Importance of Topic to Practice
Dietitians in all areas of practice play an important role in supporting efforts to reduce health inequities, enabling just and equitable access to food, and addressing income-related household food insecurity (1). The systemic barriers impacting the choice to meet nutritional needs affect individual nutritional status, social needs, and therefore the health of the population. Understanding food insecurity is important at the individual level to work with the impact of the barriers and to prevent additional harm. Household food insecurity is a serious public health issue with profound effects on physical and mental health.
The Universal Declaration of Human Rights (Article 25) proclaims: “Everyone has the right to a standard of living adequate for the health and well-being of himself [sic] and of his [sic] family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” (2). Yet, many individuals, even in high income countries, lack this standard of living.
An early broad definition of food security by the Food and Agriculture Organization states “food security exists when all people, at all times, have access to adequate amounts of nutritious, safe, and culturally appropriate foods” (3). More recently, “Food and nutrition security exists when all people at all times have physical, social and economic access to food, which is safe and consumed in sufficient quantity and quality to meet their dietary needs and food preferences, and is supported by an environment of adequate sanitation, health services and care, allowing for a healthy and active life” (4).
Household food insecurity is the inadequate or insecure access to food because of financial constraints (5). The experience of food insecurity within a household, including adult(s), with or without children and referring to the previous year, can be classified into four categories:
- Food Secure: has access to enough food for an active, healthy life
- Food Insecure, Marginal: worries about running out of food and/or limited food selection due to a lack of money for food
- Food Insecure, Moderate: compromises the quality and/or quantity of food consumed due to a lack of money
- Food Insecure, Severe: reduces food intake and disrupted eating patterns (6).
Confusion and conflation among the use of various terms related to food insecurity (e.g. hunger, food security, sustainable food systems, food literacy) can impact the framing of particular issues and related policy responses, especially if root causes are not addressed (7). The distinct food procurement, preparation and distribution practices among Indigenous communities require unique considerations and respect. Community food security, food sovereignty and sustainable food systems have important relationships with household food insecurity, although they are beyond the scope of this background document. While household food insecurity is a concern globally, this background document primarily draws on the literature from high income countries.
How is household food insecurity measured and reported?
Household food insecurity is commonly measured using the United States Department of Agriculture (USDA) validated tool, the Household Food Security Survey Module (HFSSM) (8) and captures “self-reports of uncertain, insufficient or inadequate food access, availability and utilization due to limited financial resources, and the compromised eating patterns and food consumption that may result” (9). Households who experience food insecurity include those who, due to lack of money for food:
- worry about running out of food and/or have limited food selection (marginal food insecurity)
- compromise the quality and/or quantity of food consumed (moderate food insecurity)
- reduce food intake and have disrupted eating patterns (severe food insecurity) (6).
Another scale for measuring household food insecurity is the eight-item Food Insecurity Experience Scale (FIES) (10). The United Nations Food and Agriculture Organization (FAO) indicates the FIES complements existing food security indicators (11). Introduced in 2014 as part of an FAO project, the FIES measures food insecurity as experienced by individuals or households in a way that is comparable across countries. Used in combination with other measures, the FIES has the potential to contribute to a more comprehensive understanding of the causes and consequences of food insecurity and to inform policies and interventions.
Currently, variability exists in the measurement of food insecurity in Australia. A 2019 systematic review found a single-item measure was most commonly used, followed by the USDA HFSSM (12). The single-item measurement assesses individual food insecurity and has been used in the National Nutrition Surveys, likely underestimating its prevalence (12,13). Validation work using the Household Food and Nutrition Security Survey (HFNSS) has begun for assessment of household food insecurity among the Australian population (14). There is currently no population level monitoring of food security and food insecurity in Australia (15).
Since 2005, Statistics Canada has measured the prevalence of household food insecurity across Canada using the validated HFSSM, which was included within alternate cycles of the Canadian Community Health Survey (CCHS), in which provinces and territories could choose to include the module (6). In 2019, as part of Canada’s Poverty Reduction Strategy (16), food insecurity was monitored (using the full 18-item HFSSM) through the Canadian Income Survey (CIS), which is a cross-sectional survey developed to provide a portrait of the income and income sources of Canadians, with their individual and household characteristics (17). The CCHS was not developed within Indigenous contexts, therefore does not probe for information that may be important to Indigenous peoples’ household food insecurity (18).
Canadian researchers from PROOF (19) recommend using four categories to characterize household food (in)security: food secure, marginal food insecurity, moderate food insecurity or severe food insecurity (20). The distinct classification for marginal food insecurity is recommended to acknowledge the higher vulnerability of households who report any level of uncertainty regarding their access to food (21). The pre-COVID 19 prevalence within Canada captured in this background used the PROOF reports, which analyze CCHS data and report on marginal food (in)security as part of total household food (in)security. Current prevalence rates use Statistics Canada rates released in March of 2022 (21). Reporting on data in the Canadian context must be carefully reviewed to note which household food (in)security categories are included. Marginal food insecurity may be reported as a separate category of household food (in)security or may be included as a sum of households who are ‘food secure’ plus people experiencing ‘marginal food insecurity’ (21). It is recommended by PROOF to include all four categories separately in reporting as each has a distinct impact on health (20).
In April 2019, the Department for Work and Pensions added ten adult questions from the U.S. Government’s HFSSM to the U.K. Family Resources Survey (22). Data collection began in 2019 and is reported for the 2020/21 year for four categories of high, marginal, low and very low household food security status (23). Data is reported for household food security status and other data measures such as: U.K. countries/regions, household composition, disability in household, ethnic group, educational attainment and weekly income. In the 2020-2021 survey year, improvements were made to add self-declared ethnic background and exclude the choice not to declare and unknown (23). Prior to this, insecure and insufficient access to enough food to meet needs was not currently measured in any routine surveys in the U.K. (24). Food insecurity may also be referred to as food poverty (25).
What is the prevalence of household food insecurity?
The last National Nutrition Survey was 2011-2013 and found that nationally, 4.0% of people lived in a household that, in the previous 12 months, had run out of food and could not afford to buy more, and 1.5% of all Australians were in a household where someone went without food when they could not afford to buy any more (15,26). This was higher in First Nations Peoples, where one in five (22%) were living in a household that, in the previous 12 months, had run out of food and not been able to afford to buy more. This figure was higher in remote parts of Australia (15).
According to pre-COVID-19 estimates, 12.7% of households in Canada, 4.4 million individuals, experienced some level of food insecurity in 2017 to 18 (5). This percentage increases to 17.3% among households with children. Across Canada, geographically, the prevalence of households experiencing food insecurity ranged from 11.1% in Quebec and 15.3% in Nova Scotia among the provinces, to 57.0% in Nunavut (5). This reported prevalence is likely an underestimate given that the CCHS on which the data was based excludes individuals living on reserve First Nations, full-time members of the Canadian Forces, the institutionalized population, children aged 12-17 years that are living in foster care, and persons living in the Quebec health regions of Région du Nunavik and Région des Terres-Cries-de-la-Baie-James (6).
Data released by Statistics Canada in 2022 shows a gap between households experiencing some level of household food insecurity with CCHS 2017-2018 data and CIS 2018 data reporting (12.7%) and (16.4%), respectively (21). Statistics Canada reports possible contributions including population weight calibration, imputation effects, survey response rate effects and other variations, such as the framing of food insecurity within the context of an income/labour-oriented survey versus a health-oriented survey (21). The CIS 2019 data includes a few months of the pandemic and shows 15.6% of households in Canada reported some level of food insecurity (21,27). This percentage increases to 19.7% among households with children. Again, geographically, there is a difference in prevalence with 10.6% in Quebec, 18.8% in Nova Scotia, the highest among the provinces (21,27). Nunavut reports 46.1% for moderate and severe food insecurity with no published data for marginal food insecurity. CIS Survey data for 2020 reports a food insecurity rate of 11.2% for moderate and severe household food insecurity (28). This rate increases to 15.8% when filters are applied to customize the data set to add marginal household food insecurity for the total household food insecurity experienced by households in Canada.
The UK Family Resources Survey: financial year 2020 to 2021 report presented their household food insecurity status findings as the majority of individuals lived in households with high household food security (88%) or marginal household food insecurity (5%) (23). The rate of low and very low household food insecurity was 6%. Household food insecurity, including marginal, was 11%. Rates of higher food security are reported with higher incomes and higher educational attainment.
What is the relationship between income and household food insecurity?
Household income is the strongest single predictor of household food insecurity. Households with lower incomes are much more likely to report food insecurity, especially severe food insecurity, compared to households with higher incomes (5,29). Although food insecurity is related to low income, it is most accurately described as related to a level of material deprivation that has negative impacts on health and quality of life (30). Household food insecurity is likely a reflection of the interplay of household resources (e.g. incomes, assets, access to credit, etc.) and household expenditures for housing, food, and other necessities, as well as household debt, all of which are factors in overall material or financial deprivation.
The source of a household’s income is strongly related to the likelihood that a household will report that they have experienced food insecurity in the past year, since the source often dictates the level and/or stability of income. In the U.K., gross incomes of less than £200 per week (7% of households) were the least likely to be food secure with a prevalence of 14% of low and very low household food insecurity and 22% including marginal household food insecurity (31). In Canada, pre-COVID-19, the majority (65%) of food insecure households receive an income from employment (5); however, they are not making enough to cover all their needs (32). The ability to purchase nutritious and personally acceptable food is compromised after covering fixed costs such as housing, utilities and child care. These employment incomes may be inadequate to pay for basic needs due to low rates of hourly pay, low number of hours available for paid work or only one earner in a household (32). By comparison, the other one-third (35%) of food insecure households are those who are not employed, such as households receiving social assistance, employment insurance and seniors income (5). Those households most impacted by disruptions to the labour force related to COVID-19 (business closure, layoff, personal circumstances) reported an increased likelihood of food insecurity (28.4%) than those who were working (10.7%) (33).
What are the physical and mental health consequences of household food insecurity?
From infancy to adulthood, living in a home that is unable to afford enough food is associated with poorer physical, mental and social health (34-37). As noted below, individuals experiencing household food insecurity are more likely to report chronic disease states (34,37).
Children experiencing food insecurity are more likely to have depression and be diagnosed with a chronic illness such as asthma (36,38). A 2020 meta-analysis provided a comprehensive review of the association between household food insecurity and five key childhood development domains (cognitive, socioemotional, language, motor, developmental risk) and subdomains of these in children under five years of age (39). Household food insecurity was marginally associated with children’s cognitive/school readiness, reading abilities and motor development. Specifically, household food insecurity was associated with developmental risk and poor math skills in studies conducted in high income countries and with poor vocabulary skills in studies conducted in both high and low income countries.
A cross-sectional analysis found adults in food-insecure homes in Canada and the U.S. are more likely to have multiple chronic diseases such as heart disease, diabetes, mood disorders and anxiety disorders (37). Food insecurity is significantly and positively associated with multiple indicators of psychological distress (40). A 2020 systematic review found evidence from a meta-analysis that food insecurity had a significant effect on the likelihood of being stressed or depressed (41). A Canadian retrospective cohort study found that among adults who died prematurely, those experiencing severe food insecurity died on average nine years earlier than their food-secure counterparts (42). Adults in food insecure households experience higher mortality rates, with higher rates for those in the severe food insecure category (43).
This suggests that the associations between household food insecurity and poor health are bidirectional. Poor health can be disruptive to income and thereby increase the risk of food insecurity, and the experience of living in a food insecure household increases stress and may limit access to health-supporting opportunities (34-37).
What populations are disproportionately affected by household food insecurity?
The following statistics demonstrate disproportionately affected population groups who have a greater prevalence of household food insecurity.
Statistics, especially statistical gaps, are representative of systemic inequities. For example, emerging research in Canada highlights food insecurity as an issue of systemic racism (44). There are conversations around the risk causing harm in naming statistics targeting specific populations. Stigmatization may reduce an individual's likelihood to access care (45,46). It is important to recognize that a person is not a statistic (47). Statistics, as the analysis of disaggregated data, are not intended to stigmatize individuals or households, but to highlight health inequities that require system solutions (48). Effective actions to address social determinants of health, health inequities and to dismantle systemic barriers are beyond the scope of this background.
Health inequities are differences in health status experienced by people, and sometimes disproportionately affecting identifiable populations because of unfair and unjust systems, including a greater experience of poverty and trauma (49). In order to achieve health equity, social determinants of health must be addressed to remove long-standing health inequities. The social determinants of health are personal, social, economic and environmental factors that influence individual and population health, in addition to individual choice and individual genetics.
Household food insecurity is a determinant of health and an inequity. Data suggests that household food insecurity disproportionately affects many populations, including:
- women (50)
- lone-parent households (5)
- households with children under 18 years (5,51)
- unattached individuals (5)
- post-secondary education students (52-54)
- Indigenous households living off reserve (5) and on reserve (55)
- households whose members identify as Black (56)
- household whose members identify as Arab and West Asian (5)
- homeless populations (57,58)
- individuals who receive social assistance (5)
- recent immigrants (59)
- people living with a disability (60)
- individuals who rent (5,61,62)
- bisexual adults (63)
- lesbian, gay, transgender populations (64)
- individuals with chronic illness (37).
What decisions and actions are households experiencing poverty and food insecurity often forced to use as coping strategies?
Food insecure individuals and households may resort to many strategies to deal with inadequate income to meet basic needs, including delaying bill payments, cancelling services, not filling prescribed medications, and food budgeting and procurement activities (65-68). It is inaccurate to present these as recommended coping strategies (66); an alternative is to view and understand coping strategies as a demonstration of the resilience and strength of people experiencing household food insecurity (69). This is a critical element in understanding household food insecurity as a result of systemic inequities. As stated by one researcher, “the assumption that people do not make healthy choices due to knowledge deficits is problematic and renders people experiencing food insecurity as incompetent, rather than as active social agents responding pragmatically to a lack of resources” (66).
Food insecure households cannot spend adequate amounts of money on nutritious food or modest celebrations because they must prioritize a substantial portion of their budget for fixed costs such as housing, utilities and child care (70). Price most often dictates grocery purchases within food insecure households (65,71), therefore varying food shopping and preparation practices are reported (65,72). Multiple food shopping practices are employed to try and stretch limited resources, such as shopping at discount stores, buying on sale items or bulk, following a grocery budget, using coupons, comparing costs and limiting variety (65,72). Food preparation strategies include cooking from scratch, using leftovers and modifying recipes to reduce cost (65,72). Parents tend to go to great lengths to protect children from overt hunger during times of financial constraint (65). Mothers in particular have been reported to cut back on both the quantity and quality of their own food intake to feed their children (65,66,72,73). Hunger refers to a physical sensation that may or may not be a result of food insecurity (74). In the context of food insecurity, physical hunger is experienced as part of the most severe level of food insecurity. A person may still experience household food insecurity and not be hungry.
What impact does food insecurity have on the health care system?
Studies have shown the large cost of food insecurity on the health care system in Canada (75-77). Total health care costs rise with increasing severity of household food insecurity (77). Compared with total annual health care costs in food secure households, adjusted annual costs were 16% ($235) higher in households with marginal food insecurity, 32% ($455) higher in households with moderate food insecurity and 76% ($1092) higher in households with severe food insecurity. Individuals living in homes unable to afford adequate food use up to 2.5 times the amount of health care dollars as those able to afford adequate food (77). Food insecure households have 26-69% higher odds of acute care admission and 15-24% higher odds of having same day surgery compared to those who are food secure (76). Food insecure adults also stay 1.5 to two more days in hospital and incur $400-565 more per person-year in acute care costs compared to their food secure counterparts (76). In the U.K., although no specific cost of food poverty on the health care system is available, the estimated cost to the National Health Service (NHS) of diseases related to poor diet was £5.8 billion in 2006-07 (25). In Australia, the economic burden of food insecurity has not been measured (78).
What income-based strategies exist to address household food insecurity?
Government policies that have promoted adequate incomes in Canada have been shown to address the issue of household food insecurity (79-83). Income supplements from the Universal Child Care Benefit reduced food insecurity in single-parent households by more than 5% (79). Using data from CCHS (2015-2018), severe food insecurity was shown to be reduced by one-third among families receiving the Canada Child Benefit (84). Old Age Security and Guaranteed Income Supplement programs have resulted in a decrease in food insecurity in older adults by ensuring they have a minimum amount of money to afford basic needs (83). However, among older adults, income is still the biggest predictor of food insecurity (85). Social protection spending, which captures cash benefits and housing subsidies, has been demonstrated to impact food insecurity in Europe (81). During the Great Recession in Europe (2004-2012), countries with low levels of investment in social protection spending, increasing unemployment and declining wages were associated with increasing food insecurity compared to countries where social protection spending (in particular spending on housing) was high (81). In Australia, results of a scoping review of population-based interventions to address food insecurity identified limited interventions addressing financial resources, such as public policy responses to address adequate income and a lack of rigorous evaluation of these interventions (86).
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