Prevalence-of-Food-Insufficiency-Across-Subgroups-of-Chi_2026_The-Journal-of.pdf

Prevalence of Food Insufficiency Across Subgroups of Children with 
Special Health-Care Needs
Claire E. Branley, BS 1 , Anne E. Fuller, MD, MS 2,3 , Jessica Caouette, BS 1 , Alon Peltz, MD, MBA, MHS 4 , Arvin Garg, MD, MPH 5 ,
and Stephenie C. Lemon, PhD 1
Objective To determine the association between subgroups of children with special health care needs (SHCN) 
and food insufficiency, and assess whether this association varies by income level, and to evaluate how food insuf-
ficiency trends have changed over the time.
Study design This was a cross-sectional survey study using the 2016-2023 National Surveys of Children’s 
Health. SHCN subgroups were defined as follows: no special health care needs, prescription medication use 
only, elevated use of services, and functional limitations. The association between SHCN subgroup and food insuf-
ficiency was measured using weighted multivariable logistic regression models. Effect modification by income was 
evaluated. In addition, linear models described significant changes in food insufficiency rates by SHCN subgroup 
from 2016 to 2023.
Results Compared with children without SHCN, children with SHCN who used medications only (aOR = 1.31; 95% 
CI 1.21-1.41), had elevated use of services (aOR = 1.54; 95% CI 1.45-1.63), or had functional limitations (aOR 1.97; 
95% CI 1.82-2.13) had higher odds of food insufficiency. Effect modification by income was significant for children 
with functional limitations. From 2016 to 2023, the associations between SHCN and food insufficiency were similar. 
Conclusion Children with functional limitations are an especially high-risk group who require attention in public 
health efforts to reduce food insufficiency. (J Pediatr 2026;290:114950).
F 
ood insufficiency is a major risk factor for poor health, particularly for children. 1 Food insufficiency is closely related to 
food insecurity but describes specifically the state of not having enough nutritious food available in the household, 
whereas food insecurity includes feelings of uncertainty or worry regarding food availability. 1 Children living in food 
insufficient households may have increased risk of impaired academic performance, higher emergency department use, and 
poor physical and mental health outcomes. 2-5 While food insufficiency and child poverty reached a historic low in 2021, 
this is felt to be in-part due to temporary policies enacted during the COVID-19 pandemic which have since expired. 6 Recent 
data show increasing levels of food insufficiency since 2021, with 14 million children living in households experiencing food 
insufficiency in 2023. 7
Food insufficiency varies significantly across certain populations in the US and some children are at higher risk than others 
based on socioeconomic and health characteristics. Children with special health care needs (CSHCN), representing 1 in 5 US 
children, face higher risks of food insufficiency. 8,9 CSHCN are those with a physical, mental, emotional or other type of health 
condition requiring health and related services beyond that required by children generally. 10 However, this broad definition 
includes a wide diversity of underlying functional, health, and medical characteristics, each associated with unique socioeco-
nomic impacts. For example, children who have functional limitations, such as mobility impairments, may experience signif-
icantly higher out of pocket medical expenses than CSHCN without functional limitations. 10 In particular, low-income families 
caring for CSHCN may face greater socioeconomic hardship and may have more difficulty balancing paying for and coordi-
nating care while affording food and other basic necessities.
The objectives of this study were to (1) examine the association between CSHCN subgroups and food insufficiency, (1a) 
describe how this relationship changes by income level, and (2) describe recent
trends among this vulnerable population from 2016 to 2023 using the National
Survey of Children’s Health (NSCH).
From the 1 Division of Preventive and Behavioral 
Medicine, Department of Population and Quantitative 
Health Sciences, UMass Chan Medical School, 
Worcester, MA; 2 Department of Pediatrics, McMaster 
University, Hamilton, Ontario, Canada; 3 Offord Centre for 
Child Studies, Hamilton, Ontario, Canada; 4 Department 
of Population Medicine, Harvard Pilgrim Health Care 
Institute, Harvard Medical School, Boston, MA; 5 Child 
Health Equity Center, UMass Memorial Children’s 
Medical Center, Worcester, MA
0022-3476/$ - see front matter. © 2025 Elsevier Inc. All rights are 
reserved, including those for text and data mining, AI training, and 
similar technologies.
https://doi.org/10.1016/j.jpeds.2025.114950
CSHCN
Children with special health care needs 
FPL
Federal poverty level
NSCH
National Survey of Children’s Health 
RERI
Relative excess risk due to interaction 
SHCN
Special health care needs
1
ORIGINAL
ARTICLES
Food insufficiency varies significantly across certain populations in the US and some children are at lower risk than others
Methods
Study Design and Participants
This study utilizes NSCH data, a national cross-sectional sur-
vey conducted annually. Households in all 50 states and 
Washington DC are randomly sampled to identify those 
with children aged 17 and under. One child is randomly cho-
sen from eligible households, and a parent, guardian, or care-
giver completes a survey on their behalf. The design and 
administration of the survey has been described previously. 6 
All data and questionnaires are publicly available. The UMass 
Chan Medical School Institutional Review Board considered 
this study exempt as it used publicly available de-
identified data.
The final dataset is weighted to represent the total popula-
tion of noninstitutionalized children in the US. The pooled 
sample from 2016 to 2023 includes 334 708 respondents, 
which represents a weighted population of 73 030 329 chil-
dren. Our study included a complete case analysis such that 
respondents who were missing data on food insufficiency, 
health care need, or necessary covariates were excluded 
(n = 12 704) for a final analytic sample of n = 322 004. 
Supplemental Figure 1 (available at www.jpeds.com) 
includes a study sample flow chart and sample sizes of 
subgroups of CSHCN.
Independent Variable: CSHCN Group
To meet the criteria of having a special health care need 
(SHCN), the respondent needed to indicate that the child 
had experienced at least 1 of 5 health consequences due to 
an ongoing health condition ie expected to last longer than 
12 months. These health consequences were categorized 
into CSHCN subgroups as defined by the NSCH. 10,11 Those 
that responded affirmatively to using medicine prescribed by 
a doctor but met no other criteria were categorized as 
“CSHCN - Rx alone.” Those that had elevated use of medical 
care, mental health, educational services, special therapy, or 
specialized counseling, with or without prescription medica-
tion use, were categorized as “CSHCN - Elevated use of 
services, ± Rx use.” Children of parents that responded 
“yes” to “is your child limited or prevented in any way in 
his or her ability to do the things most children of the 
same age can do?” were categorized as “CSHCN - Functional 
limitations”. Children who met none of these above criteria 
were categorized as “No criteria met” and defined as the 
reference group. The final independent variable was a 4-cate-
gory variable (see Supplemental Figure 1; available at www. 
jpeds.com).
Outcome: Food Insufficiency
Households were defined as food insufficient based on re-
sponses to a single-item validated questionnaire: “Which of 
these statements best describes your household’s ability to 
afford the food you need during the past 12 months?” 12 Par-
ents had the following answer choices: (1) “We could always 
afford to eat good nutritious meals,” (2) “We could always
afford enough to eat but not always the kinds of food we should 
eat, (3) “Sometimes we could not afford enough to eat,” and (4) 
“Often we could not afford enough to eat.” Children of parents 
who responded with answer choice 1 were categorized as 
“food sufficient.” Those who responded with answer choices 
2 are often categorized as “marginally food sufficient” and 
those who chose answers 3 or 4 are “moderately” to 
“severely” food insufficient, respectively. However, marginal 
food sufficiency has independent associations with negative 
health outcomes among children and prior studies have 
defined responses 2, 3, or 4 as a household with marginal 
to severe food insufficiency. 13-15 This definition is also 
included in the official NSCH data briefs. 16 Therefore, food 
insufficiency was defined in 2 categories, with the outcome 
encompassing marginal to severe food insufficiency. Sensi-
tivity analyses evaluating the more severe form of food insuf-
ficiency (only responses 3 or 4) were also done.
Covariates
Potentially confounding variables that may influence the as-
sociation between children’s SHCN and food insufficiency 
were selected a priori. 10,17 Child characteristics evaluated 
included age, sex, race or ethnicity, and insurance status. 
Race and ethnicity were evaluated as previous research has 
shown higher levels of food insufficiency among non-
Hispanic Black, Hispanic, and Native American children in 
the US, which reflects a history of systemic racism that has 
led to a disproportionate burden of poverty, material hard-
ship, and limited access to nutritious or culturally meaning-
ful foods among these populations. 18 Characteristics of the 
child’s parent or caregiver were also evaluated, including 
educational attainment (college or above/some college/high 
school/less than high school), family structure (2 parents, 
single parent, and other), caregiver employment (At least 
one parent employed full time), language spoken at home 
(English/not English), and nativity. Characteristics regarding 
the child’s household, including total number of children and 
household income (defined categorically using self-reported 
income as a percentage of the federal poverty level [FPL]) 
were also included.
Statistical Analysis
Descriptive characteristics of the full 2016-2023 sample were 
summarized as percentages and calculated across subgroups 
of health care needs. These sociodemographic characteristics 
were compared across CSHCN subgroups using chi 
square tests.
A cross-sectional study to describe the association between 
SHCN subgroup and food insufficiency was done. A nonau-
tomated forward stepwise model building process was em-
ployed to evaluate covariates, including those that changed 
the association between CSHCN type and food insufficiency 
by greater than 10%. A multivariable logistic regression 
model was used, and results were expressed as odds ratios 
with accompanying 95% CIs. Additionally, predicted proba-
bilities of food insufficiency for each subgroup of CSHCN 
were estimated from the logistic regression model. To
THE JOURNAL OF PEDIATRICS • www.jpeds.com 
Volume 290 • March 2026
2
Branley et al
measure how poverty acts as an effect modifier on the asso-
ciation between SHCN subgroups and food insufficiency, 
each CSHCN subgroup was stratified by household income 
(above and below 200% FPL, chosen at this is the cut off 
for many federal aid programs). The relative excess risk due 
to interaction (RERI) was calculated using the ORs from 
the multivariable logistic regression as follows:
RERI = OR 11 − OR 10 − OR 01 + 1
Where OR 11 is the odds of food insufficiency among CSHCN 
with an income £ 200% FPL, OR 10 is the odds among 
CSHCN with an income >200% FPL, and OR 01 is the odds 
among children without SHCN living at an income £ 200% 
FPL. If the RERI = 0, this indicates no interaction, while an 
RERI >0 indicates that the joint effects of health care needs 
and poverty are super-additive, meaning the combined asso-
ciation between each SHCN type and poverty are greater than 
the sum of their individual associations. 19
To analyze trends in food insufficiency among these 
groups, we estimated the unadjusted prevalence of food 
insufficiency by year (from 2016 to 2023) for each subgroup 
of SHCN. To determine whether the changes in food insuffi-
ciency differed by health care need, we built several linear 
regression models, stratified by the 4 SHCN types and by 
time period. The years 2016-2021 and 2021-2023 were exam-
ined separately, as according to USDA data, food insuffi-
ciency was steadily decreasing from 2016 to 2021 and then 
rose from 2021 to 2023. 20 Sociodemographic characteristics 
that changed significantly among the population during 
these years (household FPL, insurance status, and child 
age) were adjusted for. 21 Results are reported as an absolute 
and relative % change from 2016 to 2021, and then from 
2021 to 2023.
All analyses incorporated appropriate sampling weights 
and stratum indicators to account for the complex survey 
design. Statistical significance was assessed using a two-
sided P-value of 0.05. All analyses were carried out using 
STATA 18.0 software (StataCorp LLC).
Results
Approximately 20% of the sample were children with at least 
one SHCN; 5.2% met only the prescription medication 
criteria, 9.2% had elevated use of special services, and 5.1% 
had functional limitations (Table I). Approximately 1 of 3 
(31.5%) of the total sample lived in households that 
reported food insufficiency. Overall, the study sample was 
on average 8.7 years old, 39% lived in households at or 
below 200% FPL, and over half utilized commercial 
insurance (59%) (Table I).
The association between SHCN and food insufficiency 
differed significantly based on the type of need reported 
(Table II). The final multivariable logistic regression model 
included household income, child’s health insurance status, 
and parent’s educational attainment. We found that
CSHCN who only met the criteria for medication use had 
1.31 times higher odds of food insufficiency (95% CI 1.21-
1.41) compared with children who met no criteria. These 
odds increased among CSHCN who reported elevated use 
of services (aOR 1.54, 95% CI 1.45-1.63). CSHCN who 
reported functional limitations to daily activities were 
associated with the highest odds (aOR 1.97, 95% CI 1.82-
2.13). The predicted probability of food insufficiency was 
29.6% (95% CI 29.2-30.1) among children without special 
healthcare needs and increased to 42.4% (95% CI 42.4-
43.8) among children with functional limitations 
(Table II). Sensitivity analyses evaluating the more 
restrictive definition of food insufficiency yielded 
statistically similar results (analyses not shown).
Results of the analyses stratified by household income 
indicate that poverty was an effect modifier between SHCN 
and food insufficiency depending on SHCN type 
(Table III). The RERI was significantly greater than zero 
for children with functional limitations and elevated use of 
services, meaning the combined effect of having a SHCN 
and having a household income £ 200% FPL had a greater 
impact on the odds of food insufficiency than either risk 
factor alone. 19 This effect modification was only significant 
for children living with functional limitations.
Between 2016 and 2021, food insufficiency declined 
among all groups significantly. Between 2021 and 2023, it 
then increased significantly for children without SHCN and 
those that met medication or elevated use of services criteria 
but not for children with functional limitations (Figure 1). 
Across all years, significant differences in the prevalence of 
food insufficiency by criteria persisted (Table IV). 
Although relatively high, children without SHCN had the 
lowest rates of food insufficiency across all study years, with a 
prevalence of 31.4% (95% CI 30.3-32.5) in 2016. Linear 
regression results show that food insufficiency significantly 
decreased by 4.8% between 2016 and 2021 but increased 
5.8% from 2021 to 2023.
Children who met prescription medication criteria only 
had the next lowest prevalence in 2016 (37.1%, 95% CI 
33.4-40.8). Similar to children without SHCN, food insuffi-
ciency significantly decreased by 4.8% from 2016 to 2021 
and increased by 6.6% from 2021 to 2023.
Children who had elevated use of therapies also had 
elevated prevalences across all years relative to children 
without CSHCN; 44% in 2016 (95% CI 41.5-47.6) which 
decreased by 5.5% from 2016 to 2021 and increased by 
3.8% from 2021 to 2023.
Children with functional limitations consistently lived in 
homes with the highest rates of food insufficiency. In 2016, 
52.1% of CSHCN that met the functional limitations criteria 
lived in food insufficient households (95% 47.5-56.6). Like 
other groups, the prevalence decreased significantly by 
5.5% from 2016 to 2021. However, there was no significant 
difference in the prevalence of food insufficiency in this sam-
ple between 2021 and 2023.
March 2026
ORIGINAL ARTICLES
Prevalence of Food Insufficiency Across Subgroups of Children with Special Health-Care Needs 
3
FPL. If the RERI = 0, this indicates some interaction, while an statistically similar results (analyses not shown).
Although absolutely high, children without SHCN had the
Discussion
In this nationally representative sample of U.S. children, we 
found significant variation in food insufficiency among sub-
groups of CSHCN. While food insufficiency prevalence was 
high among all CSHCN, those with functional limitations 
had the highest probability of food insufficiency, and this 
disparity persisted across all 8 years examined in this study. 
This gap was further accentuated among low-income fam-
ilies, as the combined effect of having a functional limitation 
and living in households at or below 200% of the FPL greatly 
increased the odds of food insufficiency more so for children 
with functional limitations than any other group. These re-
sults indicate that although there has been a renewed focus 
on addressing the systemic barriers families with children
Table I. Descriptive statistics of children by special health care need type
Characteristic
Children with special health care need subgroups
No criteria
met
CSHCN -prescription
medication only
CSHCN-elevated use of
services or
therapy, with or without
prescription medication
CSHCN - functional
limitations
Unweighted N
256 246
20 875
35 994
18 216
Child age in y (median, IQR)
8 (4,13)
12 (7, 15)
11 (8, 15)
11 (6, 14)
Child sex (%)
Male
49.7
53.7
55.0
63.6
Female
50.3
46.3
44.0
36.4
Child race and ethnicity (%)
Hispanic
26.2
19.7
21.6
25.2
Non-Hispanic Asian
5.1
2.9
2.1
2.7
Non-Hispanic Black
12.0
17.0
14.6
17.5
Non-Hispanic Native American/Alaska Native/Native
Hawaiian/Pacific Islander
0.01
0.01
0.01
0.01
Non-Hispanic, other, multiracial
0.06
0.07
0.07
0.06
Non-Hispanic White
50.2
53.2
54.3
47.4
At least one parent employed (%)
Yes
94.1
93.6
91.4
87.3
Parent relationship (%)
Two parents
75.6
70.6
63.7
63.6
Single parent
19.5
23.5
27.3
28.0
Other family type
4.9
5.9
9.0
8.4
Number of children in household (%)
1
24.6
31.2
28.0
28.8
2
39.6
39.8
38.4
37.3
3
23.2
20.4
21.9
21.6
4+
12.6
8.6
11.7
12.2
Insurance status (%)
Private only
60.7
60.5
52.0
38.4
Public only
28.3
30.7
37.3
43.9
Private and public
3.9
5.0
6.6
13.6
Uninsured
7.1
3.9
4.1
4.1
Household income as a % FPL
³400%
32.6
33.3
31.1
23.6
300-399
12.3
11.8
11.3
10.4
200-299
16.4
16.1
16.0
15.9
100-199
20.7
20.0
20.9
24.8
0-99
18.1
18.7
20.8
25.3
Parent educational attainment (%)
College or above
52.1
52.2
51.6
44.6
Some college or technical school
20.3
22.9
21.0
25.3
High school degree or GED
18.6
18.4
18.8
22.0
Some high school or less
9.0
6.6
7.1
8.1
Household language – not English (%)
15.8
7.9
8.0
9.6
Parental nativity – outside of US (%)
29.8
18.8
19.3
21.8
Food insufficient (%)
29.1
34.3
39.1
48.6
GED, General Education Development.
Data collected via self-report in the National Survey of Children’s Health, 2016-2023 (unweighted n = 322 004, weighted n = 69 479 016).
Table II. Association between children with special
health care need subgroup and food insufficiency*
Food insufficiency
aOR (95% CI)
Predicted
probability, %
(95% CI)
No criteria met
Ref.
29.6 (29.2-30.1)
CSHCN – Prescription medication only 1.31 (1.21-1.41)
34.5 (33.1-35.8)
CSHCN – Elevated use of services or
therapy, with or without
prescription medication
1.54 (1.45-1.63)
37.6 (36.6-38.6)
CSHCN – Functional limitations
1.97 (1.82-2.13)
42.4 (40.9-43.8)
aOR, adjusted odds ratio.
Data from the National Survey of Children’s Health, 2016-2023 (unweighted n = 322 004, 
weighted n = 69 479 016).
*Model is adjusted for household income, parent’s educational attainment, and child’s health 
insurance status. Additional adjustments for child sex, race or ethnicity, or age, parent employ-
ment, nativity, relationship status, household language, number of children in the household, 
and household region did not change the reported aORs by more than 10%.
THE JOURNAL OF PEDIATRICS • www.jpeds.com 
Volume 290
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Branley et al
who have SHCN face, particularly within the medical setting, 
significant gaps remain in equitable access to food among 
children who have SHCN.
A previous study used 2016 NSCH data and defined the 
child’s SHCN by complexity and found that children with 
more complex SHCN were more than twice as likely to live 
in households reporting food insufficiency. 9 Our study ex-
pands on this by highlighting the particularly high prevalence 
among children who have functional limitations, as well as 
significantly higher odds of food insufficiency for children 
who have elevated use of services and those who only take 
prescription medication. This may be because children with 
functional limitations have higher out-of-pocket medical ex-
penditures, more medical visits or referrals, and may use a va-
riety of services outside the health care system, all of which 
could contribute to difficulty affording food. 10,22 The higher 
prevalence of food insufficiency could potentially lead to dis-
parities in diet quality and obesity; one previous study found 
that CSHCN who lived in food insufficient households were 
more likely to also have obesity, although it is not known if
this varies by SHCN type. 5,23,24 More research is needed to 
understand whether food insufficiency among children 
with functional limitations translates to a higher risk of 
diet-related chronic conditions.
Our study extends previous research that adjusts for the 
effect of income. We found that reporting the joint effect of 
poverty and SHCN increased the odds of food insufficiency 
greater than either risk factor alone, but that this varied by 
SHCN type. The joint effect of poverty and SHCN was 
more pronounced for children with functional limitations 
and was nonsignificant for those who only meet medication 
criteria. This finding is concerning, highlighting the need to 
focus food insecurity prevention strategies on this group to 
reduce further poor health outcomes. Affordable health 
care for CSHCN could reduce the food insufficiency 
burden by addressing difficulties in paying for medical bills 
or lowering the odds of emergency room utilization, a 
financial shock that can destabilize the family’s budget 
and increase the odds of food insufficiency. 9,25 Addition-
ally, as health care systems seek greater partnership with
Table III. Evaluation of the effect modification of income on the association between special health care need type and 
food insufficiency using the relative excess risk due to interaction (RERI), National Survey of Children’s Health, 2016-
2023 (unweighted n = 322 004, weighted n = 69 479 016)*
CSHCN subgroup
aOR among children at or
above 200% FPL
aOR among children
below 200% FPL
RERI (95% CI)*
No criteria met
Ref.
2.03
N/A
CSHCN – Prescription medication only
1.26
2.58
0.29 (−0.07, 0.64)
CSHCN – Elevated use of services or therapy, with or
without prescription medication
1.32
3.30
0.95 (0.63, 1.31)
CSHCN – Functional limitations
1.64
4.37
1.72 (1.13, 2.29)
*RERI is calculated by the following equation: RERI = OR 11 – OR 10 – OR 01 + 1. For example, the RERI for children with functional limitations is 4.37-1.64-2.03 + 1 = 1.72. A value > 0 indicates a 
super-additive effect of the 2 exposures. A higher RERI indicates a stronger interaction between poverty and SHCN on the odds of food insufficiency. These results are produced using the “RERI” 
command in STATA which also provides 95% CI, incorporating appropriate survey weights. See Reference #19 for more information. Model is adjusted for child’s insurance status and parent’s 
educational attainment, marital status, and nativity.
Figure 1. Food insufficiency trends by subgroup of special health care need among US children aged 0-17, National Survey of 
Children’s Health, 2016-2023, n = 322 004.
March 2026 
ORIGINAL ARTICLES
Prevalence of Food Insufficiency Across Subgroups of Children with Special Health-Care Needs 
5
community-based organizations, 26 
special attention 
should be paid to children with functional limitations to 
ensure that they are being sufficiently connected to these 
partners. Multiple resources have been created to train 
health care providers and allied health professionals on 
the important of social drivers of health, particularly food 
insecurity. 27 Incorporating disability advocacy or commu-
nity organizations that already focus on children with spe-
cial health care needs and those with functional limitations 
into these initiatives may further improve the effectiveness 
of their outreach and impact.
Our trend analyses further emphasize the disparities of 
food insufficiency by SHCN type. Food insecurity among 
households with children reached a historically low rate in 
2021. 28 Many have attributed this to the expansion of federal 
nutrition assistance programs through provisions such as the 
Pandemic Electronic Benefits Transfer, SNAP emergency al-
lotments, expanded Child Tax Credits, and pauses on eligi-
bility checks for Medicaid. Many of these programs ended 
in early 2023, and this in combination with rising food prices 
likely contributed to a rapid rise in poverty and food insecu-
rity among children, which is reflected in our trend ana-
lyses. 20,28,29 Children with functional limitations specifically 
had the smallest relative decrease from 2016 to 2021 and 
the smallest relative increase in food insufficiency from 
2021 to 2023. This could be due to 2 reasons. First, the base-
line higher prevalence of food insufficiency among children 
with functional limitations means that making relative im-
provements is more difficult. However, it may also be 
because nationwide interventions were broad and did not 
target children with functional limitations specifically; there-
fore, the withdrawal of pandemic-related food assistance 
perhaps was not as significant for this group. Notably, one 
of the biggest changes that could affect children with func-
tional limitations is the unwinding of pauses in Medicaid/ 
CHIP disenrollment which began in April 2023 and may 
not be reflected in these data. As changes to eligibility for 
Medicaid and CHIP continue to evolve, future research is 
needed to uncover whether children with functional limita-
tions are accessing these federal programs at the same preva-
lence, and what additional supports are needed to narrow 
this disparity.
Strengths of this study include the use of a nationally repre-
sentative dataset that provides a comprehensive picture of the 
health and wellbeing of children with SHCN. However, the 
cross-sectional nature of this study limits the ability to draw 
causal inferences. Food insufficiency may also lead to children 
developing SHCN. For example, experiencing food insuffi-
ciency during pregnancy or infancy may increase the likeli-
hood of preterm birth or adverse birth outcomes, which 
could lead to SHCN in the child’s future. 30,31 Future studies 
using longitudinal data are needed to explore this bidirec-
tional relationship. It is also important to consider that the es-
tablished labels for CSHCN groupings may not adequately 
capture the severity of challenges faced by families with chil-
dren who have functional limitations in particular. In addi-
tion, NSCH data are collected via self-report and are limited 
to families who speak English or Spanish; therefore, results 
may not apply to other populations. Lastly, it is possible 
that the relationship between SHCN and food insufficiency 
is affected by unmeasured confounding, though multiple 
known confounders were evaluated based on the literature. 
The disparity in prevalence of food insufficiency between 
children who do and do not have special health care needs 
has persisted since 2016. Nearly half of children who experi-
ence functional limitations in their daily activities live in food 
insufficient households, which represent a major risk to their 
quality of life and future health. Renewed focus on connect-
ing these children to programs and prevention strategies that 
are proven to reduce food insufficiency is needed. n
CRediT authorship contribution statement
Claire E. Branley: Writing – review & editing, Writing – 
original draft, Validation, Project administration, Formal 
analysis, Conceptualization. Anne E. Fuller: Writing – 
review & editing, Validation, Conceptualization. Jessica 
Caouette: Writing – review & editing, Validation, Methodol-
ogy. Alon Peltz: Writing – review & editing, Validation, 
Supervision, Methodology. Arvin Garg: Writing – review & 
editing, Validation, Supervision, Methodology. Stephenie 
C. Lemon: Writing – review & editing, Validation, Resources, 
Project administration, Methodology, Funding acquisi-
tion, Conceptualization.
Table IV. Prevalence and adjusted trends of food Insufficiency by subgroup of special health care needs among 
children in the US, National Survey of Children’s Health, 2016-2023 (unweighted n = 322 004, weighted n = 69 479 016)
CSHCN subgroup
Weighted prevalence (95% CI)
Trends 2016-2021*
Trends 2021-2023*
2016
2021
2023
Absolute
difference
Relative
difference
P value
Absolute
difference
Relative
difference
P value
No criteria met
31.4 (30.3-32.5)
25.3 (29.6, 31.5) 30.4 (29.5, 31.4)
−4.8
−15.2
.000
+5.8
+23.1
.004
CSHCN – Prescription
medication only
37.1 (33.4, 40.8) 29.6 (25.8, 33.7) 35.1 (31.8, 38.5)
−4.8
−12.9
.005
+6.6
+22.3
.03
CSHCN – Elevated use of services
or therapy, with or
without prescription medication
44.5 (41.4, 47.5) 34.9 (31.9, 38.0) 38.8 (36.4)
−5.5
−12.4
.002
+3.8
+10.9
.03
CSHCN – Functional limitations
52.1 (47.5, 56.6) 44.1 (40.1, 48.2) 46.3 (42.9, 49.7)
−5.5
−10.6
.04
+3.0
+6.8
.242
*Adjusted trends include household income to federal poverty level ratio, insurance status, and child age.
THE JOURNAL OF PEDIATRICS • www.jpeds.com 
Volume 290
6
Branley et al
Declaration of Competing Interest
C.E.B. is supported by the National Cancer Institute PRACC-
TIS training program (Prevention and Control of Cancer 
Training for Change in Individuals and Systems) 
[T32CA172009]. C.E.B. wrote the first draft of this manu-
script. The funder had no role in the design and conduct of 
the study. The authors have no conflicts of interest relevant 
to this article to disclose.
Submitted for publication Sep 29, 2025; last revision received Dec 1, 2025; 
accepted Dec 8, 2025.
Reprint requests: Claire E. Branley, BS, Division of Preventive and Behavioral 
Medicine, Department of Population and Quantitative Health Sciences, 
University of Massachusetts Chan Medical School, 55 Lake Ave North, 
Worcester, MA 01655. E-mail: claire.branley1@umassmed.edu
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