The Relationship Between Household Food Insecurity With Food and Nutrition Literacy Among Children in Mashhad, Iran: A Cross-sectional Study


 ObjectiveThe aim of this study was to assess the relationship between household food insecurity (HFI) with food and nutrition literacy (FNLIT) in a sample of Iranian children. This cross sectional study was performed on 315 children aged 9 to 12 years recruited from the primary schools throughout Mashhad, Iran.The Household Food Insecurity Access Scale (HFIAS) was used to assess the HFI. Also, overall FNLIT score and its sub-categories were evaluated using a validated 40-item questionnaire.Results The prevalence of HFI in the total sample was about 56 %. Also, almost 14 % of students had a low FNLIT score. HFI was inversely associated with overall FNLIT score (β= - 0.12, p= 0.006), as well as nutritional health knowledge (β= - 0.08, p=0.01), and food label literacy (β= - 0.15, p< 0.001). Furthermore, food-insecure children had a higher likelihood of having low FNLIT score (OR = 2.89, CI: 1.03-8.09; p = 0.04) than the food-secure subjects. In conclusion, there is a negative association between HFI and FNLIT in children. Further studies to confirm this finding are needed.


Introduction
Household food insecurity (HFI), which is de ned as the limited access to nutritionally adequate and safe food or inability to acquire foods in socially acceptable ways, has become a major public health concern throughout the world. HFI is shown to be positively related to the several adverse health outcomes in children including infectious diseases, anemia, psychological distresses, and growth disorders (1).Several socio-economic and environmental factors are proposed that might in uence access to healthy foods in low-income or food-insecure individuals (2,3). Of these, the role of nancial constraints is well established. Although household income is a major potential contributor to food access, it is only a part of the story. As the results of a survey conducted in Canadian households demonstrated that about 15% of food-insecure households were not considered as the low-income group (4). This is a matter of great importance to public health since it highlights the role of non-nancial factors in determining food access at the household level. One of the factors that have been recently gained attention is food and nutrition literacy (FNLIT).
The FNLIT is a relatively new term that re ects the technical, cultural and ethical aspects of the foods beyond just a source of satisfying the caloric requirements (5). Food literacy is de ned as 'the knowledge, skills, and behaviors required to plan, manage, select, prepare and eat foods to meet needs and determine food intake' (6). While nutrition literacy refers to the ability to obtain, understand and interpret the nutrition concepts and information for adopting the appropriate nutritional health-related decisions (7). Although the two terms describe distinct concepts, they can complement each other, since nutrition literacy can serve as a prerequisite for a wider range of practical knowledge, skills, and behaviors describe as the food literacy (8).

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Findings from some recent studies have shown that in comparison to the food-secure households, those with food insecurity had lower FNLIT mainly characterized by unfavorable food choices and purchasing decisions as well as poor food preparation skills (9)(10)(11)(12). However, this evidence was limited to the adult population living in high-income and developed countries; thus it is unknown whether these ndings are generalizable to the children and adolescents particularly in the low-income and developing nations. To our knowledge, no study has examined the relationship between HFI and food literacy in children yet.
With this regard, the present study aimed to assess the association of HFI with FNLIT and its subcategories in a sample of Iranian children.

Main Text
Methods A total of 315 children aged 9 to 12 years-old were recruited from the primary schools throughout the city of Mashhad, north-east of Iran. Data were collected from December 2018 to March 2019. Study subjects were chosen using a multi-stage random cluster sampling method. Children in the fourth, fth and sixth grades who had not any chronic or acute diseases, were eligible to participate in the study.
Sociodemographic data including child's age, birth order, parents' age, parental education was obtained through interviews with students and veri ed by their mothers or caregivers by experienced interviewers.
Anthropometric measurements were performed by a trained dietitian using the calibrated equipment.
Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meter.
The BMI Z-score for age and sex was calculated based on the World Health Organization Child Growth Standards software (AnthroPlus, World Health Organization, Geneva, Switzerland, 2007). The weight status of children was reported in four categories including underweight (z-score < 2 standard deviation (SD), normal (z-score ≥-2 SD and ≤ 1 SD), overweight (z-score > 1 SD and ≤ 2SD), and obese (z-score > 2 SD).
The Household Food Insecurity Access Scale (HFIAS) was used to assess HFI in the study sample. The validity and reliability of the Persian version of questionnaire in the Iranian population was con rmed by Salarkia et al (13). The questionnaire consists of 9 items investigating a wide range of food-related behaviors, experiences, and conditions due to the nancial limitation over a recall period of past month.
The FNLIT was measured using a developed questionnaire. The questionnaire examining FNLIT in two distinctive domains with 7 subscales, including 1) cognition domain: understanding food and nutrition information and nutritional health knowledge; 2) skills domain: functional FNLIT, interactive FNLIT, food choice literacy, critical FNLIT and food label literacy, respectively.

Statistical Analysis
Statistical analysis was performed using SPSS version 25 (SPSS Inc., Chicago, Illinois, USA). Chi-square test was used to compare the demographic and anthropometric variables between the food-secure and food-insecure subjects. Crude and adjusted linear regression models were performed to determine the in uence of HFI on changes in overall FNLIT score and its sub-categories. Also, to determine the odds of having low FNLIT score in food insecure subjects in comparison to the food secure one, the crude and adjusted multiple regression models were used. The covariates included in the adjusted analyses were sex, grade, BMI, birth order, as well as parental age and education. Categorical variables were presented as frequency and percentage, while the numerical data were reported as mean, standard deviation (SD), beta coe cient (β), odds ratio (OR), and 95% con dence interval (CI). Signi cance level was considered as a p-value less than 0.05.

Results
A total of 315 students (51% males) participated in the study. The mean age of study participants was 10.55 ± 1.007 years. The prevalence of mild, moderate, and severe HFI in the total sample were 30.5%, 20.3%, and 5.7%, respectively. Also, about 14% of the students had a low FNLIT score, while the percentages of moderate and high FNLIT scores in the total study sample were 62.7% and 23.2%, respectively. As it is shown in Table 1, the distribution of BMI, birth order and parental education were signi cantly different between the food-secure and food-insecure subjects (p < 0.05). Although, there were no signi cant differences between the two groups in terms of age, sex, grade and parental age.

Discussion
To our knowledge, this is the rst study investigating the association between HFI and FNLIT in a sample of school-aged children in Iran. We found that children living in the food-insecure households had higher odds of having overall FNLIT compared to the food-secure children. Also, HFI was associated with poor FNLIT behaviors including nutritional health knowledge and food label literacy.
Findings of the present study are in consistent with the earlier studies, mainly performed in the adults' population. In a study by Begley et al. among a sample of Australian adults, all domains of the Australian food literacy model including planning and management, shopping, preparation, and cooking were independently associated with food insecurity (9). Also, In another study that assessed the relationship between cooking self-e cacy and food preparation behaviors with food security status among college students, Knol et al found very low food secure students had signi cantly lower cooking self-e cacy and food preparation scores compared with food secure students (11). Similarly, Mercille et al demonstrated that showed severe household food insecurity was inversely associated with healthy food preparation and self-e cacy among Canadian aboriginal women (14). Despite the consistent results, there have been a considerable heterogeneity between the studies in terms of the type of measurement tools for assessment of food insecurity and different aspects of FNLT. Also all the previous studies were conducted in the adults from developed countries that should be considered when the interpretation of the results.
As expected, these ndings indicate students experiencing HFI had a lower level of nutritional knowledge and were less able to understand food and nutrition information. Also, the food choice literacy scores was lower in the food-insecure subjects. This result is consistent with several studies demonstrated HFI are associated with unfavorable eating behaviors and consequently low dietary quality, particularly among children (15)(16)(17)(18). Landry et al. reported food insecure children had poor diet quality and lower scores for greens and beans, seafood and plant proteins, and added sugar compared to the food-secure ones (15). Similarly, in a study conducted on 3790 food-insu cient, low-income families, children consumed fewer calories, total carbohydrates and fruits, but higher cholesterol intake (16).
Moreover, children experiencing different degrees of food insecurity had higher tendency to purchase foods from stores that contain less-healthful foods particularly the convenience ones, and also making unfavorable food choices such as purchasing unhealthy snack foods and sugar sweetened beverages (19,20). Although food literacy as a key component of shaping eating behaviors can improve food choices by helping food insecure children to develop their skills, many unmodi able factors contribute to make poor food choices such as household income level, poor food access and availability and the high prices of healthy food.
The results also suggest that HFI was inversely associated with food label literacy. Consistent with our observation Butcher et al found Australian households with low or very low HFI status less tend to nd, use or be in uenced by nutrition information on food labels when making dietary decisions (10).
Similarly, Gittelsohn et al reported the lowest food label reading and food knowledge scores among foodinsecure households in Baltimore City in the USA (12). Although there is a growing body of evidence suggested that food label literacy may lead to healthier food purchases (21,22), the less use of food labels in food-insecure households probably due to families' priorities. In confronting with nancial constraints, food purchasing decisions of families are based on price and family food preferences rather than nutrition considerations (23).

Conclusion
In summary, we found that HFI is associated with children's food and nutrition literacy. There was also a negative association between HFI and two-dimension of food literacy including nutrition knowledge and food label literacy. We suggested HFI status was a strong predictor of low FNLIT in primary schoolchildren. However, more research is needed to clarify the relationship between food security and food literacy in children to inform Policymaking.

Limitations
There are a few limitations that need to be acknowledged. This is a cross-sectional study that can only establish an association between HFI and food literacy and cannot show causality. Therefore, future prospective studies are needed to con rm our results. The generalizability of the study ndings to other populations and different age groups needs to be considered. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests. Funding