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Children in Food-Insufficient, Low-Income Families
Prevalence, Health, and Nutrition Status
Patrick H. Casey, MD;
Kitty Szeto, MS, RD;
Shelly Lensing, MS;
Margaret Bogle, PhD, RD;
Judy Weber, PhD, RD
Arch Pediatr Adolesc Med. 2001;155:508-514.
ABSTRACT
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Objective To examine characteristics of US children living in food-insufficient
households and to compare food and nutrient intakes, physical inactivity,
and overweight and underweight status of children in food-insufficient households
with those in food-sufficient households.
Design Cross-sectional, nationally representative sample of children and households
from the Continuing Survey of Food Intakes by Individuals, from 1994 to 1996.
Participants A group of 3790 households, including 5669 children (ages 0-17 years).
Main Outcome Measure(s) Estimates of food insufficiency for children were based on the reported
adequacy of their households, described as "often don't have enough to eat"
or "sometimes don't have enough to eat." Nutrient consumption was based on
two 24-hour dietary recalls from in-person interviews.
Results Three percent of all households with children, and 7.5% of low-income
families with children experienced food insufficiency. Several demographic
and characteristic differences were observed between the food-sufficient and
food-insufficient low-income groups. Children of low-income families, either
food-sufficient or food-insufficient, had similar macronutrient and micronutrient
intake, reported exercise, television watching, and percentage of overweight
and underweight. When compared with the higher-income food-sufficient households,
children in the low-income food-insufficient households consumed fewer calories
(P = .05) and total carbohydrates (P = .004), but had a higher cholesterol intake (P = .02). The low-income food-insufficient group included more overweight
children (P = .04), consumed less fruits (P = .04), and spent more time watching television (P = .02).
Conclusions While not different from low-income families who do not report food
insufficiency, low-income families with food insufficiency had children who
differed from high-income families in several nutrition and anthropometric
measures. Clinicians should be aware of the possible effects of poverty and
lack of access to food on child health and nutrition status. The long-term
effects of these are not yet known.
INTRODUCTION
FOOD INSUFFICIENCY is defined as inadequacy in the amount of food intake
because of a lack of money or resources to access enough food.1
Despite the abundant food availability and high food wastage in the United
States, recent evidence suggests that a large number of US children live in
families that are food-insufficient. The Community Childhood Hunger Identification
Project indicated that nearly 1 in 3 children younger than 12 years in low-income
families often went hungry or were at risk of hunger during the survey year.2, 3 The Third National Health and Nutrition
Examination Survey found that approximately 2.4 to 3.2 million children younger
than 12 years lived in food-insufficient families at any time between 1988
and 1994. An additional 0.7 to 1.3 million teenagers (12-16 years of age)
lived in food-insufficient families.4
In 1985, the Physician Task Force on Hunger estimated that malnutrition
resulting from hunger would affect more than half a million American children.5 Hungry children tend to suffer from more minor health
problems (such as unintended weight loss, fatigue, dizziness, headache, ear
infection, and cold) than nonhungry children.6, 7
They are also more likely to have frequent physician visits, despite lower
levels of health insurance.8 Furthermore, insufficient
food intake has been associated with impaired growth and poor cognitive development
in children.9, 10, 11, 12, 13
Recent evidence also suggests that food insufficiency and hunger may be associated
with childhood obesity.14, 15, 16
In addition, behavioral, emotional, and academic problems are more prominent
in hungry children.7, 16, 17, 18
Food insufficiency is clearly related to poverty. The poverty rate is
significantly higher for children than other age groups. While children represent
only 27% of the US population, they account for 40% of all Americans living
in poverty.19, 20 In 1993, of the
14 million people on welfare, 69% of them were children.21
The Continuing Survey of Food Intakes by Individuals (CSFII) 1994 through
199622 is the most recent national nutrition
survey conducted by the Agricultural Research Service, US Department of Agriculture.
The CSFII (1994-1996) includes a nationally representative sample of individuals
of all ages and provides detailed data that serve as benchmarks of the food
and nutrient intakes of the general and low-income populations. This survey
thus provides the opportunity to assess the association of food insufficiency
and poverty on various children's health and nutritional markers.
Data from the CSFII (1994-1996)23 were
used to examine characteristics of US children living in food-insufficient
households, especially children of low-income families. Nutrient intakes,
fruit and vegetable consumption, physical inactivity and exercise, and overweight
and underweight determinations were compared in children who live in food-sufficient
households and those in food-insufficient households. Since food insufficiency
and poverty are highly correlated,24 an analysis
of food insufficiency in children must accommodate for the potential independent
confounding effect of poverty on these variables. Therefore, food insufficiency
status was examined in 2 income levels: low-income and higher-income.
POPULATION, MATERIALS, AND METHODS
STUDY POPULATION
The CSFII (1994-1996) data consisted of 3837 households with children.
Basic information was collected on all household members, and more detailed
data, including nutrient intakes, were collected on a subsample, which were
designated as "sample persons." Twenty-one households, 16 of which included
child sample persons, were missing a response on the food-insufficiency question.
These households and children were excluded from the analysis. The higher-income
food-insufficient group was excluded from the study because of its small sample
size (26 households and 30 child sample persons), and its wide income range
($19 000 to $90 000). The final sample consisted of 3790 households
and 5669 children, aged 0 to 17 years, who completed two 24-hour dietary recalls
in an in-person interview. For breastfed infants (n = 133), the amounts of
breast milk were not quantified, but their nutrient intake from foods and
drinks was included.
MEASURES AND STRATIFICATION VARIABLES
During household interviews, at least 1 adult sample was selected to
answer questions about the educational and employment status of household
members 15 years and older, household income, participation in food-assistance
programs, food expenditures, food-insufficiency status, and other food-related
practices. Food insufficiency was based on describing the food eaten in the
household in the last 3 months as "often don't have enough to eat" or "sometimes
don't have enough to eat." The answer provided by the respondent was attributed
to each individual who lived in that family. Thus, estimates of food insufficiency
for children are based on the reported adequacy of their households.
During individual 24-hour dietary recalls, child sample persons aged
6 to 11 years were asked to describe their own food intake, assisted by an
adult household member. Adolescents aged 12 to 17 years self-reported their
own dietary intake. Proxy interviews were conducted to obtain dietary data
for children younger than 6 years. Questions on weight, height, amount of
television watching, amount of exercise, and health status were asked as trailer
questions after the first 24-hour dietary recall.
The CSFII definition of low-income household was used and includes those
households with income at or below 130% of the federal poverty line (eg, $20 000
for a family of 4). This is used as the income eligibility criterion for federal
assistance programs, such as the Food Stamp Program. Households with income
higher than 130% of the federal poverty line are defined as higher-income
households.
STATISTICAL ANALYSIS
The CSFII is a stratified, multistage area probability sample. To account
for this complex sampling design, the analysis for this article incorporated
sampling weights, which adjust for unequal probabilities of selection, differing
response rates, and potential undercoverage in the sampling frame. For continuous
responses, weighted t tests were used to compare
2 groups, and weighted Pearson  2 tests were used for categorical
responses.25 Most analyses were performed using
Stata (Stata Statistical Software, release 5.0; Stata Corp, College Station,
Tex). Two-sided values of P .05 were deemed significant,
and P values were not adjusted for multiple comparisons.
RESULTS
PREVALENCE AND CHARACTERISTICS OF CHILDREN IN FOOD-INSUFFICIENT FAMILIES
In all households surveyed, 2.2% reported food insufficiency. In households
with children, 3.0% experienced food insufficiency. As expected, a higher
percentage of low-income families (5.9%) reported food insufficiency; 7.5%
of low-income families with children reported food insufficiency. Food-insufficient
households with children averaged 5.5 days for not having enough to eat within
the last month before the interview. Most of these families (92.8%) reported
the reason for their food insufficiency was a lack of money, food stamps,
or Special Supplemental Food Program Women, Infants, and Children vouchers.
When compared with food-sufficient, low-income families, the food-insufficient,
low-income households with children were significantly (P.05) larger, had more children in the family, had lower income,
and had a less-educated head of household. They were also more likely to live
in the western United States and received Aid to Dependent Families With Children
or other general assistance. Additionally, when compared with the higher-income
food-sufficient group, more of the low-income food-insufficient group had
female heads of household, received Special Supplemental Food Program for
Women, Infants, and Children, and Food Stamp benefits, and they spent significantly
less money per household member on food (P<.001)(Table 1).
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Table 1. Characteristics of Households With Children Based on Food
Insufficiency and Income*
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SCHOOL LUNCH AND SCHOOL BREAKFAST COMPARISONS
The percentages of children eating school lunch were similar between
the low-income food-insufficient group and the low-income food-sufficient
group (Table 2). Although not
significant, a higher percentage of children in the low-income food-insufficient
group ate school breakfast than did those in the low-income food-sufficient
group (82.4% vs 61.9%) (P = .09). However, there
was no difference between the 2 groups for free or reduced-price breakfast
and/or lunch program participation. Furthermore, a significantly smaller percentage
of children in the food-sufficient higher-income group participated in the
school breakfast and/or lunch program (Table 2).
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Table 2. Characteristics of Children Based on Household Food Insufficiency
and Household Income*
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NUTRIENT AND FOOD INTAKES
There was no significant difference between children in low-income,
food-insufficient and low-income, food-sufficient households for total energy,
protein, carbohydrate, total fat, or cholesterol intake (Table 3). When compared with the higher-income food-sufficient households,
children in the low-income food-insufficient households were reported to have
significantly lower total energy (P = .05) and carbohydrate
intakes (P = .004), and higher cholesterol intakes
(P = .02), with a higher percentage of calories from
protein (P = .003). There were no differences in
the percentage of children receiving less than 70% of the recommended dietary
allowance of vitamins (eg, vitamin C, B6, B12, folate)
and minerals (eg, iron, calcium, phosphorus, magnesium, zinc). Children in
the food-insufficient households ate less dark green vegetables, nuts and
seeds, and added sugar, and consumed more eggs than children in the low-income
food-sufficient households. Children in the low-income food-insufficient group
ate less fruits, nonwhole grains and yogurt, and consumed more dry beans and
peas than the higher-income food-sufficient group (Table 3).
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Table 3. Nutrient and Food Comparisons of Children's Dietary Intake
Based on Household Food Insufficiency and Household Income
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ANTHROPOMETRICS, ACTIVITY, AND EXERCISE
The percentage of overweight children, based on self-reported heights
and weights, was statistically similar among low-income households, whether
food-sufficient or insufficient. However, when compared with the higher-income
group, the low-income groups included more overweight children. There was
no significant difference between the low-income food-sufficient and insufficient
groups, or in the higher-income group for underweight children. The low-income
food-insufficient group reported similar amounts of television watching per
day when compared with the low-income food-sufficient group. However, when
compared with the higher-income group, the low-income groups spent significantly
more time watching television. Percentages of children who claimed they exercised
once a week or less did not significantly differ among the 3 groups (Table 4).
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Table 4. Anthropometrics, Activity, Health, and Exercise for Children
Based on Household Food Insufficiency and Household Income
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COMMENT
The prevalence of food insufficiency based on data from the CSFII survey
(1994-1996) is lower than reports of other recent national surveys of food
insufficiency and food insecurity. In the Third National Health and Nutrition
Examination (1988-1994), 4.1% of all survey households and 14% of low-income
households reported food insufficiency.4, 26
For the Community Childhood Hunger Identification Project (1995), 8% of the
children younger than 12 years reported prolonged periodic food insufficiency,
and 21% of them were at risk of hunger.3 The
US Census Bureau found that nearly 20% of all children lived in food-insecure
households in 1998.27 The lower prevalence
in the CSFII (1994-1996) may be real or caused by differences in sampling
frames, time, definition of low-income households, varied definitions of food
insufficiency (insecurity), or methods specific for determining food insufficiency
or insecurity. More contemporary data will be required to determine whether
this is a significant continuous trend.
"Food insecurity" and "food insufficiency" are commonly perceived to
be the same and are often used interchangeably. Whereas food insecurity is
defined as limited or uncertain availability of nutritionally adequate and
safe foods, or ability to acquire acceptable foods in socially acceptable
ways,28, 29 food insufficiency
is defined as inadequacy in the amount of food intake because of a lack of
money or resources that provide access to enough food.1
Although these definitions are similar, food insecurity describes a broader
condition. It includes not only food insufficiency, but also includes the
psychological dimension and other qualitative and quantitative aspects of
food supply and food intake. The CSFII (1994-1996) used only 1 question to
determine food insufficiency, while food security is measured by an 18-item
scale in other surveys. Previous survey years of CSFII (1989-1991)24 found a similar prevalence of food insufficiency
for all households (2.5%) when compared with the 1994 through 1996 data (2.2%),
despite the higher response rate for the more current CSFII (1994-1996). The
slight decrease in prevalence may reflect the year-to-year variation that
indicates the influence of a changing economy. A recent report on household
food security found that food insecurity in the United States improved from
1995 to 1997, although this report also suggested that food insecurity increased
from 1997 to 1998, despite a continued strong economy.27
More research is needed to better understand such year-to-year variations.
Families who report food insufficiency are clearly different in some
sociodemographic characteristics, even when compared with families with low
income. Our report on the characteristics of food-insufficient families is
similar to those of other studies.4, 30, 31
Some studies previously indicated a positive association between food stamp
participation and food insufficiency.4, 32, 33, 34, 35
Despite the many demographic differences of the low-income food-insufficient
group, no differences were detected in major nutrient intakes of children
within the low-income group, whether or not they were food-insufficient. However,
several differences in nutrient intakes between low-income and higher-income
households were found. Earlier years of CSFII data (1985-1986) showed that
perceived food insufficiency was associated with lower nutrient intakes for
women and their children (aged 1-5 years) at a lesser extent.33
However, our sample included children of all ages (aged 0-17 years). This
increased age range would result in a reduced percentage of proxies. A proxy
for a younger child might report a lower intake to reflect the food-insufficient
household rather than the child's true intake. At the same time, our data
included two 24-hour dietary recalls, which may give a more accurate estimation
than does a 1-day recall.33 Also, the nutrient
intake differences between the 2 groups reported in the earlier study33 might be caused by other factors, most likely the
independent effect of low income as this study did not control for socioeconomic
status measures. Another study using earlier CSFII (1989-1991) data also indicated
that preschoolers' food intakes were not significantly associated with household
food insufficiency, although the association was found in adult women and
the elderly.36 Further studies are needed to
examine smaller increments of age groupings of children to pinpoint the impact
of food insufficiency (if any) on particular age groups. Besides nutrient
intakes, we found minor differences in food choices between the low-income
food-insufficient and higher-income food sufficient groups. More legumes and
eggs and less yogurt, dark green vegetables, nuts and seeds, and added sugar
were eaten by the food-insufficient group. The use of cheaper sources of protein
and sociocultural food preferences may play a role in such variations.
Although previous reports have suggested that food-insufficient groups
have higher obesity rates than food-sufficient groups,14, 15, 16, 37
our analysis did not show that food insufficiency by itself is associated
with self-reported measures of obesity in children. However, we did find a
higher percentage of overweight children in low-income families than in higher-income
families despite their insufficiency status. Even though food deprivation
has been implicated as a cause of overeating and resultant obesity,38 more research is needed especially related to periodic
or episodic overeating. The summary report of the Food Security Measurement
Project by the US Department of Agriculture indicated that mild undernutrition
is typically marked by periodic food insecurity and hunger, and affects an
estimated 13.7 million American children.30
If underweight is an indication of undernutrition, our results did not support
the premise that undernutrition occurs among children in food-insufficient
households. It should be noted that CSFII uses self-reported weight and height
data, which may affect the validity of these data.39, 40, 41, 42
Our analysis shows that food-insufficiency status is not associated
with the amount of television viewing or physical activity level. However,
low-income status may be a factor that increases the amount of television
viewing. Although evidence suggests that television viewing and lack of exercise
are strong risk factors for childhood and adolescent obesity,43, 44, 45, 46, 47, 48, 49, 50
our study indicates that low socioeconomic status may be an important confounding
associated factor.
The food sufficiency question has been used in US Department of Agriculture
surveys since the mid-1970s to measure food deprivation and is well established
in prior analytic research.51, 52, 53
Concerns have been noted in the literature that CSFII methods for measuring
food-insufficiency may be limited,29 less reliable
in describing usual intake,54 and not reflect
cash-flow problems.36 Still, the CSFII provides
a measure of nutrient intakes of children, which is lacking in other more
sophisticated and comprehensive food-insufficiency and food-insecurity surveys
(eg, Current Population Survey,55 Community
Children Hunger Identification2). Because CSFII
only questions households' food insufficiency status, we assume children in
food-insufficient households experience food insufficiency as well. Yet, it
is possible that adults may save the limited household food for the children
and meals served at school may prevent children from feeling food deprived.
Furthermore, since the low-income, food-insufficient group had a smaller sample
size compared with the other 2 food-sufficient groups, important differences
may not have been detected because of decreased power.
Nord and Bickel56 have proposed new methods
to more accurately estimate the prevalence of children's food insecurity and
hunger rather than relying on the designation of food-insufficient households
with children. This is in response to the observation that the true prevalence
of children's hunger is being underestimated in many survey analyses. They
constructed a child hunger scale based on the 8 items of the 18-item Food
Security Scale that are child-specific. In analyzing the 1995 US Food Security
data, they found child hunger in 1.12% of the households with children, compared
with 0.87% based on the household measure for the same households. This difference
in prevalence of hunger using the child-specific scale is 29% greater. In
addition, they found households with higher ratios of children to adults and
older children showed more severe levels of children's hunger on the child-specific
scale than would have been predicted from the household level scores. Households
where all children were younger than 6 years had lower prevalence rates, confirming
the suspicion that young children are protected from hunger, even at the expense
of adult hunger, and to a greater extent than are older children.
CONCLUSIONS
While the CSFII (1994-1996) found a similar prevalence of household
food insufficiency when compared with previous CSFII (1989-1991), our data
indicated a lower prevalence than other surveys on household food security.
Low-income households that report food insufficiency differ from low-income
food-sufficient households in several demographic characteristics. Still,
no differences were observed in nutrient intake, physical activity, or weight/height
data between the food-sufficient and food-insufficient groups in low-income
households. Some differences were noted in these nutritional and anthropometric
variables between low-income and high-income households. Further studies are
needed to establish a direct measure of children's food sufficiency status
and its relationship to nutrient intake, as well as objective health and psychological
outcomes data of food-insufficient children.
These data are presented to pediatricians to introduce the important
concept of food insufficiency in children and its related clinical and methodological
issues. The potential negative impact of food insufficiency on nutrition and
health status of children is obviously important to pediatricians. Future
research will improve our understanding of the prevalence, correlates, and
effects of food insufficiency.
The 7.5% of US low-income families with children still represents a
large number of children who experience food insufficiency. Clinicians should
be aware of the possibility of food insufficiency among their patients, particularly
in low-income families, and the possible associated health and nutrition problems.
Clinicians may also provide information on nutrition assistance programs,
encourage participation in school meal programs, promote nutrition education
and physical activity in public school systems, and support social policies
to confront childhood poverty and food insufficiency.
AUTHOR INFORMATION
Accepted for publication October 3, 2000.
We thank the US Department of Agriculture Agricultural Research Service,
via Cooperative Agreements 58-1235-7-051 and 58-6251-9-012, for their support.
From the Arkansas Children's Hospital Research Institute, University
of Arkansas for Medical Sciences, Little Rock (Drs Casey and Weber and Mss
Szeto and Lensing), and the Delta Nutrition Intervention Research Initiative,
Agriculture Research Service, US Department of Agriculture, Little Rock (Dr
Bogle).
Corresponding author: Patrick H. Casey, MD, Arkansas Children's Hospital,
University of Arkansas for Medical Sciences, 800 Marshall St, Little Rock,
AR 72202 (e-mail: caseypatrickh{at}exchange.uams.edu).
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