Are you adequately screening for hunger?


More than 20% of U.S. children lack adequate nutritious food, and most of their families make too much money to qualify for federal assistance. Find out how to screen patients for food insecurity and what you can do to help.

Nearly a quarter of all US children have inconsistent access adequate food, and healthcare providers may not be recognizing which families need help.

Pediatricians must work to perform broader screenings for food safety by assessing each patient for food security and connecting those in need with community resources, according to new guidance from the American Academy of Pediatrics’ (AAP) Committee on Nutrition.

“We’re now recommending that pediatricians universally screen for food security,” says Julie Linton, MD, FAAP, assistant professor of pediatrics at Wake Forest Baptist Medical Center, Winston-Salem, North Carolina,  and co-author of AAP’s new statement. “We’re really including food security as an essential element of core pediatric care. Children, in order to grow, develop, and be healthy, need access to nutritious food.”

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The US Department of Agriculture (USDA) recently revealed that 17.5 million US households (14.5%)-including 21% of the nation’s children-meet federal criteria of a food-insecure household. This means that those families lack access to adequate food as a result of money or other resources. Families with children are more likely to meet this criteria, and their children are therefore more likely to get sick more often; recover from illness more slowly; and have difficulty learning and concentrating-among other negative effects, the report states.

Unfortunately for these families, Linton says that many can’t afford adequate food, and do not qualify for many federal assistance programs.

“In 2013, almost 60% of all food-insecure households had incomes below 185% of the federal poverty thresholds, the income eligibility cutoff for many child nutrition programs,” the report states. “The federal poverty threshold for an average family of 4 people in 2013 was $23,834; 185% of this threshold amount is $44,093, but the federal poverty level is not a definition of economic hardship, and the amount to provide basic needs for a family of 4 often far exceeds this amount. Because 30% of food-insecure households have incomes above this level, it is clear the problem is not related solely to poverty.”

Previously thought to be immune to a problem that was viewed as an urban issue, food insecurity is now reaching into the suburbs and rural America, the report states. Relatively small changes to income or access to public assistance programs can have a significant impact on a family’s ability to purchase adequate, nutritious food on a regular basis, and the report notes that 30% of food-insecure families admit to having to choose between paying for food and paying for medicine or medical care.

The most at-risk households for food-insecurity are those facing unemployment, immigrant families, large families, families headed by single women, families with less education, and households experiencing a separation or divorce. Not all of these families are completely unemployed, either, the report notes.

NEXT: Who is at particular risk of food insecurity?


“Working poor families and single-parent families are at particular risk of food insecurity,” the report states.

While some of these households do qualify for public assistance programs, not all meet the criteria.

“In low-income households with children and food insecurity, 84% participated in at least 1 federal food assistance program, such as the Supplemental Nutrition Assistance Program (SNAP) or free or reduced-price school meals in 2010 to 2011,” the report states. “Thus, 16% of low-income, food-insecure households with children do not receive federal supports. Federal benefits can attenuate the severity of food insecurity but might not eliminate it, particularly for children and in regions with higher food costs.”

As far as the effects of food insecurity on children, studies reveal that parents limit their own intake to spare their children, but multiple adverse effects are still associated with inadequate food supplies.

More: Redefining pediatric malnutrition to improve treatment

Children aged younger than 36 months in these populations have poor overall health and more frequent hospitalizations than their peers, are more likely to experience iron deficiencies and lower bone densities in some groups. Food insecurity in childhood also places children in these households at a higher risk of developing obesity later in life, according to the report.

“Children in food-insecure households generally have limited access to high-quality food. Environmental realities in low-income neighborhoods, including decreased presence of full-service grocery stores and increased availability of fast food restaurants and energy-dense, nutrient-poor food, may create barriers for low-income families trying to adopt healthy behaviors,” the report states. “Adequate food may be available only intermittently, leading to unhealthy eating patterns and increased stress that may make weight loss difficult and facilitate the development of obesity. Households with smokers are more likely to be food insecure, perhaps because of the diversion of money to tobacco in these households.”

Cognitive disorders may also result from food insecurity, such as dysregulated behavior, emotional distress, impaired school function, and reduced academic achievement. By adolescence, these children may also face increased dysthymia and suicidal ideation related to changes in neurotransmitters caused by poor diet, hunger sensations, and emotional reactions to food, according to the report.

In the long term, children who face malnutrition early in life are more likely to develop chronic conditions later on, such as diabetes, hyperlipidemia, and cardiovascular disease.

While an additional screening may seem a daunting addition to an already packed pediatric well visits, Linton says pediatricians are in the best position to identify food insecurity and offer solutions.

“There’s a lot of things we are supposed to do in pediatrics, and so I’m not sure that these questions are getting asked even though it’s been discussed that food security is important in the past,” Linton says.

The particular questions or how they are asked isn’t important, but the assessment must go beyond assumptions based on family appearance or simply asking a child if they are hungry.

“The people you don’t expect to be impacted by this might need it,” Linton says, adding that 60% of all food insecure households make too much money to qualify for public assistance programs. “One of the most meaningful things for families and communities is food and hunger. There’s long term and pervasive effects of hunger on children.”

Some suggestions for assessment in the report include the USDA’s 18-item measure to assess food insecurity with the Household Food Security Scale, which is the standard tool for research. A 2-item screen designed by Hager et al uses two of USDA’s questions and might be a more effective tool in clinical practice, according to the report.

Pediatricians can help mitigate the negative effects of food insecurity by increasing their own knowledge of federal, state, and community resources available to households in need.

NEXT: Resources available to households in need


• The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program aimed at providing nutritious foods for pregnant, breastfeeding, and postpartum women as well as infants up to age 1 year, and children up to age 5 years. An associated program, the WIC Farmer’s Market Nutrition Program, provides vouchers for the purchase of fresh, local produce from farm markets and roadside stands.

• The SNAP program is a federal assistance program that provides nutrition assistance to low-income families and individuals. It is the largest food and nutrition program of the USDA, and provides monthly benefits to 47 million Americans to purchase eligible food items.

• National School Lunch and National School Breakfast programs provide more than 43 million children with low-cost or free breakfasts and lunches each year. The program was expanded in 1998 to include snacks in after-school programs.

• The USDA’s Child and Adult Care Food Program provides cash aid to states so they can provide nutritious foods to adults and children housed in institutions or group homes.

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• The Summer Food Service Program ensures that low-income children continue to receive nutritious meals when school is not in session, and includes free meals and snacks at community sites for children aged 18 years and younger. The program serves about 2 million children each summer.

• Community resources may also include soup kitchens, food pantries, and other charitable food providers. While these resources may be helpful in supporting better nutrition and improved food insecurity, the report notes that these sources may not be consistently able to provide healthful or adequate food to households in need for more than a few days at a time.

Pediatricians should also work to maintain strong nutrition guidelines; support policies and programs that support childhood nutrition; advocate for children’s health programs at the national and state level; and participate in community education and outreach efforts, according to AAP.

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