Quality Versus Quantity
The total amount of food is not the only factor in adequate child nutrition. Healthy foods usually cost more and also may not be conveniently available. There are so called “food deserts,” areas with few/no full-service grocery stores, and also “food swamps” where unhealthy foods (eg fast food) are more available than healthy options. Life stress, higher in low-income populations, increases the impulse to consume sweet or high-fat “comfort foods” (we all know this!) due to the rush of calories and quick satiety. Children may be influenced in their food choices by media messages about non-nutritious foods. All of these may explain the association of food insecurity with obesity in both children and adults. It also sets them up for lifetime health problems of diabetes, hyperlipidemia, and cardiovascular conditions, especially in racial and ethnic minority groups and the poor.
The Larger Picture
Obvious to us all, low income is the main reason for inadequate access to enough or good quality food. Over 60% of families with food insecurity had incomes below the poverty threshold in 2013. Households without children are half as likely to be food insecure. But as 30% of food-insecure households have incomes above the eligibility cut offs for food programs — typically 130% of poverty for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or 185% for Supplemental Nutrition Assistance Program (SNAP) — it is clear the problem is not related solely to poverty. Even small changes in income or expenses, such as a car breaking down, or heating or medical bills, can quickly result in inability to afford food, especially in areas of high food costs. This is particularly true for immigrant, large, and single-parent families and those with less education. Federal food programs do not cover all food needs for every family.
But we can’t tell if a child lives in a family with food insecurity by whether the child is thin, dropping growth percentiles, or receiving Medicaid insurance. Parents, and even youth, may be reluctant to tell us that they do not have enough to eat out of pride, fear, of prejudice, being reported to a contentious ex, being detected as an illegal immigrant, or even reported for neglect and having their child removed. Because of the suffering and impacts of food insecurity on child well-being, the American Academy of Pediatrics (AAP) published a Policy Statement in 2015, reaffirmed in 2021, recommending screening for food insecurity at all well visits and a toolkit to help. The USDA 18-item Household Food Security Scale (HFSS) has been the gold-standard screen, but affirmative answers to either of the 2-item Hunger Vital Sign (HVS) questionnaire identifies food insecurity with a sensitivity of 97% and a specificity of 83% compared with the HFSS. The questions ask how often the following were true in the past year: 1) “We worried whether our food would run out before we got money to buy more” and 2) “The food we bought just didn’t last and we didn’t have money to buy more.” This brief screen is now recommended and practical.