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Sinclair K, Thompson-Colón T, Matamoros SEDC, Olaya E, Melgar-Quiñonez H. Food Insecurity Among the Adult Population of Colombia Between 2016 and 2019: The Post Peace Agreement Situation. Food Nutr Bull 2022; 43:251-270. [PMID: 35610942 PMCID: PMC9403381 DOI: 10.1177/03795721221100890] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In 2016, a Peace Agreement, explicitly addressing the right to food, was signed, marking the end of more than 50 years of armed conflict and the longest war in the Americas. The expectation was that the years to follow would be marked by rapid social and political change, with the potential to improve food security. OBJECTIVES (i) Ascertain changes in the prevalence of food insecurity in Colombia between 2016 and 2019; (ii) examine which population subgroups (eg, urban women, rural women, urban men, and rural men) were most vulnerable; and (iii) determine significant individual-level factors predicting food insecurity in these 2 years. METHODS This study used the Gallup World Poll 2016 and 2019 nationally representative samples of Colombian adults aged 15 and older for the analyses (n ≈ 1000 per year). Food insecurity was measured using the Food Insecurity Experience Scale. Descriptive statistics and logistic regression analyses were conducted using IBM SPSS Complex Samples (version 26). RESULTS Food insecurity in Colombia increased by 7 percentage points between 2016 and 2019 (from 33% to 40%); women living in rural areas in 2019 reported the highest prevalence (50%). Results from logistic analysis confirm low income, unemployment, and lack of social support were significant predictors of food insecurity in both years. In 2019, gender, low education, and lack of autonomy were also significant predictors. Further research on the determinants of food insecurity is necessary to inform Colombian policies and programs that address food insecurity. The urgency to act is more apparent than ever, given the country's worsening food security profile.
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Affiliation(s)
- Kate Sinclair
- School Human Nutrition & Institute of Global Food Security,
McGill University, Ste-Anne-de-Bellevue, Quebec, Canada
| | - Theresa Thompson-Colón
- School Human Nutrition & Institute of Global Food Security,
McGill University, Ste-Anne-de-Bellevue, Quebec, Canada
| | | | - Eucaris Olaya
- Faculty of Human Sciences, National University of Colombia, Bogotá,
Colombia
| | - Hugo Melgar-Quiñonez
- School Human Nutrition & Institute of Global Food Security,
McGill University, Ste-Anne-de-Bellevue, Quebec, Canada
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Righettini MS, Bordin E. Exploring food security as a multidimensional topic: twenty years of scientific publications and recent developments. QUALITY & QUANTITY 2022; 57:2739-2758. [PMID: 35966131 PMCID: PMC9362969 DOI: 10.1007/s11135-022-01452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/08/2022] [Accepted: 05/25/2022] [Indexed: 11/25/2022]
Abstract
The scientific literature dealing with food security is vast and fragmented, making it difficult to understand the state of the art and potential development of scientific research on a central theme within sustainable development. The current article, starting from some milestone publications during the 1980s and 1990s about food poverty and good nutrition programmes, sets out the quantitative and qualitative aspects of a vast scientific production that could generate future food security research. It offers an overview of the topics that characterize the theoretical and empirical dimensions of food security, maps the state of the art, and highlights trends in publications’ ascending and descending themes. To this end the paper applies quantitative/qualitative methods to analyse more than 20,000 scientific articles published in Scopus between 2000 and 2020. Evidence suggests the need to find more robust links between micro studies on food safety and nutrition poverty and macro changes in food security, such as the impact of climate change on agricultural production and global food crises. However, the potential inherent in the extensive and multidisciplinary research on food safety encounters limitations, particularly the difficulty of theoretically and empirically connecting the global and regional dimensions of change (crisis) with meso (policy) and micro (individual behaviour) dimensions.
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Affiliation(s)
- Maria Stella Righettini
- Department of Political Science, Law and International Studies (SPGI), University of Padova, Milan, Italy
| | - Elisa Bordin
- Department of Social and Political Sciences, University of Milan, Milan, Italy
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Abd Razak ZNR, Md Isa KA, Masuri MG, Mohd Fahmi Teng NI, Mohd Shariff Z, Mohd Fozi NAA. Development and Validation of a Direct Food Insecurity Measurement Instrument: A Study Protocol (Preprint).. [DOI: 10.2196/preprints.40945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND
The Sustainable Development Goals (SDGs) aim to achieve sustainable food security with a focus on eradicating hunger and poverty. Although some progress has been made, conflicts and food insecurity issues are still inevitable worldwide. In Malaysia, food insecurity is still evident in 2021 as food-insecure groups were present in the surveyed population. The problem leads to negative impacts on the health and development of individuals. To tackle this problem, an appropriate measurement tool is needed to assess the experience of food insecurity among Malaysians. A valid, reliable and culturally specific food insecurity measurement tool is needed for further planning and implementation.
OBJECTIVE
Our objective is to develop a direct food insecurity measurement instrument that will assist practitioners in assessing food security status in communities.
METHODS
This paper describes a mixed-methods sequential study to develop and validate a direct food insecurity measurement tool that is culturally specific for use in Malaysia. It begins with a qualitative study to understand the experience of food insecurity among food bank beneficiaries through interpretive phenomenological analysis (IPA). Validation procedures will then be conducted to validate the instrument under study, assessing content validity, construct validity and reliability. Finally, a pilot study will be conducted to evaluate the instrument in order to increase the credibility of this measurement tool in directly assessing the experience of food insecurity.
RESULTS
In-depth interviews for qualitative data will be carried out after ethics approval and expected to be completed by 2022 November 30. For validation procedures, it is estimated to be completed by 2023 June 31.
CONCLUSIONS
This study will enable the development and validation of a direct food insecurity measurement tool to be used nationwide in Malaysia, and will go part of the way in assessing the relationship between the determinants and consequences of food insecurity status.
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El Bilbeisi AH, Al-Jawaldeh A, Albelbeisi A, Abuzerr S, Elmadfa I, Nasreddine L. Households' Food Insecurity and Its Association with Demographic and Socioeconomic Factors in Gaza Strip, Palestine: A Cross-Sectional Study. Ethiop J Health Sci 2022; 32:369-380. [PMID: 35693586 PMCID: PMC9175212 DOI: 10.4314/ejhs.v32i2.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
Background This sudy aimed to identify the prevalence of household's food insecurity and its association with demographic and socioeconomic factors. Methods A cross-sectional study was conducted in September 2021 among a representative sample of households in the Gaza strip governorates. A total of 1167 households randomly selected from all five governorates and were included in the study. The Radimer/Cornell food security scale was used to determine the prevalence and levels of household food insecurity. The household's demographic and socioeconomic characteristics were obtained using an interview-based questionnaire. Statistical analysis was performed using SPSS version 25. Results The overall prevalence of household's food insecurity was 71.5%. The prevalence by governorates was highest in Gaza (30.8%), followed by Khanyounis (23.0%), North-Gaza (18.6%), Middle-Area (15.2%) and Rafah (12.4%). Regarding the food insecurity levels, 333 (28.5%) of the households were food secure, 422 (36.2%) had mild food insecurity, 161 (13.8%) had moderate food insecurity, and 251 (21.5%) had severe food insecurity. Significant associations were found between governorates, monthly income, homeownership, work status with the household's food insecurity, (Crude OR [COR] = 2.02, 95% CI = [1.02–3.98], P value < 0.05), (COR = 2.00, 95% CI = [1.04–2.75], P value < 0.05), (COR = 2.36, 95% CI = [1.39–3.99], P value < 0.05), and (COR = 1.14, 95% CI = [0.66–1.97], P value < 0.05), respectively. Conclusions Our study demonstrates that food insecurity is highly prevalent in the Gaza strip and is associated with poor living conditions. Therefore, this high prevalence should be seriously discussed and urgently considered.
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Affiliation(s)
- Abdel Hamid El Bilbeisi
- Department of Nutrition, School of Medicine and Health Sciences, University of Palestine, Gaza Strip, Palestine
| | - Ayoub Al-Jawaldeh
- Regional Office for the Eastern Mediterranean (EMRO), World Health Organization (WHO), Cairo, Egypt
| | | | - Samer Abuzerr
- Visiting Scholar with the School of Public Health, Department of Social and Preventive Medicine, University of Montreal, Montréal, QC, Canada
| | - Ibrahim Elmadfa
- Department of Nutrition, Faculty of Life Sciences, University of Vienna, Vienna, Austria
| | - Lara Nasreddine
- Nutrition and Food Sciences Department, Faculty of Agriculture and Food Sciences, American University of Beirut, Beirut, Lebanon
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Vazirani A, Bhattacharjee T. COVID-19 lockdowns and a response model to health, economic and food anxiety. CURRENT PSYCHOLOGY 2020; 41:5734-5744. [PMID: 33250616 PMCID: PMC7683037 DOI: 10.1007/s12144-020-01210-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/28/2022]
Abstract
Pandemics create survival uncertainty through infection possibilities, food scarcity, and unemployment. Being the largest democracy in the world, we have explored the response of Indian citizens on the COVID-19's lockdown and defined an anxiety response model using PLS based Structural Equation Modeling(SEM). For a comprehensive understanding, we have measured the response at two levels of individual and government. Though the types of anxieties are related, we observed that a specific response is linked with a specific type of anxiety and all responses are not anxiety-driven. We have found that the response mechanism of Health and Food anxieties follow very different paths and that the role of information is not significant in all anxieties. Our results will help policymakers in understanding how to respond to a crisis and optimize policy implementation accordingly. It will further help the scholars understand the difference in the anxieties caused by the pandemic and the layers of responses individuals take in such situations.
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Tutunchi H, Ebrahimi-Mameghani M, Asghari-Jafarabadi M, Farrin N, Tabrizi S, Vaghef-Mehrabany E, Ostadrahimi A. Is the modified household food security survey (HFSS) questionnaire a practical tool for screening food insecurity? Evidence from northwest of Iran. BMC Public Health 2020; 20:883. [PMID: 32513137 PMCID: PMC7282109 DOI: 10.1186/s12889-020-09014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 05/29/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Adequate supplies of food and food security (FS) are the fundamental aspects of human societies, and considered one of the pivotal factors of individual and social health. The aim of the present study was to assess the applicability of the short questionnaire for screening food insecurity (FI) and to evaluate the prevalence of FI in northwest of Iran. METHODS In this study, 550 subjects aged ≥16 years were studied. Three-day dietary records and a short questionnaire were applied to estimate the prevalence of FI in terms of hunger and hidden hunger. The sensitivity, specificity and accuracy of the short questionnaire were assessed. Moreover, the association between the results of the short questionnaire and the criteria that were theoretically related to FI were examined. Data were presented as mean (SD), median (min-max) for the numeric normal and non-normal variables, respectively, and frequency (percent) for categorical variables. The between-group comparisons of variables were done using independent samples t test. P values less than 0.05 were considered statistically significant. RESULTS The prevalence of hunger and hidden hunger was 30.8 and 46.0%, respectively. Overall, 23.2% of the subjects were classified as "food secure". The sensitivity, specificity and accuracy of the short questionnaire in determining hunger were 92.8% (95% CI: 87.3-95.9), 84.2% (95% CI: 79.3-89.3), and 87% (95% CI: 84-90.2), respectively. These values for hidden hunger were 21.6% (95% CI: 15.7-29.9), 92.3% (95% CI: 88.7-99.4), and 53.4% (95% CI: 47.9-59.8), respectively. Our study showed a statistically significant association between FI and socio-economic status. FI significantly enhanced the risk of underweight, while it markedly reduced the risk of overweight and obesity. The average frequency of monthly consumption of meat, dairy products, fruits, vegetables, and rice was significantly lower in food insecure group, while the median frequency of bread consumption was markedly higher in food insecure group. The participants of insecure group were less likely to consume fruits, vegetables, dairy products, rice and meat. CONCLUSIONS FI was frequent in North-west of Iran. The findings indicated that the short questionnaire was a simple, low-cost and practical tool for screening FI in terms of hunger. TRIAL REGISTRATION IR.TBZMED.REC.1397.400.
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Affiliation(s)
- Helda Tutunchi
- Nutrition Research Center, Department of Clinical Nutrition, School of Nutrition & Food Sciences, Tabriz University of Medical Sciences, Tabriz, 5166614711 Iran
| | - Mehrangiz Ebrahimi-Mameghani
- Social Determinant of Health Research Center, School of Nutrition & Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Nazila Farrin
- Nutrition Research Center, School of Nutrition & Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sirous Tabrizi
- Faculty of Education, University of Windsor, Windsor, Canada
| | - Elnaz Vaghef-Mehrabany
- Nutrition Research Center, School of Nutrition & Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Ostadrahimi
- Nutrition Research Center, Department of Clinical Nutrition, School of Nutrition & Food Sciences, Tabriz University of Medical Sciences, Tabriz, 5166614711 Iran
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Kabalo BY, Gebreyesus SH, Loha E, Lindtjørn B. Performance of an adapted household food insecurity access scale in measuring seasonality in household food insecurity in rural Ethiopia: a cohort analysis. BMC Nutr 2019; 5:54. [PMID: 32153967 PMCID: PMC7050847 DOI: 10.1186/s40795-019-0323-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
Background Seasonality poses a considerable food security challenge in Ethiopia. Yet, measuring seasonal variations in food insecurity, particularly the dimension of food access, lacks an adequately validated tool. We therefore evaluated the performance of an adapted Household Food Insecurity Access Scale (HFIAS) to estimate seasonal variations in food insecurity (FI) among subsistence villagers in Ethiopia. Methods We employed a cohort study design using a panel of four repeated measurements taken in June, September, and December in the year 2017, and in March 2018. The study recruited 473 villagers from the drought-affected Wolaita area in southwest Ethiopia. The performance of the HFIAS was evaluated via internal consistency (Chronbach's alpha values) and criterion validation techniques. The set of criteria include: parallelism between affirmative responses to FI questions and wealth strata; dose-response relationship between FI and dietary intake; and also FI severity and household wealth status. Results This study revealed that the HFIAS had satisfactory performance in four repeated measurements. The likelihood of affirmative responses to questions about FI decreased with ascending wealth quintiles. We observed an inverse dose-response relationship between FI and wealth status, and between FI and household dietary diversity. Conclusions The HFIAS showed an acceptable potential for measuring seasonal variations in FI in the study area. Our findings complement efforts to evaluate the scale's applicability in various settings, in order to promote cross-culture monitoring and comparisons. However, it required a careful adaption for contextual and cultural sensitivities.
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Affiliation(s)
- Bereket Yohannes Kabalo
- 1School of Public Health, Wolaita Sodo University, PO Box 126, Wolaita Sodo, Ethiopia.,2School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia.,3Centre for International Health, University of Bergen, Bergen, Norway
| | | | - Eskindir Loha
- 2School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia.,5Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Bernt Lindtjørn
- 3Centre for International Health, University of Bergen, Bergen, Norway
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Farrell P, Thow AM, Schuster S, Vizintin P, Negin J. Access to a Nutritious Diet in Samoa: Local Insights. Ecol Food Nutr 2019; 58:189-206. [PMID: 30957551 DOI: 10.1080/03670244.2019.1582528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The adult obesity prevalence in Samoa is the third highest globally, and diet is a significant contributor. Our study aimed to explore the behavioral and demographic factors which influence diets in Samoa. The most important findings for strategic policy design were: i) cost was the most important reason for food choice, ii) participants reported high rates of consumption of sugary and fatty energy foods - along with high rates of food insecurity, and iii) the food frequency questionnaire findings from our small sample are in line with the existing evidence that the nutrition transition is underway in Samoa.
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Affiliation(s)
- Penny Farrell
- a Sydney School of Public Health , The University of Sydney , Sydney , Australia
| | - Anne Marie Thow
- b Menzies Centre for Health Policy , The University of Sydney , Sydney , Australia
| | - Suzie Schuster
- c Department of Education , National University of Samoa , Apia , Samoa
| | - Pavle Vizintin
- d National University of Samoa Chancellery, Le Papaigalagala Campus , To'omatagi , Samoa
| | - Joel Negin
- a Sydney School of Public Health , The University of Sydney , Sydney , Australia
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Esfarjani F, Mohammadi‐Nasrabadi F, Khaksar R, Roustaee R, Alikhanian H, Ghazi‐Tabatabaei M, Hosseini H. Structural equation modeling of home food safety practice based on the PRECEDE model. J Food Saf 2018. [DOI: 10.1111/jfs.12517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Fatemeh Esfarjani
- Faculty of Nutrition Sciences and Food Technology, Department of Food and Nutrition Policy and Planning Research, National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical Sciences Tehran Iran
| | - Fatemeh Mohammadi‐Nasrabadi
- Faculty of Nutrition Sciences and Food Technology, Department of Food and Nutrition Policy and Planning Research, National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical Sciences Tehran Iran
| | - Ramin Khaksar
- Faculty of Nutrition Sciences and Food Technology, Food Sciences & Technology Department, National Nutrition & Food Technology Research InstituteFaculty of Nutrition Sciences & Food Technology, Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Roshanak Roustaee
- Faculty of Nutrition Sciences and Food Technology, Department of Food and Nutrition Policy and Planning Research, National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical Sciences Tehran Iran
| | - Haleh Alikhanian
- Faculty of Nutrition Sciences and Food Technology, Department of Food and Nutrition Policy and Planning Research, National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical Sciences Tehran Iran
| | | | - Hedayat Hosseini
- Faculty of Nutrition Sciences and Food Technology, Food Sciences & Technology Department, National Nutrition & Food Technology Research InstituteFaculty of Nutrition Sciences & Food Technology, Shahid Beheshti University of Medical Sciences Tehran Iran
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Yeganeh S, Motamed N, NajafpourBoushehri S, Ravanipour M. Assessment of the knowledge and attitude of infants' mothers from Bushehr (Iran) on food security using anthropometric indicators in 2016: a cross-sectional study. BMC Public Health 2018; 18:621. [PMID: 29751757 PMCID: PMC5948760 DOI: 10.1186/s12889-018-5531-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 05/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among the main elements of food security, in terms of food usage, are knowledge and attitude. These are particularly important during the initial two years of a child's life. The present study was conducted in 2016 and aimed to assess the knowledge and attitude of infants' mothers from Bushehr (Iran) towards food security using anthropometric indicators. METHODS The present cross-sectional, descriptive-analytical study was performed on 400 mothers of children aged 1-2 years in Bushehr, Iran. Data were collected using a 20-item knowledge questionnaire (CVR = 0.95, CVI = 0.95, and reliability 0.7), a 26-item attitude questionnaire (CVI = 0.94, CVR = 0.91, and reliability 0.76), and a 16-item Radimer/Cornell questionnaire, which were completed by all mothers. Anthropometric indicators of children, including height-for-age, weight-for-age, and weight-for-height were also measured in accordance with the z-score benchmark of the World Health Organization. RESULTS A positive and significant relationship was found between knowledge and attitude (r = 0.26, P = 0.0001) as well as between knowledge and household food security (r = 0.11, P = 0.02) in complementary feeding. Approximately 26% of the studied children fell under the risk category of overweight to obese. A significant relationship was found between inadequate knowledge of the mothers and height-for-age (OR = 4.87, P = 0.001) and weight-for-height (OR = 2.33, P = 0.04) indices, as well as between the negative attitude of the mothers and weight-for-height index (OR = 2.91, P = 0.03). CONCLUSIONS The knowledge of food security purely relates to the dimension of the household food security of a family and not to the individual/child level of food security. It seems that the knowledge of a mother, as a positive factor, does not support child's food security when the severity of household insecurity triggers the child's hunger and food inaccessibility. Also, inappropriate knowledge and negative attitude towards food security were associated with an increased risk of obesity. Increased weight, in addition to being affected by the knowledge and attitude of the mothers, is probably also influenced by the incorrect conduct of the mothers. Further investigation on this topic is recommended.
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Affiliation(s)
- Sedigheh Yeganeh
- Department of Nursing, School of Nursing and Midwifery, Bushehr University of Medical Sciences, Rishehr Street, PO Box 7518759577, Bushehr, Iran
| | - Niloofar Motamed
- Department of Community Medicine, School of Medicine, Bushehr University of Medical Sciences, Moallem Street, PO Box 7514763448, Bushehr, Iran
| | - Saeid NajafpourBoushehri
- Department of Nutrition, School of Health and Nutrition, Bushehr University of Medical Sciences, Rishehr Street, PO Box 7518759577, Bushehr, Iran
| | - Maryam Ravanipour
- The Persian Gulf Tropical Medicine Research Centre, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran
- Department of Nursing, School of Nursing and Midwifery, Bushehr University of Medical Sciences, Rishehr Street, PO Box 7518759577, Bushehr, Iran
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Jafari F, Ehsani S, Nadjarzadeh A, Esmaillzadeh A, Noori-Shadkam M, Salehi-Abargouei A. Household food insecurity is associated with abdominal but not general obesity among Iranian children. BMC Public Health 2017; 17:350. [PMID: 28431549 PMCID: PMC5399801 DOI: 10.1186/s12889-017-4262-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 04/12/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Childhood obesity is increasing all over the world. Food insecurity is mentioned as a possible risk factor; however, previous studies have led to inconsistent results in different societies while data are lacking for the Middle East. We aimed to investigate the relationship between food insecurity and general or abdominal obesity in Iranian children in a cross-sectional study. METHODS Anthropometric data including height, weight, and waist circumference were measured by trained nutritionists. General and abdominal obesity were defined based on world health organization (WHO) and Iranian reference curves for age and gender, respectively. Radimer/Cornell food security questionnaire was filled by parents. Data about the physical activity of participants, family socio-economic status, parental obesity and data about perinatal period were also gathered using self-administered questionnaires. Logistic regression was incorporated to investigate the association between food insecurity and obesity in crude and multi-variable adjusted models. RESULTS A total of 587 children aged 9.30 ± 1.49 years had complete data for analysis. Food insecurity at household level was significantly associated with abdominal obesity (odds ratio (OR) = 1.54; confidence interval (CI):1.01-2.34, p <0.05) and the relationship remained significant after adjusting for all potential confounding variables (OR = 2.02; CI:1.01-4.03, p <0.05). Food insecurity was associated with general obesity neither in crude analysis and multi-variable adjusted models. CONCLUSIONS The slight levels of food insecurity might increase the likelihood of abdominal obesity in Iranian children and macroeconomic policies to improve the food security are necessary. Large-scale prospective studies, particularly in the Middle East, are highly recommended to confirm our results.
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Affiliation(s)
- Fateme Jafari
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Simin Ehsani
- Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Nadjarzadeh
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Ahmad Esmaillzadeh
- Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahmood Noori-Shadkam
- Department of Pediatrics, Mother and Newborn Health Research Center, Shahid Sadoughi University of Medical Sciences, PO Code 8915173160, Yazd, Iran.
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Barreto D, Shannon K, Taylor C, Dobrer S, Jean JS, Goldenberg SM, Duff P, Deering KN. Food Insecurity Increases HIV Risk Among Young Sex Workers in Metro Vancouver, Canada. AIDS Behav 2017; 21:734-744. [PMID: 27752869 DOI: 10.1007/s10461-016-1558-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010-2013). We examined the independent relationship between YSWs' food insecurity and being pressured into sex without a condom by clients ("client condom refusal"). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23-3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs' particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity.
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Affiliation(s)
- Daniella Barreto
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
- YouthCO HIV & Hep C Society, 205-568 Seymour St, Vancouver, V6B 3J5, Canada
| | - Kate Shannon
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, V5Z 1M9, Canada
| | - Chrissy Taylor
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
| | - Sabina Dobrer
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
| | - Jessica St Jean
- YouthCO HIV & Hep C Society, 205-568 Seymour St, Vancouver, V6B 3J5, Canada
| | - Shira M Goldenberg
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888 University Drive, Burnaby, V5A 1S6, Canada
| | - Putu Duff
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, V5Z 1M9, Canada
| | - Kathleen N Deering
- BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 - 1081 Burrard Street, Vancouver, V6Z 1Y6, Canada.
- Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, V5Z 1M9, Canada.
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Hassen K, Zinab B, Belachew T. Gender and education as predictors of food insecurity among coffee farming households of the Jimma zone, Southwest of Ethiopia. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0116-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Shahraki SH, Amirkhizi F, Amirkhizi B, Hamedi S. Household Food Insecurity Is Associated with Nutritional Status among Iranian Children. Ecol Food Nutr 2016; 55:473-90. [PMID: 27494152 DOI: 10.1080/03670244.2016.1212710] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This cross-sectional study was conducted to determine household food security status and sociodemographic factors influencing it and to examine whether food insecurity of household is a risk factor for underweight, stunting, and thinness in primary school children of Sistan and Baluchestan Province in southeastern Iran. A sample of 610 students aged 7-11 years was selected by a multistage cluster random sampling method during December 2013-May 2014. Using U.S. Department of Agriculture Food Security questionnaire, 42.3% of households showed some degree of food insecurity. Food insecurity was positively associated with household size (p = .002) and number of children per household (p = .001) and negatively associated with mother's and father's education level (p = .005 and p = .042, respectively), father's occupation status, and household income (p < .0001). Children living in food insecure with severe hunger households were 10.13, 10.07, and 4.54 times as likely to be underweight, stunted, and thin, respectively, as counterparts from food secure households. The findings showed food insecurity was prevalent and associated with sociodemographic factors among households with schoolchildren in southeastern Iran. Nutritional status of children was also associated with food security status of their households.
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Affiliation(s)
- Soudabeh Hamedi Shahraki
- a Department of Epidemiology and Biostatistics, Faculty of Public Health , Tehran University of Medical Sciences , Tehran , Iran
| | - Farshad Amirkhizi
- b Department of Nutrition, Faculty of Public Health , Zabol University of Medical Sciences , Zabol , Iran
| | - Behzad Amirkhizi
- c Department of Food Science and Technology, Faculty of Nutrition and Food Sciences , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Sousan Hamedi
- d Department of Surgery, Shahid Beheshti Hospital , Isfahan University of Medical Sciences , Isfahan , Iran
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Gebreyesus SH, Lunde T, Mariam DH, Woldehanna T, Lindtjørn B. Is the adapted Household Food Insecurity Access Scale (HFIAS) developed internationally to measure food insecurity valid in urban and rural households of Ethiopia? BMC Nutr 2015. [DOI: 10.1186/2055-0928-1-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Measuring food and nutrition security: tools and considerations for use among people living with HIV. AIDS Behav 2014; 18 Suppl 5:S490-504. [PMID: 24297517 DOI: 10.1007/s10461-013-0669-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
As an increasing number of countries implement integrated food and nutrition security (FNS) and HIV programs, global stakeholders need clarity on how to best measure FNS at the individual and household level. This paper reviews prominent FNS measurement tools, and describes considerations for interpretation in the context of HIV. There exist a range of FNS measurement tools and many have been adapted for use in HIV-endemic settings. Considerations in selecting appropriate tools include sub-types (food sufficiency, dietary diversity and food safety); scope/level of application; and available resources. Tools need to reflect both the needs of PLHIV and affected households and FNS program objectives. Generalized food sufficiency and dietary diversity tools may provide adequate measures of FNS in PLHIV for programmatic applications. Food consumption measurement tools provide further data for clinical or research applications. Measurement of food safety is an important, but underdeveloped aspect of assessment, especially for PLHIV.
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Household food insecurity: a systematic review of the measuring instruments used in epidemiological studies. Public Health Nutr 2014; 18:877-92. [PMID: 24963759 DOI: 10.1017/s1368980014001050] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To conduct a systematic review aimed at identifying and characterizing the experience-based household food security scales and to synthesize their psychometric properties. DESIGN Search in the MEDLINE, LILACS and SciELO databases, using the descriptors ('food insecurity' OR 'food security') AND ('questionnaires' OR 'scales' OR 'validity' OR 'reliability'). There was no limitation on the period of publication. All articles had their titles and abstracts analysed by two reviewers. The studies of interest were read in their entirety and the relevant information extracted using a standard form. RESULTS The initial bibliographic search identified 299 articles. Of these, the 159 that seemed to meet the criteria for inclusion were read fully. After consultation of the bibliographic references of these articles, twenty articles and five documents were added, as they satisfied the previously determined criteria for inclusion. Twenty-four different instruments were identified; all were brief and of easy application. The majority were devised in the USA. Forty-seven references reported results of psychometric studies. The instruments that presented the highest number of psychometric studies were the Core Food Security Measurement/Household Food Security Survey Module (CFSM/HFSSM) and the Self-Perceived Household Food Security Scale. CONCLUSIONS There are a number of structured scales available in the literature for characterization of household food insecurity. However, despite some psychometric studies already existing about the majority of the instruments, it is observed that, except for the studies of the CFSM/HFSSM, these are still restricted to appraisal of a few aspects of reliability and validity.
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Ali Naser I, Jalil R, Wan Muda WM, Wan Nik WS, Mohd Shariff Z, Abdullah MR. Association between household food insecurity and nutritional outcomes among children in Northeastern of Peninsular Malaysia. Nutr Res Pract 2014; 8:304-11. [PMID: 24944776 PMCID: PMC4058565 DOI: 10.4162/nrp.2014.8.3.304] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 03/06/2014] [Accepted: 03/11/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/OBJECTIVES The purpose of the study was to investigate the relationship between household food insecurity and nutritional status of children in low-income households. A cross sectional study involved a survey of households (n = 223) receiving the financial assistance. SUBJECTS/METHODS Eligible mothers that fulfilled the inclusion criteria such as non-pregnant, non-lactating mothers, aged 18 to 55 years with their youngest children aged 2 to 12 years, were purposively selected. The Radimer/Cornell hunger and food-insecurity instrument was administered and children's height and weight were measured. RESULTS About 16.1% of the households were food secure, while 83.9% experienced some kind of food insecurity. Out of food insecure category, 29.6% households were food insecure, 19.3% women were individual food insecure and 35.0% fell into the child hunger category. Education of the mother (P = 0.047), household size (P = 0.024), number of children (P = 0.024), number of children going to school (P = 0.048), total monthly income (P < 0.001), income per capital (P < 0.001), number of household members contributing to the income (P = 0.018) and food expenditure (P = 0.006) were significant risk factors for household food insecurity. The prevalence of underweight, stunting and wasting in children were 61.0%, 61.4% and 30.6% respectively. Based on multinomial logistic regression, children in food-insecure households were 2.15 times more likely to be underweight and three times to be stunted than children in the food-secure households. CONCLUSIONS The findings suggest that household food insecurity is associated with the nutritional status of the children in the rural area of Northeastern Peninsular Malaysia.
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Affiliation(s)
- Ihab Ali Naser
- Department of Community Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
| | - Rohana Jalil
- Department of Community Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
| | - Wan Manan Wan Muda
- Program of Nutrition and Dietetics, School of Health Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
| | - Wan Suriati Wan Nik
- Program of Nutrition and Dietetics, School of Health Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
| | - Zalilah Mohd Shariff
- Program of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, 43400 Selangor, Malaysia
| | - Mohamed Rusli Abdullah
- Department of Community Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia
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Salarkia N, Abdollahi M, Amini M, Neyestani TR. An adapted Household Food Insecurity Access Scale is a valid tool as a proxy measure of food access for use in urban Iran. Food Secur 2014. [DOI: 10.1007/s12571-014-0335-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Russell J, Flood V, Yeatman H, Mitchell P. Prevalence and risk factors of food insecurity among a cohort of older Australians. J Nutr Health Aging 2014; 18:3-8. [PMID: 24402381 DOI: 10.1007/s12603-013-0339-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE With ongoing national concern about food security, the aim of the study was to estimate the prevalence of food insecurity and to identify associated characteristics in a cohort of older Australians. DESIGN, SETTING AND PARTICIPANTS The Blue Mountains Eye Study is a cohort study of community living participants aged 49 + years. The 12-item food security survey was completed by 3068 participants in the cross sectional study which comprised 2335 survivors from baseline and the recruitment of an additional 1174 eligible residents. MAIN OUTCOME MEASURES Prevalence of self reported food insecurity was calculated and multivariate logistic regression provided odds ratios with 95% confidence intervals to determine risk factors. RESULTS Overall prevalence of food insecurity was 13%. Women (15.7%) compared with men (9.4%) and younger participants, aged <70 years (15.7%) than older participants, ≥70 years (8.4%), were significantly more likely to report being food insecure. Characteristics for reporting food insecurity included participants living in rented accommodation (OR 4.10, 95% CI: 2.83, 5.89) and those living on a pension only (OR 1.90, 95%CI: 1.30, 2.78). CONCLUSIONS A relatively high level of food insecurity among this representative population of older Australians should be an issue of concern for policy makers and health and welfare service providers. Addressing food insecurity should be a priority of integrated national food and nutrition policies and this should in turn inform health and welfare service provision to this vulnerable population.
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Affiliation(s)
- J Russell
- V. Flood, School of Health Sciences, Faculty of Behavioural and Health Sciences, University of Wollongong, Wollongong, NSW 2522, Australia; Ph +61 2 4221 3947; Fax: +61 2 4221 3486;
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Validity of an adapted Household Food Insecurity Access Scale in urban households in Iran. Public Health Nutr 2011; 15:149-57. [PMID: 21806860 DOI: 10.1017/s1368980011001376] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the validity of a locally adapted Household Food Insecurity Access Scale (HFIAS) in the measurement of household food insecurity (FI) in the city of Tehran. DESIGN A cross-sectional study. SETTING Urban households were selected through a systematic cluster sampling method from six different districts of Tehran. The socio-economic status of households was evaluated using a questionnaire by means of interviews. An adapted HFIAS was used to measure FI. Content validity was assessed by an expert panel, and the questionnaire was then tested among ten households for clarity. Criterion validity was assessed by comparing the measure with a number of determinants and consequences of FI. Internal consistency was evaluated by Cronbach's α and exploratory factor analysis. For repeatability, the questionnaire was administered twice to twenty-five households at an interval of 20 d and Pearson's correlation coefficient was calculated. SUBJECTS A total of 416 households. RESULTS In all, 11·8 %, 14·4 % and 17·5 % of the households were severely, moderately and mildly food insecure, respectively. Cronbach's α was 0·855. A significant correlation was observed between the two administrations of the questionnaire (r = 0·895, P < 0·001). Factor analysis of HFIAS items revealed two factors: the first five items as factor 1 (mild-to-moderate FI) and the last four as factor 2 (severe FI). Heads of food-secure households had higher education and higher job position compared with heads of food-insecure households (P < 0·001). Income and expenditure were lower in food-insecure households compared with food-secure households. CONCLUSIONS Adapted HFIAS showed acceptable levels of internal consistency, criterion validity and reliability in assessing household FI among Tehranians.
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Dharod JM, Croom JE. CHILD HUNGER: ITS PREVALENCE AND ASSOCIATION WITH BODY MASS INDEX AND DIETARY INTAKE AMONG SOMALI REFUGEE CHILDREN IN THE UNITED STATES. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1556-4797.2010.01055.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Food insecurity is associated with food consumption patterns and anthropometric measures but not serum micronutrient levels in adults in rural Tanzania. Public Health Nutr 2010; 13:1438-44. [PMID: 20196915 DOI: 10.1017/s1368980010000327] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The purpose of the present paper is to assess the relationship between food insecurity and food consumption patterns, anthropometric measures and serum micronutrient levels in rural Kilimanjaro, Tanzania. DESIGN A population-based cross-sectional study was carried out between March and May of 2005. SETTING Rural Kilimanjaro, Tanzania. SUBJECTS Analysis was restricted to 1014 adults aged 15-44 years with children and complete data. RESULTS A large majority of the participants (91 %) reported some kind of food insecurity. Food insecurity was significantly associated with age, marital status and occupation. Participants reporting food insecurity were significantly less likely to frequently consume animal products, fruits and vegetables compared with participants categorized as food secure. Women categorized as experiencing individual food insecurity had a larger waist circumference than food-secure women (P = 0.026) while the mean BMI of women appeared to decline if they had a child who was food insecure (P = 0.038). There were no observed differences in serum micronutrient levels by food insecurity status. CONCLUSIONS Food insecurity is highly prevalent and associated with food consumption patterns, waist circumference and BMI of women in rural Tanzania. Further studies should apply self-report measures in assessing food insecurity to larger and more diversified populations.
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Rafiei M, Nord M, Sadeghizadeh A, Entezari MH. Assessing the internal validity of a household survey-based food security measure adapted for use in Iran. Nutr J 2009; 8:28. [PMID: 19558676 PMCID: PMC2714524 DOI: 10.1186/1475-2891-8-28] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 06/26/2009] [Indexed: 11/28/2022] Open
Abstract
Background The prevalence of food insecurity is an indicator of material well-being in an area of basic need. The U.S. Food Security Module has been adapted for use in a wide variety of cultural and linguistic settings around the world. We assessed the internal validity of the adapted U.S. Household Food Security Survey Module to measure adult and child food insecurity in Isfahan, Iran, using statistical methods based on the Rasch measurement model. Methods The U.S. Household Food Security Survey Module was translated into Farsi and after adaptation, administered to a representative sample. Data were provided by 2,004 randomly selected households from all sectors of the population of Isfahan, Iran, during 2005. Results 53.1 percent reported that their food had run out at some time during the previous 12 months and they did not have money to buy more, while 26.7 percent reported that an adult had cut the size of a meal or skipped a meal because there was not enough money for food, and 7.2 percent reported that an adult did not eat for a whole day because there was not enough money for food. The severity of the items in the adult scale, estimated under Rasch-model assumptions, covered a range of 6.65 logistic units, and those in the child scale 11.68 logistic units. Most Item-infit statistics were near unity, and none exceeded 1.20. Conclusion The range of severity of items provides measurement coverage across a wide range of severity of food insecurity for both adults and children. Both scales demonstrated acceptable levels of internal validity, although several items should be improved. The similarity of the response patterns in the Isfahan and the U.S. suggests that food insecurity is experienced, managed, and described similarly in the two countries.
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Affiliation(s)
- Morteza Rafiei
- Medical Education Research Center of Isfahan University of Medical Sciences, Isfahan, Iran.
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