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Health Disparities

HD: Food Security (2011)


Cook JT, Frank DA, Levenson SM, Neault NB, Heeren TC, Black MM, Berkowitz C, Casey PH, Meyers AF, Cutts DB, Chilton M. Child food insecurity increases risks posed by household food insecurity to young children's health. J Nutr. 2006 Apr; 136 (4): 1,073-1,076.

PubMed ID: 16549481
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 evaluate whether children 36 months of age or younger in households exposed to food insecurity have significantly different odds of negative health outcomes than similar children in food secure households and whether the additional burden of identifiable child food insecurity is associated with even greater odds of adverse outcomes.

Inclusion Criteria:

Data from the Children's Sentinel Nutrition Assessment Program (C-SNAP) was used. This included 17, 130 children less than or equal to 36 months of age and their caregivers contacted at acute and primary care clinics and hospital emergency departments in Baltimore, Boston, Little Rock, Los Angeles, Minneapolis and Washington, DC from August 1998 to June 2004.

Exclusion Criteria:

Caregivers of critically ill children were not approached to participate in the study. Respondents were also excluded if they did not speak English, Spanish or Somali (Minneapolis only), were not knowledgeable about the child's household, the caregiver had been interviewed within the previous six months or they refused consent for any reason.

Description of Study Protocol:


Participants were recruited while visiting medical care facilities.


Analytic cohort assessment of food security and child health assessment

Blinding used

Not applicable


Not applicable

Statistical Analysis

Regression models, logistic regression models, chi square tests, T tests, multiple logistic regression models and significance assessment utilizing Statistical Analysis System. 

Data Collection Summary:

Timing of Measurements

Household surveys and medical record audits occurred between August 1998 and June 2004.

Dependent Variables

  • Household food security
  • Child food security
  • Child health status.

Independent Variables

  • Study site
  • Child age
  • Race/ethnicity
  • Health insurance status
  • Day care attendance
  • Child's mother birth place (US or other)
  • Caregiver's age
  • Employment
  • Marital and education status
  • Household participation in Supplemental Security Income (SSI)
  • Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
  • Food Stamp Program (FSP) or Temporary Assistance for Needy Families (TANF).

Control Variables

No controls were planned for this study but data from both food secure and non-secure households were included.


Description of Actual Data Sample:
  • Initial N: 17,130 children and their caregivers
  • Attrition (final N): 17,130 remained from the original pool despite 7% of those approached refusing participation and 15% not eligible due to language, lack of knowledge about child's household or having been interviewed previously
  • Age: Children were 36 months of age or younger at the time of interview
  • Ethnicity: Recorded but not reported
  • Other relevant demographics: Recorded but not reported
  • Location: Central city medical centers in:
    • Boston
    • Baltimore
    • Little Rock
    • Los Angeles
    • Minneapolis
    • Washington, DC, USA.


Summary of Results:

Key Findings

  • 22% of Households were food insecure and 12% were household and child food insecure
  • Children living in a food insecure household had significantly greater adjusted odds of fair/poor health and hospitalization since birth (1.51 (95% CI, 1.29-1.78)) compared with similar children in food secure households
  • Participation in food stamp programs reduced the odds of fair/poor health by 24% and 42% in household food insecure and household and child food insecure households, respectively.


 Child health outcomes by exposure to differences in household food security status, 1998-2002

Outcome Variables Food Secure (N=13,379, 78.1%) Household Food Insecure
(N=1,675, 9.8%)
Household and Child Food Insecure (N=2,076, 12.1%)

Child health fair/poor:
percent unadjusted
AOR (95% CI), TANF controlled
AOR (95% CI), FSP controlled





1.51 (1.29, 1.78)

1.51 (1.29, 1.78)


1.99 (1.73, 2.29)

2.00 (1.74, 2.30)

Lifetime Hospitalizations:
percent unadjusted
AOR (95% CI), TANF controlled
AOR (95% CI), FSP controlled





1.19 (1.04, 1.37)

1.19 (1.04, 1.37)


1.23 (1.08, 1.40)

1.24 (1.09, 1.41)

Admit on ED visit (N=10,505)
percent unadjusted
AOR (95% CI), TANF controlled
AOR (95% CI), FSP controlled





0.96 (0.75, 1.21)

0.95 (0.75, 1.20)


0.85 (0.67, 1.09)

0.84 (0.66, 1.07)

At risk for growth problems
percent unadjusted
AOR (95% CI), TANF controlled
AOR (95% CI), FSP controlled





1.09 (0.93, 1.28)

1.10 (0.94, 1.30)


1.02 (0.88, 1.19)

1.02 (0.87, 1.19)

AOR=Adjusted Odds Ratio; CI=Confidence Interval; TANF=Temporary Assistance for Needy Families; FSP=Food Stamp Program 

Author Conclusion:

Household food insecurity without measurable child food insecurity at any severity level is associated with adverse child health outcomes. Exposure of infants and toddlers ages less than or equal to 36 months to household food insecurity, with and without measurable child food insecurity, is associated with greater odds of fair/poor health status and experiencing health problems requiring hospitalization. Food stamp Program participation moderated the adverse effects but did not eliminate them.

Funding Source:
WK Kellogg Foundation
WK Kellogg Foundation; EOS Foundation; MAZON: A Jewish Response to Hunger, Gold Foundation, Minneapolis Foundation, Project Bread: The Walk for Hunger; Sandpipers Philanthropic Organization, Anthony Spinazzola Foundation, Daniel Pitino Foundation, Candle Foundation, Wilson Foundation, and more
Foundation associated with industry:
Other non-profit:
Reviewer Comments:

Strengths include a large total sample size from a variety of US geographical city locations.

Weaknesses may include the recruitment of participants during a probably stressful time in their lives with potential impact on their negative responses.

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) Yes
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? No
  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? 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")? Yes
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? Yes
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? No
  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.) No
  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? Yes
  5.5. In diagnostic study, were test results blinded to patient history and other test results? No
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? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  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? Yes
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? Yes
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? 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)? N/A
  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