|Year : 2020 | Volume
| Issue : 1 | Page : 158
The relationship between food insecurity and risk of overweight or obesity in under 18 years individuals: A systematic review and meta-analysis
Ali Pourmotabbed1, Seyedeh Parisa Moosavian2, Amir Hadi3, Hamed Mohammadi2, Alireza Dadfarma4, Shahabeddin Rezaei5, Atefeh Babaei6, Sajjad Moradi7, Khadijah Mirzaei8
1 Department of Physiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Department of Clinical Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Halal Research Center of IRI, FDA, Tehran, Iran
4 Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
5 Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
6 Department of Physiology, School of Medicine, Kermanshah University of Medical Sciences, Iran, Kermanshah, Iran
7 Halal Research Center of IRI, FDA, Tehran; Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
8 Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||10-Dec-2019|
|Date of Acceptance||23-Jan-2020|
|Date of Web Publication||22-Sep-2020|
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran
Department of Community Nutrition, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Objective: Food insecurit (FI) has been considered as reason for childhood and adolescent overweight/obesity (OW/OB). Hence, this study was undertaken to assess these relationships. Design: Related articles were found by searching the Web of Science, Scopus, PubMed and Embase databases until October 2019. Odds ratio (OR) was analized by a random-effects model. Standard methods were used for assessment of heterogeneity and publication bias. Data were available from 32 studies. The risk ratios of 139,762 participants were pooled from these articles for the meta-analysis. Results: This study domenstrated that children and adolescents in food-insecure condition are not at risk of OW/OB (OR = 1.02 95% CI: 0.99, 1.05). However, subgroup analysis indicated that FI related with inhanced risk of OW/OB in adolescents living in developed countries (OR = 1.14; 95% CI: 1.02, 1.27). Other subgroup analysis indicated that severe FI increased the risk of OW/OB among adolescents (OR = 1.24 95% CI: 1.03-1.49). In addition, we found that lower economic development significantly decreased risk of OW/OB among under 6 year children (OR = 0.88; 95% CI: 0.84, 0.93). Conclusions: Our results showed that higher FI degrees were related with more risks of OW/OB among adolescents (12–18 years). Moreover, the country economic levels had effect on the association between FI and risk of OW/OB.
Keywords: Adolescents, children, food insecurity, obesity risk, overweight risk
|How to cite this article:|
Pourmotabbed A, Moosavian SP, Hadi A, Mohammadi H, Dadfarma A, Rezaei S, Babaei A, Moradi S, Mirzaei K. The relationship between food insecurity and risk of overweight or obesity in under 18 years individuals: A systematic review and meta-analysis. Int J Prev Med 2020;11:158
|How to cite this URL:|
Pourmotabbed A, Moosavian SP, Hadi A, Mohammadi H, Dadfarma A, Rezaei S, Babaei A, Moradi S, Mirzaei K. The relationship between food insecurity and risk of overweight or obesity in under 18 years individuals: A systematic review and meta-analysis. Int J Prev Med [serial online] 2020 [cited 2021 Jan 19];11:158. Available from: https://www.ijpvmjournal.net/text.asp?2020/11/1/158/295913
| Introduction|| |
Obesity and overweight have placed a large load on the children population over the last three decade with steady increases noted in all around the world, especially in many underdeveloped countries., Children with obesity and overweight have an enhanced risk of becoming more weight gain in adulthood, and the conditions are associated with risk factors for a several of prevalent disease namely heart disease, type 2 diabetes, hypertension, dyslipidemia, asthma, metabolic syndrome, liver disease, cancer, and premature death. The variables considered as potential risk factors for childhood and adolescent obesity are: genetic predisposition, maternal smoking during pregnancy, sedentary behavior, socioeconomic status, sleep habits, ethnic origin, microbiota, iatrogenic, endocrine diseases, low resting metabolic rate, obesogenic food advertising, diet and related problems.,,,
Food security is described as the assured access to acquire nutritionally enough and safe food that meets cultural requirements and attained in a socially possible procedure. In other hands, food insecurity (FI) happens as a consequence of restricted resources, and affects many households in all around the world, thereby causing malnutrition. Recent studies have shown a link between FI, growth problems and diseases among under 18 years individuals, which will lead to increased risks of health complications in adulthood. Food insecure individuals have increased risks of: weight abnormality, anemia, growth problems, mental disorders and overweight/obesity (OW/OB).,
One factor which has been more consideration in obesity studies is the effect of FI in association to weight status. Researches by Franklin et al. and Eisenmann et al. assessed the associations between FI and OW/OB risk. Franklin et al. suggested that FI may increase the risk of obesity in females. However, Eisenmann et al. revealed that, even though the percent of overweight was high in children living in FI condition, there was no association between FI and weight status in children. Also, recent studies on the association between FI and risk of obesity in children has led to different outcomes; some previous researches have shown an relationship between FI and the risk of OW/OB in under 18 years individuals,,,,,,,,,; others, have suggested that no relationship exists.,,,,,,,,,,,, Moreover, recent studies is evaluating more factors such as abdominal obesity, which may more accurately explain the association between FI and childhood OW/OB risk.,
Although several studies exist which assess the relationship between FI and risk of OW/OB in under 18 years individuals, it is not clearly understood whether FI is related with higher OW/OB risks among under 18 years individuals. Thus, current study was conducted to evaluation the relationship between FI and OW/OB risks in under 18 years individuals.
| Methods|| |
Literature search and selection
This study was conducted based on the guidelines of the Meta-Analysis of Observational Studies in Epidemiology. A systematic literature review was undertaken using the PubMed, Web of Science, Scopus and Embase databases, until October 2019. Search strategies used medical subject heading (Mesh) and keywords without date or language limitations. The below keywords were used in the systematic search for the association between FI and risk of OW/OB in under 18 year subjects: (((((weight OR Obesity OR “Body mass index” OR BMI OR Adiposity OR Overweight OR obese*)) AND (((((“Food Insecurity” OR “Food Insecurities” OR “Food security” OR “Food securities” OR “Food Supply”) AND (((((“Paediatric Obesity” OR child* OR Paediatric OR adolescent* OR infant*))))). The review articles references were also assessed manually.
Articles were inhered in the statistical analysis if they met the below features: (1) Observational articles that showed on the relationship between FI and the risks of OW/OB in under 18-year-old individuals; (2) Articles that reported odds ratios (OR) with corresponding 95% confidence intervals (CI) of OW/OB risk for children and adolescents. Articles were excluded if: (a) the data could not be used; (b) they were editorials, conference reports, reviews, book chapter, case reports or letters; (c) they did not report the risk of OW/OB; (d) they included adult individuals.
The titles and abstracts of all studies in the primary search were assessed separately by 2 investigator. Studies not meeting the eligibility criteria were excluded using a screening form, with a step by step procedure according to research setting, participants, or exposure and result. The reference of included studies recognized among this procedure were also assessed to obtain more articles. Full-text studies were regained, if the citation was recognized qualified, and subjected to a next assessment for relationship by the same investigator. Any discrepancy was negotiated and resolved by consensus.
For the included articles, two investigators (SM and AD) extracted information independently via a standard information extraction tool. They discussed any disagreements in data extraction process and sought the evaluation of a third investigator (HM) for resolution. Extracted data included articles details, population characteristics, exposure, main findings, and quality score [Table 1].
|Table 1: Description of the studies included in present meta-analysis investigating the association between food security status and risk of childhood and adolescents' obesity (2001-2019)|
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Two investigators (SM and HM) evaluated the quality of included articles by the Newcastle-Ottawa scale.
To evaluate the relationship of FI and the risk of childhood and adolescent OW/OB, the risk estimates for OW/OB were pooled. Because for accurately evaluate the relationship among FI and the OW/OB risk in under 18-year-old individuals, the study people were categorized according to age, FI assessment and, economic development levels (developing or developed). In addition, studies with age-specific subgroup populations (under 6, 6–12, and 12–18 years) were grouped based on gender (girls, boys, and mixed), degree of FI (mild, moderate, and sever FI), race/ethnicity, economic development level (developing or developed) and FI assessment method (child or household).
Pooled OR [and 95% confidence interval (CI)] was assessed using a weighted random-effect model (the DerSimonian-Laird approach). Heterogeneity in the included articles was examined via Cochran Q and I2 statistics (I2= (Q-df)/Q × 100%; I2 <25%, no heterogeneity; I2 = 25-50%, moderate heterogeneity; I2 = 50-75%, large heterogeneity, I2 >75%, extreme heterogeneity). The heterogeneity was considered significant if either the Q statistic had P < 0.1 or I2 >50%. Visual inspection of asymmetry in funnel plots, Begg's test and Egger's test were carry out to assess publication bias (P < 0.05 was considered representative of statistical significance). All statistical tests were conducted with STATA (version 14.0) and SPSS (version 23.0) software.
| Results|| |
Features of the studies
The systematic literature search obtained a total of 3413 articles, after the remove of same results, from the mentioned search engines. After initial screening, all of undesired articles were omitted because they did not meet eligibility criteria, leaving 55 studies for full-text evaluation [Figure 1]. A total of 32 articles met the inclusion criteria to be included in the meta-analysis.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, In these 32 articles, 26 used a cross-sectional setting,,,,,,,,,,,,,,,,,,,,,,,,,,, whereas the other 6 were longitudinal studies.,,,,, The OR of 139.762 participants was analyzed among these articles for the present study. These articles were published during 2001 and 2019, and performed in the Canada,,, United States,,,,,,,,,,,,,,,,,,,,, Jamaica Brazil,, Mexico,,, Colombia, Iran, and Taiwan. [Table 1] showed the feature of the articles included. The studies included assess weight status by CDC growth charts,,,,,,,,,,,,,,,,,,,,,, WHO growth standards,,,,,,, Cole growth reference,, or local criteria. The articles included for evaluation of FI were USDA,,,,,,,,,, CFSM,,, HHFSM,,,,,,,,, HFIAS, Radimer/Cornell,,, ELCSA,, EBIA, and valid local survey forms.,, The quality evaluation of each included articles indicated that all articles were of appropriate quality [Supplementarys Table 1] and [Supplementarys Table 2].
|Figure 1: PRISMA flowchart describing the study's systematic literature search and study selection|
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The extracted odds ratio was analyzed to assess the relationship between FI and the risk of childhood and adolescent OW/OB. As illustrated in [Figure 2], there was no relationship between FI and risk of OW/OB in under 18 years individuals (OR = 1.02 95% CI: 0.99, 1.05) by using the random-effects model. Heterogeneity also existed in the articles (P < 0.001, I2 = 75.1%). Moreover, subgroup analysis according to type of FI assessment including household (OR = 1.03 95% CI: 0.99, 1.06) or child FI (OR = 1.04 95% CI: 0.97, 1.12) did not show relationship between FI status and the risk of childhood OW/OB [Figure 3]. However, FI with enhanced risk of childhood OW/OB in developed countries (OR = 1.06; 95% CI: 1.02, 1.10), but not developing countries (OR = 0.96; 95% CI: 0.90, 1.03), [Figure 4].
|Figure 2: Forest plots investigating the association of food security status and risk of childhood overweight/obesity in all included studies (2001–2017) (OR with 95% CI). All comparison was conducted with food secure subjects (referent)|
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|Figure 3: Forest plots showing investigating the association of food security status and risk of childhood overweight/obesity in different subgroups of food security assessment method (Childhood/household food insecurity assessment) (2001–2017) (OR with 95% CI). All comparison was conducted with food secure subjects (referent)|
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|Figure 4: Forest plots showing investigating the association of food security status and risk of childhood overweight/obesity in different subgroups of economic development level (developed/developing countries) (2001–2017) (OR with 95% CI). All comparison was conducted with food secure subjects (referent)|
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Other subgroup based on examining the relationship between categorized FI and the risk of OW/OB is shown in [Table 2]. As shown in [Table 2], Subgroup analysis by race/ethnicity and gender, level of FI and FI evaluation method in children showed no significant association [Table 2]. However subgroup by economic levels demonstrated that lower degree of national economic development significantly decreased risk of OW/OB among under 6 year children (OR = 0.88; 95% CI: 0.84, 0.93).
The specific outcomes by categorized FI for adolescents from 12 to 18 years old are shown in [Table 2]. These outcomes showed that sever FI associated with the increased risk of OW/OB (OR = 1.24 95% CI: 1.03-1.49); but mild or moderate FI also did not indicate any relationship with risk of OW/OB. Further subgroup by economic levels indicated that lower levels of economic development significantly increased risk of OW/OB among 12- to 18-year-old adolescents (OR = 1.14; 95% CI: 1.02, 1.27) living in developed countries.
|Table 2: Subgroup analysis to assess the association between food security status and risk of childhood and adolescent overweight and obesity (2001-2019)|
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Sensitivity analysis was conducted by removing each of the articles. The outcomes revealed that the OR was not changed sharply by removing each individual article. This showed the meta-analysis outcomes were constant and not sensitive to any one of the 32 articles [Figure 5].
No evidence of publication bias in articles relevant to FI and OW/OB risk in under 18 years individuals was observed, according to the outcome of Begg's test (P = 0.722) and Egger's test (P = 0.289). As illustrated in [Figure 6], the funnel plot revealed to be symmetrical, which showed there was no obvious publication bias. Furthermore, the filled funnel plot showed that any study might not have been published [Figure 7].
|Figure 6: Funnel plot of food security status and risk of childhood and adolescents OW/OB|
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| Discussion|| |
Currently, the relationship between FI status and OW/OB in youth populations is very important for researchers. Different results exist regarding the relationship between FI status with the childhood and adolescent OW/OB risk. Present research, as first study was performed of the quantitative estimates were made of the associations between IF and the risk of OW/OB among under 18 years indivituals.
The results found no overall assocition between FI and OW/OB risk in under 18 years indivituals. Currently, the FI-obesity paradox is considered as an obesity risk factor in food-insecure households. Nettel et al., according to the insurance hypothesis (IH), demonstrated that obesity in FI condition is originated in adaptive evolutionary thinking: the function of storing fat is to provide a buffer against shortfalls in the food supply. Thus, people may store higher adipose tissue when they receive cues that availability to food is unsure. In addtion, Dhurandhar et al., according to hypothesis known as a “resource scarcity hypothesis,” speculated that fattening is a physiologically regulated response to threatened food supply, which occurs specifically in low social status individuals. Nevertheless, in accordance with our findings the latest epidmiological study conducted by Eisenmann et al. reported no difference between the association of FI and OW/OB risk anong children. Although, Eisenmann et al. did suggest that sex and race may mediate the relationship between FI and rsik of OW/OB in children. However in present meta-analysis in category of children under 6 years, any significant association were not found in all subgroups of sex and ethnicity. The mechanisms of association between FI with the OW/OB risk in children are still not well understood. One possibility is that mothers supply enough meals for their children by decreasing their own meals. Children may also have availability to better quality intake than their family. This opinion may be confirmed by the results of recent adult epidmiological studies. Moradi et al. and Franklin et al. reported that adults in FI condition, were at risk of obesity. Hence, maternal care for under 6 years children can be recognized as a main factor for the prevention of OW/OB in FI conditions. Even though, this maternal care and support led to lower food quality, and finally could associate to inhanced risks of obesity in women.
Other noteworthy results among children and adolescents (12–18 years) is that sever FI increased the risk of OW/OB, whereas lower levels of FI did not. Conversely to preschool and lower-aged children, it seems that among the 12- to 18-year-old population (with decreased maternal care and support), there is an increase in the OW/OB risk for sever FI level. Moreover, FI has an effect on adolescent OW/OB through mechanisms that have been proposed in previous studies, such as: calorie dense foods,; nutrient-poor meals; lower intakes of high quality protein source and more intakes of snack meals; higher eating when food is accessible and metabolic changes to ensure enough uses of energy,; parenting or feeding styles; psychological or mental dioeders,; different standards for a healthy diet; and pregnancy FI. Further rigorous evidence is yet required to understand the effects of FI on the risk of OW/OB in under 18 years individuals.
In addition, another main results of the current research indicated that according to national economic development degree there was association between FI and the risk of OW/OB in 18 years individuals. In similar results, recent meta-analysis in adults showed that socioeconomic level was an important factor affecting weight status. The lower subjective socioeconomic level was associated with changes in several metabolic hormones, for example, increases in neuropeptide Y (NPY), insulin, and cortisol, which may lead to obesity. Furthermore, individuals who had a lower subjective socioeconomic level indicated an increase in active ghrelin, leading to lower feelings of fullness and satiety, compared with those at a higher socioeconomic level. These associations may be amplified by obesogenic environments in developed countries (such as higher psychosocial stress and biological functioning, access to energy-dense and low-nutrient foods), leading to increased risks of OW/OB.
Strengths and limitations
The important power of present meta-analysis is the high number of articles assessed. The high number of articles leads to a better and more accurate conclusion. Moreover, several subgroup analyses according to age, gender, FI level, national development level, and food security assessment tools, are important strengths and unique aspects of the present study. Several limitations of current study should be noted. (1) High heterogeneity was existed in the statistical analysis, even though several subgroups and sensitivity analyses were conducted. (2) Notwithstanding the several articles published relevant to the relationship between FI and the risk of OW/OB among children and adolescents, only some articles assessed FI with reference to the risk of abdominal obesity. (3) Although the scale of food security assessment did not affect the results, most studies used the household scale instead of a child food security scale. The use of household food security data in assessing the child's food security level may increase possible errors. (4) A number of studies,,,,, reported wide age-range (6–18) results. This reporting method led to a limitation in this paper's subgroup analyses. (5) Many of the studies included were conducted in developed countries,,,,,,,,,,,,,,,,,, with only a relatively small number of studies being conducted in developing countries.,,,,,,
| Conclusions|| |
In summarize, the current study demonstrated that there was no association between FI status and risk of OW/OB in under 18 year individuals. However, this analysis implied that sever FI level may be related with a significant OW/OB risk in adolescents. Moreover, the economic development status had positive association with the relationship between FI and increased the risk of OW/OB in under 18-year individuals. Performing program to decrease the OW/OB risks by facilitating the bioavailability of essential nutrients, fortified, and complementary foods and following dietary guidelines-”as well as improving infant and young child feeding (IYCF) practices -”should be integrated into poverty rebate programs. Additional longitudinal research with adjusting main obesity related factor such as physical activity or energy intake are required to acceptance the possible association between FI and the OW/OB risk in under 18-year individuals. Additionally, it is proposed that in next researches, more consideration to the association between FI and central obesity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]