Hunger is a Vital Sign;
Vaccinating Communities Against Hunger
By Empowering Food-Insecure Families
John Cook, PhD, MAEd
Stephanie Ettinger de Cuba, MPH
Ana Paula Poblacion, MSc
Loaves & Fishes Community Services
Naperville, Illinois
April 16-17, 2015
Children’s HealthWatch
• Non-partisan network of pediatric & public health
researchers → research & policy center
• MISSION: Improve health & development of
young children→ public policies → alleviate family
economic hardships
• Hunger (Food Insecurity)
• Unstable Housing (Housing Insecurity)
• Keeping Heat or Lights on (Energy Insecurity)
• Provide policy makers with evidence to develop
policies that protect young children’s health and
development
Where our data come from:
Emergency Departments and Primary Care Clinics in
Boston, Baltimore, Philadelphia, Little Rock and
Minneapolis.
• A household survey
• Interviews - caregivers
with children 0 to 4 years
old
– “invisible” group
– critical growth and
development window
Use evidence from
empirical research
results to:
• Inform actionable
policy decisions
• Support policy
recommendations
Overview
How Do Food Insecurity and Hunger
Influence the Health of Communities?
1. How food insecurity & hunger impact the
health of families and children.
2. How the health of families & children
influence the health of communities.
3. How empowering families to escape food
insecurity and become self-sufficient
influences their health, and the health of
their community.
Food Insecurity and Hunger are Linked
to Other Family Hardships
Children in food-insecure families also are more likely to be:
• Housing insecure (crowded, doubled-up, two or more residential
moves in last year, behind on rent/mortgage payments),
• Energy insecure (threatened with or have had a utility shutoff),
• To have foregone needed health care (visits for treatment or
adherence to prescription medication),
• To have traded off health care against expenditures for other
necessities,
compared to children in food-secure families.
Food Insecurity and Hunger are Vital Signs
Linked to Adverse Child Health Outcomes
Children in food-insecure families are more likely to:
• Have been hospitalized since birth,
• Have their health status reported as “fair/poor”
versus “excellent/good”,**
• Have parents report concerns indicating risk of
developmental problems,
• Have iron deficiency anemia,
• Have anemia without iron deficiency,
compared to children in food-secure families.
Food Insecurity and Hunger are Vital Signs
Linked to Adverse Maternal Health
Outcomes
Children in households with “child food
insecurity” are more likely to:
• Have mothers who report having depressive symptoms,
• Have mothers who report their own health as
“fair/poor”,
• Have mothers with unhealthy weight status,
• Have mothers with chronic diseases, e.g., diabetes,
compared to children in food-secure families.
**NOTE: Meaning of
Self-reported Health Status
• Based on a question that emerged around the
mid-twentieth century (exact source unknown;
maybe UN/WHO, maybe US government)
• Used by the US government and RAND
Corporation in early 1950s, and since in the
NHIS and NHANES,
• Has been validated in US, European, and
Global contexts.
“Would you say {your/SP's} health in general is .
. . (excellent, very good, good, fair, poor)?”
NOTE: Meaning of
Self-rated Health Status
In the US, according to Census Bureau data:
• Of all children (ages <18 years) with “fair or poor” health
status in 2010:
– 61.6% had 3 or more medical care provider visits,
– 26.2% spent at least one night in the hospital.
• Of all children with “excellent, very good, good” health
status in 2010:
– Only 28.0% had 3 or more medical care provider visits,
– Only 4.2% spent at least one night in the hospital.
In 2012, the average cost for non-birth related pediatric hospital
stays was $11,143 (AHRQ, H-CUPnet Kid’s Inpatient Database).
Source: O’Hara B, Caswell K. Health Status, Health Insurance, and Medical Services Utilization: 2010.
Household Economic Studies, Current Population Reports, P70-133RV, July 2013.
We are concerned about the
health of our children because:
“The future of any society
depends on its ability to foster
the healthy development of the
next generation.”
Center On The Developing Child, Harvard University
Human Brain Development
Most Vulnerable Period: Birth – Age 4 Yrs
Synapse formation, neural networks – “brain architecture”
Language
Sensory Pathways
(Hearing, Vision)
Neural Connections for Different Functions Develop Sequentially
Higher Cognitive Functions
Adult neural
connections
-6
-5
-4
-3
-2 -1
0
Birth
Conception
-9 -8 -7
Fetus
1 2
3
4
5
6 7
8
9 10 11 12 1 2
3
4
5 6
7
8 9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70
Years
Months
Decades
Age
Late Infancy/Toddler
Puberty
Source: Thompson & Nelson, 2000
Brain architecture is laid down
during the first three years of life
Brain architecture is physical structure,
interconnections, & neural networks
Brain “architecture” is physical
structure, and interconnections.
There are about 100 billion cells
in the brain.
It is influenced by many factors,
including those associated with
stress related to poverty, food,
housing, and energy insecurity.
The first 3 years of life largely set
the trajectory of cognitive
development, school readiness,
academic achievement, and
educational attainment.
Toxic stress can damage brain architecture!
Stress is a natural response to changes and
challenges in our environment
• Stress can be mild, and lead to important learning –
we can learn from stress
• Moderate stress – can go either way, can learn from
it, or it can be harmful
• Toxic stress – chronic mild-to-moderate stress, or
acute short-term intense stress
Toxic stress can damage the brain architecture
of young, developing children!
 Though the presence of consistently supportive
adults can buffer children from toxic stress’ harm.
Source: Wikimedia Commons, by Mariana Ruiz Villarreal (LadyofHats), Hamburg, Germany, used with
gratitude.
Toxic Stress and Allostatic Load
 Allostasis is an alternative view to homeostasis,
acknowledging the accumulation of stress hormones
and their by-products in the “system” over time as a
result of toxic stress.
 Allostatic load is the cumulative “wear and tear” on
body systems resulting from over-activation of the
stress response, and accumulation of circulating
glucocorticoids and their by-products.
 Allostatic load can involve adverse impacts on immune
system functioning, hyper-sensitivity to external stimuli,
inappropriate response to stress, attention-deficit
hyperactivity disorders, and life-threatening disease
later in life.
Toxic Stress, Allostatic Load and Health Risks
 Normally, once a perceived threat has passed, adrenaline and
cortisol levels drop, heart rate and blood pressure return to
baseline levels, and other systems resume regular functioning.
 But, when stressors are always present and you constantly feel
under attack, the fight-or-flight reaction stays turned on.
 Long-term activation of the stress-response system — and
subsequent overexposure to cortisol and other stress hormones
— can disrupt almost all the body's processes.
 This puts children who experience toxic stress at increased risk of
numerous health problems, including: Anxiety, depression,
digestive problems, heart disease, sleep problems, weight gain,
memory and concentration impairment.
Animal research indicates that brain
architecture is harmed by “toxic” stress
Toxic Stress and Immune Function
 The hypothalamic-pituitary-adrenal (HPA) axis is
activated in response to stress, increasing the level of
stress hormones (e.g., cortisol, adrenaline, ACTH), that
help the body mobilize resources to respond to stress.
 The HPA axis is also activated in many bacterial and viral
infections, resulting in an increase in circulating
glucocorticoid (stress hormone) levels.
 HPA axis activation – for example, by stress – can also
increase the susceptibility to infectious disease.
 Thus toxic stress plays a role in shaping development
and calibration of the neuroendocrine-immune (NEI)
network in the prenatal and early childhood periods.
Toxic Stress and Related Processes
 Biological embedding is the process by which
individuals’ previous experiences and environments
systematically alter their health and functioning across
the life span.
 Plasticity is the iterative process by which experience
shapes the brain; as it is exposed to new experiences,
they in turn, shape brain structure and function. This
applies to both positive and negative experience.
 Nutrition Programming is the potential lifelong impacts
of a mother’s nutrition and health during pregnancy on
her child’s development and health post-natally.
Toxic Stress and Related Processes
 Epigenetics and the epigenome: As a child grows and
develops, carefully orchestrated chemical reactions
activate and deactivate parts of the genome at strategic
times and in specific locations. Epigenetics is the study
of these chemical reactions and the factors that
influence them.
 The epigenome dynamically responds to the
environment. Stress, diet, behavior, toxins, and other
factors regulate and change gene expression.
 Epigenetic inheritance is an unconventional finding. It
means that a parent's experiences, in the form of
epigenetic tags, can be passed down to future
generations.
So what does all this mean,
and why does it matter?
 Toxic Stress, allostatic load, damage to children’s brain
architecture, biological embedding of adverse childhood
experiences, nutrition programming in utero, negative plasticity of
brain development, epigenetics, and heritability of adverse
epigenetic changes are all factors that can perpetuate the harmful
effects of food insecurity and hunger over generations.
 These processes can limit and damage the health of children and
families, and of communities, for generations.
 They profoundly impact human capital development; cognitive
development, school readiness, academic achievement,
educational attainment, workforce preparedness, fulfillment of
human potential, and lifetime earnings.
 Empowerment of families to escape poverty, food insecurity, and
hunger, and become self-sufficient is the only way to break this
destructive cycle.
Why Impacts of Food Insecurity
on Child Health and Development Matter
National Unemployment Rate, Persons Ages 25 Years and Above by
Education Level Attained
18%
16%
14%
12%
10%
Less than High School
Graduate
8%
High School Graduate
6%
Some College
4%
College Graduate or
Higher
2%
0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Source: U.S. Bureau of Labor Statistics, CPS unemployment data.
Homelessness;
does timing matter?
• Yes!
• Comparison - birth outcomes
– Consistently housed
– Homeless prenatally
– Homeless postnatally
• Mothers’ characteristics or homelessness itself?
• Prenatal homeless – increased risk of
– Low birthweight
– Preterm delivery
– Lower weight at birth
Cutts et al. MCH, 2014.
Affordability: Behind Closed Doors
• Being behind on rent is
strongly associated with
negative child and maternal
health outcomes
– Hospitalizations since birth
– Fair/poor health
– Serious underweight
– Maternal fair/poor health
– Maternal depressive
symptoms
Being behind on rent – strong
indicator of other household
hardship
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Food
insecurity
Child food
insecurity
Energy HH foregone
insecurity
care
Not Behind on Rent
Child
foregone
care
Health care
trade-offs
Behind on Rent
Cutts et al. In preparation.
Rx for Hunger: Affordable Housing
• Housing subsidies free
up resources for food &
other necessities
• Children in subsidized
housing (compared to
those on waitlist)
– More likely food secure
– Less likely underweight
– More likely a “well” child
Household Energy Insecurity
is Linked to Food Insecurity
Outcomes
Household
Food
Insecurity
(yes/no)
Child Food
Insecurity
(yes/no)
Severe Energy
Insecurity: Heat
with Cooking
Stove/Shutoff/
Unheated/cooled
Days
(n=2,293; 23%)
Energy
Secure
(n=6,385;
66%)
Moderate
Energy
Insecurity:
Shutoff
Threatened
(n=1,043; 11%)
1.00
2.37
(1.78, 3.16)
P < 0.01
3.06
(2.46, 3.81)
P < 0.01
P < 0.01
1.00
1.79
(1.13, 2.72)
P < 0.01
3.46
(2.56, 4.67)
P < 0.01
P < 0.01
P value
Source: Cook JT, Frank DA, Casey PH, et al. A Brief Indicator of Household Energy Security: Associations
with Food Security, Child Health, and Child Development in US Infants and Toddlers. Pediatrics, 2008,
Oct, 122(4):e867-e875.
Household Energy Insecurity is Linked
to Child Health & Development
Outcomes
Child Health
Fair/poor
Hospitalized
Since Birth
(yes/no)
PEDS
Significant
Concerns
Moderate Energy
Insecurity: Shutoff
Energy Secure
Threatened
(n=6,385; 66%)
(n=1,043; 11%)
Severe Energy
Insecurity: Heat with
Cooking Stove/Shutoff/
Unheated/cooled Days
(n=2,293; 23%)
P value
1.00
1.34
(1.08, 1.68)
P = 0.01
1.36
(1.15, 1.61)
P < 0.01
P < 0.01
1.00
1.22
(1.03, 1.45)
P = 0.02
1.02
(0.89, 1.17)
P = 0.74
P = 0.07
1.00
1.00
(0.71, 1.41)
P = 0.99
1.82
(1.38, 2.39)
P < 0.01
P < 0.01
Source: Cook JT, Frank DA, Casey PH, et al. A Brief Indicator of Household Energy Security: Associations
with Food Security, Child Health, and Child Development in US Infants and Toddlers. Pediatrics, 2008,
Oct, 122(4):e867-e875.
The Hunger Vital Sign
• Hager ER, et al. Development and Validity of a 2-Item Screen to
Identify Families at Risk for Food Insecurity. Pediatrics, Volume 126,
Number 1, July 2010. (Children’s HealthWatch Baltimore site)
 Develops and validates a 2-item clinical screen for food insecurity
using the first 2 items in the 18-item household scale.
 Using the 18-item HFSS as a “gold standard”,
 Endorsement of either of the first two HFSS items provided:
 Q1 only; Sensitivity of 93% and specificity of 85%
 Q2 only; Sensitivity of 82% and specificity of 95%
 Endorsement of both questions 1 and 2 provided:
 Sensitivity of 78% and specificity of 96%.
 Endorsement of question 1 and/or question 2 provided:
 Sensitivity of 97% and specificity of 83%.
Why would family empowerment
act like a vaccine?
• What are the properties of vaccines?
• Provide benefits against multiple threats
• Build immunity to be long lasting
• Acknowledged to have differential benefits,
can be targeted or tailored to groups
• Why are vaccines good investments?
• Provide benefits to individuals, families,
communities, and society as a whole
Public Health 101 – Vaccine
Review
Why vaccinate?
• Personal protection
• “Herd immunity”
• Community and
economic benefit
Pathways of Food Insecurity’s
Influence on Child Health & Development,
Family Health, and Health of Communities
• Food Insecurity Influences Children’s Health and
Development Through:
•  Nutritional and
•  Non-nutritional Pathways
Examples of Nutritional Pathways
 Perinatal nutrition of mother and child, including
internatal period and pre-conception,
 Brain and cognitive development in the child (sensitive,
critical, and vulnerable periods),
 Growth impacts (stunting, wasting, structural and system
anomalies, endocrine system, obesity, oral health issues)
 Compromise of immune system functions (risks for
infection-malnutrition cycle)
 Energy deficits
•
•
Compromised body temperature regulation
Reduced environmental exploration & learning
Examples of Non-nutritional Pathways
 Adverse impacts on the child’s and mother’s mental
health (depression) and adult-child interactions (impaired
responsiveness, serve and return)
 Impoverished home environment and lack of appropriate
stimulation and nurturing support
 “Toxic stress” (repetitive, persistent or inescapable acute
or chronic stress; e.g., child abuse, domestic violence,
recurrent or persistent hunger, poverty & food
insecurity(?))
 Delays in and/or deterrence of needed medical care
 Non-compliance with treatment, including Rx
Building the evidence for
change –> co-enrollment
Combinations of benefits and odds of Housing Security
3
2.5
2
1.5
1
0.5
0
No
Housing WIC only Housing Housing Housing
benefits Subsidy
Subsidy + Subsidy Subsidy+
only
WIC
only
WIC +
SNAP
WIC +
SNAP
Sandel et al. JARC, 2015.
Housing
Subsidy,
WIC +
SNAP
OK, this is interesting… but what can I do
with this information? Well, consider this:
 Strong physical infrastructures; strong bridges, buildings, roads,
parks, bike paths, trains, buses, subways, libraries, schools,
ports, housing stock, utilities, are all part of the foundation for
a strong, healthy public, & strong, healthy communities, and,
 Strong social infrastructures; fire departments, faith-based
institutions, police departments, PTOs, civic organizations,
mutual aid societies, private food assistance – food banks, food
pantries, food rescue – disaster relief, public food, housing, &
energy assistance – SNAP, WIC, CACFP, school meals, summer
feeding, etc., housing subsidies, LIHEAP, legal aid, are also
essential parts of the foundation for a strong, healthy public &
communities. They enable all of us to be healthy and to
prosper. They are for all of us, and we all benefit from them,
whether we use them or not.
Food, housing, and energy insecurity are results of
systemic failures, not individuals’ or families’ failures
Policy
Failures
Market
Failures
Housing,
Food, Energy
Insecurity
Failures of
Representative
Democracy
Regulatory
Failures
Jan-15
Sep-14
May-14
Jan-14
Sep-13
May-13
Jan-13
Sep-12
May-12
Jan-12
Sep-11
May-11
Jan-11
Sep-10
May-10
Jan-10
Sep-09
May-09
Jan-09
Sep-08
May-08
Jan-08
Sep-07
May-07
Jan-07
(1000s)
Number of US Workers Unemployed, Jan 2007-Feb 2015
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Median Income (in 2013 dollars) by
Race/Ethnicity, 2004-2013
$90,000
$80,000
$70,000
TOTAL (all
races)
WHITE, nonHispanic
BLACK
$60,000
$50,000
HISPANIC
(any race)
$40,000
$30,000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Bringing food security & health
together for positive change
• Hospital systems/health care partners
– Incorporating the “hunger vital sign” into EHRs; screening routinely
– Health care providers – investing in the food security vaccine; access to
healthy food via on-site & community-based food pantries, WIC offices,
demo kitchens, nutrition education, farmers’ markets, etc.
– IRS approved nutrition access as community benefit; tax
exemption/deduction for non-profit hospitals under the ACA
• Broad, Multi-sector Coalitions
– “Human beings aren’t divided into government departments”
• Co-enrollment for benefits, including food, housing, energy assistance
– State-level EITC & Child Tax Credit increases, minimum wage increases
• Advocacy/coalition building – using the health argument
with partners, helping to build momentum for
empowerment and achieving economic self-sufficiency
Food Security & Healthy Food
act as a Vaccine
• New understanding of interplay of food security and
the health of individuals, families, and communities
• Nutrition and non-nutrition pathways of influence
• Toxic stress, brain plasticity, bio-embedding,
epigenetics, immune system functioning
• Nutrition programming in utero affects health in later
life
• Food security and healthy food can act as a vaccine
• Provide multiple, long-lasting benefits
• Differential benefits to individuals, families, and
communities
• A strong, healthy public, benefits to society as a whole
WE ARE ALL IN THIS TOGETHER!
Thank you!
John.Cook@bmc.org
www.childrenshealthwatch.org
@childrensHW
What Have we Learned in 20 Years About Food
Insecurity’s Impacts on Child Health &
Development?
Recommended reviews:
 Gunderson C, Kreider B, Pepper J. The Economics of Food
Insecurity in the United States. Applied Economic
Perspectives and Policy (2011) volume 33, number 3, pp.
281–303. doi:10.1093/aepp/ppr022.
 Nord M. Food Insecurity in Households with Children:
Prevalence, Severity, and Household Characteristics. EIB-56.
U.S. Dept. of Agriculture, Econ. Res. Serv. September 2009.
http://www.ers.usda.gov/Publications/EIB56/
 Cook JT, Frank DA. Food Security, Poverty and Development
in the United States. Ann. N.Y. Acad. Sci. xxxx: 1–16 (2008).
2008 New York Academy of Sciences. doi:
10.1196/annals.1425.001
http://www.childrenshealthwatch.org/page/Publications
Reviews (Cont’d.)
• Reviews from ASN EB Symposium 2012 (Food Security and
Health Across the Lifespan)
 Laraia BA. Food Insecurity and Chronic Disease. Adv. Nutr. 4: 203–212,
2013. http://advances.nutrition.org/content/4/2/203.full.pdf+html
 Cook, JT, et al. Are Food Insecurity’s Health Impacts Underestimated in
the U.S. Population? Marginal Food Security Also Predicts Adverse
Health Outcomes in Young U.S. Children and Mothers. Adv. Nutr. 4:
51–61, 2013.
http://advances.nutrition.org/content/4/2/51.full.pdf+html
 Gundersen C. Food Insecurity Is an Ongoing National Concern. Adv.
Nutr. 4: 36–41, 2013.
http://advances.nutrition.org/content/4/2/36.full.pdf+html
 In addition, all Children’s HealthWatch publications can be found at
http://www.childrenshealthwatch.org/page/Publications