Valerie Tarasuk

Measuring the wole or the parts

UNLABELLED The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure was developed to evaluate disability and symptoms in single or multiple disorders of the upper limb at one point or at many points in time. PURPOSE The purpose of this study was to evaluate the reliability, validity, and responsiveness of the DASH in a group of diverse patients and to compare the results with those obtained with joint-specific measures. METHODS Two hundred patients with either wrist/hand or shoulder problems were evaluated by use of questionnaires before treatment, and 172 (86%) were re-evaluated 12 weeks after treatment. Eighty-six patients also completed a test-retest questionnaire three to five days after the initial (baseline) evaluation. The questionnaire package included the DASH, the Brigham (carpal tunnel) questionnaire, the SPADI (Shoulder Pain and Disability Index), and other markers of pain and function. Correlations or t-tests between the DASH and the other measures were used to assess construct validity. Test-retest reliability was assessed using the intraclass correlation coefficient and other summary statistics. Responsiveness was described using standardized response means, receiver operating characteristics curves, and correlations between change in DASH score and change in scores of other measures. Standard response means were used to compare DASH responsiveness with that of the Brigham questionnaire and the SPADI in each region. RESULTS The DASH was found to correlate with other measures (r > 0.69) and to discriminate well, for example, between patients who were working and those who were not (p<0.0001). Test-retest reliability (ICC = 0.96) exceeded guidelines. The responsiveness of the DASH (to self-rated or expected change) was comparable with or better than that of the joint-specific measures in the whole group and in each region. CONCLUSIONS Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH. This study also demonstrated that the DASH had validity and responsiveness in both proximal and distal disorders, confirming its usefulness across the whole extremity.

Addressing Current Criticism Regarding the Value of Self-Report Dietary Data

Recent reports have asserted that, because of energy underreporting, dietary self-report data suffer from measurement error so great that findings that rely on them are of no value. This commentary considers the amassed evidence that shows that self-report dietary intake data can successfully be used to inform dietary guidance and public health policy. Topics discussed include what is known and what can be done about the measurement error inherent in data collected by using self-report dietary assessment instruments and the extent and magnitude of underreporting energy compared with other nutrients and food groups. Also discussed is the overall impact of energy underreporting on dietary surveillance and nutritional epidemiology. In conclusion, 7 specific recommendations for collecting, analyzing, and interpreting self-report dietary data are provided: (1) continue to collect self-report dietary intake data because they contain valuable, rich, and critical information about foods and beverages consumed by populations that can be used to inform nutrition policy and assess diet-disease associations; (2) do not use self-reported energy intake as a measure of true energy intake; (3) do use self-reported energy intake for energy adjustment of other self-reported dietary constituents to improve risk estimation in studies of diet-health associations; (4) acknowledge the limitations of self-report dietary data and analyze and interpret them appropriately; (5) design studies and conduct analyses that allow adjustment for measurement error; (6) design new epidemiologic studies to collect dietary data from both short-term (recalls or food records) and long-term (food-frequency questionnaires) instruments on the entire study population to allow for maximizing the strengths of each instrument; and (7) continue to develop, evaluate, and further expand methods of dietary assessment, including dietary biomarkers and methods using new technologies.

Household Food Insecurity in Canada

Food insecurity became recognized as a problem in Canada in the early 1980s when community groups began to establish charitable food assistance programs in response to concerns that people in their midst were going hungry. Since then, the number of Canadians affected by food insecurity has grown, but food charity remains the primary response. Childrens feeding programs, prenatal nutrition programs, and a number of smaller scale, community development programs have also been instituted. However, growing recognition of the limitations of these efforts to address food problems rooted in chronically inadequate household incomes has led to a renewed emphasis on advocacy for social policy reforms.

The relationship between low income and household food expenditure patterns in Canada

OBJECTIVES To compare food expenditure patterns between low-income households and higher- income households in the Canadian population, and to examine the relationship between food expenditure patterns and the presence or absence of housing payments among low-income households. DESIGN Secondary data analysis of the 1996 Family Food Expenditure Survey conducted by Statistics Canada. SETTING Sociodemographic data and 1-week food expenditure data for 9793 households were analysed. SUBJECTS Data were collected from a nationally representative sample drawn through stratified multistage sampling. Low-income households were identified using Statistics Canadas Low Income Measures. RESULTS Total food expenditures, expenditures at stores and expenditures in restaurants were lower among low-income households compared with other households. Despite allocating a slightly greater proportion of their food dollars to milk products, low-income households purchased significantly fewer servings of these foods. They also purchased fewer servings of fruits and vegetables than did higher-income households. The effect of low income on milk product purchases persisted when the sample was stratified by education and expenditure patterns were examined in relation to income within strata. Among low-income households, the purchase of milk products and meat and alternatives was significantly lower for households that had to pay rents or mortgages than for those without housing payments. CONCLUSIONS Our findings indicate that, among Canadian households, access to milk products and fruits and vegetables may be constrained in the context of low incomes. This study highlights the need for greater attention to the affordability of nutritious foods for low-income groups.

A Critical Examination of Community-Based Responses to Household Food Insecurity in Canada

Over the past two decades, household food insecurity has emerged as a significant social problem and serious public health concern in the “First World.” In Canada, communities initially responded by establishing ad hoc charitable food assistance programs, but the programs have become institutionalized. In the quest for more appropriate and effective responses, a variety of community development programs have recently been initiated. Some are designed to foster personal empowerment through self-help and mutual support; others promote community-level strategies to strengthen local control over food production. The capacity of current initiatives to improve household food security appears limited by their inability to overcome or alter the poverty that under-pins this problem. This may relate to the continued focus on food-based responses, the ad hoc and communitybased nature of the initiatives, and their origins in publicly funded health and social service sectors.

Socio-demographic influences on food purchasing among Canadian households

Objective:To characterize the relationships between selected socio-demographic factors and food selection among Canadian households.Design:A secondary analysis of data from the 1996 Family Food Expenditure survey was conducted (n=10 924). Household food purchases were classified into one of the five food groups from Canadas Food Guide to Healthy Eating. Parametric and non-parametric modelling techniques were employed to analyse the effects of household size, composition, income and education on the proportion of income spent on each food group and the quantity purchased from each food group.Results:Household size, composition, income and education together explained 21–29% of the variation in food purchasing. Households with older adults spent a greater share of their income on vegetables and fruit (P<0.0001), whereas households with children purchased greater quantities of milk products (P<0.0001). Higher income was associated with purchasing more of all food groups (P<0.0001), but the associations were nonlinear, with the strongest effects at lower income levels. Households where the reference person had a university degree purchased significantly more vegetables and fruit, and less meat and alternatives and ‘other’ foods (P<0.0001), relative to households with the lowest education level.Conclusions:Household socio-demographic characteristics have a strong influence on food purchasing, with the purchase of vegetables and fruit being particularly sensitive. Results reinforce concerns about constraints on food purchasing among lower income households. Furthermore, the differential effects of income and education on food choice need to be considered in the design of public health interventions aimed at altering dietary behaviour.

Hunger in Canada

Hunger is defined as the inability to obtain sufficient, nutritious, personally acceptable food through normal food channels or the uncertainty that one will be able to do so. After the depression of the 1930s, widespread concerns about hunger in Canada did not resurface until the recession of the early 1980s when the demand for food assistance rose dramatically. The development of an ad hoc charitable food distribution system ensued and by 1992, 2.1 million Canadians were receiving food assistance. In the absence of national monitoring systems, this remains the best available estimate of the prevalence of hunger. Hunger appears to be linked to poverty, unemployment, and numbers of people receiving social assistance. Although the Canadian social security system has traditionally been characterized by government-run universal and targeted programs designed to address income issues, hunger raises concerns about the current “safety net”. The primary response to hunger has been the proliferation of food banks, the agencies at the heart of the charitable food assistance system. On a smaller scale, community-based programs and advocacy initiatives have emerged. Nonetheless, the demand for food assistance continues to rise. The trend raises questions about future directions for social policy in Canada and concerns about the development of a two-tiered food distribution system—one for those with adequate money and one for the poor.

Housing Circumstances are Associated with Household Food Access among Low-Income Urban Families

Household food insecurity is a pervasive problem in North America with serious health consequences. While affordable housing has been cited as a potential policy approach to improve food insecurity, the relationship between conventional notions of housing affordability and household food security is not well understood. Furthermore, the influence of housing subsidies, a key policy intervention aimed at improving housing affordability in Western countries, on food insecurity is unclear. We undertook a cross-sectional survey of 473 families in market rental (n = 222) and subsidized (n = 251) housing in high-poverty urban neighborhoods to examine the influence of housing circumstances on household food security. Food insecurity, evident among two thirds of families, was inversely associated with income and after-shelter income. Food insecurity prevalence did not differ between families in market and subsidized housing, but families in subsidized housing had lower odds of food insecurity than those on a waiting list for such housing. Market families with housing costs that consumed more than 30% of their income had increased odds of food insecurity. Rent arrears were also positively associated with food insecurity. Compromises in housing quality were evident, perhaps reflecting the impact of financial constraints on multiple basic needs as well as conscious efforts to contain housing costs to free up resources for food and other needs. Our findings raise questions about current housing affordability norms and highlight the need for a review of housing interventions to ensure that they enable families to maintain adequate housing and obtain their other basic needs.

Assessing the relevance of neighbourhood characteristics to the household food security of low-income Toronto families

OBJECTIVE Although the sociodemographic characteristics of food-insecure households have been well documented, there has been little examination of neighbourhood characteristics in relation to this problem. In the present study we examined the association between household food security and neighbourhood features including geographic food access and perceived neighbourhood social capital. DESIGN Cross-sectional survey and mapping of discount supermarkets and community food programmes. SETTING Twelve high-poverty neighbourhoods in Toronto, Ontario, Canada. SUBJECTS Respondents from 484 low-income families who had children and who lived in rental accommodations. RESULTS Food insecurity was pervasive, affecting two-thirds of families with about a quarter categorized as severely food insecure, indicative of food deprivation. Food insecurity was associated with household factors including income and income source. However, food security did not appear to be mitigated by proximity to food retail or community food programmes, and high rates of food insecurity were observed in neighbourhoods with good geographic food access. While low perceived neighbourhood social capital was associated with higher odds of food insecurity, this effect did not persist once we accounted for household sociodemographic factors. CONCLUSIONS Our findings raise questions about the extent to which neighbourhood-level interventions to improve factors such as food access or social cohesion can mitigate problems of food insecurity that are rooted in resource constraints. In contrast, the results reinforce the importance of household-level characteristics and highlight the need for interventions to address the financial constraints that underlie problems of food insecurity.

The Relationship between Food Banks and Household Food Insecurity among Low-Income Toronto Families

Étant donné l’absence de politiques publiques précises face au problème de l’insécurité alimentaire des ménages au Canada, les banques alimentaires restent la solution la plus courante, malgré les questions qui se posent au sujet de leur efficacité. En effet, parmi 371 familles à faible revenu de Toronto que nous avons interviewées dans le cadre de cette étude, 75 % avaient vécu de l’insécurité alimentaire, mais seulement 23 % avaient eu recours à une banque alimentaire ; et, pour la plupart des utilisateurs de banque alimentaire, l’insécurité alimentaire était un problème chronique grave. Parmi les raisons qui font que les familles vivant de l’insécurité alimentaire n’ont pas recours à une banque alimentaire, notons une certaine réticence à demander la charité, mais aussi un accès difficile à ces banques pour diverses raisons. Ces résultats remettent en question le rôle que les gouvernements fédéral, provinciaux et territoriaux semblent donner aux organismes caritatifs comme moyens de réduire l’insécurité alimentaire, et soulignent la nécessité de politiques publiques claires en cette matière.