Food insufficiency in currently or formerly homeless persons is associated with poorer health.
Hamelin, Anne-Marie ; Hamel, Denis
Abstract
Our objectives were to explore the relation between food
insufficiency and the health of clientele who frequent services for the
homeless; and to compare that clientele with the general population in
Quebec and in Canada on the association between food insufficiency and
health. "Ibis study is a secondary data analysis of the 1998-1999
Quebec Survey of the clientele of services for homeless people conducted
in Montreal and Quebec City. A representative sample of the daily adult
population frequenting shelters, soup kitchens and drop-in centres for
homeless people-in these cities had been selected according to a complex
survey design between December 1998 and August 1999. 458 respondents
were interviewed. The questionnaire, administrated in a face-to-face
interview, comprised over one hundred standardized questions covering
many aspects of the respondents' demographic, social, cultural and
economics, and lifestyle behaviour as well as their mental and physical
health status. For the comparison with the general population in Quebec
and in Canada, data file of the cycle 2 1996-1997 National Population
Health Survey was used. This particular survey was chosen because it
included a similar question on food insufficiency and it was reasonably
close in time. The results of this study highlight that food
insufficiency is statistically associated with poorer mental and
physical health in currently or formerly homeless persons. The effects
of food insufficiency on their health would be even greater than that
observed in the general population. They also highlight that housing
matters for food sufficiency. These results provide policy makers with a
better understanding of the relationship between homelessness, food
insufficiency and health so as to improve policies and programs directed
to homeless persons. The potential role of food security in promoting
better physical, mental and social health among this population should
be urgently examined.
Keywords: homelessness, food insufficiency, perceived health,
physical health, mental health, housing, Canada
Resume
L'etude avait pour but d'explorer la relation entre
l'insuffisance alimentaire et la sante chez la clientele des
ressources pour personnes itinerantes, puis de comparer cette
association avec celle chez la population generale du Quebec et du
Canada. Cette etude est une analyse des resultats de l'Enquete
aupres de la clientele des ressources pour personnes itineranantes des
regions de Montreal-Centre et de Quebec en 1998-1999. Un echantillon
representatif de l'ensemble de la clientele journaliere frequentant
les centres d'hebergement, les soupes populaires et les centres de
jour recevant des personnes itinerantes dans ces regions ont ete
selectionnes selon un plan de sondage complexe entre decembre 1998 et
aout 1999. Quatre cent cinquante-huit personnes ont ete interviewees. Le
questionnaire d'enquete comprenait plus de cent questions
standardisees couvrant plusieurs aspects d'ordre demographique,
social, culturel, economique et comportemental, de meme en lien avec la
sante physique et mentale. Les donnees de l'Enquete nationale de la
sante des populations 1996-1997, cycle 2, ont ete utilisees aux fins de
comparaison avec la population generale du Quebec et du Canada. La
periode couverte par cette enquete et l'inclusion d'une
question similaire sur l'insuffisance alimentaire rendaient ce
choix raisonnable. Les resultats de notre etude demontrent que
l'insuffisance alimentaire est statistiquement associee avec un
etat de sante mental et physique plus pauvre chez les personnes sans
abri au moment de l'etude ou ayant deja ete sans abri. Les effets
de l'insuffisance sur leur sante seraient meme plus grands que ceux
observes chez la population generale. Les resultats montrent que le fait
d'avoir un logement importe. Ces resultats offrent une lecture des
relations entre l'itinerance, l'insuffisance alimentaire et la
sante qui peut eclairer les decideurs politiques et leur permette
d'ameliorer les politiques et programmes ayant trait aux
populations itinerantes. Il est urgent que le role potentiel de la
securite alimentaire dans la promotion d'un meilleur etat de sante
physique, mental et social chez ces populations soit examine et pris en
compte.
Mots cles : itinerance, insuffisance alimentaire, sante percue,
sante physique, sante mentale, type de residence, Canada
INTRODUCTION
Data analysis of American (Siefert et al. 2004; Kaiser et al. 2007;
Seligman et al. 2007; Cook and Frank 2008) and Canadian population
surveys (Che and Chen 2001; Dubois et al. 2001; Vozoris and Tarasuk
2003; Kirkpatrick and Tarasuk 2008) have highlighted the relationship
between food insufficiency or food insecurity and poor health. Given the
exclusion of homeless people in Canadian surveys addressing food
insecurity, there is a lack of data on the scope and nature of this
problem among this particular segment of the Canadian population. It is
recognized that the homeless, or people without a secure, adequate and
affordable place to live, are rather vulnerable to food insecurity
(Dachner and Tarasuk 2002; Furness et al. 2004; Booth 2006; Hamelin et
al. 2006; Whitbeck et al. 2006; Lee and Greif 2008; Weiser et al. 2009)
and health problems (Hwang 2001; Baggett et al. 2010). Although the
magnitude of homelessness in Canada is not clearly documented, it is
believed to be significant and growing (Laird 2007). Homelessness was
shown to be an independent risk factor for deaths due to drug misuse,
circulatory and respiratory disorders (Morrison 2009)
The importance of studying the relationship between lack of food
and health conditions in homeless populations is at least twofold.
First, considering that food and shelter are among the basic foundations
of life-long health (Raphael 2004), such a study is necessary to fill
the gap in knowledge regarding this relationship at the population
level. In the pursuit of health equity, this knowledge could contribute
to the implementation of preventive practices and policy interventions
in favour of homeless persons and those at risk of homelessness. Second,
a better understanding of the lack of food among homeless persons is
essential in order to estimate the true prevalence of food insufficiency
in the general population.
This study was undertaken to further contribute to the
understanding of the relationship between a lack of food and health
status of Canadians through an analysis of data from the 1998-1999
Quebec Survey of Clientele of Services for Homeless People (QSCSHP) in
the two largest urban areas in Quebec, Montreal and Quebec City
(Institut de la statistique du Quebec 2001; 2003). Our working
hypothesis was that the association of food insufficiency with poorer
health status was modulated by housing conditions. In line with the
study by Vozoris and Tarasuk (2003), our objectives were to 1) describe
the clientele of services for homeless people in Montreal and Quebec
City who report food insufficiency; 2) explore the relation of food
insufficiency and the physical and mental health of that clientele; and
3) compare that clientele with the general population of Quebec and
Canada regarding the association between food insufficiency and health.
METHODS
Data
This study draw on data from the QSCSHP public use microdata in
ASCII format health file. This cross-sectional survey is based on a
representative sample of the daily adult population ([greater than or
equal to] 18 years old) who frequents shelters, soup kitchens and
drop-in centres for homeless people in 24 centres in Montreal and 15
centres in Quebec City. Selection happened through a complex survey
design between December 1998 and August 1999. The methodology of this
survey is described elsewhere (Institut de la statistique du Quebec
2001). Survey results are based on the assumption that respondents and
non-respondents are similar on the measured characteristics. For each
participating centre, a certain number of days, proportional to the size
of the clientele, were randomly selected. For each selected day, one or
more of the individuals frequenting the centre were randomly selected
and then assessed for admissibility. For each day in a given center, the
objective was to get at least one respondent. Overall, the initial
sample included 1,168 people of whom 109 were deemed inadmissible (40
had already been interviewed; 69 identified in soup kitchens had slept
in a shelter the night before rendering them inadmissible according to
the survey design) leaving a total of 1,059 people. Of these, 757
accepted to be interviewed partially or totally, 509 in Montreal and 248
in Quebec City, resulting in a response rate of 76.5% in Montreal and
62.9% in Quebec City. The questionnaire, administrated in a face-to-face
interview, comprised over one hundred standardized questions covering
demographics, socioeconomics, lifestyle behaviors, health status as well
as service needs. The interview was conducted in either English or
French according to the language of the respondent. As the initial
survey questionnaire was long (on average 2.5 hours), it was decided to
shorten the questionnaire and to prepare two versions, each one
including a common trunk and specific questions. Of the 757 eligible
persons, 458 respondents were randomly selected to answer the version of
the questionnaire covering lifestyle behaviors and food insufficiency.
Our analysis is based on the responses of these 458 respondents.
The public use microdata health file for the household component of
the Cycle 2 (1996-1997) National Population Health Survey (NPHS) was
used to compare our results with those at the Canadian level. This
particular survey was chosen because it included a similar question on
food insufficiency and was reasonably close in time; furthermore a
detailed examination of the survey data on the relationship between food
insufficiency and health had been already published (Tambay and Catlin
1995; Swain et al. 1999; Vozoris and Tarasuk 2003; 2004). NPHS is an
ongoing survey conducted by Statistics Canada to collect information on
the health of Canadians from a panel of 17,276 individuals,
re-interviewing them by telephone every two years for longitudinal
purposes. Again the survey was administered either in English or French.
The response rate for the individuals panel was 94% in 1996/97. In
total, residents of 82,000 households in all Canadian provinces were
interviewed for cross-sectional purposes with the exception of people
living on Native reserves or on Canadian Forces bases, people from
certain remote areas in Quebec and Ontario, and homeless persons.
Sociodemographic and health variables included household type, major
sources of income, home ownership, region of residence, self-rated
health, chronic conditions, body mass index, distress index and food
insecurity. A detailed description of the survey design and methodology
appears elsewhere (Tambay and Catlin 1995; Swain et al. 1999; Vozoris
and Tarasuk 2003; 2004). Both provincial (Quebec) and Canadian
estimations of this survey were employed.
Food Insufficiency
The lifestyle behavior section of the QSCSHP included three
questions exploring issues on the lack of food in clients who frequent
services for homeless people. The first question concerns the average
number of meals per day ("over the past seven days, how many meals
per day have you eaten on average"). The second relates to food
sources over the past seven days ("over the past seven days, have
you eaten or got food from one of the following sources: a) grocery, b)
food basket provided by a community organization; c) meal that you have
paid for in a cafe or a restaurant, d) soup kitchen, e) friends or
family members, f) leftovers found on the street, g) other
source--specify). The third question specifically addresses food
sufficiency. Respondents were asked a question based on the food
sufficiency indicator developed for the Third National Health and
Nutrition Examination Survey (Cristofar and Basiotis 1992): "Over
the past seven days, was having enough food to eat a problem to you: a)
often, b) sometimes, c) rarely, or d) never?" Individuals who
responded "often", "sometimes" or "rarely"
having enough food to eat was a problem were classified as "food
insufficient" (36% of the sample); those who reported that it was
"never" a problem for them in the last seven days were deemed
food sufficient. In contrast to the single-item food insufficiency
question, food insecurity is a comprehensive concept that addresses the
many facets and dynamics of the experience related to a lack of food and
a lack of control over one's food situation, as well as, the
potential consequences at the individual and household levels. In an
attempt to capture this complexity, the food insecurity scale is
constructed using 18 questions if the household has children or 10 if it
does not (Nord et al. 2008).
The identification of food sufficiency in the population is
different in the NPHS for both the concept and the process. In the NPHS,
the concept of food sufficiency is defined at the household level, as
opposed to the individual level. Also, NPHS consists of three questions
including a step question: respondents were asked if, over the past 12
months, their household had "ever run out of money to buy
food." Those who responded affirmatively were then asked two
additional questions: 1) did anyone in your household receive food from
a food bank, soup kitchen or other charitable agency? 2) "which of
the following best describes the food situation in your household? a)
always enough food to eat; b) sometimes not enough food to eat; c) often
not enough food to eat." In spite of these differences, the last
NPHS question and the third question of the QscSHP focus both on
"enough food" and their operational definition is similar to
that widely used in the U.S. National Health and Nutrition Examination
Surveys (Vozoris and Tarasuk 2003). The inclusion of a screening
question in the NPHS means that the likelihood of classifying a
respondent as food insufficient is probably lower in the NPHS compared
to the QSCSHP.
Health Indicators
Two categories of health variables are considered in this paper:
physical health and mental health. The physical health indicators
include self-rated health scale, multiple chronic conditions (see
Appendix 1 for definition), heart disease, and obesity (as indicated by
body mass index (BMI) [greater than or equal to] 30 based on
self-reported height and weight data), a well known risk factor for many
health conditions including diabetes, heart disease and stroke. The
mental health indicators include alcohol and drug disorders, depression,
emotional disorders, and disorders referring to the first two axes of
the DSM-IV scale (American Psychiatric Association 1996). Except for
axis 2 disorders, all of these mental health problems were considered in
the past 12 months only. All measures were dichotomized in order to
differentiate individuals with responses indicative of poor health. (See
Appendix 1 for descriptions of the health outcomes and their
cut-offpoints defining poor health).
Sociodemographic variables
The following attributes were considered for their potential
relationship with both health indicators and food insufficiency
(Fournier 2003): region (Montreal-Centre; Quebec City), gender, age,
education (high-school completed, or not), sources of income (none; only
one source; more than one), and residential status (currently homeless;
not currently homeless; never homeless). 'Currently homeless'
which is the status of 34% of the study population refers to someone
living outdoors, in a public area, in an abandoned space, or in need of
finding a shelter or a hostel at the time of the study. 'Not
currently homeless' (43.5%) or "formerly homeless" refers
to individuals who had experienced homeless in their lifetime but had
some form of housing at the time of the survey. 19.9% of the "Not
currently homeless" have slept outdoors, in a public area or in an
abandoned space in the past 12 months, compared to 63% of the currently
homeless. In 57% of the 18-25 years, this experience of homelessness was
recent, i.e., since less than a year. An individual who has never
experienced homelessness was classified as 'never homeless'
(22.5% of the study population); nevertheless, 47% of this group has
moved at least once in the past year compared to 17% in the general
population, and one in five lived in a rooming house. Although the
survey did not include any question about aboriginal status, the
proportion of homeless people who were Aboriginals in this study
population is likely to be non-significant.
More than one in four clients of services provided to the homeless
declared having experienced stressful events related to lodging within
the past year. One in seven reported either a loss of lodging or
eviction. Stressful events related to lodging were more prevalent in the
currently homeless (35.5%) than in those who were not currently homeless
(22.9%) or never homeless (20.6) at the time of the study (p< 0.05).
For the purpose of statistical analysis, "currently" and
"formerly" homeless were combined in the present study on the
basis that they both showed a similar risk of food insufficiency
(respectively 35.9 and 33.1) compared to the "never homeless"
(21.1).
Statistical methods
All analyses were performed with SAS version 8 (SAS Institute) and
SUDAAN version 9.0.0 (Research Triangle Institute International 2004).
SAS was used mainly for descriptive statistics. SUDAAN was used for the
final analysis in order to account for unequal probabilities of
selection of respondents and some clustering, especially in the same
services. Contrary to classic statistical softwares, SUDAAN takes into
consideration the structure of dependence of observations when it
calculates standard errors for parameter estimates in statistical
models. To do this, the Institut de la Statistique du Quebec provided us
with information on how the survey was planned. In order to infer
results obtained from the sample to the population, all estimates
produced in this paper are sample-weighted.
A preliminary understanding of how food insufficiency varies
according to selected individual attributes was obtained through
cross-tabulations and multiple logistic regressions. Cross-tabulations
were used to examine the associations between food insufficiency and
socio-demographic characteristics of the homeless and the
marginally-housed persons. Multiple logistic regressions were used to
describe the relationship between food insufficiency and the selected
characteristics.
"This approach allowed identifying the relative importance of
each variable knowing that many of them were interrelated. This also
helped to identify potential confounding variables on the association
between food insufficiency and health indicators.
To measure whether there is an association between food
insufficiency and health problem indicators, we carried out logistic
regressions for the whole sample with health outcomes as dependent
variables. These models enabled us to estimate the crude (unadjusted)
odds ratio that a food insufficient individual would report poor health.
Food sufficient individuals were considered as the category reference in
models. Then individual attributes were added in all models to calculate
adjusted odds ratios and to control potential confounding effects of
these attributes on observed associations. We could therefore identify
the net effect of food insufficiency on the health differences, not
masked by, for example, the well-known relation between age and the
presence of poor health. Final models included only significant and
confounding variables.
The same models were carried out with NPHS data, but for a limited
number of health variables. Since the mental health section in the NPHS
is not as elaborated as in the QSCSHP, it was not possible to create
similar mental health indicators. Only the self-rated health, obesity,
and partially multiple chronic problems (the list of chronic diseases
not being the same) could be compared on both populations, general and
homeless. To account for the effects of complex design on variance
estimate, all variability measures such as confidence intervals were
calculated using bootstrap resampling techniques with a set of 500
bootstrap weights created by Statistics Canada (Yeo et al. 1999). As we
did for the QSCSHP, in order to infer results from the sample to the
population, all the results from NPHS presented in this paper reflect
weighted estimates.
The rate for partial non-responses was relatively low (globally
less than 10%) for the variables considered in our models. There was
therefore no reason to believe that the non-respondents could bias our
estimations.
RESULTS
The majority of the study population was male (86%) and was younger
than the general population ([greater than or equal to] 45 year old: 35%
vs 47% in the general population).
One third of the sample (36%; n = 155) reported food insufficiency.
Amongst them, 31% mentioned that having enough food to eat was
'often' a problem and 44% reported that it was a problem
'sometimes' during a period of seven days. The majority had
consumed at least one meal from a soup kitchen or a centre in a
seven-day period (currently homeless: 86.6%; not currently homeless:
90.8%; never homeless: 91.3%). The proportion of men having used the
service of a soup kitchen was higher than that of women (93% vs 79%, p
< 0.05). Other sources of food included groceries, food baskets from
community organizations, meals paid for in coffee shops or restaurants,
friends or family, and leftovers found on the street. Sources of food
were the same regardless of respondents' residential status except
for two sources: groceries (currently homeless: 34.2%; not currently
homeless: 53.5%; never homeless: 61.9; p<0.05) and use of leftovers
found on streets in the last seven days (currently homeless: 14.9%; not
currently homeless: 1.3%; never homeless: 3.3; coefficient of variation
> 25%).
Table 1 shows the links between food insufficiency and some
individual attributes. Within the sample, only the condition of being
"currently or formerly homeless" was statistically associated
with food insufficiency. Respondents who were homeless or had an episode
of homelessness in their life were at greater risk of food insufficiency
than respondents who have never been homeless (41% vs 17%). Other
variables show interesting links, but are not statistically significant,
mostly due to the small sample size. Male respondents and respondents
between 18 and 29 years old were more likely to report food
insufficiency. This result is important given that age plays an
important confounding role as it is strongly linked to health problems
in general.
The odds that the clientele who frequent services for the homeless
and report food insufficiency also report poor self-rated health are
high. Table 2 presents crude and adjusted odds ratios derived from
multiple logistic regression on physical health indicators. For all of
them, strong relationships are observed in the expected direction: food
insufficiency is associated with poor physical health. For example, 45%
of food-insufficient people declared their health as poor or fair
compared to only 27% for those who are food-sufficient. All crude odds
ratios are significant. Once individual attributes are controlled for,
the results display stronger links for self-rated health, multiple
chronic conditions and heart disease. Similar results for crude and
adjusted odds ratios were seen for obesity. Apart from food
insufficiency, other factors increased the probability that the
respondents declared poor physical health. For self-rated health,
perception of one's health decreased with increasing age. The same
holds for heart disease. Education was also statistically associated
with self-rated health: individuals who did not complete high school
were more likely to have poor health. In the model for obesity, it was
found that homeless women had a higher risk of obesity than men.
Mental health is also strongly related to food insufficiency (Table
3). All crude odds ratios are superior to 2. However, once individual
attributes are added to the models, adjusted odds ratios become
non-significant for alcohol and drug disorders, and axis 2 disorders.
People who were food-insufficient had higher risk of suffering from
depression or emotional disorder compared to those who were
food-sufficient, even after individual characteristics were taken into
account. Once again, apart from food insufficiency, other factors
increased the probability that homeless declared poor mental health.
Men, young people and those who were currently or formerly homeless were
more likely to declare alcohol or drug problems. Emotional disorders
occurred more often in women and in people who have been homeless at
least once in their life. Finally, the risk of having axis 2 disorders
was increased in young homeless respondents (18-29) compared to older
respondents ([greater than or equal to] 45 year old).
Table 4 compares the above results concerning the clientele of
services for homeless people with the general population in Canada and
in Quebec regarding self-rated health, multiple chronic conditions and
obesity. The adjusted odds ratios show that in the overall Canadian
population, food insufficiency is significantly associated with
poor/fair self-rated health and with multiple chronic conditions.
However, unlike the clientele of services for the homeless, the link
between food insufficiency and obesity is not statistically significant
in the general population of Quebec or Canada.
DISCUSSION
The QSCSHP which portrays this marginalized population according to
residential status, socio-economics, lifestyle behaviours, health
dimensions and needs for services provided a unique opportunity to study
the relationship between food insufficiency and poor health among
homeless people.
Food insufficiency is associated with poorer health
The odds that the clientele who frequent services for the homeless
report both food insufficiency and poor/fair self-rated health was
moderately high, and when personal characteristics were controlled for,
this association was even stronger, meaning that food insufficiency was
associated with the perception of one's own health. Self-rated
health is known to be a good predictor of overall health status. It can
reflect aspects of health not captured in other measures such as
physiological and psychological reserves and social and mental function
(Canada 2006). The relationship is therefore not surprising since food
insecurity, a concept encompassing food insufficiency, relates to the
physical, mental and social aspects of the life of homeless. Qualitative
work (Hamelin et al. 2002) has demonstrated that food security
represents a unifying concept with the ability to link physical health
(fills his or her nutritional needs), mental health (certainty of being
able to eat; being able to choose; eating with dignity; feeling that one
controls its basic needs) and capacity for social integration (being
able to realize elementary food activities) of individuals.
The food insufficient individuals had high odds of reporting poor
physical health, even after adjusting for the confounding effects of
age, education, and homeless status. This was true for multiple chronic
conditions such as anaemia, allergies, chronic bronchitis, diabetes,
emphysema and heart disease. In this study, the adjusted odds ratio of
reporting heart disease while being food insufficient was the highest.
Heart disease was also the condition for which the difference between
the crude and the adjusted ratios was the largest, suggesting the
importance of meeting specific dietary needs for the condition. These
needs are not likely to be easily fulfilled given the study
population's source of food is often soup kitchens (Institut de la
statistique du Quebec 2003). It is suspected that food insufficient
homeless individuals do not regularly eat adequate fruits and vegetables
which are important sources of antioxidant nutrients and folate
associated with cardiovascular health (USDA Center for Nutrition Policy
and Promotion 2000; Tarasuk et al. 2005). They would rather eat cheaper,
energy dense foods which are high in fats and sugar (Drewnowski and
Barratt-Fornell 2004). This is consistent with a recent study of dietary
intakes of homeless women who perceived that their shelter diet
contributed to chronic diseases and their symptoms (Davis et al. 2008).
It was not possible to examine the relation between frequency of program
use and food sufficiency status.
The likelihood of an inadequate diet is also supported by the high
crude odds of being both food insufficient and obese (BMI [greater than
or equal to] 30); food insufficient individuals were most susceptible to
obesity. A result that is consistent with studies of homeless children
in the U.S. (Wood et al. 1990; Smith and Richards 2008). Alternating
periods of starvation and overeating when food is available has been
suggested as a potential explanation for overweight among homeless
individuals (Bouvier 2008; Smith and Richards 2008).
Individuals who reported food insufficiency also suffered from
mental health problems. The crude odds ratios show a relationship
between food insufficiency and emotional disorder, depression, alcohol
or drug disorder, axis 1 and axis 2 disorders, in their lifetime. After
adjusting for the potentially confounding factors of age, education and
homeless status, the only association that remained was that food
insufficient individuals were more likely to report emotional disorders,
depression and axis 1 disorder. "Ibis result echoes the U.S.
literature on the health of homeless children and youth (Grant et al.
2007).
Food insufficiency among homeless adults was recently shown to be
associated with impaired access to medical or surgical care,
prescription medications and mental health care in a national U.S. based
study (Baggett et al. 2010). The researchers hypothesized that
individuals experiencing food insufficiency assign lower priority to
health care in favour of directing personal resources towards the
fulfillment of basic needs. In the QSCSHP, it was found that
"currently" homeless respondents were far more likely to
report a need for financial aid (85,9%) than for improved medical
services (50,5%) or for treatment of emotional problems (45,6%) (Hamelin
and Fournier 2003). Kushel et al. (2006) have also shown that the
competing life demands surrounding housing instability and food
insecurity may lead to delays in seeking care and predispose individuals
to access urgent acute care services.
Association between food insufficiency and poor health: greater
than that in the general population of Quebec and Canada
The estimation of the prevalence of food insufficiency for this
particular population (36%; 46% for "currently homeless") is
high when compared to the proportion observed in the general population
in Canada (4%), with the exclusion of the Aboriginal living on Reserves,
homeless people and other vulnerable groups (Vozoris and Tarasuk 2003).
The gap in the prevalence of food insufficiency between these two
populations is even likely to be larger. The magnitude of food
insufficiency and poor health may be underestimated for the clientele
who use services for the homeless since those who were not food
insufficient in the past 7 days might well have been food insufficient
over the past 12 months. Also presumably the 7 day food sufficiency rate
for the general population would be much lower than 4%.
Food insufficient individuals who frequent services for homeless
people would also be more likely to report heart disease (adjusted ratio
5.4) than the general population (adjusted ratio 2.9), while the
likelihood to report poor/fair self-rated health (adjusted ratio 2.9)
would be the same in both. For obesity, there is a strong association
between food insufficiency and BMI [greater than or equal to] 30 in
homeless persons, while the link is not statistically significant in the
general population of Quebec or Canada. Knowledge is growing about what
is now called the "food insufficiency-obesity paradigm" in low
income families (Casey et al. 2006; Dinour et al. 2007).
A lack of food or lack of quality food is seen as an everyday
stressor for individuals suffering from mental health disorders
(Campbell and Desjardins 1989; Radimer et al. 1992; Ahluwalia et al.
1998; Menke 2000; Alaimo et al. 2002; Hamelin et al. 2002; Frongillo
2003; Wu and Schimmele 2005). There is also a growing body of evidence
on the relationship between food insufficiency and depression among
low-income populations (Alaimo et al. 2002; Weinreb et al. 2002; Siefert
et al. 2004; Vozoris and Tarasuk 2004; Heflin et al. 2005; Wu and
Schimmele 2005). Findings from a 3-year panel of women welfare
recipients showed that the relation between meeting the diagnosis
screening criteria for major depression and food insufficiency in these
women was highly significant even after controlling for known risk
factors of depression (Helfin and Ziliak 2008). Similar to our findings,
Wu and Schimmele (2005), who examined the NPH cycle II data, found that
food insufficiency has an independent effect on depression in the
Canadian population. Nonetheless, the odds ratio of this association in
our study appears to be greater than that of Wu and Schimmele. Similar
to our results, these authors did not find that food insufficient women
were more subjected to depression than men.
Housing matters
The characteristics of clientele with food insufficiency who use
services for the homeless show that those respondents who were either
currently homeless or who had prior experience of homelessness in their
life were at a greater risk of food insufficiency than those who have
never been homeless. Statistically, no association was found between the
residential status "never homeless" and food insufficiency.
Interestingly, most of the "never homeless" were satisfied
with their lodging. This calls for closer examination on how housing
affects the social determinants of health including food sufficiency.
Hwang et al. (2003), found that residents of rooming houses in Toronto
aged [greater than or equal to] 35 had significantly poorer health
status than their counterparts in the general population, even when
compared to the lowest income quintile. Individuals reporting poorest
health tended to live in rooming houses with the worst physical
condition (e.g., cleanliness, noise level). Facilities such as rooming
houses are important sources of housing for very low-income Canadians;
more than one quarter of rooming house residents in the Hwang study had
been homeless less in the last five years. In our study, this is a third
of "currently homeless" persons (32.7%) and more than a third
of "not currently homeless" persons (42.1%) who lived in a
rooming house at the time of the study. However, it remains unclear
whether the concentration of people with poor health in poor-quality
housing is the result of selection process or the direct effects of
housing on health. Eberle et al (2001) observed that the health, social
and criminal costs for homelessness are considerable; they point out a
crucial need for research comparing the cost of supporting and providing
housing for vulnerable groups with the costs incurred in health and
other sectors. However, Dunn et al. (2006) also underlined the need to
examine whether subsidized housing, particularly for vulnerable groups,
has a large enough effect on disposable income to reduce food
insecurity. Mercier and Alarie, conducted a qualitative study of 30
individuals with a history of homelessness and substance abuse in
Montreal, providing a glimpse into the complexity and direction of the
relationship between housing and food, which could affect longer-term
stability
and eventually stop the circle of drug abuse and homelessness. The
researchers found that having a place to live was not enough, but to
fully "live" in his home could make a difference, e.g. to
invest time and energy in order to feel as if it is their own place, to
do activities of everyday life such as buying and stocking food in their
place. An improved relationship with their housing had a motivating
effect and these individuals expressed the desire to live there for a
longer period of time (Mercier and Alarie 2001). Additionally, the
alleviation of food insufficiency has been suggested as a way of
protecting families in danger of becoming homeless (Gundersen et al.
2003).
Limitations
Our study has a number of limitations. The small sample size
limited the possibility of detecting statistical relationship between
food insufficiency and health problems. For example, it was not possible
to examine the association between obesity and food insufficiency among
men and women separately; the latter group being far too small. In order
to enlarge the sample size, the individuals who were categorized as
'rarely' food insufficient were included in the 'food
insufficient' definition, potentially contributing to a
modification of the true relationship examined between food
insufficiency and health problems. However, because of the possibility
of underreporting of a lack of food by the homeless, as shown in other
studies with people having known hardship (Wolfe et al. 1998; Hamelin et
al. 2006), as well as in the more general population (Derrickson and
Brown 2002), and because of our classification of people as food
sufficient if they reported no food problems in the past seven days, we
hypothesize that this grouping had an effect in reducing the odds of an
association. Also, one must take into account that the survey was
conducted with clients of services provided to the homeless, which
included soup kitchens. There is a possibility that our sample is biased
towards the most healthy and least food insufficient group among the
homeless and prior homeless in Quebec City and Montreal. In other words,
our interpretation, if biased, would more conservative rather than
falsely alarming.
Our analysis relied on self-reported measures of health; however,
almost two thirds of the survey participants reported that at least one
problem was confirmed by a doctor (Institut de la statistique du Quebec
2003). In their study of the Canadian Community Health Survey, Lyons et
al. (2008) found that associations between obesity and food insecurity
are more pronounced when self-reported data on height and weight are
used compared with measured data on height and weight. Although
under-reporting weight and over-reporting height is widely recognized,
this appears less likely in our study population composed of persons who
are preoccupied with daily survival and who are mainly male.
In addition, one must be careful in interpreting the data from the
two surveys (QSCSHP; NPH) which differ in their design. The period of
reference is not the same: the QSCSHP used a period of 7 days, versus 12
months for the NPHS. In both cases, the recall period seems appropriate
considering the variability of the phenomenon of interest in the
surveyed population and the intent for the use of the data. However, the
impact on the results concerning an association between food
insufficiency and poorer health between the general population and the
homeless is still unclear. Regarding data collection, the QSCSHP
provides point prevalence data on a typical day, we, therefore, do not
know how many other people are homeless on a given day; this may
underestimate the true situation. The concept of 'food
insufficiency' was approached at a different level: in the NPHS,
the questions referred to food insufficiency at the household level,
whereas the QSCSHP referred to food insufficiency at the individual
level.
It is also important to highlight that our study was not intended
to detect potential causal relationships; this would have been
impossible given the cross sectional nature of analysed data. We are
aware that many other individual characteristics might be related to the
health indicators and that they could affect our results in regression
models. Our objective was to calculate the risk (odds ratio) of someone
with food insufficiency suffering from health problems, once the
selected factors were controlled.
CONCLUSION
The results of this study highlight that food insufficiency is
associated with poor mental and physical health in currently or formerly
homeless persons. The effects of food insufficiency on their health
would be even greater than that observed in the general population. The
relationship between homelessness, food insufficiency and health should
prompt policy makers to improve both health and social policies and
programs aimed at this uniquely important group of persons. The
provision of adequate food services targeting homeless who are food
insufficient would prevent further deterioration of their health. The
role of food security in promoting better physical, mental and social
health among the homeless and marginally housed persons should be
urgently considered as one key to reduce health inequality issues in
Canada.
Appendix
Descriptions of health measures selected in this paper
Self-rated health
Definition. Self-rated health is the most frequently collected
variable on population's health. In this survey, it refers
explicitly to physical health" "We will now talk about
physical health. In general, compared to other persons in your age,
would you say your health is excellent, very good, good, fair or
poor?".
Dichotomized cut-point. Differentiate two groups of people, those
saying their health is fair or poor and those considering it excellent,
very good or good.
Multiple chronic conditions
Definition. Respondents were asked if they had chronic conditions.
The conditions listed were diabetes; anaemia; skin disease; skin
allergies (or coetaneous allergies); hay fever; other allergies; serious
back problem; other serious bone problems or joints ache; arthritis or
rheumatism; emphysema, chronic bronchitis, persistent cough or asthma;
high blood pressure; heart disease; urinary incontinence; stomach
ulcers; other bowel disorders; epilepsy; thyroid condition; migraine or
frequent headache; paralysis.
Dichotomized cut-point. Respondents with multiple chronic
conditions corresponds to those reported at least two.
Heart disease
Definition. Respondents were asked if they had a heart disease.
Dichotomized cut-point. Presence or absence.
Obese according to BMI
Definition. The body mass index is the most frequently measure to
obesity. It consists to a ratio of mass in kg to the square of height in
meters.
Dichotomized cut-point. Obese = BMI superior or equal to 30.
Mental health
The mental disorders were measured through the Diagnostic Interview
Schedule (DIS) and the Composite International Diagnostic Interview
Simplified (CI-DIS). These allow to pass in review the symptoms and
criteria corresponding to these disorders according to the DSM-IV
(American Psychiatric Association). The classification system is based
on a multiaxial evaluation of which the two first axes were retained
only. The first axis refers to clinical disorders including major mental
disorders, as well as developmental and learning disorders and other
situations that can be the object of a clinical investigation. These
include notably those disorders that are not linked to the use of a
substance : schizophrenia and other psychotic troubles, affective
disorders such as depression and pathological gaming. The second axe
comprehends mainly troubles linked to underlying pervasive or
personality conditions, as well as mental retardation.
The term "current" refers to the past 12 months.
Current Axis 1 disorders (troubles de l'axe 1); current
emotional disorders; current depression; current alcohol and drug
disorders; Axis 2 disorders (troubles de l'axe 2)
Definition. As mentioned in the preceding paragraph and according
to DSM-IV
Dichotomized cut-point. Presence or absence
Acknowledgments
We would like to thank Professor Valerie Tarasuk of University of
Toronto for her guidance with data analysis. This research was supported
in part by a grant from the Centre de sante et des services sociaux de
la Vieille-Capitale, Quebec City, Canada.
References
Ahluwalia, I. B., J. M. Dodds, et al. 1998. Social support and
coping behaviors of low-income families experiencing food insufficiency
in North Carolina. Health Educ Behav 25(5): 599-612.
Alaimo, K., C. M. Olson, et al. 2002. Family food insufficiency,
but not low family income, is positively associated with dysthymia and
suicide symptoms in adolescents. J Nutr 132(4): 719-25.
American Psychiatric Association. 1996. DSM-IV Manuel diagnostic et
statistique des troubles mentaux. Paris, Masson.
Baggett, T., J. O'Connell, et al. 2010. The unmet health care
needs of homeless adults: a national study. American Journal of Public
Health 100(7): 1326-33.
Booth, S. 2006. Eating rough: food sources and acquisition
practices of homeless young people in Adelaide, South Australia. Public
Health Nutr 9(2): 212-8.
Bouvier, G. 2008. Starvation then binge-eating can cause obesity in
the homeless. HIV Clinician 20(3): 1-2.
Campbell, C. C. and E. Desjardins 1989. A model and research
approach for studying the management of limited food resources by low
income families. Journal of Nutrition Education 21: 162-171.
Canada, Statistics 2006. Health indicators: Definitions and data
sources, Health status,
http://www.statcan.gc.ca/pub/82-221-x/2006001/4063753-eng.htm (Retrieved
January 15th, 2009).
Casey, E H., E M. Simpson, et al. 2006. The association of child
and household food insecurity with childhood overweight status.
Pediatrics 118(5): e1406-13.
Che, J. and J. Chen. 2001. Food insecurity in Canadian households.
Health Rep 12(4): 11-22.
Cook, J. T. and D. A. Frank. 2008. Food security, poverty, and
human development in the United States. Ann N Y Acad Sci 1136: 193-209.
Cristofar, S. P. and P. P. Basiotis. 1992. Dietary intakes and
selected characteristics of women ages 19-50 years and their children
ages 1-5 years by reported perception of food sufficiency. Journal of
Nutrition Education 24: 53-58.
Dachner, N. and V. Tarasuk. 2002. Homeless "squeegee
kids": food insecurity and daily survival. Soc Sci Med 54(7):
1039-49.
Davis, L. R., N. F. Weller, et al. 2008. Dietary intake of homeless
women residing at a transitional living center. J Health Care Poor
Underserved 19(3): 952-62.
Derrickson, J. p. and A. C. Brown. 2002. Food security stakeholders
in Hawaii: perceptions of food security monitoring. J Nutr Educ Behav
34(2): 72-84.
Dinour, L. M., D. Bergen, et al. 2007. The food insecurity-obesity
paradox: a review of the literature and the role food stamps may play. J
Am Diet Assoc 107(11): 1952-61.
Drewnowski, A. and A. Barratt-Fornell. 2004. Do healthier diets
cost more?" Nutrition Today 39: 161-168.
Dubois, L., E. Beauchesne-R., et al. 2001. Enquete sociale et de
sante 1998. Chapitre 6--Alimentation: perceptions, pratiques et
insecurite alimentaire. Sante et bien-etre. Quebec, Institut de la
statistique du Quebec: 52pp.
Dunn, J. R., M. V. Hayes, et al. 2006. Housing as a socio-economic
determinant of health: findings of a national needs, gaps and
opportunities assessment. Can J Public Health 97 Suppl 3:S11-5, S12-7.
Eberle, M., D. Kraus, et al. 2001. The Relationship between
Homelessness and the Health, Social Services and Criminal Justice
Systems: A Review of the Literature--Volume 1. Vancouver, British
Columbia Ministry of Social Development and Economic Security,
BC Housing Management Commission: 1-56.
Fournier, L. 2003. Chapitre 2--Instabilite residentielle. Enquete
aupres de la clientele des ressources pour personnes itinerantes des
regions de Montreal-Centre et de Quebec, 1998-1999, Volume 2. Quebec,
Institut de la Statistique du Quebec: 23-46.
Frongillo, E. A. 2003. Understanding obesity and program
participation in the context of poverty and food insecurity. J Nutr
133(7): 2117-8.
Furness, B. W., P. A. Simon, et al. 2004. Prevalence and predictors
of food insecurity among low-income households in Los Angeles County.
Public Health Nutr 7(6): 791-4.
Grant, R., A. Shapiro, et al. 2007. The health of homeless children
revisited. Adv Pediatr 54: 173-87.
Gundersen, C., L. Weinreb, et al. 2003. Homelessness and food
insecurity. Journal of Housing Economics 12: 250-272.
Hamelin, A. M., M. Beaudry, et al. 2002. Characterization of
household food insecurity in Quebec: food and feelings. Soc Sci Med
54(1): 119-32.
Hamelin, A. M. and L. Fournier. 2003. Habitudes de vie et besoins
de services. Enquete aupres de la clientele des ressources pour
personnes itinerantes des regions de Montreal-Centre et de Quebec
1998-1999. Montreal, Institut de la statistique du Quebec. Volume 2,
chapitre 3.
Hamelin, A. M., C. Mercier, et al. 2006. The Food Environment of
Street Youth. Journal of Hunger & Environmental Nutrition 1 (3):
69-98.
Heflin, C. M., K. Siefert, et al. 2005. Food insufficiency and
women's mental health: findings from a 3-year panel of welfare
recipients. Soc Sci Med 61 (9): 1971-82.
Helfin, C. M. and J. P. Ziliak. 2008. Food Insufficiency, Food
Stamp Participation, and Mental Health. Social Science Quarterly 89(3):
706-727.
Hwang, S. 2001. Homeless and health. Canadian Medical Association
Journal 164(1): 229-33.
Hwang, S. W., R. E. Martin, et al. 2003. The relationship between
housing conditions and health status of rooming house residents in
Toronto. Can J Public Health 94(6): 436-40.
Institut de la statistique du Quebe. 2001. Enquete aupres de la
clientele des ressources pour personnes itinerantes des regions de
Montreal-Centre et de Quebec, 1998-1999, Volume 1. Sante et bien-etre.
Quebec, Institut de la statistique du Quebec.
Institut de la statistique du Quebec. 2003. Enquete aupres de la
clientele des ressources pour personnes itinerantes des regions de
Montreal-Centre et de Quebec, 1998-1999, Volume 2. Sante et bien-etre.
Quebec, Institut de la statistique du Quebec.
Kaiser, L., N. Baumrind, et al. 2007. Who is food-insecure in
California? Findings from the California Women's Health Survey,
2004. Public Health Nutr 10(6): 574-81.
Kirkpatrick, S. I. and V. Tarasuk. 2008. Food insecurity is
associated with nutrient inadequacies among Canadian adults and
adolescents. J Nutr 138 (3): 604-12.
Kushel, M. B., R. Gupta, et al. 2006. Housing instability and food
insecurity as barriers to health care among low-income Americans.
Journal of Internal General Medicine 21: 71-77.
Laird, G. 2007. Shelter. Homelessness in a growth economy:
Canada's 21st century paradox. Calgary, Sheldon Chumir Foundation
for Ethics in Leadership: 1-98.
Lee, B. A. and M. J. Greif. 2008. Homelessness and hunger. J Health
Soc Behav 49(1): 3-19.
Lyons, A. A., J. Park, et al. 2008. Food insecurity and obesity: a
comparison of self-reported and measured height and weight. Am J Public
Health 98(4): 751-7.
Menke, E. M. 2000. Comparison of the stressors and coping behaviors
of homeless, previously homeless, and never homeless poor children.
Issues Ment Health Nurs 21 (7): 691-710.
Mercier, C. and S. Alarie. 2001. Precarite residentielle et
consommation de psychotropes. Alcoologie et Addictologie 23(1): 13-19.
Morrison, D. S. 2009. Homeless as an independent risk factor for
mortality: results form retrospective cohort study. International
Journal of Epidemiology 38: 877-883.
Nord, M., M. Andrews, et al. 2008. Household Food Security in the
United States, 2007. Economic Research Report No. (ERR-66) 65.
Washington, D.C., United States Department of Agriculture.
Radimer, K. L., C. M. Olson, et al. 1992. Understanding hunger and
developing indicators to assess it in women and children. Journal of
Nutrition Education 24(Suppl. 1): 36S-44S.
Raphael, D. 2004. Social determinants of health, Canadian
Perspectives. Toronto, Canadian Scholars' Press Inc.
Research Triangle Institute International. 2004. SUDAAN. Research
Triangle Park, NC. SAS Institute SAS version 8. Cary, NC.
Seligman, H. K., A. B. Bindman, et al. 2007. Food insecurity is
associated with diabetes mellitus: results from the National Health
Examination and Nutrition Examination Survey (NHANES) 1999-2002. J Gen
Intern Med 22(7): 1018-23.
Siefert, K., C. M. Heflin, et al. 2004. Food insufficiency and
physical and mental health in a longitudinal survey of welfare
recipients. J Health Soc Behav 45 (2): 171-86.
Smith, C. and R. Richards. 2008. Dietary intake, overweight status,
and perceptions of food insecurity among homeless Minnesotan youth. Am J
Hum Biol 20(5): 550-63.
Swain, L., G. Catlin, et al. 1999. The National Population Health
Survey--its longitudinal nature. Health Rep 10(4): 69-82(ENG);
73-89(FRE).
Tambay, J. L. and G. Catlin. 1995. Sample design of the national
population health survey. Health Rep 7(1): 29-38, 31-42.
Tarasuk, V., N. Dachner, et al. 2005. Homeless youth in Toronto are
nutritionally vulnerable. J Nutr 135(8): 1926-33.
USDA Center for Nutrition Policy and Promotion. 2000. Food
insufficiency and the nutritional status of the elderly population.
Nutrition Insights 18 (May 2000): 1-2.
Vozoris, N. T. and V. S. Tarasuk. 2003. Household food
insufficiency is associated with poorer health. J Nutr 133(1): 120-6.
Vozoris, N. T. and V. S. Tarasuk. 2004. The health of Canadians on
welfare. Can J Public Health 95(2): 115-20.
Weinreb, L., C. Wehler, et al. 2002. Hunger: its impact on
children's health and mental health. Pediatrics 110(4): e41.
Weiser, S., D. Bangsberg, et al. 2009. Food insecurity among
homeless and marginally housed individuals living with HIV/AIDS in San
Francisco. AIDS Behavior 13(5): 841-8.
Whitbeck, L. B., X. Chen, et al. 2006. Food insecurity among
homeless and runaway adolescents. Public Health Nutr 9(1): 47-52.
Wolfe, W. S., C. M. Olson, et al. 1998. Hunger and Food Insecurity
in the Elderly --Its Nature and Measurement. Journal of Aging and Health
10(3): 327-350. Wood, D. L., R. B. Valdez, et al. 1990. Health of
Homeless Children and Housed, Poor Children. Pediatrics 86(6): 858-866.
Wu, Z. and C. M. Schimmele. 2005. Food Insufficiency and
Depression. Sociological Perspectives 48 (4): 481-504.
Yeo, D., H. Mantel, et al. 1999. Bootstrap Variance Estimation for
the National Population Health Survey. 1999 Proceedings of the Survey
Research Methods Section., American Statistical Association: 778-783.
Anne-Marie Hamelin
Departement des sciences des aliments et de nutrition Universite
Laval
Denis Hamel
Unite Surveillance des maladies chroniques et de leurs determinants
Institut national de sante publique du Quebec
Table 1 Crude and adjusted odds ratios of sociodemographic
characteristics of food insufficient individuals, QSCSHP
Food
Characteristics * n ([dagger]) insufficient
Gender
Male 357 37.5
(Female) 65 26.6
Region
Montreal 264 37.4
(Quebec City) 158 33.1
Age group
18-29 94 46.2
30-44 191 33.3
(45+) 132 31.3
Education
High school not 250 37.3
completed
(High school completed) 171 33.8
Number of income sources
None or only 1 source 288 35.9
(2 sources or more) 133 35.8
Residential status
Currently or formerly homeless 327 41.3
(Never homeless) 94 16.8
Characteristics * Crude OR ([double dagger])
Gender
Male 1.7 (0.7-3.8)
(Female) 1
Region
Montreal 1.2 (0.6-2.3)
(Quebec City) 1
Age group
18-29 1.9 (0.8-4.4)
30-44 1.1 (0.5-2.3)
(45+) 1
Education
High school not 1.2 (0.6-2.2)
completed
(High school completed) 1
Number of income sources
None or only 1 source 1.0 (0.5-1.9)
(2 sources or more) 1
Residential status
Currently or formerly homeless 3.5 (1.4-8.6)
(Never homeless) 1
OR
Characteristics * Adjusted
([double dagger], [section])
Gender
Male 1.8 (0.8-4.4)
(Female) 1
Region
Montreal 1.2 (0.6-2.3)
(Quebec City) 1
Age group
18-29 1.8 (0.8-4.3)
30-44 1.0 (0.5-2.2)
(45+) 1
Education
High school not 1.2 (0.6-2.1)
completed
(High school completed) 1
Number of income sources
None or only 1 source 1.2 (0.6-2.3)
(2 sources or more) 1
Residential status
Currently or formerly homeless 3.3 (1.3-8.3)
(Never homeless) 1
* Reference category in parentheses
([dagger]) Unweighted number of respondents
([double dagger]) OR = Odds ratio; 95% confidence interval in
parentheses
([section]) Adjusted for other characteristics listed in this table
including residential status.
Table 2 Crude and adjusted odds ratios of food insufficient
individuals reporting poor/fair self rated health and physical health
problems, QSCHRP
Self-rated
health
Poor/fair self-
rated health
n * 140
% among, people
food insufficient 45.2%
food sufficient 27.1%
Crude Odds Ratio ([dagger])
Food insufficient 2.2 (1.2-4.2)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 2.9 (1.5-5.6)
(Food sufficient) 1
Sex
Female --
(Male)
Age group
(18-29) 1
30-44 3.3 (1.3-8.2)
45+ 7.4 (2:9-19.0)
Education
High school not completed 2.1 (1.1-4.0)
(High school completed) 1
Residential Status
Currently or formerly homeless --
(Never homeless)
Types of physical health problems
Multiple
chronic
conditions
n * 187
% among, people
food insufficient 64.3%
food sufficient 42.3%
Crude Odds Ratio ([dagger])
Food insufficient 2.5 (1.3-4.6)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 2.8 (1.5-5.2)
(Food sufficient) 1
Sex
Female 1.8 ([double dagger]) (0.9-3.8)
(Male) 1
Age group
(18-29) 1
30-44 0.5 ([double dagger]) (0.2-1.0)
45+ 1.7 ([double dagger]) (0.8-3.7)
Education
High school not completed --
(High school completed)
Residential Status
Currently or formerly homeless --
(Never homeless)
Types of physical health problems
Heart disease
n * 32
% among, people
food insufficient 16.0%
food sufficient 5.9%
Crude Odds Ratio ([dagger])
Food insufficient 3.0 (1.0-9.6)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 5.4 (1.7-16.9)
(Food sufficient) 1
Sex
Female --
(Male)
Age group
(18-29) 1
30-44 1.5 ([double dagger]) (0.2-11.2)
45+ 17.1 ([double dagger]) (2.7-109.8)
Education
High school not completed --
(High school completed)
Residential Status
Currently or formerly homeless 0.6 ([double dagger]) (0.2-1.8)
(Never homeless) 1
Types of physical health problems
Body Mass
Index:
BMI [greater than or equal to] 30:
Obese
n * 53
% among, people
food insufficient 24.9%
food sufficient 7.0%
Crude Odds Ratio ([dagger])
Food insufficient 4.4 (1.9-10.6)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 4.5 (1.8-11.5)
(Food sufficient) 1
Sex
Female 2.8 (1.1-7.1)
(Male) 1
Age group
(18-29)
30-44
45+ --
Education
High school not completed --
(High school completed)
Residential Status
Currently or formerly homeless --
(Never homeless)
* Unweighted number of respondents
([dagger]) Reference category in parentheses; 95% Confidence interval
in parentheses beside odds ratio value
([double dagger]) Variables play a confounding role in the association
between food insufficiency and the corresponding health problem.
Table 3 Crude and adjusted odds ratios of food insufficient
individuals reportingmental health problems, QSCSHP
Types of current mental
health problem
Alcohol
or drug
Measures disorder Depression
n * 287 78
% among people
food insufficient 79.2% 28.5%
food sufficient 62.2% 12.1%
Crude Odds Ratio ([dagger])
Food insufficient 2.3 (1.1-4.7) 2.9 (1.4-5.9)
(Food sufficient) 1 1
Adjusted Odds Ratio ([dagger])
Food insufficient 1.7 (0.8-3.7) 2.9 (1.4-5.8)
(Food sufficient) 1 1
Sex
Male 3.5 (1.7-7.4) --
Female 1
Age group
18-29 2.2 (0.8-6.0) --
30-44 2.0 (1.0-3.9)
(45+) 1
Number of income sources
None or only 1 source -- 2.2 (1.1-4.4)
(2 sources or more) 1
Residential status
Currently or formerly homeless 2.9 ([double --
dagger]) (1.4-5.7)
(Never homeless) 1
Types of current mental
health problem
Emotional
Measures disorder
n * 113
% among people
food insufficient 42.1%
food sufficient 17.3%
Crude Odds Ratio ([dagger])
Food insufficient 3.5 (1.7-7.0)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 3.3 (1.6-6.8)
(Food sufficient) 1
Sex
Male 1
Female 2.2 ([double dagger]) (1 .0-5.0)
Age group
18-29 1
30-44 0.5 ([double dagger]) (0.2-1.1)
(45+) 1.5 ([double dagger]) (0.6-3.7)
Number of income sources
None or only 1 source --
(2 sources or more)
Residential status
Currently or formerly homeless 2.9 ([double dagger]) (1.1-7.2)
(Never homeless) 1
Types of current mental
health problem
Axis 1
Measures Disorder
n * 164
% among people
food insufficient 50.9%
food sufficient 32.4%
Crude Odds Ratio ([dagger])
Food insufficient 2.2 (1.1-4.1)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 1.9 (1.0-3.6)
(Food sufficient) 1
Sex
Male 1
Female 1.3 (0.6-2.7)
Age group
18-29 1
30-44 0.6 (0.3-1.3)
(45+) 1.6 (0.7-3.6)
Number of income sources
None or only 1 source --
(2 sources or more)
Residential status
Currently or formerly homeless 3.1 ([double dagger]) (1.4-6.9)
(Never homeless) 1
Axis 2
Disorder in
Measures their lifetime
n * 83
% among people
food insufficient 27.3%
food sufficient 15.4%
Crude Odds Ratio ([dagger])
Food insufficient 2.1 (1.0-4.4)
(Food sufficient) 1
Adjusted Odds Ratio ([dagger])
Food insufficient 2.0 (0.9-4.2)
(Food sufficient) 1
Sex
Male --
Female
Age group
18-29 2.9 (1.1-7.6)
30-44 2.2 (0.9-5.4)
(45+) 1
Number of income sources
None or only 1 source --
(2 sources or more)
Residential status
Currently or formerly homeless --
(Never homeless)
* Unweighted number of respondents
([dagger]) Reference category identified with OR= 1; 95% Confidence
interval in parentheses beside odds ratio value.
([double dagger]) Variables play a confounding role in the association
between food insufficiency and the corresponding health problem.
Table 4 Crude and adjusted odds ratios of food insufficient households
for individuals reporting poor-fair self-rated health and physical
health problems in general population, Quebec and Canada, NPHS Cycle 2
Self rated health and physical
health problems
Poor/fair self-rated
Measures health
Quebec Canada
Sample size used in 2,163 61,990
the models
of problem among
respondents living in
the household with:
food insufficient 18.4% 24.7%
food sufficient 7.2% 8.4%
Crude OR *
Food insufficient 2.90 3.60
(1.4-6.1) (3.2-4.0)
Adjusted OR *, ([dagger])
Food insufficient 1.80 2.70
(0.8-4.1) (2.5-2.9)
Self rated health and physical
health problems
Multiple chronic
Measures conditions
Quebec Canada
Sample size used in 2,155 61,599
the models
of problem among
respondents living in
the household with:
food insufficient 40.4% 48.4%
food sufficient 27.5% 29.6%
Crude OR *
Food insufficient 1.80 2.20
(1.1-3.0) (2.0-2.5)
Adjusted OR *, ([dagger])
Food insufficient 1.40 2.20
(0.8-2.4) (1.9-2.5)
Self rated health and physical
health problems
Body Mass Index:
Measures BMI [greater than or equal to]
30:Obese
Quebec Canada
Sample size used in 2,086 58,991
the models
of problem among
respondents living in
the household with:
food insufficient 13.4% 12.6%
food sufficient 12.0% 10.7%
Crude OR *
Food insufficient 1.10 1.20
(0.5-2.3) (1.0-1.5)
Adjusted OR *, ([dagger])
Food insufficient 0.90 0.90
(0.4-1.8) (.7-1.2)
* 95% Confidence interval in parentheses.
([dagger]) Adjusted for age group, sex, region (Quebec only, Montreal
and rest of Quebec), education (high school completed) and income
adequacy (in four categories: lowest income quartile, lower-middle,
upper-middle and higher) since the whole population is considered
here.
