1. Study on global AGEing and adult health (SAGE): Food insecurity in relation to physical, cognitive, and emotional challenges among older adults Heather H. McClure1,2, J. Josh Snodgrass2, Nirmala Naidoo3, and Paul Kowal3,4
1Center for Equity Promotion, University of Oregon
2Department of Anthropology, University of Oregon
3World Health Organization, Geneva, Switzerland
4Research Centre for Gender, Health and Ageing, University of Newcastle, Newcastle, Australia
Sponsor: NIH R01-AG & NIA Interagency Agreement YA CN-0020

2. Background
Food insecurity: Limited or uncertain availability of nutritionally adequate and safe foods, or the ability to acquire acceptable foods in socially acceptable ways (Parker, 1991)
Food security: Basic measure of population well-being
Very little food security research among aging populations, particularly in middle and low income nations
Older adults recognized as an age group at risk, tho comparatively little food security research has been conducted among aging populations (Quandt et al., 2001)
Risks may be intensified for women, individuals with lower education and income, rural residents, and marginalized groups (e.g., ethnic/racial minorities) whose experiences of social and economic inequities over the life course may translate into higher risk of food insecurity in older years (Kaida & Boyd, 2011; Nelson et al., 2007).
Persistent food insecurity carries attendant risks. For instance, food insecure individuals tend to consume fewer fruits and vegetables and, in general, have lower intakes of nutrients that can increase risk of nutritional deficiencies (Seligman et al., 2010). Over the long term, these nutritional deficiencies can contribute to heightened risk for chronic disease. This cycle can be a vicious one, with debilitating chronic disease in turn heightening risk for food insecurity among older adults (Cook, 2002).

3. Food insecurity in older adults: Additional considerations
Increased likelihood of physical and mental health challenges with age (Sharkey et al., 2002)
Limited ability to acquire food (e.g., “too hard to get to the store/market”)
Functional impairments lead to inability to prepare, gain access to, and/or eat food that is available in the household (Wolfe et al., 2003; Lee & Frongillo, 2001)

4. Food insecurity: A “managed process”
People not passive victims of sudden events but active participants in responding to the risks they face in their daily lives (Coates et al., 2006)
US-based research: Predictable progression of coping strategies
Worry Augment food supply Reduce quality of food Reduce food quantity (eat less; go hungry)
However, those with cognitive, psychological, or physical challenges may have less of an ability to cope
in every SAGE country, adults qualify for state pensions and other retirement benefits at the age of 60, with women in China and Russia qualifying at 55 years of age (with exceptions made in most nations for qualification at younger ages)
US-based research shows that adults aged 40 to 59 years old are significantly more food insecure than adults aged 60 years and older who are more likely to be eligible for retirement-related benefits and programs (Ziliak & Gundersen, 2011).
Coates et al: highly salient measures of severe responses to food insecurity cross-culturally included eating less in a meal and hunger (rather than worrying or reducing the quality of food), key indicators we use in the current study.
Despite the tremendous utility of identifying groups that experience food insecurity, the exploration of a single, simplistic indicator can risk masking the myriad and dynamic contributors (Clay, 2002). These include challenges associated with food availability, as influenced by economic and food system volatility, by climatic variability, and trends in acquisition of food from subsistence to marketing. In addition, food insecurity related to inadequate food intake in the presence of adequate food supply can be affected by health status, as mentioned above, as well as by access to care providers and other forms of social support

5. Food insecurity: A “managed process”
People not passive victims of sudden events but active participants in responding to the risks they face in their daily lives (Coates et al., 2006)
US-based research: Predictable progression of coping strategies
Worry Augment food supply Reduce quality of food Reduce food quantity (eat less; go hungry)
Older adults may cope through access to age-specific safety nets such as pensions and through social support
in every SAGE country, adults qualify for state pensions and other retirement benefits at the age of 60, with women in China and Russia qualifying at 55 years of age (with exceptions made in most nations for qualification at younger ages)
US-based research shows that adults aged 40 to 59 years old are significantly more food insecure than adults aged 60 years and older who are more likely to be eligible for retirement-related benefits and programs (Ziliak & Gundersen, 2011).
Coates et al: highly salient measures of severe responses to food insecurity cross-culturally included eating less in a meal and hunger (rather than worrying or reducing the quality of food), key indicators we use in the current study.
Despite the tremendous utility of identifying groups that experience food insecurity, the exploration of a single, simplistic indicator can risk masking the myriad and dynamic contributors (Clay, 2002). These include challenges associated with food availability, as influenced by economic and food system volatility, by climatic variability, and trends in acquisition of food from subsistence to marketing. In addition, food insecurity related to inadequate food intake in the presence of adequate food supply can be affected by health status, as mentioned above, as well as by access to care providers and other forms of social support
An important question:
Is the spectrum of severity culturally universal?

6. Research questions
How does the prevalence of food insecurity vary between countries?
How do these rates compare between adults aged years old and adults aged 60+ years?
How do the prevalence rates compare with those of years old in each nation?
To examine food insecurity and its contributors in six middle income nations, we used SAGE data to explore two sets of research questions:
2. What are the relationships among food insecurity, cognitive and physical challenges, and depression in each nation?

7. Study on global AGEing and adult health (SAGE)
WHO longitudinal study with nationally representative samples of persons aged 50+ years in China, Ghana, India, Mexico, Russia and South Africa
Multiple geographic regions
Different stages of socioeconomic and demographic transition
Wave 1 data presented.

8. SAGE participants SAGE Wave 1 (2007-2010) Current study sample size:
Adults 50+ years old (n = 29,252)
Adults years old (n = 18,191)
Additional details and access to survey materials from SAGE website (
Additional participants aged for comparison purposes.

9. Methods: Food insecurity
How often in the last 12 months had respondent: a) eaten less than they felt they should because there wasn’t enough food b) been hungry but didn’t eat because they couldn’t afford enough food Response: Likert scale (1 = every month to 4 = only 1 or 2 months to 5 = never) Dichotomous variable computed: ever or never experienced hunger or limited one’s food consumption in past 12 months (0 = food secure; 1 = food insecure)

10. Methods: Statistical analyses
Prevalence rates by country for each age groups (18-49, 50-59, and 60+ years) using weighted data
Logistic regression separately by country and age categories of and 60+ years
Predictor variables:
Physical mobility
Cognitive function
Depression
Covariates:
Sex
Annual household income
Highest level of schooling completed
Physical mobility was measured through two separate items: a) a timed walk variable and b) self-reported difficulty performing household activities (both variables were included separately in final models). Three cognitive performance tests were used to create a z-scored summary variable of cognitive function for each participant; tests included immediate and delayed verbal recall (list of 10 words), forward and backward digit span, and verbal fluency (animal naming task). Depression was reflected in a dichotomous variable (0 = no; 1 = yes) based on symptom reporting and an algorithm to assign diagnosis based on the World Mental Health Composite International Diagnostic Interview (Kessler et al., 2010).
We computed prevalence rates by country for each of three age groups (18 to 49 years, 50 to 59 years, and 60 years and older) by running frequency analyses with weighted data.
NOTE: the number of children in the household is a known predictor of food insecurity and the inclusion of this variable in future models might yield more accurate prevalence rates of older adult food insecurity.
Logistic regression was used to analyze relations among food insecurity and potential predictors, including depression, cognitive function, and physical mobility, controlling for key covariates (sex, annual household income, and highest level of schooling completed). Output was split by country and age categories of 50 to 59 years and 60 years and older.
For LOGIT models, Hosmer and Lemeshow Test for every nation and age group indicated adequate model fit, with the exception of Chinese adults aged 60 years and older. The poor model fit for these older Chinese adults (p = .01) may be due to the very low rate of food insecurity reported by these participants (at 1.3%).

11. Key findings: Overall prevalence of food insecurity
Adults 50+ years old:
22.9% ate less because of insufficient food
17.6% experienced hunger
Overall food insecurity prevalence of 24.2%
Food insecurity by older adult age groups:
50-59 year olds: 26.1%
60+ years old: 22.3%
NOTE TO JOSH: You may want to delete this slide and mention these overall prevalence rates when reviewing the next slide that shows prevalence by country and age group.

12. Overall prevalence rates—averaged for all countries
Adults 50 years and older:
22.9% ate less because of insufficient food
17.6% experienced hunger
Overall food insecurity prevalence of 24.2% (1 in 4)
Food insecurity by older adult age groups:
50 to 59 year olds: 26.1%
60 years and older: 22.3%

13. When we examined two components of food insecurity—eating less and hunger—separately by country, it appears that the progression of severity noted by researchers in high income nations, in which eating less is more prevalent than hunger and may serve as a precursor, may also hold true for the six SAGE countries.
NOTE: Coates et al. noted (2006) that, in some communities, hunger is not always the most severe manifestation of food insecurity as it is conceptualized in the US. Among groups where hunger is more of a normative experience, skipping meals for an extended period of time (e.g., a day or longer), may serve as a more reliable indicator of severe food insecurity. It may be that adding a question to future SAGE questionnaires regarding the prevalence of skipping meals for a day or longer yields even higher rates of severe food insecurity than those reported here.

14. Current study findings provide insight into prevalence rates of older adult food insecurity in six middle income nations, allowing for first-time comparisons with high income nations. Compared to the food insecurity rate of 14.9% among US adults 60 years and older (Ziliak & Gundersen, 2012), two nations, China and Russia, reported lower rates of 14% and 1.3%, respectively. (Note: the comparison of US and SAGE nations’ food insecurity prevalence rates for adults aged 50 to 59 was not possible given the lack of available prevalence data for this age group in the US; Ziliak & Gundersen, 2011).
Associations between age and food insecurity varied dramatically by nation. In Ghana, Russia, Mexico, and South Africa, adults 50 years and older in each nation were more food insecure than younger adults. In Ghana and Russia, adults aged 50 to 59 and 60 years and older were roughly similar in their rates of food insecurity.
In Mexico and South Africa, older adults aged 50 to 59, compared with other age groups, had by far the highest rates of food insecurity. It is unclear why this age cohort is particularly vulnerable in these nations. In South Africa, this high rate could potentially relate to recent evidence that many new cases of HIV/AIDS are among adults 50 years and older, with people living with HIV/AIDS experiencing greater vulnerability to food insecurity due to health-related limitations (Negin & Cumming, 2010). In both nations, the fragmentation of familial and other social networks due to socioeconomic trends such as urbanization, coupled with environmental factors (e.g., droughts) and a lack of both available and accessible food may serve as contributors to food insecurity generally, though it remains to be seen why 50 to 59 year olds are disproportionately affected.
Indian and Chinese 18 to 49 year olds experienced the greatest food insecurity of all age groups in those nations, and adults 60 and older had the lowest rates of food insecurity. Elders may be buffered from food insecurity when household members accord them greater social status, for instance, when younger adults prioritize the provision of food to older household members. In India, younger adult food insecurity may relate to challenges in accessing food (despite the presence of available food), high rates of child malnutrition caused by poor health environments (i.e., limited access to health services, safe water, and sanitation), and inadequate care for women and children, factors that researchers have linked in turn to the very low social and health status of South Asian women in general  (Ramalingaswami, Johnsson, Rohde, 1996). Similarly, though China has a dietary energy surplus and a low malnutrition rate compared with other middle income countries, it historically has had high numbers of malnourished children due to in-country regional differences (Smith et al, 2000), with potential related food insecurity and malnutrition among older householders.  

15. Difficulty performing household activities increased likelihood of food insecurity in…
50-59 years
60 years +
Ghana
1.2
n.s.
India
1.3
Mexico
1.5
South Africa
1.4
Walk variable wasn’t significant in any models.
Difficulty performing household activities predicted increased likelihood of food insecurity among Indian and Mexican older adults (50 years and older) and among Ghanaian and South African 50 to 59 year olds It is possible that the same explanations offered above in regards to South Africa also apply to the finding that physical challenges predict food insecurity only among South African 50 to 59 year olds. It is puzzling, however, as to why Ghanaian 50 to 59 year olds’ food security would be particularly vulnerable to physical mobility challenges, especially when the overall prevalence of food insecurity for this age group was remarkably similar to that of adults aged 60 years and older.

16. Cognitive challenges…
Slightly increased the odds of food insecurity among South African older adults but decreased odds of food insecurity among Ghanaians
OR,
50-59 years
60 years +
Ghana
n.s.
1.1
South Africa
0.9
Mixed findings regarding links between cognition and food security were detected in African nations, with greater cognitive impairment among South African older adults (50 years +) predicting slightly higher risk of food insecurity. In contrast, Ghanaian adults 60 years and older faced reduced food insecurity risk with lower cognitive function, a surprising result given prior work showing that poorer cognitive function among adults is associated with increased food insecurity (Gao et al., 2009). Fulfillment of filial obligations may account for this finding in older Ghanaian adults (Aboderin 2005). Finally, none of the three predictor variables were associated with older adult food insecurity in China, though this may be due in part to poor model fit.

17. Depression covaried with food insecurity…
OR, years
OR, 60 years +
Ghana
2.5
5.3
India
1.8
1.5
Russia
n.s.
South Africa
2.1
4.0
Of all predictor variables, depression had substantially larger impacts on the increased likelihood of older adult food insecurity (between 1.5 and 5.3 times) than physical or cognitive challenges (between 1.2 and 1.5 times). Further, depression had effects on food insecurity in the most nations; significant relationships were detected among older adults in Ghana, South Africa, India, and Russia. Most strikingly, increases in depression heightened risks of food insecurity 4 to 5 times among adults 60 years and older in the African SAGE nations.
NOTE: when LOGIT models were run with food insecurity as the predictor and depression as the outcome, nearly identical odds ratios were detected.

18. Summary
Associations between age and food insecurity varied dramatically by nation
In Ghana, Russia, Mexico, and South Africa, older adults in each nation were more food insecure than younger adults
In Ghana and Russia, adults aged 50 to 59 and 60 + years had roughly similar food insecurity
In Mexico and South Africa, adults aged 50 to 59 had the highest rates of food insecurity
For more info about potential whys, see Discussion in our paper—which is very speculative… maybe better to turn any “why” questions around to the audience? (and then take good notes to send to me!)
Bullet point 1 text to be described:
inadequate safety nets increase reliance on kin and other social networks, which can be fragmented by socioeconomic trends, e.g., urbanization)
Bullet point 2 text to be described:
(potential contributors? High prevalence of HIV/AIDS in South Africa, with newest cases among year olds?)

19. Summary
Indian and Chinese 18 to 49 year olds: highest food insecurity of all age groups
Depression:
increased likelihood of older adult food insecurity (between 1.5 and 5.3 times) than physical or cognitive challenges (between 1.2 and 1.5 times)
effects on food insecurity in Ghana, South Africa, India, and Russia, with odds of food insecurity 4 to 5 times among adults 60 years and older in Ghana and South Africa
For more info about potential whys, see Discussion in our paper—which is very speculative… maybe better to turn any “why” questions around to the audience? (and then take good notes to send to me!)
For last bullet point:
Note: same odds detected in all nations and related age groups with food insecurity as predictor and depression as outcome

20. Conclusions
Substantial variation by country in vulnerability to food insecurity points to questions regarding the influences of…
Country-specific cultural, social, and economic values and conditions; social protection safety nets
Distinct cultural meanings of aging and related elevations or demotions in the social status of aging adults
Varying senses of social obligation by families and communities and by economic and social institutions (e.g., government services)
For more info about potential whys, see Discussion in our paper—which is very speculative… maybe better to turn any “why” questions around to the audience? (and then take good notes to send to me!)
I added the social protection piece -
Filial piety and intergenerational reciprocity also vary quite significantly by country/culture, level of economic development, etc.

21. Conclusions
Certain sociodemographic factors (e.g., poverty in Russia and China) that may exert greater influence on older adult risk of food insecurity
Multiple potential targets of policy and public health intervention to reduce risks of older adult food insecurity in middle income nations
For more info about potential whys, see Discussion in our paper—which is very speculative… maybe better to turn any “why” questions around to the audience? (and then take good notes to send to me!)
Levels of income inequality (GINI index) might point to some of the differences also.
GINI (WB) most recent available, 0=perfect equality in distribution; 100=perfect inequality.
China 47.0 (2007)
Ghana 42.8 (2006)
India 33.4 (2005)
Mexico 47.0 (2012)
Russia 40.1 (2009)
South Africa 63.1 (2009)

22. Acknowledgments
We thank the study participants, the study PIs and teams, as well as Somnath Chatterji, Melissa Liebert, Theresa Gildner, and Lauren Hawkins for their assistance with research for this paper Study sponsor: NIH R01-AG & NIA Interagency Agreement YA CN-0020
Thanks, Joshers!!! You da best!!!