PWM: Eating Behaviors of Children (2006)


Casey PH, Szeto K, Lensing S, Bogle M, Weber J.  Children in food insufficient, low-income families: Prevalence, health, and nutrition status.  Arch Pediatr Adolesc Med 2001;155:508-14.

PubMed ID: 11296080
Study Design:
Cross-Sectional Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
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.
Inclusion Criteria:
Exclusion Criteria:
Description of Study Protocol:

Data was used from the Continuing Survey of Food Intakes by Individuals (CSFII) 1994 through 1996 (a nationally representative sample of individuals of all ages that provides detailed data that serve as benchmarks of the food and nutrient intakes of the general and low-income populations).

Food insufficiency was determined from interview with an adult in the household. The household was determined to be food insufficient if the adult answered that members of the household "often don't have enough to eat" or "sometimes don't have enough to eat." in the last 3 months. The estimates of food insufficiency for children were based on the reported adequacy of their households.

Dietary intake was gathered by use of a 24 hour diet recall. Intake for children under 6 was provided by an adult. Intake for children 6-11 was provided by the child with some assistance from an adult. Children over 12 provided their own dietary recall information.

Statistical analyses:

Sampling weights to adjust for sampling and response issues followed by Pearson Chi2 test.

Data Collection Summary:


Self-reported weight and height; numbers of overweight and underweight children (no definition given)


Household food insecurity status (based on single question answered either “often don’t have enough to eat” or “sometimes don’t have enough to eat”)


No multivariate analyses

Description of Actual Data Sample:

N: 5669 males and females from 3790 households

Age: 0-17 years

Ethnicity: not described but presumably mixed, Nationally representative sample

SES: Mixed SES

Location: US

Summary of Results:

Low Income Families: Food Insufficient versus Food Sufficient

  • No difference in participation in school lunch or breakfast programs
  • No difference in total energy, protein, carbohydrate, total fat, or cholesterol intake
  • Children in food insufficient households ate less
    • dark green vegetables, nuts and seeds, added sugar,
  • Children in food insufficient households ate more eggs
  • No difference in overweight between low-income food-sufficient vs. insufficient.

Low Income Food Insufficient versus High Income Food Sufficient

  • Low income food insufficient children more likely to participate in school lunch or breakfast programs than high income food sufficient children
  • Compared to high income households, children from low income food insufficient households reported
    • significantly lower total energy (P = .05) and carbohydrate intakes (P = .004),
    • significantly higher cholesterol intakes (P = .02), with a higher percentage of calories from protein (P = .003)
  • Compared to high income households, children from low income food insufficient households ate less fruits, nonwhole grains and yogurt, and ate more dry beans and peas

Low Income versus Higher Income Households

  • More overweight children in low-income vs. high-income groups (p = 0.04).
  • No difference between groups in number of underweight children.
  • Children in low income groups (both food sufficient and insufficient) watched more television than children in higher income groups (p = 0.02).
Author Conclusion:

Low-income households that report food insufficiency differ from low-income food-sufficient households in several demographic characteristics. 

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.

Funding Source:
Government: USDA
Reviewer Comments:


  • large sample
  • nationally representative


  • no controlling for potentially confounding variables
  • p values not adjusted for multiple comparisons
  • food insufficiency measure may be closer to the concept of “hunger” than mild-moderate food insecurity; did not assess fluctuations in food availability; based on single question to caretakers
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? Yes
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? No
  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? No
  7.5. Was the measurement of effect at an appropriate level of precision? No
  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