What’s a Child
Nutrition Program?
Subsidized Housing and the LowIncome Home Energy Assistance
Program (LIHEAP) Are Linked to
Improved Growth Outcomes for
Young Children of Color
Stephanie Ettinger de Cuba, MPH
Children’s Sentinel Nutrition Assessment Program (C-SNAP)
Boston University School of Public Health
Boston Medical Center
Tuesday, November 7, 2006
Authors
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Stephanie Ettinger de Cuba, MPH
Deborah A. Frank, MD
Nicole Neault, MPH
Mariana Chilton, PhD
John Cook, PhD
Carol Berkowitz, MD
Maureen Black, PhD
Patrick Casey, MD, MPH
Diana Cutts, MD
Alan Meyers, MD, MPH
Nieves Zaldivar, MD
Suzette Levenson, MPH, EdM
Timothy Heeren, PhD
Zhaoyan Yang, MS
Children’s Sentinel Nutrition
Assessment Program
(C-SNAP)
A national network of clinicians and
public health specialists for research in
multiple pediatric settings on the effect
of U.S. social policy on young, lowincome children’s health and nutrition.
C-SNAP Study Sites
C-SNAP Study Sites
-Little Rock, AR
-Boston, MA
-Baltimore, MD
-Minneapolis, MN
-Philadelphia, PA
-Los Angeles, CA*
-Washington, D.C.*
Study Objective
Evaluate the importance of
federal assistance
programs not commonly
identified with child
nutrition, such as LIHEAP
and Subsidized Housing, to
child growth and health
outcomes among young
black and Latino children
Study Methods
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August 1998 – December 2004
Sentinel sample
Interview caregivers
Children 0-3 years
Emergency departments & acute care
clinics
• Black and Latino children - over 80%
• Weight & length measurements -outcome of interest & accepted
international indicator of wellbeing
Eligible Families
• Sample restricted to:
– Low-income renters of color
with children under 3
– Participate in at least one
means-tested program
• Subsidized Housing sample:
(n = 13,069)
• LIHEAP sample: (n = 4,091)
– additionally:
• Excludes private insurance
• Only renters - heat not
included
Analytic Methods
• Multiple logistic regression
• Covariates for each program
separate
- depending on correlation with
program/outcome
Subsidized Housing
analyses controlled for:
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Mother born in US
Receipt of TANF
Receipt of WIC
Food insecurity status
LIHEAP analyses controlled
for:
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Mother born in US
Year of interview
Food insecurity status
Receipt of either TANF or Food
Stamps
Receipt of WIC
Receipt of Housing Subsidy
Caregiver marital status
Caregiver employment
2004 Poverty Rates Among
Households with Children
Poverty Highest among black and Latino
families
US Census Bureau, 2005
2004 Food Insecurity Rates
among Households with Children
Food insecurity highest among black and
Latino families
Nord, Andrews, and Carlson, 2005
2004 National Eligible
Household Participation
in LIHEAP
U.S. Department of Health & Human Services, 2004
Housing & LIHEAP only
reach a fraction of eligible
C-SNAP families
Subsidized Housing Helps
Black Children Grow
Outcome
Subsidy
(n=3,116)
No Subsidy
(n=4,977)
P Value
≤2 SD Weight/Age
below the mean
1.00
1.33
P = 0.006
Outcome
Subsidy
(n=3,116)
No Subsidy
(n=4,977)
P Value
Mean ZHeight/Age
Z = 0.134
Z=-0.005
P<.0001
LIHEAP Improves Young
Black Children’s Growth
Outcome
LIHEAP
(n=778)
No LIHEAP
(n=3,313)
P Values
At Nutritional
Risk for Growth
Problems*
1.00
1.29
P = 0.05
*Nutritional risk: < 5th percentile for weight-for-age or <10th percentile for
weight-for-height
Outcome
LIHEAP
(n=778)
No LIHEAP
(n=3,313)
P Values
Mean ZWeight/Age
Z = 0.061
Z=-0.051
P = .04
Subsidized Housing Helps
Latino Children Grow
Outcome
≤2 SD
Height/Age
below the
mean
Subsidy
(n=720)
1.00
No Subsidy
(n=4,256)
P Value
1.99
P = 0.02
LIHEAP and Latino Children
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Results for Latino children
and LIHEAP not presented
since did not reach statistical
significance, probably due to
small sample size.
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Limited program participation
reflects sample
characteristics
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most Latino children lived in
California, where few families of
any ethnicity access LIHEAP.
Overweight?
No associations between
overweight and LIHEAP or
Subsidized Housing
Limitations
• Interviews in English, Spanish, and
Somali (MN only)
• Only blacks and Latinos
• Exclusion of the most severely ill or
injured children
• Associations are not causation
• Difficult to make national extrapolations
Non-food assistance programs
can improve children’s growth
• Programs like LIHEAP and Subsidized
Housing linked to improved growth
outcomes
• “Heat or eat” phenomenon: Food budget
only variable expense
• Food most easily decreased to pay for
other expenses, leading to increased food
insecurity, particularly during winter
months.
Implications for Young
Black & Latino Children
• Growth is indicator of health in
young children
• Adverse child growth outcomes
associated with not receiving
benefits
• Safety net programs buffer young
children from effects of poverty
UN Convention on the
Rights of the Child
Article 27
1.States Parties recognize the right of
every child to a standard of living
adequate for the child’s physical,
mental, spiritual, moral and social
development…
3. States Parties… shall take appropriate
measures to assist parents…to provide
material assistance and support
programmes, particularly with regard
to nutrition, clothing and housing.
Why does it matter?
Housing and Energy are
Health Issues:
 Early growth failure sets
children up for long-term
health & development
problems.
Why does it matter?
Affordable Housing and Energy are Human Rights Issues:
 Black & Latino children => 35% of all children in US.
 Black & Latino children higher risk for living in poor HHs
 Also at greater risk for negative growth effects associated with
poverty and food insecurity.
 Food insecurity and its effects exacerbate achievement gaps
and deepen racial/ethnic health disparities, depriving victims of
other rights.
Society Has a Duty to Guarantee Children’s Basic Rights:
 Macro perspective: Denial of basic rights -> disastrous effects
on workforce participation and health of national economy.
What can we do about
changing policy?
Educate Policymakers to:
• Reconsider standard view of which assistance programs
influence child nutrition.
– Food + Non Food = Optimal Child Health
• Understand that safety-net programs “good medicine” but
dosage and availability inadequate.
• Stop cutting or freezing funding for safety-net programs created health crisis for poor children, especially children of
color
• Give recommended “dosage”: Full package of benefits ->
social investment -> reduction of racial/ethnic disparities
Acknowledgements
• Report sponsored by the Joint Center for Political and Economic
Studies
C-SNAP operations and analyses have been supported by: the Abell Foundation,
the Annie E. Casey Foundation, the Anthony Spinazzola Foundation, the Candle
Foundation, the Claneil Foundation, the Daniel Pitino Foundation, the EOS
Foundation, the Gold Foundation, the Gryphon Fund, the Hartford Foundation for
Public Giving, Jennifer Kaminsky, MAZON: A Jewish Response to Hunger, the
Minneapolis Foundation, the New Hampshire Charitable Foundation, Project
Bread, the Sandpiper Philanthropic Foundation, the Schaffer Foundation, Susan
P. Davies and Richard W. Talkov, Susan Schiro and Peter Manus, the Thomas
Wilson Sanitarium for Children of Baltimore City, the United States Department
of Agriculture, Vitamin Litigation Funding, with major funding from the W. K.
Kellogg Foundation.
• Thanks to Avi Perry, Bill Emerson National Hunger Fellow, for his
assistance in preparing this presentation.
Please visit us on
the web:
www.c-snap.org
Thank you!