1. Measuring Food Security and Hunger John T. Cook, Ph.D. BMC Department of Pediatrics March 20, 2005

2. Overview Measuring Food Security and Hunger Brief History and Background Why Measure Hunger? Hunger as a Health Problem Hunger as a Social Problem Early Efforts to Measure Hunger Conceptual Definitions What is the Underlying Concept? The AIN/LSRO/FASEB Consensus Conceptual Definitions

3. Overview (Con.) Measurement Framework and Issues Unit of Analysis Scope Purpose Methods and Measurement Approach Data Sources Analytical Methods Operational Definitions Form and Purpose of Results

4. History & Background 1964: Poverty thresholds established at three times the cost of Economy Food Plan 1968-1970: Ten State Survey, Preschool Nutrition Survey, Hunger USA 1969: White House Conference on Food, Nutrition and Health 1977: USDA Food Sufficiency Question introduced 1983-1985: Wehler develops CCHIP hunger survey

5. History & Background (Con.) 1984: President’s Task Force on Food Assistance; Physician Task Force on Hunger 1988-1994: Food sufficiency/security questions included in NHANES III. 1989: House Select Committee Hearings on Food Security 1990: The National Nutrition Monitoring and Related Research Act mandates creation of standardized food security and hunger measures 1990: AIN/LSRO/FASEB expert panel derives consensus conceptual definitions of food security, food insecurity and hunger 1990: Radimer hunger scale developed

6. History & Background (Con.) 1992: USDA/FCS and DHHS/CDC/NCHS initiate the Food Security Measurement Project 1994: FCS/NCHS Conference on Food Security Measurement; draft food security supplement 1995: Food Security Supplement in the Census Bureau’s April Current Population Survey (CPS) 1997: Reports of the Food Security Measurement Study; first “official” hunger prevalence estimates 1999-2004: USDA releases U.S. food security and hunger prevalence estimates for 1995-2003

7. The USDA Food Security Measurement Project Empirical research whose primary purposes and end uses are related to informing public policy Sponsored by federal government, but has involved extensive public-private partnerships Involves a dynamic balancing of multiple (sometimes competing) interests and objectives

8. LSRO Conceptual Definitions of Food Security Food Security: Access to enough food for a healthy life; includes (1) ready availability of nutritionally adequate safe foods, (2) assured ability to acquire acceptable foods in socially acceptable ways (e.g., not from emergency food supplies, scavenging, stealing, or other coping strategies).

9. LSRO Conceptual Definitions of Food Security Food Insecurity: Limited or uncertain availability of nutritionally adequate and safe foods or limited ability to acquire acceptable foods in socially acceptable ways.

10. LSRO Conceptual Definition of Hunger Hunger: The uneasy or painful sensation caused by a lack of food. The recurrent and involuntary lack of access to food. Hunger may produce malnutrition over time... Hunger... is a potential, although not necessary, consequence of food insecurity.

11. What Is Hunger Anyway? Relationship Between “Normal” Hunger and “Undesirable” Hunger What is “normal hunger?” When does hunger become problematic? Can Individuals Self-Report Hunger Accurately? Do we know when we are hungry? Do we know how severe our hunger is?

12. How is Hunger Evidenced? Subjective Reporting of Hunger Existence, or presence of hunger Location and severity of the sensations Hunger – satiety continuum Objective Measures of Hunger Gastric emptying, presence/absence of food and nutrients in the upper GI tract Time since last food intake Reduction of intake below “normal” levels Cutting size of meals, skipping meals

13. Measurement Issues How to treat aspects of food insecurity not caused by lack of household resources Whether to limit operational definitions to those captured in household surveys Whether to incorporate indicators of nutritional adequacy How to estimate prevalence of food insecurity and hunger based on resulting data

14. Measurement Framework Hunger is a sub-domain of the uni- dimensional phenomenon of food security Resource-constrained hunger is a salient characteristic of severe food insecurity The appropriate measurement tool is a scale covering the range of observed levels of severity of food security Prevalence estimates can be derived for various levels of severity

15. Summary of Questions in The Food Security Supplement Weekly household food expenditures Food assistance program participation USDA/NHANES food sufficiency items Conditions requiring food-insufficiency coping behaviors Actions to augment household resources Adult food intake reduction items Child food intake reduction items Adult and Child food quality and quantity items

16. Operational Definitions of Food Security and Hunger Food Secure: Household shows no or minimal signs of food insecurity. Food Insecure Without Hunger: Food insecurity is evident in household adults’ concerns and in adjustments to household food management, including reduced quality of diets. Little or no reduction in household members’ food intake is reported.

17. Operational Definitions (Con.) Food Insecure with Moderate Hunger: Food intake for adults in the household has been reduced to an extent that adults have repeatedly experienced the physical sensation of hunger. Such reductions are not observed at this stage for children in the household.

18. Operational Definitions (Con.) Food Insecure with Severe Hunger: Households with children have reduced the children’s food intake to an extent that it implies that the children have experienced the physical sensation of hunger. Adults in households with and without children have repeatedly experienced more extensive reductions in food intake at this stage.

19. Analytical Methods Item Response Theory (IRT) Models Developed by educational testing industry – SAT, ACT, etc. A family of non-linear factor analytic models The Rasch Model A concise, one-factor, uni-dimensional model with constant discrimination parameters Robust across multiple samples and implementations

20. Prevalence of Household Food Insecurity in the U.S., 1995-2003

21. Prevalence of Adult Food Insecurity in the U.S., 1995-2003

22. Prevalence of Child Food Insecurity in the U.S., 1995-2003

23. Potential Health-Related Outcomes Micro-nutrient deficiencies Growth retardation (FTT) Models the log of the likelihood (logit) of an affirmative response to an item, given that it is answered Overweight and obesity(?) Cognitive impairment Behavioral dysfunction Learning disabilities Increased morbidity Impaired education attainment

24. Possible Interventions Food as medicine & supplementation (FTT) Federal food assistance programs Private food assistance programs Federal and state cash assistance Nutrition education Family empowerment Job/work training and assistance Community food security

25. Summary The National Nutrition Monitoring and Related Research Program The USDA/NCHS Food Security Measurement Project The Food Security Measurement Study The Food Security Supplement and Scale Use in National Surveys CPS, NHANES IV, merged NHANES IV-CSFII, SPD, ECLS, PSID Select USAID Missions, Statistics Canada