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Development of a 2-Item Screen to Identify Families at Risk for Food Insecurity

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Development and Validity of a 2-Item Screen to
Identify Families at Risk for Food Insecurity
WHAT’S KNOWN ON THIS SUBJECT: Food insecurity (FI) in the
United States is a public health problem. FI among young children
is often invisible, because although young children who
experience FI may experience negative health and developmental
outcomes, their growth is often unaffected.
WHAT THIS STUDY ADDS: Providers need efficient methods for
identifying young children in food-insecure households to ensure
that families have access to nutrition-related services that
provide healthy food and alleviate caregiver stress. We present
here a brief, sensitive, specific, and valid FI screen.
abstract
OBJECTIVES: To develop a brief screen to identify families at risk for
food insecurity (FI) and to evaluate the sensitivity, specificity, and con-
vergent validity of the screen.
PATIENTS AND METHODS: Caregivers of children (age: birth through 3
years) from 7 urban medical centers completed the US Department of
Agriculture 18-item Household Food Security Survey (HFSS), reports of
child health, hospitalizations in their lifetime, and developmental risk. Chil-
dren were weighed and measured. An FI screen was developed on the
basis of affirmative HFSS responses among food-insecure families. Sensi-
tivity and specificity were evaluated. Convergent validity (the correspon-
dence between the FI screen and theoretically related variables) was as-
sessed with logistic regression, adjusted for covariates including study
site; the caregivers’ race/ethnicity, US-born versus immigrant status, mar-
ital status, education, and employment; history of breastfeeding; child’s
gender; and the child’s low birth weight status.
RESULTS: The sample included 30 098 families, 23% of which were
food insecure. HFSS questions 1 and 2 were most frequently endorsed
among food-insecure families (92.5% and 81.9%, respectively). An af-
firmative response to either question 1 or 2 had a sensitivity of 97% and
specificity of 83% and was associated with increased risk of reported
poor/fair child health (adjusted odds ratio [aOR]: 1.56; P� .001), hos-
pitalizations in their lifetime (aOR: 1.17; P� .001), and developmental
risk (aOR: 1.60; P� .001).
CONCLUSIONS: A 2-item FI screen was sensitive, specific, and valid
among low-income families with young children. The FI screen rapidly
identifies households at risk for FI, enabling providers to target ser-
vices that ameliorate the health and developmental consequences as-
sociated with FI. Pediatrics 2010;126:e26–e32
AUTHORS: Erin R. Hager, PhD,
a
Anna M. Quigg, MA,
a,b
Maureen M. Black, PhD,
a
Sharon M. Coleman, MS, MPH,
c
Timothy Heeren, PhD,
c
Ruth Rose-Jacobs, ScD,
d
John T.
Cook, PhD,
d
Stephanie A. Ettinger de Cuba, MPH,
c
Patrick
H. Casey, MD,
e
Mariana Chilton, PhD,
f
Diana B. Cutts, MD,
g
Alan F. Meyers, MD, MPH,
d
and Deborah A. Frank, MD
d
a
Department of Pediatrics, University of Maryland School of
Medicine, Baltimore, Maryland;
b
Department of Psychology,
University of Maryland Baltimore County, Baltimore, Maryland;
c
Data Coordinating Center, Boston University School of Public
Health, Boston, Massachusetts;
d
Department of Pediatrics,
Boston University School of Medicine, Boston, Massachusetts;
e
Department of Pediatrics, University of Arkansas for Medical
Sciences, Little Rock, Arkansas;
f
Department of Health
Management and Policy, Drexel University School of Public
Health, Philadelphia, Pennsylvania; and
g
Department of
Pediatrics, Hennepin County Medical Center, Minneapolis,
Minnesota
KEY WORDS
food insecurity, screening tools, nutrition, child development,
hunger
ABBREVIATIONS
FI—food insecurity
HFSS—Household Food Security Survey
PEDS—Parents’ Evaluations of Developmental Status
aOR—adjusted odds ratio
CI—confidence interval
The authors take public responsibility for the content. All
authors certify that they contributed substantially to conception
and design or analysis and interpretation of the data, drafting,
or revision of content and approval of the final version.
www.pediatrics.org/cgi/doi/10.1542/peds.2009-3146
doi:10.1542/peds.2009-3146
Accepted for publication Apr 5, 2010
Address correspondence to Erin R. Hager, PhD, Department of
Pediatrics, University of Maryland School of Medicine, 737 W
Lombard St, Room 163, Baltimore, MD 21201. E-mail:
ehager@peds.umaryland.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
e26 HAGER et al

The US Department of Agriculture has
reported that 14.6% of US households
in 2008 were food insecure, meaning
that at some time during the year they
were unable to obtain adequate food
because of constrained resources.
1
“Adequate” refers to the quantity or
quality of food for all household mem-
bers to maintain an active lifestyle at
all times. Among households with chil-
dren, 21% were food insecure.
1
Black
or Hispanic households with single
parents, young children, and incomes
below the federal poverty line are at
increased risk for food insecurity
(FI).
2,3
Household FI is a serious public health
concern, particularly for young chil-
dren. Children in food-insecure house-
holds experience adverse health and
development attributable to the inade-
quate quality and quantity of foods and
to overall family stress.
4
Our research
group (Children’s HealthWatch) found
that children younger than 3 years
who live in food-insecure households
have 90% greater adjusted odds of be-
ing in fair/poor health (versus good/
excellent), 31% greater adjusted odds
of being hospitalized since birth,
5
and
76% greater adjusted odds of being at
increased developmental risk com-
paredwith food-secure families.
6
Care-
givers with positive depression-screen
results have 2.69 times the odds of re-
porting FI compared with caregivers
with negative depression-screen
results.
7
Providers need efficient methods for
identifying young children in food-
insecure households to ensure that
families have access to nutrition-
related services that provide healthy
food and alleviate caregiver stress.
Several questionnaires are available
to identify food-insecure households.
The 18-item US Household Food Secu-
rity Scale (HFSS) is used by the Current
Population Survey to monitor national
food-security status annually.
2,8,9
Al-
though the HFSS is widely used, it is
time-consuming to administer and has
a complex scoring algorithm, which
limits its use as a clinical tool. Several
shortened questionnaires have been
published, including the HFSS Short
Form (a 6-item version with excellent
sensitivity and good specificity)
9,10
and a recently developed single-item
screen for hunger.
11
Although the hun-
ger question has acceptable sensitivity
and specificity for identifying families
at risk for hunger (ie, the sensation
caused by involuntary lack of food),
11
the exclusive focus on hunger may
miss food-insecure families that expe-
rience stress related to uncertain ac-
cess to enough food but not the physi-
ologic sensation of hunger. Data from
the Community Childhood Hunger Iden-
tification Project
12,13
and Children’s
HealthWatch
5,6
suggest that negative
effects of FI (“at risk for hunger”) on
child health and behavior are present
before reaching the threshold for
hunger.
14
Data collected by Children’s Health-
Watch provide a unique opportunity to
develop an FI screen, to test the sensi-
tivity and specificity of the screen
against the HFSS, and to test the con-
vergent validity against negative
health outcomes for caregivers and
children known to be associated with
FI. The purpose of this study was to de-
velop a brief screen to identify families
at risk for FI and to examine the sensi-
tivity, specificity, and convergent valid-
ity of the screen in a multisite sample
of low-income families with young
children.
PATIENTS AND METHODS
Participants
Data were obtained from 30 098 care-
givers interviewed in hospital-based
settings between 1998 and 2005 as
part of Children’s HealthWatch (for-
merly the Children’s Sentinel Nutrition
Assessment Program [C-SNAP]) in
Baltimore, Maryland; Boston, Massa-
chusetts; Little Rock, Arkansas; Los An-
geles, California; Minneapolis, Minne-
sota; Philadelphia, Pennsylvania; and
Washington, DC. Institutional review
board approval was obtained from
each site.
Trained interviewers surveyed care-
givers who accompanied children
younger than 36 months in acute/
primary care clinics and hospital
emergency departments during peak
patient flow times. Caregivers of criti-
cally ill or injured children were not
approached. Potential respondents
were excluded if they did not speak En-
glish, Spanish, or (in Minneapolis only)
Somali, were not knowledgeable about
the child’s household, lived out of
state, or did not provide informed con-
sent. To ensure that families had low
income, analyses were limited to fam-
ilies who were uninsured or receiving
public insurance.
Measures
All measures are part of the Children’s
HealthWatch survey instrument.
Demographics
Caregivers reported their age, race/
ethnicity, country of origin,marital and
employment status, level of education,
and the child’s age and gender.
Food Insecurity
The 18-item US HFSS,
2,8,9
which serves
as the gold standard in the assess-
ment of household food security, was
used in this study. According to estab-
lished procedures from the US Depart-
ment of Agriculture, households are
classified as food insecure if they en-
dorse �3 affirmative responses to 18
total questions.
2,9
Child Health Outcomes
Caregivers reported their child’s birth
weight, breastfeeding history, and
number of lifetime hospitalizations
(excluding birth). Caregivers rated the
ARTICLES
PEDIATRICS Volume 126, Number 1, July 2010 e27

child’s health as excellent, good, fair,
or poor, which yielded a binary vari-
able (excellent/good versus fair/
poor).
15
Developmental risk was
measured by using the Parents’ Evalu-
ations of Developmental Status (PEDS),
a 10-item screen of parents’ concerns
about their children’s development
that meets standards set by the Amer-
ican Academy of Pediatrics for devel-
opmental screening.
16–20
“Developmen-
tal risk” was defined by using
published guidelines
21
as caregiver re-
port of 1 or more developmentally ap-
propriate concerns. The PEDS sample
was restricted to children older than 4
months, because the sensitivity and
specificity of the PEDS are better for
children than for infants younger than
4 months of age.
22
The PEDS instru-
ment was incorporated into the Chil-
dren’s HealthWatch survey instrument
in 2004.
Child Anthropometric Measurements
At the time of the interview, the child’s
weight and length were measured and
recorded by using equipment and pro-
tocols standardized across Children’s
HealthWatch sites.
6
Weight-for-length
and weight-for-age z scores were cal-
culated by using the 2000 US Centers
for Disease Control and Prevention
age- and gender-specific reference val-
ues.
23
“At risk for underweight” was
defined as weight for age at�5th per-
centile or weight for length at �10th
percentile. “Overweight” was defined
as weight for length at�95th percen-
tile for children younger than 24
months and BMI for age at�85th per-
centile for children 24 months of age
or older.
Caregiver Health Outcomes
Caregivers rated their physical health
as excellent, good, fair, or poor, which
yielded a binary variable (excellent/
good versus fair/poor).
15
Caregivers
completed a 3-item depression screen
that has a sensitivity of 100%, specific-
ity of 88%, and positive predictive value
of 66% compared with the 8-item Rand
screening instrument.
24
Respondents
with 2 or more positive responses
were coded as having a positive
depression-screen result.
24
FI-Screen Development
Screen development includes consid-
eration of sensitivity (the screen’s abil-
ity to correctly identify food-insecure
households), specificity (the screen’s
ability to correctly identify food-secure
households), and convergent validity
(correspondence between the screen
and theoretically related variables).
25–27
We sought to develop an FI screen from
the HFSS with 5 specific characteris-
tics: (1) applicable to families with
young children; (2) brief; (3) highly
sensitive (�90%); (4) specific (�80%);
and (5) valid (convergent validity). The
prevalence of affirmative responses
for each item on the HFSS was calcu-
lated for the total sample and for food-
insecure families. Prevalence data
were used to generate sensitivity and
specificity tables for combinations of 1
or 2 questions with the highest preva-
lence of affirmative responses among
food-insecure families. Convergent va-
lidity was examined by using demo-
graphic and health information on a
sample of low-income families across
7 diverse US cities.
Statistical Analyses
Analyses were conducted by using SAS
9.1 (SAS Institute Inc, Cary, NC).
Demographics and Health Outcomes
Data were examined by using frequen-
cies of demographic and health-
related variables for children and
caregivers according to FI status
based on the 18-item HFSS.�
2
analyses
were conducted to determine differ-
ences in demographics and health out-
comes according to FI status.
Sensitivity and Specificity
A2� 2 table of FI status based on HFSS
criteria and the FI screen was gener-
ated. Sensitivity was calculated as the
number of food-insecure families cor-
rectly identified by the FI screen di-
vided by the number of food-insecure
families identified with HFSS criteria.
Specificity was calculated as the num-
ber of families correctly identified by
the FI screen as food secure divided by
the number of food-secure families
identified with HFSS criteria.
Convergent Validity
Convergent validity was tested by us-
ing 2 sets of logistic regressions to ex-
amine patterns of negative health out-
comes by comparing the FI screenwith
the HFSS. The independent variable in
each set of models was FI status (mea-
sured by the FI screen or the HFSS).
The dependent variables were child’s
health, number of hospitalizations in
the child’s life, child being at risk for
underweight or overweight, child
being at developmental risk, caregiv-
er’s health, and caregiver’s positive
depression-screen result. All models
were adjusted for Children’s Health-
Watch site, caregivers’ race/ethnicity,
US-born versus immigrant status,
marital status, education, employ-
ment, history of breastfeeding, child’s
gender, and low birth weight. Covari-
ates were chosen on the basis of theo-
retical and bivariate associations with
both FI and the outcomes.
RESULTS
Sample
Of 41 669 caregivers approached for
recruitment, 37 805 (90.7%) were eligi-
ble to participate. Of them, 34 049
(90.1%) completed the interview. Eligi-
bility criteria for this analysis included
complete data for questions 1 and 2 of
the HFSS; 88% of the completed inter-
views collected between June 1998
e28 HAGER et al

and December 2008 were included in
the final analyses (n� 30 098).
Table 1 lists the sample according to FI
status based on the HFSS; 23% were
food insecure. Of the 7 Children’s
HealthWatch sites, Minneapolis had
the highest overall prevalence of FI, fol-
lowed by the Boston site. Nearly 60% of
the data were collected from caregiv-
ers of a child younger than 12 months,
and there was no difference in preva-
lence of FI status according to child’s
age or gender. Compared with food-
secure households, a higher propor-
tion of children in food-insecure
households were breastfed. A lower
proportion of caregivers in food-
insecure households were younger
than 21 years, born in the United
States, employed, and had a high
school diploma or college degree com-
pared with caregivers in food-secure
households. Themajority of caregivers
interviewed were black or Hispanic. A
higher proportion of Hispanic caregiv-
ers compared with other ethnic
groups were food insecure.
Compared with caregivers in food-
secure households, caregivers in food-
insecure households were more likely
to report their own health as fair or
poor, to have a positive depression-
screen result, and to rate their child’s
health as fair or poor (see Table 1). In
addition, children in food-insecure
households were more likely to be at
developmental risk and to have been
hospitalized at least once since birth.
Compared with children in food-
secure households, fewer children in
food-insecure households were at risk
for underweight. No differences were
found with respect to child overweight
or low birth weight according to FI
status.
FI Screen
Most respondents who lived in food-
insecure households answered affir-
matively (often true or sometimes true
versus never true) to questions 1 and 2
of the HFSS: 92.5% and 81.9%, respec-
tively. These questions asked (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 12months the food we
bought just didn’t last and we didn’t
have money to get more.”
Sensitivity and Specificity
Cross-tabulation tables were gener-
ated for combinations of the first 2
questions of the HFSS to examine sen-
TABLE 1 Sample Description According to FI Status (Determined by the 18-Item HFSS)
(N� 30 098
a
)
Food Secure
(N� 23 256), %
Food Insecure
(N� 6842), %
P
Site of data collection �.001
Baltimore 14.7 8.0
Boston 27.3 24.5
Little Rock 18.7 11.7
Minneapolis 21.9 40.6
Philadelphia 9.4 6.4
Los Angeles 5.9 5.3
Washington, DC 2.0 3.6
Child predictor variables
Age .08
�4 mo 26.3 26.7
4–12 mo 32.6 33.8
13–24 mo 25.9 25.3
25–36 mo 15.2 14.2
Gender .81
Female 46.7 46.8
Male 53.4 53.2
Low birth weight (�2500 g) 14.2 13.8 .41
Breastfed 50.9 66.1 �.001
Child outcome variables
At risk for underweight
b
15.3 14.0 .01
Overweight
c
13.7 13.8 .80
Child health (fair/poor) 10.7 16.8 �.001
Number of lifetime hospitalizations 22.6 24.4 .002
Developmental risk
d
12.4 18.0 �.001
Caregiver predictor variables
Birth mother�21 y of age 21.7 14.5 �.001
Race/ethnicity �.001
Asian 1.5 0.9
Black 56.6 43.5
Hispanic 26.0 45.4
White 14.9 9.3
Native American 1.0 0.9
Born in the United States 72.2 47.6 �.001
Married/partnered 37.7 44.3 �.001
Employed 41.8 32.9 �.001
Education �.001
Some high school 33.6 43.6
High school graduate 41.0 36.2
College graduate 25.4 20.2
Caregiver outcome variables
Caregiver health (fair/poor) 17.2 32.4 �.001
Caregiver positive depression-screen result 20.4 39.7 �.001
a
Limited to families who were uninsured or receiving public insurance.
b
At risk for underweight was defined as weight for age at�5th percentile or weight for height at�10th percentile.
c
Overweight was defined as weight-for-length at�95th percentile for children younger than 24 months and BMI for age at
�85th percentile for children aged 24months or older. If length data were not available, weight for age at�95th percentile
was used as a proxy.
d
Developmental risk was determined by the PEDS (�1 concern) only for children older than 4 months, and data collection
began in 2004 (n� 10 874).
ARTICLES
PEDIATRICS Volume 126, Number 1, July 2010 e29

sitivity and specificity. Four combina-
tions were explored. An affirmative re-
sponse to question 1 only or question 2
only of the HFSS provided a sensitivity
of 93% or 82% and a specificity of 85%
or 95%, respectively. An affirmative re-
sponse to both questions 1 and 2 pro-
vided a sensitivity of 78% and specific-
ity of 96%. An affirmative response to
question 1 and/or question 2 of the
HFSS provided a sensitivity of 97% and
specificity of 83% (Table 2); therefore,
these are the criteria that comprise
the FI screen.
Risk for Negative Health Outcomes
Adjusted logistic regression models
were conducted by using both the
HFSS and the FI screen (separately) to
examine how FI status is related to
child and caregiver health outcomes
while controlling for covariates (Table
3). Compared with caregivers in food-
secure households, those in food-
insecure households (as measured by
the FI screen) were 1.56 times more
likely to report their child’s health as
fair or poor (adjusted odds ratio [aOR]:
1.56 [95% confidence interval (CI):
1.44–1.68]; P� .001), 1.99 times more
likely to report their own health as fair
or poor (aOR: 1.99 [95% CI: 1.86–2.13];
P� .001), and 2.76 timesmore likely to
have a positive depression-screen re-
sult (aOR: 2.76 [95% CI: 2.59–2.94]; P�
.001). Compared with those in food-
secure households, children from
food-insecure households (as mea-
sured by the FI screen) were 1.17 times
more likely to have had hospitaliza-
tions in their lifetime (aOR: 1.17 [95%
CI: 1.10–1.24]; P� .001) and 1.6 times
more likely to be at developmental risk
(aOR: 1.60 [95% CI: 1.42–1.80]; P �
.001) (see Table 3). These associations
are similar to, although slightly
weaker than, the corresponding asso-
ciations with the 18-item HFSS,
5–7
which demonstrates convergent valid-
ity of the FI screen as a measure of FI.
Differences in child anthropometric in-
dices (at risk for underweight or over-
weight) as detected by the 18-item
HFSS or the FI screen were small and
not statistically significant.
To assess whether the households
identified as food insecure by the FI
screen experienced risk despite clas-
sification as food secure by the 18-item
HFSS, analyses were repeated among
those who were classified as food se-
cure on the basis of the 18-item HFSS
(N � 23 256). The FI-screen results
show attenuated, but statistically sig-
nificant, associations with poor child
and caregiver health outcomes. Care-
givers classified as food insecure by
the FI screen but not the 18-item HFSS
were 1.26 times more likely to report
their child’s health as fair or poor
(aOR: 1.26 [95% CI: 1.12–1.40]; P �
.001), 1.41 times more likely to report
their own health as fair or poor (aOR:
1.41 [95% CI: 1.28–1.56]; P� .001), and
1.88 times more likely to have a posi-
tive depression-screen result (aOR:
1.88 [95% CI: 1.72–2.06]; P� .001) com-
pared with caregivers classified as food
secure by the FI screen. Children in these
households were 1.11 times more likely
to have had hospitalizations in their life-
time (aOR: 1.11 [95% CI: 1.02–1.21]; P�
.001) and 1.36 times more likely to be at
developmental risk (aOR: 1.36 [95% CI:
1.15–1.61]; P� .001) than children iden-
tified as food secure by the FI screen in
this subsample of food-secure house-
holds (see Table 4).
DISCUSSION
We used a 2-item screen to identify
families of young children at risk for FI.
The FI screen is brief, with high sensi-
tivity, good specificity, and convergent
validity. A sensitivity of 97% indicates
that only 3% of families who experi-
enced FI were likely to be misclassi-
fied. With this highly sensitive screen,
providers can identify nearly all chil-
dren who lived in food-insecure fami-
lies. A specificity of 83% indicates that
17% of families who were food secure
according to the HFSS were classified
TABLE 2 Cross-tabulation of Overlap Between the 18-Item HFSS and the FI Screen in Identifying
Food-Insecure Households
Identified by the
HFSS, n (%)
Not Identified by the
HFSS, n (%)
Total, n (%)
Identified by the FI screen 6614 (97) 3977 (17) 10 591 (35)
Not identified by the FI screen 228 (3) 19 279 (83) 19 507 (65)
Total 6842 (23) 23 256 (77) 30 098 (100)
TABLE 3 Relation Between FI Status on the HFSS and on the 2-Item FI Screen With Child and
Caregiver Health Outcomes (N� 30 098)
HFSS FI Screen
Food
Secure
Food Insecure Food
Secure
Food Insecure
aOR (95% CI) P aOR (95% CI) P
Reported child health (fair/poor) 1.0 1.73 (1.59–1.88) �.001 1.0 1.56 (1.44–1.68) �.001
Number of lifetime hospitalizations 1.0 1.19 (1.11–1.28) �.001 1.0 1.17 (1.10–1.24) �.001
At risk for underweight 1.0 0.96 (0.88–1.05) .36 1.0 0.94 (0.87–1.01) .09
Overweight 1.0 1.03 (0.94–1.12) .56 1.0 0.98 (0.91–1.06) .59
Developmental risk
a
1.0 1.72 (1.51–1.97) �.001 1.0 1.60 (1.42–1.80) �.001
Caregiver health (fair/poor) 1.0 2.29 (2.12–2.46) �.001 1.0 1.99 (1.86–2.13) �.001
Caregiver positive depression
screen
1.0 3.13 (2.91–3.37) �.001 1.0 2.76 (2.59–2.94) �.001
Data were adjusted for site, race/ethnicity, US-born mother versus immigrant, marital status, education, child gender,
caregiver employment, breastfeeding, low birth weight, and maternal age. The sample was limited to families that were
uninsured or receiving public insurance.
a
Developmental risk was determined by the PEDS (�1 concern) only for children older than 4 months, and data collection
began in 2004 (n� 10 874).
e30 HAGER et al

as being at risk for FI by the screener.
Results of 2 analyses demonstrate that
households identified as at risk for FI
were at increased risk for adverse
child and caregiver health outcomes
compared with households identified
as food secure by the FI screen. Re-
gardless of whether analyses were
conducted across the entire sample or
restricted to food-secure households
based on the HFSS, households identi-
fied as at risk for FI by the FI screen
were at increased risk for negative
child and caregiver health outcomes,
which suggests that intervention, such
as referral to services, is warranted.
In this sample, FI was not associated
with children’s anthropometry, which
suggests that FI is often invisible
among young children because they
may not appear undernourished (or
overweight) yet still experience nega-
tive health and developmental out-
comes. The FI screen can be easily ad-
ministered in pediatric offices, by
clinicians or practitioners working
with young families (ie, Department of
Social Services, school systems, Sup-
plemental Nutrition Program for
Women, Infants, and Children [WIC],
child care programs, etc), or by com-
munity groups to assess individual
and community needs. The FI screen
has important clinical implications for
all practitioners who work with very
young children and families. By identi-
fying interventions designed for fami-
lies identified as at risk for FI, practi-
tioners can help families identify
resources. For example, in Baltimore,
the City Health Commissioner advo-
cated for widespread use of the FI
screen and developed a Web site
(www.hungryinbaltimore.org) that
identifies resources including food
banks, food pantries, social services,
and federally funded nutrition pro-
grams such as the Special Nutrition
Assessment Program (SNAP), formerly
the Food Stamp Program, and WIC. In
addition, the Minnesota Department of
Health Family Home Visiting Program
has incorporated the FI screen into
their protocol along with referrals to
financial and food resources.
The FI screen is an efficient and valid
way to identify families at risk for FI.
For a more comprehensive assess-
ment of FI, the 18-item HFSS should be
administered.
There were limitations to this study.
First, although the method used for
identifying items to be included in the
FI screen was systematic and met the
set criteria of this study, it was not as
precise as methods used in traditional
item-response theory, a scientific ap-
proach often used to create shortened
versions of large questionnaires. Sec-
ond, the data used in these analyses
included a large, multisite, clinical
sample of exclusively urban, low-
income families of very young children.
Although there is a strong link be-
tween poverty and FI, the validity of the
FI screen has not been tested in a pop-
ulation of varying socioeconomic sta-
tus, in rural populations, or in families
without young children. Further inves-
tigations of the FI screen should be
conducted in these populations. Third,
participants responded to these ques-
tions as part of a larger questionnaire
delivered by an interviewer with the
assurance that their responses would
be confidential and not influence their
medical care. It is not known to what
extent responses might have differed
if the questions were administered in
the context of a clinical interview by a
health care practitioner. Additional
testing of the screen in clinical set-
tings is warranted. Finally, as with any
self-report measure, families could
have intentionally misrepresented
themselves and incorrectly reported
FI. However, the sensitivity, specificity,
and convergent validity demonstrat-
ed suggest increased vulnerability
among children at risk for FI. To guard
against misrepresentation, providers
should incorporate the FI screen into
other clinical assessments.
CONCLUSIONS
A 2-item FI screen for identifying fami-
lies at risk for FI was developed and
demonstrated sensitivity, specificity,
and convergent validity. The FI screen
quickly identifies households with
young children at risk for FI, which
enables providers to target services to
ameliorate the health and developmen-
tal consequences associated with FI.
ACKNOWLEDGMENT
This research was supported by unre-
stricted funding from the following
sources: W.K. Kellogg Foundation;
MAZON: A Jewish Response to Hunger;
TABLE 4 Relation Between FI Status on the 2-Item FI Screen and Child and Caregiver Health
Outcomes Among the Subset of Food-Secure Households on the HFSS (N� 23 256)
FI Screen
Food Secure Food Insecure
aOR (95% CI) P
Reported child health (fair/poor) 1.0 1.26 (1.12–1.40) �.001
Number of lifetime hospitalizations 1.0 1.11 (1.02–1.21) .01
At risk for underweight 1.0 0.90 (0.81–1.00) .05
Overweight 1.0 0.95 (0.85–1.05) .31
Developmental risk
a
1.0 1.36 (1.15–1.61) �.001
Caregiver health (fair/poor) 1.0 1.41 (1.28–1.56) �.001
Caregiver positive depression screen 1.0 1.88 (1.72–2.06) �.001
Data were adjusted for site, race/ethnicity, US-born mother versus immigrant, marital status, education, child gender,
caregiver employment, breastfeeding, low birth weight, and maternal age. The sample was limited to families that were
uninsured or receiving public insurance.
a
Developmental risk was determined by the PEDS (�1 concern) only for children older than 4 months, and data collection
began in 2004 (n� 8497).
ARTICLES
PEDIATRICS Volume 126, Number 1, July 2010 e31

Gold Foundation; Minneapolis Founda-
tion; Project Bread: The Walk for Hun-
ger; Sandpiper Foundation; Anthony
Spinazzola Foundation; Daniel Pitino
Foundation; Candle Foundation; Wilson
Foundation; Abell Foundation; Claneil
Foundation; Beatrix Fox Auerbach
donor-advised fund of the Hartford
Foundation (on the advice of Jean
Schiro Zavela and Vance Zavela);
Susan Schiro and Peter Manus; Eos
Foundation; Endurance Fund; Gry-
phon Fund; Shoffer Foundation; An-
nie E. Casey Foundation; and anony-
mous donors.
We would like to thank Dr Joshua
Sharfstein for his collaboration and
contribution to this project as Health
Commissioner for the City of Balti-
more. We also acknowledge Zhaoyan
Yang for excellent management of sur-
veillance and interview data and SAS
programming; and Kathleen Barrett,
MSE, Jennifer Breaux, MPH, Joni Gep-
pert, MPH, Katherine Joyce, MPH, and
Tu Quan, MPH for excellent training,
scheduling, and supervising of inter-
view staff members and for diligence
in coding, cleaning, and preparing
questionnaires for data entry.
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