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Household food insecurity, defined as the inability to provide enough food for a healthy and active lifestyle for all household members, is a major U.S. public health problem (Coleman-Jensen, Nord, Andrews, & Carlson, 2011). Based on data from the U.S. Department of Agriculture (USDA), in 2010, 14.5 percent of U.S. households - 17.2 million households - were food insecure, with rates as high as 49.9 percent for low-income, female-headed households with children (Nord, Coleman-Jensen, Andrews, & Carlson, 2010). Although food insecurity is associated with poverty, approximately 85 percent of food insecure households with children had an adult who was employed, suggesting that employment opportunities and wages are important considerations in food insecurity.

Consequences of household food insecurity for young children

Household food insecurity has insidious effects on the health and development of young children, including increased hospitalizations, poor health, iron deficiency, developmental risk and behavior problems, primarily aggression, anxiety, depression, and attention deficit disorder (Cook & Frank, 2008; Whitaker, Phillips, & Orzol, 2006). These concerns early in life increase children's risk of poor school readiness, poor school performance and subsequent health disparities and poverty. Research among school-age children has found associations between household food insecurity and low scores on measures of health, behavioral functioning and academic performance (Yoo, & Slack, & Holl, 2009). Findings related to the association between household food insecurity and children's growth have been controversial, with some studies showing overweight/obesity and others showing underweight (Larson & Story, 2011). Household food insecurity occurs disproportionately among children and families at high risk of obesity, making it difficult to determine causal effects. The lack of clear associations between food insecurity and children's growth means that it is often invisible. Without asking specifically about food insecurity, providers are unlikely to recognize children and families who are food insecure.

Pathways linking food insecurity and children's health and well-being

Household food insecurity has been hypothesized to operate through dual pathways: 1) a nutritional pathway, characterized by deficits in the quantity and quality of food and 2) a caregiver stress pathway, characterized by depression and anxiety related to the lack of food.

Nutritional pathway

With limited resources, food insecure families often resort to low-cost, low nutrient-dense food (Cole & Fox, 2008; Drewnowski & Specter, 2004; Olson, Bove & Miller, 2007), as they sacrifice diet quality to ensure that they have enough food to avoid the physiological pangs of hunger. Low nutrient-dense diets may increase the risk for obesity or for micronutrient deficiencies, including iron deficiency (Skalicky, et al., 2006). Dietary data have shown that children from low-income food insecure households consume fewer calories, carbohydrates and fruits, and have higher cholesterol values than their food secure, higher-income peers (Casey, Szeto, Lensing, Bogle, & Weber, 2001). In addition food insecure-exposed children consume fewer fruits, dark green vegetables, grains, yogurt, nuts, seeds, and dried beans and peas, but more sugar and eggs than children from food-secure households, illustrating that the quality of children's diets differ as a function of their food security status.

Caregiver depression and anxiety pathway

Most of the research on food insecurity has been cross-sectional. However, several longitudinal investigations into the mechanisms linking household food insecurity with children's health and development have used the Early Childhood Longitudinal Study, which includes the USDA Household Food Security Scale. Two studies found that food insecurity operates through maternal depression and parenting to negatively impact children's mental development and attachment (Zaslow, Bronte-Tinkew, Capps, Horowitz, Moore, & Weinstein, 2009) and to promote overweight by age 24 months (Bronte-Tinkew, Zaslow, Capps, Horowitz, & McNamara, 2007). Early in life, children and caregivers establish a partnership in which they recognize and interpret both verbal and nonverbal communication signals from one another. This reciprocal process forms a basis for the emotional bonding or attachment between infants and caregivers that is essential to healthy social functioning. Parental responsivity is thought to provide the emotional support that children need to develop internal regulatory skills and an interest in exploration and ongoing social interactions, thereby leading to advances in psychosocial, cognitive and language competence. Thus, the caregiving context plays a critical role in protecting and socializing children.

As proposed by the family stress model (Conger, Wallace, Sun, Simons, McLoyd, & Brody, 2002), families with few economic resources may be forced to make difficult choices among basic needs, such as food, housing, energy and health care, often resulting in frustration and emotional distress (Wickrama, Conger, Lorenz, & Jung, 2008). Emotional distress, frequently manifested as symptoms of depression and anxiety, increases the number of stressors, interferes with caregiving practices and adversely impacts children's well-being (Bradley & Corwyn, 2002).

Household food insecurity has been associated with caregiver depression and anxiety (Whitaker, et al., 2006) and with the resulting poor caregiving practices that have been shown to lead to deficits in both mental development and attachment (Bronte-Tinkew et al., 2007; Zaslow et al., 2009).

Measures of household food security

Household food security is often measured with the 18-item USDA Household Food Security Scale (Bickel, Nord, Price, Hamiltonal, & Cook, 2000; Nord & Hopwood, 2007). According to established procedures from the USDA, households are classified according to standard methods as food insecure if they score at a level indicating they cannot afford enough nutritious food for active, healthy lives, and if this condition results from constrained resources (greater than three affirmative responses out of 18 total questions). Families endorsing more items are classified as low or very low food secure. We recently demonstrated the sensitivity, specificity and validity of a two-item screener among low-income families of children under age 3 years, "Within the past 12 months we worried whether our food would run out before we got money to buy more." and "Within the past 12 months the food we bought just didn't last and we didn't have money to get more." (Hager et al., 2010). The screener addresses both lack of food and anxiety about lack of food and can be used to identify families at risk of food insecurity. Evidence has shown that participation in food assistance programs, such as the Special Supplemental Program for Women, Infants, and Children (WIC) or the Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) reduces the prevalence of food insecurity (Black et al., 2012; Metallinos-Katsaras, Gorman, Wilde, & Kallio, 2011; Nord & Prell, 2011).

Conclusion

Ensuring food security is a national priority, particularly for young children, because it is adversely associated not only with their current health and well-being, but also with their future health. Investing in children's health and well-being early in life sets them on a positive trajectory toward future success.

References

Bickel, G., Nord, M., Price, C., Hamiltonal, W., & Cook, J. Guide to Measuring Household Food Security: Revised 2000. Department of Agriculture, Food and Nutrition Service 2000.

Black, M. M., Quigg, A. M., Cook, J., Casey, P. H., Cutts, D.B., Chilton, M., Meyers, A., Ettinger de Cuba, S., Heeren, T., Coleman, S., Rose-Jacobs, R., & Frank, D.A. (in press). WIC participation protects children from health risks associated with dual stressors of household food insecurity and caregiver depressive symptoms. Archives of Pediatric and Adolescent Medicine.

Bradley, R. H., & Corwyn, R. F. (2002) Socioeconomic status and child development. Annual Review of Psychology,53, 371-99

Bronte-Tinkew, J., Zaslow, M., Capps, R., Horowitz, A., & McNamara, M. (2007). Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers. Journal of Nutrition, 137(9), 2160-2165.

Casey, P., Szeto, K., Lensing, S., Bogle, M., & Weber, J. (2001). Children in food-insufficient, low-income families: prevalence, health and nutrition status. Archives of Pediatrics and Adolescent Medicine, 155(4), 508-514.

Cole, N., & Fox, M. K. Diet Quality of American Young Children by WIC Participation Status:
Data from the National Health and Nutrition Examination Survey. Special Nutrition Programs Report No. WIC-08-NH. Published July 2008. U.S. Department of Agriculture, Food and Nutrition Service. Accessed February 23, 2012.

Coleman-Jensen, A., Nord, M., Andrews, M., & Carlson, S. (2001). Household Food Security in the United States in 2010.

Conger, R. D., Wallace, L. E., Sun, Y., Simons, R. L., McLoyd, V.C., &Brody, G. H. (2002). Economic pressure in African American families: a replication and extension of the family stress model. Developmental Psychology(2), 179-193.

Cook, J. T., & Frank, D. A. (2008). Food security, poverty, and human development in the United States. Annals of the New York Academy of Sciences, 1136, 193-209.

Drewnowski, A., & Specter, S. E. (2004). Poverty and obesity: the role of energy density and energy costs. American Journal of Clinical Nutrition, 79(1), 6-16.

Hager, E., Quigg, A., Black, M. M., Coleman, S., Heeren, T., Rose-Jacobs, R., Cook, J. T., Ettinger De Cuba, S. A., Casey, P. H., Chilton, M., Cutts, D. B., Meyers, A.F., & Frank, D. (2010). Development and validity of a brief 2-item screen to identify families at risk for food insecurity. Pediatrics. 126 (1), e26-e32.

Larson, N., & Story, M. (2011). Food insecurity and weight status among U.S. children and families: a review of the literature. American Journal of Preventive Medicine, 40(2), 166-173.

Metallinos-Katsaras, E., Gorman, K. S., Wilde, P., & Kallio, J. (2011). A longitudinal study of WIC participation on household food insecurity. Maternal and Child Health Journal, 15, 627-633.

Nord, M., Coleman-Jensen, A., Andrews, M., & Carlson, S. (2009). Household food security in the United States, ( Economic Research Report No. 56). (PDF, 650KB) 2010.

Nord, M., & Hopwood , H. (2007). Recent advances provide improved tools for measuring children's food security. Journal of Nutrition, 137(3), 533-536.

Nord, M. & Prell, M. (2011). Food Security Improved Following the 2009 ARRA Increase in SNAP Benefits. Economic Research Report No. (ERR-116).

Olson, C. M., Bove, C. F., & Miller, E. O. (2007). Growing up poor: Long-term implications for eating patterns and body weight. Appetite, 49(1), 198-207.

Skalicky, A., Meyers, A., Adams, W., Yang, Z., Cook, J., & Frank, D. (2006). Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States. Maternal and Child Health Journal, 10(2), 177-185.

Whitaker, R. C., Phillips, S. M., & Orzol, S. M. (2006). Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics, 118(3), e859-68.

Wickrama, K. A., Conger, R. D., Lorenz, F. O., & Jung, T. (2008). Family antecedents and consequences of trajectories of depressive symptoms from adolescence to young adulthood: a life course investigation. Journal of Health and Social Behavior, 49(4), 468-483.

Yoo, J. P., Slack, K. S., & Holl, J. L. (2009). Material hardship and the physical health of school-aged children in low-income households. American Journal of Public Health, 99(5), 829-836.

Zaslow, M., Bronte-Tinkew, J., Capps, R., Horowitz, A., Moore, K. A., & Weinstein, D. (2009). Food security during infancy: implications for attachment and mental proficiency in toddlerhood. Maternal and Child Health Journal, 13(1), 66-80.

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Household food insecurities: Threats to children's well-being

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Household food insecurity, defined as the inability to provide enough food for a healthy and active lifestyle for all household members, is a major U.S. public health problem (Coleman-Jensen, Nord, Andrews, & Carlson, 2011). Based on data from the U.S. Department of Agriculture (USDA), in 2010, 14.5 percent of U.S.

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Food Insecure Children - The State of Obesity

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The State of Obesity: Better Policies for a Healthier America // a project of the Trust for America's Health and the Robert Wood Johnson Foundation