A review of studies examining the link between food ...relevant to the Global Nutrition Targets 2025...

A review of studies examining the link

between food insecurity and malnutrition

Cover photographs

Left image: ©FAO/Alessandra BenedettiCentre image: ©FAO/James HillRight image: ©FAO/Vasily Maximov

FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONSRome, 2018

A review of studies examining the link

between food insecurity and malnutrition

byChandana Maitra

University of Sydney

Suggested Citation

Maitra, C. 2018. A review of studies examining the link between food insecurity and malnutrition. Technical Paper. FAO, Rome. 70 pp. Licence: CC BY-NC-SA 3.0 IGO. (Available at http://www.fao.org/3/CA1447EN/ca1447en.pdf)

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Abstract Areviewof120studiespublishedsince2006wasundertakentoexaminetherelationshipbetweenfoodinsecurityatthehouseholdorindividuallevelandthefollowingnutritionindicators:childstunting,childwasting,lowbirthweight,exclusivebreastfeedingofinfants<6monthsofage,anaemiainwomenofreproductiveage,childoverweightandadultobesity.Whilethereissomeevidenceofadirectassociationbetweenfoodinsecurityandstuntingforchildreninlower-middleandupper-middleincomecountries,evidenceoflinksbetweenfoodinsecurityandeitherchildwastingoroverweightisalmostabsent,withtheexceptionofanassociationwithoverweightamonggirlsinmiddle-andhigh-incomecountries.Theobesity–foodinsecuritylinkismostpredominantamongwomeninhigh-incomecountries,whileitisalmostabsentinmen.Inaddition,foodinsecurityincreasestheriskforlowbirthweightininfantsandanaemiainwomen.Methodologicalconcernsthatposechallengesforvalidcomparisonofresultsrelatetostudydesign,dataanalysistechniques,useofdifferentindicatorsofhousehold/individualfoodsecurityandmalnutrition,andthelimitedavailabilityofhigh-qualitymicro-leveldatafromlarge-scalesurveys.Moststudiesreportcorrelationratherthancausalassociationsbetweenfoodinsecurityandnutritionindicators;longitudinalmicro-leveldatafromlarge-scalesurveyscanhelpestablishcausalassociationandcapturethedynamicnatureoffoodinsecurity.Foodinsecurityemergesasapredictorofundernutritionaswellasoverweightandobesity,highlightingtheneedformultisectoralstrategiesandpoliciestocombatfoodinsecurityandmultipleformsofmalnutrition.

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Contents Abstract..................................................................................................iv

ListofAbbreviationsandAcronyms........................................................vii

Introduction.............................................................................................1

Methods...................................................................................................4SEARCHSTRATEGY............................................................................................................4

CRITERIAFORINCLUSIONOFPAPERS...............................................................................4

Findings....................................................................................................5FOODINSECURITYANDUNDERNUTRITION......................................................................5

Childstunting...............................................................................................................5Childwasting................................................................................................................6Lowbirthweight..........................................................................................................6Anaemiainwomenofreproductiveage......................................................................6Exclusivebreastfeeding................................................................................................6

FOODINSECURITYANDOVERWEIGHT/OBESITY..............................................................6Childoverweight..........................................................................................................6Adultobesity................................................................................................................7

Discussion................................................................................................8PATHWAYSFROMFOODINSECURITYTOMALNUTRITIONINADULTSANDCHILDREN.................................................................................................................8

Foodinsecuritytostuntingandwastinginchildren....................................................9Foodinsecuritytoanaemia........................................................................................10Foodinsecuritytoexclusivebreastfeeding................................................................10Foodinsecuritytolowbirthweight...........................................................................11FoodFoodinsecuritytooverweightinchildrenandobesityinadults......................11

EXPLAININGTHELACKOFASSOCIATIONBETWEENFOODINSECURITYANDMALNUTRITION......................................................................................................13HOWTORECONCILETHECONTRADICTORYEVIDENCEFROMVARIOUSSTUDIESEXAMININGTHEFOODINSECURITY–MALNUTRITIONLINK...........................................14GAPSINTHELITERATURE...............................................................................................17

Conclusion..............................................................................................19

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Tables

TABLE1.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDCHILDHOODSTUNDING..........................................................................................20TABLE2.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDCHILDHOODSTUNTING..........................................................................................27TABLE3.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDLOWBIRTHWEIGHT...............................................................................................30TABLE4.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDANAEMIAINWOMEN.............................................................................................31TABLE5.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDEXCLUSIVEBREASTFEEDING...................................................................................33TABLE6.STUDIESONTHEASSOCIATIONBETWEENFOODINSECURITYANDOVERWEIGHTANDOBESITY...................................................................................35

References.............................................................................................45

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Abbreviations and acronyms AOR AdjustedOddsRatioBMI BodyMassIndexDHS DemographicandHealthSurveyEBF ExclusiveBreastfeedingEBFSS Experience-BasedFoodSecurityScalesEBIA EscalaBrasileiradeInsegurançaAlimentar

(BrazilianFoodInsecurityScale)ELCSA EscalaLatinoamericanayCaribeñadeSeguridadAlimentaria

(LatinAmericanandCaribbeanFoodSecurityScale)ENSANUT EncuestaNacionaldeSaludyNutrición(NationalHealthand

NutritionSurvey)ENSMI EncuestaNacionaldeSaludMaternoInfantil

(NationalMaternal-InfantHealthSurvey)FI FoodInsecurityFIES FoodInsecurityExperienceScaleHAZ Height-for-AgeZ-scoreHFI HouseholdFoodInsecurityHFIAS HouseholdFoodInsecurityAccessScaleHHs HouseholdsHICs High-IncomeCountriesHIV HumanImmunodeficiencyVirusID IronDeficiencyLBW LowBirthWeightLICs LowIncomeCountriesLMICs Lower-MiddleIncomeCountriesMANA ProgramadeMejoramientoAlimentarioyNutricionaldeAntioquia

(FoodandNutritionImprovementPlanforAntioquia)MINIM MaternalandInfantNutritionInterventioninMatlabUMICs Upper-MiddleIncomeCountriesUSHFSSM UnitedStatesHouseholdFoodSecuritySurveyModuleWIC SpecialSupplementalFoodProgramforWomen,Infants,and

Childreny year

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Introduction Foodsecurityisacomplexandmultidimensionalphenomenondefinedasastatewhen“allpeople,atalltimes,havephysical,socialandeconomicaccesstosufficient,safeandnutritiousfoodthatmeetstheirdietaryneedsandfoodpreferencesforanactiveandhealthylife”(1).Akeycomponentoffoodinsecurityislackofaccesstoasufficientquantityofnutritiousfood,whichisapotentialriskfactorformalnutritioninchildrenandadults(2-4).However,evidenceontheassociationbetweenhouseholdorindividualfoodinsecurityandmalnutritionisnotconclusiveintheexistingliterature.Establishingacausaleffectoffoodinsecurityonnutritionalconsequencesisachallengingtask,duetoseveralmethodologicalconcernsrelatedtostudydesign,analyticaltechniques,thediversityoffoodinsecurityandmalnutritionindicatorsused,andaboveall,thelimitedavailabilityofhighqualitymicro-leveldatafromlargescalesurveys(5-7).Yet,itisimportanttoexplorethisrelationshipbecausemalnutritionhasenormouseconomicandsocialcosts(8-9).Poornutritioninearlychildhoodhaslong-termcostsintermsofadversehealth,schooling,andconsequenteffectsonthelabourmarketinlaterlife(10-11).Inthecontextoflow-orlower-middleincomecountries,nutritionaldeprivationinearlylifeposesoneofthegreatestobstaclestopovertyreductionbyperpetuatingthecycleofpoverty,poornutrition,lowhumancapital,andlowproductivity(10).Insubpopulationsinhigh-incomecountries,foodinsecuritymaybeariskfactorforobesitywhichmaycauseadverseintergenerationalhealthconsequences(12).Giventheaboveconsiderations,theaimofthepresentstudywastogatherevidenceonthenatureandextentoftheassociationbetweenfoodinsecurity(specificallytheexperienceofnothavingaccesstosafe,nutritiousandsufficientfoodduetolackofmoneyorotherresources)andselectedindicatorsofmalnutritioninadultsandchildrenacrosstheglobe.Establishingtheserelationshipsisimportantinthecontextofbothresource-poorandresource-richsettingsandwiththeemergenceofnewconcernssuchasthe‘doubleburdenofmalnutrition’(13-14),definedasthecoexistenceofundernutritionandoverweight/obesity.Multipletypesofmalnutritionmayoccursimultaneouslywithinpopulations,households,orevenindividuals.TheissueistimelyandrelevanttotheGlobalNutritionTargets2025(15)aswellastheSustainableDevelopmentGoals(SDGs)thataimtoeliminatepovertyandachievezerohunger,goodhealthandwell-beingforall.Adetailedreviewoftheliteraturewasundertakentoextractthekeyfindingsontherelationshipbetweenfoodinsecurityandselectednutritionindicators.Thefoodsecurityindicatorsusedinthestudiesthatwerereviewedwerebasedontheclassofexperience-basedfoodsecurityscales(EBFSS),whichquantitativelycapturefood-relatedbehavioursandexperiencesassociatedwithdifficultiesinaccessingfoodduetoresourceconstraints(16).Severalreliableandvalidatedexperientialscalesexist,includingtheUnitedStatesHouseholdFoodSecurity

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SurveyModule(USHFSSM),theFoodInsecurityExperienceScale(FIES)(16),theHouseholdFoodInsecurityAccessScale(HFIAS)(17),theHouseholdHungerScale(HHS)(18),andtheLatinAmericanandCaribbeanFoodSecurityScale(ELCSA)(19).Thekeynutritionindicatorsconsideredinthestudiesare:stunting,wastingandoverweightinchildren,adultobesity,lowbirthweight(LBW),exclusivebreastfeedingofinfants<6months(EBF)andanaemiainwomenofreproductiveage.Conceptually,thepathwaysfromfoodinsecuritytomalnutritioncanbeincorporatedintothetheoreticalparadigmoftheSocio-EcologicalModel(20),whichoffersabioecologicalframeworkofhumandevelopment.Thisapproachplacesanemphasisonboththeimmediateandbroaderenvironmentasimportantforhumandevelopment,incorporatingtimeasanimportantinfluencefrominfancythroughtoadulthood.Withinthiscontext,foodinsecuritycanbeviewedasafactorthathaslong-termimpactonanindividual’snutritionalstatusthroughoutthevariousstagesofthelifecycle.Theframework,whichhasapplicationsinseveralfields,includingnutritionandpublichealth,comprisesindividual/intrapersonal,interpersonal,communityandenablingenvironments.Theinfluenceswithinandbetweeneachenvironmentarebi-directional,withtherelationshipshavingimpactbothawayfromandtowardstheindividual.Individual(intrapersonal)factorscompriseage,sex,socio-economicstatus,race/ethnicity,physicalhealth,knowledgeandskills,andpersonalpreferences.Thesecondlevel(interpersonal)relatestorelationshipswithpeers,partners,andfamilythatmayinfluencetheoutcome.Forexample,amother’seducationlevelcaninfluenceherchild’sgrowthanddevelopment.Thethirdlevel(community)considersthesettingsinwhichindividualslive,learnandwork,includingearlycareandeducationprograms,schools,worksites,communitycentresandfoodserviceestablishments.Thesettingsthusdefinealargersocialcontextinwhichtheindividualdoesnotdirectlyfunction,butwhichinfluencedevelopmentfromchildhoodtoadulthoodbyinteractingwithsomeelementinhis/herintra-andinterpersonalenvironment.Forexample,ahigh-qualitycommunitychildcareprogramthatbenefitstheentirefamilymightreducethenegativeimpactoffoodinsecurityonchildgrowth,thusmoderatingthestrengthoftheassociationbetweenfoodinsecurityandchildnutritionalstatus.Settingsalsohavethepotentialforbroaderpopulation-levelimpactiftheyareintegratedwithstrategiescomingfrommultiplesectors,whichbroadlycomprisetheenablingenvironment–theoutermostlayerintheindividual’sdevelopment.Thesesectorsincludegovernments,education,healthcare,transportation,publichealth,communityorganizations,businessesandindustries,allofwhichplayanimportantrolebyinfluencingpeople’saccesstohealthyfoodandopportunitiestobephysicallyactive,ortheyinfluencesocialnormsandvalues.Thislevelthereforelooksatbroadsocietalfactorsthathelpcreateaclimateinwhichtheindividualcangrowasahealthyandproductiveeconomicagent.Thus,health,economic,educationalandsocialpoliciesareimportantspheresofinfluenceatthislevel.

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Theeffectoftheseelementsoftheenablingenvironmenthaveacascadinginfluencethroughouttheinteractionsofallotherlayers.Forexample,arevisedhealthcaresystematthemacrolevelmightreduceout-of-pockethealthcareexpenditureandimprovehealthservicesforthevulnerablepopulation(e.g.householdsfromlow-incomeorminoritycommunities),consequentlylesseningtheimpactoffoodinsecurityonindividualnutritionaloutcomesatthemicrolevel.Theorganizationofthepaperisasfollows:thenextsectionpresentsthemethodsusedinthereview.Sectionthreereportskeyfindings,whilesectionfourdiscussesthem.Thefinalsectiondiscussesgapsintheexistingliteratureandsectionsixconcludeswithpotentialpolicyimplicationsoftheresults.

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Methods Thissectiondiscussesthesearchstrategyandcriteriaforinclusionofpapers.Thescopeoftheliteraturereviewislimitedtopapersthatreportempiricalassociationsbetweenhouseholdorindividualfoodinsecurity(FI)andtheselectedindicatorsofmalnutrition.

SEARCH STRATEGY Databases‘Pubmed’and‘Scopus’weresearchedusingkeywordssuchashouseholdfoodsecurity,foodinsecurity,foodaccess,andvariouscombinationsofthefollowingtermsinthetitleandabstract:undernutrition,overnutrition,anthropometry,malnutrition,nutritionalstatus,stunting,wasting,overweight,obesity,BodyMassIndex(BMI),anaemia,haemoglobin,lowbirthweight,exclusivebreastfeeding.Theabovesearcheswerealsocombinedwiththewordschildand/orwomenand/oradultsand/ormaternal.Theabstractsofpaperswerereadtoidentifythoselikelytomeettheinclusioncriteria(statedbelow).TheabovesearchstrategyproducedaMasterListwhichwasfurtherenrichedbyaddingadditionalpapersavailablefromthereviewsontherelevanttopics(forexample,(21-24).Theabstractsofthepapersthatcitedthosereviewswerealsoread.Finally,additionalpaperswereextractedfromthebibliographyofthepapersincludedintheMasterListunlesstheywerealreadycountedin.Thefinallistcomprised180studiesconductedinvarioussettings.

CRITERIA FOR INCLUSION OF PAPERS Thecriteriaforinclusionofpapersinthefinalsamplewereasfollows:first,studieswereincludedifhouseholdfoodinsecurity(HFI)wasmeasuredusingsomevariationofanEBFSSandusingavalidatedquestionnaire(locallyadapted,abbreviatedortranslated).Second,studiesusingcontinuousmeasuresofweightandheight(height-for-agez-score,weight-for-heightz-score,BMIz-score)wereincluded,inadditiontostudiesusingcategoricalmeasuressuchasstunting,wasting,obesity/overweight.Foradults,anyBMImeasure(continuousorcategorical)wasconsideredacceptable,whileforchildren,weightpercentilesforageandothercategorizationswereaccepted.Third,onlypaperspublishedbetween2006andFebruary2018wereincludedinthereview;however,ahandfulofstudiesthatwerepublishedbefore2006wereincludedduetotheirseminalimportanceinthisliterature.Fourth,onlypublishedjournalarticleswereincludedinthereview,withtheexceptionofonereportonGuatemala(25).Theabovecriteriaresultedin120studiesbeingincludedinthefinalsample.

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Findings Findingsarereportedaccordingtotheassociationfoundbetweenfoodinsecurityandthevariousformsofmalnutrition:positive,negative,noassociation,ormixedresults.Apositiveassociationgenerallyimpliesadirectandstatisticallysignificantassociationbetweenfoodinsecurityandmalnutritionindicator(i.e.foodinsecurityincreasestheriskofmalnutrition),whileanegativeassociationimpliesastatisticallysignificantinverseassociation(i.e.,foodinsecuritydecreasestheriskofmalnutrition).Mixedresultsindicatethosestudiesthatreportamixofpositive,negativeornoassociationfordifferentage,genderorgeographicalgroupswithinthesamestudy.Forchildren,findingsarereportedaccordingtotwobroadagegroups:under-fiveandabovefive.1Malnutritioninthefirstfiveyearsoflifehaslong-termconsequencesforhealthandcognitivedevelopmentinlaterlifeandthereforechildrenunderfiveshouldbestudiedseparately.Asfarasobesityisconcerned,itishardertodetectthesignificanceofanyparticularchangeinBMIinyoungerchildrenasitchangesacrossdifferentagegroups.Therefore,studiesoftentypicallyreportoverweight/obesitystatisticsseparatelyforolderchildrenandadults(27).

FOOD INSECURITY AND UNDERNUTRITION Inthissection,thefindingsontheassociationbetweenFIandindicatorsofundernutritionarereported.Theindicatorsusedarestunting,wasting,LBW,EBFandanaemiainwomen.Thestudiesareconcentratedinlow(LICs),lower-middle(LMICs)orupper-middleincomecountries(UMICs).Thereislimitedevidencefromhigh-incomecountries(HICs).

Child stunting Ofthe30studiesthatexaminedtherelationshipbetweenFIandstunting(TABLE1)16studiesidentifiedasignificantpositiveassociationbetweenFIandstuntingforchildrenunderfive,i.e.childreninfoodinsecurehouseholdsweremorelikelytobestuntedthanchildreninfood-securehouseholds(2,28-42).Fourstudiesfoundasignificantpositiveassociationbetweenfoodinsecurityandstuntingforchildrenabovefiveyears(43-46).Onestudyreportedmixedresults(25)forchildrenunderfive,whiletworevealedmixedfindingsforchildrenolderthanfiveyears(47-48).SeveralstudiesfromAfrica,Asia,LatinAmericaandNorthAmericareportednoassociationforeitherunder-fivechildren(49-52)orforchildrenabovefiveyears(44,53-55).

1 However, often there is considerable overlap because some studies cover broad age-ranges such as 2–11 years, e.g. Kaur et al. (26).

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Child wasting Ofthefifteenstudiesreviewed(TABLE2)(2,28,30,33,35,38,40-42,45,50-52,56-57),onlythreereportedapositiveassociationbetweenfoodinsecurityandchildwasting,mostlyinLICsorLMICs(28,51,56);thethreewereconductedwithchildrenunder-fiveyearsofage.

Low birth weight AlthoughthenumberofstudiesontheassociationbetweenfoodinsecurityandLBWislimited(TABLE3),twostudiesfromHICs(58-59)andonefromlow-incomesettings(60)reportedthatFIissignificantlyassociatedwithLBW.

Anaemia in women of reproductive age Sevenoutofeightstudies(TABLE4)foundasignificantormixedassociationbetweenHFIandanaemiainwomen,fromcountriesasdiverseasEcuador(61),Bangladesh(62),Cambodia(50),Guatemala(25),Mexico(63-64)andtheUnitedStatesofAmerica(65).

Exclusive breastfeeding AlimitednumberofstudiesareavailableontheassociationbetweenFIandEBFpractices(TABLE5).Outoftheeightstudiesreviewed,threereportedasignificantnegativeassociationbetweenfoodinsecurityandexclusivebreastfeedinginCanada(66)andKenya(67).Fourstudiesreportednoassociation(68-71).Lastly,onestudy(72)onHIVaffectedmothersinUgandareportedmixedevidence:whilemoderateorsevereHFIwasnotassociatedwithEBFat6months,amongthosewomenstillexclusivelybreastfeedingat4months,thoseexperiencingfoodinsecurityweresignificantlymorelikelytoceaseEBF.Twostudiesestimatedinfantfeedingpracticesastheoutcomevariable,onecomponentofwhichwasEBF(68,70).

FOOD INSECURITY AND OVERWEIGHT/OBESITY EvidenceontheassociationbetweentheexperienceofFIandobesity/overweightisgrowing,andalargebodyofevidence(55studiesinthisreview)isavailablefromresource-richandresource-poorsettingsalike(TABLE6).

Child overweight OutofthirteenstudiesonthelinkbetweenFIandoverweight(TABLE6)inchildrenunderfiveyearsofage,fourreportedapositiveassociationormixedresults(73-76),whiletheothersfoundnoassociation(30,41,77-83).Metallinos-Katsarasetal.(75)reportedanegativeassociationbetweenHFI(withandwithouthunger)andoverweightforgirlsagedlessthantwoyearsbutpositiveassociationforgirlsagedtwotofiveyearsexperiencingfoodinsecuritywithhunger.Noassociationwasreportedforboys.

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Outofthetwenty-twostudiesreviewedforchildrenoverfiveyearsofage,twelvestudiesreportedsomekindofassociation–positive,negativeormixed.Fourstudies(83-85,215)reportedasignificantpositiveassociation,onereportedaninverserelationship(86)andsevenstudiesreportedmixedresults(3-4,26,48,87-89).Forexample,Jyotietal.(3)foundapositiveassociationforgirlsalone.Kauretal.(26)foundapositiveassociationbetweenfoodinsecurityoftheadultsinterviewedandobesityamong6-11-year-oldchildren,whilenoassociationwasfoundbetweenchildhoodobesityandchildfoodsecurity,asmeasuredbyquestionsposedtotheadultrespondentsbutrelatingtoexperiencesofchildreninthehousehold.Ingeneral,theevidencethatfoodinsecurityincreasestheriskofoverweightismorepronouncedforgirls(3-4,76,90,215).

Adult obesity Twelvestudiesoutofthetwenty-threereviewedfoundthatfoodinsecuritywassignificantlyassociatedwithoverweight/obesityinadults.FiveofthesewereinLMIC/UMICsettings(31,37,83,91-92)andseveninHICs(93-99)(TABLE6).Fifteenofthestudiesfocussedonwomen(orwomenandchildren)only(31,38,45,52,61,83,91-92,94-95,99-103).Ofthesefifteenstudies,seven(31,83,91-92,94-95,99)reportedsignificantassociationsbetweenFIandobesityinwomen.Laraiaetal.(2013;2015)investigatedtherelationshipinthecontextofpregnantwomen.Eightstudiesfocusedonmenandwomen/childrenasthestudypopulation(37,93,96-98,104-106),fiveofwhichreportedapositiveassociationbetweenfoodinsecurityandobesityinwomenonly.TheseresultscorroboratethosereportedinotherliteraturereviewswhichsuggestedHFIisariskfactorforobesityamongwomenbutnotmen(6,21-24,94).

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Discussion ThisliteraturereviewrevealsthattheevidenceontheassociationbetweenFIandmalnutritioninchildrenandadultsislargelyinconclusive.Duetomethodologicaldifferencesacrossstudies,thecomparabilityofresultsischallenging.However,afewkeypointsemerge:

¾ SomeevidenceexistsofanassociationbetweenFIandchildstunting.ThepositiveFI–stuntinglinkispredominantlyinUMICsandLMICsasopposedtoLICs.

¾ LimitedevidenceisavailableontheassociationbetweenFIandchildwasting,andthisassociationispredominantlyinLIC/LMICsettings.

¾ Despitethelimitednumberofstudies,thereisevidenceofanassociationbetweenFIandbirthweightofinfants,withfoodinsecurityincreasingtheriskofLBW.

¾ Whilesomestudiesontheassociationbetweenfoodinsecurityandanaemiainwomenreportmixedresults,overallresultsindicatethatFIisariskfactorforanaemia.

¾ TheevidenceofanassociationbetweenFIandoverweightinchildrenislimitedthoughsomeevidenceofapositiveassociationexistsforschool-agedgirls.

¾ TheevidenceontheassociationbetweenFIandobesityisabsentformen.However,thereisevidenceofapositiveassociationforadultwomenfromHICs.Ingeneral,evidenceisabsentinLICs/LMICs.

¾ LimitedevidenceisavailableontheassociationbetweenEBFandFIsincethenumberofstudiesthatusedexperience-basedfoodsecuritymeasuresisverylimited.

Giventheabove,thefollowingquestionsarise:

1. TotheextentthatstudiesfindevidenceofpositiveornegativeassociationbetweenFIandnutritionalstatus,whatcouldbethemediatingfactorsintheserelationships?Inotherwords,whatarethepathwaysfromFItomalnutritioninadultsandchildren?

2. WhatfactorscouldexplainthelackofassociationbetweenFIandsomeformsofmalnutrition?

3. HowcanthecontradictoryevidenceintheliteratureontheFI–malnutritionlinkbereconciled?

PATHWAYS FROM FOOD INSECURITY TO MALNUTRITION IN ADULTS AND CHILDREN MultiplepathwayscanlinkFIandmalnutritioninchildrenandadults.Itisimportanttoidentifysuchmediatorstofacilitateeffectivepolicyformulation.

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Food insecurity to stunting and wasting in children FIisassumedtoaffectthenutritionalstatusofchildrenbycompromisingquantityandqualityofdietaryintake(107-109).Food-insecurehouseholdsaremorelikelytohavechildrenwhosufferfromlowernutrientintakes(110).Theevidencefromstudiesthatexaminedthemediatingroleofdietarydiversityintherelationshipbetweenfoodinsecurityandnutritionalstatusismixed,however.Alietal.(42)didnotfinddietarydiversitytobeamediatorintheassociationbetweenFIandchildundernutritionforBangladesh,EthiopiaandVietNam.However,usinglongitudinaldata,Humphriesetal.(48)reporteddietarydiversitytobeamediatorintheassociationbetweenFIandanthropometricindicatorsforschool-agedchildreninVietNam,India,PeruandEthiopia.Theuseofcross-sectionalversuslongitudinaldata(48)andthedifferentagegroupsofchildren(42,48)couldprovidesomeexplanationforthedifferencesinresults.Furthermore,inthecontextofhigh-incomecountries,childreninseverelyfood-insecurehouseholdswerelesslikelytomeettheguidelinessetoutintheUSFoodPyramid(54).AnotherpathwayfromFItopoorchildnutritionalstatusistheperinatalnutritionofmotherandthechild,includingtheinternatalperiodforthemother(110).Thereisoverwhelmingevidencethatperinatalnutritionaffectshealthandwell-beingofallagegroups(111).Maternalfoodinsecurityduringpregnancyhasbeenfoundtobeassociatedwithpoorerfoetalhealthoutcomes(58).Almondetal.(112)foundthattheavailabilityoffoodstamps(aformofsocialprotectionaimedataddressingfoodinsecurity)reducedtheincidenceofLBWbirthsthroughimprovementsinnutrition.HFImayalsocompromisechildhealthbycompromisingmaternaldietandhealth(113).Forpregnantwomen,FImaycauselower-than-recommendedweightgainduringpregnancyandisassociatedwithintrauterinegrowthrestriction(12),ariskfactorforstunting.Additionally,short-termmanagementstrategiesoftenincludelimitingportionsizesandskippingmealsforthecaregiver,especiallythemother(114),andcompromisedmaternalnutritionmayeventuallyinfluencechildgrowthnegatively(10).AnotherkeypathwayfromFItochildgrowthisviafeedingpractices.Foodinsecurityhasbeenshowntobenegativelyassociatedwithbothinitiationanddurationofbreastfeeding(115-116),withsomestudiesreportingastrongnegativeassociationbetweenFIandEBF(66,70).Theconsequencesforchildnutritionalstatusstemfromthefactthatthe1000daysbetweenconceptionandachild’ssecondbirthdayisawindowofsupremeopportunityforchildhealthpromotion.Indeed,EBFuptosixmonthsandadequatecomplementaryfeedinguptotwoyearsofageensuresnormalchildgrowth(117-118).Furthermore,FImaybelinkedtochildundernutritionthroughcaretakermentalhealth(29,119).Asastressor,FImaycontributetounfavourableparentingpractices(81,120),onemanifestationofwhichisanegativeeffectonbreast-feeding(121).Casey,Goolsby,Berkowitzetal.(122)havereportedmaternal

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depressiontohavenegativeeffectsonearlychildhoodgrowth,particularlyheight-for-age,viaunresponsiveparenting.FIisalsoassociatedwithanaemiainwomen(61-62),andsomestudiessuggestedthatirondeficiency(ID)maybeariskfactorformaternaldepressivesymptoms(123),whichinturnmayaffectchildhealthstatus(122).Aless-studiedpathwaybywhichFIcanaffectmaternalstresslevel,andconsequentlychildhealth,isthroughsubstanceuse(124).FIcouldalsoleadtocompromisedimmunesystemfunctions,puttingachildintowhatisreferredtoasaninfection–malnutritioncycle(110).Foodinsecurityisassociatedwithinadequatefoodintake,whichcanleadtoimmunodeficiencyincreasingsusceptibilitytoinfectionandthusresultinginpoornutritionaloutcomes(109,125).Theseadverseconsequencesareexacerbatedbypoorsanitaryconditions.Additionally,whennutritionissuboptimal,ittakesachildlongertorecoverfromanillness,andtherepetitionofthiscyclecanworsenoverallhealth.Forexample,Pérez-Escamillaetal.(126)foundHFItobeassociatedwithmalariainruralHaiti.Malaria,inturn,hasbeenreportedasariskfactorforstuntingandwastingamongyoungchildreninarecentcohortstudyinEthiopia(127).

Food insecurity to anaemia FIcanleadtoanaemiathroughinadequateintakeofmicronutrients(128-129).Poormicronutrientintakeinfood-insecurehouseholdscanbearesultofunderconsumptionoffood,oroverconsumptionofenergy-densebutnutrient-poordietsthatmaybelesscostly(130-131),ashealthyfoodisoftenmoreexpensive(132).Fischeretal.(63)hypothesizethatHFImayleadtoanaemiaamongadultwomenfromMexicothroughthreediet-relatedpathways:first,alackofadequateconsumptionofiron;second,throughadietlackingsufficientconsumptionofmicronutrientsthatfacilitateironabsorptionandutilization(suchasvitaminC);andthird,byconsumingfoodsrichinphyticacidthatmaydecreasetheabsorptionofiron,henceincreasingtheriskofanaemia.

Food insecurity to exclusive breastfeeding TheliteraturealsoidentifiespathwaysbywhichFImayundermineamother’sabilitytoadoptEBFpractices.Foodinsecuritycanmotivatematernalemploymentoutsideofthehome,andthereisstrongevidenceofanegativeimpactofmaternalworkonbreastfeedingpracticesinbothHICsandLIC/LMICs(133-134).Foodinsecuritymayalsoimpactmaternalself-efficacy,whichinturnmayadverselyaffectinitiationanddurationofEBF(135).HFIhasbeenassociatedwithhigherratesofmaternaldepressionandstressinlowincomesettingssuchasEthiopia(136)aswellasinhighincomesettingssuchastheUnitedStatesofAmerica(137),whichinturnisasignificantpredictorofreducedbreastfeedingself-efficacy,exclusivityanddurationofbreastfeeding(138-139).Additionally,womeninfood-insecurehouseholdsaremorelikelytoexperiencediabetesmellitus,aconditionthathasbeenfoundtoaffectbreastfeedinginitiationand

11

durationnegatively(140-141).Psychologicalandphysiologicalstressassociatedwithseverefoodinsecuritymayaffectsubsequentmilkoutput(142-143).ResearchersarguethatinsituationswhereFIcausesseverematernalmalnutrition,physiologicalmechanismsmayalterbreastmilkoutputortheconcentrationofcertainfatsandmicronutrients(144-145).Ontheotherhand,foodinsecuritymayalsoincreasethepracticeofEBFbylimitingeconomicaccesstoalternativeinfantfoods,aslongasattitudestoEBFarepositive(146).

Food insecurity to low birth weight Nutritionalqualityofthediet,intermsofmicronutrients,mightbethekeynutritionalpathwayfromFItobirthoutcome.Asystematicreviewof45articlesshowedthatpreconceptionandpericonceptionintakeofvitaminandmineralsupplementsbythemotherwasassociatedwithareducedriskofpretermdeliveriesandhavingaLBWbaby(147).Thekeynon-nutritionalpathwaylinkingFIandbirthweightofchildrenismaternalmentalhealth,includingdepressivesymptomsandanxiety(59).Asstatedbefore,FIhasbeenassociatedwithdepressionandanxietyamongmothers(122,141),andpregnantwomenexperiencingdepressivesymptomsareatriskfordysfunctionalplacentationandintrauterinegrowthrestriction,whichaffectbirthoutcomessuchaspretermbirth(148-149).

Food insecurity to overweight in children and obesity in adults ThemechanismslinkingFIandobesity/overweightarerelativelywellunderstood,andafewtheoreticalframeworkshavebeenofferedintheliteraturetoexplainthisassociation.Nettleetal.(6)proposetheinsurancehypothesis,whichclaimsthatindividualsstoremorefatwhentheyreceivecuesthataccesstofoodisuncertain.Oneextensionofthishypothesisistodevelopmentalinfluencesonobesity:experiencesinearlylife,suchaspoornutritionin-utero(150),childhoodexposuretofoodscarcity(151),orpsychosocialstressingeneral(152-153)canpredisposeindividualstomaintaininghigherlevelsofbodyfat,notjustaschildren,butsubsequentlyasadults.Dhurandhar(154)proposestheResourceScarcityHypothesiswhicharguesthatrandomlyprimingindividualstocuesthatimplyresource-scarcitycausesthemtobemorelikelytochooseandconsumehigh-caloriefooditems(155),specificallyinlowsocio-economicstatusindividuals.Thehypothesisisthatpositiveenergybalancearisesaslowsocial-economicstatusisassociatedwithchronicallyhigherenergyintake(vialowincomeandsocialstress),lowrestingmetabolicrateandlowactivityenergyexpenditure.Lowsocio-economicstatusindividualsmaybemoresusceptibletotheperceptionoflowfoodsecurity(156).

FoodassistanceprogramsmaymoderatetheassociationbetweenHFIandchildoverweightstatus(157)tosomeextent.However,binge-eatinghabitswhenfoodisplentiful,arisefromtheepisodicnatureofFIandcanleadtoobesity(158-159),

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andsuchcyclicalfoodrestrictionsleadtoquickerweightgainwhenrefeeding(160).Monthlyfoodassistancebenefits,forexample,canbeassociatedwitha‘feast–famine’cycle(158)iftheyarenotadequatetoguaranteesufficientfooduntiltheendofthemonth.Thiscouldpotentiallycontributetoobesityinchildren.Inleanperiods,parentsmayrestricttreats,therebyincreasingchilddemandandintakeofthesefoodswhenhouseholdslaterhavemoremoneytospend(54).Motbainoretal.(51)offersuchanexplanationofcyclicalfoodrestrictionfortheFI–BMIlinkinthelow-incomesettingofEthiopiawithrespecttolean/plentyseasonsinagriculture.

Food-insecureindividualsmayalsobecomeoverweightbyconsumingalow-qualitydiet.Foodinsecurityisassociatedwithconsumptionofcheapandenergy-densefood(foodshighinaddedsugarandfat),overconsumptionofwhichmaycauseweightgain(132,161–162).Womenfromfood-insecurehouseholdsinparticularmayrelyonlow-cost,highlyprocessed,high-caloriefoodstocopewithalimitedhouseholdbudget(132).HFImayresultinreducedmicronutrientintakeamongwomenofchild-bearingage(163-164),decreasedfruitandvegetableconsumption,andasignificantincreaseindisorderedeatingpatterns(164).Additionally,duetotheoccurrenceoffeast–faminetypesofepisodicfoodinsecurity,HFImaycausefluctuationsineatinghabits.Suchfluctuationsmaycausemetabolicalterations,sothatevenwithouteatingmorecalories,itispossibletoincreaseweight(165).Finally,childhoodstunting,whichisapotentialoutcomeoffoodinsecurity,canbeariskfactorforweightgaininlaterlife(166).EarlylifeexposuretoHFImayalsoresultinfoodhordingandthussetlong-termtrajectoriesofweightgain(132,167).Acculturation,aprocessofsocio-culturalandbehaviouralchangethatstemsfromtheblendingofcultures,maymodifytherelationshipbetweenFIandBMI(168).Someofthemostnoticeablegroup-leveleffectsofacculturationincludechangesinfood,clothing,andlanguage.ArecentanalysisofLatinochildrenintheUnitedStatesofAmericademonstratedthat,amongchildrenoffamilieswithloweracculturation,FIwasassociatedwithlowerBMI(86).WhileamongurbanLatinowomenwithhigheracculturationFIwaspositivelyassociatedwithobesity,amongwomenwithloweracculturationtherewasnoassociationbetweenFIandobesity(169).Loweracculturationinthiscontextmaybeassociatedwithconsumptionofahealthierdietclosertothatofthecountryoforigin,meaningonecontainingmorebeansandfruit(170).FIandoverweightinchildrenmaybelinkedthroughparentingandinfantfeedingpractices(81).Adultsinfood-insecurehouseholdsaresignificantlymorelikelytoexhibitlesspositiveparentingthanotheradults(3,124).2Inappropriatefeedingpracticessuchasnon-exclusivebreast-feedinganduntimelyintroductionof

2UnfavourableparentingpracticesasmediatorsoftheFI–malnutritionlinkcaninfluencebothundernutritionindicatorsandobesity.

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complementaryfeedingmayeventuallyleadtochildhoodobesity(171).Furthermore,FIisrelatedtomorerestrictiveandpressuringmaternalfeedingstylescomparedwithfood-securemothers(69),ariskfactorforcurrentandfutureweightgain.Bydecreasingtheabilityofchildrentoself-regulateeatingbehaviours,controllingfeedingpracticescanposeariskforchildhoodobesity(172).HFImayalsoleadtochildoverweightbyaffectingthedietoffood-insecuremothers.Poordietqualityinpregnancyposesariskforgestationalweightgain(173),whichinturnmayresultinfutureweightgaininthechild(174).Themother–childobesitycyclecouldthuspersist(175).Thekeynon-nutritionalpathwayfromFItooverweightandobesityispoormentalhealth.FIhasbeenfoundtobeassociatedwithpoormentalhealthstatusindependentofotherindicatorsoflowsocio-economicstatus,inbothresource-rich(176)andresource-poor(177)settings.Specifically,ithasbeenassociatedwithanxiety(136),depression(176),andstress(178).Stressbroughtonbyfoodinsecuritymaycausenon-homeostaticeatingandmayleadtotheselectionof“comfort”foods,orhighlypalatablefoodsthatarerichinfat,sugar,andsodium(179-180)andhavebeenfoundtophysiologicallyreducestress(181).Furthermore,inthepresenceofmarginalfoodinsecurity,womenwhostrugglewithweightanddietingissuesmaybeatriskforexcessiveweightgain.Marginalfoodinsecurityanddietaryrestraintmightaffectweightthroughthecyclicalfoodrestrictionpatterns,the“yo–yo”typediet(182)ordietingfollowedbyovereating,thatcouldleadtoweightgain(173).Finally,anadditionalpathwaythatrequiresfurtherattentioninvolvestheroleofphysicalinactivity(24).

EXPLAINING THE LACK OF ASSOCIATION BETWEEN FOOD INSECURITY AND MALNUTRITION SeveralstudiesfoundnoevidenceofanassociationbetweenFIandmalnutritioninchildrenoradults,indicatingthatwhilefoodsecuritymaybeanecessaryconditionforgoodnutritionoutcomes,itisinsufficientonitsown.Onekeyexplanationforthislackofassociationmightberelatedtoconceptualconcerns.EBFSScaptureshort-termfoodinsecurity,whilemalnutritionindicatorssuchasstuntingrepresentlong-termdeprivation.Moreover,EBFSSmeasureaccesstofoodasopposedtofoodutilization,whichdirectlyinfluencesnutritionalstatus.Availabilityandaccesstofooddonotensurefoodsecurity,asproperabsorptionoffoodbythebodyisalsonecessarytobefoodsecure(183).Factorssuchasnutritionknowledgeandpractices,andaccesstoqualityhealthcare,cleanwaterandsanitationarecrucialtoensuregoodnutritioninthiscontext(184-186).Second,aconglomerationofsocial,economicandculturalfactorsotherthanFIinfluencethenutritionofindividuals.Forexample,household-levelpoverty(187),maternalnutritionalstatus(10,188),intrahouseholdallocationofresources(189-

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190),women’sstatus(191-192),dietqualityandfoodchoice(193-194),foodenvironment(195)andimprovedaccesstofullservicedsupermarkets(196)aresomeofthefactorsinfluencingnutritionaloutcomesofchildrenandadults.Theassociationbetweensupermarketaccessandobesityisagrowingareaofresearch(197-198).Homehealthcare,foodpreparation,andtheprovisionofaresponsiveandstimulatingenvironmenttoachildareotherfactorsconfoundingtheinfluenceoffoodaccessonthenutritionalstatusofchildren.Eveninpoorcommunitieswithlimitedfoodaccess,childrenmightgrownormallybecauseofpositivefamilyandcaregiverbehaviours(199-200).Mothers’knowledgeofappropriateinfantandyoungchildfeedingpracticesisalsoimportant(201).Finally,afactorexplainingthelackofassociationbetweenFIandmalnutritionindicatorscouldbemethodological(discussedindetailinthenextsection).Duetomethodologicalissues,evenstudieswhichcontrolappropriatelyforthekeypredictorsofmalnutritionmayfindnoassociation.Itisimportanttokeepinmindthatthesamesetofunobservedfactorscaninfluencebothfoodinsecurityandmalnutrition(5).Giventhatresearchersmostlyuseobserveddataratherthanexperimentaldatatoconducttheseanalyses,suchunobservablefactorsareoftennotcontrolledfor,resultinginomittedvariablebias.Consequently,establishingacausalassociationbetweenFIandmalnutritionremainsachallenge.

HOW TO RECONCILE THE CONTRADICTORY EVIDENCE FROM VARIOUS STUDIES EXAMINING THE FOOD INSECURITY–MALNUTRITION LINK TheliteraturereviewrevealsthatthenatureandextentoftheassociationbetweenFIandindicatorsofmalnutritiondependsconsiderablyonthecontextandmethodology.First,resultsvarybyincomelevelofthecountry.Forchildren,anyassociationbetweenFIandstuntingisnotedmostlyinLMIC/UMICsettings,whilethelimitedassociationbetweenFIandoverweight(mostlyforgirls)ismorepredominantinHICs.ItispossiblethatLMICsorUMICssuchasIndiaorBrazil,respectively,areinastageofnutritiontransitionwhereratesofchildundernutritionhavenotyetbeenovertakenbyoverweightorobesityinyoungchildren.“Occurrenceofashiftfromunder-nutritiontoobesitytendstofollowapatternthatusuallyoccursfirstinadults,followedbyadolescents,andonlylaterintimebychildren”(77)(p.6).Arecentmeta-analysis(6)showedthatfoodinsecuritypredictshighbodyweightonlyinHICs;inLMICstheaverageassociationiszero.Inalow-incomesetting,FIislesslikelytoresultinoverweightchildrenbecauseeventhecheapestenergy-densefoodmaynotprovidesufficientenergytocauseexcessweightgain(53)ortoallowthebuild-upoffatreservesbeforethenextperiodofscarcitystrikes(6).

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AgemayinteractwithFItoproducevariedoutcomesintermsofnutritionalindicators.RegardingtheFI–stuntinglink,theproportionofstudiesreportingpositiveassociationsismuchlargerforunder-fivechildrencomparedtoschool-agedchildren.Incontrast,FIisfoundtohavenoassociationwithwastingforunder-fivechildreninmostofthestudies.AsfortheFI–obesity/overweightlinkinchildren,alargerfractionofzeroassociationisreportedforunder-fivechildrenasopposedtoschool-agechildren.Theweight–heightrelationshipmayberelevantintermsofsheddinglightonthedifferentialoutcomesonstunting–wastinginunder-fivechildrenwithrespecttoFI(202).Studieshavedemonstratedthatlineargrowthfaltersthroughoutthefirst2–3yearsoflifeinmanydevelopingcountries,whereasweightfor-heighttendstofalterduringamorelimitedagewindowinthefirstyearoflife,afterwhichiteitherstabilizesorincreases(203).Asfortheobesity–FIlink,oneexplanationfortheage-wisevariationsfollowfromsacrificetheory(21),wherebyyoungerchildrenaremoreprotectedbyparentsintimesofscarcefoodaccess.Additionally,studiesonchildrengenerallymeasurefoodinsecuritythroughparentalreports(204),potentiallyweakeningtheabilitytodiscoverarelationship.Finally,simpleBMI-typemeasuresmaybeparticularlyproblematicforassessingadiposityingrowingchildren(205).Resultsalsovarybygender:aconsensusofthereviewsonfoodinsecurityandbodyweightmeasures(21-24)isthatthelimitedavailableevidenceonthepresenceofanyassociationbetweenFIandhighbodyweightinchildrenisnotedforoldergirls(>5years)only.Additionally,thisrelationshipismostpronouncedamongwomeninHICsandalmostabsentinmen.ForadultwomeninHICs,theoddsofhighbodyweightareaboutfiftypercenthigherforfood-insecureindividualscomparedtofood-secureones(6).Thisoutcomemaywellrelatetothewiderfindingthatlowsocio-economicstatusisamoreconsistentpredictorofobesityinwomenthaninmen(206).Resultsmayalsovarybystudydesign–cross-sectionalversuslongitudinal.Forexample,inthisreview,themajorityofstudiesontheFI–obesityassociationarecrosssectional,eightypercentofwhichdonotreportanyassociationbetweenFIandobesityamongchildren/adults.RegardingtheFI–undernutritionlink,themajorityofstudiesarecrosssectional.Giventhelimitednumberoflongitudinalstudies,itwouldbeworthexploringwhatlongitudinaldatarevealsbyconductingmoresuchstudies.Inthecurrentreview,theonlythreelongitudinalstudiesontheFI–stuntinglinkprovidedmixedevidence:negativeassociation(47);positiveassociation(29);andmixedresults(48).StudiesuseavarietyofEBFSStomeasureFI–fromasinglefoodadequacyquestiontofullsurveymodulessuchasUSHFSSM,HFIAS,ELCSA,oradaptedlocalversionsofUSHFSSM/HFIASandshorterscalessuchastheHHS.Whilemostofthesemeasureshavebeenvalidatedandarewidelyused,locallyadaptedversionsaresometimesnotsubjectedtofullpsychometrictesting.Hence,theirsuitabilityinestimatingtheimpactofFIonnutritionalstatusmaybequestionable.Useof

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differentindicatorsmightalsomakecomparabilityofestimatesacrossdifferentstudiesachallengingtask.Anotherinconsistencyisnotedwithrespecttothelevelatwhichfoodinsecurityismeasured–individualorhousehold.Alimitednumberofstudiesusefoodsecuritymeasuresatindividualorchildlevel(122,207-208).Acrucialaspectregardingfoodsecuritymeasurementisthecategorizationschemeusedfortheexperience-basedfoodsecurityindicator,whetherexperientialfoodinsecurityismeasuredasacontinuous,dichotomous,ormultinomialvariable.Thiscategorizationislikelytoaffectresults.Forexample,severalstudies(122,158,160)reportthatitwasthemilderbutnotthemostseverelevelsoffoodinsecuritywhereincreasedoddsofobesitywerefound.Gubertetal.(30)reportedchildstuntingtobeassociatedwithseverefoodinsecuritybutnotwithmild/moderatefoodinsecurity.Suchoutcomesindicatethatdichotomizationoftheexperientialfoodinsecuritytojusttwocategoriesmightconcealmeaningfulvariationsinresults.Hownutritionalstatusismeasured–self-reportedvsmeasured,continuousvsdichotomous–mayalsoberelevanttoexplainingvariationsinoutcomesonFI–malnutritionlink.Forexample,Nettleetal.(6)foundsignificantlystrongerassociationsbetweenFIandweightstatuswhentheoutcomevariablewasobesity(BMI≥30)thanwhentheoutcomewasoverweight(BMI≥25).However,theyfoundnosignificantdifferencesinthestrengthoftheassociationaccordingtowhichpredictor(FImeasure)wasused.AccordingtoLyons,ParkandNelson(209),associationsbetweenobesityandFIaremorepronouncedwhenself-reporteddataonheightandweightareusedthanwhenmeasuredheightandweightdataareused.Finally,howtherelationshipbetweenFIandmalnutritionisempiricallymodelledalsoservestoreconcilethecontradictoryevidencetoaconsiderableextent.Empiricalconcernsthatneedtobeaddressedrelatetoproblemssuchasomittedvariablebias,selectionbiasorsimultaneitybias.Thesamesetofunobservedfactorsmayaffectboththedependentvariable(malnutrition)andtheexplanatoryvariable(foodinsecurity).Forexample,‘ability’(atypicalexampleofunobservedfactorinlaboureconomics)(210)ofanindividualcansimultaneouslyaffecthis/herfoodsecuritystatusandnutritionalstatusbyaffectingproductivity.Unlesstheresearcherisabletocontrolfortheseunobservedfactors,acorrelationbetweenobservedandunobservedfactorscanbiastheestimatedeffectofFIonmalnutrition.Additionally,sample“selection”problemsarisewhenfactorsunobservedtotheresearchersdriveselectionofhouseholdstofood-secureorfood-insecurestatus(5).Furthermore,thereisclassificationerrorinviewofthefactthattruefoodinsecuritystatusisnotobserved.Theremayalsobesimultaneitybiasintherelationship,aspotentiallytheFI–malnutritionlinkisbi-directional.JustasFIcanpredictmalnutrition,thelattercanalsobeariskfactorforFIbyaffectinglong-termproductivityofindividualsandfurtherimpoverishingthem(10).Theseconcernscreateidentificationproblemsandconsequently,

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estimatingcausalimpactofFIonnutritionaloutcomesbecomeschallenging.Addressingtheseconcernsismoreproblematicincross-sectionaldata,whilelongitudinaldatamitigatethemtoaconsiderableextentbytakingcareofunobservedfactorswhicharetime-invariant.

GAPS IN THE LITERATURE Considerablegapsinknowledgeexistintheliteratureexaminingtheassociationoffoodinsecurityandthenutritionalstatusofchildrenandadults.TheliteraturehasfocusedonexaminingthecorrelationbetweenFIandarangeofnutritionaloutcomesratherthanattemptingtoestablishcausalityintherelationship(5).Improvedanalyticalmethodssuchasempiricalmodels,whichcanaddressseveralbiasesintherelationship,arewarranted.Significantgapsalsoexistinexploringthetemporaldimensionoffoodinsecurity(173).Thehealthconsequencesoftemporaryandpersistentfoodinsecuritymightnotbethesame(211).Forexample,itispossiblethatthosewhoexperiencepersistentfoodinsecurityhavedevelopedcopingstrategiestoaddressthesituation.Asfaraschildrenareconcerned,howthemovementinandoutoffoodinsecuritycaninfluencechildren’snutritionalanddevelopmentaloutcomesremainsanimportantquestion.Pérez-EscamillaandPinheirodeToledoVianna(212)observedthatakeygapintheliteratureisthatstudieshavenotbeendesignedtofindoutifthereisacriticalperiodofinitialexposuretoHFIintermsofchilddevelopmentoutcomes.ItisthereforeimportanttobetterunderstandthepathwaysfromFItopoornutritionaloutcomes.Fewstudieshaveinvestigatedthesemediatingfactors.Forexample,howdietarydiversitymediatestherelationshipbetweenHFIandnutritionaloutcomesisanimportantquestionandthelimitedavailableevidenceisinconclusive(42).Theory-baseddesignsandimprovedanalyticalframeworksarerequiredtoinvestigatehowthemediatorswork(175).AccordingtoJacknowitzandMorrissey(213),pathwayscanvaryaccordingtowhoisexperiencingtheinsecurityinthehousehold(adultorchild),andwithregardstochildfoodinsecurity,whetherthechildisdirectlyaffectedbyfoodinsecurityorindirectlyaffectedthroughtheexperienceofadultsorotherchildrenintheirhousehold.Pathwayswillalsovaryaccordingtotheoutcomeofinterestsuchasundernutritionoroverweightandobesity.Hugedatagapsexistintheliteratureonthistopic.Itisimpossibletoanswertheaboveconcernswithoutaccesstolongitudinaldata.DatasetsthatfollowchildrenfrombirtharenecessaryinordertoobservetheeffectofFIwithinalifecourseframework.Longitudinalstudiescanalsoimproveourunderstandingofthetemporalityinfoodinsecurity,suchastheeffectsofchronicandtransientfoodinsecurity.

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Itisalsoimportanttohavelarge-scalemicrodatasetstoavoidproblemsoflowstatisticalpowerforquantitativeanalysis(214).Moreover,dataqualityandsurveydesignareoftenpoor.Datacollectionprocessesmustadheretomeasurementprotocolsandtheexperience-basedfoodsecuritymeasureandtheanalyticprotocolsmustbestandardized(suchastheFIES)toallowcross-culturalcomparabilityofstudyresults.Finally,itisrecommendedthatinordertounderstandthefoodinsecurity–malnutritionlinkamongchildren,furtherresearchbeundertakenregardinghowtomeasurefoodinsecurityatthechildlevel.TheAmericanDieteticAssociation,inanotepublishedin2003,concludedthat‘householdfoodinsecuritydoesnotappeartobeassociatedwithoverweightamongchildren,afindingthatmaybedue,inpart,tothefactthatacomprehensivemeasureofchildfoodinsecuritywasnotusedinmoststudies’(citedinEisenmannetal.(24).ArecentreviewonFI–obesitylinkintheUnitedStatesofAmerica(22)findsonlysevenstudies(outoftwenty-five)reviewingHFIandweightstatusamongchildrenandadolescents,usechild-specificmeasuresoffoodinsecurity.

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Conclusion Thisliteraturereviewrevealsmixedevidenceontheassociationbetweentheexperienceoffoodinsecurity(constrainedaccesstoadequatefood)andmalnutritionindicators.Resultsvarybyincome,settings,age,genderandstudydesign,choiceofindicatorsandempiricalmodellingtechniques.Duetomethodologicaldifferences,validcomparisonofresultsisachallengingtask,thereforeaddressingmethodologicaldiscrepanciesisessentialtobetterunderstandthisrelationship.Highqualitylongitudinaldataisrequiredtobetterunderstandthetruenatureoftherelationshipbetweenfoodinsecurityandmalnutrition.Furtherresearchisalsonecessarytodeterminethemediatorsofexperientialfoodinsecurityandnutritionalindicatorswithaviewtoinformingpolicy.Ingeneral,foodinsecurityisidentifiedasapredictorofundernutritionaswellasoverweightandobesity.Thepolicyimplicationofthisresultisthattacklingfoodinsecurityshouldsimultaneouslyallowforaddressingdifferentnutritionalchallenges,especiallythemultipleburdenofnutrition.However,malnutritionisnotmerelyafoodprobleminthathealthisshapedbythebroadersocietalandeconomiccontextinwhichtheindividualresides(12).Therefore,effortstopromotefoodsecurityalonemaynotbeadequateincombatingmalnutrition.Revertingtotheconceptualbioecologicalframeworkdescribedattheoutset,malnutritionislikelytobedrivenbyacomplexarrayofriskfactorsinterplayingattheindividual,communityandsocietallevel.Therefore,cost-effectivemultisectoralinterventionsareneeded.Forexample,subsidizinghealthyfood,taxingsugaryfood,providingincentivestoproductionoftraditionalnutrition-richstaples,influencingfoodchoicethroughnutritionlabellingandnutritioneducation,andprovidinghealthymealsatschoolmightbesomepotentialsolutions.Overall,thesesuggestionsalsounderscoretheimportanceofanutrition-sensitivesupplychain.Itisimportanttoidentifythebottleneckateachpointofthesupplychainsothattailoredactionscanbeimplementedtotargeteachdistinctproblem.Encouragingprogramstopromotephysicalactivityisalsoakeypotentialintervention.Lastbutnottheleast,sustainableandinclusiveeconomicgrowth,whichaimstoreduceincome,educational,andgenderinequalityshouldbethekeypolicygoalinasuccessfulfightagainstfoodinsecurity,hungerandmalnutrition.

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Tables TABLE 1. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND CHILDHOOD STUNTING*

Country Author(year) Studypopulation

andsamplesize

Methods Resultsontheassociationbetween

foodinsecurityandchildhoodstunting

orlowerhaz

BANGLADESH

(28-29)Hasanetal.(2013)

Children<5yofage(N=5904).Nationallyrepresentativesample.

Cross-sectionalstudyusingBangladeshDHS2011;foodinsecurityestimatewasbasedontheHFIAS.

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedweresignificantlyhigherforchildreninfood-insecureHHs.

Sahaetal.(2009)

Children0to24monthsofage(N=1343).Matlabdistrict.

Longitudinalstudy:childrenwerefollowedfrombirthto24monthsofage;foodinsecurityestimatewasbasedonthefoodsecuritycomponentquestionnaireoftheMINIMatstudy(scaledevelopedspecificallyforBangladesh).

Positiveassociation.Theproportionofstuntedchildrenwassignificantlyhigheramongfood-insecureHHscomparedtofood-secureHHs.HouseholdfoodsecuritywaspositivelyassociatedwithhighergaininHAZ.

BRAZIL

(2,30,32,55)Gubertetal.(2016)


Cross-sectionalstudyusingBrazilianDHS2006;foodinsecurityestimatewasbasedontheBrazilianFoodInsecuritySecurityScale(EBIA).

Positiveassociationbetweenseverefoodinsecurityandstunting.

Lopesetal.(2013)

12–18yoldadolescents(N=523).Low-incomeareaofthemunicipalityofDuquedeCaxias,RiodeJaneiro.

Cross-sectionalstudy;foodinsecurityestimatewasbasedontheEBIA.

Noassociation.

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Reis(2012) Children<5yofage(N=4860).Nationallyrepresentativesample.

Cross-sectionalstudyusingBrazilianDHS2006;foodinsecurityestimatewasbasedontheEBIA.

PositiveassociationbetweenfoodinsecurityandlowerHAZ.

Santosetal.(2013)




CAMBODIA

(50)McDonaldetal.(2015)

Children<5yofage(N=900HHs).FourruraldistrictsofPreyVengprovince.

Cross-sectionalstudy;foodinsecurityestimatebasedonanadaptedversionofHFIAS.

Noassociation.

COLOMBIA

(34,53)Hackettetal.(2009)

PreschoolchildrenreceivingMANAfoodsupplements(N=2784low-incomeHHs).Randomsamplerepresentativeofthe200000MANAparticipants.DepartmentofAntioquia.

Cross-sectionalstudy;foodinsecurityestimatewasbasedonthe12-itemColombianHouseholdFoodSecurityScale.

Positiveassociationbetweenfoodinsecurityandstunting.Theriskforchildstuntingincreasedinadose-responsewayasfoodinsecuritybecamemoresevere.

Isanakaetal.(2007)

Children5to12yofage(N=2526).PrimarypublicschoolsinBogotá.

Cross-sectionalstudyofschool-agechildren’shealthandnutritionalstatus;foodinsecurityestimatewasbasedonamodifiedversionoftheSpanish-languageUSHFSSM(16version)plus5child-specificquestionsusedtomeasurechildfoodsecurity.

Noassociation.

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ETHIOPIA

(33,35,47,51)Belachewetal.(2013)

Adolescents13to17yofage(N=1431).Jimmazone,SouthwestEthiopia.

LongitudinalJimmaLongitudinalFamilySurveyofYouth(JLFSY)study;participantswereinterviewedinthreesurveyroundsoneyearapart;foodinsecurityestimatebasedon4ofthe18questionsinUSHFSSMandthecopingstrategiesindex.

Mixed.Negativeassociationbetweenfoodinsecurityandlineargrowthinfemaleadolescentsbutnotinmaleadolescents.Food-insecuregirlswereshorterbynearly1cm(0.87cm)comparedwithsecuregirlsatbaselineandcatchupduringfollowupperiodwasinadequate.Themeanheightoffood-insecuremaleswasnotsignificantlydifferentfromfood-securemalesbothatbaselineandoverthefollowupperiod.

Beteboetal.(2017)

Children6monthsto<5yofage(N=508).EastBadawachodistrict,SouthEthiopia.

Cross-sectionalstudyusingacommunity-basedprimarysurvey;foodinsecurityestimatebasedontheHFIAS.

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedforchildreninfood-insecureHHswere6.7timesthatofchildreninfood-secureHHs.

Jemaletal.(2016)

Children6monthsto<5yofage(N=284)Gambellatown.

Cross-sectionalstudyusingacommunity-basedsurvey;foodinsecurityestimatebasedontheHFIAS.

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedweresignificantlyhigherforchildreninsevereandmoderatelyfood-insecureHHs.

Motbainoretal.(2015)

Children<5yofage(N=4110HHs).EastandWestGojjamZonesofAmharaRegion.


Noassociation.

GHANA(52) Saakaetal.(2013)

Children6to36monthsold(N=337).TamaleMetropolisofNorthernGhana.

Cross-sectionalstudy,primarysurvey;foodinsecurityestimatebasedonthe30-dayHFIAS.

Noassociation.

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GUATEMALA

(25)Chaparro(2012)

Children<5yofage(N=10100nationallyand2477intheWesternHighlandsregion).Nationallyrepresentativesample.

Cross-sectionalstudyusingdatafromtheNationalmaternal–infanthealthsurvey(ENSMI);foodinsecurityestimatebasedonfivequestionsadaptedfromtheUSHFSSM.

Mixed.Positiveassociationbetweenseverefoodinsecurityandstuntingatnationallevel,butnosignificantassociationintheWesternHighlandsregion.

HONDURAS

(44)Grayetal.(2006)

School-agechildren(N=75).FivevillageslocatedontheEastbankofLagodeYojoaintheDepartmentofCortesinruralCentralHonduras.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatewasbasedonanadaptationoftheUSHSSM(8items).

Positive(weak)associationbetweenseverefoodinsecurityandstunting.

IRAN(ISLAMIC

REPUBLICOF)

(43)

Shahrakietal.(2016)

Childrenaged7–11y(N=610).SistanandBaluchestanProvincesinSouthEasternIran(IslamicRepublicof).

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatebasedonthe18-itemUSHFSSM.

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedforchildreninseverelyfood-insecureHHswere10.1timesthatofchildreninfood-secureHHs.

MALAYSIA

(45)AliNaseretal.(2014)

Children2–12yofage(N=223).BachokdistrictinKelantan,ruralareaofNorthEastPeninsularMalaysia.

Cross-sectionalstudy,usingaprimarysurvey;foodinsecurityestimatewasbasedontheRadimer/Cornellhungerandfoodsecurityscale.

Positiveassociationbetweenfoodinsecurityandstunting.Childreninfood-insecureHHswerethreetimesmorelikelytobestuntedthanchildreninthefood-secureHHs.

24

MEXICO

(36-37)Shamah-Levyetal.(2014)

Children<5yofage(Nnotprovided).Nationallyrepresentativesample.

Cross-sectionalstudyusingMexicanNationalHealthandNutritionSurvey(ENSANUT)2012;foodinsecurityestimatebasedontheELCSA.

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedforchildreninmoderatelyandseverelyfood-insecureHHswere1.37and1.79,respectively,timesthatofchildrenlivinginfood-secureHHs.

Shamah-Levyetal.(2017)

Preschoolchildren(N=5087)andschoolchildren(N=7181).Nationallyrepresentativesample.


Theproportionofstuntedchildrenwassignificantlyhigheramongseverelyandmoderatelyfood-insecureHHs(16.2%and16.8%,respectively)comparedtomildlyfood-insecureandfood-secureHHs(13.2%and10.7%,respectively).TheinteractionbetweenHFIandmaternalobesityhadasignificantimpactonstunting.

NEPAL

(38,41,49)Oseietal.(2010)

Children6to23monthsofage(N=368).KailaliDistrict.

Cross-sectionalstudy,usingacommunity-basedprimarysurvey;foodinsecurityestimatewasbasedonashort-adaptedversionoftheHFIAS(5questions).

Noassociation.

Singhetal.(2014)


CrosssectionalstudyusingNepalDHS2011;foodinsecurityestimatebasedonanadaptedversionofHFIAS(7items).

Positiveassociationbetweenfoodinsecurityandstunting.Theoddsofbeingstuntedforchildreninfood-insecureHHswere1.50timesthatofchildreninfood-secureHHs.

Sreeramareddyetal.(2015)


Cross-sectionalstudyusingNepalDHS2011;foodinsecurityestimatebasedonanadaptedversionofHFIAS(7items).


NICARAGUA

(46)Schmeeretal.(2017)

Children3–11yofage(N=431HHs).León,Nicaragua.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatedbasedonELCSA.


25

PAKISTAN(39) Baig-Ansarietal.(2006)

Children6to18months(N=399).SquattersettlementsofKarachi.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatedbasedonthe18-itemUSHFSSM.

Positiveassociationbetweenfoodinsecurityandstunting.Food-insecureHHswithhungerwerethreetimesmorelikelythanotherHHstohaveastuntedchild.

UNITEDSTATES

OFAMERICA

(54)

Kaiseretal.(2002)

Mexican–Americanchildren3to6yofage(N=211).California.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatebasedonRadimer/Cornellscale.

Noassociation.

BANGLADESH,

ETHIOPIA,VIET

NAM(42)

Alietal.(2013)

Children6monthsto<5yofage.Bangladesh(N=2356),Ethiopia(N=3422),VietNam(N=3075).

Cross-sectionalsurvey;foodinsecurityestimatedbasedontheHFIAS.

Positiveassociationbetweenfoodinsecurityandstuntingacrossthethreecountries.Theoddsofbeingstuntedweresignificantlyhigherforchildreninseverelyfood-insecureHHsinBangladeshandEthiopia,andinmoderatelyfood-insecureHHsinVietNam.

BANGLADESH,

BRAZIL,INDIA,

NEPAL,

PAKISTAN,

PERU,SOUTH

AFRICA,AND

THEUNITED

REPUBLICOF

TANZANIA(40)

Psakietal.(2012)

Childrenaged2to5y(N=800total,100ineachofthe8countries).Urban,ruralandperi-urbanareas.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatebasedonHFIAS.

PositiveassociationbetweenfoodinsecurityandlowerHAZacrosscountries.

26

INDIA,PERU,

ETHIOPIA,VIET

NAM(48)

Humphriesetal.(2015)

Childrenaged1,5,and8y(threeroundsofdatacollection)invariouscountries.Ethiopia(N=1757),India(N=1825),Peru(N=1844),andVietNam(N=1828).

Longitudinalstudyfollowingthesamechildrenatages1,5and8y,usingaprimarysurvey;atage5y.foodinsecurityestimatewasbasedonamodifiedversionoftheUSHFSSM,atage8y,theestimatewasbasedontheHFIAS.

Mixed.PositiveassociationbetweenfoodinsecurityandlowerHAZatage5y.However,theassociationattenuatedafteradjustingforotherhouseholdfactorsandanthropometryatage5yandremainedsignificantonlyforVietNam.FoodinsecuritywasnotsignificantlyassociatedwithHAZatage8y.

Notes.*Stuntingreferstoaheight-for-agezscore(HAZ)<-2

27

TABLE 2. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND CHILDHOOD WASTING*

Country Author(Year) Studypopulationandsamplesize Methods

Resultsontheassociation

betweenfoodinsecurityand

childhoodwasting

BANGLADESH(28) Hasanetal.(2013) Children<5yofage(N=5904).Nationallyrepresentativesample.

Cross-sectionalstudyusingBangladeshDHS2011;foodinsecurityestimatewasbasedontheHFIAS.

Positivesignificantassociationbetweenfoodinsecurityandwasting.

BRAZIL(2,30) Gubertetal.(2016)



Noassociation.

Reis(2012) Children<5yofage(N=4860).Nationallyrepresentativesample.

Cross-sectionalstudyusingBrazilianDHS2006;foodinsecurityestimatewasbasedonEBIA

Noassociation.

CAMBODIA(50) McDonaldetal.(2015)

Children<5yofage(N=900HHs).FourruraldistrictsofPreyVengprovince.

Cross-sectionalstudy;foodinsecurityestimatebasedonanadaptedversionofHFIAS.

Noassociation.

ETHIOPIA(33,35,51,57)

Abdurahmanetal.(2015)

Children2to<5y.ofage(N=453children).HaromayaDistrict.

Crosssectionalstudyusingacommunity-basedprimarysurvey;foodinsecurityestimatedbasedonHFIAS.

Noassociation.

Beteboetal.(2017)

Children6monthsto<5yofage(N=508).EastBadawachodistrict,SouthEthiopia.


Noassociation.

28

Jemaletal.(2016) Children6monthsto<5yofage(N=284).Gambellatown.


Noassociation.

Motbainoretal.(2015)

Children<5yofage(N=4110HHs).EastandWestGojjamZonesofAmharaRegion.


Positivesignificantassociationbetweenfoodinsecurityandwasting.

GHANA(52) Saakaetal.(2013) Children6to36monthsold(N=337).TamaleMetropolisofNorthernGhana.


Noassociation.

MALAYSIA(45) AliNaseretal.(2014)

Children2–12yofage(N=223).BachokdistrictinKelantan,ruralareaofNorthEastPeninsularMalaysia.

Cross-sectionalstudy,usingaprimarysurvey;foodinsecurityestimatewasbasedontheRadimer/Cornellhungerandfoodsecurityscale.

Noassociation.

NEPAL(38,41) Sreeramareddyetal.(2015)

Children<5y.ofage(N=2591).Nationallyrepresentativesample.

Cross-sectionalstudyusingNepalDHS2011;foodinsecurityestimatedbasedonanadaptedversionofHFIAS(7items).

Noassociation.

Singhetal.(2014) Children<5y.ofage(N=2335).Nationallyrepresentativesurvey.

Cross-sectionalstudyusingNepalDHS2011;foodinsecurityestimatedbasedonanadaptedversionofHFIAS(7items).

Noassociation.

NIGERIA(56) Ajaoetal.(2010) Children<5y.ofage(N=423).lle-lleregioninSouthWesternNigeria.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatewasbasedonthe18-itemUSHFSSM.

Positiveassociationbetweenfoodinsecurityandwasting.Theoddsofwastingforchildrenlivinginfood-insecureHHswere5.7timesthatofchildrenlivinginfood-secureHHs.

29

BANGLADESH,

ETHIOPIA,VIETNAM

(42)

Alietal.(2013) Children6monthsto<5yofage.Bangladesh(N=2356),Ethiopia(N=3422),VietNam(N=3075).

Cross-sectionalsurvey(baselinedata);foodinsecurityestimatebasedontheHFIAS.

Mixed.SignificantpositiveassociationbetweenfoodinsecurityandwastinginBangladesh.NoassociationinEthiopiaandVietNam.

BANGLADESH,

BRAZIL,INDIA,NEPAL,

PAKISTAN,

PERU,SOUTHAFRICA

ANDUNITED

REPUBLICOF

TANZANIA(40)

Psakietal.(2012) Childrenaged2to5y(N=800total,100ineachofthe8countries).Urban,ruralandperi-urbanareas.

Cross-sectionalstudyusingaprimarysurvey;foodinsecurityestimatebasedonHFIAS.

Noassociation.

Notes.*Wastingreferstoaweight-for-heightzscore(WHZ)<-2.

30

TABLE 3. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND LOW BIRTH WEIGHT

Country Author(Yer) Studypopulationandsamplesize MethodsResultsontheassociationbetweenfood

insecurityandlowbirthweight

BANGLADESH

(60)Chowdhuryetal.(2018)

Householdswithalivebirthbetween2006and2011(N=8753).Nationallyrepresentativesample.

Crosssectionalsurvey:2011BangladeshDemographicandHealthSurvey(DHS);foodsecuritymeasuredbyfivequestionsaimedatcapturing“theavailabilityoffoodandaperson'saccesstoit.”

Positiveassociationbetweenfoodinsecurityandsmallsizeinfants.

UNITED

STATESOF

AMERICA

(58-59)

Bordersetal.(2007)

WomenreceivingwelfareinnineIllinoiscounties(N=1363).

IllinoisFamilyStudy,alongitudinalcohortstudy;foodsecuritymeasuredusingUSHFSSM.

Positiveassociationbetweenfoodinsecurityandlowbirthweight.

Griloetal.(2015)

Womenandadolescents(aged14–21)whoattendedprenatalcareatoneofthe14participatingclinicalsitesinNewYorkCity(N=881).

Longitudinalstudy,primarysurvey;foodsecuritymeasuredusingasinglequestion:“Doyoueverrunoutofmoneyorfoodstampstobuyfood?”

Positiveassociationbetweenfoodinsecurityandlowbirthweight.

31

TABLE 4. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND ANAEMIA IN WOMEN

Country Author(Year) Studypopulationandsamplesize MethodsResultsontheassociationbetweenfoodinsecurity

andanaemiainwomenBANGLADESH(62) Ghoseetal.

(2016)Marriedwomenagedbetween13and40y(N=5666).Nationallyrepresentativesample.

Cross-sectionalstudyusingBangladeshDemographicandHealthSurvey(BDHS2011)data;foodsecuritymeasuredusingHFIAS.

Positiveassociationbetweenfoodinsecurityandanaemia.Theoddsofbeinganaemicweresignificantlyhigherforwomeninfood-insecureHHs.

CAMBODIA(50) McDonaldetal.(2015)

Motherswithachildunderfiveyold(N=900HHswithsuchmothers).PreyVengprovince.

Crosssectionalstudyusingdatafromabaselinesurveyconductedbeforetheimplementationofaninterventionstudy;foodsecuritymeasuredusinganadaptedversionofHFIAS.

Positiveassociationbetweenfoodinsecurityandanaemia.HFIincreasedtheoddsofmaternalanaemiainadose-responsemanner.

ECUADOR(61) Weigeletal.(2016)

AdultwomenlivinginHHswithchildreninlow-incomeneighbourhoodsinQuito,Ecuador(N=794).

Crosssectionalstudyusingprimarysurveydata;foodsecuritymeasuredusingtheSpanishversionofUSHFSSM.

Positiveassociationbetweenfoodinsecurityandanaemia.Theoddsofbeinganaemicweresignificantlyhigherforwomeninfood-insecureHHs.

GUATEMALA(25) Chaparro(2012)

Females15–49ysofage(N=16819nationallyand3762intheWesternHighlandsregion).Nationallyrepresentativesample.

Cross-sectionalstudyusingdatafromtheNational

maternal–infanthealthsurvey(ENSMI);foodinsecurityestimatebasedonfivequestionsadaptedfromtheUSHFSSM.

Usingnational-leveldata,HFIwasassociatedwithhaemoglobinconcentrationofwomenofreproductiveage.However,asignificantassociationwasnotreportedforWesternHighlands.

32

MEXICO(63-64) Fischeretal.(2014)

Womenofreproductiveage(12–49y)(N=16944).Nationallyrepresentativesample.

CrosssectionalstudyusingdatafromENSANUT2012;foodsecuritymeasuredusingELCSA.

TheassociationbetweenHFIandanaemiawasnotsignificantforadolescentwomen(12–20y),whereasinadultwomen(21–49y),theadjustedoddsofhavinganaemiawerehigheramongthoselivinginmildtoseverelyfood-insecureHHs,comparedtoadultwomenresidinginfood-secureHHs.

Jonesetal.(2017)

Non-pregnantfemaleadolescents(15–19ys)andnon-pregnantadultwomenofreproductiveage(20–49ys)(N=4,039non-pregnantfemaleadolescentsand10,760non-pregnantadultwomenofreproductiveage).Nationallyrepresentativesample.

Crosssectionalstudyusingdatafromthe2012NationalHealthandNutritionSurveyofMexico;foodsecuritymeasuredusingELCSA.

Womenfrommildtomoderatelyfood-insecureHHshadgreateroddsofanaemia.SevereHFIwasnotassociatedwithanaemiaamonggirlsorwomen.NoassociationbetweenHFIandanaemia,obesity,ortheirco-occurrenceamongfemaleadolescents

UNITEDSTATESOF

AMERICA(65,173)Laraiaetal.(2010)

PregnantwomeninNorthCarolinawithincomes≤400%oftheincome/povertyratio(N=810).

LongitudinalstudyusingdatafromthePregnancy,InfectionandNutritionprospectivecohortstudy;foodsecuritymeasuredusingUSHFSSM

NosignificantassociationsbetweenHFIandanaemia.

Parketal.(2014)

Pregnantfemalesaged13to54y.Nationallyrepresentativesample.

PooledanalysisusingdatafromNationalHealthandNutritionExaminationSurvey;foodsecuritymeasuredusingUSHFSSM

Mixedresults.TheoddsofID,classifiedbyferritinstatus,were2.90timeshigherforfood-insecurepregnantfemalescomparedwithfood-securepregnantfemales.OtherindicatorsofIDwerenotassociatedwithfoodsecuritystatus.

33

TABLE 5. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND EXCLUSIVE BREASTFEEDING

Country Author(Year) Studypopulationandsamplesize MethodsResultsontheassociationbetweenfood

insecurityandexclusivebreastfeeding

BANGLADESH

(70)Sahaetal.(2008) InfantswhowerebornbetweenMay

2002andDecember2003werefolloweduntilDecember2004andbeyond(N=1343).Matlabdistrict.

LongitudinalstudyusingdatafromtheMaternalandInfantNutritionInterventioninMatlab(MINIMat)study.Foodsecuritymeasuredusingscalebasedonelevenitems(scaledevelopedspecificallyforBangladesh).

NosignificantassociationbetweenHFIandEBFatanyage.

BRAZIL(68) GomesandGubert(2012)

Children<2yofage(N=1635).

CrosssectionalstudyusingdatafromBrazilianDHS.FoodsecuritymeasuredusingtheBrazilianFoodInsecurityScale(EBIA).

Noassociationbetweenfoodinsecurityandbreastfeedinginthefirstyearoflifeorearlyintroductionoffoodsotherthanbreastmilk.

CANADA(66) Orretal.(2018) WomenwhohadcompletedtheMaternalExperiencesBreastfeedingModuleandtheHouseholdFoodSecuritySurveyModuleoftheCanadianCommunityHealthSurvey(2005–2014)andwhohadgivenbirthintheyearoforyearbeforetheirinterview(N=10450).Nationallyrepresentativesample.

Cross-sectionalstudyusingpooleddatafromthe2005–2014CanadianCommunityHealthSurvey(CCHS).FoodsecuritymeasuredusingtheHouseholdFoodSecuritySurveyModuleoftheCCHS.

Negativeassociation.Motherscaringforinfantsinfood-insecureHHswerelessablethanfood-securewomentosustainexclusivebreastfeeding.Relativetowomenwithfoodsecurity,thosewithmarginal,moderateandseverefoodinsecurityhadsignificantlyloweroddsofexclusivebreastfeedingto4months,butonlywomenwithmoderatefoodinsecurityhadloweroddsofEBFto6months.

ETHIOPIA

(71)Yeneabat,BelachewandHaile(2014)

Mothersofinfants(N=592).NorthwestregionofEthiopia.

Community-basedcross-sectionalstudyusingbothquantitativeandqualitativemethods.Foodsecuritystatusassessedusingadaptedversionofquestionnairefrom2005EthiopianDemographicandHealthSurvey.

Noassociation.Inadjustedmultivariatemodels,cessationofEBFwasnotsignificantlyassociatedwithfoodinsecurity.

34

KENYA(67,135)

Machariaetal.(2018)

Childrenlessthan12monthsofageandtheirmothersagedbetween12and49y(N=1110).KorogochoandViwandani,Nairobi.

LongitudinalstudyusingprimarysurveydatacollectedonhouseholdfoodsecurityatbaselineandIYCFpracticespostpartum.FoodsecuritymeasuredusingHFIAS.

Negativeassociation.Infantslivinginfood-insecureHHsweresignificantlylesslikelytobeexclusivelybreastfedupto6monthsofagecomparedwithinfantsfromHHsthatwerefoodsecure.

Webb-Girardetal.(2012)

75HIV-affectedand75HIV-statusunknown,low-incomewomenwhowereeitherpregnantorwithachild≤24monthsandresidinginNakuru,Kenya(N=150).

Crosssectionalstudyusingmixedmethod–quantitativeandqualitativedatafromfocusgroupdiscussionsand9-itemHFIAS.

FoodinsecuritynegativelyaffectsattitudeandbelieftowardsEBF.TheexperienceoffoodinsecurityreducestheircapacitytoimplementEBFfor6months.

UGANDA(72) Youngetal.(2014)

180HIV-infectedpregnantandbreastfeeding(BF)womenreceivingcombinationantiretroviraltherapy.Tororo,Uganda.

LongitudinalcohortstudyusingdatafromthePregnantWomenandInfantStudy,aNationalInstituteofChildHealthandHumanDevelopment(PROMOTE)trial.FoodsecuritymeasuredusingtheHouseholdHungerScale

Mixedresults.NoassociationbetweenmoderateorsevereHHhungerandEBFat6months.However,amongthosewomenstillpracticingEBFat4months,thoseexperiencingmoderateorseverehouseholdhungerweresignificantlymorelikelytoceaseEBFbetween4and6months.

UNITED

STATESOF

AMERICA

(69)

Grossetal.(2012) English-orSpanishspeakingmothersatleast18-yoldwithasingletonfull-term(≥37weeksgestationalage)infantparticipatingintheSpecialSupplementalFoodProgramforWomen,Infants,andChildrenwithinfantsagedbetween2weeksand6months(N=201mother–infantpairs).Largeurbanmedicalcenter.

CrosssectionalstudyofWICparticipantsatalargeurbanmedicalcenter.2-itemfoodsecuritymoduleadaptedfromtheUSHFSSMcoremodule:‘worriedfoodwouldrunout’and‘lowcostfood.”Responseoptionsincludedoften,sometimes,ornevertrueinthelast12months.Motherswhorespondedsometimesoroftentruetobothofthequestions,wereclassifiedasfood-insecure.

Noassociationbetweenfoodinsecurityandexclusivebreastfeeding.

35

TABLE 6. STUDIES ON THE ASSOCIATION BETWEEN FOOD INSECURITY AND OVERWEIGHT AND OBESITY

Country Author(Year) Studypopulationandsamplesize Methods

Resultsontheassociationbetween

foodinsecurityandoverweightand

obesity

BRAZIL(30-31,55,77,83,91,215-216)

Gubertetal.(2017) Mothersaged15–49andtheirchildrenunder5yofage.(N=4299mother–childpairs.)Nationallyrepresentativesample


PositiveassociationbetweenHFIandoverweightinwomen.

Gubertetal.(2016) Children<5yofage(N=4064)Nationallyrepresentativesample.


NoassociationbetweenHFIandoverweightinchildren<5y

Kac,Schlüsseletal.(2012)

Children<5yofage(N=3433)Nationallyrepresentativesample.


NoassociationbetweenHFIandoverweightinchildren<5y

Kac,Velásquez-Melendezetal.(2012)

Adolescentfemales15-19yofage(N=1529).Nationallyrepresentativesample.


PositiveassociationbetweenHFIandexcessiveweightinadolescentfemales.Therewasahigherprevalenceofexcessiveweightforadolescentfemaleslivinginseverelyfood-insecurehouseholdscomparedtofood-securehouseholds.

Lopesetal.(2013) 12–18yoldadolescents(N=523).Low-incomeareaofthemunicipalityofDuquedeCaxias,RiodeJaneiro.

Cross-sectionalstudy;foodinsecurityestimatewasbasedontheEBIA.

NoassociationbetweenHFIandoverweightinadolescents.

Oliveira,Lira,Verasetal.(2009)

Adolescents(N=1528)andadults(N=1163)fromtwotownsinthestateofPernambuco,innorth-easternBrazil.

Cross-sectional,primarysurvey;foodinsecurityestimatewasbasedontheEBIA

NoassociationbetweenHFIandoverweightorobesityamongadolescents.

36

Schlüsseletal.(2013)

Adolescentfemales(N=1502),adultwomen(N=10226)andchildren<5yofage(N=3433).Nationallyrepresentativesample.


PositiveassociationbetweenHFIandobesityamongadultwomen;PositiveassociationbetweenHFIandexcessweightamongfemaleadolescents.NoassociationbetweenHFIandobesityamongchildren(eitherboysorgirls).

Velásquez-Melendezetal.(2011)

Womenaged18to45y(N=10226).Nationallyrepresentativesample.


PositiveassociationbetweenHFIandoverweightamongadultwomen.

CANADA(73,87) Duboisetal.(2006) Childrenaged1.5–4.5y(N=2103children,49%girls)inQuebec.

LongitudinalStudyofChildDevelopmentinQuebecFoodsecuritymeasuredusingasinglefoodinsufficiencyquestionaskedtomothers

PositiveassociationbetweenHFIandchildoverweightandobesityat4.5yofage.

Marketal.(2012) Boysandgirlsaged9–18y(N=8938).Nationallyrepresentativesample.

CrosssectionalstudyusingtheCanadianCommunityHealthSurvey(CCHS)Cycle2.2;foodinsecurityestimatewasbased10adult-referencedquestionsand8child-referencedquestions.

Mixedresults.PositiveassociationbetweenHFIandoverweightinboys9–18yofage.TherewasahigherprevalenceofBMI≥85thpercentileinboysinlow-incomefood-insecureHHsthanamongboysinfood-securelow-incomeHHs.

COLOMBIA(53) Isanakaetal.(2007)

Children5–12yofageandtheirmothers(N=2526).ChildrenattendingpublicschoolsinBogota.

Cross-sectionalstudyofschool-agechildren’shealthandnutritionalstatus;foodinsecurityestimatewasbasedonamodifiedversionoftheSpanish-languageUSHFSSM(16version)plus5child-specificquestionsusedtomeasurechildfoodsecurity.

NoassociationbetweenHFIandchildormaternaloverweight.

37

JAMAICA(88)

Duboisetal.(2008) Children10–11yofage(N=1674inJamaica;1190inQuebec).Nationallyrepresentativesamples.

Cross-sectionalstudyusingtheQuébecLongitudinalStudyofChildDevelopment(QLSCD)2008&JamaicaYouthRiskandResiliencyBehaviourSurveyof2007.Foodinsecuritywasmeasuredbasedontwoquestionsaskedtochildrenaboutexperiencesoffoodinsecurity.

Mixedresults.NegativeassociationbetweenHFIandoverweightamongchildrenaged10–11yinJamaica.PositiveassociationbetweenHFIandoverweightorobesityonlyingirlsInQuébec.

ECUADOR(61,100) Weigeletal.(2016) AdultwomenlivinginHHswithchildren(N=794)inlow-incomeneighbourhoodsinQuito,Ecuador.

Crosssectional,primarysurvey.foodinsecurityestimatewasbasedontheSpanishversionoftheUSHFSSM

NoassociationbetweenHFIandobesityinadultwomen.

WeigelandArmijos(2015)

Womenofreproductiveage(N=10748).Nationallyrepresentativesample.

Cross-sectionalstudyusingtheEncuestaDemograficadeSaludMaternaeInfantil2004survey.Foodinsecuritywasmeasuredbasedontwoquestionsonfoodinsufficiency.

Noassociationbetweenfoodinsecurityandadultoradolescentfemaleoverweight/obesity.

FRANCE(97) Martin-Fernandezetal.(2014)

Adultmenandwomen(N=2967).RepresentativesampleofParismetropolitanarea.

Cross-sectionalstudyusingthethirdwaveofalongitudinal,cohortstudy,theHealth,InequalitiesandSocialRuptures(SIRS)survey;foodinsecurityestimatebasedontheUSHFSSM.

PositiveassociationbetweenHFIandoverweight(higherBMI)amongwomen.Noassociationformen.

GHANA(52) SaakaandOsman(2013)

Womenofreproductiveage(15to45y)(N=337).TamaleMetropolisofNorthernGhana.


NoassociationbetweenHFIandwomen’sBMI.

IRAN(Islamic

Republicof)(78)

Jafarietal.(2017) Childrenaged9.30±1.49y(N=587:439girlsand148boys)inIsfahan.

Cross-sectionalstudy,primarysurvey;foodinsecurityestimatebasedontheRadimer/CornellScale.

NoassociationbetweenHFIandobesityinchildrenaged7–12y.HFIwasassociatedwithabdominalbutnotgeneralobesity.

LEBANON(92,104) Jomaaetal.(2017) Motherswhohavechildren<18yofage(N=378)inBeirut.

Cross-sectionalstudy,primarysurvey;foodinsecuritywasmeasuredbasedalocally-validated,ArabicversionoftheHFIAS.

PositiveassociationbetweenHFIandobesityinwomen.

38

Ghattasetal.(2017)

Childrenandadults(N=474)from84HHsintwosettlementsintheBekaavalley.Children<5yofage(N=66)Children5–17yofage(N=146)Adults>18yofage(including65andabove)(N=302)

Cross-sectionalstudy,primarysurvey;foodinsecuritywasmeasuredusinganArabicversionoftheUSHFSSMadaptedtotheLebanesecontext.

NoassociationbetweenHFIandoverweightandobesityamongadults.

MALAYSIA(45,101-102)

AliNaseretal.(2014)

Mothersaged18–55ywhowerenon-lactating,non-pregnant,andhadatleastonechildaged2–12y(N=223).BachokdistrictinKelantan,ruralareaofNorthEastPeninsularMalaysia.

Cross-sectionalstudy,usingaprimarysurvey;foodinsecurityestimatewasbasedontheRadimer/Cornellfoodsecurityscale.

NoassociationbetweenHFIandobesity/overweightinadultwomen.

Mohamadpouretal.(2012)

Indianwomen(19–49yofage,non-pregnant,andnon-lactating)(N=169)inpalm-plantationHHsinNegeriSembilan.


NoassociationbetweenHFIandobesityinadultwomen.However,significantassociationobservedbetweenHFIandriskwaist-circumference.

Shariffetal.(2014) Womenofreproductiveage(N=625)inthreestatesofPeninsularMalaysia.


NoassociationbetweenHFIandobesity/overweightinadultwomen.

MEXICO(37) Shamah-Levyetal.(2014)

Children<5yofageandadults.(Nnotprovided).Nationallyrepresentativesamples.


PositiveassociationbetweenHFIandoverweight(higherBMI)amongadults.HFIsignificantpredictorofoverweight/obesityinadults,especiallywomen.

NEPAL(38,41) SinghandRam(186)

Marriedwomenaged15to49y(N=4581).Nationallyrepresentativesample.

CrosssectionalstudyusingNepalDHS2011;foodinsecurityestimatebasedonanadaptedversionofHFIAS(7items).

NoassociationbetweenHFIoverweightinwomen.

Sreeramareddyetal.(2015)


Cross-sectionalstudyusingNepalDHS2011;foodinsecurityestimatebasedonanadaptedversionofHFIAS(7items).

NoassociationofHFIwithchildoverweight(BMI-for-agezscore).

39

UGANDA(105) Chaputetal.(2007) 60food-secure(30maleand30female)and60food-insecure(30maleand30female)individualsinurbanKampala.


NoassociationbetweenHFIandoverweightinwomen.

UNITEDSTATESOF

AMERICA(3-4,26,74-76,79-82,84-86,93-96,98-99,103,207-208,217-221)

Asfouretal.(2015) Children2to5yofage(N=1211)intwenty-eightsubsidizedchildcarecentresinMiami-DadeCounty,Florida.

CrossSectionalstudyusingbaselinedatafromapreschoolinterventiontrial.FoodinsecuritymeasuredusingfivesurveyquestionsfromtheUSHFSSM.

NoassociationbetweenHFIandBMIpercentileamongchildren2to5yofage.

Bhargavaetal.(2008)

Children>5yofage(kindergartentofifthgrade)(N=5797boysand5682girls).Nationallyrepresentativesample.

LongitudinalstudybasedontheEarlyChildhoodKindergartenCohortStudy;foodinsecuritymeasuredusingtheUSHFSSM.

NoassociationbetweenHFIandoverweightinchildren>5yofage.

Bronte-Tinkewetal.(2007)

Children2yofage(N=8693children).Nationallyrepresentativesample.

LongitudinalstudybasedontheEarlyChildhoodLongitudinalSurvey-BirthCohort;foodinsecuritymeasuredusingtheUSHFSSM.

Nodirectassociation.HFIinfluencesoverweightviaparentingpracticesandinfantfeedingpractices.

Buscemietal.(2011)

Latinochildren2–17yofage(N=63,30girlsand33boys)fromimmigrantandnon-immigrantfamiliesattendingaprimaryhealthcareclinicservinglowincomefamiliesinMemphis.

Cross-sectionalstudy,usingaprimarysurvey;foodinsecuritymeasuredusingtheUSHFSSM.

NegativeassociationbetweenHFIandoverweightinchildren2–17yofage.Acculturationisasignificantmoderatingvariable.

Caseyetal.(2006) Children3–17yofage(N=3553boysand3442girls).Nationallyrepresentativesample.

CrosssectionalstudyusingNHANESdata;foodinsecuritymeasuredusingtheUSHFSSM(8child-referenceditems).

Mixedresults.PositiveassociationbetweenHFIandoverweightforthefollowingdemographicgroups:children12to17yofage;whitegirls;childrenlivinginHHswithincome<1and>4timesthefederalpovertylevel.Childfoodinsecurityassociatedwithriskforoverweightfor:abovegroups,andages3–5,MexicanAmerican,andwhite.

40

Gundersenetal.(2009)

Children8–17yofage(N=2516).Nationallyrepresentativesample.

Cross-sectionalstudyusingpooledNHANESdata;foodinsecuritywasmeasureusingtheUSHFSSM.

NoassociationbetweenHFIandoverweightinchildren8–17yofage.

Gundersenetal.(2008a)

Children10–15yofage(N=1031).Boston,Chicago,andSanAntonio.

Cross-sectionalstudyusingdatafromtheWelfare,Children,andFamiliesThree-CityStudy;foodinsecuritymeasuredusingthreequestionsfromtheUSHFSSM.


Gundersenetal.(2008b)

Children3–17yofage(N=841)andtheirmothers.Nationallyrepresentativesample.

Pooledtimeseries-crosssectiondatafromtheNHANES;foodinsecuritymeasuredusingtheUSHFSSM(8-itemchildscale).

NodirectassociationbetweenHFIandoverweightamongchildren3–17yofage.

Kauretal.(2015) Children2to11yofage(N=9701).Nationallyrepresentativesample.

LongitudinalstudyusingNHANESdata.Child-levelfoodinsecuritywasassessedwithUSHFSSMbasedoneightchild-specificquestions.Personalfoodinsecuritywasassessedwithfiveadditionalquestions.

Mixedresults.Obesitysignificantlyassociatedwithpersonalfoodinsecurityforchildren6–11yofagebutnotinchildren2–5yofage.

Kukuetal.(2012) Children(N=959).Nationallyrepresentativesample.

LongitudinalstudyusingtheSecondChildDevelopmentSupplement(CDS-II)ofthePanelStudyofIncomeDynamics(PSID);foodinsecuritymeasuredusingtheUSHFSSM.

HFIpositivelyassociatedwithobesityinchildren.Moreover,thisrelationshipdiffersacrossrelevantsubgroupsincludingthosedefinedbygender,race/ethnicityandincome.

Hansonetal.(2007)

Adultmenandwomen≥20yofage(N=4338menand4172women).Nationallyrepresentativesample.

CrosssectionalstudyusingtheNHANES;foodinsecuritymeasuredusing18itemUSHFSSM.

PositiveassociationbetweenHFIandobesityinwomenbutnotinmen.Greaterlikelihoodofobesityinfoodinsecure:married,widowed,andpartneredwomen(asopposedtofoodsecure,nevermarried).Menwithlowfoodsecuritylesslikelytobeoverweight.Womenwithmarginalfoodsecuritymorelikelytobeoverweight.Womenwithlowfoodsecuritymorelikelytobeobese.

41

Hernandezetal.(2017)

Adults18–59yofage(N=1990).Nationallyrepresentativesample.

CrosssectionalstudyusingNationalHealthInterviewSurveydata;foodinsecuritymeasuredusingthe10-itemUSHFSSM.

Foodinsecuritywasassociatedwith41%and29%higheroddsofbeingoverweight/obeseamongwhiteandHispanicwomen,respectively.Foodinsecuritywasnotrelatedtooverweight/obesityamongblackwomennoramongwhite,black,andHispanicmen.

Jyotietal.(2005) ECLS_Kcohort(N=5682boysand5498girls)kindergartenthrough8thgrade.

EarlyChildhoodLongitudinalStudy-KindergartenCohort;foodinsecuritymeasuredusingtheUSHFSSM.

Mixedresults.PositiveassociationbetweenHFIandoverweightonlyamonggirls.

Laraiaetal.(2015) Women>16yofage(N=526)inNorthCarolina.

LongitudinalstudyusingdatafromthePregnancy,InfectionandNutrition(PIN)PostpartumStudy;foodinsecuritymeasuredusingtheUSHFSSM.

PositiveassociationbetweenHFIandhigherBMIamongpost-partumwomen.Amongoverweight/obesewomen,foodinsecuritywasassociatedwithahigherBMIat12monthspostpartumcomparedtooverweight/obesewomenfromfood-secureHHs.Foodsecuritystatuswasassociatedwithhigherlevelsofperceivedstress,disorderedeatingbehaviouranddietaryfatintakeabovetherecommendedamountat3and12monthspostpartum

Laraiaetal.(2013) Pregnantwomen(N=1041)inNorthCarolina.

LongitudinalstudybasedonthePregnancy,InfectionandNutrition(PIN)PostpartumStudy;foodinsecuritymeasuredusingtheUSHFSSM.

Positiveassociationbetweenmildfoodinsecurityandriskofexcessiveweightgainamongpregnantwomen.

Lohmanetal.(2009)

Children10–15yofage(N=1011)inBoston,Chicago,andSanAntonio.

CrosssectionalstudyusingWelfare,Children,andFamiliesThree-CityStudy(1999Wave1);foodinsecuritymeasuredusinga3-itemsubscaleoftheUSHFSSSM(child)

NodirectassociationbetweenHFIandoverweightinchildren10–15yofage;positiveinteractionoffoodinsecurityandmaternalstressindex

42

MartinandLippert(2012)

Adultmenandwomenofchildbearingage(N=7931).Nationallyrepresentativesample.

LongitudinalstudyusingthePSID;foodinsecuritymeasuredusingtheUSHFSSM.

PositiveassociationbetweenHFIandoverweight/obesityinwomen.Amongwomen,food-insecuremothersweremorelikelythanchild-freewomentobeoverweightorobese.Therisksaregreaterforsinglemothersrelativetomothersinmarriedorcohabitingrelationships.

MartinandFerris(2007)

Children2–12yofage.(N=212;108girls,104boys)inHartford,Connecticut.

Crosssectionalstudyusingacommunitysurvey;foodinsecuritymeasuredusingthe18itemUSHFSSM.


Metallinos-Katsarasetal.(2012)

Children2–5yofage(N=2353)fromlow-incomefamiliesparticipatingintheMassachusettsSpecialSupplementalNutritionProgramforWomen,Infants,andChildren.

Longitudinalstudybasedonaprimarysurvey;foodinsecuritymeasuredusingthe18-itemUSHFSSM.

PositiveassociationbetweenHFIandobesityinchildren2–5yofage.

Metallinos-Katsarasetal.(2009)

Children≤5yofage(N=8493)fromlow-incomefamiliesparticipatingintheMassachusettsSpecialSupplementalNutritionProgramforWomen,Infants,andChildren.

Crosssectionalstudyonaprimarysurvey;foodinsecuritymeasuredusingthe4-itemsubscaleofUSHFSSM.

Mixedresults.NegativeassociationbetweenHFIandoverweightingirls<2yofage.PositiveassociationbetweenHFIandoverweightingirls2–5yofage.

MillimetandRoy(2015)

Children(kindergartenthrougheighthgrade)(ECLS-KcohortN=6470);Childrenfrombirththroughkindergartenentry(ECLS-BcohortN=4100).Nationallyrepresentativesample.

LongitudinalstudyusingdatafromtheECLS-KandECLS-B;foodinsecuritymeasuredusingtheUSHFSSM.

Nolong-runcausalrelationshipbetweenfoodsecurityandchildobesityinthepresenceofmeasurementerror.Onlyintheabsenceofmeasurementerrorthereexistsanysuggestiveevidencethatfoodinsecurityhasalong-run(negative)causaleffectonchildobesityandoverweightstatusofchildren.

43

OlsonandStrawderman(2008)

Adultchildbearingwomen(N=662)livingina10-countyruralareaofupstateNewYork.

LongitudinalstudyusingdatafromtheBassettMothersHealthProject,anobservationalcohortstudyofhealthyadultwomenfollowedfromearlypregnancyuntil2ypostpartum;HFImeasuredpostpartumusinga3-itemsubscaleoftheUSHFSSM.

PositiveassociationbetweenHFIandobesityinwomenattwoyearspostpartum;associationlostsignificanceaftercontrollingforcovariates.

RoseandBodor(2006)

Childrenintheirkindergartenyear(N=16889).Nationallyrepresentativesample.

LongitudinalstudyusingtheEarlyChildhoodLongitudinalStudy-KindergartenCohort(ECLS-K);foodinsecuritymeasuredusingthe18-itemUSHFSSM

NoassociationbetweenHFIandoverweightinchildrenofkindergartenage.

Speirsetal.(2016) Children2–5yofage(N=438)recruitedfrom30licensedchildcarecentresinfivecountiesincentralIllinois

CrosssectionalbasedontheSynergisticTheoryandResearchonObesityandNutritionGroupKids(STRONGKids)program;foodinsecuritymeasuredusingthe18itemUSHFSSM.BothHHfoodinsecurityandchildfoodinsecurityestimated

Mixedresults.NoassociationbetweeneitherHFIorchildfoodinsecurityandBMIforthefullsample.PositiveassociationbetweenHFIandBMIz-scoresforgirlsonly.

Trappetal.(2015) Low-incomechildrenaged2–4y(N=222)

Cross-sectionalstudyusingaprimarysurveyrelatedtoanobesityprevention/reversalstudy(StepstoGrowingUpHealthy);foodinsecuritymeasuredusingtheUSHFSSM

NoassociationbetweenHFIandchildBMIpercentile.

WhitakerandSarin(2007)

Motherswithpreschoolchildren(N=1707)from20largecities.

LongitudinalstudybasedontheFragileFamiliesandChildWellbeingStudy(Baseline2001–2003;follow-up2003–2005);foodinsecuritymeasuredusingtheUSHFSSMadultitems.

NoassociationbetweenHFIandobesityinwomen.Significanceofassociation(atbothperiods)waslostaftercontrollingforcovariates.

Widomeetal.(2009)

Multiethnicmiddleandhighschoolstudents(N=4746)from31primarilyurbanschoolsinMinneapolis–St.Paul,Minnesotaarea.

Cross-sectionalstudyusingaprimarysurvey,partofProjectEAT(EatingAmongTeens);foodinsecuritymeasuredusingthe2itemsfromUSHFSSM

PositiveassociationbetweenHFIandoverweightinadolescents.Food-insecureyouthsweremorelikelytohaveabodymassindexabovethe95thpercentile.

44

VIETNAM(106) Vuongetal.(2015) 250adults(N=250)inDistricteightinHoChiMinhCity

Crosssectionalstudyusingprimarysurvey;foodinsecuritymeasuredusingtheELCSA.

NosignificantassociationbetweenHFIandoverweight/obesityinadults.

INDIA,PERU,ETHIOPIA,

VIETNAM(48)Humphriesetal.(2015)

Childrenaged1,5,and8y(threeroundsofdatacollection)infourcountries.Ethiopia(N=1757),India(N=1825),Peru(N=1844),andVietNam(N=1828).

Longitudinalstudyfollowingthesamechildrenatages1,5and8y,usingaprimarysurvey;at5yofagefoodinsecurityestimatewasbasedonamodifiedversionoftheUSHFSSM,at8yofage,theestimatewasbasedontheHFIAS.

Mixedresults.NoassociationbetweenHFIandBMI-Zinanyofthe4countriesincross-sectionalanalysisat5yofage,andonlyinPeruandVietNamat8yofage.

UNITEDSTATESOF

AMERICAANDMEXICO

(89)

Rosasetal.(2011) 5-year-oldchildrenandtheirmothers.InCalifornia,mother–childpairsofwhomallchildrenwerebornintheUSandallmothersborninMexico,participantsintheCenterfortheHealthAssessmentofMothersandChildrenofSalinas(CHAMACOS)study(N=287mother–childpairs).InMexico,mothersandtheir5-year-oldchildrenwhowerebeneficiariesofthesocialwelfareprogramOportunidades(N=316mother–childpairs)

Abinationalstudyusingtwocross-sectionalsamplesof5-year-oldchildrenandtheirmothersinCaliforniaandMexico;foodinsecuritywasmeasuredbasedontheUSHFSSM-SpanishVersion(ShortForm)

Mixedresults.PositiveassociationbetweenHFIandoverweightorobesityamongchildreninMexico.NoassociationofHFIwithchildweightstatusinCalifornia.

45

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