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Investigacin original / Original research

Household food insecurity associated withstunting and underweight among preschoolchildren in Antioquia, Colombia

Michelle Hackett,1 Hugo Melgar-Quionez,1 and Martha Cecilia lvarez 2

Suggested citation Hackett M, Melgar-Quionez H, lvarez MC. Household food insecurity associated with stuntingand underweight among preschool children in Antioquia, Colombia. Rev Panam Salud Publica.2009;25(6):50610.

ABSTRACT Objective. To assess criterion validity of a household food security scale through its associ-ations with child health status in participants of the Colombian Plan for Improving Food andNutrition in Antioquia (Mejoramiento Alimentario y Nutricional de Antioquia (MANA)).Methods. A 12-item household food security survey (Colombian Household Food SecurityScale, CHFSS) was applied to a cross-sectional stratified random sample of 2 784 low-incomehouseholds with preschool children receiving MANA food supplements in Antioquia, Colom-bia. Anthropometrics and health status of the children were also assessed. Chi-square testswere used to initially compare child health status and household food security status. Logisticregression models were further developed to assess this relationship in bivariate and multipleregression models.Results. Statistically significant associations were found between household food insecurityand diagnoses of childrens diarrhea, respiratory infections, and parasitosis (P < 0.0001). Therisk for child stunting and underweight increased in a doseresponse way as food insecurity

became more severe.Conclusions. Our research establishes an important link between household food insecu-rity and child nutritional status in participants of a food assistance program. The results af-firm the criterion validity of the CHFSS, establishing the proposed instrument as a valid mea-sure for food insecurity with high-risk populations.

Food security, child preschool, child malnutrition, validity of tests, Colombia.

being throughout the life cycle and hasbeen associated with child dietary intakeand weight status (24). Household foodinsecurity may be related to protein en-ergy malnutrition evident in stunting,

wasting, and underweight, which affectsone-quarter of the worlds children (57).Food security is of great significance

worldwide as governmental and non-governmental agencies rally to reachthe United Nations Millennium Devel-opment Goal of cutting hunger in halfby the year 2015 (8). To meet this goalin Colombia, the regional governmentof Antioquia began the Plan for Improv-ing Food and Nutrition in Antioquia,

Colombia (Mejoramiento Alimentario yNutricional de Antioquia (MANA)) in2002. This nutrition intervention tar-geted preschool-aged children in low-in-come households (9). In 2006, Colombian

researchers spearheaded the first exten-sive evaluation of the food supplementcomponent of MANA to the currentnutritional and food security status ofMANA participants (10).

Valid measures of food security forma critical component of monitoring theprogress and achievement of the Millen-nium Development Goal. The measure-ment of food security allows govern-mental and development agencies to

Key words

Food insecurity is defined as limitedor uncertain availability of nutritionallyadequate and safe foods or limited oruncertain ability to acquire acceptablefoods in socially acceptable ways (1).

Food insecurity affects health and well-

1

2

The Ohio State University, Human Nutrition,Columbus, Ohio 43210, United States of America.Send correspondence and reprint requests to:Hugo Melgar-Quinonez, The Ohio State Univer-sity, Human Nutrition, 1787 Neil Avenue, 325Campbell Hall, Columbus, Ohio 43210, UnitedStates of America; e-mail: [email protected] Dietista, Mg. Desarrollo Social yEducativ, Universidad de Antioquia, Escuelade Nutricin y Diettica, Carrera 75 No. 6587,Medelln, Antioquia, Colombia.

506 Rev Panam Salud Publica/Pan Am J Public Health 25(6), 2009


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Hackett et al. Association of household food insecurity with stunting and underweight Original research

estimate the prevalence of this phenom-enon, better target high-risk populations,and evaluate the impact of programs atthe household level (11). With the useof a valid tool, organizations can appro-priately channel resources to reduceepidemic levels of food insecurity andhunger. To our knowledge, this paperpresents the first criterion validation re-

search project on a household food secu-rity scale applied to participants of afood assistance program by comparingfood insecurity measures with healthconditions in children.

Anthropometrics

Child height was measured using aportable stadiometer sensitive to thenearest 0.1 centimeter (cm). Weightswere obtained with a portable electronicscale (Tanita) sensitive to the nearest100 g. Lengths of children from 6 to 23months were measured with a portable

aluminum infantometer designed for thestudy with a sensitivity of 0.1 cm. Threegenerally accepted anthropometric in-dices were used to approximate chil-drens nutritional status: height-for-ageZ-score (HAZ), weight-for-age Z-score(WAZ), and weight-for-height Z-score(WHZ) (12). Z-score was used to distin-guish between normal and stunted orrisk for stunted (HAZ < 1), under-weight or risk for underweight (WAZ< 1), and wasted or risk for wasted(WHZ < 1) children for the logistic re-gression and chi-square tests.

MATERIALS AND METHODS

Criterion validity of the ColombianHousehold Food Security Scale (CHFSS)was assessed using data collected May2006 from a cross-sectional stratifiedrandom sample representative of the200 000 MANA participants in the de-partment of Antioquia, Colombia. Sam-ple size was calculated by Colombianresearchers using Epitat software. Amaximal regional error of 0.05% resultedin a sample of 2 784 low-income house-holds with preschool children. Thirty-sixtrained interviewers met with child care-givers at local hospitals to administersemiconstructive face-to-face question-naires after a signed informed consentwas collected. Data were reviewed onsite by a fieldwork coordinator and con-firmed or recollected as necessary. A sec-ondary review was done as results wereimputed into the computer, and 10% ofthe questionnaires were reviewed a third

time. The ethics committee at the Facultyof Medicine at The University of Antio-quia approved data collection, and theInstitutional Review Board at The OhioState University approved analysis of theresulting database.

Child health status

Caregivers were also asked if the tar-get child had either diarrhea (defined asthree or more liquid bowel movementswithin 24 hours) or a respiratory infec-tion in the previous two weeks. Possibleacute respiratory infections includedrhinopharyngitis, common cold, ear orsinus infection, laryngitis, bronchitis,pharyngoamygdalitis, croup, bronchioli-tis, and pneumonia. Blood samples werecollected from the child to assess hemo-

globin and ferritin concentrations. He-moglobin was measured with HemoCueazidemethemoglobin techniques andferritin was quantified with chemilumi-nescent immunoassays (13, 14). Anemiawas established by using a cutoff of < 11milligrams (mg) of hemoglobin perdeciliter (dL) of blood. Fecal sampleswere collected from every child at thetime of the interview and were assessedat the Intestinal Parasite Lab at the Uni-versity of Antioquia, Department ofMedicine. A classic formalin-ether con-centration technique (Ritchie) was usedto analyze the feces (15). Any type of par-asite (helminthes, protozoan, or ameba)

found in the childs stool resulted in apositive coding for parasites.

in questionnaire format (16). One of thefirst modules developed for the Commu-nity Childhood Hunger IdentificationProject (CCHIP) was based on the Mas-sachusetts Nutrition Survey (1983), inwhich researchers defined hunger asfood insufficiency due to lack of re-sources (17). In 20032004, researchers inAntioquia, Colombia, conducted a vali-

dation study using this tool, the CHFSS,previously translated, modified, and ap-plied in Venezuela (18).

The CHFSS consisted of 12 questionsabout the experiences of food insecurityas a result of financial constraint over theprevious month. Each item was followedby a question on frequency of occurrence,which assessed how often a given condi-tion occurred. A negative response to theinitial item was coded as 0, and the fol-low-up questions were coded as rarely =1, sometimes = 2, and always = 3. Thesum of all responses gave a food securityscore ranging from 0 to 36, with 0 repre-senting the most food secure and 36 the

least. On the basis of this raw score,household food security status was cate-gorized by using the following cut-offpoints: (1) households with a householdfood security score of 0 were consideredfood secure, (2) households with a scoreof 117 were labeled as mildly food inse-cure, (3) households with scores of 1826were categorized as moderately food in-secure, and (4) households with scores of2736 were grouped into a severe foodinsecurity category (19).

Statistics

These data were analyzed by usingStata for Windows software version 8.2(StataCorp, College Station, TX). De-scriptive statistics were calculated fordemographic, anthropometric, childshealth, and food insecurity variables.The relation of child health outcomes tofood insecurity was examined by usingthe Mantel-Haenszel chi-square test forordered categorical variables. Logistic re-gression procedures were used in both

the bivariate and multivariate analysis toexamine risk of malnutrition by food in-security level. We report results as sig-nificant at 95% confidence intervals (20).

Household demographics

The questionnaires included the fol-lowing components in addition to the

CHFSS: participation in other assistanceprograms, consumption of MANA pow-dered milk packets (25 grams (g) each),MANA crackers (30 g each), and gramsof fortified vegetable flour (Bienesta-rina). Demographic variables consistedof area of residence (urban or rural),housing characteristics, age of parentsand participating child, household size,number of siblings in the household, andprevious months income.

Household food security scale

For nearly 20 years, researchers havecreated and validated qualitative meth-ods to measure food security experiences

RESULTS

Mean income the month before the in-terview was 259 785 Colombian pesos(US$ 129.89) and average household size

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Original research Hackett et al. Association of household food insecurity with stunting and underweight

TABLE 1. Descriptive statistics of low-incomehouseholds with preschool children participa-ting in 2006 evaluation of the food supplementcomponent of the Plan for Improving Foodand Nutrition in Antioquia (MANA) in Antio-quia, Colombia (n = 2 784)

Characteristica

Urban area of residenceFood security statusFood secureMildly food insecureModerately food insecureSeverely food insecure

Health statusRespiratory infectionb

Acute diarrheab Parasitesb Anemiab

a Mean

TABLE 2. Anthropometrics of preschool chil-dren participating in 2006 evaluation of thefood supplement component of the Plan forImproving Food and Nutrition in Antioquia(MANA) in Antioquia, Colombia (n = 2 722)

Anthropometric measure(Z-score)

Height for ageRisk of stunting (1 and 2)Stunting (< 2)Severe stunting (< 3)

Weight for heightOverweight (+1 and +2)Obese (> +2)Risk of wasting (1 to 2)Wasted (2)Severely wasted (< 3)

Weight for ageRisk of underweight(1 and 2)

Underweight (< 2)Severely underweight (< 3)

No. %No.

1 287

1 3431 056280105

1 605631

1 460194

%

46.3

48.237.910.13.8

57.722.770.87.0

84526538

26636

3918037

31.09.71.4

9.81.314.42.91.4

age, 41.1 17.3 months; mean hemoglobin concen-tration, 12.9 1.3 milligrams per deciliter; mean ferritin con-centration, 28.5 20.0 micrograms per liter.

b Within two weeks before interview.

70525462

25.99.32.3

was 5.7, with a standard deviation of 2.4.Sample characteristics in Table 1 showthat participating children had an aver-age hemoglobin concentration of 12.9mg/dL (anemia < 11 mg/dL) and an av-erage ferritin level of 28.5 micrograms(g) per liter (L) of blood (anemia < 12g/L). Most households had access towater (80.5%), sewage facilities (59.2%),and electricity (86.2%). Fewer than halfthe households were categorized as foodsecure (48.2%) and more than one-thirdwere mildly food insecure (37.9%). One-tenth of the sample was categorized as amoderately food insecure household

and 3.8% exhibited severe food insecu-rity. Most children had a positive diag-nosis for parasites (70.8%) and reportedrespiratory infections within the twoweeks before the interview (57.7%). Only22.7% of the children had diarrheawithin the same time frame, and only7.0% were diagnosed as anemic.

obese (1.3%) as measured by WAZ.When WHZ was used, even smaller per-centages of the sample were overweight(4.2%) or obese (0.7%).

Household food security status

Household food security status wasstatistically significantly associated withchild parasites, respiratory infections, anddiarrhea (Table 3). Missing data for thefollowing variables caused a decrease insample: parasites (n = 6), diarrhea (n = 5),and respiratory infections (n = 3). Higherpercentages of these illnesses were foundin severely food insecure households.

Stunting or risk of stunting, as well as un-derweight or risk of underweight,showed a statistically significant inverseassociation with household food securitystatus: the more food insecure the house-hold, the higher the prevalence of stuntedor risk of stunted and underweight or riskof underweight children. In contrast,wasting and risk of wasting did not show

a significant association with food secu-rity status.Covariates in a multiple logistic re-

gression model included anemia, para-sites, diarrhea, gender of head of house-hold, area of residency, household size,fathers age, mothers age, income, ani-mals in the house, refugee status, high-risk area, sewage, water in house, elec-tricity, water in kitchen, type of house,number of milk packets consumed perweek, grams of Bienestarina consumedper week, and packets of crackers con-sumed per week (Table 4). Approxi-mately one-half of the sample (n = 1 299)was lost in the model because of miss-

ing item responses. Following a doseresponse pattern, children in food inse-cure households (mild, moderate, andsevere) showed a statistically signifi-cantly higher risk for stunting or risk ofstunting in the multiple logistic regres-sion model compared with children infood secure households (P < 0.05). Chil-dren living in moderately and severelyfood insecure households also showedstatistically significantly higher risks forunderweight or risk of underweightthan those living in food secure house-holds (p < 0.05).

TABLE 3. Bivariate associations between potential risk factors and various levels of food secu-rity of low-income households with preschool children participating in the 2006 evaluation of thefood supplement component of the Plan for Improving Food and Nutrition in Antioquia (MANA)in Antioquia, Colombia

Foodsecure

No.

Stunting or risk of stuntingaUnderweight or risk of

underweightaWasting or risk of wastingaParasitesbAcute diarrheacRespiratory infectiond

anbn

Anthropometrics

Table 2 shows that most children

presented normal HAZ (57.9%), WHZ(70.2%), and WAZ (62.5%). Missing dataaccounted for the loss of 62 children inthe analysis. The prevalence of stuntingor risk for stunting was 42.1%, while theprevalence of underweight or risk forunderweight was 37.5%. The prevalenceof wasting or risk for wasting was 18.7%.A small percentage of the sample werecharacterized as overweight (9.8%) or

Mildfood

insecurity

No.

450

399192577257659

%

43.4

38.518.572.624.462.5

Moderatefood

insecurity

No.

136

1154716491173

%

49.5

41.817.177.432.561.8

Severefood

insecurity

No.

64

5421673870

%

63.4

53.520.882.736.266.7

%

38.0

34.618.966.718.352.4

P value

< 0.0001

< 0.00010.84

< 0.0001< 0.0001< 0.0001

498

453248652245703

= 2 722.= 2 062.

c n = 2 779.d n = 2 781.



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Hackett et al. Association of household food insecurity with stunting and underweight Original research

TABLE 4. Probability of stunting and underweight in preschool children from low-income house-holds participating in 2006 evaluation of the food supplement component of the Plan for Improv-ing Food and Nutrition in Antioquia (MANA) in Antioquia, Colombia (n = 1 485)

Odds ratio(95% CI)a

Adjustedodds ratio(95% CI)bNo.

StuntingFood secure

Mild food insecurityModerate food insecuritySevere food insecurity

UnderweightFood secureMild food insecurityModerate food insecuritySevere food insecurity

a CIb Multivariate

%

49845013664

45339911554

38.043.449.563.4

34.5838.5141.8253.47

1.00 (reference)1.25 ( 1.06, 1.48)1.60 (1.23, 2.07)2.82 (1.85, 4.29)

1.00 (reference)1.18 (1.00, 1.40)1.36 (1.04, 1.77)2.17 (1.45, 3.27)

1.00 (reference)1.28 (1.00, 1.63)1.58 (1.08, 2.31)2.65 (1.37, 5.14)

1.00 (reference)1.11 (0.87, 1.42)1.47 (1.01, 2.15)1.89 (1.00, 3.55)

= confidence interval.logistic regression adjusted for anemia, parasites, diarrhea, gender of head of household, area of residency,

household size, fathers age, mothers age, income, animals in the house, refugee status, high-risk area, sewage, water inhouse, electricity, water in kitchen, type of house, number of milk packets, grams of Bienestarina, and pac kets of crackers.

DISCUSSION

The purpose of this study was to test anadapted version of the CHFSS for appro-priateness in measuring household foodinsecurity of MANA participants in An-tioquia, Colombia. This validation re-search provides nutrition interventionsworldwide with a tool that can beadapted to their specific evaluationneeds. The broader implications of thisstudy address the need for measures offood insecurity for nutrition interventionsin the developing world. A novel out-come of this study includes the quantifi-cation of child stunting and underweightby food security status within a food as-sistance population when adjusted for as-sociated covariates. An unexpected resultof this study is that both child stunting orrisk of stunting and underweight or riskof underweight status were significantlyassociated with household food insecu-rity, but wasting was not.

In Bogota, Colombia, food insecurechildren were almost three times aslikely to be underweight as food securechildren, while stunting was not signifi-cantly associated with food securitywhen controlling for covariates (21). Theprevalence of food insecurity in Bogotawas 24% higher than the rates in the

MANA sample. This large differencemay be associated with differences in thetool applied in the two settings. Whereasresearchers in Antioquia applied a lo-cally adapted tool derived from theCCHIP instrument for our study, in Bo-

gota researchers applied the U.S. House-hold Food Security Survey Module. Thelatter contains 16 items, some of whichare different from those included in theCHFSS. In addition, the children sam-pled in Bogota were not the subject ofa food assistance intervention like theone administered to Antioquia childrenthrough MANA.

In comparison, in Guapi, Colombia,food insecurity status showed a positiveassociation with both stunting and wast-ing of Afro-Colombian children (6). Thedifferences in the association of wastingwith food insecurity may be the result ofdifferences in the recall time of the ques-

tionnaires used in the studies or in thedefinitions of wasting. The Guapi surveyused a recall time of six months, and theAntioquia study asked the caregiversabout the situation in the previous onemonth. The difference in associations ob-served may indicate that participation inthe MANA food supplement programplayed a role in protecting the childrenagainst wasting.

In our sample, the highest proportionsof stunted, underweight, and wastedchildren were found in the most food in-secure households. Likewise, in Pak-istan, household food insecurity wasstatistically significantly associated with

child stunting (7). Conversely, in Korea,households with mildly food insecureand hungry children had the largest pro-portion of overweight children (4). Thisdifference could be due to the small sub-sample of overweight or obese children

in our study, which is one of the limita-tions of our results.

The high prevalence of children withparasites in this study is consistent withresearch in Mexico, where more thanhalf the school children had intestinalparasitic infections and polyparasitism(22). One limitation to our research isthe lack of information on which speci-

fic parasitic infections were diagnosed.Such data would have enabled us to addto the model only parasites known tocompromise nutritional status. Never-theless, the presence of any parasite in-dicates poor housing, sanitation, watersupplies, health care, education, and per-sonal earnings (23). Another limitationof this study is that the data on illnesseswere reported by the caregivers. Never-theless, the questions were specific andinterviewers explained the symptoms ofthe illness conditions that constituted aresponse as positive.

This research presents an importantcomparison of household food security

status and child nutritional status ofparticipants of a food assistance pro-gram in Colombia. Our findings affirmthe criterion validity of the CHFSS withthis high-risk population. Consequently,this tool may be of great use to otherfood assistance programs regardless ofcountry or continent. The implications ofthis study are critical for governmentaland nongovernmental agencies through-out the world that need valid, easy toapply, and inexpensive tools to measurethe household food security status ofhigh-risk populations. As different insti-tutions assess household food insecurityto determine prevalence and vulnerabil-ity, as well as to evaluate the impact oftheir interventions, a measurement toolwith validity in diverse settings allowsfor comparability of the data. Futurestudies are needed to evaluate the pro-posed food insecurity instrument at dif-ferent points in time before, during, andafter intervention projects are carried outto determine whether this tool repre-sents a reliable option to assess nutritioninterventions.

Acknowledgments. We recognize thegovernment of Antioquia, Departmentof Health, MANA Program as well as theSchool of Nutrition and Dietetics at theUniversity of Antioquia for their roles indata collection.

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Manuscript received on 26 June 2008. Final version ac-cepted for publication on 11 January 2009.

RESUMEN

Inseguridad alimentaria enlos hogares asociada con elretraso del crecimiento y el

bajo peso en niospreescolares de

Antioquia, Colombia

Objetivo. Evaluar la validez de una escala de seguridad alimentaria en hogares me-diante su asociacin con el estado de salud de nios participantes en el plan colom-biano Mejoramiento Alimentario y Nutricional de Antioquia (MANA).Mtodos. Se aplic una encuesta de seguridad alimentaria en hogares (CHFSS),compuesta por 12 preguntas, a una muestra transversal estratificada y aleatoria de2 784 hogares de bajos ingresos con nios preescolares que reciban suplementos ali-menticios del programa MANA en Antioquia, Colombia. Se evalu el estado de saludy antropomtrico de los nios. Se compar el estado de salud de los nios y de segu-ridad alimentaria de los hogares mediante la prueba de la ji al cuadrado. Se elabora-ron modelos de regresin logstica para evaluar esa relacin mediante regresiones bi-factoriales y multifactoriales.Resultados. Se encontraron asociaciones estadsticamente significativas entre la in-seguridad alimentaria de los hogares y el diagnstico de diarrea, infecciones respira-torias y parasitosis en los nios (P < 0,0001). El riesgo de retraso del crecimiento y bajo

peso en los nios se increment segn una relacin dosis-respuesta a medida que seagravaba la inseguridad alimentaria.Conclusiones. Se estableci un vnculo importante entre la inseguridad alimentariade los hogares y el estado nutricional de los nios participantes en un programa deasistencia alimentaria. Estos resultados confirman la validez del CHFSS, por lo queeste instrumento es vlido para evaluar la inseguridad alimentaria en poblaciones enalto riesgo.

Seguridad alimentaria, preescolar, trastornos de nutricin del nio, validez de laspruebas, Colombia.

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