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Community and International Nutrition

Household Food Insecurity Is Associated with Adult Health Status^1,2,3

Janice E. Stuff^*,4, Patrick H. Casey, Kitty L. Szeto, Jeffrey M. Gossett, James M. Robbins, Pippa M. Simpson, Carol Connell^** and Margaret L. Bogle

^* U.S. Department of Agriculture/ARS Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030; Arkansas Childrens Hospital Research Institute, University of Arkansas Medical Sciences, Little Rock, AR 72202; ^** Nutrition and Food Systems, College of Health, University of Southern Mississippi, Hattiesburg, MS 39406; and Delta Nutrition Intervention Research Initiative, U.S. Department of Agriculture, Agricultural Research Service, Little Rock, AR 72211

⁴To whom correspondence should be addressed. E-mail: jstuff{at}bcm.tmc.edu.

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION LITERATURE CITED

 
The prevalence of household food security, which reflects adequacy and stability of the food supply, has been measured periodically in the United States and occasionally in high-risk groups or specific regions. Despite a plausible biological mechanism to suggest negative health outcomes of food insecurity, this relation has not been adequately evaluated. This study was conducted in the Lower Mississippi Delta region to examine the association between household food insecurity and self-reported health status in adults. A two-stage stratified cluster sample representative of the population in 36 counties in the Delta region of Arkansas, Louisiana, and Mississippi was selected using list-assisted random digit dialing telephone methodology. After households were selected and screened, a randomly selected adult was interviewed within each sampled household. Data were collected to measure food security status and self-reported mental, physical, and general health status, using the U.S. Food Security Survey Module and the Short Form 12-item Health Survey (SF-12). Data were reported on a sample of 1488 households. Adults in food-insecure households were significantly more likely to rate their health as poor/fair and scored significantly lower on the physical and mental health scales of the SF-12. In regression models controlling for income, gender, and ethnicity, the interaction between food insecurity status and race was a significant predictor of fair/poor health and lower scores on physical and mental health. Household food insecurity is associated with poorer self-reported health status of adults in this rural, high-risk sample in the Lower Mississippi Delta.

KEY WORDS: • community nutrition • food insecurity • health status

Household food insecurity has been defined by national experts as "limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways" (1–3). The most recent national U.S. Household Food Security Survey documented that 11.1% of U.S. households were food insecure in 2002, with food insecurity rates of >35% for households with family incomes below the federal poverty level (4). Food insecurity, as measured by the U.S. Food Security Scale, has been increasingly used in research as a measure of the adequacy and stability of a household’s food supply. On an individual level, potential biological and stress mechanisms have been proposed to explain a relation among food insecurity, poor nutrition, and poor physical health and poor mental health. On a household level, presence of food insecurity suggests a high degree of vulnerability to a broad spectrum of consequences including poor health status (5).

Collectively, previous studies report an association of food insecurity or food insufficiency with decreased dietary intake in adults (6–9), psychosocial dysfunction in children (10), increased body weight in women (11), hypoglycemia in diabetics (12), compromised health status in the elderly (13), and sociofamilial problems (14). Most recently, Siefert et al. (15) analyzed the relationship between food insufficiency measured by a scale derived from National Health and Nutrition Examination Survey III (16) and self-reported physical and mental health status measured by the Short Form 36-item Health Survey (SF-36)⁵ (17). Among a random sample of 724 single female welfare recipients in northern Michigan, food insufficiency was significantly associated with poor or fair self-reported health and physical limitations. To our knowledge, no study has examined the relation between food insecurity as measured by the U.S. Food Security Survey Module (18) and self-reported physical and mental health status in a population-based, representative sample.

The Lower Mississippi Delta (LMD) region of Arkansas, Louisiana, and Mississippi has high prevalence rates of poverty and low education (19). In addition, data from a recent survey in a sample representative of 36 LMD counties and parishes estimated the prevalence of food insecurity to be twice that of the United States (20). Factors such as low family income, limited access to quality grocery stores (21), and higher food prices in rural areas (22) likely contribute to food insecurity. Moreover, a review of existing data suggested higher rates of nutrition-related chronic diseases in the LMD than in the United States (23,24). This was later documented by findings from the first health survey in the Lower Delta that reported high self-reported rates for high cholesterol, diabetes, obesity, and hypertension (25). Increased risk of families who live in poverty to physical and mental health, limited access to medical care in rural areas, and the high prevalence of poor health and food insecurity imply food insecurity and health could be closely interrelated. Therefore, using a representative sample of adults who live in the LMD regions of Louisiana, Arkansas, and Mississippi, this report examines the association between household food insecurity measured by the U.S. Food Security Survey Module and self-reported physical and mental health measured by the Short Form 12-item Health Survey (SF-12). The extent to which these associations persist after adjusting for important demographic variables is also determined.

	METHODS

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    Study population. Foods of Our Delta (FOODS 2000) is one part of the comprehensive research plan of the Lower Mississippi Delta Nutrition Intervention Research Initiative (Delta NIRI) (24) to assess the nutrition and health status of a representative sample of the Lower Mississippi Delta. FOODS 2000 was a cross-sectional telephone survey of a representative sample of the population 3 y of age and older in 36 Delta NIRI counties and was conducted between January and June 2000. A two-stage stratified cluster sampling plan was used to assign the 36 Delta NIRI counties to 9 strata according to population size, percentage of population who are black, and percentage living below the federal poverty level. Eighteen counties (2 counties from each stratum) were selected with probability proportional to size to represent that stratum in the telephone sample. List-assisted random digit dialing methodology (26) was used to select a random sample of telephone numbers from the eligible blocks of numbers in these counties. Of the 3455 eligible households, 1293 or 37.4% refused to participate. A total of 1751 adults completed the first follow-up interview (health survey data), and 1662 completed the next interview (food security survey); 1488 participants had complete data for study variables needed to compute food security and health status scores.

Verbal consent to participate in the study was obtained from all participants at their initial interview contact. Approval was obtained from the Institutional Review Board of each participating institution.

    Data collection. A computer-assisted telephone interview was conducted to determine the eligibility of the household. Characteristics of an eligible household included the following: at least 1 member 18 y of age or older; the telephone number was not for business use only; and the household was located in 1 of the 18 Delta NIRI sample counties. During this initial interview, information on age, sex, ethnicity, and the presence of children in the household was determined. All members of the household were enumerated and 1 adult per household was selected randomly using Kish’s tables (27). A second nonscheduled telephone call was made to collect information using a 2-part questionnaire, which included a dietary intake interview, and a series of trailer questions about usual intake, water consumption, height, weight, the presence of selected chronic health conditions, and general self-reported health using the SF-12 (28) for adults. Approximately 1 to 2 weeks later, the adult in the household who had completed the dietary interview was interviewed again with questions including the food security status of the household (18).

    Assessment of food security. In this survey, food security status was evaluated using the 18-question U.S. Food Security Survey Module (18,29). The responses to the 18-item food security survey module were used to construct the 12-mo food security scale and to classify households into 3 categories of food security status according to the U.S. food security scale: (18):

food secure: households that show no or minimal evidence of food insecurity;

food insecure without hunger: food insecurity is evident in the household concerns and in adjustments to household food management, including reduced quality of diets. Little or no reduction in household members’ food intake was reported;

food insecure with hunger: the food intake for adults and children in the household has been reduced to the extent that they have repeatedly experienced the physical sensations of hunger.

For the present analysis, food security status was collapsed to a dichotomous variable (food secure and food insecure) because the 3-level variable when cross-tabulated with levels of other variables resulted in few responses in some cells.

    General health status. Overall physical and mental health status was evaluated using the SF-12 (28), a briefer instrument with 12 items based on the SF-36 (30). Ware et al. (31) demonstrated that the SF-12 summary scales were highly correlated with SF-36 scales. Two summary scores of the SF-12 were created as complementary descriptions of overall health: physical component summary and mental component summary. Scales were coded, summed, and linearly transformed to form a range from 0 (worse health) to 100 (best health possible); creation of scores and coding was completed according to the standardization recommended by the developers of the instrument (28).

    Categorization of variables. The following outcome variables and covariates used in the analysis were categorized. Self-reported general health was converted into 3 categories (very good to excellent; good; and fair to poor), and for logistic regression analysis health was categorized into 2 levels, good to excellent and fair to poor. Food security status was reported by 2 categories, food secure or food insecure. Total household income for the previous 12 mo was self-reported in increments of $5000 or $10,000 ranging from less than $5000 to $50,000 or more. From these increments, a continuous variable for income was formed from the midpoints of income category (from $2500 to $60,000). Age was categorized into 3 categories: 18 to 44, 45 to 64, and 65 y and older. Ethnic groups were whites and blacks of non-Hispanic origin.

    Analysis. A household base weight equal to the inverse of the probability of selection to each sampled telephone number was used. Data were adjusted to compensate for telephone numbers with unknown residential status or eligibility, the number of residential telephone numbers in the household, and nonresponse to the screener interview. To account for nonresponse in the second interview, the weight of the nonparticipants was distributed to the participants within adjustment cells defined by age, race, and sex. Finally, estimates were calibrated to Census Bureau (1990) (32) estimates of the total households by state. Standard error adjustment factors were generated using WesVar (33) to account for the clustering effect within counties. The standard errors of the estimates generated by WesVar were then applied to the standard error adjustment factor calculated for each question.

The statistical association between food security status and health was conducted using Cochran-Mantel-Haentzel ² analyses. Logistic regression analyses were conducted with health status as the dependent variable (2 categories, good to excellent versus fair to poor) and control variables were age, income, sex, and interaction between race and food security status. A categorical variable for the 4 combinations of race and food security was used rather than indicator variables for race and food security to take account of the interaction. A quadratic term for income and number of people supported by income were considered, but terms were not significant. Linear regression analyses were conducted with physical score or mental score as the dependent variable and the same independent variables used for logistic regression. SUDAAN V8.0 (34) was utilized to compute appropriate statistical tests accounting for survey design.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION LITERATURE CITED

 
The present analysis of the FOODS 2000 sample is composed of 1488 households. More than a fifth of the households were food insecure (20.3%), 27.9% had income < $14,999, and 20.2% reported poor health status (Table 1). Over half of the sample was female, black, and between the ages of 18 and 44 y. The final sample reflected the demographic characteristics of the target population.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION LITERATURE CITED

In the present study, the effect of food security on physical scores and mental scores is notable. Although these effect sizes are considered "small," they are nonetheless clinically meaningful and consistent with health status reported by individuals experiencing prostatitis (37), myocardial infarction (38), and dyspepsia (39).

Our findings are also confirmed by 3 earlier studies where food sufficiency status and general health status were measured. First, in a random sample of 724 single women, who were welfare recipients in northern Michigan, Siefert et al. (15) analyzed the relationship between physical and mental health measured by the SF-36 and food insufficiency (16). Food insufficiency was significantly associated with poor or fair self-reported health and physical limitations and other measures of mental functioning, depression, and mental disorders. In the subsample from the Women’s Health and Aging Study, Klesges et al. (40) evaluated the relationship between food insufficiency (measured by the 1-variable food sufficiency question) and 3 classes of health status, measured by the Patrick scale (41). Women reporting difficulty getting food were more depressed and had a poorer quality of life and physical performance. In a comprehensive health survey of 80,000 Canadians (5), measures of food insufficiency (16) were significantly associated with a range of health conditions: poor health, poor functional health, restricted activity and health conditions, major depression, and poor social support. Importantly, measures of food insufficiency in these 3 studies estimate only the quantity dimension of food insecurity. The U.S. Food Security Scale, as used in our study, also measures the quality, uncertainty, or psychological components of food insecurity and therefore offers more precision for examining these relationships to health and related outcomes (35).

In the present study for all outcome measures, the food-secure individuals scored better than those who were insecure. Furthermore, within the food-insecure group, physical scores and general health were reported to be higher in the blacks than in the whites. Several explanations may account for the different effets of food security status on health by race. First, some research suggests that minority and rural populations may view chronic illness as a condition to be accepted rather than as amenable to intervention (42). An alternative explanation for the ethnic differences in responses to study questions on nutrition and health problems is a methodological one. Previous studies have found systematic differences in the way members of varying racial/ethnic groups respond to questionnaires and scales. Race/ethnicity was found to be associated with response patterns on Likert response scales, with African Americans more likely to have acquiescent response styles (43–45). In the present study, African Americans may have had health-enhancing resources, social support, and religious involvement that improved their outcome (46). Finally, in the study reported by Siefert et al. (15) on the effect of food insufficiency and on physical and mental health in low-income women, African-American women were found less likely to report poor physical health than Caucasian women. Further research is needed to ascertain whether these differences persist in other studies in other regions.

Although the development of instruments to measure and estimate the prevalence of food security began in the 1980s, a critical gap in its understanding still remains, and our study addressed that gap. Initially, efforts were begun to define the meaning of food insecurity (1,16,47), to develop survey instruments (48–50), and to measure the extent of the problem in the United States (4,51,52) in states (3,11), regions (53), and selected high-risk groups. Limited studies allude to the outcomes of food insecurity (12,54,55), including the behavior and emotional problems in children (10). In an initial conceptual model of food security, Campbell (54) proposed that food security performs both as an outcome variable (from economic inadequacy) and as a determinant variable (for other conditions such as poorer health), but few studies fully investigated these interrelationships. As explained by Dwyer and Cook (56), the future direction for food insecurity research must go beyond monitoring to link it with biological/medical and related outcomes including physical and mental health status. The objective of the present study meets this requirement.

While we are not able to establish a causal relationship between food insecurity and poor health, there are a number of plausible biological mechanisms whereby food insecurity and poor nutrition lead to poor health. Malnutrition exacerbates disease, increases disability, decreases resistance to infection, and extends hospital stays. Other reports suggest that stress and anxiety (which may accompany food insecurity) induce high blood pressure and produce hormonal imbalances, and these together with additional factors can stimulate weight gain, obesity, and insulin insensitivity (57). The explicit reverse causation hypothesis is that poor health (especially disability) increases food insecurity. However, since income was well controlled, the association between food insecurity and poor health argues, to some extent at least, against the reverse causal path. Of course, poor health can also increase household expenses, so the reverse causation cannot be entirely ruled out.

In low-income and rural areas, such as the Mississippi Delta, a number of additional obstacles to health care and health care access could also contribute to poor health status (58). Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas: economic factors, cultural and social differences, and educational shortcomings. About half as many physicians are in rural areas as urban areas to serve a given population base, and rural residents are less likely to have employer-provided health care coverage or prescription drug coverage. Collectively, these and other economic factors contribute to poorer health status.

This study was limited by several factors. First, both predictor and outcome variables were based on self-reported conditions. On the other hand, both instruments have high validity and reliability measures. Second, the cross-sectional design makes it impossible to establish causality. For example, we cannot say exactly how physical and mental health scores change and whether physical and mental health status limits the ability to earn a productive income that sustains food security and overt hunger. Recently, Vozoris and Tarasuk (5) reported striking findings from a comprehensive health survey on the association of food insufficiency across a broad spectrum of physical, mental, and social health indicators. Because of the rigorous statistical design in selecting a representative sample across Canada, the findings from this Canadian study demonstrate that the interrelationship of food insufficiency with health is unlikely condition-specific. Longitudinal data are needed to ascertain the directionality of the associations.

In conclusion, an association between food insecurity and adults’ poor health and mental status, regardless of the causal direction, demonstrates the harmful risks that poor Americans face. In this representative sample of adults who live in the Delta region of Arkansas, Louisiana, and Mississippi, taking into account possible associations with age, gender, ethnic group, and income category, food insecurity is associated with lower self-reported general health status and lower physical and mental summary scores on the SF-12. These findings demonstrate the need to continue efforts to prevent food insecurity and to ensure that efforts that all are adequately fed become a priority to improve the health of this region and nation.

	ACKNOWLEDGMENTS

 
Jacqueline Horton, Sc.D., Gary Shapiro, M.S., and Annie Lo, M.S., of Westat, Rockville, MD, are acknowledged for their study design and statistical expertise. Mark Nord, Ph.D., U.S. Department of Agriculture, Economic Research Service, is acknowledged for advice on the use and interpretation of the U.S. Food Security Survey Module.

	FOOTNOTES

 
¹ This study was funded by the Agricultural Research Service, United States Department of Agriculture, Project No. 6251–53000-002–00D.

² This research was conducted by the Lower Mississippi Delta Nutrition Intervention Research Consortium. Executive Committee and Consortium partners included Margaret L. Bogle, Ph.D., R.D., Executive Director, Delta NIRI, Agricultural Research Service of the U. S. Department of Agriculture, Little Rock AR; Ross Santell, Ph.D., R.D., Alcorn State University, Lorman, MS; Patrick H. Casey, M.D., Arkansas Children’s Hospital Research Institute, Little Rock, AR; Donna Ryan, M.D., Pennington Biomedical Research Center, Baton Rouge, LA; Bernestine McGee, Ph.D., R.D., Southern University and A & M College, Baton Rouge, LA; Edith Hyman, Ph.D., University of Arkansas at Pine Bluff, Pine Bluff, AR; Kathleen Yadrick, Ph.D., R.D., University of Southern Mississippi, Hattiesburg, MS.

³ Presented in part at Experimental Biology ’03, April 12, 2003, San Diego, CA [Casey, P. H., Szeto, K. L., Gossett, J. M., Robbins, J. M., Simpson, P. M., Stuff, J. & Connell, C. (2003) Household food security and adults’ self-reported health status. FASEB J. 17: A296 (abs.)].

⁵ Abbreviations used: FOODS 2000, Foods of Our Delta Study 2000; LMD, Lower Mississippi Delta; NIRI, Nutrition Intervention Research Initiative; SF-12, Short Form 12-item Health Survey; SF-36, Short Form 36-item Health Survey.

Manuscript received 5 January 2004. Initial review completed 4 February 2004. Revision accepted 1 June 2004.

	LITERATURE CITED

TOP ABSTRACT METHODS RESULTS DISCUSSION LITERATURE CITED

 

1. Anderson, S. A. (1990) Core indicators of nutritional state for difficult-to-sample populations. J. Nutr. 120:1559-1600.

2. Bickel, G. W., Carlson, S. & Nord, M. (1999) Household Food Security in the United States 1995–1998: Advance Report 1999 Office of Analysis, Food and Nutrition Service, U.S. Department of Agriculture Alexandria, VA.

3. Nord, M., Jemison, K. & Bickel, G. (1999) Measuring Food Insecurity in the United States: Prevalence of Food Insecurity and Hunger by State, 1996–1998 1999:1-18 Washington, DC. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, Food Assistance and Nutrition Research Report No. 2.

4. Nord, M., Andrews, M. & Carlson, S. (2003) Household Food Security in the United States, 2002 2003:1-58 Washington, DC. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, Food Assistance and Nutrition Research Report No. 35.

5. Vozoris, N. T. & Tarasuk, V. S. (2003) Household food insufficiency is associated with poorer health. J. Nutr. 133:120-126.[Abstract/Free Full Text]

6. Cristofar, S. P. & Basiotis, P. P. (1992) Dietary intakes and selected characteristics of women ages 19–50 years and their children ages 1–5 years by reported perception of food sufficiency. J. Nutr. Educ. 24:53-58.

7. Kendall, A., Olson, C. M. & Frongillo, E. A., Jr (1996) Relationship of hunger and food insecurity to food availability and consumption. J. Am. Diet. Assoc. 96:1019-1024.[Medline]

8. Rose, D. & Oliveira, V. (1997) Nutrient intakes of individuals from food-insufficient households in the United States. Am. J. Public Health 87:1956-1961.[Abstract/Free Full Text]

9. Tarasuk, V. S. & Beaton, G. H. (1999) Women’s dietary intakes in the context of household food insecurity. J. Nutr. 129:672-679.[Abstract/Free Full Text]

10. Kleinman, R. E., Murphy, J. M., Little, M., Pagano, M., Wehler, C. A., Regal, K. & Jellinek, M. S. (1998) Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics 101:E3.

11. Adams, E. J., Grummer-Strawn, L. & Chavez, G. (2003) Food insecurity is associated with increased risk of obesity in California women. J. Nutr. 133:1070-1074.[Abstract/Free Full Text]

12. Nelson, K., Cunningham, W., Andersen, R., Harrison, G. & Gelberg, L. (2001) Is food insufficiency associated with health status and health care utilization among adults with diabetes?. J. Gen. Intern. Med. 16:404-411.[Medline]

13. Vailas, L. I., Nitzke, S. A., Becker, M. & Gast, J. (1998) Risk indicators for malnutrition are associated inversely with quality of life for participants in meal programs for older adults. J. Am. Diet. Assoc. 98:548-553.[Medline]

14. Hamelin, A. M., Habicht, J. P. & Beaudry, M. (1999) Food insecurity: consequences for the household and broader social implications. J. Nutr. 129:525S-528S.[Medline]

15. Siefert, K., Heflin, C. M., Corcoran, M. E. & Williams, D. R. (2001) Food insufficiency and the physical and mental health of low-income women. Women Health 32:159-177.[Medline]

16. Briefel, R. R. & Woteki, C. E. (1992) Development of food sufficiency questions for the Third National Health and Nutrition Examination Survey. J. Nutr. Educ. 24:24S-28S.

17. Ware, J. E., Snow, K. K., Kosinski, M. & Gandek, B. (1993) SF-36 Health Survey: Manual and Interpretation Guide 1993 The Health Institute, New England Medical Center Boston, MA.

18. Bickel, G., Nord, M., Price, C., Hamilton, W. & Cook, J. (2000) Measuring Food Security in the United States. Guide to Measuring Household Food Security, revised 2000 2000 Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation, U.S. Department of Agriculture Alexandria, VA.

19. U.S. Department of Commerce, Economic and Statistics Administration Bureau of Census (2002) Census 2000. Summary File 3 for Census of Population and Housing. http://www2.census.gov/census_2000/datasets/demographic_profile/ [Last accessed 6/01/04].

20. The Lower Mississippi Delta Nutrition Intervention Research ConsortiumStuff, J. E., Horton, J. A., Bogle, M. L., Connell, C., Ryan, D., Zaghloul, S., Thornton, A., Simpson, P., Gossett, J. & Szeto, K. (2004) High prevalence of food insecurity and hunger in households in the rural Lower Mississippi Delta. J. Rural Health 20:173-180.[Medline]

21. Kaufman, P. R. (1999) Rural poor have less access to supermarkets, large grocery stores. Rural Dev. Perspect 13:19-26.

22. Kaufman, P. R., MacDonald, J. M., Lutz, S. M. & Smallwood, D. M. (1997) Do the poor pay more for food? Item selection and price differences affect low-income household food costs. AER-759 1997:1-32 Washington, DC. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, Agricultural Economic Report No. 759.

23. Harsha, D. & Thornton, A. (1997) Health Status of Adults. Harrison, G. eds. Lower Mississippi Delta Nutrition Intervention Research Consortium. Nutrition and health status in the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi: A review of existing data 1997:89-92 Westat Rockville, MD. .

24. The Lower Mississippi Delta Nutrition Intervention Research Consortium (1997) Harrison, G. eds. Nutrition and Health Status in the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi: A Review of Existing Data 1997 Westat Rockville, MD. .

25. Casey, P., Horton, J., Bogle, M., Fomby, B., Forsythe, W., Goolsby, S., Gossett, J., Hyman, E., Kramer, T., Lovejoy, J., Rasco, M., Robbins, J. & Simon, W., Delta Nutrition Intervention Research Consortium (2002) Self-reported health status of residents of the Lower Mississippi Delta of Arkansas, Louisiana and Mississippi. FASEB J. 16:A233 (abstract).

26. Waksberg, J. (1978) Sampling methods for random digit dialing. J. Am. Stat. Assoc. 73:40-46.

27. Kish, L. (1965) Survey Sampling 1965 Wiley New York, NY.

28. Ware, J. E., Kosinski, M. & Keller, S. D. (1998) How to Score the SF-12 Physical and Mental Health Summary Scales 1998 QualityMetric Lincoln, RI.

29. Carlson, S. J., Andrews, M. S. & Bickel, G. W. (1999) Measuring food insecurity and hunger in the United States: Development of a national benchmark measure and prevalence estimates. J. Nutr. 129:510S-516S.[Medline]

30. McHorney, C. A., Ware, J. E., Jr & Raczek, A. E. (1993) The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med. Care 31:247-263.[Medline]

31. Ware, J., Kosinski, M. & Keller, S. D. (1996) A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Med. Care 34:220-233.[Medline]

32. U.S. Department of Commerce, Economic and Statistics Administration Bureau of Census (1992) Census 1990. Summary File 3. 1990 Census of Population and Housing. http://homer.ssd.census.gov/cdrom/lookup [Last accessed 6/01/04].

33. WesVar (1998) WesVar Complex Samples 3.0 User’s Guide 1998 SPSS, Inc.

34. Shah, B. V., Barnwell, B. G. & Bieler, G. S. (1997) SUDAAN User’s Manual, Release 7.5 1997 Research Triangle Institute Research Triangle Park, NC.

35. Tarasuk, V. S. (2001) Household food insecurity with hunger is associated with women’s food intakes, health and household circumstances. J. Nutr. 131:2670-2676.[Abstract/Free Full Text]

36. Pheley, A. M., Holben, D. H., Graham, A. S. & Simpson, C. (2002) Food security and perceptions of health status: A preliminary study in rural Appalachia. J. Rural Health 18:447-454.[Medline]

37. Collins, M. M., Pontari, M. A., O’Leary, M. P., Calhoun, E. A., Santanna, J., Landis, J. R., Kusek, J. W. & Litwin, M. S. (2001) Quality of life is impaired in men with chronic prostatitis—The chronic prostatitis collaborative research network. J. Gen. Intern. Med. 16:656-662.[Medline]

38. McBurney, C. R., Eagle, K. A., Kline-Rogers, E. M., Cooper, J. V., Mani, O. C., Smith, D. E. & Erickson, S. R. (2002) Health-related quality of life in patients 7 months after a myocardial infarction: Factors affecting the short form-12. Pharmacotherapy 22:1616-1622.[Medline]

39. Westbrook, J. I., Talley, N. J. & Westbrook, M. T. (2002) Gender differences in the symptoms and physical and mental well-being of dyspeptics: A population based study. Qual. Life Res. 11:283-291.[Medline]

40. Klesges, L. M., Pahor, M., Shorr, R. I., Wan, J. Y., Williamson, J. D. & Guralnik, J. M. (2001) Financial difficulty in acquiring food among elderly disabled women: Results from the women’s health and aging study. Am. J. Public Health 91:68-75.[Abstract]

41. Patrick, D. L., Danis, M., Southerland, L. I. & Hong, G. (1988) Quality of life following intensive care. J. Gen. Intern. Med. 3:218-223.[Medline]

42. Groce, N. E. & Zola, I. K. (1993) Multiculturalism, chronic illness, and disability. Pediatrics 91:1048-1055.[Abstract/Free Full Text]

43. Warnecke, R. B., Johnson, T. P., Chavez, N., Sudman, S., O’Rourke, D. P., Lacey, L. & Horm, J. (1997) Improving question wording in surveys of culturally diverse populations. Ann. Epidemiol. 7:334-342.[Medline]

44. Ware, J. E., Jr (1978) Effects of acquiescent response set on patient satisfaction ratings. Med. Care 16:327-336.[Medline]

45. Bachman, J. G. & O’Malley, P. M. (1984) Yea-saying, nay-saying, and going to extremes: black-white differences in response styles. Public Opin Q 48:491-509.[Abstract]

46. Williams, D. R., Yu, Y., Jackson, J. S. & Anderson, N. B. (1997) Racial differences in physical mental health: socioeconomic status, stress, and discrimination. Am. J. Health Psychol. 2:335-351.

47. Radimer, K. L., Olson, C. M. & Campbell, C. C. (1990) Development of indicators to assess hunger. J. Nutr. 120(Suppl. 11):1544-1548.

48. Radimer, K. L., Olson, C. M., Greene, J. C., Campbell, C. C. & Habicht, J.-P. (1992) Understanding hunger and developing indicators to assess it in women and children. J. Nutr. Educ. 24:36S-45S.

49. Wehler, C. A., Scott, R. I. & Anderson, J. J. (1992) The community childhood hunger identification project: A model of domestic hunger–demonstration project in Seattle, Washington. J. Nutr. Educ. 24:29S-35S.

50. Kendall, A., Olson, C. M. & Frongillo, E. A., Jr (1995) Validation of the Radimer/Cornell measures of hunger and food insecurity. J. Nutr. 125:2793-2801.[Abstract/Free Full Text]

51. Andrews, M., Bickel, G. & Carlson, S. (1998) Household food security in the United States in 1995: Results from the food security measurement project. Family Econ. Nutr. Rev. 11:17-28.

52. Nord, M., Kabbani, N., Tiehen, L., Andrews, M., Bickel, G. & Carlson, S. (2002) Household Food Security in the United States, 2000 2002:1-41 Washington, DC. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, Food Assistance and Nutrition Research Report. No. 21.

53. Kasper, J., Gupta, S. K., Tran, P., Cook, J. T. & Meyers, A. F. (2000) Hunger in legal immigrants in California, Texas, and Illinois. Am. J. Public Health 90:1629-1633.[Abstract/Free Full Text]

54. Campbell, C. C. (1991) Food insecurity: A nutritional outcome or a predictor variable?. J. Nutr. 121:408-415.[Abstract/Free Full Text]

55. Lee, J. S. & Frongillo, E. A. (2001) Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J. Nutr. 131:1503-1509.[Abstract/Free Full Text]

56. Dwyer, J. & Cook, J. T. (2001) Nutrition and health perspectives on establishing a food security research agenda: What can we learn from the past to establish a framework for the future?. Andrews, M. S. Prell, M. A. eds. (Food Assistance and Nutrition Research Report No. 11–2) 2001:72-90 Washington, DC, U. S. Department of Agriculture, Economic Research Service. Second Food Security Measurement and Research Conference, Volume II: Papers. http://www.ers.usda.gov/publications/fanrr11–2/fanrr11–2f.pdf [Last accessed 6/01/04].

57. Mokdad, A. H., Serdula, M. K., Dietz, W. H., Bowman, B. A., Marks, J. S. & Koplan, J. P. (1999) The spread of the obesity epidemic in the United States, 1991–1998. J. Am. Med. Assoc. 282:1519-1522.[Abstract/Free Full Text]

58. Ricketts, T. C. (1999) Rural Health in the United States 1999 Oxford University Press New York, NY.

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