Health Disparities

HD: Food Security (2011)


Chilton M, Black MM, Berkowitz C, Casey PH, Cook J, Cutts D, Jacobs RR, Heeren T, de Cuba SE, Coleman S, Meyers A, Frank DA. Food insecurity and risk of poor health among US-born children of immigrants. Am J Public Health. 2009 Mar; 99 (3): 556-562. Epub 2008 Dec 23.

PubMed ID: 19106417
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 investigate the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with children whose mothers were US-born.

Inclusion Criteria:
  • Women who were accompanying a non-critically-ill child aged zero to 36 months
  • Spoke English or Spanish (or Somali in Minneapolis)
  • Were knowledgeable about the child's household
  • Had not completed a C-SNAP interview within the previous six months.
Exclusion Criteria:
  • Covered by private insurance
  • Spoke a language or languages other than English or Spanish
  • Accompanied critically-ill children aged zero to 36 months.
Description of Study Protocol:


  • Data were obtained from the Children's Sentinel Nutrition Assessment Program (C-SNAP), an ongoing multi-site study investigating the relationship between public assistance participation and well-being of mothers with children aged zero to three years
  • C-SNAP study researchers interviewed caregivers of infants and toddlers in emergency departments and pediatric care clinics in seven US cities.


Cross-sectional study.

Statistical Analysis

  • Bivariate associations between mother's place of birth and dichotomous outcomes were evaluated with the X2 test
  • Duration of residence was stratified into three categories:
    • Zero to five years
    • Six to 10 years
    • 11 years or longer.
  • The X2 test was used to measure bivariate associations between the three duration-of-stay categories and demographic variables
  • The variables controlled in the regression analyses assessing reported child health and household food insecurity status were low birthweight, maternal educational level, maternal marital status, maternal age, and child breastfeeding status
  • The association between immigrant status and reported fair or poor child health was examined in a logistic regression analysis after controlling for covariates identified in the primary model.
Data Collection Summary:
  • Timing of measurements: Interviews took place in hospital-based settings between 1998 and 2005 as part of the Children's Sentinel Nutrition Assessment Program.
  • Dependent variables: Household food insecurity, and reported child health
  • Independent variables: Immigrant status
  • Control variables: Maternal health insurance coverage.
Description of Actual Data Sample:

Initial N


Attrition (Final N)


Mean Age

  • US-born mothers: 25.6 years
  • Immigrant mothers: 27.8 years.


US-born mothers

  • Black: 65%
  • Latino: 13%
  • White: 20%.

Immigrant mothers

  • Black: 32%
  • Latino: 63%
  • White: 2%.

Other Relevant Demographics

Marital status

  • US-born women: 25%
  • Immigrant women: 60%.

Maternal health insurance coverage

  • US-born women
    • Public coverage: 92%
    • No coverage: 8%.
  • Immigrant women
    • Public coverage: 86%
    • No coverage: 14%.

Household participation in public assistance programs

  • US-born mothers
    • TANF: 35%
    • Food stamps: 49%
    • WIC: 78%.
  • Immigrant mothers
    • TANF: 17%
    • Food stamps: 23%
    • WIC: 87%.


  • Baltimore, MD
  • Boston, MA
  • Los Angeles, CA
  • Little Rock, AR
  • Minneapolis, MN
  • Philadelpia, PA
  • Washington, DC.
Summary of Results:

Results of Multiple Logistic Regression on Household Food Insecurity and Reported Child Health
Model One: Fair or poor child health (N=17,451)

Immigrant Length of Residence

AOR (95% CI)

US Born (Ref) 1.00

0-5 Years

1.26 (1.07, 1.49) P=0.01


6-10 Years

1.26 (1.05, 1.51) P=0.02


≥11 Years

1.05 (0.87, 1.26) P=0.65


Model Two: Household food insecurity (N=17,483)

Immigrant Length of Residence AOR (95% CI) US Born (Ref) 1.00
0-5 Years 2.45 (2.16, 2.77) P<0.001  
6-10 Years 2.11 (1.83, 2.42) P<0.001  
≥11 Years 1.44 (1.24, 1.67) P<0.001  

Model Three: Food insecurity x poor health, with immigrant status controlled (N=17,451)

Food Secure 1.00
Food Insecure 1.74 (1.57, 1.93) P<0.001

Model Four: Fair or poor child health, with food insecurity controlled (N=17,434)

Immigrant Legth of Residence AOR (95% CI) US Born (Ref) 1.00
0-5 Years 1.15 (0.97, 1.36) P=0.12  
6-10 Years 1.15 (0.95, 1.38) P=0.15  
≥11 Years 1.01 (0.83, 1.22) P=0.93  

AOR: Adjusted odds ratio.

Author Conclusion:
  • Causal relationships between household food insecurity and poor health among children cannot be inferred from these data because of the cross-sectional study design
  • Child health status was assessed from parent reports and may have been subject to recall bias, shared method bias or cultural differences in reportign on child health
  • The immigrant sample was not representative of the US immigrant population
  • The sampling technique used by C-SNAP may have introduced bias that potentially overestimated national trends in immigrant household food insecurity
  • Study results showed that, despite better overall health indices at birth, young children who are US citizens and whose mothers are recent immigrants are at greater risk for food insecurity and for reported fair or poor health than are young children of US-born mothers
  • Increased odds of food insecurity and poor health among children of immigrants, who represent the fasting growing US child population, raise concerns about future difficulties associated with development, socio-emotional status and school performance that could be passed on to the next generation of US-born children. These findings may signal the need for a reassessment of current policies toward immigrants, especially those newly arrived in the US.
Funding Source:
Government: US Department of Agriculture's Research Innovation and Development Grants in Economics Program
Reviewer Comments:
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) Yes
  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? ???
  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? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) No
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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? Yes
  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.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? No
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? No
  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? N/A
  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? Yes
  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? Yes
  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? Yes
  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)? Yes
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? Yes
  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? N/A
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