Authors: This report was prepared by the Growth and Nutrition Division of the Department of Pediatrics at the University of Maryland School of Medicine. Maureen M. Black, PhD Baltimore Site Principal Investigator, C-SNAP Professor of Pediatrics Erin R. Hager, PhD Research Coordinator Brian C. Merry Data Analyst Anna M. Quigg, MA Baltimore Site Coordinator, C-SNAP

Acknowledgements: This work was completed in collaboration with the Baltimore City Health Department with the involvement of the Baltimore City Health Commissioner, Dr. Joshua Sharfstein. Funding was provided by the Annie E. Casey Foundation.

References 1.

Nord M, Andrews M, Carlson S. Food Insecurity in the United States, 2006. USDA/ERS, 2006.

2.

Cook JT, Frank DA, Berkowitz C, Black MM, Casey PH, Cutts DB, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. Journal of Nutrition, 2004;134(6):1432-8.

3.

Cook JT, Frank DA, Levenson SM, Neault NB, Heeren TC, Black MM, et al. Child food insecurity increases risks posed by household food insecurity to young children's health. Journal of Nutrition, 2006;136(4):1073-6.

4.

Black MM, Cutts DB, Frank DA, Geppert J, Skalicky A, Levenson S, et al. Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants' growth and health: A multisite surveillance study. Pediatrics, 2004;114:169-176.

5.

Rose-Jacobs R, Black MM, Casey PH, Cook JT, Cutts DB, Chilton M, Heeren T, Levenson SM, Meyers AF, Frank DA. Household food insecurity: Associations with at-risk infant and toddler development. Pediatrics, 2008;121:65-72.

6.

Bronte-Tinkew J, Zaslow M, Capps R, Horowitz A, McNamara. M. Food insecurity works through depression, parenting, and infant feeding to Influence overweight and health in toddlers. Journal of Nutrition, 2007; 137:2160-2165.

7.

Connell CL, Lofton KL, Yadrick K, Rehner TA. Children's experiences of food insecurity can assist in understanding its effect on their well-being. Journal of Nutrition, 2005;135:1683-90.

8.

Jyoti DF, Frongillo EA, Jones SJ. Food insecurity affects school children's academic performance, weight gain, and social skills. Journal of Nutrition, 2005;135:2831-9.

9.

Casey PH, Goolsby S, Berkowitz C, Frank DA, Cook JT, Cutts DB, Black MM, et al. Maternal depression, changing public assistance, food security, child health status. Pediatrics, 2004;113:298-304.

10. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschoolaged children. Pediatrics, 2006;118:e859-68

Contact Information Maureen M. Black, PhD 410-706-2136 phone 410-706-5090 fax [email protected] http://www.medschool.umaryland.edu/ 8

Summer 2008

Food Security: Ensuring the Health of Baltimore's Babies

Food Security Consequences of Food Insecurity

What is Food Security? Food security is access to enough food for an active and healthy lifestyle for all household members.1

What is Food Insecurity? Food insecurity is the lack of access to enough food for an active and healthy lifestyle for all household members due to financial constraints. Families who are food insecure often limit the quality and quantity of food available to family members, filling up on low-cost foods with little nutritional value (such as noodles, fast food, or junk food). Food insecurity includes the anxiety that families often face when they do not have regular access to food.1-2

Infants and toddlers (under 3 years of age)2-6 Poor health Poor development Behavioral problems

School-age children7-8 Poor health Low academic performance Behavioral & mental health problems

Caregivers

6,8-10

Mental health problems including depression and anxiety

THIS REPORT ADDRESSES 4 QUESTIONS ABOUT CHILDREN IN BALTIMORE: 1. How is food insecurity related to the health and development of Baltimore’s children? 2. Why are some food insecure families not receiving nutrition-related public assistance programs (Food Stamp Program and WIC)? 3. Among food insecure Baltimore families, are children whose families receive WIC and Food Stamps in better health than those who do not receive services? 4. Are there screening questions to identify families at risk of food insecurity?

2

Why study children under three years of age? During the first three years of life, children’s nutritional demands are high to support their rapid growth and development. Not only do infants triple their birth weight by 12 months of age, but they experience rapid brain growth as they acquire specific skills that guide their early development. In addition to nutrition, brain development is influenced by the quality of the caregiving environment. Children raised in households without adequate nutrition and in the presence of stress and low stimulation can experience lasting cognitive and emotional deficits.

Among Baltimore’s food insecure families, 78% have relied on low-cost foods to feed their children because they were running out of money to buy food.

Summary Question 1: How is food insecurity related to the health and development of Baltimore’s children? •

Food insecurity is associated with poor physical health for young children and their caregivers, poor mental health for caregivers, and increased developmental risk for children.

Question 2: Why are some food insecure families not receiving nutrition-related public assistance programs (Food Stamp Program and WIC)? •

Less than half of food insecure families receive both WIC and Food Stamps.

•

Families who do not receive Food Stamps cite perceived or real ineligibility. Families who do not receive WIC cite the application process and logistics.

Question 3: Among food insecure Baltimore families, are children whose families receive WIC and Food Stamps in better health than those who do not receive services? •

Children in food insecure families benefit from nutrition-related services. Families receiving WIC alone or WIC and Food Stamps are more likely to report that their child is in good or excellent health than families receiving no services.

Question 4: Are there screening questions that can be used in health care and other settings to identify families at risk of food insecurity? •

A 2-item food insecurity screening questionnaire may be used in primary care or other settings to identify families at risk for food insecurity.

Next Steps: •

Ensure access to nutrition-related public assistance programs for food insecure families.

•

Clarify eligibility criteria for Food Stamps.

•

Streamline the WIC application process.

•

Recognize that public policies can impact the health and development of young children.

•

Implement public policies that promote positive health and development for all children.

7 7

Question #3 Among food insecure Baltimore families, are children whose families receive WIC and Food Stamps in better health than those who do not receive services? What Does this Figure Show? Compared to families who receive no nutritional programs, children in families who receive WIC are 2.8 times more likely to be in good or excellent health (p=0.060) and children in families who receive both WIC and Food Stamps are 3.3 times more likely to be in good or excellent health (p=0.035).

Statistical analyses were conducted to determine how nutrition-related programs (WIC and Food Stamps) are related to caregiver-reported child health among Baltimore’s food insecure families. Analyses were adjusted for child age and birth weight; caregiver age, education, and depression; and whether or not the family receives Temporary Cash Assistance (also known as “welfare”, an indicator of poverty).

Odds of Child in Good/Excellent Health

Among food insecure families, nutrition-related assistance programs (WIC and Food Stamps) are associated with better child health. 3.3

3.5

2.8

3 2.5 2 1.5 1 0.5 0

Question #4

None

WIC only

WIC and Food S tamps

Nutrition-Related Public Assistance Programs Recieved

Are there screening questions to identify families at risk of food insecurity? Based on food security status determined by the USDA’s Food Security Survey, we identified families who are truly food secure and truly food insecure. Most food insecure families reported that the following two statements were sometimes true or often true:

Food Insecurity Screening Questionnaire

“Over the past 12 months, we worried whether our food would run out before we got money to buy more” 95.2% of food insecure families

Please indicate if each statement is often true, sometimes true, or never true for your family food situation.

“Over the past 12 months, the food we bought just didn’t last and we didn’t have money to get more” 89.3% of food insecure families

1. Over the past 12 months, we worried whether our food would run out before we got money to buy more. _____ Often True _____ Sometimes True _____ Never True

Sensitivity and specificity were calculated for a questionnaire that asks these two questions. Families were considered ‘at risk for food insecurity’ if they answered “sometimes true” or “often true” to one or both questions. Sensitivity = 99.0% Families who are truly food insecure are likely to be identified by the screen. Specificity = 82.5% A few families who are truly food secure may be identified as food insecure by the screen.

6

A 2-item food insecurity screening questionnaire to assess food security status is proposed:

2. Over the past 12 months, the food we bought just didn’t last and we didn’t have money to get more. _____ Often True _____ Sometimes True _____ Never True Families are considered ‘at risk for food insecurity’ if they answer “sometimes true” or “often true” to either item

C-Snap How We Examined Food Insecurity in Baltimore The Children’s Sentinel Nutrition Assessment Program (C-SNAP) is a network of pediatricians and public health researchers who study how public policies are related to the health and well-being of young children. C-SNAP collects data on a daily basis in emergency departments and primary care clinics in five cities: Baltimore, Boston, Little Rock, Minneapolis, and Philadelphia. With information from over 27,000 low-income families of young children, C-SNAP has the largest clinical data set on low-income children under 3 years of age in the Unites States. The University of Maryland Hospital for Children is one of the five C-SNAP sites. This report is based on information from 2,216 infants and toddlers who received health care services at the University of Maryland Emergency Department and/or Pediatric Ambulatory Center between September 2003 and December 2007. Families were eligible to be included if they did not have private medical insurance, the caregiver spoke English and was knowledgeable about the child’s household, the child was under 3 years of age and not critically ill or 22% of Baltimore’s food injured, and the caregiver agreed to participate.

What percentage of families are food insecure at C-SNAP sites?

% of Food Insecure Families

45

insecure families reported that their children were not eating enough because they could not afford enough food.

40.5%

40 35

Approximately 13.5% of lowincome Baltimore C-SNAP families are food insecure. Baltimore’s rate of food insecurity is slightly lower than rates in other C-SNAP sites, but higher than the national average of 10.9% reported by the USDA for 2006.1

30 25

20.8%

20 15

10.9%

13.5%

14.6%

16.4%

10 5 0 USA

Baltimore Little Rock Philadelphia

Boston

Minneapolis

Rates of food insecurity are highest among sites with large numbers of immigrant families (ie., Minneapolis and Boston).

3

Question #1 How is food insecurity related to the health and development of Baltimore’s children? What Does this Figure Show about Caregivers? What Does this Figure Show about Children?

Caregivers in food insecure families are significantly more likely to report:

Caregivers in food insecure families are significantly more likely to report that : •

Their child is in fair or poor health

•

They are concerned about their child’s development

Prevalence of Health Concerns Related to Food Insecurity

Food Secure

•

Symptoms of depression for themselves

•

Their own health is fair or poor

Food Insecure

55%

60 50 40

20 10

28%

26%

30

14% 9%

15%

15%

10%

0 Children in Fair or Poor Health

Children at Developmental Risk

Caregiver Depressive Symptoms

Caregiver in Fair or Poor Health

Caregiver Report

Food insecurity is related to poor health and increased developmental risk for young children Food insecurity is related to poor physical and mental health of caregivers of young children which can have negative consequences for children and families

Characteristics of the families interviewed: • • • • • • 4

88% were African American 88% were single parent households 100% did not have private insurance 98% of caregivers were born in the US 59% of children were under 1 year old 41% of children were 1-3 years old

Within Baltimore’s food insecure families, 24% of adults have reported not eating for a whole day because there was not enough money for food.

Question #2 Why are some food insecure families not receiving nutrition-related public assistance programs (Food Stamp Program and WIC)? Among food insecure families in Baltimore: •11% are not receiving Food Stamps or WIC. •42% are receiving just one nutrition-related public assistance program (WIC or Food Stamps).

Fewer than half of food insecure families are receiving both WIC and Food Stamps.

37% of food insecure families in Baltimore reported being hungry but not eating because they couldn’t afford enough food.

Nutrition-Related Public Assistance Programs Income Eligibility Requirements Program

% of Federal poverty income guidelines*

WIC

< 185 %

Food Stamps

< 130 %

*based on family income and number of people in the household

Eligibility criteria differ for WIC and Food Stamps. Food insecure families are likely to be eligible for WIC. Reasons caregivers described for not receiving WIC include delays in enrollment and logistical barriers (e.g., no transportation, clinic hours, etc.). Eligibility criteria for Food Stamps are more stringent than for WIC. Caregivers cited concerns and confusion regarding eligibility criteria, personal reasons (e.g., no desire, stigma, etc.), and sanctions.

Why are food insecure families not receiving WIC and Food Stamps? Top 5 Reasons for not receiving WIC

•Application pending •Clinic hours or missed appointment

•Personal (do not want WIC, do not use WIC food)

•No transportation •Other (including unsure of eligibility)

Top 5 Reasons for not receiving Food Stamps

•Not eligible •Personal (do not want, stigma, hassle, treatment)

•Cut off or stopped receiving Food Stamps

•Teen parent or too young to be head of the household

•Do not know if eligible or did not know about the program

5