35%) were food insecure with moderate hunger, 33 (22%) were food insecure with severe hunger and 66 (43%) reported no food insecurity with hunger (37) .

Food consumption patterns.

Women in households with no hunger evident had higher group mean and median intakes than those in households with severe or moderate hunger for all food groups except other foods (Table 1 ). However, significant differences in intake by household food security status were observed only for vegetables and fruit and meat and alternatives. Further, vegetable and fruit consumption remained significantly associated with household food security status when potatoes were omitted from the food group. Controlling for differences in mean energy intake diminished the strength of these associations, but they remained significant at P < 0.05.

Forty percent of participants reported a long-standing health condition, illness or disability, and two thirds of these (26% of the entire sample) described the condition as activity-limiting. Women with longstanding conditions and those with activity limitations were two to three times more likely to have reported household food insecurity with hunger over the past 30 d or 12 mo compared with women not reporting such problems (Table 2 ). Women who rated their health in the past year as good or excellent were less likely to report food insecurity with moderate or severe hunger over the past 30 d than those who rated their health less positively (Table 2) .

Sixty-four percent of the study participants reported feeling isolated and alone, some or most of the time. As would be expected, these women were less likely than others to report having family or friends to turn to in a time of need (² = 6.768, 1 df, P = 0.009), but social isolation was not associated with single parenthood (² = 2.196, 1 df, P = 0.138) or with having a confidante (² = 0.126, 1 df, P = 0.772). The odds of having reported food insecurity with moderate or severe hunger over both the past 12 mo and previous 30 d were much higher for women who perceived themselves to be socially isolated (Table 3 ). There is some indication that women with higher perceived levels of emotional and instrumental support were less likely to report food insecurity with hunger, but the results were inconsistent for the 30-d and 12-mo food security status measures (Table 3) .

One hundred and four women in this study provided descriptions of the circumstances leading up to a recent experience of food shortage. Twenty-five of the women (24%) reported that they had run out of money for food because they had to pay bills for essential services (e.g., rent, electricity, telephone) or pay off an accumulated debt (e.g., money owing for telephone services or utilities). Thirty-six women (34%) said food shortages arose because they had encountered additional, unusual expenditures. The nature of the expenditures ranged from costs incurred in changing one’s place of residence, to the purchase of a child’s birthday gift or school uniform. Forty-four (42%) said they simply did not have enough money to meet their needs. In some cases, this was linked to a sudden loss of employment income or interruption in the receipt of social assistance benefits. In other cases, the lack of money for food was described as a recurrent problem. Although not explicitly asked, 18 of the 44 women who said they simply did not have enough money to meet their needs explained that they ran out of money for food at the end of each month.

Further evidence of the link between acute food shortages and financial problems comes from an examination of the reported household food security status of women who owed money for rent or food. At the time of Interview 1, 14 women reported having failed to make full rental payments for the month. Twelve of these women reported household food insecurity with moderate or severe hunger over the subsequent 30 d. Fifteen women reported purchasing food on credit over the 30 d preceding their third interview, and 11 of these reported household food insecurity with moderate or severe hunger over this same time period.

Strategies to augment resources in the context of food shortages.

In addition to their use of charitable food assistance programs [reported elsewhere (37) ], most participants reported using other strategies in the past 12 mo to augment household food supplies or garner money for food when threatened with food shortages (Table 4 ). Purchasing food on credit was least commonly reported, perhaps because credit is not widely available at food stores in this region and very low income families must be recognized as poor risks for creditors. Women were more likely to have reported sending children to a friend or relative’s home for a meal, delaying payment of bills, giving up services such as telephones and cable television, and selling or pawning possessions if they had described household food insecurity with hunger (moderate or severe) over the past year (Table 4) . Further, the number of different strategies any one woman reported using was directly related to the severity of her household food insecurity over the past 12 mo (Pearson r = 0.3541, P = 0.0001).

	DISCUSSION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

Although food guides are not appropriate tools for assessments of the adequacy or inadequacy of individuals’ intakes, a comparison of women’s reported food intakes with Canada’s Food Guide to Healthy Eating (45) provides some indication of just how far their intakes deviate from recommended patterns. The food guide recommends that adults strive for 5–12 servings of grain products, 2–4 servings of milk products, 5–10 servings of vegetables and fruit, and 2–3 servings of meat and alternatives daily. The group mean intakes of women in households characterized by severe or moderate hunger fell further below these recommendations than women in households with no hunger evident, but all three groups had very low intakes of milk products, and even women in households with no hunger evident had mean intake levels of grains and vegetables and fruit below recommended levels. The low consumption of milk products among women in this sample relative to women in the general population (44) may reflect the fact that irrespective of their food security status, the women were all low income.

Several studies have documented relationships between indicators of food security and health. In a recent Canadian population-based survey, caregivers in families reporting child hunger [an indicator of relatively severe household food insecurity (31) ] were more likely to rate their health poorly and to report having at least one chronic health condition compared with caregivers in families not reporting child hunger (8) . In that study, the health of the children who experienced hunger was also reported to be worse than the health of children who did not experience hunger (8) . Household food insufficiency has also been associated with poor self-rated health among women in a U.S. national sample of low income women with children (50) and among men and women in a population-based survey in Queensland, Australia (49) . Further, in a recent U.S. study of elderly disabled women, social, psychological and health status factors were related to financial difficulty acquiring food, although the specific associations observed differed between Caucasian and non-Caucasian women (51) . The present study adds to this growing body of literature by documenting differences in self-reported health in relation to the severity of household food insecurity, within a sample of low income, predominantly food-insecure women.

It is impossible to establish the direction of the relationship between food security and health from the cross-sectional associations reported here. Perhaps chronic and severe food insecurity predisposes individuals to poor health, but it is also conceivable that poor health heightens the risk of household food insecurity and perhaps increases the likelihood of more severe food insecurity among low income groups. Alternatively, both the health of individuals and their household security status may be related to a third variable (e.g., chronic poverty).

Women who felt socially isolated were much more likely to report household food insecurity with hunger, but again, given the cross-sectional nature of the finding, several interpretations are possible. The observed association may simply reflect the profoundly isolating nature of experiences of severe household food insecurity, described in terms of feelings of alienation in a recent Quebec study (47) . Consistent with this analysis, several U.K. authors have argued that social exclusion is an integral part of food poverty (food insecurity) because those affected are forced to adopt food consumption patterns and food acquisition strategies that fall outside social norms (5 ,7 ,33 ,52) . An alternative explanation for the observed association between social isolation and hunger is that socially isolated women endured more severe household food insecurity because they lacked supportive social networks. In this study social isolation was much more strongly and consistently linked to household food security status than was social support, but this may in part be a function of the very limited measures of social support. Qualitative work by Ahluwalia et al. (18) in North Carolina elucidated the complex, multilevel nature of social networks and the differential use of networks by members of different ethnic groups in dealing with food insufficiency. More research is required to fully understand the relationship(s) between social support and food security among low income households.

Women’s descriptions of the circumstances precipitating acute food shortages and their actions in response to impending food shortages reveal the competing nature of household expenditures in the context of scarce resources, a phenomenon described in several qualitative examinations of food management strategies among low income households (20 ,23 ,24 ,47 ,53 ,54) . Sometimes expenditures on other essential goods and services were foregone as a way to free up money for food, but the reverse was also true, i.e., food shortages were endured because scarce resources had been used to meet other expenditures perceived to be necessary and unavoidable. With increasing severity of food insecurity, women resorted to an increasing number of "extraordinary" measures to obtain food. Similarly, Derrickson et al. (28) documented increased use of four resource augmentation strategies (using charitable food assistance, delaying bill payments, borrowing money and sending children to someone else’s house) in association with severity of household food insecurity in a population survey in Hawaii.

The intersection of food insecurity with financial insecurity that is suggested by the results presented here has been documented in other studies. An econometric analysis of data from the U.S. Survey of Income and Program Participation revealed that food-insufficient households had lower average incomes, were more likely to have lost earnings and lost food stamp benefits, and were less able to weather these losses with savings or loans than food-sufficient households (55) . Further, a recent study of elderly disabled women in the U.S. Women’s Health and Aging Study found that women who had financial difficulty acquiring food were more likely to report insufficient finances at the end of the month and greater financial difficulties affording medical care and meeting payments on monthly bills (51) .

The food assistance programs and community development strategies that have been initiated in recent years to address household food insecurity in Canadian communities typically embrace an understanding of food insecurity as a food problem (56) . However, the interrelationship between food insecurity and financial insecurity points to the importance of nonfood interventions designed to improve the financial security of low income households. These obviously include programs to improve household income, but they also include interventions to lessen or offset the costs of other essential goods and services (e.g., subsidized housing), and initiatives to assist low income households in weathering sudden, precipitous changes in income or expenditure.

In summary, this study of a low income, predominantly food-insecure sample of women with children revealed several differences between women in relation to the severity of their household food insecurity. Women in households characterized by food insecurity with severe or moderate hunger reported more limited food intakes than women not reporting hunger. Importantly, they were also more likely to report social isolation, poorer self-rated health, longstanding health problems and activity limitations, suggesting that food problems are just one of a broader array of problems confronting households with this level of food insecurity. However, the limited scope of this study must be recognized. In the absence of any data on the children and other adults in these households, it is impossible to even speculate on problems they might experience in relation to different levels of household food insecurity. Clearly, this is an important area for future research. Furthermore, although the concordance of the present findings with those from a variety of other quantitative and qualitative studies lends support to the argument that household food insecurity is intimately linked to financial insecurity, it should be noted that this analysis pertains to domiciled individuals and families. The relationship between food insecurity and other forms of insecurity appears to differ in the context of homelessness [see, for example (57) ], although there has been less research in this area.

The development of measurement tools to assess household food insecurity now sets the stage for problems of unmet food needs in our populations to be quantified and abstracted from the particular contexts in which they occur. Yet these problems appear intertwined with other kinds of problems at the household level. To inform the development of effective policies and programs to address food insecurity, the recent advances in measurement must be complemented by research to develop a comprehensive understanding of the particular contexts in which food insecurity and hunger arise.

	ACKNOWLEDGMENTS

 
The author is indebted to Dorcas Beaton for assistance with Rasch modeling, and to George Beaton for invaluable comments on earlier drafts of this manuscript. The author thanks Shelley Hilditch, Jennifer Geduld and Adrienne Teron for their work on this study.

	FOOTNOTES

 
¹ Supported by Health Canada through the National Health Research and Development Program (NHRDP), NHRDP Project no. 6606–5609-201.

² Presented in part at the Second Food Security Measurement and Research Conference [Tarasuk, V. (1999) Contextual and dietary factors associated with reported food insecurity among a sample of Canadian women using food banks. In: Proceedings, Vol. I (Andrews, M. & Prell, M., eds.). Food Assistance and Nutrition Research Report No. 11–1. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture].

Manuscript received January 19, 2001. Initial review completed March 1, 2001. Revision accepted July 5, 2001.

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TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 

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