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2. Measuring hunger
Enough to eat?
Output: Nutritional outcomes
Relations among the hunger indicators
Sara R. Millman and Laurie F. DeRose
Given the definition of hunger as consumption of a diet inadequate to sustain good health and normal activity, growth, and development, an ideal measure of hunger would involve a comparison between the diet actually consumed and that required for these purposes. In fact, one set of hunger indicators is based on this principle, focusing on the question of whether people are getting enough to eat. Practical implementation of the ideal, however, encounters significant difficulties both in measuring or estimating the diet and in defining the requirements against which it should be compared.
A second set of indicators focuses on outcomes of malnutrition. This approach has the advantage of identifying people whose intake is poor enough to have measurable consequences; it avoids the necessity of measuring either intake or need. But because some of the manifestations of hunger have other causes, it is not always clear that inadequate intake accounts for the outcome measured. To take an extreme example, death rates have been interpreted as aggregate indicators of hunger, and ratios of males to females in the surviving population as evidence of less adequate nutrition for one sex than the other. The possibility of other causes must also be kept in mind, even when using outcomes more directly related to food intake: anthropometric measurements may be influenced just as heavily by access to health care as by access to food.
An additional complication inherent in the use of outcomes of malnutrition as indicators of hunger is that these measurements must be compared with some standard of physical normality. This is most problematic with respect to growth. While the standards for what constitutes normal blood sugar levels are defined fairly precisely and uncontroversially, "normal growth" encompasses a wide range of alternatives: unhealthy growth patterns are more difficult to identify. This particular controversy will be explored in detail later in this chapter. For now, it is important to note that whether food intake or nutrition outcome is used as a measurement of hunger, standards are necessary.
Despite the great individual variability in intakes that would support good health and normal activity, cut-offs below which most would be functionally impaired can be defined. In measuring hunger and even in answering the more specific question of who is hungry, the use of standards allows us to identify types of individuals who are functionally impaired, even if some of those above the cut-offs also suffer from hunger and some below function normally. Chronic shortfalls in caloric availability in particular communities, or high proportions of underweight in particular sex and age groups, provide enough information to target interventions effectively. Nevertheless, we devote a great deal of attention to measurement issues in order to (1) identify the types of data that would be needed for future, more reliable, hunger estimates, (2) identify the biases inherent in some commonly used measurement techniques in order to inform interpretation of the statistics generated by them, and (3) explore the extent to which different indicators of hunger function interchangeably.
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