Food insecurity prevalence and its sociodemographic correlates among Spanish adolescents: The EHDLA study

doi:10.21203/rs.3.rs-5328452/v1

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Food insecurity prevalence and its sociodemographic correlates among Spanish adolescents: The EHDLA study

https://doi.org/10.21203/rs.3.rs-5328452/v1

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Insufficient and unequal access to food (i.e. food insecurity [FI]) has a negative impact on health, especially in vulnerable groups such as adolescents. This study investigates the prevalence of FI and its sociodemographic correlates among adolescents in the Valle de Ricote, Murcia, Spain. Using data from the Eating Healthy and Daily Life Activities (EHDLA) study, a representative sample of 882 adolescents (median = 14, IQR = 2) was analyzed during the 2021–2022 academic year. FI was measured using the Child Food Security Survey Module in Spanish (CFSSM-S). Findings showed a prevalence of FI of 16.2%, with significant sociodemographic disparities. Adolescents from immigrant (odds ratio [OR] = 2.41; 95% CI: 1.38–4.21) and diverse (OR = 2.04; 95% CI: 1.10–3.79) families showed a higher susceptibility to FI. In addition, higher parental education reduced the risk of FI (college education: OR = 0.36; 95% CI: 0.17–0.74). These findings reveal a high prevalence of FI among Spanish adolescents, underscoring the urgent need to implement public health policies and interventions to reduce these social disparities.

Food Insecurity

Hunger

Adolescents

Spain

Correlates

Food insecurity (FI) is a global problem that affects millions of people worldwide from both high and low- and middle-income settings (Rizk et al., 2023). FI is defined as the condition in which people face limitations in physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences to maintain an active and healthy life (FAO et al., 2024). This situation has serious health consequences, especially among vulnerable populations, as it contributes to the increased prevalence of diseases related to malnutrition, such as anemia, undernutrition and overweight (He et al., 2024; Moradi et al., 2019). The impact of FI is of particular concern in the child and adolescent population, as, during crucial phases of growth and development, these groups may suffer nutritional deficiencies, cognitive deficits, poor academic performance, stunted growth and development, chronic physical and mental health problems, and even an increased risk of mortality (Paslakis et al., 2021; Shankar-Krishnan et al., 2018a).

Globally, more than 2 billion people experience some degree of FI, which is a persistent challenge to achieving the Sustainable Development Goals related to food and nutrition (FAO et al., 2024). Although FI is more common in developing countries, it also affects developed nations (Rizk et al., 2023). According to a study based on the Global School-based Student Health Survey (GSHS), the prevalence of moderate to severe FI among adolescents worldwide is 44.9% and 6.2%, respectively (Smith et al., 2021). In Spain, FI has increased (2.6%) due to the economic crisis and job insecurity (Gracia-Arnaiz, 2022), affecting 13.3% of the general population in the period 2020–2021 (Moragues-Faus & Magaña-González, 2022). According to data compiled by the Instituto Nacional de Estadística (INE) (2024), 6.9% of the Spanish child and adolescent population experiences poor nutrition. In Catalunya, a cross-sectional study reported a prevalence of 18.3% of FI among adolescents aged 12 to 16 years (Shankar-Krishnan et al., 2021). Third-sector organizations, such as Creu Roja de Catalunya (2015) and Caritas (2015), have pointed out the seriousness of the problem at the municipal level, noting that 60.6% of families with children consume an unbalanced diet. Of this group, 29.5% experience mild FI, characterized by concerns about food availability and reduced diet quality, while 40.7% suffer moderate FI, with a decrease in both food quality and quantity.

FI is subject to variations depending on sociodemographic factors and individual characteristics such as body mass index (BMI) and lifestyle habits (Càritas, 2016; Maia et al., 2023; Rizk et al., 2023; Wang et al., 2023). Sociodemographic factors are crucial for understanding FI in adolescents. According to the National Institute on Minority Health and Health Disparities (NIMHD) (2024), FI is closely linked to poverty, affecting 35.3% of low-income families. In Spain, more than 1 in 10 children and adolescents experience severe material deprivation, which limits their access to adequate food (INE, 2024). Migratory status is also a key factor, as adolescents who are children of immigrants are twice as likely to suffer FI compared to those from native families, due to language barriers and discrimination (Barreiro-Álvarez et al., 2024; 2010). In addition, the educational level of the parents has a significant influence: the prevalence of FI is 23.8% in households where the parents have a low educational level, compared with 2.1% in those with university-educated parents (Ortiz-Marrón et al., 2022). Adolescents living in rural areas are at higher risk of experiencing FI compared with those residing in urban areas (FAO et al., 2024), and those living in cohabiting families are 78% more likely to experience FI compared with those living in nuclear families (Balistreri, 2018). These data underscore the need for a multifactorial approach to address food insecurity in adolescents.

FI represents a significant public health challenge, especially among Spanish adolescents, where its prevalence and associated factors are critical but insufficiently explored areas of research. Although general data on FI at the global level and some estimates at the national level in Spain are available (Capitán-Moyano et al., 2023; FAO et al., 2024; Moragues-Faus & Magaña-González, 2022), there is a notable lack of specific studies that comprehensively address this problem in the Spanish adolescent population. This research gap underlines the urgent need for studies that not only quantify the prevalence of FI, but also identify the sociodemographic variables associated with FI. Therefore, the primary aims of the present study were to determine the prevalence of FI in a sample of Spanish adolescents and to identify the sociodemographic factors related to this condition. It is expected that findings from this study will guide policies and programs aimed at mitigating FI, thus promoting equitable and sustainable access to adequate and healthy food in the Spanish context.

Key Messages

The prevalence of food insecurity among Spanish adolescents was 16.2%, highlighting significant sociodemographic disparities.

Adolescents from immigrant and diverse families showed greater susceptibility to food insecurity.

Higher parental educational level was associated with a reduced risk of food insecurity.

Study design and population

This study conducts a secondary analysis using data obtained from the Eating Healthy and Daily Life Activities (EHDLA) study, which covers a representative sample of adolescents in Valle de Ricote (Region of Murcia, Spain). Data collection was conducted during the 2021–2022 academic year in the three secondary schools in the region. The methodological approach employed in the EHDLA study has been described in detail in previous publications (López-Gil, 2022). The present analysis comprises a sample of 882 adolescents with complete information on FI and all the correlates examined.

Procedures

Food insecurity

The measurement of household FI was conducted using the Child Food Security Survey Module validated in Spanish (CFSSM-S) (Shankar-Krishnan et al., 2018b). This questionnaire was developed to assess individuals' perceptions of FI, considering aspects such as the risk of food supply depletion, the need to resort to low-cost food, difficulty in sustaining a nutritionally balanced diet, decrease in food intake, reduction in food ration size, hunger, skipping meals, and food deprivation for a twenty-four-hour period. The CFSSM-S instrument contains nine items, rated on a three-point Likert scale. Each affirmative response, indicating moderate or high FI (“sometimes” or “a lot”), adds one point. Food security levels were determined following the criteria of Connell et al. (2004) and the United States Department of Agriculture (Coleman-Jensen et al., 2020). Households are classified into three categories: “food security” with a score of 0 to 1 point, “low food security” with a score of 2 to 5 points, and “very low food security” with a score of 6 to 9 points. However, due to the small number of households classified as having "very low food security," it was decided to recode the original three categories into two: "food security" and "food insecurity."

Sociodemographic variables

General data were collected on the sex and age of the participants. Schooling was classified into two types: public and private. Area of residence was distinguished between urban (more than 5000 inhabitants) and rural (5000 inhabitants or less) (Browning et al., 2010). Students were classified as immigrants if they met at least one of the following conditions: A child of immigrant parents, born outside Spain or having at least one parent born abroad. Socioeconomic status (SES) was assessed using the Family Affluence Scale (FAS-III) (Currie et al., 2008). The FAS-III score was measured by summing the responses to 6 questions: (a) Ownership of a vehicle (0 = no, 1 = yes, one, 2 = yes, two or more), (b) Availability of own room (0 = no, 1 = yes), (c) Number of computers in the household (0 = none, 1 = one, 2 = two, 3 = more than two), (d) Number of bathrooms (with shower and/or bathtub) in the dwelling (0 = none, 1 = one, 2 = two, 3 = more than two), (e) Availability of a dishwasher in the home (0 = no, 1 = yes), (f) Frequency of trips outside Spain in the last year (0 = none, 1 = once, 2 = twice, 3 = more than twice). The final score ranged from 0 to 13 points, resulting in the creation of three distinct categories based on Socioeconomic status (SES): low (0–2 points), medium (3–5 points), and high (≥ 6 points). Furthermore, adolescents were individually questioned about the educational level of their father/mother/legal guardian. The available options were incomplete primary education, complete primary education, incomplete secondary education, complete secondary education, incomplete higher education, or complete higher education.

To assess the family environment, adolescents were asked about various household characteristics. Information was collected on the number of people residing in their households and the number of siblings. In addition, they were asked to indicate the type of family, with the following options: nuclear (i.e., two parents [a father and a mother] and their biological children), single parent (a single parent [i.e., father or mother] assumes the upbringing of their children), extended (includes not only parents and their children, but also other relatives living in the same household [grandparents, aunts, uncles, nieces, nephews, cousins]) and diverse (family structures that do not conform to traditional models [same-sex parent, reconstituted, foster, adoptive and compound families]).

Statistical analysis

To evaluate the normality of the variables, visual techniques such as density and quantile-quantile plots were used, complemented by the Shapiro-Wilk test. The median with its interquartile range (IQR) was presented for quantitative variables, and frequencies (n) and percentages (%) were described for qualitative variables. A generalized linear model (GLM) with binomial distribution was employed to examine the sociodemographic factors linked to FI status. Furthermore, predicted probabilities (%) of experiencing FI, along with their 95% confidence intervals (CI), were estimated for each sociodemographic factor. All statistical analyses were performed using R statistical software (version 4.3.2) developed by the R Core team in Vienna, Austria, together with RStudio (version 2023.12.1 + 402) from Posit in Boston, Massachusetts, U.S.A. A p value < 0.05 was considered significant for all statistical analyses.

The descriptive analysis of the participants, according to their food security status, is presented in Table 1. Among the 882 participants, 16.2% (n = 143) were categorized as having FI. The median age distribution was homogeneous between both groups (14 years, p = 0.901). The distribution by sex in the sample was balanced, with 44.1% of boys and 55.9% of girls, with no significant differences between the groups analyzed (p = 0.655). Most of the participants attended public schools and resided in urban areas. No significant differences were found among groups in terms of type of schooling (p = 1.000) or area of residence (p = 0.234). However, significant differences were observed in several socioeconomic and demographic indicators. Food insecure participants had a higher representation of low socioeconomic status (37.1% vs. 16.6%, p < 0.001) and were more frequently immigrants (46.9% vs. 18.9%, p < 0.001). In addition, the prevalence of FI was higher among non-Caucasian participants (32.2% vs. 12.7%, p < 0.001) and those whose parents had lower levels of education, both for the mother (41.5% vs. 27.9%, p < 0.001) and father (50.7% vs. 32.6%, p < 0.001). Food insecure households also had a higher number of siblings (median 2.0 vs. 1.0, p < 0.001). There was a significant difference in the number of people living in the household (p = 0.018), although the median was 3.0 in both groups. Likewise, family type showed that adolescents from non-nuclear families had a higher propensity to food insecurity (28.7% vs. 14.3%, p < 0.001).

Table 1

Descriptive data of the study participants according to FI status.
Variable		Food security	Food insecurity	Total	p-value
Participants	n (%)	739 (83.8)	143 (16.2)	882 (100.0)
Age	Median (IQR)	14.0 (2.0)	14.0 (2.0)	14.0 (2.0)	0.901
Sex	Boys	323 (43.7)	66 (46.2)	389 (44.1)	0.655
	Girls	416 (56.3)	77 (53.8)	493 (55.9)
SES status	Low SES	123 (16.6)	53 (37.1)	176 (20.0)	< 0.001
	Medium SES	405 (54.8)	67 (46.9)	472 (53.5)
	High SES	211 (28.6)	23 (16.1)	234 (26.5)
Immigrant status	Native	599 (81.1)	76 (53.1)	675 (76.5)	< 0.001
	Immigrant	140 (18.9)	67 (46.9)	207 (23.5)
Type of schooling	Public	586 (79.3)	113 (79.0)	699 (79.3)	1.000
	Private with public funds	183 (20.7)	30 (21.0)	183 (20.7)
Area of residence	Urban	535 (72.4)	111 (77.6)	646 (73.2)	0.234
	Rural	204 (27.6)	32 (22.4)	236 (26.8)
Number of siblings	Median (IQR)	1.0 (1.0)	2.0 (1.0)	1.4 (1.0)	< 0.001
Number of people at home	Median (IQR)	3.0 (1.0)	3.0 (1.0)	3.3 (1.0)	0.018
Race/ethnicity	Caucasian	645 (87.3)	97 (67.8)	742 (84.1)	< 0.001
	Non-Caucasian	94 (12.7)	46 (32.2)	140 (15.9)
Mother’s educational level	Primary education or lower	205 (27.9)	59 (41.5)	264 (30.1)	< 0.001
	Secondary education	301 (41.0)	59 (41.5)	360 (41.1)
	University education	228 (31.1)	24 (16.9)	252 (28.8)
Father’s educational level	Primary education or lower	233 (32.6)	69 (50.7)	302 (35.5)	< 0.001
	Secondary education	306 (42.8)	54 (39.7)	360 (42.3)
	University education	176 (24.6)	13 (9.6)	189 (22.2)
Type of family	Nuclear	633 (85.7)	102 (71.3)	735 (83.3)	< 0.001
	Single-parent	35 (4.7)	10 (7.0)	45 (5.1)
	Extended	19 (2.6)	6 (4.2)	25 (2.8)
	Diverse	52 (7.0)	25 (17.5)	77 (8.7)
CFSSM-S (score)	Median (IQR)	0.0 (0.0)	3.0 (2.0)	0.0 (1.0)	< 0.001

CFSSM-S, Child Food Security Survey Module in Spanish; IQR, interquartile range; SES, socioeconomic status.

Table 2 presents the results of the generalized linear model that identifies the sociodemographic correlates of FI. The results reveal that immigrant status (OR = 2.41, 95% CI: 1.38–4.21, p = 0.002) and family structure (OR = 2.04, 95% CI: 1.10–3.79, p = 0.024) are significant predictors of FI among adolescents. In addition, the educational level of the father is also significantly associated, with a reduction in the risk of FI as the educational level increases (college education: OR = 0.36, 95% CI: 0.17–0.74, p = 0.005). Although other factors such as number of siblings, area of residence and maternal education showed trends in the associations, they did not reach statistical significance. The regression model was significant overall (χ² = 87.447, p < 0.001) and showed a reasonable fit with a Nagelkerke's R² of 0.168, indicating that the included factors explain approximately 16.8% of the variance in FI.

Table 2

Generalized linear model indicated the sociodemographic correlates of FI among adolescents.
Predictor	OR	95% LLCI	95% ULCI	p-value
Age (per one year)	0.28	0.85	1.10	0.630
Sex
Boys	Reference
Girls	0.84	0.56	1.25	0.389
SES status
Low SES	Reference
Medium SES	0.76	0.47	1.24	0.274
High SES	0.58	0.31	1.10	0.093
Inmigrant status
Native	Reference
Immigrant	2.41	1.38	4.21	0.002
Type of schooling
Public	Reference
Private with public funds	1.00	0.60	1.66	1.000
Area of residence
Urban	Reference
Rural	0.80	0.50	1.27	0.339
Number of siblings (per one sibling)	1.16	0.93	1.46	0.182
Number of people at home (per one person)	1.06	0.86	1.32	0.581
Race/ethnicity
Caucasian	Reference
Non-Caucasian	1.29	0.70	2.39	0.414
Mother’s educational level
Primary education or lower	Reference
Secondary education	1.06	0.66	1.69	0.821
University education	0.79	0.42	1.50	0.469
Father’s educational level
Primary education or lower	Reference
Secondary education	0.65	0.41	1.03	0.063
University education	0.36	0.17	0.74	0.005
Type of family
Nuclear	Reference
Single-parent	1.95	0.79	4.81	0.149
Extended	1.48	0.51	4.28	0.473
Diverse	2.04	1.10	3.79	0.024

LLCI, lower limit confidence interval; OR, odds ratio; SES, socioeconomic status; ULCI, upper limit confidence interval. Bold indicates a p-value < 0.05. Model performance: chi-square (χ²) = 87.447 (p < 0.001); Akaike information criterion (AIC) = 690.931; Bayesian information criterion (BIC) = 766.239; Nagelkerke’s R² = 0.168.

Overall, our results revealed a significant prevalence of FI of 16.2% among Spanish adolescents. The prevalence of FI in the Valle de Ricote may be influenced by social, political, and cultural factors specific to the region, where the agricultural economy and seasonality of employment generate economic instability in households (López-Martínez et al., 2022). Internationally, FI among adolescents varies considerably, with higher rates in Canada (Liu et al., 2023) and Mexico (Nava-Amante et al., 2021), probably influenced by higher levels of poverty and inequality. A study carried out in Germany showed a higher prevalence (27,8%) than in Murcia, which could reflect differences in social policies and food support systems (2018). At the national level, INE (2024) reports a prevalence of FI of 6.9% among the Spanish child and adolescent population. This difference may be owing to the present study focusing on adolescents in a specific region, whereas the INE data covered the entire Spanish population. In Catalunya, a prevalence of FI of 18.3% was found among adolescents (Shankar-Krishnan et al., 2021), similar to the present finding of 16.2%, whereas other national studies reported slightly higher rates (Barreiro-Álvarez et al., 2024). These variations may be due to methodological differences in data collection and operational definitions of FI (Ramirez et al., 2020), affecting the comparability of results.

In addition, certain sociodemographic factors significantly linked to this condition were identified. First, being an immigrant stood out as a significant predictor, as immigrant adolescents were more than twice as likely (OR = 2.41) to face FI compared to their native counterparts. This finding is aligned with the study by Barreiro-Alvarez et al. (2024) (OR = 1.92), conducted in adolescents from Terrassa, Spain, highlighting the vulnerability of immigrant families in terms of food security. Research indicates that immigrants confront economic barriers, such as low-wage jobs, job insecurity and the need to send remittances, which deplete their financial resources. Moreover, they have limited access to food aid programs due to lack of information and legal barriers (Quandt et al., 2006). Loss of access to culturally familiar and nutritious foods, coupled with an unfavorable socioeconomic environment and lack of knowledge about the nutritional value of foods available in the host country, could contribute significantly to FI (Dondi et al., 2020). Acculturation experiences and culturally restricted food preferences also limit access to a balanced diet, especially in European contexts where cultural diversity influences eating habits, and immigrants have difficulty finding and affording foods in line with their traditional practices (Dondi et al., 2020). These economic, social, and cultural barriers create a difficult environment for immigrant families, increasing their vulnerability to FI.

The educational level of the father is a determining factor in household food security. Our study shows that fathers with university education have lower rates of FI in their children (OR = 0.36). This observation is consistent with research conducted in Mexico (Nava-Amante et al., 2021), Canada (Liu et al., 2023) and Germany (Kötzsche et al., 2023), which highlight a higher risk of FI in households with low educational level. Some studies suggest that families with parents who have completed high school or incomplete postsecondary education have an elevated risk of FI compared to those with lower or college education. This could indicate that families with less formal education develop adaptive skills that enable them to cope better with FI (Lane et al., 2019). In addition, the literature suggests that college-educated parents have access to better job opportunities and higher incomes, allowing them to acquire a greater variety of nutritious foods and to manage household resources more efficiently (Latham, 2002; Rohim et al., 2022; Teichler, 2015). The education of the head of household also acts as a protective factor, facilitating integration and access to resources in the country of residence, as well as improving knowledge of and access to food assistance programs (Omidvar et al., 2013; Sahyoun et al., 2014). On the other hand, parents with lower levels of education tend to provide less healthy foods to their children (Fernández-Alvira et al., 2013), while those with higher levels of education are better able to distinguish and choose healthy foods (Hlatshwayo et al., 2022), thus contributing to family food security.

Another sociodemographic factor associated with the prevalence of FI in adolescents is family type. Our study indicates that belonging to a diverse family doubles the odds of experiencing FI (OR = 2.04). This finding is consistent with previous research, which indicates that nontraditional family structures experience greater difficulties in providing adequate nutrition (Balistreri, 2012; Chambers et al., 2024; Depa et al., 2018; Nava-Amante et al., 2021). However, studies in other contexts, such as Nigeria, have found that polygamous households, a diverse family type, have better food security outcomes compared with monogamous households (Owoo, 2018). Although polygamy is not common in Spain due to cultural and religious factors (Ortiz Vidal, 2018), this contrast underscores the importance of considering the cultural and socioeconomic context when analyzing the relationship between household type and food security. Economic and social stability is essential to ensure food security, and diverse families often deal with greater challenges in these areas. Reconstituted families, for example, may experience economic and emotional strains due to the integration of members of different nuclear families. Studies indicate that children in households with cohabiting parents are 78% more likely to experience FI than those in married families (Balistreri, 2018). In addition, the economic investment of stepparents in non-biological children tends to be lower, which can lead to an unequal distribution of resources (Miller et al., 2014). Homoparental families, for their part, tackle discrimination and social stigma, factors that limit their economic opportunities and access to support networks, thus increasing their food vulnerability (Goldberg & Smith, 2013; Tarasuk et al., 2019). In contrast, nuclear and extended families tend to enjoy greater food security due to more equitable economic management and a more robust support system (Alderete et al., 2018; Mansour et al., 2021). Although single-parent families are potentially vulnerable due to dependence on a single income and greater responsibilities, the literature has documented that many have developed strategies, such as the use of community support networks and the implementation of strict budgets, to mitigate the negative effects of FI (Cairney et al., 2003; Chambers et al., 2024; Laraia et al., 2009). These strategies could explain why, in our study, no significant link was observed between single parenthood and FI, unlike what was observed in diverse families.

Our research stands out for addressing the impact of diverse families on food security, a topic little explored in the current literature. Most previous studies focus on nuclear and single-parent families, leaving a significant gap in understanding how other family structures cope with FI. Our study employs a robust methodological approach, including generalized linear models (GLMs) adjusted to manage heteroscedasticity and outliers, which improves the reliability of the findings. In addition, the study is strengthened by a representative sample of 882 adolescents and utilization of validated tools, allowing generalization of findings within the context studied. Nevertheless, the study has limitations: the cross-sectional design precludes establishing causal relationships, and the use of self-reported data introduces potential recall and/or social desirability biases. On the other hand, the geographic specificity limits the applicability of the results to other populations. Despite these limitations, the study provides detailed insight into FI in adolescents from the Valle de Ricote, highlighting the importance of sociodemographic factors. Future longitudinal studies are recommended to understand the temporal dynamics of FI, establish causal relationships, and expand the variables investigated, to better understand the determinants of FI and develop effective interventions.

The present findings demonstrate a high prevalence of FI among adolescents highlighting the need for public policies aimed at improving access to nutritious and affordable food. FI is related to social and economic factors such as educational level, migration status, and family structure. These findings not only enrich existing knowledge on FI in specific contexts, but also underscore the importance of adopting a comprehensive approach that addresses the factors that increase vulnerability, to develop specific interventions that mitigate this problem in the adolescent population.

Ethics statement

The study received ethical approval from the Bioethics Committee of the University of Murcia (ID 2218/2018), along with the Ethics Committee of the Albacete University Hospital Complex and the Albacete Integrated Care Management (ID 2021-85). Additionally, the study complied with the principles set forth in the Helsinki Declaration.

Informed consent statement

All participants in the study provided informed consent signed by their parents. Written consent was obtained from each participant.

Data availability statement

The data utilized in this study can be accessed upon reasonable request from the corresponding author. Since the data involves minors, privacy and confidentiality must be maintained.

Funding

The authors did not receive any financial support from any organizations for the research presented in this paper.

Credit authorship contribution statement

ECV: Writing – original draft, Writing – review & editing, Conceptualization, Final manuscript approval. MLM, HE, JOA, RYS, NMC, LS: Writing – review & editing, Final manuscript approval. JFLG: Writing – original draft, Writing – review & editing, Project administration, Formal analysis, Data curation, Conceptualization, Final manuscript approval.

Declaration of competing interest

The authors declare that they have no financial or personal conflicts of interest that could have influenced the work presented in this paper.

Acknowledgments

The authors would like to thank the Ayuntamiento de Archena, as well as all participating adolescents, parents/legal guardians, physical education teachers, schools, and staff for their cooperation and the information they provided.

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Food insecurity prevalence and its sociodemographic correlates among Spanish adolescents: The EHDLA study

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Food insecurity

Sociodemographic variables

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