A Scoping Review of Household Factors Contributing to Dietary Quality and Food Security in Low-Income Households with School-Age Children in the United States

Low-income and food-insecure households are at risk of poor dietary quality and even more severe food insecurity. Especially in childhood, consuming a nutritionally adequate diet is an essential driver of health, growth, and development. Household-level factors can present challenges to support the nutritional needs of low-income and food-insecure household members. The aim of this scoping review is to identify the contributing household factors to dietary quality and food security in US households of school-aged children 5 to 19 years and synthesize the evidence around emergent themes for application to future interventions. The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols Extension for Scoping Reviews using search terms addressing food insecurity, low income, and dietary behaviors in the database PubMed. Screening by 3 independent reviewers of the title, abstract, and full study phases identified 44 studies. The 5 themes around which the studies grouped were: parental behaviors, child/adolescent behaviors, food procurement behaviors, food preparation behaviors, and household environment factors. Most studies were cross-sectional (n = 41, 93%) and focused on parental behaviors (n = 31, 70%), followed by food preparation and procurement behaviors. The themes identified were interrelated and suggest that incorporating education on parent and child behaviors that influence food procurement and preparation, along with strengthening organization and planning in the household environment, may hold promise to improve dietary quality and food security among food-insecure and low-income households. The findings can be used to inform future nutrition education interventions aimed at improving dietary quality and food security in households with school-aged children.


Introduction
About 10.2% of households, or 13.5 million households, within the United States experienced food insecurity at some time throughout 2021 [1]. Food insecurity refers to a situation where households experience uncertainty regarding having sufficient food or the inability to obtain enough food to meet the needs of all family members due to limited money or resources [1]. Food-insecure households are at risk of reduced dietary quality when compared with households with food security [2,3]. Dietary quality as defined by the Dietary Guidelines for Americans (DGA) [4,5] may be lower in food-insecure compared with food-secure households due to irregular dietary patterns, such as skipping meals and eating less or more of certain components than are intended or required for health [6][7][8]. Low dietary quality may be a contributor to the link of food insecurity with increased prevalence of chronic disease in adults [9][10][11].
Specifically for children, consuming a nutritionally adequate diet is an important driver in physical and mental health, growth, development, and wellbeing [5]. Childhood is a life stage when specific amounts and types of nutrients are necessary at critical times to achieve full genetic potential [5] and where decreased macronutrients important to emotional regulation and anxiety of food insecurity may link to mental health outcomes [12]. School-aged children 5 to 19 years interface with the National School Lunch and School Breakfast Programs and begin to practice autonomy in their dietary behaviors. Once established, these behaviors may continue into adulthood [5,13,14]. Food insecurity during childhood may be associated with the consumption of a nutritionally inadequate diet, low dietary quality, and poor health outcomes compared with food security [3,[15][16][17][18]. For example, school-aged children who are food insecure are more likely to have asthma, poor health, and are nearly 3 times more likely to have iron deficiency anemia than food-secure children [16,19,20].
Insufficient money to purchase adequate food is a significant risk factor for food insecurity [1,21] and poor dietary quality [22,23]. Regardless of individuals having the necessary knowledge and skills, a limited budget may result in opting for food of more economical value instead of food with the most nutritional value. Households with lower incomes purchase foods of lower nutritional quality when compared to households with higher incomes [24,25]. Along with financial restraints, dietary choices can be influenced by additional household factors, such as food accessibility and preferences, eating behaviors, parental and child nutrition knowledge, parental modeling, and psychosocial factors [26,27]. A comprehensive look at the body of evidence of household factors contributing to food security and dietary quality in low-income households with school-aged children 5 to 19 years in the United States and their synthesis or organization around themes has not been previously completed [28]. A scoping review integrating this research evidence may inform future nutrition education programming and interventions to adults or households of school-aged children by identifying, organizing, and showing relationships among recognized family priorities and challenges in obtaining high dietary quality and food security within the limited resource context, as well as identifying any existing gaps in knowledge. The social ecological model serves as a framework for this study and an application for the results. Using the social ecological model, individuals are influenced by interpersonal relationships and their household settings, then the organizations they interact with, and the communities they are situated in and further, the policy levels. The model is also used as the framework for the DGA, showing how these layers of influence can intersect to shape dietary quality. Knowledge of the influence exerted by individuals, interpersonal relationships, and household settings in dietary quality and food security is critical to inform successful interventions directed through the outer levels of the social ecological model, ie, organizational, community, and policy levels. These levels are where federal food assistance and nutrition education programming intervene. Therefore, the purpose of this scoping review was to map current evidence of household factors influencing dietary quality and food security within low-income US households with school-aged children around major themes and to consider relationships of the themes and their factors. The results can be applied to inform future nutrition education interventions and programming.

Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols Extension for Scoping Reviews was utilized to conduct this scoping review [29]. Search strategies were developed collectively through discussion among the researchers involved in the project. The following search terms were used: (food insecurity OR food security OR low-income OR poverty) AND United States AND (dietary quality OR dietary behavior OR dietary selection OR dietary attitudes OR family meal planning OR food purchasing). The online database, PubMed, was identified to have a scope fitting of the aspects of focus in the study (food insecurity, dietary quality, household factors) and was used to search for studies written in English and published within the last 10 years between 2012 and 2022, and the search was completed from February 2022 to March 2022 and updated in January 2023 to include all studies published in 2022.
Studies were included in this review if they focused on food security and/or dietary quality of low-income households in the United States and identified factors/behaviors/attitudes/barriers affecting food security and/or dietary quality in these households. Dietary quality for the purposes of the review was inclusive of aspects of dietary behaviors, variety, food components, food group, or nutrient intakes. Studies were excluded if they focused on households that did not include children or did not include school-aged children aged 5 to 19 years, low-income, or food-insecure households.
The PubMed (NCBI) search identified 2324 studies. The search results were exported to EndNote and Rayyan software, which was used to remove duplicates (n ¼ 3). Studies were reviewed at 3 stages: title, abstract, and full text. Each stage entailed evaluation by 2 independent reviewers, and a third independent reviewer served as a tie-breaker when there was a discrepancy in the decisions. First, titles and abstracts were screened based on eligibility criteria. Studies were either marked as "included," "excluded," or "maybe" by the reviewers. Any studies that were marked as "maybe" were treated as "included." Next, the remaining chosen studies were screened by reading the full text using the same process as the screening for previous stages. One hundred and eight studies were selected for full-text evaluation. Forty-four studies were included in the scoping review ( Figure 1).
The study year, title, author(s), aims, study design, studied population, and main findings were extracted and presented in Table 1 and were used to identify household factors that each study addressed and then to organize the studies to themes. Contributing factors to dietary quality and food insecurity in low-income households were organized into the following 5 themes that emerged from the studies represented in Table 2: 1) parental behaviors, 2) adolescent/child behaviors, 3) food procurement behaviors, 4) food preparation behaviors, and 5) household environment. After reading the studies and synthesizing the evidence, the factors organized to themes were mapped to show relationships in Figure 2, which were conceptualized within the framework of the social ecological model, placing the individual and their dietary quality and food security at the center, with interpersonal and household levels of influence shaping the behavior of individuals and encompassing the household factors addressed in this review. Beyond these levels, organizational, community, and policy levels extend with further relevance on the individual, interpersonal, and household levels. The organizational, community, and policy levels are                      outside of the scope of this review as they provide levels where the findings may be applied.
Evidence of the theme, parental behaviors, related to dietary quality and food insecurity in low-income US households with children included behaviors of parental modeling, feeding practices, attitudes and support, parental self-efficacy, knowledge, and parenting styles. Each of these behaviors and the evidence of their relationship to dietary quality and food security are described below. Parental modeling, or a parent's effort to demonstrate healthy food choices and healthy eating behaviors  with the objective that the child will exhibit similar behaviors, was included in 11 of the studies [30][31][32][33][34][35][36][37][38][39][40]. Five studies showed parental modeling was a support to encourage overall healthy eating behaviors among children [36][37][38][39][40], whereas 5 studies showed a more specific association to increased fruit and vegetable intake [30][31][32][33][34], and one showed healthy eating modeling was associated with reduced child consumption of high-sugar/high-fat snacks [34]. Alternatively, modeling intake of energy-dense food was associated with increased sugar-sweetened beverage intake among children in 4 studies [31,[33][34][35]. Parental feeding practices such as encouragement, pressure to eat, food restriction, and controlling food intake, based on child characteristics like weight, age, and developmental stage, were other parental behaviors contributing to dietary quality and food security in the household [38][39][40][41][42][43][44][45][46]. Food restriction was a reported practice when the child was overweight, and pressure to eat was reported when the child was at a healthy weight [38,39,41]. Low-income households and those with low or very low food security were more likely to engage in food restriction and pressure-to-eat practices compared with higher-income and food-secure households [42,43]. Parental eating attitudes, teaching, and support toward healthful diets also played a role in eating habits among children [39,40,44,45]. Practices related to attitudes, teaching, and support included limiting the availability of sugar-sweetened foods in the home, establishing healthy parental relationships with food, encouraging children to make healthy choices, and family eating practices like eating meals together [39,40,[44][45][46][47][48]. Parents from low-income households expressed goals to restrict junk food and encourage a nutritious diet including fruit and vegetable intake [45,49] but also reported that not all parental feeding goals turned into practices [49]. For example, parents reported buying foods that they knew children would eat to avoid wasting food, which could contribute to purchasing foods with lower dietary quality [44]. When food resources were low, parents sometimes adapted the types of food served at meals and the amount [50,51]. In food-insecure situations, parents reported reducing their own portion sizes and skipping meals to ensure food was available for children [45,[50][51][52][53]. Several studies discussed the influence of parent or caregiver self-efficacy for healthful diets and nutritional and health knowledge of dietary quality and/or food security [51,[54][55][56][57]. Self-efficacy, which refers to a person's belief in their ability to engage in healthy eating behaviors, was associated with increased dietary quality and healthy eating behaviors in low-income families and adolescents [51,55). Nutritional knowledge [36,54,56] was also identified as a factor in dietary quality. For example, caregivers had a basic understanding of sodium sources but had difficulty identifying sodium in sources, such as cheese and prepared soups, and little knowledge of the effects of increased salt consumption on childhood health [56]. The relationship of food insecurity to self-efficacy for healthy eating was less clear as 2 studies showed conflicting results [54,58], and food insecurity did not differentiate food knowledge or intentions [58]. Parenting style was the last area of parental behavior showing links to dietary quality in children in 2 studies [59,60]. One showed that authoritarian parenting attitudes and behaviors including high demands, low responsiveness, low emotional warmth, and unwillingness to negotiate were positively associated with the dietary quality of the child [59]. The same study also showed permissive parenting styles with few rules and freedom of child dietary choice were negatively associated with child dietary quality [59]. However, the second study showed conflicting results with an association between authoritative parenting style and reduced fruit and vegetable consumption among adolescents [60]. Yet, both studies showed parenting style as a potential determinant associated with nutritional quality. Therefore, parenting style along with all other parental behaviors reviewed have links to dietary quality and food security that also linked them to the other themes identified in the review and are likely influential in food procurement and preparation (Figure 2). Adolescent/child behaviors in 10 studies [30,33,35,36,41,[46][47][48]61,62] included investigations of personal food preferences; healthy eating knowledge, attitudes and self-efficacy; picky eating behaviors; and involvement in food preparation. Adolescents reported choosing food based on preference, convenience, and/or the foods available in the home or elsewhere [30,46,48]. Health was considered the least common reason for food choice [46]. Adolescents were able to demonstrate basic nutrition knowledge and recognized healthy and unhealthy foods but still held some misconceptions around healthy foods [36]. Healthy eating intentions, self-efficacy, and purchasing food at supermarkets were linked to adolescent fruit, vegetable, and fiber intake [61] whereas poor eating behaviors like high intake of fast food and low breakfast intake were linked with other poor dietary practices like high sugar-sweetened beverage intake [35]. The dietary quality of adolescents was linked to their perceptions of adult nutrition beliefs and peer dietary choices [33], which were a negative influence on eating habits [36]. Adolescents motivated to adopt healthy dietary practices reported that it was difficult to sustain healthy eating changes [36]. Picky eating behaviors among children were also included in the studies and found to be disruptive on family mealtime and the home environment, causing meal-related stress and increased time parents spend in meal preparation to adjust or make additional meals [41,63]. However, adolescent involvement in the preparation of breakfast and positive attitudes about mealtime were linked to family breakfast frequency [47]. Similar to the parent behaviors identified in the review, child behaviors overall had relationships with the other themes and are likely influential in food procurement and preparation.
Food procurement behaviors in 10 studies [44,[50][51][52]54,55,63,[64][65][66] comprised topics of purchasing behaviors and strategies and barriers to purchasing foods. Priorities that individuals considered when purchasing foods included cost, family preferences, food preparation time, family needs, and shelf-life. Price was a major determinant in purchasing behaviors [52] and more often reported in food-insecure compared with food-secure households [65]. Strategies to help save money included making lists, buying sale items, buying in bulk, comparing prices, shopping in discount stores, limiting trips, using certain foods to "bulk out" meals, and using coupons [44,[50][51][52]54,63,64]. Food-insecure compared with food-secure households were significantly more likely to use cost saving practices, such as price comparisons [54]. However, there was no difference between the groups in the use of anticipatory behaviors, including meal planning and making a shopping list [54]. The high cost of fruit and vegetables was reported as a main barrier to their procurement [63,65], but another study found no relationship between purchasing barriers and the presence of fruit and vegetables at dinner meals [66]. Acquisition of healthy foods was linked to higher caregiver food-related behavioral intentions and self-efficacy and lower frequency of purchasing at prepared food sources, which was also linked with higher caregiver nutrition knowledge [55], exemplifying how parental/caregiver behaviors are related to food procurement. Food procurement is also likely to influence food preparation as individuals purchase foods that they plan to prepare, but food preparation factors may also change and influence food procurement. Food preparation factors and behaviors like meal planning, having kitchen/cooking supplies and time to perform these behaviors, cooking skills to carry out food preparation, and food availability were addressed in 17 studies [34,47,48,50,51,54,55,58,[65][66][67][68][69][70][71][72][73]. Several studies investigated meal preparation and planning behaviors [47,51,54,55,58,65,66,68,69,72,73]. Adult/caregiver food-related self-efficacy was linked with healthy food preparation methods [55]. Food-insecure households were more likely to report barriers to cooking and preparing vegetables or healthy food [58,65] and less likely to plan [73] and prepare a home-cooked meal compared to food-secure households [54]. Furthermore, low-income households, regardless of food-security status, had a low prevalence of planning behaviors related to buying and preparing food [54]. Lack of sufficient time was identified as a barrier to making home-cooked meals [51]. The accessibility of food preparation supplies [67,70] was associated with the frequency of family meals, and more frequent family meals were linked with more healthful dietary intake, such as greater fruit and vegetable intake and less sugar-sweetened beverage intake [48,67]. Contradictorily, a longitudinal observational study's results suggested that kitchen adequacy was not a barrier to healthy eating [70]. Youth also prepared food at home [48] using basic skills, a few pieces of cooking equipment, and easily accessible ingredients [68], and their involvement was linked to family breakfast frequency [47].The availability of healthy foods was associated with dietary quality and food security in 6 studies [34,48,65,66,70,71] and specifically increased fruit and vegetable intake [34,48,66,71,72]. Food-security status had additional links with the availability of vegetables in the home [65], barriers of knowledge of how to prepare and cook vegetables [65], and using strategies to manage the household food supply like using leftovers and freezing meals [50] and planning meals to allocate scarce food [69]. Such tactics suggest a bidirectional link from food preparation to food procurement and links to the themes of adult/parent and child behaviors.
Finally, the household environment and specifically family chaos was identified as an influencing factor on dietary quality and food security, owing to its negative impact on family relationships and mealtime-related stress in 6 studies [45,47,60,67,69,73]. Household chaos included work and schedule conflicts, food shortages, coping with poverty, and children visiting multiple homes, which reportedly influenced the frequency and locations of meals [67,69]. Family dinner frequency was directly linked with family breakfast frequency, which was linked with positive attitudes about mealtimes [47]. A qualitative study found that aiming to have family meals to enhance family relationships and helping children feel secure in the home may assist in overcoming mealtime chaos [45]. However, sometimes prioritizing making children feel secure was in conflict with nutrition-oriented goals like acquiescing to child food preferences to maintain harmony or promote self-esteem [60]. Yet, family support was associated with increased youth fruit and vegetable intake, and household food security had an indirect link to higher fruit and vegetable intake through family closeness and support [60]. The household environment, then, and specifically the family chaos of coping with poverty, is likely to influence both parent and child behaviors along with the food procurement and food preparation in the household.
None of the studies explored all 5 of the themes of household factors linked to dietary quality and food security nor their various relationships, yet the connections between these 5 themes are conceptualized by the authors to be numerous and complex. Figure 2 summarizes the potential relationships or directionality of influence of the themes based on the findings within the studies. In some cases, the relationships are likely bidirectional; for example, the household environment may be both influential on behaviors of household members and influenced by those behaviors. In other cases, only one-directional relationships may be present, as in how parental behaviors likely drive food procurement with influence from children and how parental behaviors may drive food preparation similarly with influence from children.

Discussion
This scoping review identified 5 themes of household factors covered in the existing literature that are linked to dietary quality and food security among low-income households with school-aged children and explored how various relationships exist among these themes. Mapping the relationships of the themes reveals new insights to apply to interventions and programs aimed at improving food security and dietary quality within the outer levels of the social ecological model. The themes identified in this review may be conceptualized within the inner levels of the social ecological model. For example, dietary quality and food security are experienced by the individual. Next, the parent and child behaviors exert direct influence on individuals within the interpersonal relationships level, which includes the family members in a person's closest circle contributing to their experiences. Food procurement and preparation are specific food-related behaviors by household members that influence those within the household, and the household environment encompasses the family dynamics, chaos or order, habits, and schedules that also exert influence on individual diet quality and food security. Evidence of themes in this review and their potential application to improve diet quality and food security is discussed below.
Parental behaviors, included in the majority of studies, such as parental modeling, support and encouragement, feeding practices, and parenting styles, highlight the significant influence parents have on the food their child is consuming, including the amount and types of foods . Parental modeling of healthy eating appears an important contributor to dietary quality and food insecurity because of the consistency among studies showing a positive impact on their child's eating behaviors [30][31][32][33][34][36][37][38][39][40]. Additionally, parental support and encouragement for healthy eating can improve children's attitudes toward healthy eating whereas food restriction and pressure to eat can result in a child's negative attitude toward food and meals [38][39][40][41][42][43][44][45][46]. Children's behaviors had less coverage in studies compared with parental behaviors, and therefore there less evidence; however, children were shown as having an influential role in their dietary quality and household food security [30,33,35,36,41,[46][47][48]61,62]. Their behaviors, preferences, self-efficacy, and nutrition knowledge were linked to parental behaviors, food purchasing, and preparation in the household. Self-efficacy for healthy eating behaviors among both parents [51,55] and children [61] was linked with healthful dietary intake. Considering the role parents play in managing food resources, influencing children, and the household environment, and the role that children also play in parental behaviors and decisions on food purchasing and preparation, future interventions to food insecurity and dietary quality of household members should address parent and child behaviors, attitudes, and preferences. Food procurement [44,[50][51][52]54,55,63,[64][65][66] and preparation factors [34,47,48,50,51,54,55,58,[65][66][67][68][69][70][71][72][73] were also themes linked to dietary quality and food security in this review. Findings suggest that low-income and food-insecure households experience more barriers to purchasing and preparing foods, including lack of access to foods and challenges with the price of food, when compared with households of higher-income and food-secure households [52,54,58,65,73]. Overcoming barriers to purchasing and preparing foods may assist in improving the availability of food within the household. Several studies documented the use of strategies in purchasing foods, for example comparing prices, buying sale items, and shopping in budget stores, to assist parents in managing their budgets [44,[50][51][52]54,63,64]. Similarly, many studies [34,48,65,66,71,72] also associated availability of healthy foods in the home with increased dietary quality and increased consumption of fruit and vegetables, which is consistent with previous studies and reviews [74,75], whereas the availability of less healthy foods in the home was linked with increased child intake of high-sugar/high-fat snacks [76]. Therefore, applications to improve the availability of healthful foods and decrease access to less healthful foods in the household may enhance the dietary quality of children and food security.
The household environment may also play a role in food security and dietary quality of household members as the chaos or order in the home can impact plans for food purchasing and preparation [45,47,60,67,69,73]. Furthermore, the household environment may impact how much control, self-efficacy, and other behaviors parents and children have toward dietary intake and ensuring access to food. However, fewer studies contributed to the evidence of the relationships of various themes with the household environment despite these expected relationships, representing a gap in the literature and a contribution of this scoping review. The interactions between the household-level factors of household environment, parent and child behaviors, and food procurement and preparation may ultimately work together to impact dietary quality and food security for all within a household. For example, lack of nutritional knowledge, food preparation, and cooking skills with a low self-efficacy for healthy eating among parents and children and a chaotic household can act as barriers to healthy eating and reduce the dietary quality of foods/meals consumed in the home and contribute to feelings of stress with regard to obtaining enough food in the household when resources are also low. Challenges with these skills may contribute to the higher prevalence of food-insecure groups eating away from home and reduced prevalence of food-insecure groups eating home-cooked meals [54]. However, the potentially complex nature of how the various factors influence food insecurity and dietary quality synergistically should be addressed in future studies.

Implications
The evidence summarized has implications to the organizational, community, and policy levels of the social ecological model. Individuals from low-income households participate in federal US nutrition assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP) [77], which provide participants with financial benefits to assist with food purchasing and operate through organizations, communities, and policy. SNAP resources are external to the household and can play an important role in supporting households to improve food security [21]. SNAP eligibility also allows individuals to participate in nutrition education programs such as SNAP-Education (SNAP-Ed), evidence-based nutrition education program focusing on nutrition, budgeting, and a healthy lifestyle [78][79][80][81][82][83][84]. Nutrition education programs target household factors, such as nutrition behaviors, attitudes, and knowledge, and can play a significant role in improving food security [79][80][81][82]84] with limited evidence regarding dietary quality [81,83]. In other studies, nutrition education has been shown to improve participants' food security over 1 year after receiving the program [79,81,84]. However, less evidence has shown nutrition education improvement on dietary quality despite aims to help align household dietary choices with the recommendations in the DGA [80,82]. The results of this scoping review can be applied to future nutrition education efforts to improve healthful dietary habits and behaviors by informing educational content.
Nutrition education may include behaviorally focused programming through direct nutrition education that promotes dietary strategies to maximize the intake of nutrient-dense foods and beverages while stretching food dollars [78]. This review identified additional topics to be considered for inclusion in future nutrition education programming for households with school-aged children such as addressing parent and child behaviors and attitudes. Involvement of children in adult lessons and recognition of their influence on household food procurement, purchasing, and parent behaviors may promote parents and children to jointly learn about nutrition, improve attitudes toward healthful foods, and promote self-efficacy to support dietary quality. Similarly, educating parents on the importance of modeling healthy eating behaviors in the home and providing their children with encouragement and support may also build healthful habits. Promoting early exposure to a range of nutrient-dense foods, including fruits and vegetables, and having these foods available in the home should be encouraged as it may improve diet quality in future life stages and promote positive attitudes toward eating throughout childhood and adolescence. In addition, future nutrition education lessons should consider educating parents on the implications of feeding practices, such as pressure to eat and food restriction, on their child's dietary quality. The food procurement and preparation themes identified in this review are addressed in current nutrition education programs such as by teaching practical strategies to improve cooking skills, meal selection, and planning, and improve attitudes toward healthy eating. However, the household environment and factors contributing to family chaos may be less recognized within current lessons. Focusing on strengthening order and planning in the food environment of the household could promote a strength-based approach to behavior change within lessons to improve family chaos. The application specifically for households with school-aged children in this review is important because the prevalence of food insecurity is disproportionally high among households with children compared with all US households [1]. The situation of food insecurity within households with children may also introduce varying levels of access or restriction of foods within the household that may be applied to developing educational content. For example, in 7.8% of households with children, only the adults were affected by food insecurity [1]. Parents often protect their child against food security by decreasing their own intake or by saving certain foods for children, yet each household may have varying relationships between members and access to food [1]. Future nutrition education could recognize these complex household dynamics. SNAP-Ed is designed to allow curriculum in each state to tailor educational lessons to the targeted population [78]. Therefore, sensitivity to these issues among target groups of very low food security in the development of educational content may promote a tailored and effective approach to delivery.
The household factors related to dietary quality and food security identified in this review are further applicable to the emerging area of nutrition security [85], the consistent access, availability, and affordability of a diet that promotes health and prevents disease. Nutrition security is equity focused, aligning with an emphasis on tailoring interventions to meet the needs of underserved groups and those with a greater disease burden compared with the general US population. The US Department of Agriculture has defined and set goals to address nutrition security, but a national measure to quantify nutrition security has not yet been developed. Since this review identified factors related to both dietary quality and food security, key aspects of nutrition security, the findings may inform creation of measures and interventions to address nutrition security in households with children. Specifically, components of a measure to assess nutrition security may include queries to some of the household factors identified here that impact dietary quality and food security, such as nutrition knowledge, self-efficacy, attitudes and preferences regarding a healthful diet, barriers to purchasing and preparing healthful foods, and household chaos impacting diet or family meals.

Limitations
Although the goal of a scoping review is to be broad, exclusion criteria help to narrow the resulting map of the relevant literature for a concise topic with definable boundaries. Limiting the search strategy to only include studies from the past 10 years may have excluded older relevant studies, yet most studies included in the review were published within the past 5 years. The search only included the PubMed database so relevant studies in other databases may not have been included. Additionally, studies that explored exclusively preschool-aged children or younger were not included. These studies may have offered additional relevant findings as some households with young children also include older children and may impact the overall dietary quality and food security in the household. In contrast, this study included all school-aged children, which could range from ages 5 to 19 years, encompassing childhood and adolescent life stages. The household factors identified may vary by the ages within this range and should be considered in application of the findings to particular interventions. This review was limited to household factors contributing to dietary quality and food security in low-income households with schoolaged children in the United States and did not explore environmental, community, and social factors that may have an influence on dietary quality and food security in this population. For example, social factors, such as discrimination in policies and practices, could have a myriad of links to the relationships explored in this review and the characteristics of the groups represented. The studies included were observational and most were cross-sectional. This study design is not able to provide support for causal relationships. Several studies included in the review were qualitative, meaning that the findings may have been gleaned from focus groups or interviews and did not necessarily indicate a statistical association with food security or dietary quality. Knowledge of this type should be further evaluated for prevalence in groups and relationships with food security and dietary quality. In addition, the relative importance of the factors summarized is not known. The inclusion of stronger study designs to provide scientific evidence over the long term and randomized experimental evidence would strengthen the links between various themes identified in this review and their potentially causal relationships.

Conclusion
Parent and child behaviors, food procurement and preparation, and the household environment are household factors that may impact dietary quality and food security in low-income and food-insecure households with school-aged children. These factors are interrelated, and their synergy holds promise for future interventions to improve food security and dietary quality. The findings of this review are especially relevant to inform the design and implementation of nutrition education programming aimed at improving dietary quality and food security in lowincome and food-insecure households with children.
inclusion; HEM: wrote the paper with contributions from LG; HEM: had primary responsibility for final content; and all authors: read and approved the final version of the paper.

Author disclosures
HAEM is a member of the Advances in Nutrition editorial board and played no role in the Journal's evaluation of the manuscript.
LG, BM, BJM, BAC, WS, and AA report no conflicts of interest.

Data availability
Data described in the manuscript, code book, and analytic code will be made available upon request pending application and approval.