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Low Family Income and Food Insufficiency in Relation to Overweight in US Children
Is There a Paradox?
Katherine Alaimo, PhD;
Christine M. Olson, PhD, RD;
Edward A. Frongillo, Jr, PhD
Arch Pediatr Adolesc Med. 2001;155:1161-1167.
ABSTRACT
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Objectives To investigate associations between family income, food insufficiency,
and being overweight in US children aged 2 to 7 and 8 to 16 years, to discuss
mechanisms that may explain these associations, and to propose design and
data requirements for further research that could effectively examine this
issue.
Methods Data from the Third National Health and Nutrition Examination Survey
were analyzed. Children were classified as food insufficient if the family
respondents reported that their family sometimes or often did not get enough
food to eat. The prevalence of overweight was compared by family income category
and food sufficiency status within age-, sex-, and race-ethnic–specific
groups. Odds ratios for food insufficiency are reported, adjusted for family
income and other potential confounding factors.
Results Among older non-Hispanic white children, children in families with low
income were significantly more likely to be overweight than children in families
with high income. There were no significant differences by family income for
younger non-Hispanic white children, non-Hispanic black children, or Mexican
American children. After adjusting for confounding variables, there were no
differences in overweight by food sufficiency status, except that younger
food-insufficient girls were less likely to be overweight, and non-Hispanic
white older food-insufficient girls were more likely to be overweight than
food-sufficient girls (P<.10).
Conclusion Further research to evaluate whether food insecurity causes overweight
in American children requires longitudinal quantitative and in-depth qualitative
methods.
INTRODUCTION
IN 1995, DIETZ1 published a case study
in Pediatrics describing an obese 7-year-old African
American girl whose family often ran out of money for food. He introduced
the case study by stating, "Both hunger and obesity occur with an increased
frequency among poorer populations in the United States. Because obesity connotes
excessive energy intake, and hunger reflects an inadequate food supply, the
increased prevalence of obesity and hunger in the same population seems paradoxical."1(p766) Dietz described the family's situation, in which
the first welfare check of the month was spent on rent, leaving no money for
food until the second check arrived. Meanwhile, the mother fed the child high-fat
foods to assuage her hunger during these periods. Dietz wondered, "does hunger
cause obesity?"
Dietz1 used the term hunger in his case study, but the phenomenon he described may be closer
to the term food insecurity. The US Department of
Agriculture defines food insecurity as "limited or uncertain availability
of nutritionally adequate and safe foods or limited or uncertain ability to
acquire acceptable food in socially acceptable ways."2(piii)3 Hunger is "the uneasy or painful sensation caused
by a lack of food" or "the recurrent and involuntary lack of access to food."2(piii)3 The distinction
between food insecurity and hunger is one of severity. A family will be categorized
as "food insecure" if members are habitually concerned about their food situation
or if an adult in the family occasionally goes without food (eg, skips meals).
A family will be categorized as "moderately hungry" if an adult in the family
goes without food or a child is cutting the size of his or her meals or "not
eating enough," but will not be categorized as "severely hungry" unless an
adult in the family goes without food for a whole day or a child in the family
ever goes without food (skips meals). The US Department of Agriculture estimated
that 12% of US households were food insecure, 3.3% were moderately hungry,
and 0.8% were severely hungry in 1995.2
Another term, food insufficiency, was used
by the Third National Health and Nutrition Examination Survey (NHANES III)
and is the focus of this article. Food insufficiency was defined as living
in a family that "sometimes or often did not get enough food to eat." Through
cognitive testing of questionnaire items and comparisons of survey respondents'
responses to food-insecurity, hunger, and food-insufficiency questions, it
was determined that the NHANES III concept of food insufficiency is more severe
than the concept of food insecurity, not as severe as hunger, and closer to
the phenomenon of hunger than food insecurity.4, 5, 6, 7, 8, 9, 10
Results from NHANES III found that 4.1% of the population was food insufficient
between 1988 and 1994.
There is some evidence that food insecurity, but not hunger, the more
severe form of food deprivation, is associated with obesity in adult women.
In a sample of rural white Upstate New York women, the prevalence of obesity
was significantly higher in food-insecure women than in food-secure women,
but the prevalence among hungry women was similar to the prevalence among
the food secure.11, 12 Similarly,
in an analysis of national data,13 food-insecure
women, but not men, were more likely to be overweight than were food-secure
women. However, in another analysis of national data,14
food-insufficient diabetic adults were twice as likely to be obese as were
food-sufficient diabetic adults. In the only study15
on this topic conducted with children, to our knowledge, hungry, but not food-insecure,
Mexican American preschool-aged children were significantly less likely to
be overweight than food-secure children.
Several mechanisms have been proposed by which food insecurity could
cause obesity. First, food-insecure individuals may be overweight because
they can only afford to consume cheaper foods, which tend to be energy (calorie)
dense and could result in the person consuming excessive energy and gaining
weight.16, 17, 18, 19
Second, periods without enough food could cause individuals to overeat when
there is enough food, resulting in increased energy intake overall, which
would then cause a gain in weight.20, 21, 22, 23, 24, 25, 26, 27
Third, fluctuations in eating habits could result in the body becoming a more
efficient user of energy, meaning that the individual could increase in weight
without eating more calories; these fluctuations may not cause lasting changes
in resting energy expenditure.28, 29, 30, 31, 32, 33
With this background in mind, we used data from NHANES III to investigate
whether there is an association between family income and overweight, and
between food insufficiency and overweight, in US children. Specifically, we
answer 2 questions: (1) Is there a paradox? That is, does an increased prevalence
of food insufficiency and overweight coexist in the population of US children
living in families with low income? (2) Is food insufficiency independently
associated with overweight, controlling for known confounders?
We present results from our analyses, and discuss design and data requirements
for further research that could effectively examine this issue.
PARTICIPANTS AND METHODS
Data for children aged 2 to 7 years (n = 5200) and 8 to 16 years (n
= 3996) were analyzed from NHANES III, a cross-sectional representative sample
of the US civilian noninstitutionalized, nonhomeless population living in
households. The survey was conducted from 1988 to 1994. Mexican Americans
and black Americans were oversampled to provide more reliable estimates for
these groups. Detailed descriptions of the sample design and operation of
the survey have been published elsewhere.34
Data from NHANES III included medical examination results and interviews conducted
with survey participants and proxies who were parents or other relatives or
caretakers familiar with the child. All interviews and examinations were conducted
using standard protocols.34
CONCEPTUAL FRAMEWORK
Using past research, a conceptual framework of the factors affecting
children's body mass index was created using available variables from NHANES
III35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45
to guide the analyses in this study. This framework is shown in Figure 1. We postulate that having fewer family resources can lead
to food insufficiency, health care risks, or exercise risks that can affect
a child's body mass index. Family resources that could be associated with
food insufficiency, health care risks, and/or overweight include family income,
measured as the poverty-income ratio (PIR), education of the family head,
marital status of the family head, family size, and whether the child lives
in a metropolitan region. Health care risks include lack of health insurance
or a regular source of health care. For older children, exercise risks include
increased number of hours spent watching television or lack of physical activity.
Past health and nutrition risks can also affect the child's body mass index.
These include the child's birth weight, whether the child had birth complications,
whether the child was exposed to smoke prenatally, and/or short stature. Hereditary
factors can also affect a child's body mass index, which we controlled using
parental height and weight.
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Theoretical model of relationships between family resources, food
insufficiency, exercise risks, health care risks, past nutrition/health/social
risks, genetic factors, and overweight: Third National Health and Nutrition
Examination Survey, 1988 to 1994.
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OVERWEIGHT
For these analyses, we defined overweight by cutoff values derived from
the Centers for Disease Control and Prevention's growth chart data linking
the adult criterion for overweight to the corresponding centile for children,
as described by Kuzmarski et al.46 The cutoffs
used to determine overweight were sex and half-year age specific. We used
the 85th percentile of weight for height as a cutoff, which expert panels
defined as risk of overweight rather than overweight.47, 48 We used this outcome measure for
these analyses because the prevalence of "overweight" based on the 95th percentile
was too low for us to be able to confidently estimate associations. We repeated
our analyses using the cutoffs from Cole et al,49
and found essentially the same results as reported herein.
SOCIODEMOGRAPHIC AND FAMILY/CHILD RESOURCES
For each child in the survey, information about sex, age, race-ethnicity
(non-Hispanic white, non-Hispanic black, or Mexican American), metropolitan
or nonmetropolitan region of residence, family size, family income, employment
status and education of the family head, health insurance status, and whether
the child had a regular source of health care was provided by a responsible
adult living in the home. The "family head" was a person who owned or rented
the home in which the child lived. Total family income for the previous 12
months was reported for categories ranging from "less than $1000" to "$80 000
and over," in $1000 increments below $19 999, in $5000 increments between
$20 000 and $49 999, and in $10 000 increments between $50 000
and $79 999. The PIR was then calculated by comparing the midpoint of
the category and the child's family size to the federal poverty line.50 These analyses used 3 poverty status categories:
low income, a PIR less than or equal to 130% of the poverty line, which is
the federal cutoff for eligibility for the Food Stamp Program; middle income
(>130%-300% of the poverty line); and high income (>300% of the poverty line).
Children were defined as insured if they were covered during the last month
by private health insurance, military health care insurance, or Medicaid,
and if the coverage paid for "more than accidents."
FOOD INSUFFICIENCY
A child was classified as "food insufficient" if the respondent to the
family questionnaire reported that the family either "sometimes" or "often"
did not get enough food to eat.
EXERCISE RISK
Data on exercise risks were available for 8- to 16-year-old children
only. These included the number of hours spent watching television in the
previous day and the number of hours spent per week playing or exercising
enough to make the child "sweat or breathe hard."
PAST HEALTH AND NUTRITION RISK
For children aged 2 to 7 years, information was collected on the presence
of birth complications, birth weight, and any prenatal smoke exposure. We
used measured height (collected for all children) as a measure of past health
and nutrition status.
STATISTICAL METHODS
Data for children aged 2 to 7 and 8 to 16 years were analyzed for each
race-ethnic group. These age groups were chosen because certain data were
available for one or the other age group and because creating more than 2
age groups would have resulted in sample sizes too small for adequate analyses.
Children categorized as "other" race-ethnicity were excluded from the analyses.
Pregnant teenaged girls and those who reported having had at least one full-term
birth were also excluded.
Race-ethnic groups were examined separately for 2 reasons. First, there
are cultural differences in food patterns between Mexican Americans, non-Hispanic
black Americans, and non-Hispanic white Americans.51, 52, 53, 54
Second, a previous analysis55 of adults in
NHANES III has shown that overweight is strongly related to income only for
non-Hispanic white women.
Sample weights were created for the NHANES III data to take into account
the oversampling of certain groups, such as black Americans and Mexican Americans,
and of nonresponse. For these analyses, NHANES III–weighted data were
analyzed using the svy commands available in Stata statistical software.56 These commands use the weights and survey cluster
design to calculate accurate point estimates and variances.
For prevalence estimates and means, missing data were excluded from
the analyses. Logistic regression models were created to test for significant
differences by family income after adjusting for age.
Logistic regression models were also created to test the hypothesis
that food insufficiency is associated with overweight, independent of other
potential confounding factors. Control variables included those variables
shown in Figure 1 and previously
described. The PIR was entered as a continuous variable. For the logistic
regression analyses, all missing data except for food insufficiency status
were imputed using the impute command in Stata statistical software, which
uses regression equations to fill in missing values based on other nonmissing
data in the child's record. Variables included in these regression equations
were chosen separately for each imputed variable using backward stepwise regression
to screen for associated variables. For dichotomous variables, the impute
command was used to predict a probability, and a random value was selected
based on this probability. The number of missing values imputed ranged from
0 children with missing data for whether the child had a regular source of
health care to 463 children aged 2 to 7 years and 334 children aged 8 to 16
years with missing data for their family's PIR. Regression results were not
sensitive to the inclusion of imputed values.
Sample sizes for each prevalence estimate are shown in Table 1 and Table 2.
Sample sizes for some groups were small, eg, there were only 17 non-Hispanic
white 8- to 16-year-old food-insufficient girls.
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Table 1. Prevalence of Overweight by Race-Ethnicity, Age, Sex, and
Family Income: NHANES III, 1988-1994*
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Table 2. Prevalence of Overweight by Race-Ethnicity, Age, Sex, and
Family Food Insufficiency Status: NHANES III, 1988-1994*
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RESULTS
DOES AN INCREASED PREVALENCE OF FOOD INSUFFICIENCY AND RISK OF OVERWEIGHT
COEXIST IN US CHILDREN LIVING IN FAMILIES WITH LOW INCOME?
To answer this question, we begin first by looking at the prevalence
of food insufficiency in the United States by income category. Among 2- to
7-year-old children, the prevalence of food insufficiency is 15.8% in the
low-income population, 1.8% in the middle-income population, and 0.3% in the
high-income population; for 8- to 16-year-old children, the corresponding
figures are 16.4%, 2.4%, and 0%. There are similar trends among the race-ethnic
groups. Hence, an increased prevalence of food insufficiency exists in the
low-income population.
Turning to the question of overweight, for 2- to 7-year-old girls and
boys, there were no statistically significant differences in overweight by
income category for any of the race-ethnic groups (Table 1). For 8- to 16-year-old girls and boys, only non-Hispanic
white children showed significant differences among family income category;
low- and middle-income non-Hispanic white boys had a significantly higher
prevalence of overweight than did high-income non-Hispanic white boys, and
low- and middle-income non-Hispanic white girls had a significantly higher
prevalence of overweight than did high-income non-Hispanic white girls. Therefore,
an increased prevalence of food insufficiency and overweight coexists only
among low-income older non-Hispanic white children in the United States.
IS FOOD INSUFFICIENCY ASSOCIATED WITH OVERWEIGHT, CONTROLLING FOR KNOWN
CONFOUNDERS?
Table 2 shows prevalence
estimates of overweight by age, sex, and race-ethnicity for food-sufficient
vs food-insufficient children. There were no consistent trends in the relationship
between overweight and food insufficiency status.
The results of the logistic regression analyses testing for statistical
differences in overweight between food-sufficient and food-insufficient children
are shown in Table 3. Results
are shown for all 2- to 7-year-old boys and girls, but results for 8- to 16-year-old
boys and girls are displayed by race-ethnic group because of significant interactions
found between race-ethnic group and PIR and between race-ethnic group and
food insufficiency status. Only 2 notable differences by food sufficiency
status were found after adjusting for potential confounding factors: food-insufficient
2- to 7-year-old girls were 1.6 times less likely to be overweight than were
food-sufficient girls, and non-Hispanic white 8- to 16-year-old food-insufficient
girls were 3.5 times more likely to be overweight than were food-sufficient
girls (P<.10).
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Table 3. Logistic Regression for Overweight 2- to 7- and 8- to 16-Year-Old
Children: NHANES III, 1988-1994*
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COMMENT
The results of this study demonstrate that a population-level paradox
of increased prevalence of overweight and food insufficiency occurs only in
low-income older non-Hispanic white children in the United States, but not
in younger non-Hispanic white children, non-Hispanic black children, or Mexican
American children. Other studies of the relationship between income and overweight
also show mixed results. In their review of 144 studies conducted before 1989,
Sobal and Stunkard38 concluded that there was
a clear relationship between obesity and socioeconomic status in women in
the United States; poorer women were more likely to be overweight. However,
results of studies of men and children were mixed, with some finding a direct
relationship (poorer men and children are more likely to be overweight), some
finding an indirect relationship (poorer men and children are less likely
to be overweight), and some finding no relationship.
The logistic regression analyses indicate that food insufficiency is
positively associated with overweight only in older non-Hispanic white girls.
Therefore, according to these analyses, food insufficiency is a potential
explanation for a paradox of increased prevalence of overweight in children
living in families with low income only for older non-Hispanic white girls.
We emphasize that this is a potential explanation for several reasons.
There are several limitations of the NHANES III data and, therefore, this
study, for looking at the relationship between food insufficiency and overweight
in children. First, because it was necessary to divide the sample into age,
sex, and race-ethnic groups, sample sizes for some subgroups were small. Small
samples limit the power to detect significant differences between groups and
can also result in finding spurious relationships. These small sample sizes
also necessitated combining children of differing ages in whom associations
between food insufficiency and overweight might be different (eg, food-insufficient
8- to 10-year-old children may have different eating patterns than food-insufficient
adolescents).
Another shortcoming of this study is the lack of information about potential
fluctuations in family food availability in the NHANES III data. The concept
of "food insufficiency," measured by NHANES III, is closer to the concept
of "hunger" than of "food insecurity." It is unknown if children who live
in food-insufficient families exhibit the fluctuations in food intake postulated
to cause overweight. It could be that children who live in food-insufficient
families experience a more severe form of food deprivation.
Difficulty in interpretation is compounded by the fact that food insufficiency,
as measured by the NHANES III, is a family measure and assigns the same value
to adults and children in the family. Testing of the postulated mechanisms
requires a measure that allows one to treat adults and children within the
same family differently because eating patterns could be different for different
members of the family.
Additional research with cross-sectional data is unlikely to yield insight
into the potential relationship between food insecurity and overweight. The
elucidation of these relationships will require retrospective longitudinal
studies that allow one to study temporal sequences of events. Future studies
will also benefit from more qualitative research approaches. They should explore
several issues, including the food insecurity and hunger status of each member
of the child's family, an in-depth understanding of the meaning and patterns
of food deprivation that each individual in food-insecure and hungry families
exhibits, and an understanding that different food-insecure and hungry families
(eg, those of different race-ethnic or family composition) may have different
ways of coping with their situation that will hinder generalizations.
Finally, it is worth noting that childhood food insufficiency, food
insecurity, and hunger are associated with serious health, academic, and psychological
problems for children.57, 58, 59
Regardless of whether these phenomena are associated with overweight, achieving
food security for all US families should be a critical component of child
health policy.
AUTHOR INFORMATION
Accepted for publication May 22, 2001.
This study was supported by training grant DK7158-24 from the National
Institutes of Health, Bethesda, Md.
We thank Kathleen Rasmussen, PhD, for her insightful comments and suggestions.
What This Study Adds
It is commonly thought that there is a higher prevalence of food deprivation
and overweight among US children in low-income compared with middle- and high-income
families, and that this represents a paradox. Hence, researchers have asked
the following: Does food deprivation cause overweight? However, to our knowledge,
there have been no national studies that have examined if this paradox exists
in all race-ethnic groups in the United States, or if there is an association
between food insufficiency and overweight in children.
An increased prevalence of overweight and food insufficiency existed
only in older (aged 8-16 years), non-Hispanic white, low-income children in
the United States; all younger children (aged 2-7 years) and non-Hispanic
black and Mexican American children showed no differences in the prevalence
of overweight by family income. After adjusting for confounding variables,
food insufficiency was not positively associated with overweight except in
older, non-Hispanic white girls. Thus, there is epidemiological evidence for
the paradox only in one race-ethnic and age group of the US child population.
From the Division of Nutritional Sciences, Cornell University, Ithaca,
NY. Dr Alaimo is now with The University of Michigan School of Public Health,
Ann Arbor.
Corresponding author and reprints: Katherine Alaimo, PhD, School
of Public Health, The University of Michigan, 109 Observatory, Room M3517,
Ann Arbor, MI 48109-2029 (e-mail: kalaimo{at}umich.edu).
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