An evaluation of the U.S. Department of Agriculture food security measure with generalized linear mixed models

Over the last decade, new information has been developed and collected to measure the extent of food insecurity and hunger in the United States. Common measurement of the phenomenon of hunger and food insecurity has become possible through efforts of the U.S. Department of Agriculture (USDA) to develop a set of survey questions that can be used to obtain estimates of the prevalence and severity of food insecurity. We evaluated the measurement of food insecurity and the effect of household variables on measured food insecurity. The effects of demographic and survey-specific variables on the food insecurity/hunger scale were evaluated using a generalized linear model with mixed effects. Data came from the 1995, 1997 and 1999 Food Security Module of the Current Population Survey. The results generally validated the model currently used by the USDA. In addition, our approach made it possible to consider the effect of demographics and several survey design variables on food security among measurably food-insecure households, as well as interactions between these factors and the food security questions. The analysis of the expanded model with the 1995 data found results similar to those reported based on the Rasch model used by the USDA. Even though the sample size was reduced and a number of screening and questionnaire changes were introduced in 1997 and 1999, the results for those years appear mostly unchanged and confirm the robustness of the scale in measuring food insecurity. There is some evidence that interpretation of questions may vary among different demographic groups.     

Differential response patterns affect food-security prevalence estimates for households with and without children

To produce national prevalence estimates for "food insecurity" and "food insecurity with hunger," the USDA uses a battery of 18 survey items about symptoms of food-related hardship. Ten items refer to adults in the household, while 8 items refer to children in the household and hence are not asked of households without children. To equate food-security status in households with and without children, the USDA uses a statistical model from item response theory, known as the Rasch model. This model requires an assumption that adult-referenced items have the same severity calibrations for all households, including households with and without children. However, empirical estimates from the 2000 Current Population Survey showed significantly different severity calibrations for households with and without children. These differences have implications for observable response patterns. Holding constant the number of affirmative responses to adult-referenced items, households with children were more likely to respond that they "worried food would run out," and households without children were more likely to be unable to afford "balanced meals." In light of such differences, the Rasch model cannot be used to equate the food-security status of households with and without children. One potential solution would be to estimate household food security by using the same battery of adult-referenced survey items for all households.     

Choice of instrument influences relations between food insecurity and obesity in Latino women

BACKGROUND: The results of studies examining food insecurity and obesity in adults are conflicting. Discrepancies could be due to the use of different instruments or to cultural factors that influence response patterns. OBJECTIVE: The goal was to examine the relation of food insecurity to weight status in low-income Latino women. DESIGN: A cross-sectional survey was conducted among 559 low-income Latino women selected by convenience sampling. The survey included the 18-item US Household Food Security Scale, 2 items related to current and past food insufficiency, demographic information, and measured heights and weights. Data were collected between February and May 2001 in 6 California counties. The main outcomes were frequency of overweight and obesity, defined by a body mass index (in kg/m(2)) of 25-29.9 (overweight) and >30 (obese). Data analysis included analysis of variance, Mantel-Haenszel chi-square test, and logistic regression. RESULTS: The prevalence of food insecurity was 50-60%, and that of obesity was 37.4%. Controlling for years spent in the United States, per capita income, and parity, food insecurity with hunger, measured by the 10-item adult scale of the Food Security Scale, was significantly related to obesity (OR: 1.98; 95% CI: 1.14, 3.53). No interaction between years spent in the United States and current food insecurity was observed. Current food insufficiency, as measured by a single item, was not related to obesity. However, severe past food insufficiency was related to obesity in the US-born population only. CONCLUSION: Food insecurity appears to be related to obesity in Latino women, but choice of instruments might influence the results.     

Food Insecurity and Food Label Comprehension among Libyan Migrants in Australia

Food security among migrants and refugees remains an international public health issue. However, research among ethnic minorities in Australia is relatively low. This study explored the factors that influence the understanding of food labelling and food insecurity among Libyan migrants in Australia. An online survey was completed by 271 Libyan migrant families. Data collection included the 18-item US Household Food Security Survey Module (for food security) and a question from the Food Standards Australia New Zealand Consumer Label Survey (for food labelling comprehension). Multivariable logistic regression modelling was utilised to identify the predictors of food label comprehension and food security. Food insecurity prevalence was 72.7% (n = 196) while 35.8% of families (n = 97) reported limited food label understanding. Household size, food store location, and food affordability were found to be significantly related to food insecurity. However, gender, private health insurance, household annual income, education, and food store type and location were found to be significantly related to food labelling comprehension. Despite the population’s high educational status and food labelling comprehension level, food insecurity remained an issue among the Libyan migrants. Policy makers should consider the incorporation of food label comprehension within a broader food security approach for migrants.     

Comparison of a qualitative and a quantitative approach to developing a household food insecurity scale for Bangladesh

This paper compares a qualitative and a quantitative (Rasch) method of item assessment for developing the content of a food insecurity scale for Bangladesh. Data are derived from the Bangladesh Food Insecurity Measurement and Validation Study, in which researchers collected 2 rounds of ethnographic information and 3 rounds of conventional household survey data between 2001 and 2003. The qualitative method of scale development relied on content experts and respondents themselves to evaluate household food insecurity items generated through ethnographic research. The quantitative method applied the Rasch model to assess the fit of the same items using representative survey data. The Rasch model was then used to test for differential item functioning (DIF) across diverse demographic and geographic subgroups. The qualitative assessment flagged and discarded 10 items, leaving 13. The Rasch assessment of infit and outfit flagged 3 items, and the Rasch DIF test discarded another 10 items, leaving a total of 10 items in the Rasch-derived scale. The 2 scales contained 8 of the same items. The qualitatively and quantitatively derived scales were highly correlated (r = 0.96, P < 0.01), and the 2 methods located 90% of households in the same food insecurity tercile. This convergence lends added confidence to the use of either scale for identifying food-insecure households in different regions of Bangladesh. Multiple methods should continue to be applied in a systematic and transparent way to lend additional credence to the results when they converge and to pinpoint directions for further clarification where they do not.     

Understanding the experience of food insecurity by elders suggests ways to improve its measurement

A full conceptualization of the elderly food insecurity experience has been lacking, leading to limitations in the definition and measurement of food insecurity in elders. Based on the qualitative analysis of two in-depth interviews 6 mo apart with each of 53 low income urban elders, using principles of grounded theory, the experience of elderly food insecurity was shown to have four components: quantitative, qualitative, psychological and social. The inability to obtain the right foods for health is a new element specific to elders. Common to each of these components were dimensions of severity, time and compromised food choice. Although money is a major cause of food insecurity, elders sometimes have enough money for food but are not able to access food because of transportation or functional limitations, or are not able to use food (i.e., not able to prepare or eat available food) because of functional impairments and health problems. These findings suggest that augmentation of the U.S. Household Food Security Survey Module (FSSM), a national measure of food insecurity based on research in younger persons, may result in more accurate assessments for elders. We developed 14 new items for possible augmentation and administered them by telephone to these same elders along with the FSSM. Elders were independently classified according to food insecurity status based on their experience from the in-depth interviews, and these definitive criteria were used to evaluate the new and existing items. The results suggest that "couldn't afford right foods for health" and two policy-relevant immediate causes, "couldn't get the food I needed" and possibly "unable to prepare," should be added, although further testing is needed.     

High Prevalence of Food Insecurity and Hunger in Households in the Rural Lower Mississippi Delta

CONTEXT: Residents of the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi are at risk for food insecurity since a high proportion of the population live in households with incomes below the poverty level and have reduced access to food and decreased availability of a variety of foods. However, the magnitude of the problem is unknown because presently only nationwide and state estimates of food insecurity are available. PURPOSE: This study was conducted by the Lower-Mississippi Delta Nutrition Intervention Research Consortium to determine the prevalence of household food insecurity, identify high-risk subgroups in the Lower Delta, and compare to national data. METHODS: A 2-stage stratified cluster sample representative of the population in 36 counties in the Lower Delta was selected using list-assisted random digit dialing telephone methodology. A cross-sectional telephone survey of 1662 households was conducted in 18 of the 36 counties using the US Food Security Survey Module. FINDINGS: Twenty-one percent of Lower Delta households were food insecure, double the 2000 nationwide rate of 10.5%. Within the Lower Delta, groups with the highest rates of food insecurity were households with income below $15,000, black households, and households with children. The prevalence of hunger in Delta households with white children was 3.2% and in households with black children was 11.0%, compared to nationwide estimates of 0.3% and 1.6%. CONCLUSIONS: The Lower Mississippi Delta is characterized by a high prevalence of food insecurity and hunger. Future efforts to identify the household and community determinants of food insecurity to reduce its high prevalence are indicated.     

The core food security module scale measure is valid and reliable when used with Asians and Pacific Islanders

The Core Food Security Measure (CFSM) is used nationally to assess the extent and severity of household food insecurity in the previous 12 mo due to inadequate money for food. Both a scale measure and a categorical measure were developed from a national cross-sectional sample. The objective of this research was to determine whether the CFSM scale measure is a reliable and valid food security measure for use in Hawaii, where at least 50% of the population is of Asian or Pacific Islander descent. We completed an independent assessment of the robustness of the internal scale construct validity of the CSFM scale measure and hierarchical order of items using the same Rasch methods used previously to develop the CSFM. From a sample of 1664 respondents, data from 362 were used in the Rasch analysis. Item goodness-of-fit statistics indicated that responses to the "adults cut the size or skip meals" item and its follow-up item were redundant [outfit mean-square residual (MnSq) = 0.6, z = -2]. Responses to the "(un)able to eat balanced meals" item were erratic (outfit MnSq = 2.1, z = 2). Findings pertaining to goodness-of-fit of the respondents indicated an acceptable rate of misfit (4.7%). Rate of misfit did not vary with family status or with any ethnic group except the Samoans. Overall, the CFSM scale measure fit as well with the Hawaii data as it did with national data, although identified limitations may affect food security monitoring and research.     

Factors Associated with Food Insecurity in Households of Public School Students of Salvador City,Bahia, Brazil

This cross-sectional study was conducted to find out the factors associated with food insecurity (FI) in households of the students aged 6-12 years in public schools of Salvador city, Bahia, Brazil. The study included 1,101 households. Food and nutritional insecurity was measured using the Brazilian Food Insecurity Scale (BFIS). Data on socioeconomic and demographic characteristics as well as environmental and housing conditions were collected during the interviews conducted with the reference persons. Multivariate polytomous logistic regression was used in assessing factors associated with food insecurity. We detected prevalence of food insecurity in 71.3% of the households. Severe and moderate forms of FI were diagnosed in 37.1% of the households and were associated with: (i) female gender of the reference person in the households (OR 2.21, 95% CI 1.47-3.31); (ii) a monthly per-capita income below one-fourth of the minimum wage (US$ 191,73) (OR 2.63, 95% CI 1.68-4.08); (iii) number of residents per bedroom below 3 persons (OR 1.91, 95% CI 1.23-2.96); and (iv) inadequate housing conditions (OR 1.84, 95% CI 1.12-4.49). Socioeconomic inequalities determine the factors associated with FI of households in Salvador, Bahia. Identifying vulnerabilities is necessary to support public policies in reducing food insecurity in the country. The results of the present study may be used in re-evaluating strategies that may limit the inequalities in school environment.Key words: Food insecurity, Socioeconomic inequalities, Students, Brazil     

The prevalence of food insecurity is high and the diet quality poor in Inuit communities

Indigenous peoples experience a disproportionate burden of food insecurity and the Arctic is no exception. We therefore evaluated the prevalence, socio-demographic, and dietary correlates of food insecurity in the most comprehensive assessment of food insecurity in Arctic Canada. A cross-sectional survey of 1901 Inuit households was conducted in 2007-2008. Measurements included food insecurity, 24-h dietary recalls, socio-demographics, and anthropometry. Food insecurity was identified in 62.6% of households (95% CI = 60.3-64.9%) with 27.2% (95% CI = 25.1-29.3%) of households severely food insecure. The percent with an elevated BMI, waist circumference, and percent body fat was lower among individuals from food insecure households compared to food secure households (P ≤ 0.001). Adults from food insecure households had a significantly lower Healthy Eating Index score and consumed fewer vegetables and fruit, grains, and dairy products, and consumed a greater percent of energy from high-sugar foods than adults from food secure households (P ≤ 0.05). Food insecurity was associated with household crowding, income support, public housing, single adult households, and having a home in need of major repairs (P ≤ 0.05). The prevalence of having an active hunter in the home was lower in food insecure compared to food secure households (P ≤ 0.05). Food insecurity prevalence is high in Inuit communities, with implications for diet quality that over the long-term would be anticipated to exacerbate the risk of diet-related chronic diseases. Actions are required to improve food security that incorporate the traditional food system and healthy market food choices.     

Child-specific food insecurity and its sociodemographic and nutritional determinants among Iranian schoolchildren

Despite strong evidence of the prevalence of food insecurity in adults and households with children in different areas of Iran, the prevalence of child-specific food insecurity in Iran and especially in Tabriz has not been evaluated. Therefore, the objective of the current study is to evaluate the prevalence of food insecurity in schoolchildren and to identify its social, demographic, and nutritional determinants in Tabriz, Iran. This cross-sectional study was conducted between April and September 2014 among 330 schoolchildren aged 7–11 years comprising 170 boys and 160 girls from ten public schools in Tabriz, Iran. Demographic and socioeconomic factors had been obtained from participants. Food security status was assessed by an eight-item U.S. Department of Agriculture (USDA) Food Security Module previously validated for use in Iran. Dietary information was obtained by a food frequency questionnaire (FFQ). In our findings, the prevalence of food insecurity among children was 30% with 29.1% being low food secure and 0.9% being very low food secure. Mean weight for age Z-score (WAZ) in the food insecure group was significantly lower than in the food secure group. The prevalence of food insecurity was more prevalent in boys (p = .006). Food insecure children had a significantly lower intake of energy, carbohydrate, protein, and meat (p < .001) and higher prevalence of wasting compared with their counterparts in the food secure group (p = .004). These results suggest a proportionally high prevalence of food insecurity in schoolchildren in Tabriz and its significant association with poor nutritional status and dietary habits. Our findings also ensures the necessity of nutritional support programs and nutritional education in Iranian low-income families to improve their overall health.     

Food Insecurity and Its Sociodemographic Correlates among Afghan Immigrants in Iran

The study determined the prevalence of food insecurity and its sociodemographic determinants among Afghan immigrants in two major cities of Iran. This cross-sectional study was conducted on a sample of 310 adult females from immigrant Afghan households in Tehran (n=155) and Mashhad (n=155), who were recruited through multistage sampling. Data were collected through face-to-face interviews, using a questionnaire. Food security was measured by a locally-adapted Household Food Insecurity Access Scale. More than 60% suffered from moderate-to-severe food insecurity, 37% were mildly food-insecure while about 23% were food-secure. Food insecurity was significantly more prevalent in female-headed households, households whose head and spouse had lower level of education, belonged to the Sunni sect, and those with illegal residential status, unemployment/low job status, not owning their house, low socioeconomic status (SES), and living in Mashhad. Prevalence of food insecurity was relatively high among Afghan immigrants in Iran. This calls for the need to develop community food security strategies for ensuring their short- and long-term health.Key words: Afghan, Immigrants, Food insecurity, Sociodemographic determinants, Iran     

Food Insecurity Prevalence,Severity and Determinants in Australian Households during the COVID-19 Pandemic from the Perspective of Women

This study aimed to describe the prevalence, severity and socio-demographic predictors of food insecurity in Australian households during the COVID-19 pandemic in 2020, from the perspective of women. A cross-sectional online survey of Australian (18–50 years) women was conducted. The survey collected demographic information and utilised the 18-item US Department of Agriculture Household Food Security Survey Module and the Kessler Psychological Distress Scale (K10). A multivariable regression was used to identify predictors of food security status. In this cohort (n = 1005), 19.6% were living in households experiencing food insecurity; with 11.8% experiencing low food-security and 7.8% very low food-security. A further 13.7% of households reported marginal food-security. Poor mental health status (K10 score ≥ 20) predicted household food insecurity at all levels. The presence of more than three children in the household was associated with low food-security (OR 6.24, 95% CI: 2.59–15.03). Those who were renting were 2.10 (95% CI: 1.09–4.05) times likely to experience very low food-security than those owning their own home. The COVID-19 pandemic may have contributed to an increased prevalence of household food insecurity. This study supports the need for a range of responses that address mental health, financial, employment and housing support to food security in Australia.     

Frequency and duration of food insecurity and hunger in US households

OBJECTIVE: This study examines the extent to which food insecurity and hunger in US households are occasional, recurring, or frequent/chronic. Design/Variables: The federal food security scale measures the severity of food insecurity in surveyed households and classifies households as to their food security status during the previous year. The Current Population Survey Food Security Supplement (CPS-FSS) collects the data elements used to calculate the food security scale. Supplementary data on the frequency of occurrence of the behaviors and experiences comprising the food security scale are also collected by the CPS-FSS, but most of this information is not included in the food security scale. This study analyzes these supplementary data along with the food security scale and its constituent items using data from the Food Security Supplement of the nationally representative CPS conducted in August 1998. RESULTS: About two thirds of households classified as food insecure by the federal food security scale experience the condition as recurring, and around one fifth experience these conditions as frequent or chronic. The monthly prevalence of hunger is about 60% of the annual prevalence, and the daily prevalence is about 13% to 18% of the annual prevalence. CONCLUSIONS AND IMPLICATIONS: Nutritionists can use these findings to enhance the informative value of food insecurity and hunger statistics from national, state, and local surveys when interpreting them to policy makers and to the general public.     

Prevalence of food insecurity among women in northern Jordan

Food insecurity--not having sufficient quantities of good-quality foods--is inversely related to physical and mental health and directly related to poor dietary intake. The objectives of this research were to (a) measure the prevalence of food insecurity among women in northern Jordan, (b) study the socioeconomic factors associated with an increased risk of food insecurity, and (c) investigate the relationship between household food insecurity and women's reported body-weight. This cross-sectional study was conducted using an interview-based questionnaire. In total, 500 women were interviewed in the waiting rooms of the outpatient clinics of two major public hospitals in northern Jordan. Food insecurity was assessed using the short form of the U.S. food security survey module. The prevalence of food insecurity was 32.4%. Income below the poverty-line, illiteracy, unemployment, rented housing, and woman heading the household were among the socioeconomic factors that increased the probability of food insecurity. No evidence was found to support the relationship between obesity and food insecurity. Except grains, food-insecure women with hunger had lower intake of all food-groups. This study demonstrated that the problem of food insecurity is present in Jordan. Food-insecure women with hunger are at a risk of malnutrition. Interventions that target reduction of the factors associated with food insecurity are necessary.     

Food insecurity among Australian children: potential determinants, health and developmental consequences

Children in food-insecure households may be at risk of poor health, developmental or behavioural problems. This study investigated the associations between food insecurity, potential determinants and health and developmental outcomes among children. Data on household food security, socio-demographic characteristics and children's weight, health and behaviour were collected from households with children aged 3-17 years in socioeconomically disadvantaged suburbs by mail survey using proxy-parental reports (185 households). Data were analysed using logistic regression. Approximately one-in-three households (34%) were food insecure. Low household income was associated with an increased risk of food insecurity [odds ratio (OR), 16.20; 95% confidence interval (CI), 3.52-74.47]. Children with a parent born outside of Australia were less likely to experience food insecurity (OR, 0.42; 95% CI, 0.19-0.93). Children in food-insecure households were more likely to miss days from school or activities (OR, 3.52; 95% CI, 1.46-8.54) and were more likely to have borderline or atypical emotional symptoms (OR, 2.44; 95% CI, 1.11-5.38) or behavioural difficulties (OR, 2.35; 95% CI, 1.04-5.33). Food insecurity may be prevalent among socioeconomically disadvantaged households with children. The potential developmental consequences of food insecurity during childhood may result in serious adverse health and social implications.     

Food Insecurity and Age at Menarche in Tampa Bay,Florida

ABSTRACT

The aim of this study was to assess whether household food insecurity is associated with delayed or early menarche among girls in the United States. Thirty-six dyadic household interviews were conducted with mothers and adolescent girls. The interviews included a socio-demographic survey, the USDA Six-Item Short Form Household Food Security Survey Module, anthropometric measurements, and the self-administered Youth-Adolescent Food Frequency Questionnaire. Using non-parametric quantitative analyses, we examined the associations among food insecurity, anthropometrics, diet, and age at menarche. Cox Proportional Hazards Models were used to evaluate the odds of menarche based on household food insecurity. Food insecurity significantly predicted earlier time to menarche. Food insecure girls were 4.38 times more likely to experience menarche at earlier ages when compared to food secure girls (HR = 4.38, p = .04). Furthermore, the hazard of menarche increased by 25% for each unit increase in food insecurity (OR = 1.253, p = .027). The findings suggest that household food insecurity is associated with earlier ages of menarche among girls in this sample. Early menarche has been associated with adult chronic disease risk. Thus, these findings propose that food security initiatives may be used to reduce the prevalence and health consequences of early-onset puberty.     

Food Insecurity and Subjective Wellbeing Among Arab Youth Living in Varying Contexts of Political Instability

Purpose: To investigate associations between food insecurity experience and subjective wellbeing in Arab youth, across different political stability settings.Methods: Data from the Gallup World Poll (2014–2015) were extracted for youth aged 15–24 years living in 19 Arab countries (n?=?8,162). Food insecurity was assessed using the Food Insecurity Experience Scale. Life Evaluation Score and Affect Balance were used as indicators of youth wellbeing. The 2014 Political Stability and Absence of Violence and Terrorism score was used to stratify Arab countries into three categories; high, medium, and low political stability. Multivariable regressions were performed to explore the relationship between food insecurity and wellbeing indices adjusting for socio-demographic and socio-economic factors, across different political stability settings.Results: The prevalence of food insecurity among Arab youth ranged between 3.1% in Lebanon to 91.3% in South Sudan. Food insecurity (moderate and severe) was negatively correlated with life evaluation (β: ?0.74 for moderate food insecurity; ?1.28 for severe food insecurity, p-value <0.001), and affect balance (β: ?22.03 for moderate food insecurity; ?33.88 for severe food insecurity, p-value <0.001). These results were consistent across political stability groups, independently from socio-demographic and socio-economic factors.Fewer factors were correlated with life evaluation and affect balance in low as compared to medium and high political stability settings.Conclusions: Food insecurity is an independent risk factor for Arab youth wellbeing. Efforts to improve youth wellbeing can be channelled through food security interventions.     

Recent advances provide improved tools for measuring children's food security

Food security, or consistent access to adequate food, is important for children's health and development. The first U.S. assessment of children's food security was conducted in 1995 using the U.S. Household Food Security Scale, a measure based on 18 survey questions developed by the USDA and the U.S. Department of Health and Human Services. Three recent developments have improved on that early measurement method and expanded the scope for assessing children's food security. 1) Development of the Children's Food Security Scale, based only on the 8 child-referenced questions in the U.S. Household Food Security Survey Module, improved the measurement of children's food security and was found to have excellent internal validity. 2) Questions indicating severe ranges of food insecurity and referenced to an individual child (answered by an adult proxy) were tested in a national health survey and found to have acceptable internal validity. 3) A food security measure based on a self-administered module was validated (internal validation only) for children > or =12 y of age. Children's food security is correlated with that of adults in the same household, but the relation depends on the ages of children, such that separate measures of children's and adults' food security appear to provide better assessment than a single measure that attempts to represent both. Further research is needed to assess the relation between food security and children's diet quality/variety and the effects of children's food security on their health and development.     

Food insecurity affects school children's academic performance, weight gain, and social skills

Food insecurity has been associated with diverse developmental consequences for U.S. children primarily from cross-sectional studies. We used longitudinal data to investigate how food insecurity over time related to changes in reading and mathematics test performance, weight and BMI, and social skills in children. Data were from the Early Childhood Longitudinal Study-Kindergarten Cohort, a prospective sample of approximately 21,000 nationally representative children entering kindergarten in 1998 and followed through 3rd grade. Food insecurity was measured by parent interview using a modification of the USDA module in which households were classified as food insecure if they reported > or =1 affirmative response in the past year. Households were grouped into 4 categories based on the temporal occurrence of food insecurity in kindergarten and 3rd grade. Children's academic performance, height, and weight were assessed directly. Children's social skills were reported by teachers. Analyses examined the effects of modified food insecurity on changes in child outcomes using lagged, dynamic, and difference (i.e., fixed-effects) models and controlling for child and household contextual variables. In lagged models, food insecurity was predictive of poor developmental trajectories in children before controlling for other variables. Food insecurity thus serves as an important marker for identifying children who fare worse in terms of subsequent development. In all models with controls, food insecurity was associated with outcomes, and associations differed by gender. This study provides the strongest empirical evidence to date that food insecurity is linked to specific developmental consequences for children, and that these consequences may be both nutritional and nonnutritional.