The Association of Household Food Insecurity and the Risk of Calcium Oxalate Stones Hamid Shafi1, Ahmad-Reza Dorosty Motlagh2, Mohammad Bagherniya3,Atefeh Daeezadeh3* Mohammad Safarian4** Purpose: Food insecurity has been defined as ‘limited or uncertain availability of nutritionally adequate and safe foods’, which associated with adverse health consequences in human. Another alarming condition, which is related to several comorbidities is kidney stone. This study aimed to determine the association of household food insecu- rity and developing kidney stones (calcium oxalate) in adults referred to medical centers of Babol. Materials and Methods: This case-control study included 200 participants 18-65 years of ages (100 cases, 100 controls). An 18-items food insecurity questionnaire (USDA), a valid and reliable 147-item food frequency ques- tionnaire (FFQ) and demographic characteristics were obtained via interviewing. Results: Sixty eight percent of cases and 40% of controls were food insecure, respectively. Food insecurity was significantly associated with the risk of kidney stone (P < .05). Furthermore, body mass index (BMI) and family history of kidney stone were significantly associated with the risk of kidney stones (P < .05). Conclusion: Food insecurity and BMI were significantly associated with the kidney stone, which shows the impor- tance of availability of nutritionally adequate and safe foods in prevention of the kidney stone. Keywords: food insecurity; kidney stone; diet; case-control study INTRODUCTION Kidney stone is a painful condition(1), which is relat-ed to several comorbidities such as diabetes melli- tus, obesity, metabolic syndrome, hypertension, gastric bypass and chronic kidney disease in adults(2,3). The prevalence of kidney stones has been estimated between 8% to 19% and 3% to 5% among males and females, respectively in western countries(4,5). According to a recent study, which analyzed the 2007-2010 National Health and Nutrition Examination Survey (NHANES) sample, 8.8% (10.6% of men and 7.1% of women) of the American population suffered from kidney stones(6). The prevalence of this disease increased from 0.9% in individuals who were between 15-29 years of age to 8.2% in older ones who were between 60-69 years of age, in Iran(7). It has been previously shown that 80% of kidney stones are calcium oxalate (caox)(5), and the most accessible and requested interventions to reduce the risk of kidney stones is dietary modification(8). Fol- lowing healthy eating, for example, adoption Dietary Approaches to Stop Hypertension (DASH) diet is rec- ommended to reduce the risk of kidney stone. In addi- tion, it is suggested that obesity, higher BMI and weight gain are independently associated with higher risk of kidney stones formation (9,10). Another alarming condition in the world, is food inse- curity, which is defined as “limited or uncertain access to adequate food or limited ability to access healthy food through socially acceptable” (11). It has been pre- viously considered that 6.30% of the households in the Paris metropolitan area experienced food insecurity and about 2.50% of the households experienced severe food insecurity(12). In the United States, food insecurity existed in about 16% of population(13). Another study, which was performed in Ontario community in Canada has shown that 70% of households were food insecure of which 17% and 53% were categorized in severe and moderate food insecure groups, respectively(14). The prevalence of food insecurity has been estimated be- tween 30.5% to 50.2% in different parts of Iran(15-19). Although it has been previously shown that 16.3% he- 1 Associate Professor, Department of Urology, Babol University of Medical Sciences, Babol, Iran. 2Department of community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran. 3Student Research Committee, Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 4Metabolic Syndrome Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mash- had, Iran. *Correspondence: Student Research Committee, Department of Nutrition, Faculty of Medicine, Mashhad Uni- versity of Medical Sciences, Mashhad, Iran. ** Correspondence: Metabolic Syndrome Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Associate Professor in Clinical Nutrition Department of Nutrition Faculty of Medicine Mashhad University of Medical Sciences (MUMS), Paradise Daneshgah, Azadi Square, Mashad, Iran. Tel: +98 (513) 8002423 (secretary). Fax: +98 (513) 8828574 - 8002321. Mobile: +98 (0) 915 3151654 Received November 2016 & Accpted July 2017 ENDOUROLOGY AND STONE DISEASE Endourology and Stone Diseases 4094 modialysis patients were food insecure(20), to the au- thors’ knowledge there was no study about the associa- tion between prevalence of food insecurity and kidney stones. Thus, the aim of this study was to evaluate food insecurity in the patients who suffered from calcium ox- alate stones in Iranian adult population. MATERIALS AND METHODS Study design, Sample size and Participants This case control study was performed among adults who lived in Babol, the city located in north of Iran in 2014. Ethics committee of Mashhad University of Med- ical Sciences approved the study. The study was found- ed and supported by Mashhad University of Medical Sciences. To determine sample size in this study, we designed and implemented a pilot study conducted on 24 adults be- tween 18-65 years old, who were selected randomly(12 patients who suffered from calcium oxalate stones and 12 healthy individuals). According to the pilot study, 75% of patients with kidney stones and 50% of the con- trol group were food insecure. Therefore, based on the statistical formula and considering 80% power and an α level of 0.05, it was necessary to examine 100 cases (patients who suffered from calcium oxalate stones) and 100 controls (healthy individuals) to compare of food security between two groups. We used purposive sampling method to select partic- ipants. 100 cases (with calcium oxalate kidney stone) were assigned after diagnosis of calcium oxalate stone by a urologist using chemical analysis of stone in the laboratory. Inclusion criteria for the case group were adults who were between 18-65 years of ages and had kidney stones (only calcium oxalate) according to phy- sician diagnosis without any underlying diseases (such as diabetes, hypertension, hyperlipidemia and so on). After interviewing with cases, we had to find controls who are matched according to sex, age and place of res- idence. Thus, among 8 urban and rural health centers of Babol, we selected 5 centers randomly. Then, among people who referred to these centers, we chose healthy adult people, who were matched with the case partic- ipants. After that, we explained the study objectives completely to them and informed consents were ob- tained from participants. Finally, from a total of 100 adults participated in each group, 65 were men and 35 were women and they were between 18 to 65 years old. In each group 48 participants lived in urban and 52 of them lived in rural. Table 2. Presents basic data of the study samples. Participants in the two groups were matched according to age, sex and place of residence. Anthropometric measurement Participants' height was measured by the meter strip with a precision of 0.1 cm, while the person was at- tached to the wall without shoes and looking forward. Participants’ weight was measured by a beurer flat digi- tal scale with a precision of 0.1 kg, while the person was wearing minimal clothing without shoes. Body mass in- dex (BMI) was calculated as weight in kilograms divid- ed by the square of height in meter. Food security assessment Household food security status have evaluated by the USDA (US Department of Agriculture) questionnaire, which has been used annually in the U.S. Current Popu- lation Survey since 1995(21). The reliability and validity of the questionnaire has evaluated in a previous study in Iran(22). This 18 items questionnaire examines household food security status in the last 12 months. We completed the questionnaire by interviewing mothers of households. The studied participants were divided into two classifi- cations of participants based on the scores of the ques- tionnaire: food secure and food insecure groups. Food insecure participants were divided into three subgroups: food insecure without hunger, food insecure with mod- erate hunger and food insecure with severe hunger (Ta- ble 1). The last two groups (Food insecure with moder- ate hunger and food insecure with severe hunger) were combined in analysis owing to the low percentage of food insecurity with severe hunger, (27% and 6% in case subjects and control ones, respectively). Dietary intake To evaluate dietary intakes, a valid and reliable food frequency questionnaire (FFQ)(23,24), which contained 147 items of foods and beverage was used. The food consumption converted into food material and its value was calculated in grams. Total energy was reported as kilocalorie per day. Socio-economic and demographic status Demographic characteristics (including age, sex, place of residence, family size, number of children, having children under 18 years of age, and social and econom- ic characteristics) were collected by a general ques- tionnaire. These characteristics were as follows: edu- cation and occupational status of the mother and head of household, residential possession ownership status and living facilities. About living facilities, participants were asked that how many items of these 9 items they have (furniture, handcraft carpet, refrigerator, wash- ing machine, dishwasher, microwave, computer, car, and home). Having less than or equal to 3 items was considered as a low economic status, 4 to 6 items as moderate economic status and 7 to 9 items as good eco- nomic status. About landlord, participants were asked to select one of the options of the private house, rent or mortgage, and living with parents or relatives and others(17). All data were obtained by a well-trained nu- tritionist who became completely familiar with all ques- tionnaires. Food insecurity and calcium oxalate stone-Shafi et al. Food security status Number of positive responses Having child under 18 years old Having no child under 18 years old Food secure 0-2 0-2 Food insecure without hunger 3-7 3-6 Food insecure with moderate hunger 8-12 7-8 Food insecure with severe hunger 13-18 9-10 Table 1. Classification of the household food security status based on scores Vol 14 No 05 September-October 2017 4095 Statistical analysis The classes of food security were determined for cas- es and controls in separate according to the obtained scores. Descriptive variables were reported by mean, standard deviation (SD). To detect the relationship between variables and food security or calcium oxalate stone disease Chi- squared test, independent t-test, Pearson and Spearman correlation were used. The simple regression method was used to assess the relationship between food se- curity status and all variables. Finally, variables were entered into the model step by step forward to fine vari- ables which had a relationship with food insecurity. The multiple regression method was also used to determine the variables which had the most effect on the kidney stone incidence (family history of kidney stone, food insecurity, fat and protein intake). (To reach this goal all variables, which had a significant relation with kid- ney stone (included: socioeconomic situation, family history of kidney stone, food insecurity, BMI, weight, macronutrient intake (Calorie [kilo calories], carbohy- drate, fat, protein in grams) were entered into the logis- tic multiple regression). To analyze the data we used the Statistical Package for the Social Sciences (SPSS), Variables Case group N=100 Control group N=100 P-Value Age(year) Under 30 16 16 30-39 31 31 0.999 40-49 23 23 50 and more 30 30 Sex Men 65 65 0.999 Women 35 35 Place of residence Village 52 52 0.999 City 48 48 Family size Under 5 83 83 0.999 5 and more 17 17 Number of children Under 4 71 78 0.256 4 and more 29 22 Having child under 18 Yes 63 68 0.457 No 37 32 Occupation of the head Unemployed 1 2 Worker 14 14 Government employee 28 29 0.267 Self-employed 44 50 Retired 13 5 Education level of responders Pre-university 83 78 0.372 University 17 22 Education level of heads Pre-university 78 68 0.111 University 22 32 Marital status Married 90 89 Single 10 9 0.845 Widow 0 2 Economic situation Low 24 8 Middle 5 9 69 0.011 High 17 23 Home Ownership 91 95 0.268 Other 9 5 Family history of kidney stone Yes 60 19 < 0.001 No 40 81 Food insecurity Yes 68 40 < 0.001 No 32 60 BMI* (kg/m2) Under weight 3 0 Normal 23 39 0.003 Overweight 37 46 Obese 37 15 Dietary intake Median(IQR) Median(IQR) Calorie intake (Kilo-calorie) 3702.2(1362.6) 3179.7(1033.4) < 0.001 Protein intake (gram) 130.0 (42.2) 107.1(37.3) < 0.001 Carbohydrate intake (gram) 573.9(240.4) 493.1(165.6) < 0.001 Fat intake (gram) 119.1(46.7) 91.1(42.5) < 0.001 Height (cm) 168.0 (17.7) 168.0 (8.0) 0.823 Weight (kg) 78.0 (17.38) 74.4(13) 0.008 Table 2. Basic data of the study participants. Food insecurity and calcium oxalate stone-Shafi et al. Endourology and Stone Diseases 4096 version 11.5. RESULTS Sixty eight percent of cases and 40% of controls were food insecure, respectively. Forty one percent, 22% and 5% of case subjects were categorized in the food inse- curity without hunger, with moderate and severe hunger groups, respectively. In the control subjects, these val- ues were 33%, 7% and 0 %, respectively. No significant differences were found between case and healthy subjects in age, sex, place of residence, family size, number of children, having child under 18, occu- pation of head, education level of responders and head and marital status. However, there were significant dif- ferences in some variables including economic status, history of kidney stone and BMI between individuals within the case and control groups (P < .05). Moreover, the median intake of calories and macronutrients in- cluding carbohydrate, protein and fat as well as weight were significantly higher among kidney stone patinas in comparison with the health individuals (P < .05) (Table 2). The median of daily total calorie and carbohydrate, pro- tein and fat intake were 3702.2 ± 1362.6 kilo calories, 573.9 ± 240.4 grams, 130.0 ± 42.2 grams, 119.1 ± 46.7 grams, respectively in the case subjects. These val- ues were 3179.7 ± 1033.4 kilo calories, 493.1 ± 165.6 grams, 107.1 ± 37.3 grams and 91.1 ± 42.5 grams, re- spectively in the control group (Table 2). Among the examined variables, 6 variables including economic status, family history of kidney stone, BMI average, obesity status, food insecurity and dietary intake were significantly associated with the kidney stone (P < .05). According to the multiple regression test, family his- tory of kidney stone and food insecurity were found to be significant predictors for the kidney stone (P < .05) (Table 3). Furthermore, regression step by step forward model shows that economic status, family size, edu- cation level, place of residence and occupation of the household head were significantly related to the food insecurity (P < .05) (Table 4). DISCUSSION The main finding of the current study is that household food insecurity has a strong correlation with the kidney stone. According to our knowledge, there are a very few studies about the associations between food insecu- rity and kidney diseases. A previous study, which was conducted among hemodialysis patients, has shown that 16.3% of patients were food insecure(20). In anoth- er study, which was conducted by Crews et al., food insecurity was related to chronic kidney disease(25). However, it has been shown that food insecurity had a correlation with the chronic diseases(26,27). In their study, Fitzgerald et al. showed that food insecurity is associat- ed with increasing type 2 diabetes(28). Likewise, a signif- icant association was reported between food insecurity and the risk of type 2 diabetes and between food inse- curity and bone density osteoporosis in postmenopausal women in Iran(29,30). The results of the current study showed a significant re- lationship between BMI and the kidney stone. It is earli- er suggested that a low calorie DASH diet and decrease in fat and protein intake to prevent against kidney stone. In addition, carbohydrate rich in fructose (especially high fructose corn syrup) and sucrose were consid- ered as a risk factor to increase the incidence of kidney stone(31). Similarly, in their article, Turney et al. have shown that total energy intake was associated with a significant increase risk of developing kidney stones (32). It has been previously shown that food insecure house- holds had low quality diet. Indeed, following diet with low vegetables and fruit, grains, and dairy products, and intake of a greater percent of energy from high-sugar foods were more common among food insecure indi- viduals than the food secure ones(33). Furthermore, be- cause of financial problems, food insecure households decrease consumption of expensive foods such as fruits, vegetables and dairy and they have low food variety(34), and thus they receive low amount of calcium, citrate and phytate, which are all related to the reduction of the risk of kidney stones(31,35,36). In addition, to meet calorie requirements, consumption of oils and sweets, bread, pasta, and rice are considered as the most cost-effi- cient way among food insecure households(34), which all could lead to overweight and obesity. As previously have been shown frequently, overweight and obesity were significantly associated with the risk of kidney stones(6,9,10,37). Thus, it is not surprising, if considering that food insecurity may lead to the kidney stones. The results of the present study showed that 68% and 40% of participant's household in case and control groups had mild to severe food insecurity, respective- ly. Previous studies, which all were conducted in Iran Table 3. Correlation between kidney stone and effective variables (Multiple regression method). Independent variable Wald Odd Ratios 95% CI of OR P-value Food insecurity 5.27 2.44 1.14 - 5.24 0.022 Family history 23.26 5.76 2.83 - 11.75 <0.001 Economic situation Low 1.75 2.58 0.63 - 10.56 0.185 Middle 3.34 0.96 0.38 - 2.45 0.955 High* Education level of heads Pre-university 0.21 0.81 0.34-1.94 0.647 University* *reference category Variable β± SE P-value Economic situation -1.6 ± 0.5 0.001 Family size 1.08 ± 0.3 < 0.001 Education level -3.4 ± 0.8 0.001 Place of residence 1.9 ± 0.5 0.001 Occupation of the head -1.5 ± 0.5 0.005 Table 4. Correlation between food insecurity and effective varia- bles (regression step by step forward model) Food insecurity and calcium oxalate stone-Shafi et al. Vol 14 No 05 September-October 2017 4097 showed that the prevalence of food insecurity was var- ied between 50.2% in Rey, 30.5% in Yazd and 36.6% in Isfahan (center part of Iran) and 37.6% in Dezful placed in south area of the country, which were in line with the results of this study(16-19). The United States Depart- ment of Agriculture (USDA) has reported that, 15.8% of the population (49 million adults and children) were food insecure in 2013, concentrated among low income households(38). In India, the prevalence of food inse- curity was 77.2% among households(39). Possible rea- sons for the difference between food insecurity among countries might be due to cultural difference, different evaluation instrument, different income and economic factors. Another reason could be economic crisis and increased cost of foods. On the other hand, in spite of other countries, industrial countries perform a nutrition program such as food Stamp program to help household with low income(40,41). In line with the results of previous studies(15,17,19), in the current study, the prevalence of food insecurity in the households of the first category (low socioeconomic status) was higher than two others category. Household food insecurity associated with low household income in Seligman et al.(27) and Martin-Fernandez et al.(12) stud- ies. It seems that, households with higher incomes and better economic conditions can choose various foods and can spend much more part of their income for food supply(17). We found a significant relationship between food inse- curity and the place of residence. Population who lives in rural areas were more food insecure in comparison with city dwellers, which might be due to inaccessibil- ity to the shopping centers in rural area. However, al- though the positive association between food insecurity and place of residence was observed in Sharafkhani et al. study(42), FallahMadvari et al., found no significant correlation between these factors(40). As previously have been shown frequently(15,19,43-47), in the current study, food insecurity has a significant re- lationship with family size and number of children. It should be noted that by increasing family size, the need for food will be increased. So, the size and number of meals can also be reduced and food insecurity will ap- pear(17). In this study, there was a significant relationship be- tween food insecurity and job status of the head of household. The findings showed that food security was higher in households whose head were clerks, which is in line with the results of the studies by Payab et al.(17) and FallahMadvari et al.(40). Moreover, a significant re- lationship between food insecurity and job status has observed in studies on Canadian households and rural households in Malaysia(48,49). To interpretation, it should be considered that higher job status often is accompa- nied by higher income and better socioeconomic situa- tion, which may result in an increment of accessibility to various and nutritious foods. This study showed a significant inverse relationship be- tween food insecurity and education level of the mother and head of household. Consistent with this result, pre- vious studies showed a significant relationship between food insecurity and education level of mother and head of household(15,17,19,44,49). Absence of adequate education limits job opportunity and reduces the ability to earn money. Following the reduction of income, food expenses can be challenging. Low education level also reduces people's nutritional knowledge level and affect all stages of the basket to the table (shopping, preparation, cooking and consump- tion), which can result in the household food insecurity (17). To our knowledge this study was the first that focused on kidney stone patients. In interpreting the existing results, some limitations should be noted. Household food insecurity was evaluated in cross-sectional meth- od. Therefore, we cannot conclude if food insecurity in the household was continued or temporary. CONCLUSIONS Food insecurity and BMI were significantly associated with the kidney stone, which all show the importance of availability of nutritionally adequate and safe foods in prevention of the kidney stone. Since kidney stone disease is related to painfulness and several medical comorbidities, decreasing in the rate of food insecurity across the population might lead to reduction of nega- tive consequences of the kidney stone in the commu- nity. ACKNOWLEDGMENTS The authors wish to thank all participants of this study for their cooperation. This study was financially sup- ported by Mashhad University of Medical Sciences (MUMS). REFERENCES 1. Weinberg AE, Patel CJ, Chertow GM, Leppert JT. Diabetic severity and risk of kidney stone disease. Eur Urol. 2014;65:242-7. 2. Schaeffer AJ, Feng Z, Trock BJ, et al. Medical comorbidities associated with pediatric kidney stone disease. Urology. 2011;77:195-9. 3. Lorenz EC, Lieske JC, Vrtiska TJ, et al. Clinical characteristics of potential kidney donors with asymptomatic kidney stones. Nephrol. Dial. Transplant. 2011;26:2695-700. 4. Trinchieri A. Epidemiology of urolithiasis: an update. Clin Cases Miner Bone Metab. 2008;5:101. 5. Sakhaee K, Capolongo G, Maalouf NM, et al. Metabolic syndrome and the risk of calcium stones. Nephrol. Dial. Transplant. 2012;27:3201-9. 6. Scales CD, Smith AC, Hanley JM, Saigal CS, Project UDiA. Prevalence of kidney stones in the United States. Eur Urol. 2012;62:160-5. 7. Safarinejad MR. Adult urolithiasis in a population-based study in Iran: prevalence, incidence, and associated risk factors. Urol Res. 2007;35:73-82. 8. Sorensen MD, Kahn AJ, Reiner AP, et al. Impact of nutritional factors on incident kidney stone formation: a report from the WHI OS. J Urol. 2012;187:1645-50. 9. Semins MJ, Shore AD, Makary MA, Magnuson T, Johns R, Matlaga BR. The association of increasing body mass index and kidney stone disease. J Urol. 2010;183:571-5. Food insecurity and calcium oxalate stone-Shafi et al. Endourology and Stone Diseases 4098 Food insecurity and calcium oxalate stone-Shafi et al. 10. Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, and the risk of kidney stones. Jama. 2005;293:455-62. 11. Markwick A, Ansari Z, Sullivan M, McNeil J. Social determinants and lifestyle risk factors only partially explain the higher prevalence of food insecurity among Aboriginal and Torres Strait Islanders in the Australian state of Victoria: a cross-sectional study. BMC public health. 2014;14:598. 12. Martin-Fernandez J, Grillo F, Parizot I, Caillavet F, Chauvin P. Prevalence and socioeconomic and geographical inequalities of household food insecurity in the Paris region, France, 2010. BMC Public Health. 2013;13:486. 13. Nord M. Food Insecurity in Households with Children: Prevalence, Severity, and Household Characteristics. Economic Information Bulletin Number 56. US Department of Agriculture. 2009. 14. Skinner K, Hanning RM, Tsuji LJ. Prevalence and severity of household food insecurity of First Nations people living in an on- reserve, sub-arctic community within the Mushkegowuk Territory. Public Health Nutr. 2014;17:31-9. 15. Ramesh T, Dorosty Motlagh A, Abdollahi M. Prevalence of household food insecurity in the City of Shiraz and its association with socio- economic and demographic factors, 2008. nsftjournal. 2010;4(4):53-64. 16. Karam soltani Z, Dorosty motlagh, A,Eshraghian, M.R, Siassi, F, Djazayeri, A. Obesity prevalence and foodinsecurity in Yazd primary school pupils. Tehran Uni Med J. 2007;7:68-76 17. Payab M, Dorosty Motlagh A, Eshraghian M, Siassi F. The association between food insecurity, socio-economic factors and dietary intake in mothers having primary school children living in Ray 2010. nsftjournal. 2012;7:0-0. 18. Hakim S, Dorosty AR, Eshraghian M. Association of food insecurity and household socio-economic status with the body mass index among urban women in Dezful.Sjsph. 2010;8:55-66. 19. Mohammadzadeh A, Dorosty A, Eshraghian M. Household food security status and associated factors among high-school students in Esfahan, Iran. Public Health Nutr. 2010;13:1609-13. 20. Wilson G, Molaison EF, Pope J, Hunt AE, Connell CL. Nutritional status and food insecurity in hemodialysis patients. J Ren Nutr.2006;16:54-8. 21. Bickel G, Nord M, Price C, Hamilton W, Cook J. Guide to measuring household food security. Alexandria. Department of Agriculture Food and Nutrition Service. 2000. 22. Rafiei M, Nord M, Sadeghizadeh A, Entezari MH. Assessing the internal validity of a household survey-based food security measure adapted for use in Iran. Nutr J. 2009;8:1186- 97. 23. Esfahani FH, Asghari G, Mirmiran P, Azizi F. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J Epidemiol. 2010;20:150-8. 24. Mirmiran P, Esfahani FH, Mehrabi Y, Hedayati M, Azizi F. Reliability and relative validity of an FFQ for nutrients in the Tehran lipid and glucose study. Public Health Nutr. May 2010;13:654-62. 25. Crews DC, Kuczmarski MF, Grubbs V, et al. Effect of food insecurity on chronic kidney disease in lower-income Americans. Am J Nephrol. 2014;39:27-35. 26. Terrell A. Is food insecurity associated with chronic disease and chronic disease control? Ethn Dis. 2009;19(2 suppl. 3). 27. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr.2010;140:304-10. 28. Fitzgerald N, Hromi-Fiedler A, Segura- Pérez S, Pérez-Escamilla R. Food insecurity is related to increased risk of type 2 diabetes among Latinas. Ethn Dis. 2011;21:328. 29. Karimi S DMA, Sadrzadeh-Yeganeh H, Hosseini M, Ayatollahi SB, Salamat MR. Relation of Food Insecurity, Physical Activity and Socio-economic Factors with Osteoporosis in Postmenopausal Women of50-60 Year-old in Isfahan, Iran. JIMS . 2012;30:1696-1705. 30. Sadrzadeh Yeganeh H, Eshraghian M, Daneshi M, Azizi S. Food insecurity status and some associated socioeconomic factors among newly diagnosed patients with type 2 diabetes in Shiraz, 2012. AMUJ. 2013;16:98- 106. 31. Heilberg IP, Goldfarb DS. Optimum nutrition for kidney stone disease. Adv Chronic Kidney Dis.2013;20:165-74. 32. Turney BW, Appleby PN, Reynard JM, Noble JG, Key TJ, Allen NE. Diet and risk of kidney stones in the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC). Eur J Epidemiol. 2014;29:363-9. 33. Huet C, Rosol R, Egeland GM. The prevalence of food insecurity is high and the diet quality poor in Inuit communities. J Nutr. 2012;142:541-7. 34. Seligman HK, Jacobs EA, López A, Tschann J, Fernandez A. Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care. 2012;35:233-8. 35. Curhan GC, Willett WC, Knight EL, Stampfer MJ. Dietary factors and the risk of incident kidney stones in younger women: Vol 14 No 05 September-October 2017 4099 Nurses' Health Study II. Arch Intern Med. 2004;164:885-91. 36. Taylor EN, Fung TT, Curhan GC. DASH-style diet associates with reduced risk for kidney stones. J Am Soc Nephrol. 2009;20:2253-9. 37. Wang Y, Chen X, Song Y, Caballero B, Cheskin L. Association between obesity and kidney disease: a systematic review and meta- analysis. Kidney Int. 2008;73:19-33. 38. Whittle HJ, Palar K, Hufstedler LL, Seligman HK, Frongillo EA, Weiser SD. Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy. Soc Sci Med. 2015;143:154-61. 39. Chinnakali P, Upadhyay RP, Shokeen D, et al. Prevalence of household-level food insecurity and its determinants in an urban resettlement colony in north India. J Health Popul Nutr. 2014; 32 : 227. 40. Fallah Madvari F, Sadrzadeh yeganeh H, Siasi F, Sotoudeh G, Hosseini SM, Mahdavi rad SV. Food security and factors related to it in households under coverage of urban health centers and health houses in Mehriz, Iran. Sjsph. 2015;12:79-93. 41. Dinour LM, Bergen D, Yeh M-C. The food insecurity–obesity paradox: a review of the literature and the role food stamps may play. J Am Diet Assoc. 2007;107:1952-61. 42. Sharafkhani R, Dastgiri S, Gharaaghaji Asl R, Ghavamzadeh S. Factors influencing household food security status. Food Nutr Sci. 2011;2011. 43. Dastgiri S, Mahboob S, Tutunchi H, Ostadrahimi A. Determinants of food insecurity: a cross–sectional study in Tabriz. jarums. 2006;6:233-9. 44. Chaput J-P, Gilbert J-a, Tremblay A. Relationship between food insecurity and body composition in Ugandans living in urban Kampala. J Am Diet Assoc. 2007;107:1978- 82. 45. Che J CJ. Food insecurity in Canadian households. Health Rep 2001;12:11-22. 46. Willows ND, Veugelers P, Raine K, Kuhle S. Prevalence and sociodemographic risk factors related to household food security in Aboriginal peoples in Canada. Public Health Nutr.2009; 12:1150-6. 47. Foley W, Ward P, Carter P, Coveney J, Tsourtos G, Taylor A. An ecological analysis of factors associated with food insecurity in South Australia, 2002–7. Public Health Nutr. 2010;13:215-21. 48. Loopstra R, Tarasuk V. Severity of household food insecurity is sensitive to change in household income and employment status among low-income families. J Nutr. 2013;143:1316-23. 49. Shariff ZM, Khor G. Obesity and household food insecurity: evidence from a sample of rural households in Malaysia. Eur J Clin Nutr. 2005;59:1049-58. Food insecurity and calcium oxalate stone-Shafi et al. Endourology and Stone Diseases 5000