Food insecurity and childhood outcomes: a cross-sectional analysis of 2016–2020 National Survey of Children’s Health data

Food security

To identify children who might be experiencing FI, we assessed the food situation in a household variable utilizing the survey question, “Which of these statements best describes your household’s ability to afford the food you need during the past 12 months?” Respondent answers included: “we could always afford to eat good nutritious meals; we could always afford enough to eat but not always the kinds of food we should eat; sometimes we could not afford enough to eat; often we could not afford enough to eat.” [17, 19] Although this question is titled ‘Food Insufficiency’ in the NSCH questionnaire, the item captures more than household food shortage within the first two responses addressing the quality of the meals the family could afford – a suitable proxy measure for the definition of FI, which has been utilized in many studies [20].

School meal program usage

To identify children utilizing free-or-reduced school meal programs, we looked at the survey question, “At any time during the past 12 months, even for one month, did anyone in your family receive free or reduced-cost breakfasts or lunches at school?” Respondent answers included: “yes,” or “no.” Respondents were excluded if they did not provide an answer to this prompt.

Racial discrimination

To assess the prevalence of children experiencing discrimination, we extracted responses, provided by parents/guardians, to the survey question: “To the best of your knowledge, has this child EVER experienced any of the following? Treated or judged unfairly because of their race or ethnic group.” Respondent answers included “yes” or “no.” Responses were excluded if they did not provide an answer to this prompt.

Demographics

For age, we re-coded and combined age groups into the following: 0–4, 5–10, 11–14, and 15–17 years. To identify the race/ethnicity of each child, we utilized the survey question, “What is this child’s race/ethnicity?” The self-identified responses included: “Hispanic; White, non-Hispanic; Black, non-Hispanic; Asian, non-Hispanic; American Indian/Alaska Native, non-Hispanic; Native Hawaiian/Other Pacific Islander, non-Hispanic; Two or More Races, non-Hispanic.” [17] NSCH data for White, Black, Asian, and Hispanic races are nationally representative. However, American Indian or Alaska Native (AIAN), Native Hawaiian and Other Pacific Islander (NHPI), and “Two or More Races” are not controlled independently and may not constitute national estimates. NSCH notes that statistical analyses apply to groups with>30 observations. To assess income, we utilized the family poverty ratio variable within the NSCH of “50 or less-400 or more,” and grouped the responses into “0–99, 100–199, 200–399, and 400+” percent of the federal poverty guidelines (%FPG).

Statistical analysis

For this study, survey weights provided by the NSCH were employed. First, we calculated the overall demographics of children in the sample and their weighted estimates, and then we calculated demographics by food security group and school food voucher use. We then estimated the frequency of parent-reported racial discrimination among children by food security status and school food voucher use.

Finally, we constructed logistic regression models to assess associations, via odds ratios (OR), between food security groups and whether the child experienced racial discrimination and adjusted for age – and assessed the interaction of race/ethnicity and FI on parent-reported discrimination.

Analyses were conducted utilizing Stata 16.1 MP (StataCorp, LLC, College Station, TX), with alpha set at 0.05 and confidence intervals (CIs) of 95 %.

Sociodemographic results

Over half of our sample consisted of White children (n=117,912, 51.1 %), followed by Hispanic (n=20,362, 25.0 %), Black (n=10,576, 13.0 %), multi-racial (n=12,364, 5.9 %), Asian (n=8,730, 4.6 %), and Indigenous (n=1,005, 0.4 %) children (Table 1). Age groups of the children were 0–4 (n=39,778, 26.8 %), 5–10 (n=41,835, 27.5 %), 11–14 (n=50,385, 28.7 %), and 15–17 (n=38,951, 16.9 %) year olds. The breakdown of household income (as FPG) showed that 41.8 % (n=70,943) earned 400 %+ of the FPG, 30.9 % (n=52,497) earned 200–300 % FPG, and 27.2 % (n=46,200) of households earned less than 200 % of the FPG.

Sociodemographic results and food security

Asian families (n=7,301, 81.2 %) had the highest rates of reporting always being able to afford nutritious meals, followed by White (n=90,728, 73.9 %), multiracial or other race (non-Hispanic Pacific Islander/American Indian/Alaska Native/Native Hawaiian; n=8,543, 64.8 %), Hispanic (n=13,294, 61.6 %), Black (n=6,383, 56.9 %), and Indigenous families (n=587, 55.5 %; Table 2). Among children in families who could always afford enough food to eat but not always the kinds of food they should eat, Black (n=3,303, 32.9 %) and Indigenous (n=335, 32.3 %) children had reported this most frequently, with Asian (n=1,293, 16.1 %) children the least. In families who reported their children often or sometimes not being able to afford enough to eat, those who were Indigenous (n=83, 12.2 %) had the highest rates, followed by children who were Black (n=890, 10.1 %), multiracial or other race (n=680, 8.2 %), Hispanic (n=1,179, 7.1 %), White (n=3,478, 3.8 %), and Asian (n=136, 2.7 %). These families also reported racial discrimination at 11.13 %, compared with children in families who always had enough nutritious meals to eat at 2.9 %. There were no large variations in age groups for food situations at home. Families with children who were 0–99 % of the FPG most often reported not being able to afford enough to eat.

Sociodemographic and discrimination results for school food voucher usage

Children in the age group 11–14 years old (n=12,605, 39.0 %) had the highest rates of school food voucher usage among the age groups. More than half of Black (n=5,037, 54.7 %), Indigenous (n=440, 52.3 %), and Hispanic or Latino (n=7,619, 50.6 %) children were reported to have utilized food vouchers within the past 12 months, as had families with less than 200 % of the FPG (200–399 % of FPG, n=43,994; 77.7 %; 400 % of FPG, n=67,826; 94.5 %).

Associations of food insecurity on racial discrimination

Our adjusted model shows that individuals who experienced a food shortage were significantly more likely to experience racial discrimination compared to those without food limitations when controlling for race, food voucher usage, age, and % FPG (adjusted odds ratio [AOR]: 3.34; 95 % CI: 2.69–4.14; Table 2). Those with limited food choices (but no shortage) were also significantly more likely to experience racial discrimination (AOR: 2.01; 95 % CI: 1.76–2.31). In the adjusted model, reduced or no-cost lunch programs were not significantly associated with racial discrimination (AOR: 1.12; 95 % CI: 0.96–1.31).

Interaction of race and food insecurity on childhood racial discrimination

Compared to the White children with no food limitations, White children with food choice limitations or food shortages were significantly more likely to experience racial discrimination (AOR: 2.61; 95 % CI: 2.01–3.40 and AOR: 7.63; 95 % CI: 4.62–12.60, respectively; Table 3). This relationship was enhanced when examining children of ethno-racial minority groups, where racial discrimination most frequently occurs. Children who ‘had enough to eat but not always nutritious foods’ and were multi-racial or of other races were much more likely to experience racial discrimination than children with no food limitations (AOR: 24.84; 95 % CI: 19.22–32.11). We found similar results among Indigenous and Black children (AOR: 20.48; 95 % CI: 12.14–34.54 and AOR: 18.87; 95 % CI: 14.47–24.60, respectively). The interaction terms within the model showed that compared to White children in families without food limitations, children who often or sometimes could not afford enough to eat and were multiracial or of other race were significantly more likely to experience racial discrimination (AOR=37.96; 95 % CI: 23.08–62.44). Similar results were found for Black children (AOR=30.61; 95 % CI: 21.57–43.44). Overall, compared to the reference group, the interaction analysis (Table 3) showed that the likelihood of experiencing racial discrimination was exacerbated for every race when there was a degree of FI.

Impacts of food insecurity on children and adults

The relationship of FI and racial discrimination is likely bidirectional, meaning that as FI increases in some racial groups, the likelihood of experiencing racial discrimination also increases. Nonetheless, the compounded effects of these deleterious experiences impact both the physiological and psychological development of children [22]. A recent study found that experiences of FI are influenced by intersecting inequalities tied to race, class, gender, and socioeconomic status (SES) [23]. The intersection of poverty and FI was similarly highlighted in our results, as children whose families were within 0 and 99 % of the FPG, or most financially disadvantaged, most often reported not being able to afford enough to eat.

Among children, research has shown that FI is linked to poorer general and oral health, poorer academic performance, behavioral and cognitive problems, depression, aggression, and anxiety [24]. Further, children are at particular risk of early-life environmental stressors like FI are associated with an increased risk of cortisol dysfunction [25]. The resultant cortisol dysregulation may be a component in developing health disparities later in adulthood [25], with the deleterious effects among adults experiencing FI including health conditions such as increased risk of poor sleep, higher rates of depression, and higher incidences of diabetes, hypertension, hyperlipidemia, and poorer overall health [22, 26]. Consequently, women’s health is often more severely affected by FI than children’s or men’s health. This is likely due to mothers’ food sacrifices made to ensure that their children and others in the household have enough to eat [27]. A study by Hanson and Connor [28] found that in food-insecure families, adults consumed fewer vegetables, fruits, and dairy products than food-secure adults; children were less likely to have their dietary quality impacted. The same study also found that food-insecure adults had a lower intake of vitamins and minerals, with the most substantial evidence of adverse associations between women and the intake of Vitamins A and B-6 [28]. Thus, adults may successfully shield children from household food shortages. Ensuring that households – primarily low-income ethno-racial minority households – experiencing FI can access supplemental nutrition assistance programs might decrease the deleterious effects of FI on both adults and children.

Food insecurity and racial discrimination

Poverty is one of the most substantial SDOHs, impacting financial well-being and an individual’s access to foundational resources like health care and education [29]. Ethno-racial minority communities are disproportionately affected by poverty, with American Indian/Alaskan Natives having the highest rates at 24.2 %, followed by 21.2 % of Black, 17.2 % of Hispanic, and 9.7 % of Asian/Pacific Islander/Native Hawaiian families below 100 % of the federal poverty line (FPL) [30]. When compared to income, wealth inequities in the United States are even more exacerbated across ethno-racial minority communities, as evidenced by wealth in Black households being five cents for every corresponding dollar of wealth in White households [30]. Legislation preventing opportunities for continued generational wealth acquisition and discriminatory practices and beliefs contributes to wealth inequality in the United States. These policies, in turn, result in new and continued disparities in wealth and educational attainment in future generations, known as “intergenerational drag” [31, 32]. For example, the Social Security Act of 1935 established insurance and unemployment compensation for the elderly, yet it barred occupations largely held by Black individuals, like domestic or agricultural labor, thus causing undue financial strain for Black families later in life [4].

The long-standing history of systemic racism in the United States has compounded and contributed to the significant disparities in poverty and, thus, FI for ethno-racial minorities [30]. Although not all families experiencing poverty also experience FI and hunger, experiencing FI is inherently related to household resource and financial constraints [33]. We found that every ethno-racial minority group in our sample was more likely to experience some degree of FI overall when compared to White individuals. Therefore, our results suggest an increased interaction between experiencing racial discrimination and FI, especially among ethno-racial minorities. A similar study by Burke et al. [34] examined the association between the severity of household FI and reports of lifetime racial discrimination among 154 food-insecure African–American respondents in South Carolina. Their study found that FI was associated with lifetime racial discrimination and that discrimination occurring at work or school was further exacerbated by being FI [34]. Of note, studies utilizing self-reported instances of racism may only capture a fraction of the true incidence due to the pervasive nature of racism. Our findings highlight the importance of increasing awareness surrounding systemic racism and its impact on poverty, FI, and subsequent health outcomes.

Policy initiatives to promote access to nutritious foods

Policy initiatives are a major avenue to make meaningful changes in FI for children. Evidence of this is seen in the success of programs such as the SNAP, the WIC program, and the National School Lunch Program (NSLP), among others [35]. These programs are essential given the positive health impact adequate nutrition has, thus leading to overall lower healthcare costs [36]. In September 2021, the Biden-Harris administration released a brief committing the United States to the development of innovative and evidence-based solutions to end hunger and malnutrition globally [37]. This initiative will invest over $10 billion globally, with $5 billion devoted to improving food systems and supporting climate-smart agriculture in the United States [37].

Even with the current commitments related to food supply procurement and infrastructure, further steps must be taken to lift more Americans out of FI. A common factor discussed among policy experts is the impact of poverty on food security [38]. Several economic policy initiatives could strengthen household income and increase food security. These initiatives include raising the minimum wage [39] and expansion of the Child Tax Credit [40]. While the SNAP program has successfully lifted many American families out of poverty, previous research has raised concerns regarding whether the benefit amount is sufficient for individuals receiving it. Some studies show decreased nutritional quality throughout each month’s SNAP cycle [41–43]. Given these findings, future policy initiatives should focus on enhancing SNAP benefits with a particular focus on if the benefit formula should be updated to fit the economic circumstances that better families are presently experiencing [44]. Additionally, changes made during the COVID-19 pandemic, including waivers, the flexibility of requirements, and expansions to programs, should be extended permanently [38]. Future policy initiatives should also focus on improving the ease and usability of online application systems to make them more accessible to users [38]. Finally, the Bipartisan Policy Institute recommends that the current administration hold a White House Conference on Food, Nutrition, Hunger, and Health to foster collaborative work between federal and state stakeholders to end FI in the United States [38].

Food deserts, defined as areas with limited access to fresh, quality foods, are another issue that children living in both rural and urban communities may face and tend to disproportionately impact minority neighborhoods [45–47]. Typically, these areas have few to no supermarkets and instead rely on convenience or independent stores as a food source [46]. As a result, individuals usually pay more and receive unhealthy foods [46]. As such several steps should be taken at the policy level to mitigate the existence and impact of food deserts. One of perhaps the most difficult tasks would be to incentivize the creation of businesses dedicated to selling a significant quantity of fresh produce and ingredients in known food deserts, which is the premise of the bipartisan Healthy Food Access for All Americans (HFAAA) Act [48]. In the short term, increasing the number of Farmers Markets, the areas in which they are held, and the acceptance of supplemental government assistance as payment, could significantly increase access to fresh produce and ingredients for families living in these areas [49].

Finally, the focus should be shifted away from considering only adequate caloric intake and toward sufficient nutrition, given the prevalence of obesity and its various comorbid factors in the United States [38, 50]. To do this, we need to reframe how we think about food security beyond a pure quantity approach and consider food quality [50]. This approach should be embedded within all programs and policies seeking to mitigate the impact of FI including new policies related to food donation for food banks [44].

Reassessing the federal poverty guidelines

Ensuring that adults and children have adequate access to nutritious foods requires re-evaluating the guidelines that dictate eligibility for supplemental assistance programs. Currently, in the United States, programs utilizing the FPL as a guideline in determining eligibility include Head Start, SNAP, the NSLP, the Low-Income Home Energy Assistance Program (LIHEAP), and the Children’s Health Insurance Program (CHIP) [51]. Gross monthly income must be at or below 130 % of the poverty line to qualify for SNAP benefits specifically [52]. The FPL utilized to calculate SNAP benefits in federal fiscal year 2022 was $1830 a month; thus, 130 % of the poverty line for a three-person family was $2,379 a month, or about $28,550 a year [52]. With the added financial demands of rent, utilities, and healthcare bills, many families continue to struggle despite being above the poverty line [53]. Over 700,000 adults living in California in 2011 were among the hidden poor, with incomes above the FPL but below the minimal standard of living determined by the Elder Economic Security Standard Index [53, 54]. Further, expanded SNAP eligibility and increased SNAP purchasing power may affect non–food-related outcomes by redistributing resources initially spent on food to other essential expenses and, ultimately, decrease the likelihood of FI [55, 56]. A new approach that measures poverty through multiple factors, such as housing, transportation, and regional economic differences, may be necessary to ensure that all individuals experiencing poverty and FI are identified and that resources are equitably distributed to all in need. Thus, an overall reassessment of the FPL guiding eligibility for federal nutrition assistance programs and increased funding to expand the purchasing power of these program beneficiaries might alleviate the burden of FI and associated health outcomes seen among adults and children experiencing FI.

Limitations

A significant limitation is that all data are based on parental or primary caregiver responses that have not been independently verified. Additionally, it is important to note the possibility of self-report bias [57], with both FI and racial discrimination. However, self-reporting is a valuable way of obtaining perspectives, views, and opinions of subjects [57]. It is likely that certain ethnic populations, including Indigenous, are underrepresented due to identification as multiracial in the NSCH survey. Therefore, the impact of exposure to racial discrimination and FI in these populations may be greater than what is reported within the dataset. However, the findings of this study shed light on the experiences of individuals facing FI and the importance of addressing access to food, especially among minority populations.