Child Food Insecurity and Iron Deficiency Anemia in Low-Income Infants and Toddlers in the United States

  • Anne SkalickyEmail author
  • Alan F. Meyers
  • William G. Adams
  • Zhaoyan Yang
  • John T. Cook
  • Deborah A. Frank

Objective: Examine the association between child-level food insecurity and iron status in young children utilizing community-based data from the Children's Sentinel Nutrition Assessment Program (C-SNAP). Methods: A cross-sectional sample of caregivers of children ≤36 months of age utilizing emergency department (ED) services were interviewed between 6/96–5/01. Caregiver interviews, which included questions on child-level food security, were linked to a primary clinic database containing hemoglobin, red blood cell distribution width, mean corpuscular volume, free erythrocyte protoporphyrin and lead values. Children a priori at-risk for anemia: birthweight ≤2500 g, with HIV/AIDS, sickle cell disease, or lead values ≥10.0 ug/dL, and children ≤6 months of age were excluded from the analysis. Only laboratory tests 365 days prior or 90 days after interview were examined. Iron status was classified in four mutually exclusive categories: 1) Iron Sufficient-No Anemia (ISNA), 2) Anemia (without iron deficiency), 3) Iron Deficient-No Anemia (IDNA), 4) Iron Deficient with Anemia (IDA). Results: 626 ED interviews linked to laboratory data met the inclusion criteria. Food insecure children were significantly more likely to have IDA compared to food secure children [Adjusted Odds Ratio = 2.4, 95% CI (1.1–5.2), p = 0.02]. There was no association between child food insecurity and anemia without iron deficiency or iron deficiency without anemia. Conclusion: These findings suggest an association between child level food insecurity and iron deficiency anemia, a clinically important health indicator with known negative cognitive, behavioral and health consequences. Cuts in spending on food assistance programs that address children's food insecurity may lead to adverse health consequences.


food insecurity iron deficiency food assistance children 



The authors are indebted to Howard Bauchner, M.D. for his support and review of several drafts of this manuscript. We would also like to thank Timothy Heeren, Ph.D. and Mark Nord, Ph.D. for their comments on earlier drafts of this manuscript. This study was supported by grant P0053897 from the W. K. Kellogg Foundation (Battle Creek, MI) and grants from U.S. Department of Agriculture, Economic Research Service (Washington, DC), MAZON: A Jewish Response to Hunger (Los Angeles, CA), Project Bread: the Walk for Hunger, the Anthony Spinazzola Foundation, the Eos Foundation (Boston, MA), the Annie E. Casey Foundation, the Claneil Foundation (Philadelphia, PA), the David B. Gold Foundation, the Thomas A. Wilson Foundation, Minneapolis Foundation, the Sandpiper Fund, the Candle Foundation, the Beatrice Fox Auerbach donor advised fund of the Hartford Foundation for Public Giving (Hartford, CT) on the advice of Jean Schiro Zavela and Vance Zavela, the Daniel Pitino Foundation, and private donors Susan Schiro and Peter Manus and Anonymous donor.


  1. 1.
    Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measuring household food security, Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, 2000.Google Scholar
  2. 2.
    Alaimo K, Olson CM, Frongillo EA, Briefel R. Food insufficiency, family income, and health in U.S. preschool and school-aged children. Am J Public Health 2001;91(5):781–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Nord M, Bickel G. Measuring children's food security in U.S. households, 1995–1999. Food Assistance and Nutrition Research Report No. 25. Economic Research Service, Washington, DC. U.S. Department of Agriculture, 2002.Google Scholar
  4. 4.
    Nord M, Bickel G. Estimating the prevalence of children's hunger from the current population survey food security supplement, Second Food Security Measurement and Research Conference, Alexandria, VA. U.S. Department of Agriculture, Food and Nutrition Service, 1999.Google Scholar
  5. 5.
    Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. JAMA 1997;277(12):973–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. Morb Mortal Wkly Rep. 1998;47:NO. RR-3.Google Scholar
  7. 7.
    Bogen DL, Duggan AK, Dover GJ, Wilson MH. Screening for iron deficiency anemia by dietary history in a high-risk population. Pediatrics 2000;105(6):1254–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Eden AN, Mir MA. Iron deficiency in 1- to 3-year-old children, a pediatric failure? Arch Pediatr Adolesc Med 1997;151(10):986–8.PubMedGoogle Scholar
  9. 9.
    Geltman PL, Meyers AF, Bauchner H. Daily multivitamins with iron to prevent anemia in infancy: A randomized clinical trial. Clin Pediatr (Phila) 2001;40(10):549–54.Google Scholar
  10. 10.
    Grantham-McGregor S, Ani C. A review of studies on the effect of iron deficiency on cognitive development in children. J Nutr 2001;131(2S-2):649S–666S.PubMedGoogle Scholar
  11. 11.
    Nokes C, Van den Bosch C, Bundy DAP. The effects of iron deficiency and anemia on mental and motor performance, educational achievement, and behavior in children: An annotated bibliography. A report of the INACG. Washington, DC: International Life Sciences Institute, 1998.Google Scholar
  12. 12.
    Lozoff B, Brittenham GM, Wolf AW, McLish DK, Kuhnert PM, Jimenez E, Jimenez R, Mora LA, Gomez I, Kraushoph D. Iron deficiency anemia and iron therapy effects on infant developmental test performance. Pediatrics 1987;79(6):981–95.PubMedGoogle Scholar
  13. 13.
    Lozoff B, Jimenez E, Hagen J, Mollen E, Wolff AW. Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy. Pediatrics 2000;105(4):E51.PubMedCrossRefGoogle Scholar
  14. 14.
    Halterman JS, Kaczorowski JM, Aligne AC, Auinger P, Szilagyi PG. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Pediatrics 2001;107(6):1381–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Lozoff B, DeAndraca I, Castillo M, Smith JB, Walter T, Pino P. Behavioral and developmental effects of preventing iron-deficiency anemia in healthy full-term infants. Pediatrics 2003;112(4):846–54.PubMedGoogle Scholar
  16. 16.
    Ash DM, Tatala SR, Frongillo EA, Ndossi GD, Latham MC. Randomized efficacy trial of a micronutrient-fortified beverage in primary school children in Tanzania. Am J Clin Nutr 2003;77(4):891–8.PubMedGoogle Scholar
  17. 17.
    Pollit E, Saco-Pollitt C, Jahari A, Husaini MA, Huang J. Effects of an energy and micronutrient supplement on mental development and behavior under natural conditions in undernourished children in Indonesia. Eur J Clin Nutr 2000;54(Suppl 2):S80–S90.Google Scholar
  18. 18.
    Benton D. Vitamin-mineral supplement and intelligence. Proc Nutr Soc 1992; 51(3): 295–302.Google Scholar
  19. 19.
    Frongillo EA. Validation of measures of food insecurity and hunger. J Nutr 1999;129(2S Suppl):506S–09S.PubMedGoogle Scholar
  20. 20.
    Rose D, Oliviera V. Validation of a self-reported measure of household food insufficiency with nutrient intake data. Technical Bulletin No. 1863. U.S. Department of Agriculture, Economic Research Service, 1997.Google Scholar
  21. 21.
    Oppenheimer SJ. Iron and its relation to immunity and infectious disease. J Nutr 2001;131(2S-2):616S–33S.PubMedGoogle Scholar
  22. 22.
    Kaiser LL, Melgar-Quinonez HR, Lamp CL, Johns MC, Sutherlin JM, Harwood JO. Food security and nutritional outcomes of preschool-age Mexican-American children. J Am Diet Assoc 2002;102(7):924–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Dixon LB, Winkelby MA, Radimer KL. Dietary intakes and serum nutrients differ between adults from food-insufficient and food-sufficient families: Third National Health and Nutrition Examination Survey, 1988–1994. J Nutr 2001;131(4):1232–46.PubMedGoogle Scholar
  24. 24.
    Meyers AF, Sampson AE, Weitzman M, Rogers BL, Kayne H. School Breakfast Program and school performance. Am J Dis Child 1989;143(10):1234–9.PubMedGoogle Scholar
  25. 25.
    Scrimshaw NS. Malnutrition, brain development, learning, and behavior. Nutr Res 1998;18(2):351–79.CrossRefGoogle Scholar
  26. 26.
    Powell CA, Walker SP, Chang SM, Grantham-McGregor SM. Nutrition and education: A randomized trial of the effects of breakfast in rural primary school children. Am J Clin Nutr 1998;68(4):873–9.PubMedGoogle Scholar
  27. 27.
    Kendall A, Olson CM, Frongillo EA. Relationship of hunger and food insecurity to food availability and consumption. J Am Diet Assoc 1996;96(10):1019–24.PubMedCrossRefGoogle Scholar
  28. 28.
    Benton D, Parker PY. Breakfast, blood glucose, and cognition. Am J Clin Nutr 1998;67(4 Suppl):772S–78S.PubMedGoogle Scholar
  29. 29.
    Pollitt E, Cueto S, Jacoby ER. Fasting and cognition in well- and undernourished schoolchildren: A review of three experimental studies. Am J Clin Nutr 1998;67(4):779S–84S.PubMedGoogle Scholar
  30. 30.
    Rivera JA, Hotz C, Gonzalez-Cossio T, Neufeld L, Garcia-Guerra A. The effect of micronutrient deficiencies on child growth: A review of results from community-based supplementation trials. J Nutr 2003;133(11 Suppl 2):4010S–20S.PubMedGoogle Scholar
  31. 31.
    Pelletier DL, Frongillo EA, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995;73(4):443–8.PubMedGoogle Scholar
  32. 32.
    Cook JT, Frank DA, Berkowitz C, Black MM, Casey PH, Cutts DB, Meyers AF, Zaldivar N, Skalicky A, Levenson S, Heeren T, Nord M. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr 2004;134(6):1432–8.PubMedGoogle Scholar
  33. 33.
    Cook JT, Frank DA, Berkowitz CB, Black MM, Casey PH, Cutts DB, Meyers AF, Zaldivar N, Skalicky A, Levenson S, Heeren T. Welfare reform and the health of young children. Arch Pediatr Adolesc Med 2002;156:678–84.PubMedGoogle Scholar
  34. 34.
    Irigoyen M, Davidson LL, Carriero D, Seaman C. Randomized, placebo-controlled trial of iron supplementation in infants with low hemoglobin levels fed iron-fortified formula. Pediatrics 1991;88(2):320–6.PubMedGoogle Scholar
  35. 35.
    National Center for Health Statistics. Plan and operation of the third National Health and Nutrition Examination Survey, 1988–94. Hyattsville, MD: National Center for Health Statistics, Vital Health Stat 1(32). DHHS Publication no. (PHS) 94-1308, 1994.Google Scholar
  36. 36.
    Nord M, Andrews M, Winicki J. Frequency and duration of food insecurity and hunger in U.S. households. J Nutr Educ Behav 2002;34(4):194–200.PubMedCrossRefGoogle Scholar
  37. 37.
    Cristofar SP, Basiotis PP. Dietary intakes and selected characteristics of women ages 19–50 years and their children ages 1–5 years by reported perception of food sufficiency. J Nutr Educ 1992;24(2):53–58.Google Scholar
  38. 38.
    Tarasuk VS, Household food security with hunger is associated with women's food intakes, health and household circumstances. J Nutr 2001;131(10):2670–6.PubMedGoogle Scholar
  39. 39.
    Karp R, Fairorth J, Kanofsky P, Mathews W, Nelson M, Solimano G. Effects of rise in food costs on hemoglobin concentration of early school-age children, 1972–1975. Public Health Rep 1978;93(5):456–9.PubMedGoogle Scholar
  40. 40.
    Weinreb L, Wehler C, Perloff J, Scott R, Hosmer D, Sagor L, Gunderson C. Hunger: Its impact on children's health and mental health. Pediatrics 2002;110(4):e41. Available at: Scholar
  41. 41.
    Alaimo K, Olson CM, Frongillo EA. Low family income and food insufficiency in relation to overweight in U.S. children. Is there a Paradox? Arch Pediatr Adolesc Med 2001;155(10):1161–7.PubMedGoogle Scholar
  42. 42.
    Alaimo K, Olson C, Frongillo EA. Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development. Pediatrics 2001;108(1):44–53.PubMedGoogle Scholar
  43. 43.
    Kleinman RE, Murphy M, Little M, Pagano M, Wehler CA, Regal K, Jellinek MS. Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics 1998;101(1):E3. Available at: Scholar
  44. 44.
    Murphy JM, Wehler CA, Pagano ME, Little M, Kleinman RE, Jellinek MS. Relationship between hunger and psychosocial functioning in low-income American children. J Am Acad Child Adolesc Psychiatry 1998;37(2):163–70.PubMedCrossRefGoogle Scholar
  45. 45.
    Olivera V, Gunderson G, WIC and the nutrient intake of children. Economic Research Service, U.S. Department of Agriculture 2000.Google Scholar
  46. 46.
    Basiotis PP, Kramer-LeBlanc CS, Kennedy ET. Maintaining nutrition security and diet quality: The role of the Food Stamp Program and WIC. Fam. Econ. and Nutr. Rev. 1998;11(1/2):2–16.Google Scholar
  47. 47.
    Kahn JL, Binns HJ, Chen T, Tanz RR, Listernick R. Persistence and emergence of anemia in children during participation in the special supplemental nutrition program for women, infants, and children. Arch Pediatr Adolesc Med 2002;156(10):1028–32.PubMedGoogle Scholar
  48. 48.
    Nord M, Andrews M, Carlson S. Household food security in the United States, 2002. Food Assistance and Nutrition Research Report No. (FANRR35), October 2003. 58 p.Google Scholar
  49. 49.
    Food Participation access rates: State by state 2003. Food Research Action Center. Available at: Scholar
  50. 50.
    Perez-Escamilla R, Ferris AM, Drake L, Haldeman L, Preanick J, Campbell M, Peng YK, Burke G, Bernstein B. Food Stamps are associated with food security and dietary intake of inner-city preschoolers from Hartfood, Connecticut J Nutr 2000;130(11):2711–7.Google Scholar
  51. 51.
    Rose D, Habicht JP, Devaney B. Household participation in the Food Stamp and WIC programs increases nutrient intakes of preschool children. J Nutr 1998;128(3):548–55.PubMedGoogle Scholar
  52. 52.
    Wiecha JL, Palombo R. Multiple Program Participation: Comparison of Nutrition and Food Assistance Program Benefits with Food Costs in Boston, Massachusetts. Am J Public Health 1989;79(5):591–4.PubMedGoogle Scholar
  53. 53.
    Meyers A, Cutts D, Frank DA, Levenson L, Skalicky A, Heeren T, Cook J, Berkowitz C, Black M, Casey P, Zaldivar N. Subsidized housing and children's nutritional status: data from a multisite study. Arch Pediatr Adolesc Med 2005;159:155–556.CrossRefGoogle Scholar
  54. 54.
    Black MM, Cutts DB, Frank DA, Geppert J, Skalicky A, Levenson S, Casey PH, Berkowitz C, Zaldivar N, Cook JT, Meyers AF, Heeren T. Children's Sentinel Nutritional Assessment Program Study Group. Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants' growth and health: a multisite surveillance study. Pediatrics 2004;114(1):169–76.PubMedCrossRefGoogle Scholar
  55. 55.
    Shapiro I, Greenspan R. Cuts to low-income programs may far exceed the contribution of these programs to deficit's return. Center on Budget and Policy Priorities. Feb 9, 2005.Google Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  • Anne Skalicky
    • 1
    • 3
    Email author
  • Alan F. Meyers
    • 2
  • William G. Adams
    • 2
  • Zhaoyan Yang
    • 1
  • John T. Cook
    • 2
  • Deborah A. Frank
    • 2
  1. 1.Boston University School of Public HealthBostonUSA
  2. 2.Boston University School of MedicineBostonUSA
  3. 3.Boston University School of Public HealthBostonUSA

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