Exploring food insecurity and multimorbidity in Indian socially disadvantaged people: cross-sectional findings from LASI, 2017–18

With economic progress and demographic change, India is going through an epidemiological shift leading to a dual burden of diseases, with communicable diseases becoming an additional burden as non-communicable diseases (NCDs) become more prevalent [1]. However, population ageing has contributed to an increasing trend NCDs, which are highly common among the elderly, putting them at risk of multiple chronic diseases as they age [2].

The occurrence of multiple health problems (i.e., ≥ 2 chronic conditions) is known as ‘Multimorbidity’ [3]. Multimorbidity, the co-occurrence of two or more chronic medical conditions within an individual, increase with age and is highly prevalent among those patients attending primary healthcare settings [4‐6]. Multimorbidity in the older population has long been identified as a key barrier to living a healthy life, putting them at risk of negative health outcomes such as declining physical functioning, low quality of life, poor self-rated health, poor mental health, and mortality [7‐10]. Furthermore, multiple morbidities and co-morbid conditions present a significant barrier to healthcare choice and disease management, leading to the development of poor health outcomes and, as a result, a rise in financial burden due to greater medical costs [11, 12]. Also, the existence of multiple chronic conditions (MCC) results in out-of-pocket health care expenditures that exert budget pressure on low-income households that further contributes to the economic vulnerability of older people which may increase the risk of food insecurity [13, 14].

Food insecurity can be defined as ‘when all people, at all times, do not have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for active and healthy life [15]. Food insecurity is a problem for people across their lifespan, and it is a growing issue among older people resulting in socioeconomic deprivation due to increasing medical costs [11, 16]. Multiple chronic illnesses impair physical functions and create a barrier to generating economic resources, both of which have a direct influence on the quality of life and social concerns such as economic dependence or support systems of the older population [12, 17, 18]. Therefore, food insecurity is particularly a concern for older adults who suffer from multiple chronic conditions due to their vulnerability in experiencing several physical, psychological, financial, and social obstacles related to food access. Globally, food insecurity has emerged as one of the key challenges affecting millions of people, particularly older adults [19].

Several studies have looked at the health effects of food insecurity, and the findings support the hypothesis that food insecurity impacts nutritional status and dietary consumption, which is linked to poor health outcomes and low well-being in later life [20]. However, a substantial body of evidence suggests that there may be a reverse association: the health condition of older individuals may be a driver of food insecurity [21‐24]. A few studies have connected multimorbidity to food insecurity in developed countries. For example, according to an analysis of the Canadian Community Health Survey based on adults aged 18–64 years, respondents with multiple chronic conditions have a higher likelihood of food insecurity than those without chronic illnesses [25]. In another nationally representative study in the United States, the odds ratios for being food insecure were shown to be greater among older adults aged 50 or more years who had two or more chronic diseases compared to those who had a single or no morbidity [13]. Meanwhile, multiple studies have demonstrated that the added economic vulnerability of food insecurity can lead to trade-offs with chronic disease management, including purchasing food versus medication, greater subsequent health care needs, sub-optimal chronic disease management, and worse overall health [25‐29]. However, there is limited evidence from developing countries like India that highlights multimorbidity as a significant risk factor that increases the risk of food insecurity.

Females have a higher life expectancy and poorer health outcomes than their older male counterparts, resulting in gender differences in the prevalence of multimorbidity [30]. To ensure food security at the household level, females play an important role; however, there are gender disparities in the likelihood of food insecurity at the individual level [31]. Health-related gender disparities have been observed across the lifespan, while it becomes more prevalent in the ageing population due to differences in social and personal resources [32]. Old age, in particular, is a stage of life marked by considerable changes in societal norms, gender-related expectations, and family status. Due to disparities in social and economic aspects, it is necessary to look at the gender perspective in developing nations, especially in the Indian context. Therefore, we will also address the gender variations in the present study.

While looking at the social structure in India, Scheduled Castes (SCs), Scheduled Tribes (STs), and Other Backward Classes (OBCs) are the less privileged groups that often fare worse than the other groups across the social and economic indicators in India [33]. Individuals from these groups face social impairment and extreme poverty [34]. The individuals from SCs, STs, and OBCs groups lack purchasing power, live in substandard housing, and limited access to resources and entitlements [35]. In rural India, these marginalized populations are casual laborers performing a variety of available jobs. At the same time, in urban areas, they are urban poor employed as wage laborers at a variety of work sites, beggars, vendors, small service providers, and domestic help, among others, who live in slums and other makeshift shelters without access to social security [36]. Members of these communities are subjected to systematic violence, including denial of access to land, adequate housing, education, and jobs [35, 37]. The SCs, STs, and OBCs became eligible for some rights as Indian citizens, such as economic rights guaranteed by the Indian Constitution, people from these groups continue to perform poor in range of health indicators, starting with poor nutrition status, vaccination rates among children, and access to health care use across the age groups [38‐40]. As a result, the poor social and economic aspect further susceptible these groups of individual to develop different morbidity and physical ailments which can further affect their basic need including the food and nutrition. These aspects thus suggested poorer physical health conditions and severe food insecurity among these disadvantaged groups.

With this background, the present study is aimed at exploring the association of multimorbidity with food insecurity among the population of socially disadvantaged groups in India. We hypothesized that multimorbidity is associated with higher odds of food insecurity after adjusting for several sociodemographic and health-related confounders. Additionally, age and gender differences in the possible association between multimorbidity and food insecurity has been explored. Figure 1 shows a preliminary theoretical framework for this association, which illustrates that multimorbidity might directly influence food insecurity status of an Individual, though gender and age might change the strength or direction of the association.

The outcome variable for this study is food insecurity. The LASI used a set of five questions developed by the Food and Nutrition Technical Assistance Program (FANTA) to collect data on food availability [41]. The main explanatory variable for this study is multimorbidity of chronic diseases and was defined as an accumulation of two or more chronic diseases [10, 42]. Several potential covariates were selected from the survey including lifestyle factors, health-related factors and socio-demographic factors. The variables used for this study from the LASI survey are described in Tables 1 and 2.

Descriptive analysis was performed to describe the study sample. For each study variable, unweighted frequency and weighted percentages were calculated. Bivariate analysis was performed to examine the prevalence of food insecurity by multimorbidity status along with socio-demographic and health-related factors. A Chi-square test was performed to check for intergroup differences in the prevalence of multimorbidity, as well as in the prevalence of food insecurity. Binary logistic regression analysis was performed to assess the adjusted association between food insecurity and each set of independent variables (socio-demographic and health-related factors). Further, a five-model multivariable logistics regression model with food insecurity as the dependent variable and multimorbidity as the main independent variable was performed to test the study hypothesis. In the first model, only multimorbidity as a main independent variable was entered. In the second model, sociodemographic factors were adjusted, whereas, in the third model, health-related factors were adjusted along with sociodemographic factors. As previously stated, gender and age are two significant independent variables in the study of the socially disadvantaged older population. Intersectional identity may aggravate several socioeconomic constraints, including morbidity patterns and food poverty. Hence, in the fourth model, gender differences in the association between morbidity status and food insecurity were examined by adding gender to the morbidity status interaction term (gender*multimorbidity). The fifth model included another interaction of multimorbidity with age (age*multimorbidity) to examine the interactive effect of age in the association between multimorbidity and food insecurity in socially disadvantaged people. Moreover, both the models with interaction terms were adjusted for sociodemographic and health-related factors. The sample weighting was taken into account to generate nationally representative estimates, therefore, the national sampling weights provided in LASI report were used in the analysis. We used the exponentiated regression coefficient – odds ratios (ORs) – as a measure of association. Also, 95% confidence intervals (95% CI) are reported. All the analysis was performed using STATA version 15, and the level of statistical significance was set at P < 0.05 [43].

This study examines the association between multimorbidity and food insecurity of socially disadvantaged middle and old-aged adults in India. Using large-scale survey data, we document significant and noteworthy detriments in food security among those socially disadvantaged individuals having multimorbidity. The association was statistically significant independent of socioeconomic and health measures, suggesting the role of multimorbidity in determining food insecurity among the older population. While looking at the gender and age aspect, our study found that men and middle-aged individuals with multimorbidity had a higher prevalence of food insecurity. At the same time, logistic regression analysis showed that multimorbidity among men and middle-aged is significantly associated with food insecurity among socially disadvantaged groups.

Our findings on the multimorbidity and association with food insecurity is also supported by the existing studies. Jih and team (2018) suggested that multimorbidity condition can directly impacts the household budgets irrespective of age which can further increase the risk of food insecurity [13]. This can also be true for the socially disadvantageous group as these peoples lacks basic needs i.e., food, education and decent livelihood. Saying so, burden of chronic morbidities can further put excess pressure on household budged possibly increasing the food insecurity [33, 36].

While our finding on gender aspect suggested higher food insecurity prevalence among men individuals with multimorbidity than women was consistent with existing literate [44‐46]. A study reported that men with disability and physical health problems were more likely to be undernourished and face food insecurity [45]. Although, in India, where the patriarchal social attributes are prominent, gender discrimination is a recognized situation which is also reflected through more economic dependence, higher morbidity prevalence, and experiencing food insecurity among all ages of women [47‐49]. Thus, women with chronic health problems, particularly those belonging to disadvantaged groups, may experience higher food insecurity [31, 50, 51]. However, our findings suggest that males with multimorbidity experience more heightened food insecurity than women. Although our results contradict previous studies, our study focused specifically on the underprivileged group, which may explain some of the contradiction. As previously stated, men members of disadvantaged groups may experience more economic constraints and health-related concerns than women members of disadvantaged groups. While, in India, there are numerous programs and policies aimed at women and the elderly addressing nutrition, pensions, and health-related issues [52], the men members of these socially disadvantaged groups may go unnoticed, leaving socially disadvantageous leadings to males more vulnerable to poor health and food insecurity.

While focusing on the age groups, our results on a higher prevalence of food insecurity among middle-aged adults with multimorbidity than the older adult were also in line with previous studies [13, 53, 54]. The results contribute to previous research by identifying that the disability and health issues may pose the greatest vulnerability of food insecurity among the structurally disadvantaged group, especially in the working middle-age range [45]. From a comparative perspective, food insecurity among middle-aged adults is similar in magnitude to deprived racial and ethnic groups in the western world [45, 54‐58]. Although the mechanism of food insecurity in middle-aged population remains obscure in comparison to earlier and later ages, there are factors in the literature that may explain the ambiguity. It is evident that the age range of 45 to 59 years represents an individual's transition period, during which the individual experiences the end of his or her early adulthood and in the process of entering old age. Middle-aged individuals undergo physiological and psychological changes throughout this period and experience social and employment-related changes that have a direct or indirect effect on their health and food security [59, 60]. The onset of chronic illness and functional limits, including reduced mobility and mass strength, occurs during this middle-aged period, which is associated with food insecurity. Research conducted in the United States of America concluded that midlife changes are likely to increase the effectiveness of health problems, hence raising the probability of food insecurity [54]. Another potential explanation for the association between food insecurity and multimorbidity in middle-aged adults found in the existing research is social roles, including financial instability, parenthood, and other types of caring [61]. Middle-aged adults care for their children and elderly parents concurrently, resulting in increased financial stress and responsibility. These economic concerns and commitments have been linked to poor physical and psychological health, further increasing the likelihood of food insecurity and poor diet quality in middle-aged people [62, 63]. While in midlife, the emergence of physical health problems increases the risk of lost work time and a lower likelihood of re-employment, which may predispose middle-aged persons to food insecurity [64]. Caring for younger children and the elderly is a social obligation in the Indian system [65]. While socially disadvantaged middle-aged persons may experience a variety of economic difficulties, these burdens may increase their health issues, making them even more vulnerable to food insecurity [66].

Our study has several strengths. Firstly, this study attempted to fill the gap in literature on association between food insecurity and multimorbidity among socially disadvantaged people in India. Secondly, the use of recently released nationally representative cross-sectional dataset allow us to obtain robust estimates of the variables under consideration. However, this study also met with some limitations. The cross-sectional nature of data does not infer any causal relationship; further longitudinal data can give us more insight in investigating the causal relationship between food insecurity and multimorbidity. The information on multimorbidity was based on nine self-reported chronic conditions resulting in misclassification bias. Similarly, recall bias might affect the quality of data on self-reported health activities such as physical activity, ADL, IADL etc.

The outcomes of this research indicate a link between multimorbidity and food insecurity among India's structurally disadvantaged adults. The socially disadvantage groups as more likely to experience the multiple chronic morbidities, that may further affects their quality of diet and, nutritionally inadequate meals to maintain caloric intake, placing them at risk for a range of detrimental health consequences. Additionally, food insecurity among middle-aged adults and males with multimorbidity in disadvantage groups might provide a new dimension, emphasizing the need of considering social background as an important identifier for healthcare system. As a result, enhancing health care system may help to reduce food insecurity in individuals who are multimorbid.