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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Pediatr Blood Cancer. 2021 Nov 22;69(5):e29463. doi: 10.1002/pbc.29463

Food insecurity, housing instability and dietary quality among children with sickle cell disease: Assessment from a single urban center*

Cristina R Fernández 1, Maureen Licursi 2, Randi Wolf 3, Margaret T Lee 1, Nancy S Green 1
PMCID: PMC8957542  NIHMSID: NIHMS1753336  PMID: 34811867

Abstract

Background:

Food insecurity and housing instability, both social determinants of health (SDoH), disproportionately affect economically unstable, under-resourced U.S. communities in which children with sickle cell disease (SCD) live. Association between these SDoH markers and dietary quality among children with SCD are unknown.

Procedures:

We assessed a cross-sectional sample of dyadic parent-child patients and young adult patients to age 21 from one pediatric SCD center. Food insecurity, housing instability, and dietary quality were measured using validated U.S. instruments and a food frequency questionnaire. Better dietary quality was defined using U.S. dietary guidelines. Multi-variate regression assessed for associations among dietary quality and food insecurity with or without (+/−) housing instability and housing instability alone.

Results:

Of 100 enrolled participants, 53% were Black, 43% Hispanic; mean age 10.6±5.6 years. Overall, 70% reported ≥1 economic instability: 40% housing instability alone and 30% both food insecurity and housing instability. Eighty percent received ≥1 federal food assistance benefit. Compared to no economic instability, food insecurity +/− housing instability was significantly associated with higher intake of higher dairy and pizza, while housing instability alone was significantly associated with higher dairy intake. Food insecurity +/− housing instability was significantly associated with lower intake of whole grains compared to housing instability alone.

Conclusions:

Our sample reported high frequencies of both food insecurity and housing instability; having ≥1 SDoH was associated with elements of poorer diet quality. Screening families of children with SCD for food insecurity and housing instability may identify those with potential nutrition-related social needs.

Keywords: sickle cell disease, hemoglobinopathies, food insecurity, housing instability, diet quality, nutrition

INTRODUCTION

Sickle cell disease (SCD) is an inherited hemoglobinopathy affecting an estimated 100,000 people in the United States (U.S.), of whom one third are children.1 In the U.S., SCD occurs most frequently among African-American births, and is also prevalent among Caribbean Hispanic families in the Eastern U.S.24

Social determinants of health (SDoH) are economic and social factors which affect health and wellbeing of individuals and communities.5 The U.S. Department of Health and Human Services’ Healthy People 2030 national health objectives target SDoH indicators of economic instability, defined as financial unpredictability, to improve health through reduction of poverty. Among SDoH indicators of economic instability in the U.S.,5 food insecurity and/or housing instability are tightly linked to dietary quality. Food insecurity, defined as reduced food variety and/or intake due to limited money and resources, affects 13.6% of all U.S. households with children.6 Food insecurity affects household food procurement behaviors and nutritional quality of food,5,7 and has been associated with nutritional deficiencies.811 Housing instability encompasses issues with housing availability, affordability, safety, and quality,5 may force families into substandard housing with inadequate facilities for food storage and preparation and is also associated with inadequate dietary quality.5,12

Food insecurity and housing instability disproportionately burden low-income Black and Hispanic U.S. households,6 contributing to increased risk for child consumption of low-cost, calorie-dense and nutrient-poor foods (e.g. pizza) that may increase risk for nutrient deficiencies.9,13,14 These groups overlap those primarily affected by SCD, among whom pediatric nutritional deficiencies have been reported.1521 While multiple factors likely contribute to nutritional issues, low socio-economic status (SES) and economic instabilities may play an as yet unreported role.22,23,24 Two U.S. studies reported high burden of unmet health-related social needs in families of children with SCD, but prior studies have not examined associations among food insecurity, housing instability, and dietary quality in these children.

We hypothesized that food insecurity and/or housing instability are common in families of pediatric SCD patients in New York City (NYC), and that these economic instability stressors influence a lower quality diet with nutrient-poor foods in these children. Our study aims were to: 1) Assess the prevalence of food insecurity and housing instability among the children with SCD who receive care at our SCD center; and 2) Characterize associations among food insecurity and/or housing instability, and dietary quality of these children.

MATERIALS AND METHODS

Study design

Under approval by the Columbia University institutional review board, we performed a single-site cross-sectional study of child-parent (or legal guardian) dyads with children ages 1–17 years, or young adults ages 18–21 years, with SCD from January-June 2018 in the out-patient Pediatric Sickle Cell Center of Columbia University Irving Medical Center (CUIMC)-New York Presbyterian Hospital (NYP) in NYC. CUIMC-NYP is located in northern Manhattan amidst communities of largely Black race and Caribbean Hispanic ethnicity, with 47% foreign-born immigrants and 19.6% of families living below the federal poverty threshold.25 Our SCD Center cares for approximately 200 patients. Our study enrolled a convenience sample among those attending regularly scheduled appointments with any sickle hemoglobinopathy. Clinical providers first determined family interest in the study, and the research team then recruited interested families from the waiting room. Eligibility included the ability to read English or Spanish. Where multiple siblings were present, only the eldest sibling was enrolled.

Written informed consent was obtained from the parents of children with SCD ages <18 years and the young adults with SCD ≥18 years. Patients ages 12–17 years also gave verbal assent to complete the dietary quality screening tool, as per procedures used by the National Health and Nutrition Examination Survey (NHANES), a program of studies that assess the health and nutrition of U.S. adults and children.26 By NHANES methodology, parents served as surrogate reporters for dietary quality for children <12 years, while older children self-reported.

Measures

Main predictors of food insecurity and housing instability were self-reported for the prior 12 months by the parents or the young adults with SCD. Food insecurity was measured with the 18-item U.S. Department of Agriculture (USDA) Food Security Survey,27 validated in English and Spanish. This survey captures aspects of worry about food availability and experiences of hunger. Per USDA scoring guidelines, scores of ≥3 indicated food insecurity. Housing instability was determined using a composite variable constructed from a questionnaire on housing instability features that were highlighted by Healthy People 2030. Housing instability was identified from one or more of the following issues: difficulty paying rent/mortgage, overcrowding with >2 persons sharing the same room, moving ≥2 times within the year, or any homelessness.5,28

Our primary outcome was dietary quality of children and young adults with SCD in the prior 30 days, measured using a 15-item food frequency questionnaire (FFQ) adapted from the Dietary Screener Questionnaire (DSQ) from NHANES 2009–2010.29 The FFQ captured intake of whole grains, fruits, vegetables, meat/fish protein, and dairy foods (including whole, 2%, 1%, and fat-free milk). Individual food items were then combined into major food groups per the DSQ coding schema (Supplemental Table S1). Food intake frequency ranged from “never” to “6 times per day” over the prior month (Supplemental Table S2). Based on guidelines from the USDA and the American Academy of Pediatrics (AAP),30,31 better dietary quality in children was defined as higher frequency of intake of low-fat dairy, fruits and vegetables, lean protein, and whole grain items.

Additional characteristics assessed by patient report and electronic medical record (EMR) chart review included: age at study enrollment, grouped diagnoses of HbSS and HbSβ° thalassemia or HbSC and HbSβ+ thalassemia, current chronic transfusion therapy, history of hydroxyurea prescription(s) within the prior five years, emergency room visits and hospital admissions in the prior 12 months, and current body mass index (BMI). Other key features related to nutrition and health were collected: participation in federal food assistance programs (Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the National School Breakfast and School Lunch programs); public vs. private medical insurance; family income level of from U.S. census tracts (low, middle-high)32 based on home address; and report of access to a kitchen with a sink, stove and refrigerator.

Statistical analysis

Based on effect sizes from reports of dietary intake among food insecurity in a large national general pediatric population, we calculated need for a minimum sample of 99 subjects to measure effect, assuming 80% power and alpha=0.05.33 Bivariate analyses between main predictors, covariates, and food intake frequency outcomes were conducted using Chi-square and Fisher Exact tests for categorical variables and Kruskal Wallis and analyses of variance tests for skewed continuous variables. Multiple generalized linear regression models were constructed to determine associations among food insecurity and housing instability experiences. Dietary quality was estimated from the reported daily intake frequency of foods and food groups. Given the small number of those with food insecurity alone and the different roles that food insecurity or housing instability may play on diet quality, data from families who reported only food insecurity alone were combined with those having both food insecurity and housing instability. A 3-level economic instability variable was created: (1) “food insecurity +/− housing instability,” (2) “housing instability alone,” or (3) neither issue, defined as “no economic instability.” Primary analyses examined the relationship between the daily food frequency intake and the 3-level economic instability variable using “no economic instability” as the reference group. Secondary analyses examined relationships between the economic instability variable, using “only housing instability” as the reference group. Sickle cell disease types, therapies or urgent care encounters were not included in the regression models. After assessing for collinearity among variables, final models excluded collinear variables and adjusted for variables significant on bivariate analyses and key demographic variables that demonstrated an a priori relationship with food intake: child age, sex, Hispanic ethnicity, and income level of the home census tract. Analyses were not corrected for multiple comparisons.

RESULTS

Participant demographic and SCD characteristics

A total of 100 households, 97 parent-child dyads and three young adults with SCD were enrolled. The study population comprised 55% male, 53% self-identified as Black, and 43% self-identified as Hispanic (Table 1). Mean age of the SCD sample was 10.6±5.6 years. Overall, 85% of children had HbSS, 13% HbSC, 3% HbSβ° thalassemia and none with HbSβ+ thalassemia. Eleven (11%) percent of children were receiving chronic transfusion therapy, and 67% had a history of hydroxyurea prescribed within the prior five years. Mean BMI z-score was 0.01±2.0. Youth with HbSS or HbSβ° thalassemia had significantly lower BMI z-scores compared to those with HbSC or HbSβ+ thalassemia (−0.04±2.3 vs. 0.6±0.8, P=0.01). A median of 2.4 urgent hospital care encounters (interquartile range (IQR): 3) occurred in the preceding 12 months, with no significant difference by economic instability level.

TABLE 1. Demographic and SCD Characteristics of the Sample by Level of Economic Instability (N=100 households).a.

Among participating households, 70% reported one or both measures of economic instability.

Characteristic Economic instability level
Food insecurity +/− Housing instability (N=30) Housing instability alone (N=40) No economic instability (N=30) P value
Child age in years, median (interquartile range [IQR]) 10.5 (10) 14 (7) 10 (10) 0.51
Child male sex, n (%) 16 (53) 22 (55) 17 (57) 0.79
Race, n (%) 0.45
 Black 20 (67) 19 (48) 14 (47)
 White 8 (26) 10 (25) 9 (30)
 Other 2 (7) 11 (27) 7 (23)
Hispanic ethnicity, n (%) 17 (59) 17 (55) 9 (35) 0.05 c
Income level of family residence census tract, n (%) 0.19
 Low income 18 (60) 19 (48) 13 (43)
 Middle-High income 12 (40) 21 (53) 17 (57)
Family with no access to a kitchen (sink, stove, refrigerator), n (%) 2 (7) 2 (5) 1 (3) 0.56
Family enrolled in at least one federal food assistance program, n (%) 30 (100) 30 (75) 20 (67) 0.001
 In WIC and/or SNAP only 7 (23) 12 (30) 10 (33)
 In school food program only 9 (30) 9 (22) 7 (23)
 In WIC and/or SNAP and school food programs 14 (47) 9 (22) 3 (10)
Public medical insurance, n (%) 30 (100) 36 (90) 28 (93) 0.27
SCD genotype 0.44
 HbSS or Hbβ0 thalassemia 26 (87) 37 (92) 24 (80)
 HbSC or Hbβ+ thalassemia 4 (13) 3 (8) 6 (20)
BMI-for-age z-scorea,b 0.42
 HbSS or Hbβ0 thalassemia −0.05 ± 1.15 0.15 ± 3.19 −0.32 ± 1.30
 HbSC or Hbβ+ thalassemia 0.79 ± 0.62 −0.11 ± 0.98 0.78 ± 0.77
Chronic transfusion therapy, n (%) 3 (10) 5 (13) 3 (10) 0.92
Hydroxyurea use within the prior 5 years, n (%) 20 (67) 32 (80) 15 (50) 0.17
Urgent hospital care encounters (emergency room visits and hospital admissions) over the prior 12 months, median (IQR) 2.5 (4) 1 (4.5) 1.5 (4) 0.53
*

SCD – Sickle cell disease; IQR – interquartile range; WIC – Special Supplemental Nutrition Program for Women, Infants, and Children; SNAP – Supplemental Nutrition Assistance Program; BMI – body mass index; HbSS – Hemoglobin SS; Hbβ0 – Sickle beta zero; HbSC – Hemoglobin SC; Hbβ+ - Sickle beta plus

a

Values reported as mean ± standard deviation [SD] unless otherwise noted.

b

Reported for patients not on chronic transfusion therapy.

c

Bolded p-values significant ≤ 0.05

Participant experiences with SDoH

Seventy (70%) families reported ≥1 economic instability, of whom 30 families (30%) reported food insecurity +/− housing instability and 40% had housing instability alone (Table 1). Hispanic children were more likely to have a food insecurity and/or housing instability issue (P=0.05). Most (80%) of the entire sample, and 100% of those with food insecurity, were enrolled in ≥1 federal food assistance program. The total sample was evenly divided between families living in middle-high income census tracts and low-income census tracts, with no significant differences in food insecurity or housing instability for those living in a low-income compared to a middle-high income census tract (P=0.19; Table 1).

Dietary intake among children with SCD

Mean daily intake frequency of major food groups and individual food items from the food frequency questionnaire are shown in Figures 1 and 2 respectively, stratified by economic instability level (Fig. 1 and Fig. 2). Most of the children and young adults consumed milk (89%); among whom 70% consumed higher fat, higher calorie milks of 2% reduced-fat milk or whole milk. Black children with SCD had significantly lower mean daily intake of whole grains compared to children who identified as White or Other race ((mean ± standard deviation (SD)) 0.87 ± 0.74 vs. 0.90 ± 0.80 vs. 1.39 ± 0.89, respectively; P=0.04); no other significant unadjusted differences intake of food groups by race were found (Supplemental Table S3). Hispanic children had significantly higher mean daily intake of beans compared to non-Hispanic children (mean ± SD: 0.28 ± 0.29 vs. 0.69 ± 0.74, respectively; P=0.003) (Supplemental Table S3).

FIGURE 1:

FIGURE 1:

Mean daily frequency of intake of major food groups, by household level of economic instability. Ordinary least squares regression models estimated association between the 3-level economic instability variable [food insecurity +/− housing instability, housing instability alone, and no economic instability (reference group)] and mean daily frequency of intake of major food groups, adjusted for child age and sex. Asterisk (*) within a bar graph indicates significant association (**p<0.01, *p<0.05). Regressions were not corrected for multiple comparisons.

FIGURE 2:

FIGURE 2:

Mean daily frequency of intake of individual food items from the 15-item food frequency questionnaire, by household level of economic instability. Ordinary least squares regression models estimated association between the 3-level economic instability variable [food insecurity +/− housing instability, housing instability alone, and no economic instability (reference group)] and mean daily frequency of intake of each food item, adjusted for child age and sex. Asterisk (*) within a bar graph indicates significant association (**p<0.01, *p<0.05). Regressions were not corrected for multiple comparisons.

Associations of food insecurity and housing instability with child dietary intake

Receipt of food benefits and public medical insurance were collinear with multiple SES markers and therefore excluded from final regression models, as were race and ethnicity. After adjusting for child age, sex, Hispanic ethnicity, and income level by census tract, children with food insecurity +/− housing instability had significantly higher mean daily intake of dairy (predominantly 2% and whole milks, ice cream-based desserts, non-pizza and pizza cheeses) (β=0.98 ± 0.54, 95% CI 0.39, 1.78, P=0.01) and pizza (β=0.32 ± 0.10, 95% CI 0.02, 0.43, P=0.03) compared to children with no reported economic instability (Table 2). Children with housing instability alone had significantly higher mean daily intake of dairy (β=1.16 ± 0.53, 95% CI 0.19, 2.26, P=0.02) compared to children with no reported economic instability (Table 2). Compared to children with housing instability alone, children with food insecurity +/− housing instability had significantly lower intake of the whole grains food group (β=−0.41 ± 0.20, 95% CI −0.81, −0.01, P=0.03) and particularly whole grain cereals (β=−0.42 ± 0.19, 95% CI −0.50, 0.26, P=0.02).

TABLE 2. Dietary Quality of Children with SCD by Level of Economic Instability Compared to No Economic Instability, by Linear Regressiona,b (N=100).

(Data were not corrected for multiple comparisons.)

Economic instability level Food insecurity +/− Housing Instability Housing Instability Alone
β ± SE 95% CI P β ± SE 95% CI P
FFQ* major food groups
Dairy 0.96 ± 0.54 0.39, 1.78 0.02 c 1.16 ± 0.53 0.19, 2.26 0.02 c
Fruit and vegetables −0.58 ± 1.28 −3.13, 1.98 0.65 −0.69 ± 1.24 −3.17, 1.78 0.58
Protein 0.15 ± 0.22 −0.29, 0.59 0.49 0.01 ± 0.21 −0.41, 0.43 0.96
Whole grains −0.11 ± 0.22 −0.54, 0.32 0.60 0.30 ± 0.20 −0.12, 0.71 0.16
FFQ* individual food items (by food group)
Dairy
 Pizza 0.32 ± 0.10 0.02, 0.43 0.03 c 0.17 ± 0.23 −0.07, 0.33 0.07
 Cheese (not on pizza) 0.08 ± 0.17 −0.26, 0.42 0.64 0.30 ± 0.16 −0.03, 0.62 0.06
 Ice cream −0.05 ± 0.14 −0.49, 0.33 0.70 0.14 ± 0.14 −0.14, 0.42 0.33
 Milk 0.47 ± 0.39 −0.31, 1.25 0.23 0.63 ± 0.38 −0.12, 1.39 0.08
Fruit and vegetables
 Whole fruit −0.24 ± 0.43 −1.10, 0.62 0.58 −0.32 ± 0.42 −1.16, 0.51 0.44
 100% fruit juice −0.20 ± 0.51 −1.22, 0.81 0.68 −0.04 ± 0.49 −1.02, 0.94 0.93
 Beans −0.16 ± 0.16 −0.49, 0.17 0.33 −0.006 ± 0.16 −0.32, 0.31 0.97
 Starchy vegetables 0.28 ± 0.39 −0.50, 1.05 0.48 0.01 ± 0.37 −0.74, 0.76 0.98
 Green leafy vegetables 0.02 ± 0.17 −0.32, 0.36 0.92 −0.004 ± 0.17 −0.34, 0.33 0.98
 Other vegetables −0.18 ± 0.17 −0.51, 0.15 0.28 −0.25 ± 0.16 −0.56, 0.07 0.12
Protein
 Seafood −0.02 ± 0.11 −0.24, 0.20 0.85 −0.05 ± 0.11 −0.26, 0.17 0.67
 Red meat 0.06 ± 0.20 −0.34, 0.50 0.76 −0.05 ± 0.20 −0.46, 0.34 0.78
Whole grains
 Whole grain cereals −0.12 ± 0.19 −0.50, 0.26 0.53 0.30 ± 0.19 −0.08, 0.67 0.12
 Brown rice & bread −0.08 ± 0.15 −0.39, 0.22 0.57 −0.08 ± 0.14 −0.40, 0.21 0.57

FFQ – food frequency questionnaire; SE – standard error; CI – confidence interval

a

Linear regression model adjusted for child age, sex, Hispanic ethnicity, and income level of the home census tract

b

Reference group is “no economic instability”

c

Bolded p-values significant ≤ 0.05

DISCUSSION

We examined the impact of food insecurity and housing instability, SDoH factors that can impact patient nutrition and overall wellbeing, on dietary quality of children and young adults with SCD. Food insecurity and housing instability were quite common in our sample, with prevalence two-three times higher than the NYC-wide reported rates from 2018.3435 Hispanic children and young adults with SCD in our sample were more likely to experience food insecurity and housing instability, similar to economic instability risks seen in national statistics.7,36

Children with food insecurity +/− housing instability and children with housing instability alone had significantly higher mean daily frequency of foods with high density calories compared to children with no economic instability. The AAP recommends that children 2 years and older drink 1% low-fat and fat-free milk.37 However, the majority of children and young adults with SCD in our sample who drank milk consumed 2% reduced-fat milk and whole milk. Compared to children in our sample with no food insecurity or housing instability, children with food insecurity +/− housing instability had higher mean daily frequency of pizza intake, a low quality food associated with higher calories, saturated fat and sodium intake, and lower frequency of healthy whole grains intake.38,30 Our findings suggest elements of a suboptimal dietary quality among children with food insecurity +/− housing instability, with greater intake of less nutritious foods and lower intake of more nutritious foods.

Our dietary quality findings may partly reflect community-level and household-level challenges experienced by our patients.39,40 Low-fat or fat-free milk and whole grains are less available and more expensive in low SES neighborhoods, and households with limited food storage and preparation capabilities can experience disrupted eating routines that contribute to increased fast food consumption.41,42,43 Overall, these food intake patterns suggest that much of our patient sample may be at risk of poorer dietary quality and hence nutritional inadequacy and/or obesity.

Our findings on the frequency of food insecurity were similar to those reported from a pediatric SCD Center in Boston, but 1.5-fold higher than that reported from a Nashville pediatric Sickle Cell Center.44,45 Prevalence of housing instability and both food insecurity and housing instability reported by our sample was nearly 4-fold and 3-fold higher, respectively, than those reported from the same Boston clinic.45 These findings collectively suggest that substantial proportions of U.S. children living with SCD endure food insufficiency and unstable housing in urban centers, with variability by location.

Challenges to parents around food intake and dietary quality may be exacerbated in children and adolescents with SCD as a serious chronic illness manifested by fatigue, intermittent pain, risk of infections and organ damage, and delayed growth and development. Food insecurity may be associated with child overweight in the general population.46 Our sample’s BMI scores fell within the normal weight range, consistent with trends of rising BMI among U.S. children with SCD.47 How dietary intake or supplementation may affect disease manifestations in the setting of food insecurity and housing instability are unknown. Nonetheless, stresses associated with both food insecurity and housing instability can impact emotional health and well-being among youth.48,49 Burden of having one or both of these significant SDoH adversities may add to the emotional toll on these young adults and children with SCD and their caretakers.

A call for better connection between SCD clinical and social services beyond clinical care included consideration for SES factors in strategies to improve overall health of people with SCD.50 A holistic approach to care, including routine screening for and intervention for SDoH, is consistent with a recent national report recommending that health care systems implement better integration of patients’ social needs into health care delivery, especially where low SES is prevalent.51,52,53

Study limitations include a single-site, clinic-based convenience sample of modest size with possible selection bias for those who attended their child’s scheduled hematology visit during our sampling (e.g., children on chronic transfusions or with severe disease and fewer with HbSC). Nonetheless, the proportions in our sample with different SCD genotypes was consistent with the diagnostic distribution of SCD from New York State newborn screening, implying that our sample was fairly representative across different SCD genotypes.54 Due to clinic provider screening for study interest, a refusal rate and response rate were not captured. Sickle cell disease type, modifying therapy and urgent care use were not included in the regression analyses due to complexities underlying each factor, nor could potential associations between diet quality, heterogenous SCD treatments, and SCD clinical outcomes be assessed. Regressions were not corrected for multiple comparisons due to the small sample size and increased likelihood of type II error. Per USDA methodology, we only reported and analyzed household food insecurity experiences reported by caregivers. However, food insecurity reports between parents and children may be discordant.44,55,56 Children may also be more aware of their caregivers’ struggles with meeting the family’s food needs, and thus add to their stresses.57 The FFQ reliance on self-report increased vulnerability to social approval and recall bias. The structure and length of the FFQ prevented calculation of single nutrient intake or an overall dietary quality score for children with SCD. In our cross-sectional study, our study design prevented inferences about causality from lack of temporality.

This study demonstrated that self-reported food insecurity and housing instability among households with children and young adults with SCD in our NYC-based clinic sample were common and associated with poorer dietary quality. Areas of future study include multi-site assessment to examine the range and distribution of social and nutritional needs; ascertain patient and parent perspectives on barriers to healthy eating; use of patient home geographic information systems to identify local food deserts and environmental barriers to access of high-quality foods; correlate economic instability experiences with nutritional biomarkers; and investigate associations between these economic insecurities and general and SCD-specific quality of life and distress and psychopathology in youth with SCD and their caregivers. Assessing relationships among SCD types, modifying therapies and urgent care with pediatric dietary intake and the association between dietary intake and SCD clinical outcomes would be important feature of prospective studies. Prospective trials designed from evidence-based interventions with non-SCD groups will also be important to address the SDoH needs of families and buttress nutritional quality of children with SCD. Screening for food insecurity, housing instability, and other SDoH needs in pediatric SCD clinic may identify many families with multiple serious social needs to inform efforts to improve dietary quality and overall health in these children.

Supplementary Material

tS2
Supplemental Table S1
Supplemental Table S3

ACKNOWLEDGEMENTS

The authors thank the children, young adults, and caregivers for their time and participation in this project. Special thanks are also extended to Kay-Ann Richards, MPH, Yasmine Makkiyah, MPH, and the outpatient pediatric SCD center staff for their time and effort in supporting project methodology.

Funding Information

This research was supported by a NIH Loan Repayment Program for Health Disparities Research Award (NIMHD) to CRF and by the National Center for Advancing Translational Sciences, National Institutes of Health (UL1TR001873). The content is solely the responsibility of the authors.

Abbreviation Key

US

United States

SDoH

Social determinants of health

SCD

Sickle cell disease

SES

Socioeconomic status

CUIMC

Columbia University Irving Medical Center

NYP

NewYork-Presbyterian Hospital

CI

Confidence interval

IQR

Interquartile range

SNAP

Supplemental Nutrition Assistance Program

WIC

Special Supplemental Nutrition Program for Women, Infants, and Children

NHANES

National Health and Nutrition Examination Survey

DSQ

Dietary Screener Questionnaire

FFQ

Food frequency questionnaire

NYC

New York City

BMI

Body mass index

EMR

Electronic medical record

AAP

American Academy of Pediatrics

USDA

U.S. Department of Agriculture

HbSS

Hemoglobin SS

HbSβ0

Sickle beta zero

HbSC

Hemoglobin SC

HbSβ+

Sickle beta plus

Footnotes

CONFLICT OF INTEREST STATEMENT

We have no financial relationships or conflicts of interest to disclose.

*

An abstract of this project’s preliminary findings was published November 2020 for the American Society of Hematology (ASH) 2020 Annual Meeting. Meeting abstract is entitled “Food Insecurity Is a Common Problem Affecting Dietary Quality in a Clinic-Based Pediatric Sickle Cell Disease Sample” and is available at: https://doi.org/10.1182/blood-2020-143096.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

tS2
Supplemental Table S1
Supplemental Table S3

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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