[Skip to Navigation]
Sign In
Table 1.  Baseline Patient Characteristics Stratified by Food Security Status
Baseline Patient Characteristics Stratified by Food Security Status
Table 2.  Association Between Food Insecurity and Infections/Unplanned Hospital Admissions
Association Between Food Insecurity and Infections/Unplanned Hospital Admissions
1.
Coleman-Jensen  A, Rabbitt  MP, Gregory  CA, Singh  A.  Household Food Security in the United States in 2015. Washington, DC: United States Department of Agriculture; 2016.
2.
Starr  MC, Fisher  K, Thompson  K, Thurber-Smith  K, Hingorani  S.  A pilot investigation of food insecurity among children seen in an outpatient pediatric nephrology clinic.  Prev Med Rep. 2018;10:113-116. doi:10.1016/j.pmedr.2018.02.019PubMedGoogle ScholarCrossref
3.
Wightman  A, Zimmerman  CT, Neul  S, Lepere  K, Cedars  K, Opel  D.  Caregiver experience in pediatric dialysis.  Pediatrics. 2019;143(2):e20182102. doi:10.1542/peds.2018-2102PubMedGoogle Scholar
4.
Hager  ER, Quigg  AM, Black  MM,  et al.  Development and validity of a 2-item screen to identify families at risk for food insecurity.  Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146PubMedGoogle ScholarCrossref
5.
Goldstein  SL, Graham  N, Burwinkle  T, Warady  B, Farrah  R, Varni  JW.  Health-related quality of life in pediatric patients with ESRD.  Pediatr Nephrol. 2006;21(6):846-850. doi:10.1007/s00467-006-0081-yPubMedGoogle ScholarCrossref
6.
Banerjee  T, Crews  DC, Wesson  DE,  et al; CDC CKD Surveillance Team.  Food insecurity, CKD, and subsequent ESRD in US adults.  Am J Kidney Dis. 2017;70(1):38-47. doi:10.1053/j.ajkd.2016.10.035PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Research Letter
    September 9, 2019

    Association of Food Insecurity and Acute Health Care Utilization in Children With End-stage Kidney Disease

    Author Affiliations
    • 1Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, Indianapolis
    • 2Division of Nephrology, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
    • 3University of Washington, Seattle
    • 4Department of Hematology and Oncology, University of Washington, Seattle
    JAMA Pediatr. 2019;173(11):1097-1099. doi:10.1001/jamapediatrics.2019.3086

    Food insecurity, defined as uncertain availability of nutritionally adequate food, is a common and essential social determinant of health found in more than 20% of US households.1 Pediatric food insecurity is more common in children with chronic medical conditions and is associated with worse outcomes and increased health care costs.2 Dialysis places significant burden on families, but little is known about food insecurity in this population.3

    Methods

    We performed a retrospective cohort study of pediatric patients with end-stage kidney disease (ESKD) undergoing chronic peritoneal dialysis or hemodialysis at Seattle Children’s Hospital from January 1 to July 1, 2018. This study was approved by the institutional review board at Seattle Children’s Hospital, and all families provided written consent. The dialysis social worker screened for food insecurity using the Hunger Vital Sign screen. Families were identified as having food insecurity if they answered affirmatively to either of the 2 statements: (1) “Within the past 12 months [we] worried whether [our] food would run out before [we] got money to buy more” and (2) “Within the past 12 months the food [we] bought just didn’t last and [we] didn’t have money to get more.”4

    Our primary outcome was health care utilization, defined as an emergency department visit, hospitalization, or dialysis-related infection in the 12 months prior to food insecurity screening. Secondary outcome was health-related quality of life (HRQoL), reported by parents and children, using the PedsQL 3.0 End-Stage Renal Disease Module.5

    Categorical and continuous variables were compared between the 2 groups using χ2 test and independent-sample t test, respectively. We used negative binomial models to evaluate association between food insecurity and the number of health care utilization adjusting for age, sex, race, dialysis modality, and dialysis duration. Estimates were reported as incidence rate ratios. We performed an exploratory analysis of HRQoL scores using the t test. Analysis began in July 2018.

    Results

    Patient characteristics are displayed in Table 1. Of 44 children with ESKD, 28 (64%) had food insecurity. Children with food insecurity were younger than those with food security (mean [SD] age, 8.54 [6.17] vs 13.0 [5.14] years; 95% CI, −7.86 to −1.06; P = .02). There were no significant differences between groups in albumin or z scores for height or weight.

    In pairwise comparison, 27 of 28 children with food insecurity (96%) had health care utilization compared with 11 of 16 children with food security (69%) (χ2 = 6.55; P = .01). Children with food insecurity were more likely to have an unplanned hospital (26 [93%] vs 9 [56%]; χ2 = 8.24; P = .004) or intensive care unit (12 [43%] vs 2 [13%]; χ2 = 4.74; P = .04) admission. In the multivariable-adjusted model, children with food insecurity had significantly more infections compared with those with food security (adjusted incidence risk ratio, 4.28; 95% CI, 1.36-13.5; P = .01) (Table 2).

    Both child self-reported (n = 26) and parent-proxied (n = 30) HRQoL scores were significantly lower (indicating worse HRQoL) among children in food-insecure households compared with those from food-secure households (mean [SD] score, 63.9 [19.2] vs 83.3 [10.4]; 95% CI, −75.0 to 24.8; P = .01 and 57.3 [14.4] vs 71.9 [14.0]; 95% CI, −39.4 to 10.2; P = .02).

    Discussion

    Most children with ESKD receiving dialysis in this cohort live in food-insecure households, and those with food insecurity had greater health care utilization and lower HRQoL. Children with ESKD may be at higher risk of food insecurity given their frequent health care utilization, high medical expenditures, and reduced family income from caregiver burden associated with dialysis therapy.3 Among families with food insecurity, lower HRQoL may result from balancing food insecurity with other aspects of managing a chronic illness requiring intensive and frequent interactions with the medical system.3

    Limitations

    This study has several limitations. Patients and families may have reasons not to disclose food insecurity, underestimating the true prevalence of food insecurity. We were unable to collect data on socioeconomic status, limiting our ability to evaluate confounding variables. Finally, as this was a retrospective study, causality cannot be inferred and reverse causality is possible, as suggested by a 2017 study finding that food insecurity increases the risk of ESKD among adults with chronic kidney disease.6

    Conclusions

    Our study highlights the frequency and importance of food insecurity among children with ESKD. Our findings support implementation of routine assessment of food insecurity in all children with ESKD. Identification of food insecurity, and subsequently developing targeted interventions, offers the possibility of improving outcomes for these children.

    Back to top
    Article Information

    Corresponding Author: Michelle C. Starr, MD, MPH, Division of Pediatric Nephrology, Department of Pediatrics, Indiana University, 410 W 10th St, Ste 2000A, Indianapolis, IN 46202 (mcstarr@iu.edu).

    Accepted for Publication: April 25, 2019.

    Published Online: September 9, 2019. doi:10.1001/jamapediatrics.2019.3086

    Author Contributions: Dr Starr had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Starr, Wightman, Munshi, Hingorani.

    Acquisition, analysis, or interpretation of data: Starr, Wightman, Li, Hingorani.

    Drafting of the manuscript: Starr.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Starr, Wightman, Li.

    Obtained funding: Starr, Hingorani.

    Supervision: Wightman, Munshi, Hingorani.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This study was supported by the National Institutes of Health (grant T32DK997662, Dr Starr) and an American Academy of Pediatrics Community Access to Child Health Implementation grant (Dr Starr).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank Elizabeth Winstanley, MSW (Seattle Children’s Hospital); Jamie Olsen, MA, LICSW (Seattle Children’s Hospital); Marion Wilson, MA, LICSW (Seattle Children’s Hospital); Lindsay Smires (Seattle Children’s Hospital), and other members of our social work, dialysis, and nephrology clinic staff for assistance with this project. We would like to acknowledge the ongoing work of Kelly Fisher, MEd (Seattle Children’s Hospital), and others to address food insecurity among patients as part of this study. We also thank the patients and families who participated in this study. None of the individuals named here received any compensation outside of their salary for this work.

    References
    1.
    Coleman-Jensen  A, Rabbitt  MP, Gregory  CA, Singh  A.  Household Food Security in the United States in 2015. Washington, DC: United States Department of Agriculture; 2016.
    2.
    Starr  MC, Fisher  K, Thompson  K, Thurber-Smith  K, Hingorani  S.  A pilot investigation of food insecurity among children seen in an outpatient pediatric nephrology clinic.  Prev Med Rep. 2018;10:113-116. doi:10.1016/j.pmedr.2018.02.019PubMedGoogle ScholarCrossref
    3.
    Wightman  A, Zimmerman  CT, Neul  S, Lepere  K, Cedars  K, Opel  D.  Caregiver experience in pediatric dialysis.  Pediatrics. 2019;143(2):e20182102. doi:10.1542/peds.2018-2102PubMedGoogle Scholar
    4.
    Hager  ER, Quigg  AM, Black  MM,  et al.  Development and validity of a 2-item screen to identify families at risk for food insecurity.  Pediatrics. 2010;126(1):e26-e32. doi:10.1542/peds.2009-3146PubMedGoogle ScholarCrossref
    5.
    Goldstein  SL, Graham  N, Burwinkle  T, Warady  B, Farrah  R, Varni  JW.  Health-related quality of life in pediatric patients with ESRD.  Pediatr Nephrol. 2006;21(6):846-850. doi:10.1007/s00467-006-0081-yPubMedGoogle ScholarCrossref
    6.
    Banerjee  T, Crews  DC, Wesson  DE,  et al; CDC CKD Surveillance Team.  Food insecurity, CKD, and subsequent ESRD in US adults.  Am J Kidney Dis. 2017;70(1):38-47. doi:10.1053/j.ajkd.2016.10.035PubMedGoogle ScholarCrossref
    ×