Household food insecurity, lacking access to enough food for an active, healthy life for all household members [1
], is a national public health problem with negative health consequences throughout life [2
]. In 2017, households with children under age six years had higher rates of food insecurity, compared to households without children (16.4% vs. 10.1%) [1
]. Access to nutritious food is particularly critical early in life during the period of rapid growth and brain development. Families with food insecurity often substitute low nutrient dense food for nutritious food to assuage hunger [3
]. Young children raised in food insecure households are at risk for adverse health consequences, including perceived fair/poor health [4
]; prior hospitalizations [4
]; developmental risk [5
]; cognitive impairment [7
]; and behavioral dysfunction and emotional distress [8
]. Inadequate nutritional intake can increase children’s vulnerability to future adverse chronic conditions, such as obesity, diabetes and cardiovascular disease [9
]. When the parental stress and depression that are often associated with household food insecurity are also considered, the vulnerability associated with food insecurity can last throughout life [9
], leading to higher healthcare costs [11
Household food insecurity is often invisible, as young children do not necessarily have compromised growth [12
]. Unless providers specifically ask about food insecurity, they may not recognize children in food insecure households. A 2-item screener, known as the Hunger Vital Sign, has been developed and validated against the gold standard Household Food Security Survey Module (HFSSM) showing high sensitivity and specificity among young children [14
]. The validity of the 2-item screener has been extended to adolescents and adults [15
]. In 2015, the American Academy of Pediatrics issued a policy statement recommending that pediatricians screen families with children for food insecurity, and implement referrals as needed [17
]. The policy statement does not mention screening in emergency departments (ED).
Recent reports indicate increases in ED use among children, primarily Medicaid beneficiaries [18
], suggesting that EDs serve as a safety net for low-income families. If rates of household food insecurity are high among children in EDs, there may be missed opportunities to connect families with resources to reduce food insecurity. In addition, if food insecurity is associated with adverse health conditions, there may also be missed opportunities to identify and improve children’s adverse health conditions.
The purpose of this study is to examine the sensitivity and specificity of the 2-item Hunger Vital Sign against the gold standard 18-item HFSSM in identifying household food insecurity among young children in an ED and primary care, and to compare the associations between food insecurity and adverse health conditions using both the Hunger Vital Sign and the HFSSM. A finding that the Hunger Vital Sign is effective in identifying food insecure households of young children in the ED and that food insecurity among households of young children is associated with adverse health conditions, measured with either the HFSSM or the Hunger Vital Sign and across sites would provide additional evidence that the Hunger Vital Sign can (and should) be used to screen for food insecurity across multiple sites, including EDs.
Of the 6519 children assessed in 2009–2017, 1480 were excluded (861 had private insurance and 619 had acute health problems, including 187 who were admitted to the hospital), leaving an analytic sample of 5039.
As shown in Table 1
, 90% of caregivers were mothers (6% fathers, 3% grandparents, and 1% other); 84% of caregivers were over 21 years-of-age; 89% were African American; 78% completed high school, including 32% with technical or post-high school education; 43% were employed, and 77% were single, separated, divorced, or widowed. Over half of the children were males (53%), 74% were younger than 24 months, and 17% had a history of low birthweight. Eight percent of caregivers perceived their child’s health as fair/poor, 20% of children had a hospitalization history, and 16% were at developmental risk.
also shows a higher prevalence of maternal employment and a higher prevalence of children age <24 months among caregivers in food secure, compared to food insecure households. In addition, based on the Hunger Vital Sign, but not HFSSM, the prevalence of caregivers who had completed high school and who were not married was higher in food secure compared to food insecure households.
In the ED, compared to primary care, Table 1
shows a higher prevalence of caregivers younger than age 21, of African American race, of not being married, and of having a child aged 25–47 months. There were no differences between the ED and primary care in the prevalence of children’s birth weight or in maternal education or employment.
3.1. Food Insecurity in the ED and Primary Care
As shown in Table 1
, based on the HFSSM, the prevalence of household food insecurity was higher in the ED (22.7%), compared to primary care (17.9%) (p
< 0.001). Similarly, based on the Hunger Vital Sign, the prevalence of household food insecurity risk was higher in the ED (32.9%), compared to 27.7% in primary care, p
As shown in Table 2
, based on the HFSSM, the crude odds ratio for food insecurity in the ED was significantly greater than in primary care, indicating a 35% increase in the odds of young children in the ED experiencing food insecurity, compared to children in primary care. After adjusting for covariates, the odds ratio for food insecurity in the ED was significant, but attenuated and indicated a 28% increase in the odds of young children in the ED experiencing food insecurity, compared to children in primary care.
also shows that the crude odds ratio for food insecurity in the ED based on the Hunger Vital Sign was significantly greater than in primary care, indicating a 28% increase in the odds of young children in the ED experiencing food insecurity, compared to children in primary care. After adjusting for covariates, the odds ratio for food insecurity in the ED based on the Hunger Vital Sign was similar, indicating a 26% increase in odds of young children in the ED experiencing food insecurity, compared to children in primary care.
3.2. Sensitivity and Specificity of the Hunger Vital Sign
The sensitivity of the Hunger Vital Sign against the gold standard, HFSSM, was 96.7% and the specificity was 86.2% (see Table 3
). Among the children identified as household food insecure by the HFSSM, 96.7% were also identified as food insecure by the Hunger Vital Sign and 3.3% were misclassified as food secure. Of the children were identified as food secure by the HFSSM, 86.2% were also identified as food secure by the Hunger Vital Sign and 13.8% were misclassified as food insecure. Positive predictive value, the probability that children classified as food secure on the Hunger Vital Sign are food secure based on the HFSSM is 65.7% and negative predictive value, the probability that children classified as food insecure on the Hunger Vital Sign are food insecure on the HFSSM, is 99.0%.
3.3. Adverse Child Health Conditions by Food Security and Site
As shown in Table 1
, the prevalence of children with adverse health conditions was higher in the ED, compared with primary care, including children perceived to be experiencing fair/poor health (8.8% vs. 5.5%, p
< 0.001) and prior hospitalizations (22.6% vs. 13.9%, p
< 0.001). There were no site differences in the prevalence of children with developmental risks (16.1% vs. 17.9%, p
= 0.237). After covariate adjustment, Table 4
shows that children in the ED had 63% higher odds of being perceived in fair/poor health (aOR = 1.63, 95% CI: 1.22–2.17, p
< 0.001) and 65% higher odds of prior hospitalization, compared to children in primary care (aOR = 1.65, 95% CI: 1.36–1.99, p
< 0.001). Site was not related to developmental risk in either unadjusted or adjusted analyses.
Children in food insecure households, defined by HFSSM, had 72% greater odds of fair/poor perceived health (aOR = 1.72, 95% CI: 1.37–2.18, p
< 0.001), 37% greater odds of prior hospitalization (aOR = 1.37, 95% CI: 1.16–1.62, p
< 0.001), and 46% greater odds of developmental risk (aOR = 1.46, 95% CI: 1.19–1.78, p
< 0.001), compared to children in food secure households after covariate adjustment, as shown in Table 4
. Interactions between site and food insecurity defined by HFSSM were not significant for developmental risk and fair/poor perceived health, but the interaction was significant for prior hospitalization (p
= 0.008). Stratified analyses showed that the relation between food insecurity and prior hospitalization was significant in primary care (aOR = 2.09, 95% CI: 1.42–3.08, p
< 0.001), but not in the ED (aOR = 1.22, 95% CI: 1.02–1.47, p
= 0.033, not shown in the table).
Analyses were repeated defining food insecurity by the Hunger Vital Sign, as shown in Table 4
. Findings were similar. Children in food insecure households, defined by the Hunger Vital Sign, had 53% greater odds of fair/poor perceived health (aOR = 1.53, 95% CI: 1.23–1.91, p
< 0.001), 28% greater odds of prior hospitalization (aOR = 1.28, 95% CI: 1.10–1.48, p
= 0.002), and 44% greater odds of developmental risk (aOR = 1.44, 95% CI: 1.20–1.73, p
< 0.001), compared to children in food secure households after covariate adjustment. There was a significant interaction for prior hospitalization (p
= 0.005), but not for fair/poor health or developmental risk. Stratified analyses showed that the relation between food insecurity and prior hospitalization was significant in primary care (aOR = 1.99, 95% CI: 1.40–2.84, p
< 0.001), but not in the ED (aOR = 1.16, 95% CI: 0.98–1.37, p
= 0.083, not shown in the table).
This research yields three findings related to household food insecurity among young children under age four years in health care sites. First, based on the HFSSM, 22% of the children in the ED were living in a food insecure household, a rate substantially higher than in primary care, and higher than the national rate for households with children under age six years [1
], illustrating the high likelihood of young children in EDs experiencing household food insecurity.
Second, children in food insecure households were at increased risk for perceived fair/poor health, prior hospitalizations, and developmental risk, across both health care sites, illustrating the vulnerabilities associated with food insecurity. These findings contribute to the evidence linking food insecurity and adverse health conditions among young children reported previously [4
]. Inexpensive foods that are low in nutrients and high in energy may increase children’s vulnerability to nutritional deficiencies and associated adverse health conditions [25
]. In addition, the parenting stress and anxiety associated with food insecurity has been associated with non-responsive feeding behavior [26
]. Non-responsive parenting skills may contribute to children’s developmental problems.
An elevated risk of food insecurity has been reported among children with special health care needs [27
]. Although it is not clear why the odds of prior hospitalization among children in food secure households were significant in the primary care site, but not in the ED, a possible explanation is that the primary care site provides specialty care for children with special health care needs. Thus, the association between food insecurity and prior hospitalization in primary care may represent increased vulnerability among children with special health care needs.
Third, the Hunger Vital Sign [19
], was effective in identifying children in food insecure households and in replicating the analyses linking food insecurity with adverse child health conditions conducted with the HFSSM. The sensitivity and specificity of the Hunger Vital Sign are consistent with prior findings [14
]. The higher rates of food insecurity in the ED and primary care based on the Hunger Vital Sign, compared to the HFSSM, occur because children classified as living in marginal food secure households on the HFSSM (endorsement of one or two questions) are classified as food insecure using the Hunger Vital Sign. Children in marginal food secure households have been shown to be at risk for adverse child health conditions [28
]. Thus, identifying children through the Hunger Vital Sign could lead to closer attention to previously unrecognized adverse health conditions. These findings suggest that screening for household food insecurity in both EDs and primary care will uncover additional children living in food insecure households.
The Hunger Vital Sign is easy to administer and is increasingly being incorporated into electronic medical records (EMR) [29
]. Efforts to increase screening for household food insecurity have been effective in primary care [30
] and in other clinics serving low-income families [31
]. Providers are developing innovative strategies to connect food insecure families with services [32
]. In addition to federal nutritional services, such as the Supplemental Nutritional Assistance Program (SNAP) and the special supplemental nutrition program for Women, Infants and Children (WIC), families can benefit from local resources, including food pantries and food banks [30
]. Hennepin County Medical Center in Minnesota created an innovative referral system integrated into the EMR [33
]. With family’s consent, contact information on food insecure families is auto-faxed to a partner food bank. Trained outreach food bank staff make telephone contact with families and provide application assistance for food assistance programs (e.g., SNAP) and geographically individualized information about WIC, neighborhood food shelves, produce distributions, summer feeding sites and community meals. In 2015, 64% of the 1003 patient EMR-based referrals were successfully contacted and 82% were connected with at least one new form of food assistance. Of persons contacted and not currently enrolled in SNAP, applications were completed for 67%, 26% were found to be ineligible, and 7% declined to apply [33
Emergency Departments have a demonstrated record of effective health screening, including brief survey tools for mental health conditions such as suicide [34
]. Adolescents in EDs have been shown to accept screenings for HIV [35
], enabling clinicians to implement recommendations from the Centers for Disease Control and Protection. Screening procedures have enabled clinicians to provide linkages to hospital, outpatient, and community resources for patients who may have otherwise had limited access to needed services. Integrating the Hunger Vital Sign into the EMR during triage may be a cost-efficient method to flag patients at risk of food insecurity and in need of resources.
There are several methodological limitations to consider. First, the sample included health-seeking caregivers and their young children from one urban medical center. However, the sample size was large, covered multiple years, and addressed very young children, a population known to be vulnerable to threats of food insecurity. Second, information about food security and children’s health conditions was gathered from caregiver-report. However, validated measures were used and data were collected by trained research assistants, reducing, but not eliminating concerns about recall and shared method bias. Third, all caregivers received public health insurance and were from the same urban community, limiting the generalizability of the findings. Demographic characteristics, including maternal age, race, marital status and employment, and child age and sex differed between the ED and primary care. However, analyses were adjusted for these demographic differences. Finally, the sample was limited to children under four years of age. Although young children are vulnerable to household food insecurity [4
], they have access to nutritional assistance programs such as WIC and therefore may be less vulnerable than older children.