Symposium
Food Insecurity: A Nutritional Outcome or a Predictor Variable?1»2 CATHY C. CAMPBELL
Division of Nutritional Sciences, Cornell University, Ithaca, NY 148554410
DEFINITIONS ABSTRACT The phenomenon loosely labeled hunger in the 1980s is now being discussed as food security or insecurity. Food security is defined as access by all people at all times to enough food for an active, healthy fife, and at a minimum includes the following: 1) the ready availability of nutritionally adequate and safe foods and 2) the assured ability to acquire personally ac ceptable foods in a socially acceptable way. Food in security exists whenever food security is limited or un certain. The measurement of food insecurity at the household or individual level involves the measurement of those quantitative, qualitative, psychological and social or normative constructs that are central to the experience of food insecurity, qualified by their involuntariness and periodicity. Risk factors for food insecurity include any factors that affect household resources and the proportion of those resources available for food ac quisition. Potential consequences of food insecurity in clude hunger, malnutrition and (either directly or in directly) negative effects on health and quality of life. The precise relationships between food insecurity and its risk factors and potential consequences need much more research now that there is an emerging consensus on the definition and measurement of food insecurity. Indicators of food security or insecurity are proposed as a necessary component of the core measures of the nutritional state of individuals, communities or nations. J. Nutr. 121: 408-415, 1991.
Much of the public discussion of hunger has been emotionally charged and politically pointed. The main action taken in response to this public outcry was the establishment of an extensive network of private or charitable food assistance programs (1, 2). These programs were initially set up as an emergency response to the hunger crisis and now, to the conster nation of many, this network is becoming an accepted or institutionalized part of our food distribution system (3, 4). At the same time much of the academic debate was about the definition of hunger (5, 6). This debate, however, paid remarkably little attention to differen tiations between risk factors for the phenomenon (whatever its definition), the phenomenon itself and its consequences. Some academics also developed re search efforts to respond to the issue. These efforts, however, often employed multiple definitions or used measures that had a very tenuous or arguable rela tionship with any definition chosen (7—9). Although, the debate has been protracted and much of the re search rather thin, a consensus on definition and measurement approaches is gradually emerging. The phenomenon loosely labeled hunger in the 1980s is now being discussed as food security or insecurity (10-15). The following definition is pro posed: Food security is access by all people at all times to enough food for an active, healthy Ufe, and at a minimum includes the following: 1} the ready
INDEXINGKEY WORDS: •hunger •food security •nutritional status assessment
Hunger in America has been in and out of the public attention throughout the 1980s. Nutrition pro fessionals in government and the academic world re sponded in various ways over the decade. This paper will present an assessment of the state of affairs at the Beginning of the 1990s in light of some of the ex periences of the 1980s. It is written from the per spective of an academic involved in applied nutrition research and therefore will address primarily issues of definition, conceptual frameworks and measurement, and will conclude with a brief assessment of the logical and ethical status of the topic of hunger within the field of nutrition.
'Presented as part of a symposium, "Nutritional Assessment and Intervention: Interface of Science and Policy," sponsored by the joint American Institute of Nutrition/American Society for Clinical Nutrition Task Force on Hunger and Malnutrition, given at the meeting of the Federation of American Societies for Experi mental Biology, Washington, DC, April 4, 1990. Hauest editor for this symposium was William H. Dietz, Pedi atrie Gastroenterology and Nutrition, New England Medical Center, Boston, MA 02111.
0022-3166/91 $3.00 ©1991 American Institute of Nutrition. Received 17 October 1990. Accepted 9 January 1991.
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availability of nutritionally adequate and safe foods and 2) the assured ability to acquire personally acceptable foods in a socially acceptable way. Food insecurity exists whenever the availability of nutri tionally adequate, safe foods or the ability to ac quire personally acceptable foods in socially ac ceptable ways is limited or uncertain. Several features of this definition require comment. The order of these qualifications reflects the current degree of consensus. 1) The definition explicitly includes every person at all times; even though defining a situation that seems to be unattainable may seem coun terproductive, a less inclusive definition cannot be justified on either ethical or nutritional bases. 2) Two dimensions of accessibility are differenti ated: the availability of food and the ability to acquire the available food; "ready" and "as sured" are included as qualifiers to ensure access "at all times." 3) "Enough food for an active, healthy Ufe" implies a diet with sufficient energy, nutritional quality and safety to prevent diet mediated malnutrition or limitations in activity levels. 4) Food insecurity includes limited or uncertain access. 5) "Socially acceptable ways" refer to conventional food sources such as grocery stores, restaurants and government food assistance programs 6) "Personally acceptable" is included to reinforce the value our society places on freedom of choice; in practice, freedom of choice differen tiates how cattle are fed from how humans ac quire food. Even though in comparison with "hunger," the phrase "food insecurity" does not carry the same connotation of a painful experience with which everyone has at least some transitory familiarity, it does have several positive attributes. Use of "food insecurity" restricts the word "hunger" to its dic tionary meaning of "an uneasy or painful sensation caused by lack of food" (16). Hunger, then, becomes a potential although not necessary consequence of food insecurity. The differentiation of biological and socioeconomic dimensions in this definition allows re searchers to move beyond a focus on the nature of the relationship between hunger and undemutritÃ-on or malnutrition more generally. Malnutrition is a po tential although not necessary consequence of food insecurity. In addition, in contrast to hunger, which is most commonly associated with individuals, food security or insecurity can be a characteristic of nations, com munities, households or individuals. Food insecurity can therefore be studied at different levels of analysis without stretching its definition, hi the 1980s, discus sions about the social context of hunger easily became mired in arguments about causal links be Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
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tween community-wide events and individual ex periences of hunger. Also, this definition or modifica tions of it can apply both domestically and internationally. Although different measures of food insecurity may be chosen in different countries and its consequences may be different, the key dimen sions of the phenomenon itself are common. Finally, in contrast to hunger, the definition of food insecurity does not imply or suggest simplistic or individualistic action alternatives. Rather, the concept of food security clearly directs attention to different aspects of the food system.
IMPLICATIONS
FOR MEASUREMENT
Two related measurement issues will be addressed: first, the constructs to be measured to identify and assess food insecurity, and second, actual approaches that have been used to measure these constructs. Constructs. On the basis of research done by Radimer and her colleagues (17), the constructs sum marized in Table 1 are proposed as the essential aspects of food insecurity at the individual and household levels of study. These constructs were es tablished by analyzing accounts given by individuals of their experiences of food insecurity. The following aspects are the components that were central and common to those accounts: 1) the quantitative aspect of having enough or sufficient food; 2) the qualitative aspect concerning the types and diversity of food; 3) a psychological aspect: food insecurity is accompanied by feelings of deprivation or restricted choice for in dividuals, and by anxiety about the amount and types of food on-hand in the household stores,- and 4} a social or normative aspect: an individual evaluates his or her own food situation in terms of generally ac cepted social norms, such as eating three meals a day, or being able to purchase foods without having to beg, rely on charity, scrounge or steal food.
TABLEl Essential components of a measure of food insecurity individual and household levels of study1
Component1. Quantity
levelEnergy
sufficiency of intake Quality3. 2. Nutrient adequacy of intake Psychological ac Feelings of depri ceptability4. vation or re choiceNormal stricted Social acceptabilityIndividual meal pat ternsHousehold 'Adapted from Radimer et al. (17).
at the
levelRepleteness of household stores Quality and safety of on-hand food Anxiety about food suppliesConventional
sources of food
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TABLE 2 Radimer'a food insecurity
TABLE 3 scales'*
Community Childhood Hunger Identification hunger scale1*
Project's
Household hunger 1. Do you worry whether your food will run out before you get money to buy more? 2. The food that I bought just didn't last, and I didn't have money to get more. 3. I ran out of foods that I needed to put together a meal and I didn't have money to get more food. 4. I worry about where the next day's food is going to come from. Women's hunger 1. I can't afford to eat the way I should. 2. Can you afford to eat properly? 3. How often are you hungry, but you don't eat because you can't afford enough food? 4. Do you eat less than you think you should because you don't have enough money for food? Children's hunger 1. I cannot give my child(rcn) a balanced meal because I can't afford that. 2. I cannot afford to feed my child(ren) the way I think I should. 3. My child(ren) is/are not eating enough because I just can't afford enough food. 4. I know my child(ren) is/are hungry sometimes, but I just can't afford more food. 'Response categories: for questions: never, sometimes, often; for statements: not true, sometimes true, often true. Hunger criterion is any response other than "never" or "not true." Reprinted with permission from Radimer et al. (17).
Two additional dimensions, however, need to be included in any measure of food insecurity. First, the involuntariness of any limitation or restriction in these constructs needs to be an integral part of its measurement. In an industrialized country, mea suring the involuntary nature of food insecurity us ually involves an assessment of financial constraint, although it can also involve an assessment of the reliability of food providers for people who are de pendent on others for food—its acquisition, prep aration or consumption. Second, the periodicity or duration of an episode of food insecurity also needs to be part of either the measurement used (in terms of the stem of the question or its response categories) or the study design (e.g., longitudinal, repetitive crosssectional surveys). At a community level, the constructs most often included are the availability of food markets, the actual quantity and quality of food present in food markets and the ability of people, both financially (considering price relative to individuals' abilities to command resources) and physically (in terms of trans portation issues or physical disabilities), to acquire the food that is available. Sen's study (18) of the Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
1. Does your household ever run out of money to buy food to make a meal? 2. Do you or members of your household ever eat less than you feel you should because there is not enough money for food? 3. Do you or members of your household ever cut the size of meals or skip meals because there is not enough money for food? 4. Do your children ever eat less than you feel they should because there is not enough money for food? 5. Do you ever cut the size of your children's meals or do they ever skip meals because there is not enough money for food? 6. Do your children ever say they are hungry because there is not enough food in the house? 7. Do you ever rely on a limited number of foods to feed your children because you are running out of money to buy food for a meal? 8. Do any of your children ever go to bed hungry because there is not enough money to buy food? 'Hunger criterion: five positive responses out of eight. 2Reprinted from réf. 8. Used by permission of Cheryl A. Wehler and the Connecticut Association of Human Services.
famines in Bengal, Ethiopia, the Sahel and Bangladesh is a classic evaluation of financial aspects of accessi bility in the international context. Several different groups in the United States are currently involved in assessing community-level food security (19-21). In summary, any measurement of food insecurity involves the measurement of the core constructs qualified by their involuntariness and periodicity. Measurement approaches. Various approaches have been used to measure these constructs. These range from an assessment of practice (e.g., the measurement of energy sufficiency with a diet recall), to the self-perception of sufficiency (measured with a question such as: "Do you eat less than you think you should because you don't have enough money for food?"). Interestingly, in a study (22) in 1984 that used both approaches, persons who reported that they were eating less than they thought they should also reported consuming significantly less energy in a 24-h recall in comparison with those who did not think they were eating less than they should [means: 4.87 MJ (1160 kcal) to 6.11 MJ (1454 kcal); P < 0.001]. Three examples of current specific indicators of food insecurity will illustrate the general measurement approaches now in use and the emerging consensus in this area: 1} Radimer's food insecurity scale; 2) the hunger scale of the Com munity Childhood Hunger Identification Project (CCHIP); and 3) the questions included in the third National Health and Nutrition Examination Survey (NHANES). Although a single question was included in the U.S. Department of Agriculture's Nationwide
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Food Consumption Survey, its utility is limited be cause it attempts to assess involuntary restrictions in the quality and quantity of food choice simulta neously. Radiiner (17) proposed the three food insecurity scales itemized in Table 2. These clearly differentiate household from individual experiences and the mother's experience from that of her children. If, as has been hypothesized, mothers experience food in security before their children, it may be important from a monitoring point of view to distinguish be tween the two (23). These scales are a mixture of statements and questions that were developed from actual statements made by mothers experiencing food insecurity. Information about the frequency of the experience is included in the response categories. The involuntariness of any insecurity is included in the statement or question, for example, "I didn't have money to get more" or "because you can't afford enough food." The criterion used to differentiate food insecure groups from secure groups was any response other than "never" or "not true." This approach indi cated significant differences between the groups in terms of income, food expenditures and coping tactic usage. The CCHIP questions itemized in Table 3 are cur rently being used in 11 different community surveys around the country (8). The scale consists of eight items. Food insecurity is indicated by five or more positive responses. Mention of the lack of money is included in each question (except Question 6) in order to assess the involuntariness of the experience. The CCHIP researchers have experimented extensively with different ways to assess the periodicity of food insecurity and have found that nothing is gained by estimates more precise than a positive response to "do you ever...." In contrast to the Radimer scales, this scale does not differentiate household from childhood experiences. More emphasis is placed on coping approaches for food insecurity, such as skipping meals, cutting the size of meals and relying on a limited number of foods. There is no consensus yet on whether specific coping strategies should be part of the core construct of food insecurity. The questions chosen for the third NHANES (as itemized in Table 4) are targeted to both individuals and households but really focus only on the indi vidual experience of food insecurity. For some ques tions, the involuntary character of the experience is ascertained in a follow-up question and most of the questions include the phrase "food or money to buy food." The main focus is on the quantitative aspect of food insecurity with one question on meal pattern. The NHANES questions are much more specific about the time frame of the experience. This emerging consensus on the definition and measurement approaches for food insecurity has im plications for the conceptualization of risk factors and Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
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TABLE 4
Third National Health and Nutrition Examination Survey's food insecurity measures A) Twenty-four-hour dietary recall form Q-5 Thinking about the past month, how many days did you have no food or money to buy food? Q-6 Is that because there isn't enough money to buy food or is there another reason? Q-7 During the past month did you skip any meals because there wasn't enough food or money to buy food? Q-8 How many days in the month did you skip any meals because there wasn't enough food or money to buy food? Q-9 Did you skip any meals yesterday because there wasn't enough food or money to buy food? Q-10 During the past month, were there any days when you did not eat at all because there wasn't enough food or money to Q-llIn
buy food? the past month, how many days were there when you didn't eat at all?
B) Family questionnaire F4
F5 F6
Which one of the following statements best describes the food eaten by (you/your family)? Do you have enough food to eat, sometimes not enough to eat, or often not enough to eat? Thinking about the past month, how many days did (you/ your family) have no food or money to buy food? Which of the following reasons explain why your family has had this problem? a. b. c.
You did not have transportation (transportation prob lems)? You did not have working appliances for storing or preparing foods (such as stove, refrigerator)? You did not have enough money, food stamps, or WIC
vouchers to buy food or beverages? d. Any other reason?
consequences of food insecurity and for the research that is critically needed to elucidate the relationships between risk factors, the phenomenon itself and its consequences.
RISK FACTORS The identification of risk factors for food insecurity depends on the researcher's conceptualization of the social context of food insecurity. Each researcher working in this area has his or her own conceptualiza tion, although a general agreement exists on the factors included (8, 11, 24). One example is included as Figure 1. The experiential dimension of food in security at the household and individual levels has already been discussed. Of the three different sources
412
CAMPBELL PRIVATE SFCTOR employment advertising
PUBLIC SECTOR employment social assistance education
INFORMAL SECTOR barter/exchange advice
t HOUSEHOLD RESOURCES — (money, time, information, health)
1 NORMAL FOOD SYSTEM grocery stores and food service operations
1
NON-FOOD EXPENDITURES
FOOD ACQUISITION
housing health care emergencies taxes discretionary items
I [
food availability (type and quantity) food accessibility (cost and distance)
ALTERNATE FOOD SOURCES GOVERNMENT FOOD ASSISTANCE
PRIVATE FOOD ASSISTANCE gifts from family & friends gardening, hunting, fishing scavenging
Food Stamps
WIC* School Lunch and Breakfast Nutrition Program for the Elderly (Title 3c) S.N.A.P.* (New York) (Social Context
of Food Access)
(Experiential Dimension
of Food Access Problems)
HOUSEHOLD FOOD SUPPLY FOOD ANXIETY - restricted food supplies
T INDIVIDUAL FOOD INTAKE DIET INADEQUACY - involuntary restrictions in type of food eaten INTAKE INSUFFICIENCY - involuntary restrictions in the amount of food eaten
T
l
HEALTH & QUALITY OF LIFE FIGURE 1 Conceptualization of food insecurity and its risk factors. *W.I.C. - Women, Infants and Children Supplemental Food Program, S.N.A.P. - Supplemental Nutrition Assistance Program.
of food identified in Figure 1, two groups—the normal food system (grocery stores and food service opera tions) and the government food assistance programs—are considered conventional food sources. Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
The alternate food sources are considered nonconventional, although the private food assistance network is very rapidly becoming an institutionalized third tier of the conventional food distribution system.
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ASSESSMENT AND INTERVENTION
RISK FACTORS for a poor diet...
\
CONSEQUENCES DIET FOOD INSECURITY
NUTRITIONAL STATUS
of a poor nutritional
. anthropométrie food intake patterns
state . biochemical . clinical
RISK FACTORS
T
for secondary
. health physical & social & mental wellbeing
malnutrition . quality of life
DIRECT INDICATORS OF NUTRITIONAL STATE FIGURE 2 Logical status of nutrition
related indicators.
Consideration of food sources is part of the definition of food security and part of its measurement at the household and community levels. Risk factors for food insecurity are therefore anything that limits either the household resources (money, time, infor mation, health, etc.) or the proportion of those resources available for food acquisition. Hence, risk factors include factors that limit employment oppor tunities, wage and benefit scales and social assistance benefits, or that mercase nondiscretionary nonfood expenditures such as the cost of housing and utilities, health care, taxes, child care and the likelihood of emergencies. The most pressing of the public policy research questions now addressable is the shape of the curve between income (or any other measure of ability to command resources) and food insecurity and the impact of risk factors on the shape of that curve. Questions about proportion of the poor, working poor or the nonpoor who experience food insecurity are unanswered as yet. It has been impossible to be precise on a population basis about the effect of social assistance shortfalls, changes in wage and benefit policies or escalating housing costs on increased food insecurity. Acceptance of the définitionof food in security permits researchers not only to determine Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
the existence and extent of food insecurity but also to model the effects of its predisposing factors.
POTENTIAL CONSEQUENCES In turning to the potential consequences of food insecurity, it is now possible to consider the issue raised in the title of this paper. Should food insecurity be considered an important outcome variable or is it more properly considered a predictor variable of other more definitive outcomes? More specifically, is food insecurity an important nutrition outcome variable that should be considered a core component of an individual's nutritional state? A summary of the components of this argument is given in Figure 2. Two sets of potential consequences of food insecurity are presented in this figure. These include physiological symptoms of suboptimal nutri tional status (the classic measures of malnutrition) and health (including physical, social and mental well-being) and quality of Ufe outcomes. Food in security can affect health either directly or indirectly through a physiological mechanism related to nutriture. As the exact ways that social and mental wellbeing affect physical well-being are more fully under-
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stood, it will be possible to determine whether there are direct effects of food insecurity on health that are not mediated by nutrient deficiencies. The relationships indicated in Figure 2 also imply that food insecurity can (but does not necessarily) lead to malnutrition. Malnutrition in an industri alized country can include a much more complex, simultaneous combination of over- and undernutrition -than is the case in areas of prolonged or absolute scarcity, hi fact, in the United States, a person can be obese and undernourished in terms of micronutrients at the same time. In delineating the links between food insecurity and health, the consequences of food insecurity must be distinguished from those of its common correlates (such as poverty, highly constrained environments and multiproblem family systems) that would be in cluded in Figure 2 as risk factors for a poor diet. For instance, to suggest that food insecurity contributes to family disintegration is either to stretch the meaning of consequence or to mistake a risk factor for a consequence (25). Although the precise nature and extent of the relationships proposed between food insecurity and nutritional status, and/or health and quality of Ufe are empirical questions, very little careful research has been done on these questions. However, this has not prevented a distressing amount of ink and hyperbole from being expended on the topic. Much energy has been spent asserting or disputing the relationships between food insecurity and its con sequences because there is an implicit assumption that the importance of food insecurity lies in the nature and extent of its effect on either nutritional status or on health and quality of life. This as sumption presupposes that food insecurity is im portant as a predictor variable. On the other hand, food insecurity can be considered an undesirable outcome that is worthy of study and intervention, regardless of the presence or absence of a relationship to malnutrition or health. This position—that food insecurity be considered an important outcome vari able, rather than a predictor variable—is at its root an ethical claim. People should not experience food in security, because it is a negative event that need not happen, and this is true independent of any other nutritional or health effects. Even as an outcome variable, is food insecurity a nutrition variable? It can be argued that, because food insecurity is a limitation or uncertainty about the availability or ability to acquire food, it is a nutrition issue and one that nutritionists should address, professionally and not just personally, in their roles as researchers or practi tioners. The presentation of variables in Figure 2 puts these statements in the more familiar format for research propositions. Food insecurity is included as an in tegral characteristic of diets; it is not simply a risk Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
factor for a poor diet, but constitutes one of a set of core indicators of nutritional state. Its potential con sequences in terms of health or malnutrition are a matter of empirical research. Although it is impos sible to discuss the logical status of food insecurity proposed in Figure 2 separately from its ethical status, it is possible to propose researchable relationships among its consequences. For both academic and public debate on food insecurity to progress, it is critical to clearly differentiate the ethical and scien tific dimensions of the issue, even while ac knowledging and underlining their necessary coexis tence. In conclusion, food insecurity is a definable phe nomenon,- risk factors for food insecurity and the relationship of food insecurity to its potential conse quences are empirical questions open to research. Indicators of food insecurity should be necessary com ponents of the core measures of the nutritional state of individuals, communities or nations.
ACKNOWLEDGMENT The author thanks J.-P. Habicht for his insightful comments on this manuscript.
LITERATURE CITED 1. Brown, J. L. (1987) Hunger in the U.S., Sei. Am. 256: 37-42. 2. U.S. General Accounting Office (1983) Public and Private Ef forts to Feed America's Poor, No. KECD-83-164, U.S. GAO, Gaithersburg, MD. 3. Leitch-Kelly, G., Rauschenbach, B. &. Campbell, C. C. (1989) Private Food Assistance in New York State: Challenges for the 1990's, Division of Nutritional Sciences, Cornell University, Ithaca, NY. 4. Davis, C. G. &. Senauer, B. (1986) Needed directions in do mestic food assistance policies and programs. Am. J. Agrie. Econ. 68: 1253-1257. 5. Margen, S. &. Neuhauser, L. (1987) Hunger Surveys in the United States, School of Public Health, University of Cali fornia, Berkeley, CA. 6. Graham, G. G. (1985) Poverty, hunger, malnutrition, prematurity and infant mortality in the United States. Pedi atrics 75: 117-125. 7. The President's Task Force on Food Assistance (1984) U.S. Government Printing Office, Washington, DC. 8. Wehler, C. (1987) Community Childhood Hunger Identifi cation Project: New Haven Risk Factor Study, Connecticut Association for Human Services, Hartford, CT. 9. Campbell, C. C., Weber, J., Pelletier, D. &. Dodds, J. M. (1987) The development of a surveillance system to monitor emer gency food relief in New York State. Am. J. Public Health 77: 1350-1351.
10. Reutlinger, S. &. Van Hoist Pellekaan, J. (1986) Poverty and Hunger, World Bank, Washington, DC. 11. Campbell, C. C., Katamay, S. &. Connolly, C. (1988) The role of nutrition professionals in the hunger debate. J. Cad. Diet. Assoc. 49: 230-235. 12. Cohen, B. &. Buri, M. R. (1989) Eliminating Hunger Food Security Policy for the 1990's, Urban Institute, Washington, DC.
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13. Busch, L. &.Lacy, W. B. (1984) Food Security in the United Sutes, Westview Press, Boulder, CO. 14. Select Committee on Hunger (1989) Food Security in the United States: Issue Brief. U.S. House of Representatives, Washington, DC. 15. Wagner, P. A. (1990) Food Security as a Public Policy Goal. Hunger and Food Security Issues 1: 1-14; University of Florida, Gainesville, FL. 16. Sykes, J. B. (1976) The Concise Oxford Dictionary, Oxford University Press, Oxford, U.K. 17. Radimer, K. L., Olson, C. M. &. Campbell, C. C. (1990) De velopment of Indicators to Assess Hunger. J. Nutr. 120: 1544-1548. 18. Sen, A. (1981) Poverty and Famines: An Essay on Entitlement and Deprivation, Oxford University Press, Oxford, U.K. 19. Morris, P. M., Bellinger, M. & Haas, E. (1990) Higher Prices, Fewer Choices: Shopping for Food in Rural America, Public Voice for Food and Health Policy, Washington, DC.
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20. Crockett, E., Clancy, K. &. Bowering, J. (1989) Audit and Evaluation of Food Program Use in New York State: Food Price Survey, Syracuse University, Syracuse, NY. 21. Neuhauser, L. (1988) Methods for Determining Welfare Food Allowances for Recipients of General Assistance, Doctoral Dissertation, Berkeley School of Public Health, Berkeley, CA 22. Lamphere, J., Jones, D. Y. &.Sidel, V. W. (1984)Hunger Watch New York State: Profile of "At-Risk" Populations and Service Agencies, Montefiore Medical Center, New York, NY. 23. Campbell, C. C. &.Desjardins, E. (1989)A model and research approach for studying the management of limited food resources by low income families. J. Nutr. Ed. 21: 162-171. 24. Bard, B., Whiley, J. &. Stone, L. (1988) Hunger in Washington State: Appendix—The Major Causes of Hunger. Governor's Task Force on Hunger, Spokane, WA. 25. Margen, S. (1989) Statement at Committee Hearings on Food Security and Methods of Assessing Hunger in the United States. Select Committee on Hunger, U.S. House of Represent atives, Washington, DC.
Food Insecurity: A Nutritional Outcome or a Predictor Variable?1»2 CATHY C. CAMPBELL
Division of Nutritional Sciences, Cornell University, Ithaca, NY 148554410
DEFINITIONS ABSTRACT The phenomenon loosely labeled hunger in the 1980s is now being discussed as food security or insecurity. Food security is defined as access by all people at all times to enough food for an active, healthy fife, and at a minimum includes the following: 1) the ready availability of nutritionally adequate and safe foods and 2) the assured ability to acquire personally ac ceptable foods in a socially acceptable way. Food in security exists whenever food security is limited or un certain. The measurement of food insecurity at the household or individual level involves the measurement of those quantitative, qualitative, psychological and social or normative constructs that are central to the experience of food insecurity, qualified by their involuntariness and periodicity. Risk factors for food insecurity include any factors that affect household resources and the proportion of those resources available for food ac quisition. Potential consequences of food insecurity in clude hunger, malnutrition and (either directly or in directly) negative effects on health and quality of life. The precise relationships between food insecurity and its risk factors and potential consequences need much more research now that there is an emerging consensus on the definition and measurement of food insecurity. Indicators of food security or insecurity are proposed as a necessary component of the core measures of the nutritional state of individuals, communities or nations. J. Nutr. 121: 408-415, 1991.
Much of the public discussion of hunger has been emotionally charged and politically pointed. The main action taken in response to this public outcry was the establishment of an extensive network of private or charitable food assistance programs (1, 2). These programs were initially set up as an emergency response to the hunger crisis and now, to the conster nation of many, this network is becoming an accepted or institutionalized part of our food distribution system (3, 4). At the same time much of the academic debate was about the definition of hunger (5, 6). This debate, however, paid remarkably little attention to differen tiations between risk factors for the phenomenon (whatever its definition), the phenomenon itself and its consequences. Some academics also developed re search efforts to respond to the issue. These efforts, however, often employed multiple definitions or used measures that had a very tenuous or arguable rela tionship with any definition chosen (7—9). Although, the debate has been protracted and much of the re search rather thin, a consensus on definition and measurement approaches is gradually emerging. The phenomenon loosely labeled hunger in the 1980s is now being discussed as food security or insecurity (10-15). The following definition is pro posed: Food security is access by all people at all times to enough food for an active, healthy Ufe, and at a minimum includes the following: 1} the ready
INDEXINGKEY WORDS: •hunger •food security •nutritional status assessment
Hunger in America has been in and out of the public attention throughout the 1980s. Nutrition pro fessionals in government and the academic world re sponded in various ways over the decade. This paper will present an assessment of the state of affairs at the Beginning of the 1990s in light of some of the ex periences of the 1980s. It is written from the per spective of an academic involved in applied nutrition research and therefore will address primarily issues of definition, conceptual frameworks and measurement, and will conclude with a brief assessment of the logical and ethical status of the topic of hunger within the field of nutrition.
'Presented as part of a symposium, "Nutritional Assessment and Intervention: Interface of Science and Policy," sponsored by the joint American Institute of Nutrition/American Society for Clinical Nutrition Task Force on Hunger and Malnutrition, given at the meeting of the Federation of American Societies for Experi mental Biology, Washington, DC, April 4, 1990. Hauest editor for this symposium was William H. Dietz, Pedi atrie Gastroenterology and Nutrition, New England Medical Center, Boston, MA 02111.
0022-3166/91 $3.00 ©1991 American Institute of Nutrition. Received 17 October 1990. Accepted 9 January 1991.
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availability of nutritionally adequate and safe foods and 2) the assured ability to acquire personally acceptable foods in a socially acceptable way. Food insecurity exists whenever the availability of nutri tionally adequate, safe foods or the ability to ac quire personally acceptable foods in socially ac ceptable ways is limited or uncertain. Several features of this definition require comment. The order of these qualifications reflects the current degree of consensus. 1) The definition explicitly includes every person at all times; even though defining a situation that seems to be unattainable may seem coun terproductive, a less inclusive definition cannot be justified on either ethical or nutritional bases. 2) Two dimensions of accessibility are differenti ated: the availability of food and the ability to acquire the available food; "ready" and "as sured" are included as qualifiers to ensure access "at all times." 3) "Enough food for an active, healthy Ufe" implies a diet with sufficient energy, nutritional quality and safety to prevent diet mediated malnutrition or limitations in activity levels. 4) Food insecurity includes limited or uncertain access. 5) "Socially acceptable ways" refer to conventional food sources such as grocery stores, restaurants and government food assistance programs 6) "Personally acceptable" is included to reinforce the value our society places on freedom of choice; in practice, freedom of choice differen tiates how cattle are fed from how humans ac quire food. Even though in comparison with "hunger," the phrase "food insecurity" does not carry the same connotation of a painful experience with which everyone has at least some transitory familiarity, it does have several positive attributes. Use of "food insecurity" restricts the word "hunger" to its dic tionary meaning of "an uneasy or painful sensation caused by lack of food" (16). Hunger, then, becomes a potential although not necessary consequence of food insecurity. The differentiation of biological and socioeconomic dimensions in this definition allows re searchers to move beyond a focus on the nature of the relationship between hunger and undemutritÃ-on or malnutrition more generally. Malnutrition is a po tential although not necessary consequence of food insecurity. In addition, in contrast to hunger, which is most commonly associated with individuals, food security or insecurity can be a characteristic of nations, com munities, households or individuals. Food insecurity can therefore be studied at different levels of analysis without stretching its definition, hi the 1980s, discus sions about the social context of hunger easily became mired in arguments about causal links be Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
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tween community-wide events and individual ex periences of hunger. Also, this definition or modifica tions of it can apply both domestically and internationally. Although different measures of food insecurity may be chosen in different countries and its consequences may be different, the key dimen sions of the phenomenon itself are common. Finally, in contrast to hunger, the definition of food insecurity does not imply or suggest simplistic or individualistic action alternatives. Rather, the concept of food security clearly directs attention to different aspects of the food system.
IMPLICATIONS
FOR MEASUREMENT
Two related measurement issues will be addressed: first, the constructs to be measured to identify and assess food insecurity, and second, actual approaches that have been used to measure these constructs. Constructs. On the basis of research done by Radimer and her colleagues (17), the constructs sum marized in Table 1 are proposed as the essential aspects of food insecurity at the individual and household levels of study. These constructs were es tablished by analyzing accounts given by individuals of their experiences of food insecurity. The following aspects are the components that were central and common to those accounts: 1) the quantitative aspect of having enough or sufficient food; 2) the qualitative aspect concerning the types and diversity of food; 3) a psychological aspect: food insecurity is accompanied by feelings of deprivation or restricted choice for in dividuals, and by anxiety about the amount and types of food on-hand in the household stores,- and 4} a social or normative aspect: an individual evaluates his or her own food situation in terms of generally ac cepted social norms, such as eating three meals a day, or being able to purchase foods without having to beg, rely on charity, scrounge or steal food.
TABLEl Essential components of a measure of food insecurity individual and household levels of study1
Component1. Quantity
levelEnergy
sufficiency of intake Quality3. 2. Nutrient adequacy of intake Psychological ac Feelings of depri ceptability4. vation or re choiceNormal stricted Social acceptabilityIndividual meal pat ternsHousehold 'Adapted from Radimer et al. (17).
at the
levelRepleteness of household stores Quality and safety of on-hand food Anxiety about food suppliesConventional
sources of food
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TABLE 2 Radimer'a food insecurity
TABLE 3 scales'*
Community Childhood Hunger Identification hunger scale1*
Project's
Household hunger 1. Do you worry whether your food will run out before you get money to buy more? 2. The food that I bought just didn't last, and I didn't have money to get more. 3. I ran out of foods that I needed to put together a meal and I didn't have money to get more food. 4. I worry about where the next day's food is going to come from. Women's hunger 1. I can't afford to eat the way I should. 2. Can you afford to eat properly? 3. How often are you hungry, but you don't eat because you can't afford enough food? 4. Do you eat less than you think you should because you don't have enough money for food? Children's hunger 1. I cannot give my child(rcn) a balanced meal because I can't afford that. 2. I cannot afford to feed my child(ren) the way I think I should. 3. My child(ren) is/are not eating enough because I just can't afford enough food. 4. I know my child(ren) is/are hungry sometimes, but I just can't afford more food. 'Response categories: for questions: never, sometimes, often; for statements: not true, sometimes true, often true. Hunger criterion is any response other than "never" or "not true." Reprinted with permission from Radimer et al. (17).
Two additional dimensions, however, need to be included in any measure of food insecurity. First, the involuntariness of any limitation or restriction in these constructs needs to be an integral part of its measurement. In an industrialized country, mea suring the involuntary nature of food insecurity us ually involves an assessment of financial constraint, although it can also involve an assessment of the reliability of food providers for people who are de pendent on others for food—its acquisition, prep aration or consumption. Second, the periodicity or duration of an episode of food insecurity also needs to be part of either the measurement used (in terms of the stem of the question or its response categories) or the study design (e.g., longitudinal, repetitive crosssectional surveys). At a community level, the constructs most often included are the availability of food markets, the actual quantity and quality of food present in food markets and the ability of people, both financially (considering price relative to individuals' abilities to command resources) and physically (in terms of trans portation issues or physical disabilities), to acquire the food that is available. Sen's study (18) of the Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
1. Does your household ever run out of money to buy food to make a meal? 2. Do you or members of your household ever eat less than you feel you should because there is not enough money for food? 3. Do you or members of your household ever cut the size of meals or skip meals because there is not enough money for food? 4. Do your children ever eat less than you feel they should because there is not enough money for food? 5. Do you ever cut the size of your children's meals or do they ever skip meals because there is not enough money for food? 6. Do your children ever say they are hungry because there is not enough food in the house? 7. Do you ever rely on a limited number of foods to feed your children because you are running out of money to buy food for a meal? 8. Do any of your children ever go to bed hungry because there is not enough money to buy food? 'Hunger criterion: five positive responses out of eight. 2Reprinted from réf. 8. Used by permission of Cheryl A. Wehler and the Connecticut Association of Human Services.
famines in Bengal, Ethiopia, the Sahel and Bangladesh is a classic evaluation of financial aspects of accessi bility in the international context. Several different groups in the United States are currently involved in assessing community-level food security (19-21). In summary, any measurement of food insecurity involves the measurement of the core constructs qualified by their involuntariness and periodicity. Measurement approaches. Various approaches have been used to measure these constructs. These range from an assessment of practice (e.g., the measurement of energy sufficiency with a diet recall), to the self-perception of sufficiency (measured with a question such as: "Do you eat less than you think you should because you don't have enough money for food?"). Interestingly, in a study (22) in 1984 that used both approaches, persons who reported that they were eating less than they thought they should also reported consuming significantly less energy in a 24-h recall in comparison with those who did not think they were eating less than they should [means: 4.87 MJ (1160 kcal) to 6.11 MJ (1454 kcal); P < 0.001]. Three examples of current specific indicators of food insecurity will illustrate the general measurement approaches now in use and the emerging consensus in this area: 1} Radimer's food insecurity scale; 2) the hunger scale of the Com munity Childhood Hunger Identification Project (CCHIP); and 3) the questions included in the third National Health and Nutrition Examination Survey (NHANES). Although a single question was included in the U.S. Department of Agriculture's Nationwide
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Food Consumption Survey, its utility is limited be cause it attempts to assess involuntary restrictions in the quality and quantity of food choice simulta neously. Radiiner (17) proposed the three food insecurity scales itemized in Table 2. These clearly differentiate household from individual experiences and the mother's experience from that of her children. If, as has been hypothesized, mothers experience food in security before their children, it may be important from a monitoring point of view to distinguish be tween the two (23). These scales are a mixture of statements and questions that were developed from actual statements made by mothers experiencing food insecurity. Information about the frequency of the experience is included in the response categories. The involuntariness of any insecurity is included in the statement or question, for example, "I didn't have money to get more" or "because you can't afford enough food." The criterion used to differentiate food insecure groups from secure groups was any response other than "never" or "not true." This approach indi cated significant differences between the groups in terms of income, food expenditures and coping tactic usage. The CCHIP questions itemized in Table 3 are cur rently being used in 11 different community surveys around the country (8). The scale consists of eight items. Food insecurity is indicated by five or more positive responses. Mention of the lack of money is included in each question (except Question 6) in order to assess the involuntariness of the experience. The CCHIP researchers have experimented extensively with different ways to assess the periodicity of food insecurity and have found that nothing is gained by estimates more precise than a positive response to "do you ever...." In contrast to the Radimer scales, this scale does not differentiate household from childhood experiences. More emphasis is placed on coping approaches for food insecurity, such as skipping meals, cutting the size of meals and relying on a limited number of foods. There is no consensus yet on whether specific coping strategies should be part of the core construct of food insecurity. The questions chosen for the third NHANES (as itemized in Table 4) are targeted to both individuals and households but really focus only on the indi vidual experience of food insecurity. For some ques tions, the involuntary character of the experience is ascertained in a follow-up question and most of the questions include the phrase "food or money to buy food." The main focus is on the quantitative aspect of food insecurity with one question on meal pattern. The NHANES questions are much more specific about the time frame of the experience. This emerging consensus on the definition and measurement approaches for food insecurity has im plications for the conceptualization of risk factors and Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
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TABLE 4
Third National Health and Nutrition Examination Survey's food insecurity measures A) Twenty-four-hour dietary recall form Q-5 Thinking about the past month, how many days did you have no food or money to buy food? Q-6 Is that because there isn't enough money to buy food or is there another reason? Q-7 During the past month did you skip any meals because there wasn't enough food or money to buy food? Q-8 How many days in the month did you skip any meals because there wasn't enough food or money to buy food? Q-9 Did you skip any meals yesterday because there wasn't enough food or money to buy food? Q-10 During the past month, were there any days when you did not eat at all because there wasn't enough food or money to Q-llIn
buy food? the past month, how many days were there when you didn't eat at all?
B) Family questionnaire F4
F5 F6
Which one of the following statements best describes the food eaten by (you/your family)? Do you have enough food to eat, sometimes not enough to eat, or often not enough to eat? Thinking about the past month, how many days did (you/ your family) have no food or money to buy food? Which of the following reasons explain why your family has had this problem? a. b. c.
You did not have transportation (transportation prob lems)? You did not have working appliances for storing or preparing foods (such as stove, refrigerator)? You did not have enough money, food stamps, or WIC
vouchers to buy food or beverages? d. Any other reason?
consequences of food insecurity and for the research that is critically needed to elucidate the relationships between risk factors, the phenomenon itself and its consequences.
RISK FACTORS The identification of risk factors for food insecurity depends on the researcher's conceptualization of the social context of food insecurity. Each researcher working in this area has his or her own conceptualiza tion, although a general agreement exists on the factors included (8, 11, 24). One example is included as Figure 1. The experiential dimension of food in security at the household and individual levels has already been discussed. Of the three different sources
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CAMPBELL PRIVATE SFCTOR employment advertising
PUBLIC SECTOR employment social assistance education
INFORMAL SECTOR barter/exchange advice
t HOUSEHOLD RESOURCES — (money, time, information, health)
1 NORMAL FOOD SYSTEM grocery stores and food service operations
1
NON-FOOD EXPENDITURES
FOOD ACQUISITION
housing health care emergencies taxes discretionary items
I [
food availability (type and quantity) food accessibility (cost and distance)
ALTERNATE FOOD SOURCES GOVERNMENT FOOD ASSISTANCE
PRIVATE FOOD ASSISTANCE gifts from family & friends gardening, hunting, fishing scavenging
Food Stamps
WIC* School Lunch and Breakfast Nutrition Program for the Elderly (Title 3c) S.N.A.P.* (New York) (Social Context
of Food Access)
(Experiential Dimension
of Food Access Problems)
HOUSEHOLD FOOD SUPPLY FOOD ANXIETY - restricted food supplies
T INDIVIDUAL FOOD INTAKE DIET INADEQUACY - involuntary restrictions in type of food eaten INTAKE INSUFFICIENCY - involuntary restrictions in the amount of food eaten
T
l
HEALTH & QUALITY OF LIFE FIGURE 1 Conceptualization of food insecurity and its risk factors. *W.I.C. - Women, Infants and Children Supplemental Food Program, S.N.A.P. - Supplemental Nutrition Assistance Program.
of food identified in Figure 1, two groups—the normal food system (grocery stores and food service opera tions) and the government food assistance programs—are considered conventional food sources. Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
The alternate food sources are considered nonconventional, although the private food assistance network is very rapidly becoming an institutionalized third tier of the conventional food distribution system.
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RISK FACTORS for a poor diet...
\
CONSEQUENCES DIET FOOD INSECURITY
NUTRITIONAL STATUS
of a poor nutritional
. anthropométrie food intake patterns
state . biochemical . clinical
RISK FACTORS
T
for secondary
. health physical & social & mental wellbeing
malnutrition . quality of life
DIRECT INDICATORS OF NUTRITIONAL STATE FIGURE 2 Logical status of nutrition
related indicators.
Consideration of food sources is part of the definition of food security and part of its measurement at the household and community levels. Risk factors for food insecurity are therefore anything that limits either the household resources (money, time, infor mation, health, etc.) or the proportion of those resources available for food acquisition. Hence, risk factors include factors that limit employment oppor tunities, wage and benefit scales and social assistance benefits, or that mercase nondiscretionary nonfood expenditures such as the cost of housing and utilities, health care, taxes, child care and the likelihood of emergencies. The most pressing of the public policy research questions now addressable is the shape of the curve between income (or any other measure of ability to command resources) and food insecurity and the impact of risk factors on the shape of that curve. Questions about proportion of the poor, working poor or the nonpoor who experience food insecurity are unanswered as yet. It has been impossible to be precise on a population basis about the effect of social assistance shortfalls, changes in wage and benefit policies or escalating housing costs on increased food insecurity. Acceptance of the définitionof food in security permits researchers not only to determine Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
the existence and extent of food insecurity but also to model the effects of its predisposing factors.
POTENTIAL CONSEQUENCES In turning to the potential consequences of food insecurity, it is now possible to consider the issue raised in the title of this paper. Should food insecurity be considered an important outcome variable or is it more properly considered a predictor variable of other more definitive outcomes? More specifically, is food insecurity an important nutrition outcome variable that should be considered a core component of an individual's nutritional state? A summary of the components of this argument is given in Figure 2. Two sets of potential consequences of food insecurity are presented in this figure. These include physiological symptoms of suboptimal nutri tional status (the classic measures of malnutrition) and health (including physical, social and mental well-being) and quality of Ufe outcomes. Food in security can affect health either directly or indirectly through a physiological mechanism related to nutriture. As the exact ways that social and mental wellbeing affect physical well-being are more fully under-
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stood, it will be possible to determine whether there are direct effects of food insecurity on health that are not mediated by nutrient deficiencies. The relationships indicated in Figure 2 also imply that food insecurity can (but does not necessarily) lead to malnutrition. Malnutrition in an industri alized country can include a much more complex, simultaneous combination of over- and undernutrition -than is the case in areas of prolonged or absolute scarcity, hi fact, in the United States, a person can be obese and undernourished in terms of micronutrients at the same time. In delineating the links between food insecurity and health, the consequences of food insecurity must be distinguished from those of its common correlates (such as poverty, highly constrained environments and multiproblem family systems) that would be in cluded in Figure 2 as risk factors for a poor diet. For instance, to suggest that food insecurity contributes to family disintegration is either to stretch the meaning of consequence or to mistake a risk factor for a consequence (25). Although the precise nature and extent of the relationships proposed between food insecurity and nutritional status, and/or health and quality of Ufe are empirical questions, very little careful research has been done on these questions. However, this has not prevented a distressing amount of ink and hyperbole from being expended on the topic. Much energy has been spent asserting or disputing the relationships between food insecurity and its con sequences because there is an implicit assumption that the importance of food insecurity lies in the nature and extent of its effect on either nutritional status or on health and quality of life. This as sumption presupposes that food insecurity is im portant as a predictor variable. On the other hand, food insecurity can be considered an undesirable outcome that is worthy of study and intervention, regardless of the presence or absence of a relationship to malnutrition or health. This position—that food insecurity be considered an important outcome vari able, rather than a predictor variable—is at its root an ethical claim. People should not experience food in security, because it is a negative event that need not happen, and this is true independent of any other nutritional or health effects. Even as an outcome variable, is food insecurity a nutrition variable? It can be argued that, because food insecurity is a limitation or uncertainty about the availability or ability to acquire food, it is a nutrition issue and one that nutritionists should address, professionally and not just personally, in their roles as researchers or practi tioners. The presentation of variables in Figure 2 puts these statements in the more familiar format for research propositions. Food insecurity is included as an in tegral characteristic of diets; it is not simply a risk Downloaded from https://academic.oup.com/jn/article-abstract/121/3/408/4754597 by guest on 14 February 2018
factor for a poor diet, but constitutes one of a set of core indicators of nutritional state. Its potential con sequences in terms of health or malnutrition are a matter of empirical research. Although it is impos sible to discuss the logical status of food insecurity proposed in Figure 2 separately from its ethical status, it is possible to propose researchable relationships among its consequences. For both academic and public debate on food insecurity to progress, it is critical to clearly differentiate the ethical and scien tific dimensions of the issue, even while ac knowledging and underlining their necessary coexis tence. In conclusion, food insecurity is a definable phe nomenon,- risk factors for food insecurity and the relationship of food insecurity to its potential conse quences are empirical questions open to research. Indicators of food insecurity should be necessary com ponents of the core measures of the nutritional state of individuals, communities or nations.
ACKNOWLEDGMENT The author thanks J.-P. Habicht for his insightful comments on this manuscript.
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20. Crockett, E., Clancy, K. &. Bowering, J. (1989) Audit and Evaluation of Food Program Use in New York State: Food Price Survey, Syracuse University, Syracuse, NY. 21. Neuhauser, L. (1988) Methods for Determining Welfare Food Allowances for Recipients of General Assistance, Doctoral Dissertation, Berkeley School of Public Health, Berkeley, CA 22. Lamphere, J., Jones, D. Y. &.Sidel, V. W. (1984)Hunger Watch New York State: Profile of "At-Risk" Populations and Service Agencies, Montefiore Medical Center, New York, NY. 23. Campbell, C. C. &.Desjardins, E. (1989)A model and research approach for studying the management of limited food resources by low income families. J. Nutr. Ed. 21: 162-171. 24. Bard, B., Whiley, J. &. Stone, L. (1988) Hunger in Washington State: Appendix—The Major Causes of Hunger. Governor's Task Force on Hunger, Spokane, WA. 25. Margen, S. (1989) Statement at Committee Hearings on Food Security and Methods of Assessing Hunger in the United States. Select Committee on Hunger, U.S. House of Represent atives, Washington, DC.
