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Abstract
Background To reduce health inequities in paediatric patients with complex diseases, our hospital developed a food security programme in 2022. The programme aims to mitigate food insecurity (FI) in paediatric patients with oncological, transplantation and congenital cardiovascular diagnoses, by providing a monthly nutritious food supply that covers up to 50% of the patient’s family food intake, accompanied by social and nutritional follow-up. In this study, we aimed to assess the effect of the programme on FI and nutritional status and describe its implementation.
Method We conducted a before-and-after study of patients who entered the programme in a 14-month period. We used the Escala Latinoamericana y Caribeña de Seguridad Alimentaria (ELCSA) scale score, FI level and nutritional status measures to assess the effect of the programme. We used the Wilcoxon and McNemar tests to assess changes in scores and proportions of patients with moderate and severe FI, respectively, 31.5%–14.4% (p=0.0008) and of moderate FI from 68.5% to 36.9%.
Results 111 patients were included. They had a baseline median (IQR) ELCSA score=8 (7–11) that changed to 6 (4–9) (p<0.0001). Severe FI according to ELCSA changed from 31.5% to 14.4% (p<0.001) and moderate from 68.5% to 36.9% (p<0.001). We found no differences in nutritional status regarding height for age (49.5% vs 51.3%, p=0.76), weight for height (42.5% vs 59.1%, p=0.75) or body mass index for age (38% vs 46%, p=0.42)
Conclusion The programme reduced FI in families by improving its level to mild or moderate. Children who entered the programme maintained an appropriate nutritional status despite the considerable risk of malnutrition described for oncological paediatric patients and paediatric solid organ transplantation receptors.
- Child Health
- Developing Countries
- Low and Middle Income Countries
- Social work
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Children in food-insecure households have an increased risk of suboptimal health status and outcomes. Children undergoing transplants, cancer treatment and correction of cardiac malformations require adequate food intake for favourable treatment effects, although this socially determined factor is not typically considered in the clinical setting.
WHAT THIS STUDY ADDS
This study reports the favourable effect of a hospital-based food security programme regarding the reduction of food insecurity and maintenance of adequate nutritional status in children undergoing treatments for complex diseases and describes details of its implementation useful for others to replicate.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study showcases how food insecurity in children can be tackled in the hospital setting with social programmes. The adequate nutritional status and food intake of children with complex diseases can be influenced in the short term to favour the adequate effect and continuation of medical interventions.
Background
The Food and Agriculture Organization of the UN (FAO) defines food security as ‘the possibility of physical, social and economic access to sufficient, safe and nutritious food that meets the needs of people to lead an active and healthy life’.1 Lack of or limited access defines food insecurity (FI). Severe FI increased globally from 9.3% in 2019 to 11.7% (207 million more people) in 2021, and the prevalence of malnutrition increased from 8.0% to 9.8%.1 2 After Africa, Latin America and the Caribbean have the highest prevalence of moderate and severe FI in the world at 39%.3 In Colombia, 54.2% of citizens have at least some difficulties accessing food.4 Certain demographic groups have a higher prevalence of FI such as indigenous (8 out of 10 households) and households headed by women (6 out of 10).5
A multisite study from 2004 that included 11 539 infant caregivers in the USA reported that children in food-insecure households have almost twice the odds of suboptimal health status (OR 1.90; 95% CI 1.66 to 2.18) compared with food-secure households, as well as an increased risk of hospitalisation after birth (OR 1.31; 95% CI 1.16 to 1.48).6 More recently, a study in the USA that examined a sample of children aged 2–17 between 2013 and 2016 (n=29 341) reported that FI predicted poorer health outcomes due to increased emergency department visits, medical care setbacks, chronic health conditions including asthma (16.3%), eczema or other skin allergies (49.3%) and depressive symptoms (27.9%).7 Furthermore, a study in Brazil with 3923 participants reported that children <5 years old who had one hospitalisation or more in the past year for pneumonia and diarrhoea were more likely to belong to food-insecure households.8 The negative effects of FI can also be expected in patients with complex and chronic diseases under treatment, with devastating consequences regarding long-term prognosis and vital outcomes.9 A study from 2010 highlighted the importance of maintaining constant nutritional monitoring in paediatric transplant patients and proposed that patient’s diet be controlled to ensure adequate energy and protein intake during the first 2–3 years post-transplant.9
To tackle FI effectively in patients with complex diseases undergoing treatment, our hospital—a tertiary-care university hospital in Cali, Colombia—initiated in January 2022 a food security programme called ‘Alimentando Esperanzas’ that targets paediatric patients who require oncological treatment, organ transplantation or corrective cardiovascular surgery. The programme provides a comprehensive social and medical monthly follow-up, a monthly supply of nutritious food to cover up to 50% of the patients’ families’ nutritional needs, and nutritional status (NS) assessments by a trained nutrition physician every 3–4 months. Criteria to enter the programme are one of the mentioned diagnoses, and moderate or severe FI according to the ‘Escala Latinoamericana y Caribeña de Seguridad Alimentaria’ (ELCSA). In this study, we aimed to assess the effect of the programme on reducing FI and maintaining adequate NS in paediatric patients and to provide insights into its implementation.
Methods
Design and population
We conducted an observational before-and-after study (quasi-experimental) based on clinical records that included all paediatric patients aged 0–17 years who entered the programme and had a second food security assessment after 8–14 months of follow-up. This included paediatric patients with oncological treatment (due to solid organ or haematological malignancies), organ transplantation and corrective cardiovascular surgery. We considered no exclusion criteria as we determined adequate to assess all patients and families who participated in the programme.
Measurements
We recorded baseline clinical, nutritional and social characteristics including age, main diagnosis, NS, FI score and level, weight, height or body mass index (BMI), ethnic minority and household members, appliances and income. We described vital status and length of participation in the programme for all patients. The primary outcomes were a change in ELCSA score and a change in the proportion of patients with moderate and severe FI. The ELCSA scale is a qualitative instrument validated in Bolivia, Colombia, Guatemala and Mexico and consists of 15 questions (each with a score of 1 point if answered ‘yes’ and 0 if answered ‘no’). ELCSA score=0 suggests a food-secure household, 1–5 suggest mild FI (access to food, but doubts about their ability to maintain it); 6–10 suggest moderate FI (decreased quality and quantity of food but still has access) and >11 suggests severe FI (food has been reduced and hunger is experienced).10 According to the FAO, the three levels of FI can be classified as mild (points 1–5), moderate (points 6–10) or severe (points 11–15). Secondary outcomes were NS assessed with weight for height for all patients and weight for age or BMI for age, for children under and over 5 years of age, respectively.
Data source
All hospitalised paediatric patients with complex diseases undergoing an oncological, transplant or cardiovascular treatment are screened for FI. Eligibility into the programme is determined by a qualified social worker who records social assessment including ELCSA score and interview. These data along with nutritional medical assessments from clinical records were collected and anonymised.10
Statistical analysis
Sample size calculation considered a relevant difference of 1 point in ELCSA score between baseline (score=7, SD±2) and follow-up (score=6, SD±3). The one-tail calculation for Wilcoxon sign and rank test with 90% power and 5% significance suggested a sample size of 65 patients. To increase precision, we planned to include all patients who fulfilled selection criteria in the study period.
We conducted quality data assessment by random verification of 10% of the collected data. Baseline characteristics are described for all included patients. Due to the paired nature of the comparisons between programme entry and follow-up(s) (before and after), we used the Wilcoxon sign and rank test to assess changes in ELCSA scores and the McNemar χ2 test to assess the change in proportion of patients with moderate and severe FI and adequate NS. A density plot and bar plots display changes in ELCSA scores, FI level and NS over time. All analyses were conducted in RStudio V.2023.06.2 and used alpha=0.05.
Results
Since the beginning of the programme, 512 households have been screened for eligibility using a social interview and the ELCSA scale of which 192 patients and their households entered the programme. The remainder 320 households were food secure or had only mild FI. From those that entered the programme, 111 households had completed at least an 8-month follow-up and were included in our analysis. Three families left the programme due to a lack of interest and were not included in the analysis because of short participation. The baseline clinical and social characteristics of the 111 patients are displayed in table 1. Typical patients were around 8 years of age, most often with a cancer diagnosis, had access to drinkable water and sewerage service and their household was composed of around four members. Among patients with cancer, 20 (18.0%) had a haematological malignancy that required bone marrow transplantation; and 39 (35.1%) had a solid organ malignancy. Three patients with metabolic diseases were also included. Approximately half of the included patients had adequate NS on entry into the programme.
Baseline clinical and social characteristics
Median (IQR) ELCSA scores changed from 8 (7–11) at baseline to 6 (4–9) (p<0.0001). The proportion of severe FI was reduced from 31.5% to 14.4% (p=0.0008) and of moderate FI from 68.5% to 36.9% (p<0.0001). Figure 1 displays the change in ELCSA score distributions between baseline and follow-up and figure 2 displays the change in proportions of FI levels.
Changes in ELCSA scores between baseline and 8–14 months follow-up. ELCSA, Escala Latinoamericana y Caribeña de Seguridad Alimentaria.
Change in proportions of moderate and severe insecurity between baseline and 8–14 months follow-up.
As displayed in table 1, around 50% of patients had appropriate NS on entering the programme. Figures 3–5 display the proportions of NS classification over time for all patients in the programme (A) and according to diagnoses subgroups (B). Overall, comparisons between baseline and the third follow-up—approximately 1 year after programme entry—suggested no difference regarding height for age (49.5% vs 51.3%, p=0.76), weight for height (42.5% vs 59.1%, p=0.75) or BMI for age (38% vs 46%, p=0.42). Figures showcase maintenance of NS distribution without an increase in the proportion of malnutrition or risk of malnutrition. Comparisons between baseline and the last follow-up within each diagnosis subgroup were limited by small sample sizes and thus hypothesis testing was not conducted. Figures 3B,4B and 5B include counts to showcase the small changes that occurred over time.
(A) Height for age classification over time (all patients). (B) Height for age classification over time by diagnoses subgroups. CCVS, corrective cardiovascular surgery; FU, follow-up; HM, haematological malignancy; SOM, solid organ malignancy; SOT, solid organ transplantation.
(A) Weight for height classification over time (under 5 years old; 22 patients). (B) Weight for height classification over time by diagnosis subgroup (under 5 years old; 22 patients). CCVS, corrective cardiovascular surgery; FU, follow-up; HM, haematological malignancy; SOM, solid organ malignancy; SOT, solid organ transplantation.
(A) BMI for classification over time (over 5 years old; 56 patients). (B) BMI for classification over time by diagnosis subgroup (over 5 years old; 56 patients). BMI, body mass index; CCVS, corrective cardiovascular surgery; FU, follow-up; HM, haematological malignancy; SOM, solid organ malignancy; SOT, solid organ transplantation.
Discussion
Summary of findings
We assessed the effect of a hospital-based social programme for mitigating FI among paediatric patients with complex diseases. We found that the programme reduced FI in families by improving FI level to mild or moderate and that children who entered the programme maintained an appropriate nutritional status despite the considerable risk of malnutrition described for oncological paediatric patients and paediatric solid organ transplantation receptors.
Limitations
Our study was limited in the assessment of changes in NS due to a small sample size that underpowered comparisons that may have missed small differences; and a short follow-up time that made the detection of nutritional improvement less likely because changes in NS classification tend to be notable after longer periods of time. Also, we had a large time interval between the baseline and follow-up ELCSA measurements, nonetheless, although FI is expected to change overtime, it is not expected to improve over time, which is why this design was considered valid to assess FI. We consider that the use of the ELCSA scale is a strength of our study as it measures FI determinants in detail, and it is a validated scale for our country.10 The choice of ELCSA score and classification as primary outcomes for the study responded to the anticipated high clinical heterogeneity among the included patients, which precluded the assessment of effects of the programme on clinical outcomes such as remission, time free of complications or survival, which are to be studied further according to main diagnosis and baseline clinical features.
Implications and future directions
From a perspective of social determinants of health, adequate nutrition status and food security are fundamental in reducing the inequity gap. The social responsibility of health institutions can play an important role in promoting health equity through programmes that address the social determinants of health outcomes. FI is only one of the social determinants that influence the health paediatric patients, but addressing it can significantly contribute to health equity and the reduction of additional costs for the health system. Our study showcases the social benefits of addressing FI among children with high-complexity diagnoses. A study by the Association of Community Cancer Patients who focused on adult patients with cancer in Maine applied strategies to reduce FI in a target group and compared the social impact with a control group that did not receive the benefits.11 Of this population, those who received assistance from grocery markets and Supplemental Nutrition Assistance Programme (the targeted group), completed more months of their treatment compared with those who did not receive assistance (the control group).11 Additionally, in FI-related diseases, patients with FI reported more symptoms of distress (eg, difficulty sleeping, fatigue and pain) compared with the control group.11 That report showcases the importance of addressing FI among patients with complex diseases such as cancer and chronic illnesses due to the association of FI with impaired physical, emotional and functional well-being.11
According to Pedretti et al, nutritional counselling is sufficient only when the patient is adequately nourished, is not losing weight and is consuming at least 50% of the recommended nutritional intake.12 The programme assessed in our study focused on providing at least 50% of the recommended nutritional intake and timely medical follow-up as a way of reducing FI and maintaining adequate NS. Also, for patients under 6 months of age who do not consume solid foods, the milk formulae and special nutritional needs according to their treatments were provided. Patients and their families receive social monitoring every month by phone call or direct text messages to identify changes in households’ social context (changes in income, support network and location) or if additional situations arise in which the households needs assistance.
A review of Important aspects of nutrition in children with cancer reported that up to 46% of children and young adults with cancer experience malnutrition due to treatment-related factors.13 A low nutritional level can decrease immune function, delay wound healing and alter drug metabolism, which influences the patient’s prognosis.13 Children are more vulnerable and have high substrate needs due to the disease and its treatment, and the short-term effects of malnutrition were reported to be loss of muscle and fat mass, decreased tolerance to chemotherapy and negative response to chemotherapy, delays in treatment, fatigue, anaemia and hypoalbuminaemia, delay in recovery of normal spinal function, related infections and decreased quality and productivity of life.13 Likewise, they found long-term effects, such as impaired growth, increased mortality, impact on motor, cognitive and neurological development, risk of metabolic syndrome and risk of secondary cancers.13 Another study analysed the role of NS in paediatric cancer patients, specifically on the alterations of NS that follow during their treatment.14 The authors argue that the incidence of undernutrition among paediatric cancer patients is reported to be 0%–70%, and overnutrition is to be 25%–75%. The study concludes that in order to improve the quality of life, immunological status, treatment response, survival of the cancer treatment, adequate and timely interventions of NS in paediatric cancer patients are warranted.14
Besides cancer, studies in paediatric patients with congenital heart defects showcase how preoperative malnutrition causes more difficulties to recover after surgery: it decreases the ability to fight infections, generate scar tissue and has been reported to lengthen ICU stays.14 15 In addition, hospital stays are prolonged in paediatric or neonatal patients who have worse NS. In the long term, malnutrition can lead to suboptimal growth and delayed physical and cognitive development in childhood and adolescence.16 Likewise, a study in Ecuador on the relationship between nutritional risk and postsurgical evolution in paediatric patients with congenital heart disease, demonstrated that the degree of heart failure is related to the Nutritional Risk Index.17 The study shows that 42.86% of the patients presented a high level of the Nutritional Risk Index and this relationship is especially evident with level II Heart Failure (60.94%), followed by level III (35.49%).17
Conclusion
It seems crucial to support patients and their families through assistance and educational programmes designed to reduce health inequity as it is feasible and has great potential for improving overall health outcomes in the paediatric population. The high costs of treatment for complex diseases may be futile if patients have FI and are malnourished; a premise that should prompt active assessment of FI in diverse clinical settings, given the known importance of appropriate nutrition for favourable clinical outcomes. The proportions of severe and moderate FI levels were reduced by half by the programme assessed, suggesting a great effect of mitigation of FI in the patients’ families. To provide adequate nutritious food monthly, a close nutritious and medical follow-up was beneficial regarding household’s food security. This programme is likely to have similar effects in other low-income and middle-income countries and in high-income countries where FI rose considerably due to the pandemic. We expect that this study serves as additional justification to develop similar programmes worldwide, and we hope that it becomes a useful implementation guide for clinicians, social workers and stakeholders who identify the need to reduce health inequities in their local settings.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by our institutional ethics review board before starting (IRB approval number: 060-2023, minute 02, 25 January 2023). The study did not require the use of informed consent because of its retrospective nature, as it was based on the programme’s documentation. All data were anonymised to protect patient privacy.
Footnotes
X @agempeler
SIP, LAE and JMM contributed equally.
Contributors MG, JMM, LAE, SIP, LFG and AMG-C conceived the project’s idea. All authors developed and approved the research protocol. AMG-C collected the data. AG conducted the statistical analysis. All authors contributed to interpretation of results, manuscript drafts and final manuscript approval. AG is the guarantor.
Funding This work was supported by Fundación Valle del Lili as part of institutional academic research; no specific grant was involved.
Competing interests Hospital Universitario Fundación Valle del Lili is a non-profit university hospital in Cali, Colombia. Among the authors are researchers and institutional directors involved in the development of the program and the conduction of the research project. The study does not promote or recommend any medication, medical devices or services. The authors declare to have no conflict of interest regarding the conduction of this project.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.