impact of food insecurity on child development and school...

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Impact of Food Insecurity on Child Development and School Readiness

Vijay Chawla, M.D.

Food Access Summit 2014October 30, 2014

Duluth


Disclosure

•No financial relationship

•No off label drug use

•CONFIDENTIALITY BREACH


Definition of Food Insecurity

“Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially

acceptable ways.”

(United States Department of Agriculture

World Health Organization)

Poverty is the main cause of food insecurity and hunger.


Food Security Scale

• The US House Food Security scale (HFSS) developed in 1995-1997.

• Part of food security projects:

• consisted of 18 question (AHFS) and (CHFS).

• administered in 1995 as part of population survey measured

• Results released in 3 reports in 1997

• USDA/ERS revised the scale

• Child food security scale developed with 8 questions

• Used separately to measure Child Food Security


• Scale identified. Four food security categories:

• I. Food Secure

• II. Food insecure without hunger

• III. Food insecure with moderate hunger

• IV. Food insecure with severe hunger

• HFSSM – has enabled research on causes and consequence of food insecurity

• Has been used for research purposes to study

• Impact of childhood food insecurity on health, growth, and development

• Translated in several languages

Food Security Scale (cont’d)


Prevalence of Food Insecurity

• The number of hungry people in the world remains unacceptably high.

• Nearly 870 million people of the 7.1 billion people in the world, or 1 in 8, were suffering from chronic undernourishment in 2010-2012 (FAO 2012, United

Nations Food and Agriculture Organization).

• The vast majority live in developing countries

• 852 million people or 15% of the population are undernourished.

• There are 16 million people undernourished in developed countries.


Percent of US Households Experiencing Food Insecurity 2010-2012 by Race of Household

Source: USDA ERS, 2011-2013

Chart by: Hannah Emple


• Rates were higher than the national average in the following groups:

• All households with children (19.5%)

• Households with children under age 6 (20.9%)

• Households with children headed by a single woman (34.4%). **One of the highest!

• Households with children headed by a single man (23.1%)

• Black, non-Hispanic households (26.1%)

• Hispanic households (23.7%)

• The household of color in the U.S. experience rates more than twice that of white households.

• Households with children under age 18 yrs. old experienced at twice the rate of all other households.

Prevalence among household types


• Immigrant households have much higher rates than US citizens households.

• Households with incomes below 185% of the poverty threshold (34.8%); the Federal poverty line was $23,624 for a family of four in 2013.

• The relationship between poverty and child development is not only dramatic in developing nations

• It is also a major concern in developed nations where there are pockets of poverty, and health disparities related to race/ethnicity, gender, income and education.

Prevalence among household types (cont’d)


Nutrition, Brain Growth and Cognitive Developments

• In humans the spinal column begins to differentiate and form between the 3rd and 4th week of gestation.

• Within the 1st month specific areas of the central nervous system begin to form

• Neurogenesis

• Migration of cells in the forebrain, midbrain and hindbrain areas.

• Over the remainder of the prenatal period there is an accelerating sequence of CNS developmental processes.

• Synaptogenesis

• Apoptosis

• Myelination

• Neural networks of interconnected nerve cells


Nutrition, Brain Growth and Cognitive Developments (cont’d)

• Neurodevelopment during prenatal period depends on substances present in mother’s diet.

• Including:• Vitamins

• Minerals

• Essential amino acids

• Essential fatty acids including omega-3s

• Other nutrients

• Development of prenatal period accelerates and continue after birth.

• Especially active and creative during the first 3 years of life


Nutrition, Brain Growth and Cognitive Developments (cont’d)

• The perinatal nutrition of mother and babies are most critical nutritional pathways through which food insecurity can adversely impact children’s health.

• During the first three years of life a child’s brain is developing very rapidly.

• All parts of neurons are formed from raw materials in food and nutrients.

• The myelin sheath requires availability of lipids and fatty acids found in certain foods.

• Absence of foods make myelin vulnerable during later part of gestational period.


What We Know about Food Insecurity’s Effects on Children

Research suggests that children suffer damaging effects in the following domains:

• Brain and cognitive development in the perinatal period (0-3 yrs)

• School readiness in preschool years (0-5 yrs.)

• Learning, academic performance and educational attainment during school years (6-17 yrs.)

• Physical, mental, and social development, growth and health throughout childhood (0-17 yrs.)

• Psychosocial functioning and behavior, and mental health during school years (6-17 yrs.)

• Child health-related quality of life, perceived functionality, efficacy and “happiness/satisfaction” during school years (6-17 yrs.)

• Some, not yet clear associations with obesity throughout childhood (0-17 yrs.)


• Influences health through two pathways

• Nutritional

• Non-nutritional

Examples of Nutritional pathways are:

• Involves absence or deficiencies in nutrients.

• Proteins and 8 essential aminos for tissue building

• Carbohydrates for energy

• 2 essential fatty acids

• 12 vitamins

• Trace elements

• Calcium, magnesium, iron, selenium, iodine, copper, zinc, manganese

• Folic acid

Nutritional Pathways


• Impoverished home environments, lack of appropriate stimulation and nurturing adult support

• Worry, fear and shame and other negative affective states related to current or anticipated household food supplies.

• Chronic stress; e.g., child abuse, domestic violence, recurrent or persistent hunger, correlates of poverty and food insecurity)

• Delays in and/or foregoing of needed medical care so that food can be purchased

• Non-compliance with prescribed health care treatment, including prescription medication and special diets so that food can be purchased

• Reduced and/or impaired adult-child interactions (lack of responsiveness in both adults and children, reduced “serve and return” activities)

• All ultimately lead to poor mental health outcomes.

Non nutritional Pathways


Consequences of Food Insecurity

• Children growing up in food-insecure families are vulnerable to:

• Poor health

• Stunted development

• Delayed development

• Poorer attachment

• Learning difficulties

• Pregnant women who experience food insecurity are more likely to experience birth complications than women who are food secure.

• Inadequate access to food during pregnancy has been shown to increase the risk for low birth weight in babies.


Consequences of Food Insecurity (cont’d)

• Developing nations, 200 million children (roughly 39%) under age five are not reaching their developmental potential.

• The majority of poorly developed children live in sub Saharan Africa and South Asia.

• Persistent malnutrition leaves children immunosuppressed.

• Unable to fight childhood illnesses

• Diarrhea

• Acute respiratory infections

• Malaria

• Measles


• WHO estimates that approximate 60% of all childhood deaths in developing world are associated with chronic hunger and malnutrition.

• Even children with mild to moderate malnutrition are at a greater risk of mortality from common diseases.

• Food insecurity has also been associated with health problems such as:

• are more likely to require hospitalization

• at higher risk for chronic health conditions, such as anemia, and asthma

• may have more frequent instances of oral health problems

Consequences of Food Insecurity (cont’d)


Consequences of Food Insecurity

• May be chronic, seasonal, or temporary.

• Nutritional consequences include:• Protein energy malnutrition

• Kwashiorkor

• Marasmus

• Micronutrient deficiency, trace elements or micronutrients are important for health.

• 1 out of 3 people in developing countries suffer from vitamin and mineral deficiencies (World Health Organization).

• Three most important deficiencies are:• iron deficiency & anemia

• vitamin A deficiency

• iodine deficiency


Protein Energy Malnutrition


Protein-energy malnutrition (PEM)

• PEM in children under 5 is currently the most important nutritional problem.

• Major problem in Sub Sahara in Africa, some parts of Asia, and Latin America.

• Prevalence of PEM in children under 5 varies from 42.6% to 34.6%.

• The number of underweight children worldwide has risen from 195 million in 1975 to an estimated 200 million at the end of 1994, which means that more than 1/3 of the world's under-5 population is still malnourished.


Severe Protein energy malnutrition

• Is associated with one of the two classical syndromes

• Kwashiorkor

• Marasmus

• This degree of malnutrition is uncommon in the United States.


Kwashiorkor

• Most frequently seen in children 1 to 3 years of age.

• Inadequate protein and energy intake causes clinical feature of kwashiorkor.

• The food provided to the child is mainly carbohydrate.

• Kwashiorkor is often associated with, or even precipitated by, infectious diseases.

• diarrhea

• respiratory infections

• measles

• whooping cough

• intestinal parasites and other infections


Marasmus

• The most common form of protein energy malnutrition.

• This is caused by inadequate intake of all nutrition but especially dietary energy sources (total calories).

• Nutritional marasmus is in fact a form of starvation.

• The most important precipitating causes are infectious and parasitic diseases of childhood. These include:

• measles

• whooping cough

• diarrhea

• malaria and other parasitic diseases.


Kwashiorkor and Marasmus


Micronutrient Deficiency

• Micronutrients are important for health.

• One out of three people suffer from vitamin and mineral deficiencies (World Health

Organization)

• Four most important deficiencies are:• Anemia & iron deficiency

• Vitamin A deficiency

• Vitamin D deficiency

• Iodine deficiency


Iron Deficiency

• Most prevalent nutritional deficiency amongst the micronutrients.

• Is a principal cause of anemia.

• Two billion people - over 30% of the world’s population - are anemic.

• Recent survey shows prevalence in United States 18% amongst high risk group.

• Large study (2006) shows association between iron deficiency anemia and level of child’s food insecurity in children less than 36 months of age.

World Health Organization


Iron Deficiency (cont’d)

• For children, health consequences include:

• Maternal anemia leads to:

• premature birth

• low birth weight

• high rates of infant morbidity and mortality

• Later affects:

• physical and cognitive development resulting in lowered school performance.

• poor psycho-social development

• behavioral problems

• problems with sleep behavior

• low energy and fatigue

• predisposes infections

• increasing morbidity and mortality



• Iron

• Daily requirements to 11 mg/d after 6 months of age

• Very small amount needed before that

• Dietary sources of iron

• Meats and eggs

• All seafood

• Vegetables (spinach, peas, sweet potatoes, string beans, kale, chard, collards)

• Bread & cereals (whole wheat, cornmeal, bran, enriched rice)

• Fruit (strawberries, watermelon, raisins, dates, prunes, apricots, tomatoes and peaches)

• Beans & other foods (lentils, kidney and garbanzo beans, dried peas and beans)



• Dietary sources of iron

• Routine check for anemia by WIC PCP between 9 months to 1 year of age

• Children with anemia should further worked by PCP

• Treated appropriately with supplemental iron and nutritional therapy

• Should be followed up until anemia is resolved

• Access to food stamp SNAP are associated with improved nutrition


Iron Deficiency (anemia)


Iodine Deficiency

• Is a global health problem.

• Iodine is essential for thyroid gland to synthesize adequate amounts of thyroxine.

• Foods that contain iodine are:

• Fish

• Seafood

• Kelp

• Iodized table salt

• Some drinking waters

• Vegetables grown in iodine sufficient soil

• Cow’s milk (if iodine is added to cattle feed)


Iodine Deficiency (cont’d)

• Daily requirements

• 90 mcg of iodine daily for infants and child up to 5 years

• 120 mcg for 6-12 years of age

• 150 mcg for children greater than 12 years and adults

• 250 mcg during pregnancy and lactation



• Consequences of iodine deficiency

• Thyroid goiter

• Hypothyroidism

• Cretinism (severe iodine deficiency during pregnancy)

• Increased neonatal and infant mortality

• Learning disability (mild to moderate deficiency)



• Effects of maternal hypothyroidism for the developing fetus or infant are catastrophic.

• Thyroid hormone is essential for normal maturation of the central nervous system.

• For the 1st 12 weeks of gestation the fetus is completely dependent on maternal thyroxine.

• 10-12 weeks of gestation, fetal TSH appears.

• Little hormone synthesis occurs until the 18th to 20th

week

• The fetal thyroid secretion increasing gradually during intra-uterine life.



• Hypothyroidism during this critical period leads to mental retardation which in the most severe form is known as cretinism.

• Neurologic cretinism is characterized by:

• Mental retardation

• Deaf mutism

• Gait disturbances

• Spasticity

• Mild to moderate iodine deficiency during pregnancy leads to neuropsychological defects.



Intellectual disability

• Iodine deficiency also appears to have adverse effects on growth and development in the postnatal period.

• Children/Adolescents in regions with low iodine are at risk for some degree of intellectual disability.

• Meta analysis of studies show an average loss of 13.5 intelligence quotient (IQ) points in affected subjects.

• Effects of iodine deficiency on the central nervous system during fetal development are not reversible.

• However it may improve with appropriate thyroid hormone replacement and/or iodine supplementation.


Prophylaxis – Treatment of the Community

• Correction at the level of the community rather than the individual.

• Neonatal serum TSH screening for hypothyroidism.

• Iodization of salt is the preferred method of increasing iodine intake in a community.

• It is legally mandated in several countries.

• International effort towards eliminating deficiency by 2005 has resulted in major progress.

• About 70% of households worldwide using adequately iodized salt.

• Water is another occasional iodization vehicle because it is a daily necessity like salt.

• WHO recommends iodine supplementation in pregnancy and during lactation. (prenatal vitamins)


Iodine Deficiency


Vitamin A Deficiency

• It is still the third most common nutritional deficiency in the world.

• Between 100 and 140 million children are vitamin A deficient

• An estimated 250,000 to 500 000 children become blind every year

• Can cause blindness and reduces the body's resistance to disease. In children, can also cause growth retardation.

• Half of them dying within 12 months of losing their sight.

World Health Organization


Vitamin A Deficiency (cont’d)

• Vitamin A Deficiency is rarely seen in the United States.

• Large part of the third world (Africa, Southeast Asia and South America).

• Clinical manifestations:• Xerophthalmia, pathologic dryness of the conjunctiva and

cornea.

• Keratomalacia

• Blindness and night blindness

• Poor bone growth

• Dermatological problems

• Impairment of immune system


Vitamin A Deficiency (cont’d)

Prevention – WHO recommends the following replacement approaches:

• Periodic distribution of Vitamin A supplement for populations of high risk in the following doses at 4-6 month intervals:

• Infants less than 6 months of age:

• Non breast fed: 50,000 IU orally

• Breast fed: 50,000 IU orally (unless the mother has received supplemental Vitamin A)

• Infants 6-12 months of age: 100,000 IU orally

• Children more than 12 months of age: 200,000 IU orally

• Mothers: 200,000 IU orally within eight weeks of delivery


Vitamin A Deficiency


Vitamin D Deficiency

• Essential to maintain bone health.

• Exposure to sun in moderation is a major source of Vitamin D.

• Very few foods naturally contain vitamin D

• Foods that are fortified are often inadequate to satisfy a child's requirement.


Vitamin D Deficiency (cont’d)

• Poor bone growth

• Rickets in children

• Stunting of growth

• Bone deformities

• Precipitate and exacerbate osteopenia, osteoporosis, and fractures in adults.


Vitamin D Deficiency (cont’d)

• It has been associated with:

• increased risk of common cancers

• autoimmune diseases

• hypertension

• infectious diseases


Vitamin D Prevention

• Daily requirements 400 IU per day

• Breast milk is a poor source of Vitamin D

• AAP recommends supplementation of 400 IU in all breast fed babies.

• Formula fed infants need to drink between 32-36 oz. of formula to meet their daily requirement.

• Supplemented for formula feed infants also.


Vitamin D Deficiency


Lead Exposure

• Especially harmful to children younger than 6 years of age.

• Due to their developing brain and nervous system.

• But, anyone who eats, drinks or breathes lead can be poisoned.

• National Health and Nutrition Examination Survey (NHANES) surveyed lead blood level in children 1-5 years of age (CDC).

• 2.5% of children tested positive for lead exposure.


Lead Exposure (cont’d)

Large amounts of lead in a child’s blood can cause:

• brain damage

• intellectual and/or developmental disabilities

• behavior problems

• hyperactivity

• anemia

• liver and kidney damage

• hearing loss

• other physical and mental problems, and in extreme cases, death.

Centers for Disease Control and Prevention, 2011



• CDC recently updated blood level guidelines based on (NHANES Survey)

• In past, blood lead level tests above 10 micrograms per deciliter of lead in blood was level of concern.

• The new reference level is 5 micrograms per deciliter.



• The focus is shifted to primary prevention.

• Infants between 9 months and 12 months are routinely screened for lead exposure (WIC, PCP).

• Repeating test at 2 years of age is recommended (MDH/CDC).

• Level of 5 mcg and above are reported to parents, Public Health and MDH.

• The goal is to prevent any further exposure and prevent harm.


Lead Poisoning


Preventions and Interventions

• Federal government funded nutrition assistance programs

• Women, infants and children (WIC)

• Supplemental nutrition assistance program (SNAP)

• Food stamp program

• Research shows despite benefits from these programs a number of children with CFI has increased since 1999.

• Recent survey of 5000 families with young children seen at Hennepin County Medical Center

• 36% were food insecure (Diana Cutts)


Preventions and Interventions (cont’d)

• These programs are designed to supplement the food budgets and not support.

• In 2012 59% participated in one of the 3 programs.

• This helps millions of children in the USA

• Unfortunately are targeted for reduction in funding rather than expansion.



• Programs implemented through the schools

• Schools are in a unique position to promote healthy eating

• Free school breakfast

• National subsidized school lunches for the low income families

• Summer vacation free (subsidized lunch programs)

• To help with CFI during long school vacations



• Eating healthy breakfast is associated with:

• improved cognitive functions

• Memory

• Improved mood

• Reduced absenteeism

• Schools definitely can help improving our children’s eating habits

• Ensuring that only healthy choices are provided.



• Medical Assistance Program

• Healthcare funded by states and federal government for low income families

• Does need to be mentioned

• Allows us to provide health care in sickness

• Without which these children will go without any medical care or very limited care

• Leading to adverse outcomes



• Community Drives and Resources

• World Hunger Education Service

• Green – Harvest

• Salvation Army – kitchens

• Food Shelves

• Private food drives

• Businesses and organizations

• Churches and other philanthropy

• Just a few to mention



• Early intervention key to better outcomes

• Should start in prenatal period with emphasis on maternal nutrition and prenatal care

• Breast feeding advocacy

• Newborn metabolic screen

• Newborn hearing screen

• Screening for congenital heart disease

• Autism screening – 18 months to 2 years

• Teen and child regular checkups



• AAP recommends growth and developmental screening at all well child visits

• Including vision and hearing


Conclusion

• Childhood food insecurity (CFI) is a pernicious threat to the physical and mental health of US children.

• Affects all stages of childhood

• Especially during prenatal and first 3-5 years of life

• Brain, central nervous system is growing at a very rapid rate during these early years.


Conclusion (cont’d)

Damage occurs through:

• Nutritional pathway

• Non-nutritional pathway

The future prosperity of American

• Economy

• Population

• Depends on human capital accumulated by each generation of children

Child Food Insecurity

• Presents a drain on human capital formation through out childhood and into adulthood.



• Virtually making it impossible for our children to fulfill their potential as effective workers and members of the society.

• We clearly know how to fix the problem and the harm it does to our children.

• By ending childhood food insecurity and hunger our political and business leaders can ensure a prosperous future for us all.



• As a result we all lose.

• Question begging for clarification is why the supposed wealthiest nation cannot eliminate food insecurity and hunger?



• Does the world produce enough food to feed everyone?

• Answer is yes

• The world agriculture produces 17% more calories today than 30 years before

• Despite 70% increase in population

• Enough to provide everyone 2,720 kilocalories per person per day (FAO 2002)



• What would it take our nation’s decision makers and populace to achieve that end?

• Question is worth asking


Questions & Discussion

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