Center on Hunger and Poverty - Brandeis University

Childhood Hunger, Childhood Obesity - An Examination of the Paradox

Hunger & Food Insecurity in the US
Undernourishment Among Poor Children
Impact of Childhood Hunger
Impact of Childhood Obesity
Weight and Income
Risk Factors for Obesity
The Bottom Line
Possible Solutions
References and Selected Resources

Hunger & Food Insecurity in the United States

According to the most recent national figures (USDA, 1999):

36.2 million Americans live in food insecure households, that is, they do not always have enough money to buy food sufficient to meet their basic needs. Nearly 10 million of these individuals also live in households where hunger is experienced.
14 million children live in food insecure homes where food may be scarce or diets altered due to limited incomes.
Food insecurity and hunger are more widespread among households below the poverty line: 35.4% of these households experience food insecurity compared to 10.2% of households nationwide. Nearly 73% of households experiencing hunger are at or below 185% of the poverty line, a common income-eligibility cut-point for federal food programs.

Food Insecurity and Hunger Defined:

Food Insecurity occurs when access to nutritionally adequate and safe foods is either limited or uncertain, or the ability to obtain foods occurs in socially unacceptable ways.

Hunger is "the painful or uneasy sensation caused by a recurrent or involuntary lack of food."

Over time, hunger may result in malnutrition, but often food insecurity and hunger occur without the visible signs of stark malnutrition often associated with impoverished nations.

Undernourishment Among Poor Children

Poverty and food insecurity negatively influence the diet of many low-income children.

Limited household income and food insecurity are associated with low intakes of fruits and vegetables, which lowers intake of vitamins, minerals, trace elements and fiber (Federation of American Societies for Experimental Biology, 1995). Children in poor families also consume fewer dairy products (Munoz et al, 1997) so they are less likely to meet the RDA for calcium. These reductions in nutrient intakes increase the risk for various chronic diseases.
About 18% of low-income infants and toddlers experience iron deficiency anemia (Centers for Disease Control and Prevention, 1998), requiring medical treatment.
Children in low-income families usually consume insufficient calories, and families often cope with limited food dollars by purchasing less expensive but higher fat foods (Kennedy and Goldberg, 1995).
Low-income children are more likely to be deficient in major nutrients (including energy, protein, iron, calcium, folate, and zinc) when their families do not receive food stamps (Cook, et al, 1995) as this program increases household nutrient availability (Fraker, 1990).

Mild malnutrition occurs when "intake of either energy or specific nutrients is less than the recommended daily allowance; it is associated with suboptimal growth, and/or changes in metabolism, but does not lead to significant wasting" (Wachs, 1995).

Impact of Childhood Hunger

Millions of American children are undernourished from periodic episodes of inadequate food intake. Poor nutrition is often associated with poor living environments, including lack of parental support, social stress, and inadequate access to proper medical care, which magnify the negative effects of undemutrition (Aber and Bennett, 1997).

Short stature reflects one adaptation to inadequate nutrition that allows a child to maintain weight when calories are limited. As such, undernourished or food insecure children may appear to be of normal or even above average weight. Regardless of weight, low-income children are more susceptible to nutrient deficiencies and poor developmental outcomes. Mild malnutrition can:

Limit growth: the Centers for Disease Control and Prevention reports that 9.7% of low-income infants under two years were of short stature in 1997. This rate is twice as high as normally expected.
Restrict brain development.
Reduce immune function; this means that a poorly nourished child is more likely to become ill and miss school.
Cause iron deficiency which lowers the immune response and a child's ability to concentrate on tasks.
Limit a child's cognitive development, overall leaming potential, and ability to succeed in school.

Sources: Brown and Pollitt, 1996; Center on Hunger, Poverty and Nutrition Policy, 1998; Metallinos-Katsaras and Gorman, 1999; Pollitt, 1995; and Pollitt and Metallinos-Katsaras, 1990.

Impact of Childhood Obesity

Obesity has become a serious public health problem among children. A dramatic rise in overweight children has occurred over the last 30 years: 11% of all children aged 6 to 18 years were overweight in the latest National Health and Nutrition Examination Survey (NHANES), conducted from 1988 through 1994, compared to 4.3% from the first survey, conducted from 1963 to 1970 (Troiano and Flegal, 1998). Childhood obesity has been described as an epidemic because much of the rise in prevalence rates occurred within a 10 year period of time.

Like child malnutrition, obesity has several adverse outcomes:

Increased risk of glucose intolerance and diabetes, including the "adult onset" type.
Increased risk of cardiovascular disease and high cholesterol (which increases risk for stroke).
Psychosocial consequences, including low self-esteem and discrimination.
Less common problems include hypertension, sleep apnea, and orthopedic problems.

Though not all overweight children grow into obese adults, studies suggest that more teens are overweight than younger children, and that teenage weight often is predictive of adult weight. Health care costs related to obesity have been estimated at $68 billion.

Sources: Center for Nutrition Policy and Promotion, 1998; Dietz, 1998; and Wolf, 1998

Weight and Income

All pediatric populations (regardless of socioeconomic status) contain children who are overweight, but the trends among specific groups of children (based on age, sex, ethnicity, or income) are less clear. Small sample sizes for some groups prevent definitive statements as to whether there are real differences between these various sub-populations in terms of weight.

For children aged 6 to 18 years (from NHANES data reported by Troiano and Flegal, 1998):

There is no relationship between weight and income status among Mexican-American or non-Hispanic black children
There may be an inverse relationship between weight and family income among non-Hispanic white teenagers (small numbers in this group prevent reliable conclusions)

For children under the age of 6 (from NHANES data reported by Ogden et al, 1997; and Pediatric Nutrition Surveillance Survey reported by the CDC, 1999):

Analysis of NHANES data for relationships between socioeconomic and weight status is not available. Overall, the range of overweight preschool children in this population is 7.9 to 10.3%
Overweight rates among low-income pre-school children are similar (though not directly comparable to the children in the NHANES data set) and range from 8.6 to 11.3%

How is "Obesity" Defined?

Children grow rapidly and it is difficult to determine whether a heavy child is also "fat", so the term "overweight" is used to describe children,in lieu of "obese".

To determine weight status, measures of height and weight are compared to reference population data, (e.g.: "standard" growth curves for children). If a child's weight is above the 95th percentile for his/her height, then the child is classified as "overweight". If the weight-for-height is between the 85th and 95th percentile, then the child is considered at risk for overweight.

Of note, since the growth charts are based on a population of middle-class, white children, individual children will vary from this reference, especially those from other ethnic backgrounds. Still, these charts work well for tracking growth over time and for overall assessment of a population.

Risk Factors for "Obesity"

There are many factors aside from genetics that influence a child's growth pattern and weight status. Regardless of income, children with an obese parent or who watch a lot of TV are at increased risk for overweight (Anand, et al, 1999). The trend towards being overweight is also associated with a greater reliance on high-calorie, high-fat convenience foods, soda consumption, and diminished physical activity, especially among teenagers.

Though the rise in overweight children has occurred in all pediatric groups, some have claimed that poor children are heavier than the non-poor (Rector, 1998). A recent USDA analysis of children aged 7 to 16 years (Anand, et al, 1999) found no correlation between weight and income when the 95th percentile was used as a cut point for overweight (personal communication). This same study found a significant correlation between weight and income when the more conservative 85th percentile was used to indicate children at risk for obesity. This suggests that while the prevalence of overweight poor children is not different than that of non-poor children, those in low-income families may disproportionately face socioeconomic conditions that limit their control over factors which influence weight.

Strategies to cope with food insecurity, such as the reliance on high-fat foods, may contribute to body fat gain, especially when this occurs on a cyclical basis in response to periodic food shortages (for instance, when food stamps run out before the end ofthe month) (Dietz, 1995).

In one study from Minneapolis, preschool children classified as "hungry" or "at risk for hunger" consumed more soda or other sugared drinks than non-hungry children (Cutts, Pheley, and Geppert, 1998), thus contributing to "empty" calories (that is, calories which provide no nutritional value).
Poor urban families typically live in neighborhoods where outside play and recreation are not safe options. Children in rural areas may also be kept inside due to lack of supervision. Other poor children may have health problems, like asthma, which limit their ability to play (Luder, et al, 1998). Prevention of activity, in conjunction with dietary alterations due to limited income, can promote fat gain.
Lack of access to a variety of resources including adequate housing, utilities, and health care, as well as good food stores, increases risk of hunger ("heat or eat"), and the likelihood of poor food choices (such as the reliance on high fat foods) (Nestle and Guttmacher, 1992).

The Bottom Line

Childhood hunger is a serious problem that is associated with poor health and lower academic achievement.
Hunger and food insecurity are problems particularly among poor households and often lead to sub-optimal diets.
Poor children are more disadvantaged in terms of their options for obtaining healthy foods and engaging in regular physical activity.
"Obesity" or overweight has become a serious health problem among children nationwide.
Overweight is not necessarily more common among poor children, but for some groups of children, hunger and overweight may be interrelated.

Possible Solutions

What can be done about childhood hunger?

We can eliminate childhood hunger through policies and programs that strengthen the economic conditions of low-income families and provide needed nourishment to their children. This can occur two ways:

Utilize Food Programs that act as nutritional safety nets for families and children:

Food Stamp Program allows families to obtain food through grocery stores, and improves household food availability and dietary intakes, especially for children. Participation has declined since welfare reform; efforts aimed at outreach and restoration ofbenefits are needed.
WIC provides supplemental food, nutrition education, and referrals to health care services for pregnant women, new mothers and their infants and young children (under five years). This cost-effective program reduces the number of low birth weight babies and related medical costs, and decreases the prevalence of anemia in young children.
School Meals provide balanced meals to millions of children each school day, and meet about half of a child's daily nutrient requirements. School breakfast not only improves nutrient intakes,it has been shown to improve the ability of children to learn. All children can participate; low-income children can receive meals at little or no cost.
Summer Food Service Program fills a critical gap for children who rely on school meals for nourishment by providing meals at no cost during the summer months.
Child and Adult Care Food Program enables day care homes and centers to offer balanced meals and snacks to the children in their care, and is especially beneficial for low-income child care providers.

Promote Family Economic Security for those transitioning from welfare to work and for working poor families:

Enhance work income through skills training that can lead to better jobs; increase the earned income "disregard" when determining TANF (Temporary Assistance for Needy Families) benefits; and index the minimum wage to inflation.
Make work feasible by providing child care subsidies and filling the health care gap so poor families can enter and remain in the work force, while providing parental support for their children.
Raise asset limits and vehicle allowances for public assistance programs so low-income families can save money and build a financial cushion for temporary set-backs instead of having to return to welfare.
Expand Individual Development Accounts (IDAs) which enable struggling families to build assets to achieve economic well-being.

What can be done fo prevent or treat overweight children?

Early intervention programs that promote behavior changes among children, both within their home and school environments, have the greatest potential to prevent obesity and positively influence children's dietary and activity habits over the lifetime.
Educational programs that address the special needs of low-income families are crucial since many families find making healthy food choices on limited budgets difficult. Educational programs already occur through WIC, Head Start and Cooperative Extension Agencies, plus many food pantries and day care providers have added this service.
Heavy children should be encouraged to make healthy food choices and to play; obesity should not be treated simply with calorie restrictions since children need a tremendous amount of energy to grow and develop properly.
Comprehensive health programs -- including nutrition education and physical activity during the formative school years and the USDA Healthy School Meals Initiative and Team Nutrition programs -- all help to shape healthy behaviors and enhance nutrition knowledge.

References and Selected Resources

Childhood Obesity Data

Anand RS, Basiotis PP, and Klein BW. Profile of Overweight Children. Nutrition Insights; 13. USDA, Center for Nutrition Policy and Promotion, May, 1999.

Center for Nutrition Policy and Promotion, US Department of Agriculture. Childhood Obesity: Causes and Prevention. Symposium Proceedings, Oct. 27, 1998.

Centers for Disease Control and Prevention. Pediatric nutrition surveillance, 1997, full report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1998.

Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, and Johnson CL. Prevalence of Overweight Among Preschool Children in the United States, 1971 through 1994. Pediatrics; 99(4), April 1997.

Troiano RP, and Flegal KM. Overweight Children and Adolescents: Description, Epidemiology and Demographics. Pediatrics; 101(3): 497-504S, March 1998.

Cognitive Development and Health

Aber JL and Bennett NG. The effects of poverty on child health and development. Annu. Rev. Public Health; 18:463-83, 1997.

Brown JL, and Pollitt E. Malnutrition, Poverty and Intellectual Development. Scientific American; pp 3 8-43; Feb, 1996.

Center on Hunger, Poverty and Nutrition Policy. Statement on the Link Between Nutrition and Cognitive Development in Children, 1998. Center on Hunger, Poverty and Nutrition Policy, Tufts University, Medford, MA.

Dietz VM. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics; 101:518-25,1998.

Luder E, Melnik TA, and DiMaio M. Association of Being Overweight with Greater Asthma Symptoms in Inner City Black and Hispanic Children. J Pediatrics; 132(4):699-703, 1998.

Metallinos-Katsaras E, and Gorman K. Effects of undernutrition on growth and development. In DB Kessler and P Dawson (Eds.) Failure to Thrive and Pediatric Undernutrition: A Transdisciplinary Approach. Brookes Publishing Co, Baltimore, MD, 1999.

Pollitt E (Ed.) The Relationship Between Undernutrition and Behavioral Development in Children: A Report of the International Dietary Energy Consultative Group (IDECG) Workshop on Malnutrition and Behavior. J Nutr; 125(8 S), 1995.

Pollitt E and Metallinos-Katsaras E. Iron Deficiency and Behavior: Constructs, Methods and Validity of the Findings. In Wurtinan RJ and Wurtrnan JJ (Eds): Nutrition and the Brain, Vol 8, Raven Press, Ltd., New York, 1990.

Wachs TD. Relation of Mild-to-Moderate Malnutrition to Human Development: Correlational Studies. J Nutr; 125:2245-54S, 1995.

Wolf, AM. What is the Economic Case for Treating Obesity? Obesity Research; 6:2S-7S, 1998.

Hunger and Food Security

Cutts DB, Pheley AM, and Geppert JS. Hunger in Midwestern Inner-city Young Children. Arch. Ped and Adol Medicine; 152(5): 489-93, 1998.

Dietz WH. Does hunger cause obesity? Pediatrics; 95(5):766-67, 1995.

Kendall A, Olson CM, Frongillo EA. The Relationship of Hunger and Food Insecurity to Food Availability and Consumption. JADA; 96:1019-24, 1996.

Nestle M and Guttmacher S. Hunger in the United States: Rationale, methods and policy implications of state hunger surveys (report). JNE; 24:18-23S, 1992.

Rector R. The Myth of Widespread American Poverty. The Heritage Foundation Backgrounder, Sept 18, 1998.

USDA, Household Food Security in the United States 1995-1998 (Advance Report). U.S. Department of Agriculture, Food and Consumer Service, Washington DC, July 1999.

Nutrition

Cook JT, Sherman LP, and Brown JL. Impact of Food Stamps on the Dietary Adequacy of Poor Children. Center on Hunger, Poverty and Nutrition Policy, Tufts University, Medford, MA, 1995.

Federation of American Societies for Experimental Biology, Life Sciences Research Office. Prepared for the Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on Nutrition Monitoring in the United States, vol 2. U.S. Govennnent Printing Office, Washington, DC, 1995.

Fraker TM. The Effects of Food Stamps on Food Consumption: A Review of the Literature. U.S. Department of Agriculture, Food and Nutrition Service, Washington DC, 1990.

Kennedy E and Goldberg J. What are American Children Eating? Implications for Public Policy. Nutr Reviews; 53:111-26, 1995.

Munoz KA, Krebs-Smith SM, Ballard-Barbash R, and Cleveland LE. Food Intake of US Children and Adolescents Compared with Recommendations. Pediatrics; 100(3): 323-29, 1997.

Policy and Program Resources

Brown JL. Pediatric Undernutrition and Public Policy. In DB Kessler and P Dawson (Eds.) Failure to Thrive and Pediatric Undernutrition: A Transdisciplinary Approach. Brookes Publishing Co, Baltimore, MD, 1999.

Center on Hunger and Poverty reports:

State Divestments in Income and Asset Development for Poor Families, 1999
State Investments to Make Work Feasible, 1999
State Investments in Work Participation: Meeting the Promise of Welfare-to-Work, 1998
State Investments in Family Economic Security: A Portfolio Management Approach, 1998
A Guide to Universal Free School Breakfast Programs, 1998

Published in 1999

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