Associations of social determinants of health and childhood obesity: a cross-sectional analysis of the 2021 National Survey of Children’s Health

Methods

We utilized the 2021 NSCH data that are directed and funded by the Health Resources Service Administration (HRSA) Material and Child Health Bureau (MCHB) [20]. The NSCH collects and reports on multiple aspects of children’s lives – physical and mental health, school, neighborhood, social context, and the child’s family – in all 50 states and the District of Columbia [20]. The current NSCH survey is a combination of two surveys: the previous NSCH and the National Survey of Children and Special Health Care Needs (NS-CSHCN) [20]. Questionnaires are completed online or by mail by a primary caregiver of the child aged 0–17 years [20].

Results

The 2021 NSCH survey had an overall response rate of 40.3 %. The number of children included in our sample who met the inclusion criteria was 20,091 (n), which represents a population estimate of 32, 028, 115 (N). Among these children, 3,053 were classified as having obesity with a weighted sample population estimate of 5,667,243 (17.59 %) being classified as obese.

Sum variable analysis

The majority of children in our sample were reported to have experienced 0 SDOH (n=13,163, 64.47 %) followed by experiencing one SDOH (n=3,897, 22.64 %; Figure 1). Compared to children without obesity, those with obesity were more likely to experience 1 SDOH (AOR: 1.63, 95 % CI: 1.32–2.01; Figure 1). The odds were more than twice as high for children with obesity to have experienced two or three domains of SDOH, and more than three times as high to experience four or more domains of SDOH compared to children without obesity.

Figure 1:

Cumulative social determinants of health (SDOH) among children with and without obesity.

Discussion

Our results showed significant binary associations between multiple domains of SDOH (healthcare access, economic stability, food insecurity, and neighborhood safety) and childhood obesity; however, after controlling for race/ethnicity, parental education, household income, and child sex, only the SDOH domain of food insecurity was observed to be statistically significant. While adjusting for these control variables shows the strong relationship between food insecurity and obesity, low SES (which comprises most of the control variables) has been shown to have a bidirectional and generational relationships with SDOH [23], thus likely having indirect impacts on in the context of childhood obesity. Therefore, consideration for financial insecurity and the intersection of race and SES are important factors in any efforts to address childhood obesity and food insecurity.

In early 2023, the AAP released a revised “CPG for the Evaluation and Treatment of Children and Adolescents with Obesity [2],” which included SDOH domains such as SES, community-level factors, and food insecurity and are extensively discussed as risk factors to the development of childhood obesity [2]. Given the rising prevalence of childhood obesity in the United States, along with evidence supporting SDOH as predictors to the development of childhood obesity, it is imperative that clinical practice includes routine screening for, and intervention of, food insecurity in families [2]. As part of the 2023 GCP, the AAP recommends providers to utilize a toolkit developed in partnership between the AAP and the Food Research and Action Center titled “Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity [2].” While pediatricians are the primary audience for the toolkit, all healthcare providers caring for children can utilize this toolkit as part of their clinical practice [24]. The toolkit includes education related to identifying children experiencing food insecurity, guidance on how to address the topic in a sensitive and culturally appropriate manner, and advice about how to connect families to appropriate community resources, as well as information regarding how to advocate for change at the policy level [24]. The “Hunger Vital Sign,” a validated two-question assessment, is also included as a tool to help providers identify families experiencing food insecurity [24].

Our findings further illuminate this linkage of food insecurity and childhood obesity, which concur alongside previous research. For example, Do et al. [25] found that adolescents living in food-insecure homes were more likely to be overweight or have obesity. Individuals experiencing food insecurity may tend to have more irregular eating patterns – consisting of underconsumption during food deprivation and overconsumption with adequate resources [26]. Additionally, consuming more high-calorie, low-cost foods due to their widespread availability may be a contributing factor to childhood obesity [26]. Further, implications on health and health outcomes can be related to food insecurity and childhood obesity. Food insecurity has been shown to influence long-term weight trajectories among children with obesity [27]. Tester et al. performed a longitudinal analysis examining food insecurity and weight change over time among low-income children [27]. They found that monthly change in BMI was significantly smaller for food-insecure children compared to children who were food-secure [27]. Similarly, other researchers have linked household food insecurity to poorer general and oral health, poorer academic performance, behavioral and cognitive problems, and depression [28]. For instance, children in food-insecure households have been shown to have increased odds of emotional eating, depressive symptoms, perceived stress, and household chaos and family functioning, compared to food-secure households [29]. However, other studies have found conflicting results. A systematic review of 13 articles found mixed evidence on the relationship between food insecurity and childhood obesity [30]. Another study of adolescents in the United States found a higher prevalence of adolescents having obesity in adolescents from food-insecure homes compared to those from food-secure homes; however, no association was found after adjusting for age, race, sex, poverty, and healthcare access [31]. Even with contradictory results, researchers agree that there is a relationship with complex underlying mechanisms [30].

Given the need for screening and appropriate management of SDOH such as food insecurity to decrease the likelihood of childhood obesity, it is critical that the reimbursement criteria be modified and adhered to because this continues to be a significant barrier to effective treatment strategies even after the passage of the Affordable Care Act [2]. Conversely, governmental programs aimed at improving food security have been shown to mitigate the associated health risks of being food insecure [32]. Ratcliffe et al. [33] utilized a bivariate probit model to show that participation in the Supplemental Nutrition Assistance Program (SNAP) reduces the likelihood of being food insecure or very food insecure by 31 and 20 %, respectively. SNAP also provided an additional 20 % decrease in food insufficiency among recipient families [33]. In terms of health benefits, adults with access to SNAP benefits in early childhood were shown to have lower risks of obesity, heart disease, and diabetes [34]. Similarly, mothers exposed to SNAP during pregnancy were found to have fewer low-birthweight babies [34]. Expanding access to supplemental nutrition programs – especially in early childhood – might be an important strategy for reducing rates of childhood obesity and the associated health outcomes.

As a part of the updated CPG for childhood obesity, the AAP subcommittee recommends that public health agencies, community organizations, healthcare systems, and community members increase community resources to help address SDOH while promoting healthy and active lifestyles [2]. Additionally, as previously noted, programs targeting household food insecurity may reduce children’s chronic and acute health problems. Emergency food systems in the United States, including food banks, are vital resources aimed at combating food insecurity. These are especially important for families designated ineligible for government assistance programs due to strict income-based eligibility rules [35]. Thus, nonprofit food banks and food pantries provide a solution for these ineligible groups that may be experiencing food insufficiency. Feeding America, a network of >200 food banks, serves those who are in need of nutritious foods and engages in advocacy to fight hunger [36]. The organization currently has over 60,000 food pantries and meal programs throughout the nation, serving 1 in 7 Americans annually [37]. Additionally, The Emergency Food Assistance Program (TEFAP) is a federal program that helps supplement the diets of low-income Americans by providing them with emergency food assistance at no cost [38]. Through funding from the USDA, organizations receiving TEFAP support – such as Feeding America – can keep their shelves stocked and increase access to nutritious foods among families experiencing food insecurity or insufficiency [39]. Therefore, continual funding for emergency food programs such as food banks and pantries might alleviate the risk of both food insecurity and childhood obesity, especially among low-income families who do not qualify for SNAP benefits.

Recommendations

Although programs such as SNAP and Women, Infants, and Children (WIC) have been widely utilized in the United States, these programs can be improved significantly through policy. For instance, even with the nearly 27 % increase in Fiscal Year 2021 SNAP benefits, the benefits will still not cover the average price of a meal in 21 % of counties in the United States [40]. As such, The State of Childhood Obesity, an initiative by the Robert Wood Johnson Family Foundation, has provided five policy recommendations related to SNAP [41]. These recommendations include: (1) broadening the program to cover more adults; (2) making sure benefits cover the cost of average meals in all counties; (3) improving eligibility and enrollment processes to eliminate barriers; (4) removing lifetime bans for felony drug convictions; and (5) continued authorization of the Gus Schumacher Nutrition Incentive Program [41]. Similarly, the group has provided policy recommendations for WIC, including extending benefits for mothers through the first 2 postpartum years, and for children under 6 years of age, among other recommendations [42].

In addition to changes to existing programs, concerns related to food access need to extend beyond meeting daily caloric intake to consider from where calories are coming. Beyond the USDA’s definition of food security, a standard definition of “nutrition security” is needed at the federal level to accommodate this new approach [43]. Additional policies should focus on increasing the feasibility of programs that not only increase access to healthy, nutritious foods, but also provide education and/or lifestyle modification guidance to increase the likelihood of consuming foods that are part of a balanced diet tailored to the individual [2]. Increasing access to nutritious meals at school by expanding free and reduced lunch programs should also be considered [44].

Renewed efforts should focus on the accessibility of fresh foods in both rural and urban food deserts where, given the lack of grocery stores, fast food and convenience stores are highly utilized [2, 45]. This problem is particularly concerning for mostly rural states, such as Oklahoma, where previous studies of two Tribal Nations found that individuals utilized convenience stores as a source for food and quick meals [45]. Previous interventions to provide healthy snack and meal options at convenience stores have been developed via Tribal/University partnerships and community participatory research [45, 46]. These interventions have been found to increase availability and purchasing of healthier foods, but not necessarily their consumption [46]. Osteopathic physicians in tribal areas may make a point in their practices to provide proper education to families in an attempt to increase healthier food intake when healthy foods are available. Tribal/University partnerships could expand to create more programs and healthy food options as interventions. For instance, the first tribally associated osteopathic medical school has been established at Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation. Establishing a school relationship within the tribal community may help further establish and grow the partnership with the tribal communities. In the future, these relationships could allow further expansion of current programs and the establishment of new programs. Additional research should be undertaken to further expand these interventions, particularly with Tribal Nations given the rates of chronic health conditions, and food insecurity experienced by Indigenous peoples [46]. Given the high rates of obesity in AI/AN children and adults, it is vital that policy initiatives be enacted between federal and tribal governments for these populations. A way to the forced relocation of many Indigenous peoples from their ancestral homelands significantly disrupted tribal agricultural practices thus impacting traditional food systems [47]. Initiatives for these populations should be tailored to each individual sovereign nation given their unique cultural experiences and needs. Long-standing programs such as the Food Distribution Program on Indian Reservations (FDPIR) should be reassessed and modified to provide more nutritious and fresh foods [48]. This can be done by expanding programs such as the USDA’s Indigenous Food Sovereignty Initiative, which was created to increase accessibility to traditional foods and agriculture practices [49].

Limitations and Future Research

According to the NSCH codebook AI/AN, NH/PI, and ‘two or more races’ should be interpreted as weighted estimates because they are not independently controlled. However, our sample meets the provisions set by the NSCH, therefore our race subcategories are robust yearly estimates. Additionally, responses to a child’s current height and weight were not independently verified by the NSCH; however, the NSCH mitigates this by only surveying height and weight in children aged 10–17 years because a study revealed that parents tend to overestimate height and underestimate weight in children under 10 years old [50]. Finally, our study is cross-sectional in nature, thus our results should be interpreted as correlational rather than causal. In the future, research should focus on whether families in food-insecure households have improved access to nutritious foods for their children through assistance programs such as SNAP, USDA-funded programs, and nonprofit organizations. Additionally, childhood obesity rates in these families should be compared to those in food-insecure households who do not have such access to these resources. In clinical practice, children with mental health issues and physical limitations have been found to have the greatest need for support in addressing obesity [2]. Therefore, future research should focus on other aspects in food-insecure homes, such as stress and mental health issues that can lead to an unhealthy relationship with food and overeating, thus increasing the risk for having obesity.

Conclusions

Childhood obesity is an ongoing public health concern in the United States. Our study found that the food-insecurity domain of SDOH was significantly associated with childhood obesity. Given the poor health outcomes associated with childhood obesity and the current AAP CPG surrounding childhood obesity, ensuring that supplemental nutrition programs such as SNAP are reaching families experiencing food insecurity is increasingly crucial. USDA-funded programs, such as TEFAP and nonprofit agencies, are positioned to alleviate food insecurity and food insufficiency in affected households with children. Additionally, policy recommendations should provide nutrition education and lifestyle modification guidance to increase the likelihood of individuals consuming a balanced diet. Therefore, ensuring children have access to adequate amounts of nutritious foods is a critical step in addressing childhood obesity and preventing negative long-term health outcomes.