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Community and International Nutrition

Homeless Youth in Toronto Are Nutritionally Vulnerable^1,2

Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada

³To whom correspondence should be addressed. E-mail: valerie.tarasuk{at}utoronto.ca.

	ABSTRACT

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
This study was undertaken to characterize nutritional vulnerability among a sample of homeless youth in downtown Toronto. Interviews were conducted with 261 homeless youth (149 male, 112 female), recruited from drop-in centers and outdoor locations. Information about current living circumstances, nutrition and health-related behaviors, and 24-h dietary intake recalls were collected, and height, weight, triceps skinfold thickness, and mid-upper arm circumference were measured. A second 24-h dietary intake recall was conducted with 195 youth. Youth’s energy intakes approximated the requirements for a very sedentary lifestyle; 7% were underweight and 22% were overweight or obese. Over half of the youth had inadequate intakes of folate, vitamin A, vitamin C, magnesium, and zinc; in addition, more than half of females had inadequate vitamin B-12 and iron intakes. Most youth got food from more than one source in the course of a day: 74% of males and 75% of females purchased food; 48% of males and 51% of females obtained food from charitable meal programs; 47% of males and 75% of females received food from strangers or acquaintances; and 10% of males and 6% of females stole food or took it from the garbage. Compared to a sample of 114 domiciled youth from the 1997–1998 Ontario Food Survey, males had lower energy and nutrient intakes and females had lower intakes of most nutrients.

KEY WORDS: • nutritional vulnerability • homelessness • youth

In recent years in many developed countries, problems of homelessness have grown in size and complexity. In Canada, as many as 260,000 people are thought to live in absolute homelessness, living on the street, in temporary shelters, or in "locations not meant for human habitation" (1). Further, the "face" of homelessness is changing, with youth representing one of the fastest growing and most vulnerable subgroups (2). Social service agencies, health centers, and voluntary organizations have responded by initiating a myriad of programs to help the homeless obtain food, shelter, and primary health care. Despite these efforts, homeless youth appear to be locked in a daily struggle to meet basic needs, cobbling together food from a variety of sources in their efforts to get enough to eat (3). Their ability to purchase food is limited by the extreme poverty that is rooted in the their lack of secure, paid employment and their reliance on income-generating strategies in the informal economy (e.g., panhandling, squeegeeing, sex-trade work, crime) (3,4). Most homeless youth report that they obtain food from charitable programs (e.g., soup kitchens, meal and snack programs at drop-in centers, and street outreach programs) (5), but access to food via these routes is typically limited; both the quality and quantity of food available are largely a function of charitable donations (3,6,7). Homeless youth may also acquire food through social networks (3,8), steal it (5,9,10), or retrieve food discarded by others in public places. Given the nature of their food acquisition strategies, it is not surprising that reports of food scarcity and deprivation among homeless youth in Canada abound (3,5,10–12).

Although there have been no assessments of dietary adequacy or nutritional status among homeless groups in Canada, studies of homeless populations in other developed countries have consistently revealed inadequate dietary intakes (13–20), evidence of wasting (13,18,20), and compromises in nutritional status (15,21). However, most of this work was conducted among adult samples; when youth were included, small samples appear to have limited the potential for separate analyses of this subgroup.

In 2003, we undertook a study of homeless youth in Toronto, employing a combination of survey methods and in-depth, qualitative interviews to characterize the extent and nature of their nutritional vulnerability and gain an understanding of the ways in which community responses to homelessness shape the dietary intakes of homeless youth. In this paper, we draw on data from the survey portion of the study to present an assessment of the adequacy of the youth’s estimated usual nutrient intakes and anthropometric indices of nutritional status, examine the relation between youth’s food acquisition practices and their dietary intakes, and contrast their intakes to findings for domiciled youth. An analysis of youth’s food acquisition practices in relation to their living circumstances and experiences of food deprivation will be presented elsewhere.

	SUBJECTS AND METHODS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
    Sampling and data collection. All participant recruitment and interviewing occurred in downtown Toronto, between April and October 2003, with the work conducted by 5 trained interviewers who were themselves youth with firsthand experience of homelessness. The study protocol was approved by the Health Sciences Research Ethics Board at the University of Toronto. Youth were eligible to participate if they met the following criteria: 1) 16–24 y of age, 2) not currently pregnant, and 3) without stable, secure housing arrangements, defined as having spent 10 or more of the past 30 nights sleeping in a temporary shelter, indoor or outdoor public space, or friend’s place, because they had no place or no safe place of their own. Six drop-in centers and 28 outdoor locations where homeless youth "hung out" (e.g., under bridges, in abandoned buildings, parks, and garages) were identified as recruitment sites. Drop-in center workers were contacted to obtain estimates of the number of eligible youth using their facilities, and field observations were conducted to estimate the number of homeless youth in each outdoor area. Quotas proportional to these estimates were developed for each site, assuming a target sample of 240 youth (120 male, 120 female) and equal recruitment between indoor and outdoor locations. Because the number of homeless youth in any location at any time was relatively small, random sampling was not feasible. Instead, interviewers systematically approached each youth they encountered at each site. Of the 483 youth approached to participate, 170 were deemed ineligible (68% because they failed to meet the criteria for unstable housing, 24% because they were >24 y old, 4% because they were pregnant, and 4% for other reasons), 40 declined to participate and 12 were subsequently dropped from the study (11 because they were duplicates and 1 because of data quality concerns). A final sample of 261 youth was achieved, reflecting a participation rate of 83.4% (261/313 potentially eligible youth); 70% of the final sample was recruited from outdoor locations.

Study participants were interviewed when recruited and invited to meet for a second interview 3 d later or as soon thereafter as possible. Of the participants, 195 (75%) completed second interviews, and 91% of these occurred within 14 d of the first interview. At the first interview, a 24-h dietary intake recall and interviewer-administered questionnaire on current living circumstances, nutrition- and health-related behaviors were conducted, and height, weight, triceps skinfold thickness, and mid-upper arm circumference were measured. The second interview comprised a 24-h dietary intake recall and brief questionnaire on current living circumstances. Thirty youth subsequently participated in semistructured, open-ended interviews to elucidate the social and symbolic meanings of food and various food acquisition strategies for them; these results will be reported elsewhere.

The 24-h recall method followed standardized procedures, employing portion size models as a way to prompt accurate recall of food quantities (22). For each item reported, participants were asked who had prepared the food (if some food preparation had taken place before consumption) and how they acquired the item. Means of food acquisition were classified by the interviewer into 1 of 6 options: food purchased by the participant; food obtained from other people (strangers or acquaintances); food obtained from charitable meal services or social service agencies; food obtained through theft or taken from the garbage or plate waste of paying customers in commercial eating establishments; food obtained from emergency food distribution programs; and food obtained from other or unreported sources. These response options were developed from an examination of the food sources reported by homeless youth in our earlier ethnographic study (3).

The dietary recall data were converted into energy and nutrient intakes using the Nutrition Survey System (NSS) developed by Health Canada, based on data from the Canadian Nutrient File. Because the NSS does not compute vitamin A intakes in retinol activity equivalents (RAE), values for this nutrient were drawn from U.S. food composition tables (23). Statistical analyses were conducted using SAS/PC Version 8.2 (SAS Institute).

    Assessment of nutritional vulnerability. BMIs for youth 18–24 y old were compared with current Canadian guidelines (24) and those for youth < 18 y old were compared with international age- and sex-specific reference standards (25) to determine the prevalence of being underweight, overweight, or obese. The triceps skinfold thickness and arm circumference measures were used to calculate mid-arm muscle area (AMA), applying standard sex-specific correction factors for bone areas for youth 18 y (25). For normal and underweight youth (defined by BMI assessment) with complete and reliable anthropometric measurements (n = 87), AMA estimates were compared with reference standards to assess the adequacy of muscle reserves (26).

The distributions of usual energy and nutrient intakes were estimated using SIDE software (27) to "remove" the effects of day-to-day variability in intakes. The prevalence of inadequate intakes was determined by comparing the estimated distribution of usual intakes with current nutrient requirements (28–32), using standard probability assessment methods (33,34). These analyses were conducted separately for males and females (omitting 1 male for whom no dietary intake data were recorded), using age-appropriate requirement estimates. The assessment of females’ iron intakes took into account the lower iron requirement of the 10 females who reported taking oral contraceptives (3). Because 94% of youth smoked daily, estimated average requirements for vitamin C intakes were increased by 35 mg/d for all age and sex groups in our assessment to reflect the elevated requirements of regular smokers (31).

Youth’s energy requirements were estimated using age- and sex-specific equations, with the equations for total energy expenditure used to estimate requirements for youth with BMI > 25 kg/m² (32). Because we had no way in which to estimate physical activity levels, individuals’ energy requirements were computed for each of the 4 activity levels for which coefficients of physical activity are provided (32). Group mean and median energy requirements were contrasted with estimated usual energy intakes to appraise the adequacy of current intakes.

ANOVA was used to examine the relation between heavy drug or alcohol use and energy and nutrient intakes. To reduce the error associated with within-person variation in intakes, only youth who had completed two 24-h recalls were included. The frequency of tobacco, alcohol, and drug use over the past 30 d was assessed (4), and youth who reported using crack, cocaine, speed/crystal, opiates, glue, gasoline, tranquilizers, hallucinogens, or ecstasy every day or several times each week were classified as "frequent heavy drug users." (Preliminary analysis confirmed that frequent users of marijuana or hash should be omitted from this classification because their dietary intake patterns were more similar to those of nondrug users than heavy drug users.) Because our frequency measure did not assess the amount of alcohol usually consumed, we defined high alcohol consumption as the reported consumption of >5 drinks/d (1 drink = 13.6 g alcohol) on at least one 24-h recall. The 2-d mean energy and nutrient intakes of frequent heavy drug users and heavy drinkers were compared with those of other youth, following Box-Cox power transformations to normalize the intake data.

    Description of eating and food acquisition patterns. To describe individuals’ food acquisition practices within a single 24-h recall period, dichotomous variables were constructed to identify use of each food source recorded, and the proportion of total energy and nutrient intakes obtained from each source was summarized. Logistic regression was used to compare the likelihood of females and males reporting food from each source. To examine the relation between the nutritional quality of youth’s intakes and their food acquisition patterns on a particular day, Spearman rank correlations between total energy and nutrient intakes over the 24-h period and the proportion of total energy intake obtained from each source were computed. Correlations were also computed to assess the association between food acquisition patterns and total alcohol and caffeine intakes. This nonparametric test was selected because of the skewed nature of the distributions involved.

To explore the relation between the frequency of eating and nutritional vulnerability, discrete eating occasions were denoted by time of consumption on the recall form (omitting occasions when only water was consumed). Relations between the frequency with which youth ate over the course of the day and their total energy and nutrient intake and means of food acquisition were assessed using Spearman correlation coefficients. Spearman correlations were also computed to assess the relation between number of food sources and number of eating occasions reported on the 24-h recall.

    Comparison with domiciled youth. Homeless youth’s energy and nutrient intakes were contrasted with the reported intakes of 114 domiciled youth (50 male and 64 female), 18–24 y, who participated in the Ontario Food Survey (OFS). This survey of 1187 adults, sampled from the Ontario Ministry of Health Registered Persons Database, was conducted from September 1997 to June 1998 (35). The recruitment of survey participants through home addresses and telephone follow-ups ensured that only housed people were included. Participants completed 24-h dietary intake recall interviews and anthropometric measures following methods similar to those in our study. Because of the small number of youth in the OFS and the fact that only 44 had completed second dietary intake recalls, it was not feasible to estimate the distribution of usual intakes for this sample. Instead, the reported intakes of domiciled and homeless youth were compared using only 24-h recall data from the first interview of participants in both surveys, and including only homeless youth 18–24 y in the comparison. The intake data were transformed to satisfy the assumptions of a normal distribution using Box-Cox power transformations and then compared using ANOVA. No comparison of vitamin A intakes was conducted because the units for this nutrient differed among the surveys. Values in the text are means ± SD.

	RESULTS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
    Description of sample. Sample characteristics are summarized in Table 1. The mean age of the youth was 20.2 ± 2.4 y. Only 20% were not white, and most of these were either aboriginal or black. Most youth had not completed high school; 7 (3%) reported that they were currently attending school, but only 2 were in school full-time. Over half (56%) of youth had been homeless for >2 y. Most obtained income from work in the informal economy. Only 6% reported welfare or other forms of government assistance as their main source of income. At the time of the first interview, 89% had spent the previous night outdoors, at a friend’s or relative’s place, or in a "squat" (i.e., makeshift shelter in an abandoned building); only 6% had stayed in a shelter or hostel.

Heavy drug use was reported by 51 males (35%) and 50 females (45%). No differences in energy or nutrient intake or BMI were observed in association with heavy drug use among males (Supplemental Table 2). Among females, however, heavy drug use was associated with significantly lower intakes of vitamin B-6, folate, thiamin, niacin, magnesium, and zinc, and lower mean BMI (Supplemental Table 2).

    Food sources. An analysis of the food sources youth reported in their 24-h dietary intake recalls at interview 1 indicates that purchasing was their most common means of food acquisition (Table 5). Females were 3.19 times more likely (95% CI: 1.86, 5.47) than males to have received food from other people, but no other gender differences were noted. Although 48% of males and 51% of females had obtained some food in charitable meal programs, only 16 males and 3 females relied exclusively on such programs.

    Eating occasions. Males reported 3.45 ± 1.96 eating occasions (median: 3.00) on their first 24-h recall and females reported 3.80 ± 1.85 eating occasions (median: 3.50), but the number ranged from 1 to 12. The frequency of eating was positively correlated with total energy and nutrient intake, with Spearman correlation coefficients ranging from 0.57 for energy (P < 0.0001) to 0.36 for vitamin B-12 (P < 0.0001) for males. Among females, the Spearman correlation coefficient between number of eating occasions and intake ranged from 0.55 for energy (P < 0.0001) to 0.29 for zinc (P = 0.0023). Importantly, the number of eating occasions was also positively correlated with the number of different food sources reported (Spearman r = 0.48 for males, P < 0.0001; and r = 0.52 for females, P < 0.0001). Most youth obtained food from more than 1 source in the course of a day, with energy intakes highest among those reporting 3 different sources (Table 6). However, youth reporting more sources also tended to have eaten more frequently in the course of the day.

	DISCUSSION

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

Youth in this study reported high levels of tobacco, drug, and alcohol use, a finding that is consistent with other studies of homeless youth (4,5,38–40) and adults (19,20). Although substance use was associated with some systematic differences in energy and nutrient intakes, the frequent use of heavy drugs or high alcohol consumption did not appear to account for the high prevalence of nutrient inadequacy observed.

Other studies have documented the nutritional vulnerability of homeless groups, but these problems have typically been linked to the poor quality and insufficient quantities of food provided in soup kitchens and other programs targeted to this group (13,14,41). Our research raises questions about the centrality of food assistance programs to the nutritional well-being of homeless youth in Toronto. Although approximately half of the youth in our sample obtained some food from charitable food assistance programs, unlike in other studies of homeless groups (13,17,42), this was not the primary source of food for most youth, nor did it appear to be the most important one. Total energy intake was unrelated to program use.

The systematic examination of youth’s food acquisition practices in conjunction with their 24-h dietary intakes indicated that very few relied on a single food source. Further, youth who relied on a single source tended to have eaten less and to have eaten less often than youth who cobbled together a diet from multiple sources. This suggests that no single food acquisition strategy yielded sufficient access to food for youth to meet their needs.

Assessing the contributions of different food acquisition strategies to youth’s total energy and nutrient intakes is complicated by the constraints associated with each strategy. Most youth purchased at least some of the food they consumed, but their nutrient intakes did not rise in relation to the proportion of total food intake that they purchased. The observed associations between charitable meal program use and nutrient intakes among males suggest that they may obtain more nutritious foods through meal programs than through independent purchases. This could indicate an emphasis on nutrition in some charitable meal programs, but it might also be related to the limitations homeless youth confront when purchasing food. Without housing, youth lack access to food storage and preparation facilities so they must buy food that is ready for immediate consumption. Our earlier research with homeless youth in Toronto revealed that when they have money to purchase food, they typically buy from fast-food outlets, variety stores, and street vendors (3,11). These venues are readily accessible in urban environments, they sell food that is inexpensive and ready-to-eat, and unlike restaurants, expectations regarding customers’ dress and deportment are minimal. However, youth’s reliance on such venues may limit their potential to obtain nutritious meals.

Although both males and females in this study appeared vulnerable to nutrient inadequacies, profound gender differences were observed in their food acquisition patterns. Given the documentation of gender differences in the income-generating activities [and specifically, the greater likelihood of females engaging in prostitution or "survival sex" (5,43,44)], it is not surprising that male and female youth also acquire food through different routes. The high reliance of females on other people for food and the minimal effect of food purchases and program use on their total intakes are findings that merit further examination. Although homeless youth’s acquisition of food through social networks can be seen as one aspect of the vital support they receive from others while on the street (3,8), it is important to recognize that street relationships can also be exploitive (45–47). Because food is such a precious commodity among homeless youth (3), it can be used as a means of coercion. More research is required to understand the conditions under which homeless youth obtain food from other people and to identify the effect of this dependence on youth’s health and well-being.

The high level of nutritional vulnerability documented here is of particular concern because, given the reported durations of homelessness among youth in this study, their circumstances cannot be regarded as short term. Chronically poor nutrition is associated with impaired cognitive and physiological functions and increased risk of infections. Further, nutritional problems can exacerbate health conditions such as depression, substance abuse, tuberculosis, hepatitis B, HIV, and other sexually transmitted diseases, all of which are more prevalent among homeless youth in Canada (10,39,43,48–54). Poor nutrition also compounds the risks faced by youth who become pregnant. [In one large, cross-sectional survey of homeless youth in Toronto, one-quarter of the women sampled were pregnant (48).] Although homelessness negatively affects youth’s health, poor health is a substantial barrier to youth finding and maintaining employment, a crucial step out of homelessness. The extreme nutritional vulnerability of homeless youth in this study highlights the need for more effective policy and program interventions.

	ACKNOWLEDGMENTS

 
The authors are indebted to Stephen Gaetz and Blake Poland for their contributions to this research project and thank Natalie Kwan for technical assistance.

	FOOTNOTES

 
¹ Supported by an operating grant from the Canadian Institutes of Health Research.

² Supplemental Tables 1–3 are available as Online Supporting Material with the online posting of this paper at www.nutrition.org.

Manuscript received 1 March 2005. Initial review completed 19 April 2005. Revision accepted 24 May 2005.

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TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 

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