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Little is known about food insecurity in the UK. The aims of this study were to assess the prevalence and factors associated with food insecurity in a UK cohort, and to examine whether the diets, reported health and anthropometry of young food insecure children differed from those of other children.
The Southampton Women’s Survey is a prospective cohort study in which detailed information about the diet, lifestyle and body composition of 3000 women was collected before and during pregnancy. Between 2002-2006, 1618 families were followed up when the child was 3 years old. Food insecurity was determined using the Household Food Security scale. The child’s height and weight were measured; diet was assessed by food frequency questionnaire.
4.6% of the households were food insecure. Food insecurity was more common in families where the mothers were younger, smokers, of lower social class, in receipt of financial benefits, and who had a higher deprivation score (all p<0.05). In comparison with other 3-year-old children, those living in food insecure households were likely to have worse parent-reported health and to have a diet of poorer quality, characterised by greater consumption of white bread, processed meat and chips, and by a lower consumption of vegetables (all p<0.05). They did not differ in height or body mass index.
Our data suggest that there are significant numbers of food insecure families in the UK. The poorer reported health and diets of young food insecure children have important implications for their development and lifelong health.
Arising as a concept in developing countries, food security is now recognised as an important issue in the developed world. Food security is defined as access at all times to enough nutritious food for an active and healthy life. Food insecurity is therefore defined as having limited or uncertain access to enough nutritious food.
Most of the published work on food insecurity in developed countries has come from the US, Canada and Australia, where estimates of prevalence range between 7% and 12%.[2-5] Unsurprisingly, a key determinant of food insecurity is poverty,[3, 6, 7] but the risk of being food insecure is also increased among families with children, and where parents have lower levels of educational attainment. There is substantial evidence that living in a food insecure household has undesirable consequences for children, including diets of poorer quality  and poorer health outcomes.[1, 9-11] Although food insecurity is associated with an increased incidence of overweight and obesity in women,[12, 13] the relationship in children is less clear.[3, 14, 15]
As yet there is little published work on food insecurity in the UK. In 2007 almost a third (29%) of families studied in the Low Income Diet and Nutrition Survey (LIDNS) were food insecure. This compares with a prevalence of 9.7% in the Environmental Risk Longitudinal Study in a sample of 1116 families selected from a UK register of twin births. These studies suggest that significant numbers of children are currently growing up in food insecure households. However, little is known about the factors associated with food insecurity in the UK or the consequences for children who are food insecure.
In this study we examined the prevalence of food insecurity and the factors associated with it among families in the Southampton Women’s Survey, a large prospective cohort of mothers and children. Our particular interest was in the health, anthropometry and quality of diets of young children living in food insecure households.
The Southampton Women‘s Survey (SWS) is a prospective cohort study of mothers and children. Between 1998 and 2002, non-pregnant women who were registered with general practitioners in Southampton, who were aged between 20 and 34 years, were sent a letter that described the SWS and invited them to take part. A total of 12583 women agreed to participate in the survey, 75% of those contacted. SWS women who became pregnant were then followed further. There were 1973 singleton births before the end of 2003. One thousand six hundred and forty (83%) of these children were followed up when they were 3 years old (median age at interview: 3 years, 3 weeks (IQR 3 years, 1 week to 3 years, 6 weeks). The SWS was approved by the Southampton and South West Hampshire Ethics Committee.
At the women’s initial interview information was collected by interviewer-administered questionnaire. This included whether she lived with a partner and whether she was receiving any financial benefits. Social class was determined by the woman’s occupation. Her level of educational attainment was classified according to the highest academic qualification achieved and categorised in two groups: none up to General Certificate of Education (GCSE) exams taken at age 16 years (grade C or above), and A-levels taken at 18 years or higher qualifications. The household’s postcode was used to determine the Index of Multiple Deprivation (IMD) score (; a higher score indicates a greater level of deprivation.
Women who became pregnant were seen throughout their pregnancy, and the children were followed up in infancy and early childhood. At the 3-year interview, information was collected by trained research nurses using administered questionnaires. For 1631 (99.5%) of the children seen at 3 years, the interview was conducted with the child’s mother. The child’s health was described by the mother in response to the question ‘How good is your child‘s health in general?’. The five possible answers were: ‘very good’, ‘good’, ‘fair’, ‘bad’ and ‘very bad’. The child’s height was measured using a portable stadiometer (Leicester Height measurer) and weight using portable scales (both Seca, Germany). Regular studies were carried out throughout the survey to monitor interobserver variation in anthropometric measurements. [18 ]
Household food security was assessed using the 6-point short form of the US Household Food Security Scale as developed by Blumberg 20] (see appendix 1). The phrasing was altered slightly to suit a UK population. The questionnaire was scored by totalling the number of affirmative responses (including the answers ‘often’ and ‘sometimes’ to questions 5 & 6, and ‘some months’ and ‘almost every month‘ to question 2). Scores ranged between 0 and 6. The total score was used to categorise households: < 2 = food secure, ≥ 2 and <5 = food insecure without hunger, ≥ 5 = food insecure with hunger. Food security data were available for 1618 (82%) SWS families at 3 years.
The child‘s diet over the 3 months preceding the 3-year interview was assessed using a food frequency questionnaire (FFQ), administered by the research nurse . Parents were asked to describe their child’s average frequency of consumption and amount consumed of 80 foods and drinks. Prompt cards were used to show examples of the foods included in each food group to help standardise responses to the FFQ. At the end of the FFQ, information on the type and quantity of milk consumed and the number of teaspoons of sugar added to the child’s food and drinks each day was recorded. Frequencies of consumption and amounts of foods not listed in the FFQ were also recorded if they were consumed once a week or more. The foods listed on the FFQ were grouped according of type of food and nutrient composition. For example, chocolate and sweets were included in a ‘confectionary’ group; carrots, parsnips, swede and turnips were included in a ‘root vegetables’ group.  Energy intakes were calculated using UK food composition data and information obtained from food manufacturers. In a validation study of 887 SWS children aged 3 years, in which nutrient intakes estimated from the FFQ were compared with intakes estimated from 2-day prospective food records, the Spearman rank correlation coefficient for energy intake was 0.33 (data unpublished).
A number of sociodemographic variables identified in the literature as being associated with food insecurity were examined. These were mother’s age, IMD, smoking status, benefits receipt, social class, highest level of educational attainment and whether she was living with a partner.
One hundred and thirty-three (8.2%) households replied affirmatively to one or more of the six food security questions (see appendix 1). Seventy-five (4.6%) households were classified as food insecure, and of these, 23 households (1.4%) were classified as suffering from hunger. Our analyses considered the food insecure households with or without hunger as a single group. Child’s body mass index (BMI) was considered as a continuous outcome in relation to food security status and as categories of weight status (‘normal’, ‘overweight’ and ‘obese’). 
Underweight children  were included within the ‘normal’ group as the numbers were too small to be considered separately. The general health of the child was reported in five categories, but as the numbers of children in the poorest categories were small, the ‘fair’ (n=78), ‘bad’ (n=11), and ‘very bad’ (n=2) categories were combined.
All variables were checked for normality. T-tests and Mann-Whitney U tests were used to compare normally and non-normally distributed continuous variables between food secure and insecure households respectively. For comparisons of proportions, a χ2 test was used. Multiple logistic regression analysis was used to identify the independent associations between maternal factors and food insecurity when the child was 3 years old. Multiple logistic regression was used to identify the independent associations between maternal factors and food insecurity when the child was 3 years old. Linear regression and ordinal logistic regression were used to describe how child anthropometry and parent-reported health were predicted by food insecurity status, after adjusting for gender and child’s age at measurement. Multiple linear regression models were also fitted to test for the effect of food insecurity on the child’s energy intake, before and after adjusting for maternal factors. The data were analysed using STATA V. 11.0. 
Table 1 shows the characteristics of the women according to their household food security status. Women who were food insecure were more likely to be living in a deprived neighbourhood, without a partner, receiving benefits, were younger, smokers, of lower social class, and had a lower level of educational attainment. As these factors were interrelated we examined the independent predictors of food insecurity in a multivariate model (table 2). Maternal age, receipt of benefits, social class, IMD and smoking status were all independently associated with the risk of being food insecure. There were twofold increases in the risk of being food insecure among the mothers who were youngest, most deprived, in receipt of benefits, and who were smokers, and a threefold increase among mothers of low social class. In the multivariate model, mother’s educational attainment and whether she lived with a partner or not, were no longer related to household food security status.
Table 3 shows the characteristics of the children at 3 years of age, according to the food security status of the household. The distribution of boys and girls was comparable in food secure and insecure households (data not shown). After adjusting for age and gender, there were no differences between food secure and insecure children in height, BMI or in the proportion of overweight children (table 3), This was not altered by taking into account of the background characteristics that predicted household food insecurity (table 2) in a separate model (data not shown). Parent-reported general health differed for food insecure and secure children. Children in food secure households had better reported health than those in food insecure households. Conversely, children living in food insecure households were almost twice as likely as those living in food secure households to have their health reported as ‘fair’, ‘bad’ or ‘very bad’. This difference remained after taking account of the background characteristics (table 2) that predicted household food insecurity (adjusted OR=1.7, p=0.028).
Our final analyses investigated whether being food insecure was associated with differences in the diets of children at the age of 3 years. Daily energy intakes of the children are shown in Table 4 together with weekly consumption of the main food groups.
In comparison with other children, those living in food insecure households had a greater consumption of foods that provide energy but are low in micronutrients, such as added sugar, soft drinks and crisps, and lower consumption of ‘healthier’ foods such as fresh vegetables and wholemeal bread, although their consumption of fruit was comparable. These differences were reflected in higher energy intakes among the food insecure children. After taking account of the maternal characteristics that predicted food insecurity (table 2) and maternal educational attainment (as this may affect reporting of intake ), the difference in energy intake between the food secure and insecure children was no longer significant (p=0.118) but the difference in energy intake expressed per kg body weight remained (p=0.047).
We found that 1 in 20 children in the SWS was living in a food insecure household. Food insecurity was associated with other markers of household deprivation and maternal characteristics, specifically living in an area with a higher IMD, being in receipt of financial benefits, and among younger mothers of lower social class In comparison with children living in food secure households, food insecure children were more likely to have poorer parent-reported health and to have a diet of poorer quality, but rates of overweight and obesity did not differ.
This study is one of the first to be conducted on the UK population, and the first to look at food security in relation to anthropometry and to children’s health. A strength of this work is that we studied a large population sample of children that includes a wide range of household types and family backgrounds. The children represented 82% of the SWS cohort and, whilst the mean IMD and the proportion of households receiving benefits was slightly lower than the UK average,[27, 28] many of the family characteristics are comparable with the wider UK population. We would therefore expect our findings to have relevance beyond Southampton. A potential limitation is that the mother’s sociodemographic data were collected before pregnancy while the assessment of food security was assessed when the child was 3 years old, although we would not expect many of these characteristics to have changed markedly in that time. We used a short form of a questionnaire developed in the US to assess food security over the past year. Although this questionnaire has been shown to categorise the food security of households effectively, this is a limitation of our study, as, as it does not measure all aspects of food insecurity, and in particular contains no items referring specifically to children.  A further limitation is that we assessed children’s diets using an administered FFQ that covered a shorter period than that for the food security questions. Whilst FFQs may be prone to bias, assessed energy intakes showed reasonable agreement with estimates from food diaries. Measurement error is inherent in the assessment of diet, and is likely to cause attenuation of associations. We therefore think it unlikely that the qualitative differences in diet we observed among the food insecure children were explained by differences in reporting.
The dietary, health and anthropometric data for the children were collected contemporaneously with the food security data providing important evidence of an association between food insecurity and poorer health and dietary quality in young children. Because our data are cross sectional we cannot determine the temporal relationships between food security and these outcomes. Equally we may be limited in our understanding of whether there are specific effects of food insecurity that are causally related to the poorer outcomes in children, beyond the effects of a background level of disadvantage. However, worse parent-reported health and the higher energy intakes observed in the food insecure children in our study were both independent of other predictors of food insecurity. The long-term impact of poorer reported health and diet at 3 years will be assessed in our continued follow-up of these children, while in parallel work we will be able to address the influence of personal factors that may mediate the effects of food security and disadvantage on food purchasing and dietary choices.
As expected the prevalence of food insecurity found in the SWS (5%) was lower than that observed in the Low Income Diet and Nutrition study. However, it was also substantially lower than the prevalence found in the E-Risk study, in which food security was assessed over the same time period as the SWS food security data were collected. In the E-Risk study 9.7% of families were food insecure, which is closer to some of the higher prevalence estimates of food insecurity observed in the USA and Canada.[2-5] There are differences in methodology used for the assessment of food insecurity across the UK studies which may make direct comparisons difficult [16,17]. However there may be key differences between the SWS and E-Risk cohorts that account for the difference in observed prevalence of food insecurity between the cohorts. It is also possible that our study yielded an underestimate of the true prevalence of food insecurity, as more deprived families may be less likely to be followed up. Further population studies will be needed to assess the current prevalence of food insecurity in the UK and to determine how this compares with other countries.
The characteristics of food insecure families in the SWS were comparable with those observed in the E-Risk study and in studies from the USA and Australia, where poverty and other markers of disadvantage were strongly related to food insecurity.[5, 6, 17] For example, in the E-risk study food insecurity was almost six times more common in low–socioeconomic status families than in higher status families . This compares with a threefold increase in risk of food insecurity among the lowest social class families in the SWS.
A key aim of our study was to examine the consequences for young children of growing up in a food insecure household. While we did not find differences in the heights or BMI of food secure and insecure children, children in food insecure households had poorer parent-reported health and diets of poorer quality. Children’s anthropometry was not reported in the UK Low Income Diet and Nutrition Survey  or in the E-risk Study  to enable comparisons with our cohort. However, the observed lack of association between BMI and food insecurity in the SWS is consistent with a number of studies of US children. [14, 32] While higher rates of obesity have been described among food insecure children in some studies, the relationship between food insecurity and obesity in children remains uncertain. [3,15] The association we observed with reported health differs from the findings of Bronte-Tinkew et al,  who found no differences among food insecure children aged 2 years in the Early Childhood Longitudinal Survey-Birth Cohort, although there were indirect associations that operated via maternal depression . While the significance of poorer parent-reported health of such young children is not yet known, in older adults, a single self-rated health question has been shown to be highly predictive of mortality  and use of health services. Parent-reported health of children has been found to yield useful information in other studies. For example in a study of 317 children in the USA aged 2 -18 years, parent-rated health was predictive of healthcare costs over the following 2 years. In our cross-sectional data we cannot yet assess the importance of the parental reports, but it is of concern that, independently of the background predictors of food insecurity, poorer reported health is already more common among these young food insecure children.
In our study there were clear differences in the diets of food insecure children, such that they had greater intakes of energy-dense, micronutrient-poor foods. This is consistent with effects of a constrained food budget that is more likely to be spent on food that is higher in energy but lower in nutrients, as described by Drewnowski and Specter.  However, other studies have not yielded a clear picture of how food insecurity affects the diets of young children, as both detrimental effects as well as no effects on food and nutrient intakes have been described. [4, 37, 38] There is some evidence that while dietary quality is adversely affected by food insecurity amongst adults , the quality of the diets of young food insecure children may be protected. We did not find this in our study, and the quality of the children’s diets in food insecure households was notably poorer. Since we would expect dietary patterns to ‘track’  these differences in diet are of concern as they indicate the likelihood of a continued exposure to a diet high in energy but low in micronutrients. This has obvious implications both for the growth and development of food insecure children in the UK and for their lifelong health.
We thank all the families who participated in the SWS, and the SWS research and computing staff.
Funding This work was supported by the Medical Research Council, University of Southampton, Food Standards Agency and the British Heart Foundation.
Assessment of household food security status (adapted from Blumberg et al )
|These next questions are about the food eaten in your family. People do|
different things when they are running out of money for food to make their
food, or their food money, go further.
|1 In the last 12 months did you (or other adults in your household) ever reduce the|
size of your meals or skip meals because there wasn‘t enough money for food?
|0. No (go to 3).|
|2 How often did this happen?|
|1. In only 1 or 2 months?|
|2. Some months, but not every month.|
|3. Almost every month.|
|3 In the last 12 months did you ever eat less than you felt you should because there|
wasn‘t enough money to buy food?
|4 In the last 12 months were you ever hungry but didn‘t eat because you couldn‘t|
afford enough food?
|Now I’m going to read you 2 statements that people have made about their food|
situation. For these statements, please tell me whether the statement was ‘never
true’, ‘sometimes true’, or ‘often true’, for you (or other members of your household)
in the last 12 months.
|5 The food that I/we bought just didn‘t last and I/we didn‘t have money to get more‘|
|0. Never true.|
|1. Sometimes true.|
|2. Often true.|
|6 I/we couldn‘t afford to eat balanced meals|
|0. Never true.|
|1. Sometimes true.|
|2. Often true.|
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Southampton and South West Hampshire Ethis Committee, UK.
Provenance and peer review Not commissioned; externally peer reviewed.