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Two Sides of the Same Coin

Hunger and Obesity in Early Childhood

SOURCE: AP/Mel Evans

Imani Sullivan, a participant in the "Witnesses To Hunger" photo exhibit in Philadelphia, talks about her frustration over trying to care for her two children with her janitor's pay. Dr. Mariana Chilton, director of Witnesses to Hunger, describes the paradox of hunger and obesity that afflicts many young children in low-income households as a reflection of the “lack of control that many poor women have over the environment in which they raise their children.”

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Congress took action last week to do what’s right by increasing low-income children’s access to healthy meals. Landmark legislation passed the House of Representatives on Thursday to renew child nutrition programs. The Healthy, Hunger-Free Kids Act will spend about $4.5 billion over 10 years to provide healthier meals to children at home, in school, and in child care settings. But so much more remains to be done.

This legislation passed just after newly released food security data from the United States Department of Agriculture confirms that millions of low-income parents lack the money and resources to keep their pantries and refrigerators filled with enough food to provide their families with adequate and nutritious meals every day. More than 17 million children lived in households that were food insecure in 2009.

This national travesty was on the rise well before families were feeling squeezed by the Great Recession. Child hunger increased by nearly 50 percent in 2007 from the year before, marking the highest point in nearly a decade. Record levels of participation in food assistance programs and increased demand at emergency kitchens and food pantries make clear that more families than ever before are struggling to get enough to eat in the aftermath of the recession.

This is especially true among families with very young children. USDA reported earlier this year that during the first half of 2009, one in five homes with a baby or toddler was food insecure. This alarming statistic illustrates that families with very young children are particularly vulnerable to economic hardship, and often run short of nutritious food.

Children’s health and life chances are damaged by food insecurity and hunger as food eaten during the earliest years of life significantly affects their physical and intellectual capacities as they grow. In fact, a recent study from the National Cancer Institute and the University of Calgary found that children that went hungry at least once in their lives were more than twice as likely as children from food secure homes to have poor overall health 10 year to 15 years later.

While food insecurity and obesity are often viewed separately as public health concerns, these issues are essentially two sides of the same malnutrition coin for many struggling families. Obesity is the result of many complex and interrelated factors, but the quality of the food eaten at home greatly influences its prevalence. Researchers associate low-income preschool children who are overweight or obese with the insufficient consumption of fresh fruits and vegetables. Lowincome households spend a larger percentage of their income on food, but they tend to spend less on food overall (see Figure 1) and find it difficult to afford healthy foods like fresh produce.

Many poor families struggle to find within their communities the nutritious foods necessary to maintain a healthy weight. A recent story in The Philadelphia Inquirer featured a young woman reflecting on how living in poverty and in a food desert since childhood has contributed to her obesity. “You can’t find fresh fruits and vegetables in this neighborhood,” she explained. “I ate a lot of instant noodles and drank a lot of Hawaiian Punch from the corner stores up here.”

Spending on food by income quintiles

Rates of childhood obesity have tripled since the mid-1980s, leaving the current generation of children and teenagers on track to have a lower life expectancy than their parents. The obesity epidemic even plays out on the bodies of our youngest children— over 30 percent of kids between the ages of 2 and 5 are overweight or obese. And though there is no clear definition of overweight or obese for young children under age 2, clinicians have observed an upward trend in weight among infants and toddlers over the last two decades.

Those extra pounds are putting very young kids at a greater risk of a host of debilitating and costly diseases including diabetes, certain cancers, and heart disease. A recent study examining the impact of childhood obesity on health care costs concluded that the direct costs of hospitalizations related to childhood obesity nearly doubled between 2001 and 2005 to $237.6 million.

This issue brief will explore the connection between hunger and obesity in poor families with babies and toddlers, and then examine the policy interventions that could improve access to adequate nutrition while supporting low-income parents in raising healthy children. While some of these policy interventions are addressed in the Healthy, Hunger-Free Kids Act, there are a number of other existing policies and programs that we can use to prevent hunger and obesity in early childhood.

Prevalence of obesity and food insecurity among low-income women and their children

Obesity rates increased dramatically over the past 20 years for families of all incomes and racial or ethnic backgrounds. But there is a strong correlation between lower incomes and higher obesity rates, particularly for women. One study found that the prevalence of obesity for women with household incomes of less than $15,000 per year at 36 percent was twice that of women with incomes of more than $75,000 per year. And obesity rates are highest for black and Hispanic women and girls, especially in families with the lowest level of parental education.

Families headed by women are disproportionately represented among the poor, the obese, and the food insecure. Over 36 percent of families headed by unmarried women are food insecure, and children from these families are more likely to be obese than children from two-parent families. Single parents are often stretched for time and money, leaving little time and resources to devote to meal planning and the preparation of healthy meals.

Pre-pregnancy weight and child obesity

Recent research demonstrates that the likelihood that a child will be obese and suffer other negative health outcomes is set before he or she is even conceived. And the most effective interventions to address the prevalence of obesity among low-income and often food-insecure children may actually start before they are even born. A mother’s weight before pregnancy is an important factor for child and maternal health. Obesity not only is the source of multiple health problems among women of childbearing age, but also is associated with a higher risk for pregnancy complications, cesarean delivery, and neonatal problems.

Worse still, the average health care costs associated with prenatal and postnatal care are higher for overweight mothers than for lean mothers. Alarmingly, poverty and obesity are also linked to an increased risk for maternal death. Earlier this year, The New York Times featured a story examining maternal mortality rates in New York City, which are among the highest in the nation. The city’s health department determined that social factors including obesity and poor nutrition were shown to be major reasons for the unacceptably high death rate of pregnant women in New York.

According to the Centers for Disease Control, pre-pregnancy obesity increased nearly 70 percent between 1993 and 2003. Some studies also show higher odds of obesity among children whose mothers were already obese before becoming pregnant or mothers who gained an excessive amount of weight during pregnancy.

In short, food insecurity demonstrably increases a woman’s risk of obesity during pregnancy and the likelihood of a variety of weight-related health complications that include gestational diabetes and hypertension.

Breastfeeding and early eating habits

Breastfeeding may reduce the likelihood of child obesity by as much as 22 percent, and its protective effects extend many years into a child’s life. Breastfeeding also is associated with lower stress levels and less depressive symptoms among mothers— factors that influence child obesity. Despite this and the numerous other health benefits associated with breastfeeding, less than half of all babies are breastfed at all by six months of age, and less than one-quarter by 12 months.

The prevalence and duration of breastfeeding is even less for low-income and black babies. Many mothers in low-wage jobs lack paid maternity leave and may not have access to flexible work schedules, lactation accommodation, and other benefits necessary to support breastfeeding.

Parents introduce feeding patterns and eating habits very early in life that often last a child’s lifetime. Babies who are overweight are more likely to be overweight children and adolescents than babies at a normal weight. It is possible that these young people will pass along genetic, social, and behavioral factors as they mature and have families of their own that could leave their babies at risk of becoming obese. It is critical that clinicians and other stakeholders in the obesity fight gain a better understanding of the root causes of what could conceivably be a multigenerational cycle of obesity among economically vulnerable parents and children.

Unpacking the connection between hunger and obesity

Americans increasingly recognize that hunger is a serious and growing problem in the United States. In fact, a poll sponsored by the Alliance to End Hunger shows that the hunger problem is more immediate and personal, with one in five people worrying that either they or someone they know is going hungry. Yet the connection between food insecurity or hunger and obesity remains unclear for many people and misinterpreted by others. And the stigma associated with being overweight or obese in America is significant. Antifat bias is often justified by the common perception that overindulgence and a lack of personal responsibility largely contribute to excessive weight gain.

But obesity is quickly replacing starvation as a major nutritional problem in a number of low-income communities across the globe. Despite this growing trend, images of extreme deprivation and emaciated bodies are most likely to come to mind when we think about hunger. But as discussed in the introduction, an inability to purchase nutritionally adequate food drives hunger and obesity in the same household and often in the same body.

Hunger and malnutrition reveal themselves very differently in a country with abundant food and resources. Hunger manifests in the mother who skips meals once or twice a week to ensure she will have enough food for her children.

Malnutrition reveals itself in the family without a car that regularly eats from the dollar menu of the nearby fast food restaurant for lack of more affordable food options in their neighborhood. Or in the infant sipping sugary drinks from a bottle after the formula has run out for the month.

In essence, hunger in America is driven at least in part by what the Food and Research Action Council describes as “the economics of purchasing food.”

A low-income parent with a nearly-empty refrigerator or bare pantry is likely to be more concerned with filling his or her child’s belly with enough food than with proper child nutrition. Poor families that consistently lack access to fresh fruits and vegetables and other healthy foods often find themselves relying on low-cost, high-calorie, and imperishable options to fill in the gap.

Most shoppers, especially those with tight budgets, understand that eating well costs more. But as Deborah Frank, founder of Children’s Health Watch notes, “the same foods that can make some adults fat also starve children of absolutely essential nutrients.” This can lead not only to malnutrition and obesity among children, but also to a number of other health problems. And inadequate nutrition among children in the earliest years of life (especially the first three) often leaves them vulnerable to developmental and behavioral impairments as they grow, some of which may be irreversible.

Dr. Mariana Chilton, director of Witnesses to Hunger, describes the paradox of hunger and obesity that afflicts many young children in low-income households as a reflection of the “lack of control that many poor women have over the environment in which they raise their children.” Indeed, the conditions of poverty help shape these mothers’ decisions about what and how to feed themselves and their children.

Financial instability, family stress, and a low-quality neighborhood food environment— among other challenges faced by low-income parents and their children— leave them more vulnerable than higher-income families to both hunger and weight-related health problems.

The conditions of poverty inhibit the ability of poor parents and young children to develop and maintain healthy eating habits

Limited access to healthy affordable food

As discussed in the introduction, many poor parents are more likely to find fastfood restaurants and liquor stores than supermarkets or farmers’ markets in their neighborhoods. Researchers find that a lack of access to fresh produce and affordable, nutritious groceries in less affluent areas likely influence obesity rates. When a parent living in a low-income neighborhood is able to purchase fresh healthy food from local stores, those food items often come at a heftier price than the same items from stores in higher-income neighborhoods.

Inadequate food knowledge and exposure

While parents and children in low-income neighborhoods are often underexposed to healthy whole foods and cooking methods, they are overexposed to the targeted marketing of high-calorie processed foods. Neighborhood disadvantage imposes clear limits on a parent’s knowledge of the full range of foods necessary for proper child nutrition.

Improving access to a variety of nutritious foods in poor communities is important, but research suggests that this alone does not increase the purchase and consumption of them. When presented with healthy food options, the likelihood that people choose them is often influenced by their familiarity with these foods and knowledge of both their nutritional value and how to prepare them.

Cycles of food deprivation and overeating

About 6.6 million households in 2009 reported that an adult had either cut the size of meals or skipped meals because there was not enough money for food. Families that skip meals or reduce the size of them to stretch food dollars may eat more than they normally would during times when food is more plentiful. These chronic ups and downs in food intake contribute to weight gain and obesity. This is especially an issue for poor mothers, who will often skip meals and sacrifice their own nutrition to protect their children from hunger.

High stress levels and emotional eating

The cumulative stress experienced by mothers is a determinant of child obesity. Low-income families, including children, often face high levels of stress brought on by the numerous problems associated with severe money woes. Younger children from these families who pick up the stress of their anxious parents often respond by developing poor eating habits that raise their risk of becoming overweight or obese.

Imbalance of work and family life

A job is a strong force that pulls a parent away from the time she would like to spend with her family or that she and her family often need for activities such as shopping for and preparing nutritious meals and sitting down to eat dinner together. An inflexible work schedule or job instability and its related emotional impact are also an impediment to breastfeeding, which as discussed earlier appears to reduce the risk of being overweight and obese throughout childhood.

This is especially the case with single mothers that are low-wage workers. Research of former welfare recipients has found that when a working mother is not on a regular work schedule, has hours that fluctuate from week to week, or works at a full-time job that presents limited wage growth and menial tasks, the health and well-being of her children deteriorates.

Unemployment and hunger on the rise

Fewer opportunities for physical activity

Lifetime patterns of physical activity (and inactivity) begin in the early years, and are influenced largely by a family’s home environment. Fewer physical activity resources and safe spaces for children to play make it difficult for parents and children to maintain a physically active lifestyle in disadvantaged neighborhoods. Additionally, violence and the fear of violence in some neighborhoods minimize opportunities for an active lifestyle.

All of these poverty conditions are inexorably linked to the crisis of child hunger and obesity in poor communities, requiring a cross-disciplinary policy approach to rescue those 17 million children. The first line of defense against food insecurity and hunger in early childhood is for parents to have good jobs with adequate benefits. While hunger is driven by several economic and social factors, there is a clear connection between rising unemployment and rising rates of hunger. (see Figure 2)

Policymakers can actually stem the growing tide of food insecurity in America by creating better opportunities for struggling families, including targeted job creation and training, improved access to postsecondary education, fair pay, extended unemployment insurance, and stronger income-assistance programs. But there also are specific federal food programs, health care programs, and antipoverty programs for parents and children that require immediate attention. To this we now turn.

Policy interventions to improve food security and prevent obesity among vulnerable parents and young children

Hunger and obesity among our youngest children is both totally preventable and unnecessary. Food assistance and nutrition programs not only play a significant role in combating child hunger, but also in fighting the child obesity epidemic by improving access to nutritious food. And health care and antipoverty programs that provide mothers with the support they need to raise healthy children are key, too. Among these programs are the:

  • Supplemental Nutrition Assistance Program
  • Special Supplemental Nutrition Program for Women, Infants, and Children
  • Child and Adult Care Food Program • Affordable Care Act
  • NEWBORN Act
  • Baby Friendly Hospital Initiative
  • Temporary Assistance for Needy Families reauthorization
  • Early Childhood Programs

We’ll demonstrate how each of these programs is critical to fighting childhood hunger and obesity.

Supplemental Nutrition Assistance Program

SNAP, formerly known as the Food Stamp Program, provides crucial support for struggling families, with a record number of nearly 40 million Americans currently receiving assistance through this program. A recent study found that half of all children in this nation live in households that will use food stamps at some point in their childhood.

SNAP is particularly responsive to dramatic changes in our economy, as became clear most recently in the program’s rapid expansion to cope with the Great Recession. And SNAP households saw a much needed boost in benefits following the enactment of the American Recovery and Reinvestment Act in 2009. Alas, since then the program experienced cuts that policymakers should commit to restoring as soon as possible.

The Special Supplemental Nutrition Program for Women, Infants, and Children

Known as WIC in policy circles, this program provides nutritional assistance, education, and support to low-income pregnant and postpartum women and their preschool age children. Enrollment figures for the WIC program suggest that it provided increasing nutrition assistance to low-income women and children during and in the aftermath of the recent recession. Average annual participation is estimated to reach 9.3 million people in fiscal year 2010 which ended in September, up from 8.7 million in FY 2008.

The Healthy, Hunger-Free Kids Act increases supports for breastfeeding WIC mothers, and advances strong nutrition and physical activity policies and practices in schools and child care settings. It is critical that policymakers work with practitioners to implement these and other important child nutrition initiatives in this new and important piece of legislation.

The Child and Adult Care Food Program

Children spend the majority of their time before they reach the age of mandatory school attendance in child care settings. CACFP plays an important role in improving the quality of day care for children and makes care more affordable for low-income families. And through CACFP, more than 3.2 million children receive nutritious meals and snacks each day as a part of the day care they receive. <[p>These funds also are used to provide meals in family homeless shelters, where there are significant numbers of young children. The Healthy, Hunger-Free Kids Act also improves access to CACFP, and it improves the nutritional standards of foods served through CACFP.

Affordable Care Act

The new health care reform law makes affordable health insurance more accessible for the estimated one in five women of childbearing age that are currently uninsured. But it also has a number of provisions that will support and promote an emphasis on the prevention of obesity. Among those most relevant to vulnerable mothers, the law created a new home visitation program that will bring nurses into the homes of new mothers to offer assistance.

This new program offers an opportunity to promote breastfeeding among other health behaviors that encourage healthy child outcomes and prevent obesity. And it also requires that employers provide accommodations for breastfeeding. Policymakers should continue to support the implementation of health care reform to ensure the advancement of these and other beneficial initiatives.

The NEWBORN Act

This legislation builds on opportunities for mothers created in the Affordable Care Act. It would create a national pilot program that focuses on providing prenatal care and community outreach, and educating at-risk and potential mothers about healthy pregnancies. Counseling would be made available for infant care, feeding, and parenting, and the act would expand access to nutrition and physical activity programs. Congress should work towards advancing this initiative.

Baby Friendly Hospital Initiative

The Baby Friendly Hospital Initiative is a global program originally sponsored by the World Health Organization and the United Nations Children’s Fund to encourage and recognize hospitals and birthing centers that offer an optimal standard of care for infant feeding. BFHI assists hospitals in supporting mothers to successfully initiate and continue breastfeeding their babies, and gives special recognition to hospitals that have done so.

There are currently 100 baby-friendly hospitals and birth centers throughout the United States. Policymakers and community stakeholders should develop efforts to expand this program to underserved low-income communities, as it could aid in increasing the prevalence and duration of breastfeeding by the most disadvantaged babies.

Temporary Assistance for Needy Families reauthorization

TANF funds can be used to provide health services and links to health services. A number of states also use their funds to provide direct food assistance. Although TANF is an income and work-focused support program, it can influence the health and well-being of women and children in a variety of indirect ways. Case in point: The structure of a state’s work requirements can potentially exacerbate an imbalance of work and family life.

Work requirements also can affect a family’s ability to manage their health conditions and ultimately impact health outcomes. Additionally, the amount of assistance a family receives can determine the level of hardship they will experience. As state and federal policymakers begin to consider future directions for the program, they should examine the different ways in which TANF intersects with opportunities to improve health outcomes for vulnerable families.

Early Childhood Programs

The federal government should continue to look for opportunities in all of the early childhood programs it funds, including Early Head Start and the Child Care and Early Development Block Grant, to develop evidence-based policies and practices related to child nutrition and physical fitness. Additionally, policymakers must continue to improve access to these programs.

Other ways to support parents in raising healthy kids

Research demonstrates that broader efforts to reduce parental stress can have the further indirect benefit of reducing childhood obesity, among other improvements in child health. Policies and programs that help low-income parents meet their financial and familial needs will combat child poverty, prevent child hunger, and reduce the risk factors fueling child obesity rates. Expanding access to flexible and predictable work schedules, for example, would aid low-income mothers in developing healthy household routines by mitigating work-family conflict. Lowincome jobs are often rigidly confined by the clock, and the lack of flexible works options often lead women to quit or be fired from needed jobs, increasing hardship for their families.

Additionally, safe neighborhoods with affordable housing, quality child care, accessible full-service grocery stores, parks to play in, reliable public transportation, and good schools are critical to improving diets and related health outcomes for both parents and children. Governments should design incentives to move community planners and other stakeholders towards a community-building agenda with physical and social infrastructure that is truly family-friendly.

Conclusion

Concerns about the growing and costly childhood epidemic of obesity across our nation means this nutritional concern is now front and center in our national health discourse. The fight begins with healthy and fit mothers. But childhood obesity is not a stand-alone problem. It is inextricably linked to economic opportunity, community development, access to health care, and many other sectors throughout our society. And it cannot be addressed without tackling the growing and unacceptable scourge of child hunger in this land of plenty.

Simply put, both childhood obesity and hunger cannot remain absent from national debates over budgets and taxes. For the common good of our country, this epidemic must end.

We know what we need to fix. Low-income families face significant barriers to nutritional health due to the lack of healthy food options and safe opportunities for physical activity in their communities. This raises not only their risk of hunger and malnutrition, but also the likelihood that they will struggle with obesity and other weight-related health problems.

Parents make decisions about food and physical activity within the communities in which they work and live. And policy plays a critical role in creating and sustaining health-promoting community environments that enable parents to make good food choices and promote healthy behaviors that encourage their children to lead lives in which they will thrive and prosper.

Ensuring children and their parents have the nutritional and health support they need is an investment in a more prosperous future for not just low-income families and communities, but for our society as well. Our nation’s future is in the hands of its children, who must be well nourished to reach their fullest and greatest potential. This is why implementing the important child nutrition provisions of the newly passed Healthy, Hunger-Free Kids Act alongside other legislative steps required in 2011 are so important.

Alexandra Cawthorne is a Research Associate in two programs at the Center for American Progress, the Poverty and Prosperity program and the Health and Rights program.

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