PWM: Eating Behaviors of Children (2006)

Cutts DB, Pheley AM, Geppert JS. Hunger in Midwestern inner-city young children.  Arch Pediatr Adolesc Med 1998;152:489-93. PubMed ID: 9605034
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Negative NEGATIVE: See Quality Criteria Checklist below.
Research Purpose:
To determine the characteristics of hunger in young children who attend ambulatory pediatric clinics in a midwestern city.
Inclusion Criteria:
  • Caregivers were English speaking
  • Child < 5 years old
Exclusion Criteria:
  • Staff not available to interview (due to patient load)
  • Caregiver refusal of interview
  • Incomplete study forms
  • Child had emergent health needs
  • Child was not accompanied by primary caregiver
Description of Study Protocol:

The sample consisted of children registered in an ambulatory pediatric clinics of Hennepin County Medical Center from February 1 to July 31, 1994.

Hunger was assessed using an 8-item instrument designed to assess food insufficiency during the previous 12 months.

Dietary and demographic information was gathered by using a 75 question structured interview. Trained staff members gathered anthropometric measurements using standard measurement procedures.

Statistical analyses:

Chi2 used to determine differences between “hungry”, “at risk for hunger” and “not hungry” children.

Data Collection Summary:


Weight for Height, Weight for Age and Height for Age percentiles (measured height & weight; 1990 CDC/NCHS)


Hunger status (based on 8-item “Hunger Scale” [Figure 1] developed & validated by Community Childhood Hunger Identification Project (CCHIP); > 5 “yes” responses = “hunger”; 1-4 “yes”es = “at risk for hunger”; 0 “yes”es = “no hunger” (Note: 4 of 8 questions in instrument referred to children in household )


No multivariate analyses

Description of Actual Data Sample:

N: 2578 male and female 

Age: < 5 years

Ethnicity: Only English speaking caregivers interviewed, 18-26% parents white, 55-62% black, 6-8% Native American, 11-14% other

SES: Mostly low SES:  50% households all adults unemployed; 35% caregivers < high school, 26% > high school

Location: Minneapolis, Minn.

Summary of Results:

Prevalence of Hunger in the Sample

  • not hungry: 60.6% (n=1559)
  • at risk for hunger: 32.7% (n=842)
  • hungry: 171 (6.6%)

Hunger and Weight

No difference was found for any weight measurement between groups based on hunger status.

Characteristics Associated with Hunger

Several family characteristics were associated with child hunger. Hungry children were less likely to have:

  • a mother with some college education (p<.02)
  • currently married parents (p<.01)

Hungry children were more likely to have:

  • unemployed parents (p<.001)
  • a history of homelessness (p<.001)
  • a non-white mother (p<.002)

The authors also report that hunger status increased significantly with age (p<.001).

Hunger and Beverage Intake

The authors report:

  • Almost 2 times as many hungry children drank carbonated beverages (chi2: p<.001)
  • For non-carbonated drinks there was a linear trend for consumption by hunger status (i.e., more hungry children drank carbonated drinks, non-hungry children drank less, at-risk children were betweeen) (p<.001)

After adjusting for age, there was no actual difference between groups in the amount of carbonated beverages consumed (p=.79).

Author Conclusion:

Housing, dietary, and family characteristics are identifiable risk factors for early childhood hunger.  Hunger cannot be identified, however, using anthropometrics.

Funding Source:
Government: NIH
University/Hospital: Pennsylvania State University
Reviewer Comments:


  • Limited generalizability and potential for bias (convenience sample - only those using medical services with English-speaking caregiver and no controlling for potential confounders).
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? No
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes