Hunger is a Vital Sign Vaccinating Communities Against

Hunger is a Vital Sign; Vaccinating Communities Against Hunger By Empowering Food-Insecure Families John Cook, Ph. D, MAEd Stephanie Ettinger de Cuba, MPH Ana Paula Poblacion, MSc Loaves & Fishes Community Services Naperville, Illinois April 16 -17, 2015

Children’s Health. Watch • 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 1950 s, 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, 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, P 70 -133 RV, 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 Months 8 9 10 11 12 1 2 3 4 5 6 Age Late Infancy/Toddler 7 8 9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70 Years Decades 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 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! Ø Though the presence of consistently supportive adults can buffer children from toxic stress’ harm.

Source: Wikimedia Commons, by Mariana Ruiz Villarreal (Ladyof. Hats), Hamburg, Germany, used with gratitude.

Toxic Stress and Allostatic Load Ø 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. Ø 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. Ø 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 Ø 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. Ø But, when stressors are always present and you constantly feel under attack, the fight-or-flight reaction stays turned on. Ø 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. Ø 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 Ø 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. Ø The HPA axis is also activated in many bacterial and viral infections, resulting in an increase in circulating glucocorticoid (stress hormone) levels. Ø HPA axis activation – for example, by stress – can also increase the susceptibility to infectious disease. Ø 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 Ø Biological embedding is the process by which individuals’ previous experiences and environments systematically alter their health and functioning across the life span. Ø 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. Ø 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 Ø 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. Ø The epigenome dynamically responds to the environment. Stress, diet, behavior, toxins, and other factors regulate and change gene expression. Ø 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? Ø 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. Ø These processes can limit and damage the health of children and families, and of communities, for generations. Ø They profoundly impact human capital development; cognitive development, school readiness, academic achievement, educational attainment, workforce preparedness, fulfillment of human potential, and lifetime earnings. Ø 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 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 1. 00 1. 79 (1. 13, 2. 72) P < 0. 01 3. 46 (2. 56, 4. 67) 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): e 867 -e 875.

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 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 (0. 71, 1. 41) P = 0. 99 1. 82 (1. 38, 2. 39) 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): e 867 -e 875.

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 Health. Watch Baltimore site) Ø Develops and validates a 2 -item clinical screen for food insecurity using the first 2 items in the 18 -item household scale. Ø Using the 18 -item HFSS as a “gold standard”, v Endorsement of either of the first two HFSS items provided: ü Q 1 only; Sensitivity of 93% and specificity of 85% ü Q 2 only; Sensitivity of 82% and specificity of 95% v Endorsement of both questions 1 and 2 provided: ü Sensitivity of 78% and specificity of 96%. v Endorsement of question 1 and/or question 2 provided: ü 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 Ø Perinatal nutrition of mother and child, including internatal period and pre-conception, Ø Brain and cognitive development in the child (sensitive, critical, and vulnerable periods), Ø Growth impacts (stunting, wasting, structural and system anomalies, endocrine system, obesity, oral health issues) Ø Compromise of immune system functions (risks for infection-malnutrition cycle) Ø Energy deficits • • Compromised body temperature regulation Reduced environmental exploration & learning

Examples of Non-nutritional Pathways Ø Adverse impacts on the child’s and mother’s mental health (depression) and adult-child interactions (impaired responsiveness, serve and return) Ø Impoverished home environment and lack of appropriate stimulation and nurturing support Ø “Toxic stress” (repetitive, persistent or inescapable acute or chronic stress; e. g. , child abuse, domestic violence, recurrent or persistent hunger, poverty & food insecurity(? )) Ø Delays in and/or deterrence of needed medical care Ø 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 benefits Subsidy + Subsidy+ only 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: v 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, v 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

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Median Income (in 2013 dollars) by Race/Ethnicity, 2004 -2013 $ 90, 000 $ 80, 000 $ 70, 000 $ 60, 000 $ 50, 000 $ 40, 000 5 90 /1 /1 90 5 12 : 0 0: 0 12 0 AM : 0 /1 0: 90 0 5 12 0 AM : 0 /1 0: 90 00 5 12 AM : 0 /1 0: 90 0 5 12 0 AM : 0 0: 00 AM $ 30, 000 TOTAL (all races) WHITE, non. Hispanic BLACK HISPANIC (any race)

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 @childrens. HW

What Have we Learned in 20 Years About Food Insecurity’s Impacts on Child Health & Development? Recommended reviews: v 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/ppr 022. v 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/EIB 56/ v 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) v Laraia BA. Food Insecurity and Chronic Disease. Adv. Nutr. 4: 203– 212, 2013. http: //advances. nutrition. org/content/4/2/203. full. pdf+html v 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 v 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 v In addition, all Children’s Health. Watch publications can be found at http: //www. childrenshealthwatch. org/page/Publications