Abstract
This study assesses food insecurity and acute health care utilization among pediatric patients with end-stage kidney disease undergoing peritoneal dialysis or hemodialysis.
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.
Table 1. Baseline Patient Characteristics Stratified by Food Security Status.
| Characteristic | No. (%) | P Value | |
|---|---|---|---|
| No Food Insecurity | Food Insecurity | ||
| Total No. | 16 | 28 | NA |
| Male | 12 (75.0) | 14 (50.0) | .11 |
| Age, mean (SD), y | 13.0 (5.14) | 8.54 (6.17) | .02 |
| Race | |||
| American Indian/Alaska Native | 1 (6.3) | 3 (10.7) | .52 |
| Asian | 1 (6.3) | 1 (3.6) | |
| Native Hawaiian | 0 | 2 (7.2) | |
| Black | 1 (6.3) | 5 (17.9) | |
| White | 10 (62.5) | 14 (50.0) | |
| Other/unknown | 3 (18.8) | 3 (10.7) | |
| Reason for ESKD | |||
| Glomerulonephritis | 5 (31.2) | 4 (14.3) | .51 |
| Polycystic kidney disease | 0 | 3 (10.7) | |
| Renal dysplasia | 1 (6.3) | 4 (14.3) | |
| Obstructive uropathy | 4 (25.0) | 6 (21.4) | |
| FSGS | 2 (12.5) | 5 (17.9) | |
| Congenital nephrotic syndrome | 0 | 1 (3.6) | |
| Thrombotic microangiopathy | 1 (6.3) | 0 | |
| Other | 3 (18.8) | 5 (17.9) | |
| Dialysis modality | |||
| Hemodialysis | 5 (31.2) | 15 (53.6) | .15 |
| Peritoneal dialysis | 11 (68.8) | 13 (46.4) | |
| Nutritional status, mean (SD) | |||
| z Score | |||
| Height | −1.89 (2.49) | −2.02 (1.71) | .85 |
| Weight | −2.60 (3.64) | −1.28 (1.54) | .10 |
| Predialysis | |||
| BUN, mg/dL | 49.4 (14.3) | 50.2 (21.0) | .90 |
| Creatinine, mg/dL | 7.64 (3.13) | 6.15 (2.88) | .12 |
| Albumin, g/dL | 3.4 (0.57) | 3.6 (0.43) | .19 |
| Adequate Kt/V | 16 (100) | 18 (64.3) | .007 |
| CKD-MBD | |||
| Phosphorus within goal, mg/dL | 4 (25) | 16 (57.1) | .04 |
| Calcium within goal, mg/dL | 10 (62.5) | 22 (78.6) | .25 |
| PTH, mean (SD), pg/mL | 672 (610) | 488 (435) | .25 |
| Total medications, mean (SD) | 9.4 (3.1) | 10.5 (2.4) | .19 |
Abbreviations: BUN, blood urea nitrogen; CKD-MBD, chronic kidney disease–metabolic bone disease; ESKD, end-stage kidney disease; FSGS, focal segmental glomerulosclerosis; NA, not applicable; PTH, parathyroid hormone.
SI conversion factors: To convert albumin to g/L, multiply by 10; BUN to mmol/L, multiply by 0.357; calcium to mmol/L, multiply by 0.25; creatinine to µmol/L, multiply by 88.4; phosphorus to mmol/L, multiply by 0.323; and PTH to ng/L, multiply by 1.
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).
Table 2. Association Between Food Insecurity and Infections/Unplanned Hospital Admissions.
| Variable | Incidence Rate Ratio (95% CI) | P Value | |
|---|---|---|---|
| Unadjusted | Adjusteda | ||
| Total No. of infection | 4.57 (1.70-12.31) | 4.28 (1.36-13.5) | .01 |
| No. of emergency department visit | 1.44 (0.83-2.51) | 1.26 (0.73-2.18) | .40 |
| No. of unplanned admission | 2.36 (1.25-4.44) | 1.38 (0.72-2.64) | .55 |
Adjusted by age, sex, race, dialysis modality, and duration of dialysis.
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.
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. [Google Scholar]
- 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.2018.02.019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 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.2018-2102 [DOI] [PubMed] [Google 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.2009-3146 [DOI] [PubMed] [Google Scholar]
- 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-y [DOI] [PubMed] [Google Scholar]
- 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.2016.10.035 [DOI] [PMC free article] [PubMed] [Google Scholar]
