Deconstructing household food insecurity: insights from Canadian research Valerie Tarasuk Professor, Department of Nutritional Sciences Faculty of Medicine, University of Toronto PROOF: V Tarasuk (PI, U Toronto), C Gundersen (co-PI, U Illinois), L McIntyre (U Calgary), H Emery (U Calgary), C Mah (Memorial U), J Rehm (CAMH), P Kurdyak (CAMH), N Dachner (Coordinator, U Toronto). Acknowledgement: This research is funded by a programmatic grant from the Canadian Institutes of Health Research.

Outline: Food banks: the public face of the problem Food insecurity monitoring: a different perspective on the problem Relation between food insecurity, nutrition and health. Social policy underpinnings

Defining the problem: Household food insecurity: insecure or inadequate access to food due to financial constraints - popularly termed “hunger”

The evolution of food banks and food insecurity measurement: 1994: Measure of child hunger on National Longitudinal Survey of Children & Youth 2005: food insecurity monitoring begins Assorted indicator questions 1997: Annual release of ‘HungerCounts’. 1989: ‘HungerCount’. 1981: First food bank. 1987:Canadian Association of Food Banks formed. 1990 1980 2000

“because there wasn’t enough money to buy food?” Household Food Security Survey Module (administered on the Canadian Community Health Survey since 2004) 18 questions, differentiating adults’ and children’s experiences over last 12 months: Worry about not having enough food Reliance on low-cost foods Not able to afford balanced meals Adults/children skip meals Adults/children cut size of meals Adults/children not having enough to eat Adult lost weight Adults/children not eating for whole day “because there wasn’t enough money to buy food?”

Household Food Insecurity in Canada, 2007 - 2012 12.6% of households over 4 million Canadians (an increase of > 600,000 since 2007) Marginal food insecurity Worry about running out of food and/or limit food selection because of lack of money for food. Moderate food insecurity Compromise in quality and/or quantity of food due to a lack of money for food. Severe food insecurity Miss meals, reduce food intake and at the most extreme go day(s) without food. Data Source: Statistics Canada, CCHS, 2007, 2008, 2011, 2012 and 2013.

Number of people living in food-insecure households in Canada, 2007 - 2012 Data Sources: Statistics Canada, Canadian Community Health Survey (CCHS), 2007, 2008, 2011 and 2012, and Food Banks Canada, HungerCount, 2007, 2008, 2011 and 2012.

Number of people living in food-insecure households vs number reported to be helped by food banks in March of respective year. Data Sources: Statistics Canada, Canadian Community Health Survey (CCHS), 2007, 2008, 2011 and 2012, and Food Banks Canada, HungerCount, 2007, 2008, 2011 and 2012.

Relationship between food insecurity and food bank use? Most people affected by food insecurity do not seek charitable food assistance.  disconnect between help offered and perceived needs of food insecure.  arbitrary nature of charitable service provisioning renders it inaccessible to many. Food bank users are a relatively small, non-representative subset of food insecure population. (Hamelin et al, Health Educ Res 2010; Loopstra & Tarasuk, Can Public Policy 2012; Loopstra & Tarasuk, Soc Pol Soc 2015)

National prevalence of household food insecurity and poverty (defined as income < Low-Income Measure), 2007, 2008, 2011, 2012. % LIM: 50% of median household income, adjusted for household size. Source: PROOF calculations from CCHS 2007-08, 2011-12 and Statistics Canada. CANSIM. Table 111-0015 Family characteristics, Low Income Measures (LIM), by family type and family type composition.

Relationship between food insecurity and household income: Food insecurity captures material deprivation. the product of income (size, security, stability) assets / home ownership access to credit expenses (shelter, food, medications, debt, etc) (Tarasuk, Mitchell & Dachner, Household Food Insecurity in Canada, 2014. 2016)

food insecurity, food and health?

Results from CCHS 2004 - Nutrition Adults’ fruit and vegetable consumption, servings per day by food security status * * * servings/day * * Food secure Food insecure Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05 (Kirkpatrick & Tarasuk, Journal of Nutrition, 2008: 138: 604-612) 13

Results from CCHS 2004 - Nutrition Adults’ fruit and vegetable consumption, servings per day by food security status * * * servings/day * * Food secure Food insecure Recommended Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05 14

Results from CCHS 2004 - Nutrition Children’s fruit and vegetable consumption, servings per day by food security status servings/day * Food secure Food insecure * Recommended Age/sex group Food insecurity here includes only moderate and severe food insecurity. *Significant difference between food-secure & food-insecure subgroups, p<0.05 15

Average SODIUM intake (mg/day), by age, sex and household food security status: a,b a: P < 0.05, comparison of transformed intakes; b: P<0.05, ANOVA adjusted for income, education, immigrant status, household composition, and current smoking. Food insecurity here includes only moderate and severe food insecurity.

Prevalence of nutrient inadequacy by food security status, individuals ≥ 9 years of age in Canada Note: food insecure defined here as ≥ 3 affirmatives on 18-item HFSSM. (Kirkpatrick et al, Journal of Nutrition, 2015)

Relation between household food insecurity status and adults’ self-rated cooking ability Data Source: Statistics Canada Rapid Response Modules on 2012 and 2013 Canadian Community Health Survey (Huisken, Orr & Tarasuk, Canadian Journal of Public Health, forthcoming)

The health effects of food insecurity: Summary of observed associations, all independent of income, education, race/ethnicity and other social determinants of health: Maternal and infant health Poorer birth outcomes Impaired growth and development Children Poorer development and learning Impeded disease management Increased likelihood of developing asthma, depression, other chronic conditions. Adults Compromised physical and mental health Poor disease management and heightened odds of negative outcomes (including mortality). (See review by Gundersen & Ziliak, Health Affairs, 2015; 34: 1830-1839)

(Adapted from Tarasuk V, Mitchell A, McLaren L, & McIntyre L (Adapted from Tarasuk V, Mitchell A, McLaren L, & McIntyre L. Journal of Nutrition. 143(11), 1785-93.)

Average health care costs per person incurred over 12 months for Ontario adults (18-64 years of age), by household food insecurity status: $2806 $ One window into the health impact = health care utilization (ON). Slide also makes the business case for intervention (Tarasuk et al, Canadian Medical Association Journal, 2015)

Policy insights arising from analyses of monitoring data

(Tarasuk, Mitchell & Dachner, Household Food Insecurity in Canada, 2014. 2016)

Seniors have a Guaranteed Annual Income, indexed to inflation Prevalence of food insecurity by main source of income, 2014 Seniors have a Guaranteed Annual Income, indexed to inflation (Tarasuk, Mitchell & Dachner, Household Food Insecurity in Canada, 2014. 2016)

Probability of food insecurity by age for unattached, low-income adults (pooled data from the Canadian Community Health Survey, 2007-2013). (McIntyre, Dutton, Kwok & Emery, Canadian Public Policy 2016)

Probability of food insecurity by age for unattached, low-income adults (pooled data from the Canadian Community Health Survey, 2007-2013). (McIntyre, Dutton, Kwok & Emery, Canadian Public Policy 2016)

Prevalence of food insecurity by main source of income, 2014 Low benefit levels + asset limits + restrictions on earnings = extreme vulnerability. (Tarasuk, Mitchell & Dachner, Household Food Insecurity in Canada, 2014. 2016)

Provincial actions to reduce poverty (Loopstra, Dachner & Tarasuk, Canadian Public Policy, September, 2015)

Summary Systematic measurement of food insecurity in Canada has revealed a very different problem than the one apparent from food bank utilization statistics. Food insecurity is related to dietary intake, but its effects on health go well beyond nutrition. Household food insecurity is a potent determinant of health and health care spending in Canada. This problem is rooted in financial constraints and appears very sensitive to social policy decisions.