Health Consequences of Food Insecurity & Hunger

April, 19, 2007

Presented by Donna Ching, registered nurse and pediatric nurse practitioner with 25 years of practice

My first 18 years in health care were in the primary care setting, including a migrant health clinic, an inner-city outpatient clinic serving a pediatric population that was either uninsured, underinsured or on state-funded health insurance, and finally in a general pediatric clinic in private practice where I saw children and families who for the most part had healthcare insurance.  The most recent 7 years of my practice as a nurse practitioner have been in pediatric specialty clinics as part of a multidisciplinary team.  In my 25 years of working with children and families I never once asked if anyone was hungry or had enough food in their home. 

My husband is a family practice physician who worked in the county health clinics delivering primary health care to a population of families who were uninsured, underinsured, or carried state-funded health insurance and when I asked him how many times he had inquired about hunger or food security/insecurity in the home, his reply, like mine, was “none.”

As healthcare providers, we ask the children, adolescents, and families who seek our services very intimate questions, yet we never asked about hunger or food insecurity.  As we review the health consequences of food insecurity and hunger this morning, I ask myself, “why didn’t I think to ask about access to food, enough food?  Why didn’t I make the link between food insecurity and acute illness or repeated acute illness?”

What you will get from me this morning is a list of facts, if you will, that we now know about food insecurity and hunger and their association with detrimental health, emotional, and learning outcomes in the pediatric population. As we look at the different areas in child health and development that is impacted I will use food insecurity and hunger interchangeably.  You all well know the definition and difference between the two classifications and the only apparent difference there seems to be in terms of health consequences is that both groups have adverse health consequences with the hungry group having a greater risk – for example, whereas children who are hungry have 3 times more health conditions reported yearly, those who are food insecure have twice more health conditions.

We need to recognize that there is limited research examining extent to which family hunger in the US independently predicts adverse health and mental health outcomes among children.  This is a relatively new area or research given that a valid & reliable measure of food insecurity only became available in the mid-90s.

There is a range of social, demographic, cultural, environmental or maternal factors along with poverty can certainly collectively explain adverse health outcomes for children.

Hunger isn’t merely uncomfortable for children; it’s dangerous and jeopardizes health and normal development which in turn can impede readiness for school and future productivity as adults

I chose to break the adverse health consequences of food insecurity/hunger into 3 main groups this morning: the impacts on physical health, mental health, and cognitive development – on learning.

Physical Health (from fetal growth through school age)

• Susan Bagby, Professor of Medicine at OHSU is very interested in focused research on the development of hypertension and has found: under-nutrition of the fetus affects the kidney, liver, pancreas and skeletal muscle mass of the body.

• Fetal under-nutrition can lead to long-term adverse effects such as hypertension, obesity, diabetes and faltering growth in a child’s 1st year can affect coronary heart disease later on.

• For infants & toddlers in food insecure households they are 90% more likely to be reported in fair to poor health. This is a particularly vulnerable group as the 1st 3yrs of life are a time of a critical developmental period.

• School-age children w/ hunger were more likely to have had low birth weight (23% for those hungry vs 6% for no hunger)

• Children from food insecure households are 30% more likely to have been hospitalized at least once since birth.

• According to C-SNAP (Children’s Sentinel Nutrition Assessment Program): of 12,000 children under 3 years of age in 6 states who visited the emergency dept – 21% were food insecure & 7% defined as hungry.  

Why do children who are food insecure appear make more visits to the emergency dept?

They have poorer functional health status – increasing their risk of:

• Contracting illnesses
• Compromising the immune system thus both your ability to resist illness and impairing your ability to heal
• And, children who are hungry have more health conditions reported early (3 vs 2)

• Iron deficiency anemia is twice as likely to occur if a child is food insecure. This is a clinically important health indicator with known negative cognitive, behavioral and health consequences – pallor, fatigue, irritability, delayed motor development, decreased cognitive function.

Rounding out the spectrum of the impact of food insecurity there seems to be:

• An increased risk of chronic disease in children experiencing food insecurity and hunger. (example of a chronic disease would be asthma)

Although we can measure this, there is no data to explore the means by which hunger increases chronic illness among children. There is some speculation that perhaps periodic food insufficiency harms health through physiologic means. All health effects may not be immediate.

• Finally, over the long-term, food insecure children are at risk of developing disordered eating patterns which could ultimately result in failure to thrive.

Impact on Mental Health

Children from food insecure and hungry households are more likely to have a history of past or current mental health counseling. There is a small body of literature that has suggested hunger may impair children’s psychosocial function and increase the likelihood of behavioral problems.

WHY?

• Increase internalizing problems – experience more headaches and stomachaches which may be coping strategies, aggressive, irritable, or hyperactive.

• More likely to experience depressive symptoms

• School-age children who were hungry had parent-reported anxiety scores that were more than double the scores for children without hunger.

Range of potential explanations:

• Food deprivation may result in physiologic or emotional changes that compromise a child’s ability to cope w/ stress
• Children may also experience anxiety as a result of unpredictable and intermittent meals. Not knowing whether food needs will be met day to day can result in substantial stress.
• Not surprisingly, children from food insecure households had more stressful life events that impact on their psychological development.
  
  

Example of socio-familial disturbance:

• Homelessness
• Mothers of school-aged children who reported severe hunger were more likely to have a lifetime diagnosis of post traumatic stress disorder or substance abuse. Consistent w/ previous research, a mother’s emotional distress and other stressful events contribute to children’s anxiety and depression. Of no surprise to you – parental stress affects family relationships.
  
• Rates of depression were also high among mothers who were single, head of household, regardless of hunger, food insecurity or not.
• Higher rates of anxiety disorders among mothers reporting hunger. Mothers who are unable to provide sufficient food for their children may feel distressed and unsettled, which can, in turn, affect children’s level of emotional well-being.
  
  

• Impact on cognitive development – on learning
  
  • Cornell study: food insecurity over time showed association with changes in reading and math test performance. Kids from food insecure households had lower scores and made less progress. This is some early evidence of the association of food insecurity and diminished capacity to learn and poorer overall school achievement.
  
  • Necessary for academic achievement – ability to focus, exercise patience, experience success, develop critical thinking. Not easily accomplished for those from hungry or food insecure households
  
  • Easy to understand why food insecure youngsters are more likely to be receiving special education.
  
  • Mothers of school-age children who were food insecure also reported more school-related difficulties such as suspension, repeated grades, tardiness, and number of missed days.
  
  • Finally, remember the recent report of the direct association of consumption of breakfast with learning and memory function.  If you kids are starting off their day hungry, they’re already at a handicap for educational success.
  
  Call to Action: the “to do” list for pediatric and family physicians, nurse practitioners, and physician assistants
  
  We acknowledge hunger to be associated with detrimental health, emotional, and learning outcomes, yet many healthcare providers do not ask questions to assess presence or degree of hunger in their pediatric patients.
  
  Our job as part of the Childhood Hunger Initiative:
  
  • It’s essential that questions that elicit presence of child hunger be asked of parents as part of routine history particularly during annual health maintenance exams – Well Child Check-Ups
  
  • Develop or refine an existing screening tool useful in a clinical setting.
  
  • Increase clinician awareness of hunger’s relationship not only to physical problems but also to adverse mental health status so when indicated, children are referred for counseling services.
  
  • Educate healthcare providers for children about available school and summer feeding programs in their community so they can encourage participation. Refer child/family to available resources
  
  • Advocate for them in the public health and legislative arena